Triage considerations in medical intensive care.

As an initial step toward improving admission criteria to the medical intensive care unit (MICU), we examined Acute Physiologic and Chronic Health Evaluation scores and the diagnosis-adjusted mortality rates of 2419 medical patients, including those who received MICU consultation over a 6-month period. There was considerable overlap in the physiologic scores and the predicted mortality rates between those patients who were admitted to the MICU and those who were not. There was no discrete score or mortality rate at which triage to the MICU would have included most MICU patients but excluded most patients who survived without admission to the MICU. While uniform MICU admission criteria would be desirable, current scoring systems may not have the desired sensitivity or specificity to establish such criteria. Using a receiver operating characteristic curve, we demonstrated that diagnosis-adjusted mortality rates could predict as well as Acute Physiologic and Chronic Health Evaluation scores which patients would receive MICU admission and intervention. This suggests that, for different diagnoses, specific clinical variables and laboratory tests may have different predictive importance for MICU admission. Prospective models of clinical variables using receiver operating characteristic curves in various medical diseases may improve triage procedures.

Decreases in mortality on a large urban medical service by facilitating access to critical care. An alternative to rationing.

The admission and case fatality rate (CFR) on a large urban medical service for 12 months before and after the creation of an intermediate care unit were examined. In the year after the intermediate care unit was opened, total admissions to the ICU/CCU decreased by 7.1% as a result of a 14.6% decrease in admission of low-risk patients who did not require critical care services. The CFR of patients on the medical service decreased by 13.3% in the year after implementation of the intermediate care unit. The decrease in mortality was accounted for by a 25.0% decrease in general ward deaths and a 38.8% decrease in ward cardiac arrests. There was no significant difference in the ICU/CCU CFR. The admission of low-risk patients to an intermediate care unit provided greater access to intensive care and was associated with an overall lower medical service CFR.

A randomized comparison of nifedipine and sodium nitroprusside in severe hypertension.

We randomized patients with severe hypertension in the Medical Intensive Care Unit to a treatment regimen of oral nifedipine or intravenous nitroprusside. Patients treated with nifedipine achieved a sustained reduction in diastolic blood pressure to less than or equal to 120 mm Hg in an average of less than five hours. Patients treated with nitroprusside achieved a similar reduction in 14 hours (p less than 0.05). Treatment with nifedipine was less expensive and required less time in the ICU than treatment with nitroprusside and was accompanied by no associated increase in morbidity or mortality. Oral nifedipine can be used as an alternative to intravenous nitroprusside in severe uncomplicated hypertension.

Inhibition of platelet function by uremic middle molecules.

To further define the platelet abnormality responsible for uremic bleeding, we studied platelet aggregation with adenosine diphosphate, ristocetin, and collagen in serum fractions obtained by Sephadex G-15 chromatography. We found that uremic patients had considerable inhibition in several peaks of middle molecular range, but the findings were inconsistent and not clearly related to the degree of uremia.

Causes of death in an urban public hospital.

For the study reported here, we examined the charts and autopsy reports of every death in the Department of Medicine at Cook County Hospital for the year 1983. In that period, there were 11,677 admissions to the Department and 476 deaths, yielding a mortality of 4.1 percent. There were 50 percent more deaths in the intensive care unit than on the general wards. Malignancies accounted for greater than one-third of all deaths. Lung cancer, which occurred in one of every six deaths in the department, was the single most-common diagnosis. The other leading causes of death were cirrhosis, gastrointestinal malignancies and cerebrovascular accidents. Cardiovascular mortality was somewhat less than expected. These figures reflect some of the serious diseases of the urban indigent population, which are, in turn, associated with cigarette smoking, alcoholism and hypertension. Decreases in morbidity and mortality are likely to be influenced by preventive medical measures and early detection campaigns. Department of medicine curricula and outpatient clinic programs should devote attention and resources to these areas.

Separation, isolation and amino acid composition of uremic peptides.

Gel filtration and thin layer chromatography were conducted on sera from uremic patients and normal subjects for the isolation of nitrogenous substances unique to uremia. Many ninhydrin-positive substances were found in greater amounts in uremic patients compared to normal subjects. Some of these ninhydrin-positive substances were also detected by staining with chlorine-tolidine. Amino acid analysis of these substances showed considerable qualitative and quantitative differences, perhaps reflecting interference with enzymatic activity by the uremic environment.

Fibrinous pericarditis in hepatorenal failure.

