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An account is given of 18 narcotic addicts with septicemia. The microorganism most frequently implicated was penicillinase-producing Staphylococcus aureus, sensitive to methicillin. Alpha-hemolytic...

Nosocomial infections are a distinct reality for many hospitalized patients. However, it is possible with presently available measures to substantially reduce the threat of such infection for patients in whom some physical barrier of normal immunity has been bypassed. For these patients, conscientious attention by health care personnel to such things as careful insertion and aseptic care of urinary catheters and intravenous cannulae, and cleanliness of ventilatory equipment and other mechanical devices used in intensive care units is needed. In contrast, the potential risk of actual hospital-acquired infection in patients with impaired cellular or humoral immunity is very great. No easy solutions to prevention and effective treatment of infection in these immunosuppressed patients are available. The general approach of protection from harmful bacteria, judicious use of antibiotics when infection occurs, and immunologic reconstitution of the deficient host with specific antibodies and competent phagocytic cells seems encouraging.

Eight children with the hemolytic-uremic syndrome were treated with heparin, streptokinase, aspirin, and dipyridamole. Two children died and six survived. Normal renal function at follow-up was demonstrated in all of the surviving children. A retrospective analysis of the results of treatment of this disease over a 10 year period suggested that treatment with heparin reduced the mortality rate in the acute phase of the illness. Heparin alone did not prevent the late occurrence of chronic renal disease, but treatment with heparin, streptokinase, and the anti-platelet agents did appear to prevent this complication of the disease. Bleeding during streptokinase therapy was frequent and was severe in two patients.

The prevalence and incidence of venous thromboembolism and other venous disease has been determined as part of a longitudinal study of health and disease in a Michigan community. When these data are extrapolated to 1970 U.S. census figures, a rough estimate of annual incidence of clinically recognized deep venous thrombosis is over 250,000 cases while that of superficial thrombophlebitis is over 123,000. An estimated 24 million US citizens have "significant" varicose veins while 6 to 7 million have stasis changes in the skin of the legs and 400,000 to 500,000 have or have had a varicose ulcer. The relatively high frequency of these conditions in the adult population of Tecumseh, Michigan, indicates that they represent several of the more common medical problems encountered by the practicing physician.

Five patients who had parenteral nutrition with a casein hydrolysate and dextrose mixture were compared with five patients who received a synthetic L-amino acid and dextrose mixture. The incidence of metabolic complications and sepsis was lower in the infants who had the synthetic Lamino acid and dextrose mixture. A protein intake of 2 gm/kg/day was better tolerated than was one of 4 gm/kg/day. It is concluded that at present the best amino acid and dextrose mixture is made up of synthetic L-amino acids and dextrose and is adjusted to a protein load of 2 gm/kg/day.

In the dental treatment and maintenance of cancer patients the dentist is often confronted with particularly and peculiarly accented situations which require knowledge of disease and therapy-related problems. Surgery, radiotherapy, chemotherapy, and basic disease may present a constellation of conditions which require for their control the efforts of the entire health profession team. Dental care of the irradiated head and neck cancer patient requires close follow-up and meticulous oral hygiene. There are definite indications for preirradiation extractions, basic rules for maintenance during and after irradiation, and certain precepts for post-irradiation extractions. Chemotherapy has introduced new considerations in the dental treatment of cancer patients. As most anti-tumor drugs cause thrombocytopenia, this effect on hemostasis is of great concern when contemplating oral surgery. During the acute phase of hematologic disorders dental maintenance must be limited to atraumatic procedures to control periodontal and pulp involvement. Good oral hygiene plays an important part in the dental maintenance of all patients. Dentists must take an active part in the therapy and rehabilitation of cancer patients.

Clinical and laboratory experience offers support to the belief that mediastinal displacement to the side of operation is not harmful and, indeed, may be beneficial in certain respects.

