Intravenous hyperalimentation for the onco-surgical patient

The present paper deals with caloric and protein supply for the onco-surgical patient. The technique of total intravenous hyperalimentation, described by Dudrick, was used in 85 patients in our surgical service. Among them were several onco-surgical cases in which a normal life was expected following the acute hypermetabolic state. The technique of preparation and administration of the I.V.H. is presented. Two illustrative cases are described in detail and the rationale for the use in onco-surgical cases is discussed.     

The prognostic significance of angina pectoris preceding the occurrence of a first acute myocardial infarction in 4166 consecutive hospitalized patients.

We examined the role of chronic (greater than 1 month) angina pectoris (AP) before acute myocardial infarction (AMI) in predicting hospital and long-term mortality rates among 4166 patients with first AMIs. The prevalence of AP in these patients was 43%. Chronic AP was more common in women (49%), patients with hypertension (49%), and diabetic patients (49%) than in men and counterparts free of the former conditions (p less than 0.005). In patients with AP the hospital course was more complicated and non-Q-wave AMI was more common than in counterparts without AP. In-hospital (16%), as well as 1 (8%)- and 5-year postdischarge (26%), mortality rates in hospital survivors were higher among patients with previous AP than in patients without previous AP (12%, 6%, and 19%, respectively) (p less than 0.01). After adjustment for age and all other predictors of increased hospital mortality rates in this cohort of patients, AP preceding AMI emerged as an independent predictor of increased hospital mortality rates (odds ratio 1.30; 90% confidence interval 1.10 to 1.53). For postdischarge mortality rates (mean follow-up 5 1/2 years), the covariate-adjusted relative risk of death in patients with AP was similar at 1.29 (p less than 0.0001; 90% confidence interval 1.16 to 1.44), according to estimation by Cox proportional hazards model. These data support the notion that preexisting AP identifies a group of patients at increased risk of death.     

Ameboma Presenting as Acute Urinary Retention

A patient with several weeks of diarrhea developed for the first time severe urinary frequency and urgency and was admitted with acute urinary retention. Imaging techniques showed a large mass compressing the posterior wall of the bladder adjacent to the rectosigmoid colon, leading to a bilateral dilatation of the ureters. Cystoscopy and biopsy of the affected part of the bladder showed no tumor but a nonspecific acute inflammation. After identification of trophozoites of Entamoeba histolytica in the stool and confirmation by colonoscopy, barium enema, and serology of acute amebic colitis, the patient was treated with metronidazole. Urinary symptoms immediately resolved with a complete disappearance of the mass and a later cure of the colitis. This is a first report of severe urinary symptomatology dominating the clinical picture in amebic colitis, due to compression of the urinary bladder by an ameboma.     

Computerized medical decisions in evaluating the diabetes patient

A system for computer simulation of medical reasoning is described which has been applied to classifying diabetic patients and assessing the complications due to disease. Medical knowledge is formulated into modular, interrelated inference pathways. Each module states the inference and the Boolean combinations of criteria sufficient for confirming or rejecting it. Patient data is compared to the medical logic and a status report is produced which presents the clinical findings, confirmed inferences, the diabetes evaluation score for each body system and request for additional data at the follow-up visit. After initial testing the medical logic was easily updated to fully express medical policy in our clinic. The system provides an objective and consistent method for evaluating the diabetic patient.     

Cerebrovascular hemodynamics in chronic hypertensive pregnant women who later develop superimposed preeclampsia

OBJECTIVE: We have previously shown that normotensive pregnant women who later develop preeclampsia demonstrate lower baseline pulsatility index (PI) and resistance index (RI) but normal vasodilatory responses to stimulation tests. In the current study, we tested the hypothesis that women with chronic hypertension who later developed superimposed preeclampsia behave similarly. METHODS: Transcranial Doppler ultrasound was performed on 17 women with chronic hypertension during the second trimester of pregnancy to measure middle cerebral artery (MCA) velocities. Superimposed preeclampsia developed in seven patients (SUPER group) while the rest did not develop preeclampsia (CHT group). Measurements were performed in the left lateral position at baseline on room air, during 5% CO2 inhalation, and during a 2-minute isometric handgrip test. Blood pressure, heart rate, O2 saturation, and end-tidal PCO2 were recorded with each Doppler measurement. Mean PI, RI, and cerebral perfusion pressure (CPP) at each time were compared using two-way repeated measures analysis of variance. Statistical significance was set at P < .05. RESULTS: The women who developed superimposed preeclampsia did this an average of 8.7 +/- 1.3 weeks after the study. MCA PI and RI were lower, and CPP higher, in the SUPER group compared to the CHT group (0.64, 0.46, and 80.7 vs 0.74, 0.51, and 63.6, respectively; P < .05). Both maneuvers caused reduction in MCA PI and RI in both groups, whereas CPP increased only in the SUPER group. CONCLUSIONS: These findings suggest that women destined to develop preeclampsia have cerebral hemodynamic changes that predate the development of overt preeclampsia.