Altered T-lymphocyte subsets in hospitalized intravenous drug abusers.

Baseline immunologic abnormalities were identified in 16 hospitalized intravenous drug abusers ( IDAs ) without acquired immune deficiency syndrome (AIDS). Twelve (75%) of 16 had inverted helper-suppressor ratios. In seven patients (44%), the abnormal ratio resulted from an increase in the absolute number of suppressor cells with a normal number of helper T lymphocytes. In five patients (31%), the reduced ratio resulted primarily from decreased helper cells, immunophenotypic findings similar to those seen in patients with AIDS. These findings are similar to what has been noted in other groups at risk for AIDS. Longitudinal follow-up as well as studies of "healthy" IDAs are required to understand the prognostic implications of these data.

Effect of the Omnibus Reconciliation Act 1987 on antipsychotic prescribing in nursing home residents.

OBJECTIVE: To determine the impact of OBRA 87 on antipsychotic prescribing in a 485-bed nursing home. DESIGN: Twelve-month retrospective cohort review of medical charts, medication administration records, and computerized pharmacy records. MEASUREMENTS: The percent of residents by diagnostic group and antipsychotic use. MAIN RESULTS: An attempt was made to stop or lower the dose of antipsychotic in 75% of the 107 residents studied. Antipsychotics were stopped in 45% of residents with a dementia-only diagnosis and 25% of residents with a psychiatric diagnosis (P < 0.05). Residents with documented symptoms appropriate for the use of antipsychotic, per OBRA 87, were significantly less likely to have their antipsychotic stopped. Twenty percent of residents whose antipsychotic was either stopped or its dose lowered had the agent restarted or its dose increased. CONCLUSION: OBRA 87 had a significant impact on antipsychotic use in this facility.

Songs of innocence and experience: student's poems about their medical education.

Personal creative writing is increasingly used in medical schools to foster self-reflection. This article looks particularly at poetry as a vehicle for expressing personal experiences of professional development. The authors present a series of poems written by students at their medical school. In them, the students reflect on embryology, gross anatomy, telling (or not telling) bad news to trusting patients (and family members), encountering death, and encountering their own anger and frustration with the demands of medicine. These poems not only capture individual students' feelings and imaginations but also demonstrate the students' constant struggle to sustain their idealism about medicine throughout the four years of their education.

Phytohemagglutinin induced proliferation by aged lymphocytes: reduced expression of high affinity interleukin-2 receptors and interleukin-2 secretion.

Human lymphocytes from elderly and young donors were cultured with phytohemagglutinin. Cultures from two groups of aged donors, recruited respectively from our ambulatory clinic and a nursing home, incorporated less tritiated thymidine (3H-TdR) and secreted less interleukin-2 than did young donors. Furthermore, as determined for the first time by a radioligand binding receptor assay, the aged lymphoblasts possessed significantly fewer high affinity IL-2 receptors per cell. Despite a decrease in the number of high affinity receptor cells the dissociation constant (Kd) was comparable for the three groups. It was also shown that the amounts of soluble IL-2 receptors that were released into the supernatants by mitogen stimulated cells did not differ for the aged and young donors. These data suggest that defects in IL-2 production and high affinity IL-2 receptor generation may both be responsible for immune deficiency in the elderly.

Therapeutic considerations in congenital absence of the right pulmonary artery. Use of internal mammary artery as a preparatory shunt.

Congenital unilateral absence of a pulmonary artery is rare. When present, it is usually associated with other cardiac malformations. In this communication an infant with coarctation of the aorta, ventricular septal defect and absent right pulmonary artery is reported. After correction of the first two defects, due to persistent respiratory difficulty, the infant had exploration of the right pulmonary hilum in hopes of finding a pulmonary artery remnant and re-establishing blood flow to that lung. A small hilar vessel supplying all three lobes of the right lung was found and as a first stage, to enhance pulmonary arterial growth, a palliative systemic to pulmonary artery shunt was performed utilizing a large internal mammary artery. This is the first report of a case in which the internal mammary artery is used in an infant to establish systemic to pulmonary arterial flow in congenital unilateral absence of a pulmonary artery.

Respiratory syncytial virus and ribavirin therapy: winter 1987-spring 1988. A report of 74 cases treated at Providence Hospital, Anchorage, Alaska.

Seventy-four pediatric cases of Respiratory Syncytial Virus lower respiratory tract infection were treated at Providence Hospital, Anchorage, Alaska between September 1, 1987 and April 30, 1988. These patients are described with illustrative case reports. Twenty-one patients were treated with Ribavirin and these patients are further analyzed as a special interest group. A disproportionate number of the Ribavirin treated group were Alaskan Natives. In the discussion we address concerns of possible toxicity of Ribavirin and current recommendations for patient selection for treatment with Ribavirin.

The voices of the medical record.

The medical record, as a managerial, historic, and legal document, serves many purposes. Although its form may be well established and many of the cases documented in it 'routine' in medical experience, what is written in the medical record nevertheless records decisions and actions of individuals. Viewed as an interpretive 'text', it can itself become the object of interpretation. This essay applies literary theory and methodology to the structure, content, and writing style(s) of an actual medical record for the purpose of exploring the relationship between the forms and language of medical discourse and the daily decisions surrounding medical treatment. The medical record is shown to document not only the absence of a consistent treatment plan for the patient studied but also a breakdown in communication between different health professionals caring for that patient. The paper raises questions about the kind of education being given to house staff in this instance. The essay concludes with a consideration of how such situations might be more generally avoided.

Treating nondementia illnesses in patients with dementia.

Physicians increasingly are called on to provide primary care for the growing population of people with Alzheimer-type dementia. However, little attention has been paid to the care of nondementia illnesses in this group of patients. To illustrate how presence of dementia can alter the risk-benefit ratio of treatment of a common medical problem, we present a case study in which a patient with dementia developed disastrous adverse effects to a drug commonly used to treat osteoporosis. This case and 2 composite vignettes illuminate how presence of dementia should influence the decision-making process for treatment of nondementia illnesses. We address issues such as decreased decision-making capacity, problems with reporting adverse effects, decreased cognition leading to problems with treatment adherence, and the role of screening and basic questions about acceptable burdens of treatments in patients with limited prognosis. We suggest ways to improve communication with patients with dementia in an effort to minimize complications and improve care, as well as policy changes to include patients with dementia in clinical trials. JAMA. 2000;283:3230-3235