Information was obtained concerning patients hospitalized in 1970 at institutions participating in the Commission on Professional and Hospital Activities and having a deep mycosis as a discharge diagnosis. Based on these data there were an estimated 7697 patients with systemic mycotic infection hospitalized in the United States in 1970, the cost of their hospitalization being estimated at 9·39 million dollars. Hospitalization rates conformed, in general, to the known geographic distribution of the infective agent. For patients with a primary diagnosis of a mycotic infection, case fatalities per 100 hospitalized patients ranged from 0·0 for actinomycosis to 18·0 for cryptococcosis. Despite limitations of data derived from this type of survey, the findings represent the most accurate and comprehensive study of patients hospitalized due to systemic mycoses.

Forty-two White Mountain Apache Indians with tuberculosis were placed on a supervised twice-weekly ambulatory treatment program of streptomycin and isoniazid after short periods of hospitalization. Previously, prolonged off-reservation hospitalization had been the rule due to skepticism that chemotherapy could be maintained in the nonurban setting of an Indian Reservation. Although 12 percent of the scheduled appointments were missed, chest roentgenogram findings remained stable or improved and sputa cultures remained negative. No treatment failures occurred, and no patient has been lost to follow-up in spite of the great distances, cultural conflicts and serious social problems which exist. Monetary savings have amounted to an estimated $9,000 to $14,000 (104 clinic visits @ 3.75 = $389.00 vs 365 × $40.00/day = $14,600.00) per patient treated. The early results show that ambulatory chemotherapy has proved effective, well tolerated and economical in this nonurban setting.

One hundred thirty-nine patients with disordered nitrogen metabolism received an intravenous solution of essential L-amino acids and hypertonic dextrose to provide parenteral nutrition in the presence of either acute renal failure, “hepatorenal syndrome,” chronic hepatic insufficiency without renal failure, or azotemia resulting from a variety of other causes. Infusions were managed by routine hyperalimentation technics, modified somewhat to avert potential metabolic side effects. Clinical and metabolic results attributable to the therapy included improved nutritional status and salutary serum electrolyte changes. Complications of therapy were few in number; notable was hyperglycemia which was easily managed in most instances. The capacity to safely deliver intravenous nutrients to patients even with marked disturbances in hepatic or renal function is clearly established.

The few benefits and the hazards of compound preparations and polypharmacy have been discussed. Examples of some well known interactions and their mode/site of action have been recorded. The study of drug interaction is an expanding field with an increasing appreciation of pharmacokinetics and pharmacogenetics.

C H A N G E S in neonatal care of highrisk infants over the past decade have led to the development of intensive care services which can best be provided in centers and by programs serving communities or regions on an organized basis. Recent findings strongIy suggest that neonatal intensive care has resulted in a decrease in the neonatal mortality rate and in a lower prevalence of serious handicapping conditions among the survivors.

Metolazone, a new diuretic/saluretic/anti-hypertensive agent related to quinethazone, was used to treat 20 patients with impaired renal function. Among eight water loaded hospitalized patients given m

Although corticosteroids have been used in liver disease for many years, their indications and use in various liver diseases remain controversial and some­ times unclear. Many of the reports on the value of steroid therapy have not been based on firm scientific evidence, and often the indications for use have only been on empirical grounds. Similar comments may be made about immuno­ suppressive drugs such as 6-mercaptopurine and azathioprine. In spite of these uncertainties, there is little doubt that steroid and immunosuppressive therapy does produce beneficial results in certain types of liver disease. The following article and table I is an attempt to summarise the current status of the clinical use of steroid and immunosuppressive drugs in liver disease. 2. Viral Hepatitis Acute viral hepatitis is usually a self-limiting disease, terminating in spontaneous recovery, in most cases. The most important therapeutic measure is bed rest, and there is no indication whatsoever for steroid or immunosuppressive therapy in the uncomplicatedcase as the majority of cases will recover by 2 to 6 weeks after onset of the illness. However, in the uncommon case associated with complications, notably, prolonged cholestasis, chronic persistent hepatitis, and fulminant hepatitis in coma, steroid therapy may be used.

The neuropsychiatric syndrome seen secondary to liver disease is called hepatic coma or encephalopathy, the latter term describing more comprehensively the wide neurological spectrum of this disorder. Many aspects of this subject have recently been discussed. 1 This review focuses on selected clinical features , discusses current concepts of pathology and pathogenesis, and assesses the present status of therapy of this disorder.

