Stroke in the Lehigh Valley: risk factors for recurrent stroke.

Age-specific risk of recurrent stroke for various risk factors, calculated independently, was estimated using the first year of data from the Lehigh Valley Stroke Register. The register is based on a population of more than one-half million. Among the risk factors examined, the highest overall risk of recurrent stroke, 41.4, occurred with a history of at least one transient ischemic attack (TIA). After myocardial infarction (MI), the relative risk of a recurrent stroke was 8.0, while with all other heart diseases combined it was 8.4. With diabetes, the relative risk of a recurrent stroke was 5.6; with hypertension, it was 4.5. The relative risk increased with age after TIA and MI, but not for other heart disease, diabetes, and hypertension, except in the 85+-year-old age group.

Efficacy of short-term corticosteroid therapy in outpatient treatment of acute bronchial asthma.

A group of adults with 76 episodes of acute asthma needing emergency therapy, but not requiring hospitalization, were discharged from an emergency department following standardized therapy with bronchodilators. Upon discharge, the patients were treated with a controlled regimen of oral theophylline, and were randomly assigned in double-blind manner to either a placebo treatment (42 patient episodes) or a corticosteroid treatment group (34 patient episodes). The latter were given an intravenous bolus of methylprednisolone followed by an eight-day tapering course of oral methylprednisolone, starting at 32 mg twice a day. Follow-up was carried out seven or 10 days after treatment in the emergency department. Relapse could not be predicted on the basis of peak expiratory flow rates measured during care in the emergency department. Those patients who received corticosteroids had a decrease in the need for repeated emergency care (5.9 percent versus 21 percent for placebo) and fewer respiratory symptoms (15.6 percent versus 36.4 percent for placebo). It is concluded that a short course of high-dose corticosteroids in outpatients reduces the relapse rate and symptoms following an acute asthmatic attack.

Palliative radiotherapy for inoperable carcinoma of the lung: final report of a RTOG multi-institutional trial.

Between June 1973 and February 1979, 409 patients with inoperable advanced non-oat cell carcinoma of the lung were randomized on RTOG protocol 73-02. Three treatment arms were evaluated: 40 Gy split course, 30 Gy continuous course, and 40 Gy continuous course. Patients were also randomized to receive cytoxan or no further therapy following irradiation. Three hundred sixteen patients were evaluable. Palliation of symptoms was achieved in 60% with 1/4 of the patients becoming symptom-free. Complete regression of local and regional tumor was produced in 15% and partial regression in 26%. There is no significant difference between the treatment arms in these objective response rates. Median survival times were approximately 6 months. No significant benefit was demonstrated by the adjuvant use of Cytoxan. Although the number of complete responses produced was relatively small, patients achieving a complete response had a significantly longer median survival than the remaining patients, i.e., 14.5 months versus 6 months. Significant toxicity occurred in fewer than 6% of patients. Radiation pneumonitis counted for the majority of these adverse reactions. Toxicity occurred somewhat more often in the group treated with 40 Gy split course therapy. Implications for further studies are discussed.

Combined radiation and hyperthermia: comparison of two treatment schedules based on data from a registry established by the Radiation Therapy Oncology Group (RTOG).

A registry established by the Radiation Therapy Oncology Group provides data for assessing the impact of clinical heating in a set of non-randomized patients treated with hyperthermia in participating member institutions from 1/77 to 6/81. This analysis focuses on tumor response when localized hyperthermia is produced by microwave and applied pursuant to two distinctly different treatment schedules. Hyperthermia treatments were biweekly and combined with daily radiation treatments in one patient group, and combined with biweekly radiation treatment in another. Sample X consists of 65 patients who received a course of therapy using combined hyperthermia and radiation in consecutive treatment sessions each separated by at least 48 hours, but no more than 96 hours. Sample Y consists of 34 patients who received further radiation after the start of a course of combined therapy--either between or at the end of a series of combined treatment sessions. The average length of heat treatment was 72 minutes for Sample X and 32 minutes for Sample Y patients. None of the patients received concurrent chemotherapy; all received between 3 and 13 hyperthermia treatments; all had superficial, measurable tumors. On the average, Sample X patients received 704 total minutes of heat compared to Sample Y patients who received 233 total minutes of heat. Total tumor radiation doses ranged from 17.0 Gy to 44.0 Gy among Sample X patients with 92.3% receiving radiation at either 3 Gy or 4 Gy per fraction. In Sample Y the range for total tumor dose was 16.0 Gy to 70.2 Gy with 73.4% of the patients receiving radiation at 2.5 Gy or less per fraction. Generally, the two treatment schedules achieved similar levels of tumor response. Among treated tumors in Sample X and Sample Y, complete regression rates were 52.4 and 61.8%, respectively, and partial regression rates were 16.9 and 14.7%. Adenocarcinoma and squamous cell carcinoma in both samples responded well to these combined treatments. Only in Sample X was there a statistically significant trend of decreasing complete regression rate when the treated tumor sizes increased. Best responses to treatment generally occurred between 28 and 84 days after completion of the combined therapy course. There were no differences between the two samples with respect to median days to best response or response duration. Blister, ulcer or wet desquamation were reported in 47.7% of Sample X as the maximum skin reaction. In contrast, only 20.6% of Sample Y had these complications.(ABSTRACT TRUNCATED AT 400 WORDS)