During a period of two years pericarditis was observed in five patients with decompensated cirrhosis who had only slightly raised blood-urea-nitrogen and serum-creatinine. Although this association has not been previously described, some patients with hepatic failure seem to have pericarditis in the absence of severe uraemia.

Chromatographic studies of uremic plasma.

In order to characterize the spectrum of possibly toxic retention compounds in uremia we have developed a simple reproducible method of separating fractions of uremic serum by Sephadex G-15 column chromatography. This technique, which requires no prior deproteinisation and is carried out at ambient temperatures, allowed the separation of uremic serum into several well defined fractions. Subsequent thin layer chromatography (TLC) showed that each peak represented a mixture of peptides, and that there were qualitative and quantitative differences between the plasma of normal and uremic patients as well as between patients with acute renal failure and chronic renal failure.

Role of aluminum in dialysis dementia.

Between September 1972 and January 1976 an outbreak of dialysis dementia affected 20 patients maintained by long-term hemodialysis. The clinical picture was characterized by an insidious onset of altered behaviour, dementia, speech disturbance, myoclonus, and convulsions. Nineteen patients died, but one patient has survived for 16 months. It was later established that in June 1972 the city had altered its method of water purification and that this resulted in higher water aluminum levels. The temporal relation between periods of high water-aluminum content and the appearance of new cases supports the view that aluminum may play a role in the causation of dialysis dementia.

Dialysis dementia -- the Chicago experience.

In the four years between 1972 and 1976 twenty out of 160 maintenance dialysis patients developed dialysis dementia. Their illness was characterized by an insidious onset of mental deterioration, speech disturbance, apraxia, and myoclonus. The disease progressed inexorably to a fatal outcome, the onset of seizures being an ominous sign, and the average duration of the illness being seven months. Routine biochemical studies were unremarkable, and osteodystrophy was not a prominent feature. Serial electroencephalograms (EEG) showed progressive slowing of the rhythm, usually antedating the neurologic symptoms. Brain scan and flow studies were normal. Radio-iodinated serum albumin (RISA) scans in seven patients showed changes suggesting altered cerebrospinal fluid (CSF) dynamics. Treatment was generally ineffective, but ventriculo-peritoneal shunting produced transient neurologic improvement in one patient. Epidemiologic investigations showed high aluminum levels in city water during the period of the outbreak.

Charcoal hemoperfusion for chronic renal failure.

16 patients with end-stage renal disease were treated with a fixed-bed, uncoated-charcoal hemoperfusion device, used either alone or in series with a hemodialyzer. 3 patients had one of their thrice weekly dialyses replaced by one 3 hour combined treatment for up to 6 months, and 3 patients had 150-min combined treatments thrice weekly for up to 5 months. The procedure was well tolerated. Transient hypotension occurred and interfered with fluid removal by ultrafiltration. Platelet counts were reduced, but there was no clinical bleeding. Pretreatment of the device with albumin provided no advantage over heparinized saline, and dextran caused a more severe reduction in the platelet count. The changes in platelets, white blood cells, and hematocrit were transient and noncumulative. Considerable amounts of creatinine and uric acid were removed. Regular charcoal hemoperfusion appears to be safe, and long-term studies of clinical efficacy are indicated.

Treatment of severe and moderate hypertension with minoxidil: experience in twenty-eight patients.

1. Twenty patients with severe or moderate hypertension were treated with minoxidil for 284 patient-months. 2. The blood pressure was controlled in all patients, including those refractory to maximal doses of conventional anti-hypertensive agents. 3. In patients with moderate hypertension control with minoxidil was achieved earlier and more easily than with hydrallazine. 4. Three patients developed secondary resistance and required addition of guanethidine or increased doses of diuretics. 5. Fluid retention and hypertrichosis were the main side effects with minoxidil.

High-dose bolus urography. A superior technique in advanced renal failure.

High-dose bolus urography was evaluated in 38 patients with severe renal failure. Iothalamate meglumine (Conray 60) (2 ml/kg of body weight) was injected within one minute and nephrotomograms were taken for 30 minutes, with delayed films until 24 hours. Immediate nephrograms were obtained in all cases. The collecting systems, seen in 29 cases, were dilated in three. In the rest, obstruction could be ruled out by a combination of roentgenographic criteria. No untoward reactions occurred, and all the required information was obtained within 30 minutes. The results were superior to plain nephrotomography or infusion pyelography. We conclude that bolus nephrotomography is the procedure of choice in the investigation of severe renal failure.