Outcomes of skilled cardiopulmonary resuscitation in a long-term-care facility: futile therapy?

OBJECTIVE: To assess whether cardiopulmonary resuscitation performed by in-house physicians is effective for long-term-care residents. DESIGN: Retrospective chart review. SETTING: Long-term-care facility with an intermediate care unit, skilled care unit, and a convalescent and assessment unit at a retirement community for veterans. PARTICIPANTS: All residents resuscitated from April 1987 to August 1990. All participants were male. The mean age was 75 years +/- 7.3 (range 42-93 years). MAIN OUTCOME MEASUREMENTS: Charts were abstracted for demographics, advanced directives information, information about the arrest, and post-resuscitation course. RESULTS: Forty-five elderly residents underwent resuscitation during this period. Nine residents (20%) were successfully resuscitated, with seven dying within 24 hours of hospitalization. No residents survived to return to long-term care (95% CI, 0-7%). The diagnoses were consistent with age-related chronic disease. Seventeen (38%) arrests were witnessed. The predominant rhythm at onset of resuscitation was asystole. CONCLUSION: We conclude that cardiopulmonary resuscitation, even when performed by a trained and experienced physician and team, has limited benefit for elderly long-term-care populations.

A clinico-epidemiological study of epidemic typhus in Africa.

Epidemic, louse-borne typhus persists in the rugged, mountainous areas of Ethiopia and much of northeastern and central Africa as well as in the rural highlands of Central and South America, where the conditions of living favor the harboring of body lice and where antibiotic treatment and effective louse-control measures are unavailable. The historical significance and current epidemiology of typhus, including the reservoir of Rickettsia prowazekii in flying squirrels in the United States, are reviewed, and the clinical presentation, laboratory findings, and hospital course in the cases of 60 patients admitted with epidemic, louse-borne typhus to the St. Paul's Hospital in Addis Ababa, Ethiopia, are described. Treatment of this disease with oral doxycycline, tetracycline, or chloramphenicol prevents complications and results in prompt resolution of symptoms.

Dopamine- and norepinephrine-secreting intrapericardial pheochromocytoma in a normotensive patient.

We have described a 41-year-old woman without hypertension in whom laboratory testing showed elevated urinary and plasma norepinephrine levels as well as increased plasma dopamine and enkephalin-like immunoreactivity. A pheochromocytoma was removed from the interatrial wall, but the course was complicated by intractable bleeding and the patient died. The atypical normotensive pheochromocytoma should be suspected in patients with insidious adrenergic symptoms when more routine diagnoses cannot be made.

Alterations of plasma opioid activity in human diabetics.

Plasma opioid levels were determined in 9 obese non-diabetic subjects, their 8 age matched controls, and in 29 diabetic patients; 10 maintained on diet alone, 6 on an oral hypoglycemic agent (chlorpropamide) and 13 treated with insulin. Five age matched controls for the diabetic groups were also studied for comparison. beta-endorphin and met-enkephalin levels were measured by radioimmunoassay. Enkephalin-like activity was measured by a receptor assay. Among the study groups, diabetic patients receiving insulin showed a 64% elevation of plasma beta-endorphins and diabetic patients on chlorpropamide showed a 121% increase in enkephalin-like activity. There were no statistically significant differences in the plasma met-enkephalin values in the treatment groups though levels were decreased (p less than 0.05) in diabetics vs non-diabetics. The pathophysiological importance of these alterations remains to be elucidated.

Metastatic insulinoma with long survival and glucagonoma syndrome.