Hyperfractionation in the radiation therapy of unresectable non-oat cell carcinoma of the lung: preliminary report of a RTOG Pilot Study.

Patients with localized unresectable non-oat cell carcinoma of the lung were treated by supervoltage radiation therapy to the primary tumor, mediastinum and supraclavicular lymph nodes with 50.4 Gy, 42 fractions of 1.2 Gy, twice daily, 4 to 6 hours apart, 5 times a week. Small field treatment to the known involved areas of primary and lymph nodes was given from 9.6 to 24 Gy, also with 1.2 Gy, twice daily. One hundred twenty-five patients were entered, three of whom were cancelled and two were ineligible. Of the remaining 120 eligible patients, 10 patients received a dose of 50.4 Gy, 20 received 60.0 Gy, 79 received 69.6 Gy and 11 patients received 74.4 Gy. Of these, nine patients were unable to complete hyperfractionated radiation therapy for various reasons. Treatment was discontinued or stopped in 14 patients because of early death or deterioration of the patient's condition. Four additional patients were found to have unacceptable doses to tumor or normal tissues, for a total of 27 patients with protocol violations. Complete regression occurred in 19% of T1-T3, N0-N2 patients with 9% among T3.3b, T4 or N3 patients. Partial regression was 29 and 41%, respectively. There were six cases of severe and two of life-threatening toxicity, but there were no fatalities attributable to the treatment. Toxicity consisted mainly of pneumonitis and pulmonary fibrosis as well as esophagitis. Median survival of the entire group was 7.2 months, which is consistent with previous experience with the treatment of localized inoperable non-oat cell carcinoma of the lung by radiation therapy. Further study of this method of treatment is warranted.

The Lehigh Valley Stroke Program: establishing a communitywide, hospital-based stroke register.

A communitywide, hospital-based stroke register has been established in the Lehigh Valley of Pennsylvania and New Jersey. The Lehigh Valley has about 600,000 inhabitants and is geographically somewhat isolated. Ninety-five percent of the people are white, and the population has an age-sex distribution like that of the United States as a whole. All patients falling into any of nine diagnostic categories of stroke or transient ischemic attack are registered on admission to a hospital, and medical, social, and demographic data are abstracted onto precoded data forms. A single neurologist assigns definitive diagnoses according to standardized criteria after reviewing all of the medical data. The stroke register provides a new and powerful tool for collecting population-based data on a large number of cases in a short-time. After adjusting for demographic differences, epidemiologic studies can be carried out that may be generalizable to the entire United States. Several organizational aspects of the register and its operation are described in this report, and examples of the types of information and statistics readily calculable from the data in the register are given. The completeness of the stroke ascertainment and the large population registered also offer an excellent opportunity for any interested researcher to investigate the relationships between medical, social, and demographic conditions on the one hand and stroke risk on the other; to study the efficacy of prevention and treatment programs; and to determine health care provision requirements in a well-defined population.

Linguistic predictors of adaptive bereavement.

The words people use in disclosing a trauma were hypothesized to predict improvements in mental and physical health in 2 studies. The first study reanalyzed data from 6 previous experiments in which language variables served as predictors of health. Results from 177 participants in previous writing studies showed that increased use of words associated with insightful and causal thinking was linked to improved physical but not mental health. Higher use of positive relative to negative emotion words was also associated with better health. An empirical measure that was derived from these data correlated with subsequent distress ratings. The second study tested these models on interview transcripts of 30 men who had lost their partners to AIDS. Cognitive change and empirical models predicted postbereavement distress at 1 year. Implications of using computer-based text analyses in the study of narratives are discussed.

