Underestimation of mortality following lung volume reduction surgery resulting from incomplete follow-up

STUDY OBJECTIVES: Incomplete follow-up can bias interpretation of data that are collected in longitudinal studies. We noted that many patients failed to return for follow-up in a study of effect of lung volume reduction surgery (LVRS) on quality of life (QOL). Accordingly, we designed this investigation to determine the reasons patients dropped out, and to assess differences between those who continued in the study (attendees) and those who did not (nonattendees). DESIGN: Telephone survey. SUBJECTS: Patients with advanced emphysema who had undergone LVRS and had previously agreed to participate in a longitudinal QOL study. RESULTS: No differences were found with regard to age, gender, preoperative pulmonary function, or oxygen use between attendees and nonattendees. Long-term mortality in nonattendees (27%) was considerably greater than that seen in attendees (3%, p < 0.05). Distance from the hospital, financial burden, and living out of the region were the most common reasons cited by surviving nonattendees for their failure to return for follow-up. CONCLUSIONS: Studies reporting the long-term mortality after LVRS can be biased in the direction of underestimating the true value if they are compromised by incomplete follow-up.     

Human platelet fibrinogen: purification and hemostatic properties

Conditions were developed in which 80% to 90% of platelet fibrinogen could be routinely purified in nondegraded form from the fluid phase of platelet suspensions stimulated with the calcium ionophore, A23187, in the presence of calcium, leupeptin, and prostaglandin E1. Fibrinogen was separated from other released proteins by chromatography on diethylaminoethanol (DEAE)-cellulose using a continuous pH and ionic strength gradient. Purified platelet fibrinogen, greater than 98% homogeneous by immunoelectrophoresis and sodium-dodecyl sulfate- polyacrylamide gel electrophoresis (SDS-PAGE), consisted of intact A alpha, B beta and gamma A chains, but not gamma' chains, and was 95% to 96% clottable. Platelet fibrinogen was shown to compete for the binding of radiolabeled plasma fibrinogen to ADP-activated platelets in a manner identical to that of unlabeled plasma fibrinogen itself. Also, at equivalent protein concentrations, platelet and plasma fibrinogens supported platelet aggregation to an equivalent extent. Based upon these results, we conclude that there is no significant difference between platelet and plasma fibrinogen with respect to their size, their clottability, their affinity for the activated platelet fibrinogen receptor, or their capacity to support subsequent platelet aggregation.     

Screening with the alcohol use disorders identification test (AUDIT) in an inner-city population

Objectives: 1) To determine the operating characteristics of the Alcohol Use Disorders Identification Test (AUDIT) in an inner-city population and 2) to compare AUDIT performance with physician recognition of alcohol-related problems. Design: New patients were administered a health habits questionnaire, which included the AUDIT and the alcohol portion of the Structured Clinical Interview for DSM-III-R (used as the “gold standard” for alcohol abuse or dependence). The findings were compared with physician recognition based on chart review. Setting: Inner-city general medicine clinic staffed by resident physicians with faculty supervision. Patients/participants: Consecutive new patients over a ten-week period. Of 166 consecutive new patients, 23 were not contacted, 17 refused to participate, two were excluded for gross cognitive deficits, and 124 completed the study. Results: Of the 124 patients, 41 (33%) met criteria for past or present alcohol abuse or dependence. The AUDIT correctly identified 26/27 (sensitivity of 96%) of patients with current problems and 0/14 of patients with past problems only. Physician rates of recognition of current and past alcohol-related problems based on chart review were 12/27 (sensitivity of 44%) and 1/14 (7%), respectively. The specificities of both the AUDIT and physician recognition were high, 96% and 99%, respectively. Conclusions: 1) Alcohol-related problems were common in this setting. 2) The AUDIT had a high sensitivity and a high specificity for detection of current alcohol problems in this setting, but it failed to detect patients with only past histories of alcohol problems. 3) The AUDIT performed significantly better than did the physicians in detecting alcohol problems. 4) The addition of an assessment of past alcohol use to supplement information from the AUDIT would appear to represent a promising screening strategy worthy of further investigation. Presented in part at the annual meeting of the Society of General Internal Medicine, April 30, 1993, Arlington, Virginia. Supported in part by the Alumni Association of Wayne State University Medical School.     