In 1966, during cholecystectomy for cholecystolithiasis, a 56-year-old man was found to have islet-cell carcinoma metastatic to the liver; his fasting serum glucose level was normal. In 1971, he developed peptic ulcer disease and symptoms of fasting hypoglycemia; inappropriate secretion of insulin was shown. His primary pancreatic tumor was removed in 1973. During the next 9 years, his liver metastases continued to grow and his fasting serum glucose level was maintained at 35 to 116 mg/dL with diazoxide and hydrochlorothiazide therapy. In 1982, he developed clinical evidence of the glucagonoma syndrome, with glucagon levels between 4000 and 11 000 pg/mL. Since then, his fasting serum glucose level has been maintained at 58 to 119 mg/dL without medication. This patient has survived 17 years with a malignant insulinoma and without islet-cell chemotherapy. His course shows that malignant insulinomas may secrete other peptide hormones that can induce various clinical syndromes.

Insulin, glucagon, and somatostatin secretion by cultured rat islet cell tumor and its clones.

Cells derived from rat islet tumor and grown in culture (parent cells-RIN-m) and two clones obtained from them were used to study the effect of various secretagogues on insulin, glucagon, and somatostatin secretion. Parent cells secreted all three hormones in various quantities, while clone 5F secreted predominantly insulin and clone 14B secreted predominantly somatostatin. The secretory behavior of these cells were compared to each other and to that of normal islets. In general, as in the case of normal islets, insulin secretion was stimulated by calcium, potassium, tolbutamide, theophylline, and glucagon. It was inhibited by somatostatin. Glucagon secretion was stimulated by calcium, arginine, and theophylline. Somatostatin secretion was stimulated in clone 14B by arginine, tolbutamide, theophylline, and insulin. These cells differ from normal islets, in that they do not respond to glucose or arginine with increased insulin secretion. Also somatostatin failed to inhibit glucagon secretion. The similarity in insulin secretory responses of parent cells and clone 5F suggests that local or paracrine islet hormone secretion plays only a negligible role in the control of other hormone secretion in these cells.

Studies on the role of opiate peptides in two forms of genetic obesity: ob/ob mouse and fa/fa rat.

Recent reports have indicated that genetically obese hyperinsulinemic mice (ob/ob) and Zucker rats (fa/fa) compared with their lean controls have elevated levels of pituitary and plasma B-endorphins, opiates that can stimulate insulin secretion. In this study we have measured opiate levels by a radio-receptor assay in gastro-intestinal tissues and pancreas in ob/ob and fa/fa animals and their controls. Ob/ob mice showed significantly higher levels than control mice (+/+) in most gastro-intestinal tissues and pancreas. Levels in fa/fa rats did not differ from their controls. Radioimmunoassay of pancreas for B-endorphins, revealed higher levels in ob/ob vs +/+ mice, while there was no difference in the obese and lean rats. Fasting tended to decrease gastro-intestinal opioids in mice, while B-endorphin levels rose. It is concluded that opiates may play a significant role in the obesity of the ob/ob mouse and that this genetic obesity differs from that in Zucker rats.

Starvation increases gastrointestinal somatostatin in normal and obese Zucker rats: a possible regulatory mechanism.

Normal, male Sprague-Dawley (S-D) rats and female, lean and obese Zucker rats were studied in the fed state and after 48 hours of food deprivation. Somatostatin-like immunoreactivity (SLI) was measured from acetic acid extracts of oesophagus-cardia, stomach, small and large intestine, pancreas, hypothalamus, pituitary and cerebellum. Within the CNS, the highest levels of SLI were found in the hypothalamus, while in the gut, these levels were highest in the stomach and pancreas. All Zucker rats displayed higher hypothalamic levels of SLI than did S-D rats. Obese Zucker rats in the fed state differed from their lean littermates in that SLI levels were lower in oesophagus-cardia, stomach and hypothalamus, while being higher in pancreas and pituitary. The response to starvation in both obese and lean Zucker rats was qualitatively similar, and included significant increases in stomach and oesophagus-cardia SLI, but with a significant fall hypothalamic SLI. We have concluded that the increase in gastrointestinal SLI with starvation in Zucker as well as in S-D rats may represent a significant regulatory mechanism in nutrient homeostasis. We postulate that gastric SLI may decrease the availability of intestinal insulin secretagogues in the fasting state. This adaptive mechanism appears to be intact in the obese Zucker rat.