Radiation therapy and hyperthermia in the treatment of superficial lesions: preliminary analysis: treatment efficacy, and reaction of skin, tissues subcutaneous.

Superficial and measurable tumors were treated with hyperthermia and radiation therapy according to RTOG protocol 78-06. This study focuses on a subset of patients who were heated with microwaves. Eighty patients representing 88 lesions were treated between 1978 and 1981 with a schedule which allowed 48-96 hours to elapse between treatment sessions. The mean value of the average temperatures for individual lesions was 42.3 degrees C. The mean total radiation dose was 33.95 Gy. Skin reaction was examined in terms of the maximum score reported, using a modified Fowler scale. Erythema, the most common finding, was reported as the maximum skin reaction in 24% of the cases. Ulcerations and blisters occurred with frequencies of 18% and 7%, respectively. No reaction or desquamation was reported in 19% and 17% of the cases. Complete regression was noted in 48% of the treated lesions, partial regression in 17%, and no change in 24%. Twenty-five percent of the patients enjoyed sustained response for greater than 180 days. Refinement of hyperthermia treatment equipment and technique may result in less normal tissue reaction and improved clinical responses. In view of the encouraging initial results, we recommend aggressive pursuit of hyperthermia as a new treatment modality.

Putting stress into words: the impact of writing on physiological, absentee, and self-reported emotional well-being measures.

BACKGROUND AND PURPOSE: Inhibiting or holding back one's thoughts, feelings, or behaviors is associated with long-term stress and disease. Actively confronting upsetting experiences can reduce the negative effects of inhibition. The present study describes a unique approach to aid individuals in dealing with psychological and emotional issues that they must often face. METHODS: Forty-one of the 81 university employees who were participating in a wellness program agreed to participate in the present study. Subjects were randomly assigned to write about either personal traumatic experiences (n = 23) or non-traumatic topics (n = 18) for 20 minutes once a week for four consecutive weeks. RESULTS: Results indicate that individuals who wrote about upsetting personal experiences evidenced significant drops in selected blood measures compared to those who wrote about non-traumatic topics (e.g., for SGOT: 4.0% drop among traumatic topic group versus 13.1% increase among non-traumatic topic group, ANOVA p = .029; for SGPT: 24.5% drop versus 7.7% increase, p = .001). During the month of writing, traumatic topic group subjects evidenced a 28.6% reduction in absentee rates from work relative to the eight months before the experiment compared with a 48.5% increase in absentee rates among non-traumatic topic subjects (p = .04). Subjects low in emotional inhibition evidenced the greatest reductions in absentee rates following personal disclosure compared to those high in emotional inhibition (p = .011). DISCUSSION: The proposed writing strategy offers a unique tool for health promotion practitioners.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of protective clothing in infection prevention in patients undergoing autologous bone marrow transplantation.

PURPOSE/OBJECTIVES: To determine the efficacy of cover gowns and shoe covers in the prevention of infection in patients undergoing autologous bone marrow transplantation (BMT). DESIGN: Randomized two-group controlled clinical trial. SETTING: Adult BMT unit of a university teaching hospital in the Southeastern United States. SAMPLE: 40 women and men receiving an autologous BMT for hematologic and solid tumor malignancies. Patients were assigned randomly to control or experimental groups. Thirty-one patients completed the study. Inclusion criteria required that patients be at least 18 years of age and not have received a previous autologous BMT. METHODS: Data were collected from the patients' medical records. Characteristics of the distributions for the main research variables were compared between the control group (caregivers who wore cover gowns and shoe covers) and experimental group (caregivers who wore no covers). MAIN RESEARCH VARIABLES: Time to first antibiotic treatment and length of antibiotic therapy. FINDINGS: Cover gowns and shoe covers worn by caregivers provided no benefit for this group of 31 patients. The differences in time to first antibiotic and length of antibiotic treatment were not statistically significant between the two groups. CONCLUSIONS: The mean and median number of hours to first antibiotic treatment for adult autologous BMT recipients in the control group exceeded the corresponding time for those in the experimental group by only one hour and four hours, respectively. The potential benefits and risks of cover gown and shoe cover usage by caregivers of autologous BMT recipients should be reexamined in larger randomized trials. IMPLICATIONS FOR NURSING PRACTICE: The elimination of cover gowns and shoe covers in caring for patients undergoing autologous BMT will save nursing time and hospital resources as well as eliminate one isolation barrier experienced by patients.

Amoxycillin: clinical trials in dogs and cats.

