Klebsiella pneumonia today]

Analysis of incidence and morphology of Klebsiella pneumonia nowadays in the adults (10 observations), children (5 observations) and newborns (23 observations) is presented. The pneumonias account for 11.3% of total number of lobar pneumonias in the adults dying in 1979-1989. Klebsiella infection represent 16.1% of total number of autopsies a year according to the pediatric infection pathology department. Etiological role of Klebsiella is established in 21.5% of total number of autopsies of newborns for 1985-1988, pneumonia being 61% of total Klebsiella infections. Klebsiella pneumonias in the adults correspond in principle to the Friedl?nder's pneumonia studied in detail by V.D. Zinserling (1891-1960) and his students. Generalized forms of, as a rule, hospital Klebsiellosis with most grave lung damage, unknown up to now, are frequently observed in children. Klebsiellosis was combined practically in all cases both in the adults and children with other bacterial, viral and fungal infections. The degree of clinico-morphological manifestations may considerably vary.     

Partial dehiscence of a porcine prosthesis in association with aortic annular separation producing a false aneurysm of the ascending aorta

A 44-year-old man developed intermittent left bundle branch block followed by complete heart block 18 months after aortic valve replacement, and aortic insufficiency and hemolytic anemia 5 years postoperatively. These abnormalities were associated with operative findings (7 years after aortic valve replacement) of total disruption of the aorta at the level of the aortic annulus. Echocardiographic findings of an enlarged and unusually shaped "aortic root" and angiographic findings of abnormally high origin of the coronary arteries relative to the valve ring, which should have suggested the diagnosis 2 years prior to successful surgical repair, are presented.     

Restored hypoxic pulmonary vasoconstriction by peripheral chemoreceptor agonists in dogs

Hypoxic stimulation of the peripheral chemoreceptors inhibits hypoxic pulmonary vasoconstriction (HPV). On the other hand, almitrine, a peripheral chemoreceptor agonist, has been reported in some studies to enhance HPV. To further explore this apparent contradiction, we investigated the effects of two different low intravenous doses of almitrine on pulmonary arterial pressure (Ppa) versus cardiac index (Q) plots in 32 pentobarbital-anesthetized dogs ventilated alternatively in hyperoxia (FIO2, 0.4) and in hypoxia (FIO2 0.1). HPV, defined as a hypoxia-induced increase in Ppa over the entire range of Q studied, from 2 to 5 L/min/m2, was elicited in 16 dogs. In the first eight of these "responders," almitrine 2 micrograms/kg/min had no vascular effect, and in the other eight, almitrine 4 micrograms/kg/min inhibited HPV. In 16 other dogs, hypoxia did not affect Ppa over the entire range of Q. In these "nonresponders," almitrine 2 micrograms/kg/min (n = 8) as well as 4 micrograms/kg/min (n = 8) restored HPV. To answer the question whether the ability to restore HPV would be specific to almitrine, we administered intravenously the structurally unrelated chemoreceptor agonist doxapram at the dose of 20 micrograms/kg/min to an additional group of eight "nonresponders," and this treatment also restored HPV. Intravenous infusion of the malic acid solution solvent of almitrine had no effect on Ppa/Q plots in a final group of eight "nonresponders". We conclude that low dose almitrine and doxapram restore HPV in dogs with a naturally absent hypoxic pulmonary pressor response, probably by a direct effect at the pulmonary vessels.     

Association of total and central adiposity measures with fasting insulin in a biracial population of young adults with normal glucose tolerance: the CARDIA study.

OBJECTIVE: To determine the association of computed tomography (CT)-measured visceral adipose tissue (AT) and other measures of adiposity with fasting insulin in a biracial (African American and Caucasian) study population of young adults. RESEARCH METHODS AND PROCEDURES: The study population consisted of 251 young adults with normal glucose tolerance (NGT), ages 28-40 years, who were volunteers from the Birmingham, Alabama, and Oakland, California centers of the Coronary Artery Risk Development in Young Adults (CARDIA) study. RESULTS: In regression models with total adiposity measures (body mass index or dual-energy X-ray absorptiometry-measured percent fat), visceral AT (measured as a cross-sectional area in cm2) was generally a stronger predictor of insulin than overall adiposity in all race/gender groups (partial correlation coefficients ranging from 0.31 to 0.47) except for black men, in whom the associations were nonsignificant. Partial correlation coefficients between waist circumference and insulin, controlling for percent fat, were nearly identical to those between visceral AT and insulin in women and in white men. Analyses performed on 2060 NGT CARDIA subjects who were not in this study of visceral AT showed significant correlations of waist circumference with insulin in all race/gender groups, including black men, and that black men in the visceral AT study group were significantly leaner than other black male CARDIA subjects. DISCUSSION: We conclude that visceral AT was associated with fasting insulin in NGT participants in three of the four race/gender groups (black men excepted) and that waist circumference was a good surrogate for visceral AT in examining associations of central adiposity with fasting insulin.     