Pelvic inflammatory disease and puerperal sepsis in Ethiopia. II. Treatment.

Where bacteriologic support is lacking, a combination of penicillin and streptomycin (P/S) is used empirically to treat serious gynecologic infections in Ethiopia. We compared the efficacy of P/S to a combination of penicillin and chloramphenicol (P/C) in hospitalized women who had bacteriologically confirmed pelvic inflammatory disease or puerperal sepsis (PPS). Treatment of PPS with P/C was significantly more effective in limiting the duration of fever than was treatment with P/S. Twenty-eight of 40 PPS patients had endometritis with retained products of conception that required evacuation of the uterus. The duration of fever in patients with PID who were treated with the P/C regimen was no different than that in those treated with P/S. Twenty of the 24 PID patients required surgery for drainage of abscesses, in addition to antibiotics.

PIP: Where bacteriologic support is lacking, a combination of (P/S) penicillin and streptomycin is used empirically to treat serious gynecolgoic infections in Ethiopia. We compared the efficacy of P/S to a combination of (P/C) penicillin and chloramphenicol in hospitalized women who had bacteriologically confirmed (PID) pelvic inflammatory disease or (PPS) puerperal sepsis. Treatment of PPS with P/C was significantly more effective in limiting the duration of fever than was treatment with P/S. 20 of the 40 PPS patients had endometritis with retained products of conception which required evacuation of the uterus. The duration of fever in patients with PID who were treated with the P/C regimen was no different than that in those treated with P/S. 20 of the 24 PID patients required surgery for drainage of abscesses, in addition to antibiotics.

Pelvic inflammatory disease and puerperal sepsis in Ethiopia. I. Etiology.

Among 100 outpatient women with symptoms and signs of pelvic inflammatory disease and 200 asymptomatic, postpartum women, the prevalence rates of Neisseria gonorrhoeae were 19% and 9%, respectively. Of 46 women hospitalized for PID, 33% were culture-negative, 22% grew Enterobacteriaceae, 20% grew streptococci, 15% grew gonococci, and 15% grew anaerobes from blood, pus, or abscesses. One third of 67 women hospitalized for puerperal sepsis (PPS) were culture-negative; the bacteria isolated most frequently from the uterus, blood, urine, and pus were Enterobacteriaceae (36%), gonococci (28%), streptococci (25%), and anaerobes (4%). The low frequency of isolation of anaerobes in women with PID and PPS was due largely to limitations placed on the collection and processing of specimens for anaerobic bacteriology.

Activation of protein mediators of inflammation and evidence for endotoxemia in Borrelia recurrentis infection.

Fifteen patients with Borrelia recurrentis infection were studied to evaluate the role of certain plasma proteins and endotoxin in the pathophysiology of both the acute illness and the Jarisch-Herxheimer-like reaction. The causative spirochetes disappeared from the blood during the Jarisch-Herxheimer-like reaction, which occurred about 2 hours after antibiotic therapy. The mean titers of Hageman factor, plasma prekallikrein and serum hemolytic complement activity were decreased at the time of admission and 2 hours after treatment, and rose to normal values during convalescence. Serum properdin titers were decreased in 14 patients at the time of admission, in 12 patients 2 hours after treatment, and in none during convalescence. The frequency of elevated levels of fibrinogen-related antigens increased from three patients at the time of admission to 12 patients 2 hours after treatment. Results of plasma limulus tests for endotoxin-like material were positive in 11 patients at the time of admission and in 13 patients 2 hours after treatment. These findings demonstrated that Hageman factor, prekallikrein and proteins of the complement system are activated in B. recurrentis infection and that endotoxin may play a role in both the acute illness and in the development of the Jarisch-Herxheimer-like reaction after treatment.