Amoxycillin, a new broad spectrum semi-synthetic penicillin was subjected to preliminary clinical testing in 351 cases in dogs and 264 in cats in veterinary practices. Two formulations were used: capsules by mouth and an aqueous suspension by injection. Those taking part were asked to use amoxycillin in the treatment of all conditions that they considered required an antibiotic and to report their results in terms of success or failure according to criteria laid down. Samples were taken whenever practicable for bacteriology. Dose ranges were 4 to 11 mg per kg for the oral capsules twice daily in dogs and most cats and 11 mg per kg once daily in some cat cases over five days and 2 to 7 mg per kg for the injectable suspension once daily in both species for three to five days. Results for the full range of conditions are given in tabulated form. Overall percentage of success according to the criteria laid down was 80.1%.

A chiropractic perspective on atlantoaxial instability in Down's syndrome.

The purpose of this paper is to review the current information on atlantoaxial instability in Down's syndrome. There are potentially fatal consequences to performing adjustive manipulation to the cervical spine of the Down's patient. Atlantoaxial subluxation can cause death. Up to 50% of those suffering from atlantoaxial instability have it due to anomalous axis formation and/or agenesis or laxity of the transverse ligament. Trauma or progressive anterior displacement of atlas may cause serious neurological complications. The standard treatment for atlantoaxial instability is surgical fusion of the upper cervical spine. Conservative chiropractic care is suggested as a possible alternative in some cases. Standards for adjusting patients suffering from Down's syndrome have not been established. However, guidelines reviewed in this paper may indicate when adjusting may be hazardous. Potential protocol for the evaluation and diagnosis of atlantoaxial instability are suggested.

Cost-effectiveness analysis of recruitment strategies in a community-based intervention study of HIV-infected persons.

This paper describes and evaluates recruitment methods used to reach adults with HIV infection and to enroll eligible candidates in a randomized trial of aerobic exercise. Potential participants residing in the metropolitan Washington DC area were recruited from January 1994 to December 1996. The yield and associated cost of clinic centre site-visit (CSV) recruitment are compared to similar outcomes for community-based (CB) recruitment strategies, which consisted of presentations to local groups, mail/phone canvasses of caregivers, neighbourhood network promotion, public site postings and print media notices. Of 833 HIV infected adults ascertained during the recruitment phase as prospective study candidates, 66.7% were initially contacted during CSV recruitment. The remainder, 33.3% were CB recruits. The percentage of screened candidates who were subsequently enrolled in the study was 13.5% for CSV recruitment and 21% for CB recruitment. Ascertainment and screening costs combined were $158 per CB recruit compared to $232 per CSV recruit. Using multiple recruitment approaches we successfully achieved our enrollment goal of at least 100 volunteers from diverse populations by the end of the planned recruitment period.

Compliance with an experimental drug regimen for treatment of asthma: its magnitude, importance, and correlates.

This paper reports on data from a double-blind, randomized controlled study of out-patient use of corticosteroids following an acute asthma attack. Issues related to compliance are examined, including: (1) the extent of non-compliance; (2) impact of non-compliance on interpreting the drug trial results; and (3) correlates of non-compliance. Of the 102 cases enrolled in the study, 25.5% were excluded from analysis because they were lost to follow-up (10.8%) or non-compliers (14.7%). Based on data for compliers, the drugs were found to reduce relapse rates and asthma symptomatology; when non-compliers were included in the analysis, the steroid drug appeared ineffective for reducing relapses and less effective for improving overall illness status. Examination of 24 potential correlates of compliance yielded a few significant associations, and only the "usual habit of compliance" correlation suggests an avenue for future action. The implications of the study findings for design and interpretation of clinical trials, as well as for improved management of chronic diseases, are discussed.

Stroke in the Lehigh Valley: incidence based on a community-wide hospital register.

Since July 1982 a population-based study of stroke has been carried out in the Lehigh Valley, a region in Pennsylvania and New Jersey, USA, with 580,000 people. During the first year, the annual incidence rates of stroke and transient ischemic attack were 167 and 49 per 100,000 population, respectively. Cerebral thrombosis, embolus, cerebral hemorrhage and subarachnoid hemorrhage accounted for 76, 13, 8 and 3% of the strokes, respectively. The overall incidence rate and distribution of stroke by type agree well with other population-based studies. The large size of the population in the Lehigh Valley means that information on the epidemiology of stroke, as well as the effects of various therapies on stroke frequency and outcome, can be collected in a shorter period of time than in most other communities studied to date. Finally, an assessment of concordance in diagnosis between attending physicians and a neurologist using standardized criteria was possible for the entire community.