Depression and the right to die

There is a complex relationship between depression and the capacity to forego life-sustaining treatment. On the one hand, the courts have recognized a constitutionally protected right to die for competent persons; on the other hand, psychiatrists have tended toward the presumption of incompetence on the part of anyone who refuses lifesaving treatment. This traditional psychiatric viewpoint stems from experience with many patients whose wish to die disappears when their depression is successfully treated.     

Proctocolectomy for ulcerative colitis

The majority of patients with ulcerative colitis can be managed satisfactorily throughout their lives by medical treatment, but a minority require colectomy. In severe attacks, emergency surgery is often required to save the patient's life. In chronic disease not responding well to medical treatment, elective colectomy will restore the patient to good health. Colectomy is also necessary for certain local complications, such as cancer, severe fistulas, and strictures. Prophylactic colectomy is indicated in patients with long-standing disease in whom there are factors associated with a high risk of developing cancer of the large bowel. For all these indications, it is our opinion that single-stage proctocolectomy is the operation of choice in the great majority of patients. Finally, we consider that the best results are obtained when the physician and the surgeon work together in the closest possible cooperation.     

RSR13 plus cranial radiation therapy in patients with brain metastases: comparison with the Radiation Therapy Oncology Group Recursive Partitioning Analysis Brain Metastases Database.

PURPOSE: This phase II, open-label, multicenter study assessed the efficacy and safety of the potential radiation enhancer RSR13 plus cranial radiation therapy (RT) in patients with brain metastases. The primary end point was patient survival in comparison with the Radiation Therapy Oncology Group Recursive Partitioning Analysis Brain Metastases Database (RTOG RPA BMD). PATIENTS AND METHODS: Eligibility criteria were age > or = 18 years, Karnofsky performance score > or = 70, and brain metastases with solid tumor histology. Patients received cranial RT, 30 Gy in 10 fractions of 3 Gy each, preceded by RSR13, 50 to 100 mg/kg intravenously over 30 minutes. Univariate and multivariate comparisons of survival and cause of death were made between class II study patients and RTOG BMD patients. RESULTS: Fifty-seven RPA class II patients were enrolled. With a minimum follow-up of 24 months, the median survival time and 1- and 2-year survival rates were 6.4 months, 23%, and 11% for the RSR13-treated patients compared with 4.1 months, 15%, and 3% for the RTOG BMD patients (P =.0174). In an exact-matched case analysis (n = 38), median survival time for RSR13 patients was 7.3 months versus 3.4 months for the RTOG BMD patients (P =.006). There was a 54% reduction in the risk of death for RSR13 patients (P =.0267). RSR13-related adverse events of greater than or equal to grade 3 toxicity that occurred in more than one patient included hypoxia, headache, anemia, fatigue, hypertension, and intracranial hypertension. CONCLUSION: RSR13 plus cranial RT resulted in a significant improvement in survival, as well as a reduction in death due to brain metastases, compared with class II patients in the RTOG BMD.     

Hospitalization for suicide attempt and completed suicide: epidemiological features in a managed care population

BACKGROUND: Understanding factors that contribute to high suicide risk holds important implications for prevention. We aimed to examine the sociodemographic and medical predictors of attempted suicide (severe enough to require hospitalization) and of completed suicide in a large population-based sample from a health maintenance organization (HMO) in northern California, USA. METHOD: We designed a cohort study, including 87,257 women and 70,570 men aged 15 through 89 years old at baseline (in 1977-1985) with follow-up for hospitalizations and mortality through the end of 1993. RESULTS: After a median of 10 years, 169 first hospitalizations for attempted suicide (111 among women, 58 among men) and 319 completed suicides (101 among women, 218 among men) were identified. There was a greater incidence of hospitalization for suicide attempt in women than in men and, conversely, a greater incidence of completed suicide in men than in women. The predominant methods of attempted and completed suicides were ingestion of psychotropic agents and use of firearms, respectively. In gender-specific multivariate analysis of hospitalization for suicide attempt, statistically significant associations were seen for age 15-24 years (women), 65-89 years (men), white race (women), 12th grade or less education (both genders), technical/business school education (men), never being married (men), history of emotional problems (both genders), history of family problems (women), history of job problems (men) and presence of one or more comorbidities (men). The independent predictors of completed suicide were: age 15-24 years (both genders), Asian race (women), Caucasian race (both genders), never being married (both genders), being separated/divorced (women), prior inpatient hospitalization for suicide attempt (both genders) and history of emotional problems (both genders). CONCLUSION: These findings could help health professionals be more effective in the prevention of suicide morbidity and mortality.