During the course of drug development, there are many instances where extrapolation of data from animals to man is difficult because the toxicologic and metabolic responses induced by drugs may be significantly different between the laboratory species. In cases where the drug in question has a potentially major therapeutic use in man, it is suggested that the data be evaluated on the basis of a pragmatic benefit-to-risk ratio, rather than zero-toxicity. In this way, we may provide drug therapy for those patients for whom adequate treatment does not exist, as well as protect those individuals who may be exposed to some hazard from the use of medicines.

The wide variety of clinical problems in the neonate dictate the basic equipment and personnel requirements of the neonatal intensive care unit. The infant must be provided with a controlled protective environment in which physiologic monitoring, life support systems, and diagnostic facilities are immediately available.

Summary Surgery, radiotherapy, chemotherapy and immunotherapy of glioblastoma multiforme have been briefly reviewed. It is quite clear that, with the exception of immunotherapy as it is presently understood, each therapeutic modality has something to add to the preceding one. New approaches in the therapy of glioblastoma must make use of all these modalities because none of them alone can do more than add a few months to survival. The review of surgical studies indicates that extensive surgery, whenever possible, provides a longer survival than more limited surgery or none at all. The median survival for non-irradiated patients is between 3 and 6 months. Undoubtedly, a complete removal of tumor is almost never accomplished by surgery alone and, consequently, long-term survivors are virtually negligible in this disease. The techniques of neurosurgery are now sophisticated enough to state that in the future this modality will not be able to add much more than it presently does to the survival statistics. The review of radiotherapy studies indicates that in combination with surgery it is superior to surgery alone. There is no survival data on radiotherapy alone without surgery. It appears that the benefits of radiotherapy accrue only within the first 12 months and are no longer evident by 18 months and, in addition, the response to radiotherapy is dose related at least up to 3000 rads. Radiotherapy may have more to offer through the use of high energy particles, although, like surgery, it probably will not improve significantly on what it currently adds to survival. Neither X-ray nor surgery appear to influence the ultimate course of glioblastomas and, from a pragmatic point of view, this leaves to chemotherapy the task of arriving at fresh approaches to the disease. At present, the nitrosoureas are essentially the only drugs having significant activity against this malignancy. These agents alone or in combinationtion with radiotherapy produce a more prolonged survival than either modality alone. Evaluation of chemotherapeutic efficacy is difficult, at best, and the future design of studies must include careful forethought if useful data is to be obtained for new agents. The future short-term approaches should be based on current leads, i.e. lipid-soluble drugs, drugs capitalizing on biochemical abnormalities of gliomas, and new previously untested structures known to be active in other malignancies. In the chemotherapy of this disease, we are far from the degree of sophistication that has been reached in the drug therapy of hematologic malignancies and some of the solid tumors. This review has considered the approaches that seem promising but the major advances to be made in long-term approaches must probably await concomitant strides in basic research concerning the unique physical and biochemical characteristics of the central nervous system and the glioblastoma multiforme.

The success of surgical procedures is largely dependent upon an orderly process of repair and wound healing and although we do not recount these daily, understanding of the available knowledge will influence the attitudes, techniques, and philosophies of the surgeon and lead to better overa

This paper describes the authors' approach to the problem of long term intracranial pressure measurement. Several prior devices have not proven useful for clinical studies of more than a few days duration. Study of 22 of the authors' devices in primates has established the validity of both engineering and medical design assumptions. Useful pressure data has been collected for up to 2 months. Redesign to decrease tambour permeability should allow a useful life of months or years.

Major burn injury is the most extensive stress sustained by man, and it is essential for survival to maintain optimal integrated function of the body cell mass. A review of the metabolic derangements which occur following thermal injury is presented and techniques for restoration of energy and nutritional balance are outlined.

