Do elderly patients overutilize healthcare resources and benefit less from them than younger patients? A study of patients who underwent craniotomy for treatment of neoplasm.

OBJECTIVE: Some physicians and academicians have suggested that limiting selected healthcare resources to the elderly will help curtail the rising cost of health care in the United States. In order to test this hypothesis in a specific medical context, we compared the cost of caring for younger (< 65 yrs) patients with that of caring for older (> or = 65 yrs) patients who underwent craniotomy for treatment of brain tumors. DESIGN: Prospective collection and review of data on patients undergoing craniotomy for tumor in our institution between February 1989 and December 1991. SETTING: University teaching hospital. METHODS: Patients were divided into two groups: those < 65 yrs, and those > or = 65 yrs. Demographics, severity of illness, length of stay, hospital and surgical intensive care unit (ICU) costs and charges, ICU complications, procedures, and outcome variables were analyzed. RESULTS: Of 3,265 ICU patients admitted during the study period, data on 123 (3.8%) undergoing craniotomy for brain tumor were analyzed. There were no differences between the patient groups in length of ICU stay or hospital stay, final outcome at discharge from the hospital, quality of life, or hospital or ICU costs, despite the fact that elderly patients had a greater number of procedures and complications per patient, and higher Acute Physiology and Chronic Health Evaluation II (APACHE II) severity of illness scores on admission and discharge than younger patients. CONCLUSIONS: The assertion that the elderly may, under certain conditions, consume more healthcare resources and benefit less from them than younger patients must be tested for accuracy with regard to specific disease states. In the context of the disorder studied herein, the elderly do as well as the young. Without specific study of specific pathologic processes or surgical procedures, using age to limit access to resources remains an unsubstantiated, ideologic concept, rather than a scientifically proven cost-saving measure.

Comparison of propofol and midazolam for sedation in intensive care unit patients.

OBJECTIVES: To evaluate the comparative safety and effectiveness of intravenous infusion of propofol or midazolam when used for 12 to 24 hrs of sedation and to evaluate the quality of sedation during stimulation. DESIGN: An open, comparative, prospective, randomized study. SETTING: Surgical intensive care unit (ICU) in a university hospital. PATIENTS: Postoperative, intubated, general surgical, and orthopedic patients requiring mechanical ventilation (n = 60). INTERVENTIONS: None. MEASUREMENTS: Assessments were made at baseline (0 time), 5, 10, 15, 30, 45, and 60 mins; at 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 hrs; and at the end of sedation. The assessments included systolic, mean, and diastolic blood pressures, heart rate, two-lead electrocardiogram, pulse oximetry oxygen saturation, FIO2, end-tidal CO2, respiratory rate, ventilator rate, tidal volume, and sedation scale. Vital signs and the sedation scale were obtained at 30, 60, and 90 mins and at 2, 4, 12, and 24 hrs after the end of sedation. At approximately 8 hrs and 24 hrs (or at the end of sedation), the patient's CO2 production was calculated over a 5-min interval. Every 4 hrs, the nurse would summarize and rate patient response during stimulation as well as the overall rating of the sedation and patient ability to tolerate the ICU setting. MAIN RESULTS: There were no significant differences in pulse oximetry, arterial blood gas values, or respiratory measurements during sedation with propofol or midazolam. The mean heart rate was slower in the propofol group throughout the sedation and postsedation periods. The rating of sedation and tolerance of the ICU environment were significantly better for the propofol-treated group. Postsedation, the propofol group woke up faster on discontinuation of the sedative. CONCLUSIONS: Propofol was as safe and as efficacious as midazolam for continuous intravenous sedation. The quality of sedation was better in the propofol group.

Simultaneous administration of rhesus rotavirus vaccine and oral poliovirus vaccine: immunogenicity and reactogenicity.