Improvements in preventive care and communication for deaf patients

OBJECTIVE: To test the hypothesis that profoundly deaf persons would have better preventive care compliance and improved physician communication if enrolled in a primary care program providing American Sign Language (ASL) interpreters. DESIGN: A case-cohort community-based study. The authors had ASL-fluent research assistants interview 90 randomly selected patients (the cases) enrolled in a unique primary care program for the deaf (Deaf Services Program), which provided full-tune ASL interpreters and subsidized health care costs for some patients. Eighty-five deaf controls were friends of the cases drawn from the community. RESULTS: The cases were poorer and less often married than were the controls, but other baseline characteristics were similar. The cases were more likely (p<0.05) to report receiving within the preceding three years Pap tests (90% vs 72%), mammography (86% vs 53%), and rectal examinations (72% vs 25%), but not breast examinations (76% vs 71%, p=0.7). The cases were more likely than the controls to report receiving counseling in ASL for psychiatric and substance abuse problems (49% vs 5%, p<0.001). Although only 18% of the controls were fluent in written English, 67% of them used written notes to communicate with their physicians. Twenty percent of the controls used ASL interpreters compared with 84% of the cases (p<0.001). More cases than controls were moderately or extremely satisfied with communication with their physicians (92% vs 42%, p<0.001). CONCLUSION: Deaf persons enrolled in a primary care program that included full-time interpreters were more likely to use ASL, were more satisfied with physician communications, and had improved preventive care outcomes. Presented in part at the annual meeting of the Midwest Region of the Society of General Internal Medicine, September 18. 1992, Chicago, Illinois.     

Geriatric primary care: a European perspective, Part II.

Europe is considered the parent of geriatric medicine, which was first recognized as a specialty in the United Kingdom. For the benefit of U.S. primary care physicians, GERIATRICS Editor-in-Chief Robert N. Butler, MD, convened a panel of leading European geriatricians in Lausanne, Switzerland, for a discussion of the successes and problems they are encountering in providing medical care to the aging world population. In Part I (Geriatrics 1992; 47 [Jan]:31-41) panelists described the healthcare services available to the elderly. In Part II, they discuss treatment and evaluation of dementia, use of hypnotics, rehabilitation approaches, and dietary and exercise recommendations for the elderly.     

Pulsatile growth hormone, insulin-like growth factors and antler development in red deer (Cervus elaphus scoticus) stags

Plasma samples taken every 30 min over a 26-h period each month from six 4- to 15-month-old red deer stags were analysed for GH. In addition, two samples taken at 10.00 and 22.00 h were analysed for insulin-like growth factor-I (IGF-I) and insulin-like growth factor-II (IGF-II). A concentrate diet was available ad libitum. Food intake, body weight and antler status were recorded. Concentrations of GH were analysed using the PULSAR peak detection routine. Secretion of GH was pulsatile in every month of sampling, but the pattern of pulsatility differed seasonally. During the autumn and early winter (April-June in the Southern hemisphere) GH pulses were frequent and of low amplitude. In contrast, GH pulses in spring (August-September) were of high amplitude and high frequency resulting in a high mean level of GH circulating in the plasma. In early summer (November) the GH pulse amplitude was much lower and pulse frequency fell. There was a rise in GH pulse frequency not accompanied by an increase in GH pulse amplitude in summer (December-January). GH pulse amplitude seemed to be the main determinant of mean GH plasma level. Secretion of IGF-I was raised 1 month after peak monthly mean GH secretion. There was little consistent relationship between concentrations of IGF-II and mean daily GH. Concentrations of GH correlated positively and significantly with liveweight gain and antler growth rate with a delay of 1 month. Significantly positive correlations between concentrations of IGF-I, liveweight gain and antler growth rate were observed. It is considered that the spring and summer (September-December) seasonal acceleration of liveweight gain and antler development in stags could be a consequence of high winter/early spring (August-September) GH pulse frequency and amplitude resulting in increased concentrations of IGF-I, particularly in October.