In support of Health Effects Research Studies, pulmonary function tests are periodically administered to a large number of children. The ventilatory performance of these children is being evaluated by measuring the 0.75-sec forced expiratory volume (FEV0.75) with a waterless mechanical volume spirometer used in conjunction with an electronic timing unit. During a 1-yr testing period, operation with the volume spirometer and the EPA designed electronic timing unit proved to be highly successful. The volume spirometer was found to be more advantageous in conducting tests at remote field stations than the water spirometer and other electronic instruments which measure flow rate with a transducer element. The volume spirometer is lightweight, easy to operate, and has the capability of easy and accurate field calibration when used in conjunction with the electronic timing unit. Presently the volume spirometer and EPA designed electronic timing package are employed in all Community Health and Surveillance System (CHESS) pulmonary function testing studies. ImagesFIGURE 1.FIGURE 2.FIGURE 3.

This survey of patient compliance with drug administration reveals that approximately 25 per cent of those seen in the clinic or in hospitals will not be taking drugs as directed. Compliance failures seem to be directly related to the number of drugs taken daily. Few other etiologic factors have been identified. It is difficult for physicians to ascertain which patients have defected from a therapeutic program, yet these defections may lead to false impressions of drug failure. Assessment of compliance can be aided by chemical testing of urine and blood for presence of drug or markers such as riboflavin. Pill counting and patient interviews are not necessarily sensitive indices of compliance. Although not much data are available on the reasons behind compliance failure, intervention which involves supervision and monitoring of patients has increased adherence to a drug regimen. Some of the measures for strengthening compliance are too expensive to be widely applicable, especially in patients with a chronic disease such as epilepsy. Studies using multifactorial analysis of psychologic, social, environmental, and other parameters are needed to develop technics to ensure better compliance in most patients requiring pharmacologic agents.

300 patients have been treated under a system of outpatient management for hernia, stripping and ligations of varicose veins, and operations of equivalent severity. The crux is close cooperation between hospital staff, general practitioner, and district nurse. Early follow-up shows a complication-rate of 10%, the main complications being delayed wound healing (4%) and chest infection (3%). Discharge from hospital had to be delayed for 24 hours or longer in 9 cases (3%) and a further 5 (2%) required to be readmitted. There were no serious complications. The withdrawal of less serious cases from the inpatient milieu has repercussions which demand a greater concentration of staff and resources for the care of the seriously ill. Provided that patients are carefully selected for outpatient surgery this is a highly satisfactory method of management which is feasible, safe, and efficient.

Summary: Patient noncompliance in a therapeutic regime, although common, is not widely recognised. It can be detected objectively by such measures as tablet counting, the detection of inert markers or the measurement of levels of the drug or its metabolites in a body fluid, or by the close supervision of drug administration. Of 768 studies published in the British Medical Journal and The Lancet between January 1969 and December 1972 in which various effects of drugs are reported, 324 required the incorporation of some means of estimating compliance but in only 61 (19%) were such measures employed.

Levels of Lead in Blood and Hematocrit: Implications for the Evaluation of the Newborn and Anemic Patient

Syndromes of congenital malformations are interesting and challenging phenomena which deserve observation, description and treatment of the children and adults who are afflicted by these multiple birth defects. However, the highest level of syndrome research is etiologic research, because knowledge of the causes of multiple congenital malformations promises prevention. Although naming syndromes and classifications are important auxiliary activities, they must not be our final goal. The infinite number of combinations of congenital defects suggests that terminology and classification should be tentative and flexible and that rigidity be avoided. The same holds for statements of causation. I tried to make it clear that we are far from a full understanding of all the principles involved in the etiology of malformations. Many unexpected discoveries along these lines have been made during my lifetime and many of those who pretended to have the final answers were shown to be wrong. It was particularly distressi...

SummaryThe increment in the number of patients to be treated in Belgium by chronic hemodialysis over the next five years is evaluated. The influence of the age limits set for therapy and of the number of transplantations performed annually is analyzed. Over the next five years the presently available facilities will have to be multiplied by 3 if all patients from 15 to 55 years are treated and by 5 if these age limits are extended to 65 years.Within our model the influence of annual transplantation rate on the five year requirements for chronic dialysis is very limited. This will be even more pronounced if dialysis is extended to older, not transplantable patients. The necessity to expand home dialysis and to decrease the cost of dialysis is emphasized. Without such efforts it might become financially difficult to treat all patients up to 55 or 65 years of age.