Rotavirus vaccine could be administered most efficiently if it were incorporated into routine childhood immunizations and did not interfere with the immune response to the other vaccines, principally oral poliovirus vaccine (OPV). We conducted a placebo-controlled randomized trial giving oral rhesus rotavirus vaccine (RRV) (strain MMU 18006) alone and together with a child's first dose of OPV and diphtheria-tetanus toxoids-pertussis to examine the possible interaction of these vaccines. A total of 102 infants 2 to 3 months of age were randomized into 3 groups to receive (1) RRV with OPV, (2) placebo with OPV and (3) RRV 2 weeks after OPV. All infants were given diphtheria-tetanus toxoids-pertussis. Serum samples were collected at the time of OPV immunization and 3 to 5 weeks later. Three to 5 weeks after OPV immunization 60% of infants had a 4-fold rise in neutralization titer to at least one of the three poliovirus serotypes. The rate of antibody response to poliovirus did not differ by RRV groups but a lower rate was correlated with a shorter interval (3 vs. 5 weeks) between OPV vaccination and antibody measurement. Fifty-six percent of infants had a 4-fold rise of IgA and 62% had a 4-fold rise of neutralizing antibody to RRV; this rise did not differ according to time of OPV immunization. RRV was not associated with side effects and may be safely given with OPV to infants 2 to 3 months of age.

Reemergence of an epidemic coxsackievirus B5 genotype.

Outbreaks of coxsackievirus B5 (CB5) infections occur primarily during peak epidemic years, with comparatively few cases occurring during intervening years. This pattern of periodic CB5 epidemicity is quite distinct from the general endemicity typical of other group B coxsackieviruses. To determine the genetic relationships among CB5 isolates from different outbreaks, we compared viral RNAs by ribonuclease T1 oligonucleotide fingerprinting. Isolates obtained within an epidemic year had very similar fingerprints, an observation indicating that they were closely related variants of a single genotype. CB5 isolates from the major 1972 epidemic were not closely related to the genotype associated with the preceding epidemic of 1967. However, isolates from the most recent CB5 epidemic year, 1983, had fingerprints nearly identical to those of the 1967 strains. These findings provide clear evidence for epidemic reemergence of the 1967 genotype and suggest that the virus was maintained under conditions approaching evolutionary stasis during the intervening 16-year period.

Symptomatic coronary disease for 20 or more years: clinical aspects, angiographic findings, and therapeutic implications.

Clinical, angiographic, and therapeutic aspect of coronary artery disease of long duration (exceeding 20 years) is reviewed in 50 patients (study group) and compared to a control group of 100 consecutive patients with coronary artery disease of shorter duration. All were referred because of symptomatic coronary artery disease. The study group had a greater incidence of clinically evident extracardiac vascular disease (28% vs 4%) (p less than 0.01). Transmural infarction was more frequent in the study group (64% vs 45%). Triple-vessel and main left disease was observed respectively in 90% and 28% compared to 36% and 7% in the control group (p less than 0.01). Twenty-nine percent of collaterals were jeopardized in the study group compared to 13% of collaterals in controls (p less than 0.01). Abnormal left ventricular ejection fraction (p less than 0.05) was found in 50% of the study group compared to 28% of controls (p less than 0.01). Medical therapy was recommended for 36% of the study group with 11 of 18 (61%) considered inoperable, whereas in 39% of the control group medical therapy was continued, with 9 of 39 (23%) considered inoperable (p less than 0.01) Surgery or coronary angioplasty was recommended in 64% of the study and in 61% of the control group. No patient in the study group was considered a candidate for coronary angioplasty, whereas in 20% (12 of 61) of the control group coronary angioplasty was recommended. Patients with coronary artery disease for over 20 years have severe coronary artery disease, with one in four having main left disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Phylogenetic studies on lymphokines. Fish lymphocytes respond to human IL-1 and epithelial cells produce an IL-1 like factor.

The results obtained indicate, that catfish peripheral blood lymphocytes recognize and respond to human IL-1. The second part of this report is dealing with a substance produced by carp epidermal cells with functional similarities to mammalian IL-1.

Fish lymphocytes respond to human IL-1.

IL-1 is known to cross species barriers in that IL-1 of one mammalian species can interact with cells of other mammalian species. The work described herein demonstrates that IL-1 can cross phylogenetic classes as IL-1 derived from human peripheral blood lymphocytes (PBL) potentiated the proliferative response of catfish lymphocytes to the T cell mitogen Concanavalin A (ConA). Catfish PBL were separated by density gradient centrifugation and used in blastogenic transformation assays. IL-1 had relatively little direct stimulatory effect but with suboptimal amounts of ConA there was a significant augmentation of the proliferative response. The specificity of the response was determined by neutralization experiments in which anti-human IL-1 antibody significantly diminished the reaction of catfish lymphocytes to IL-1.