CEREBRAL ATROPHY — Clinical Manifestations in Adults

A study was made of the cases of 200 patients with demonstrated cerebral atrophy. In patients under 70 years of age cerebral atrophy was twice as common in men as women. Over 70 years the ratio was reversed. The incidence of cerebral atrophy was relatively high in the age group 35 to 50.Convulsions were present in more than a third of the 200 patients. Neurological abnormalities were present in 51 per cent of the entire series. Significant personality deviations were observed in 31 per cent. Although the electroencephalogram was abnormal in many patients, it appeared to be of little aid in the diagnosis of the cerebral atrophy. The spinal fluid did not seem to be consistently altered in any significant or diagnostic manner.Most of the patients in the 35 to 50 year age group did not have the symptoms characteristic of Alzheimer''s disease, and in only a few cases did the symptoms resemble those of other recognized disease entities.     

BIOCHEMICAL EFFECTS OF THYROID DEFICIENCY ON THE DEVELOPING BRAIN

Abstract— The effects of neonatal thyroidectomy on some constituents of the cerebrum, cerebellum and liver of the rat have been studied during the first 7 weeks of life. In the normal rat between the 6th and 14th post-natal days the RNA content per unit of DNA in the brain increased by 70 per cent. Although the brain continued to grow from the 14th to the 35th day, the amount of RNA relative to DNA decreased by about 20 per cent. The ratio of protein to DNA increased during the whole period studied and in the cerebral cortex it was more than trebled between the age of 6 and 35 days. The growth of the cerebellum extended over a longer period than that of the cerebrum, its weight increasing by 88 per cent between the ages of 14 and 35 days as compared with a cerebral increase of 34 per cent. The DNA content showed a 50 per cent increase during this period. Qualitatively these maturational changes were not affected by neonatal thyroidectomy. Quantitative changes, which applied equally to the cerebral cortex and brain as a whole, were observed. At the age of 35 days, the weights of the cerebral hemispheres and cerebellum were reduced by thyroidectomy by 20 per cent; the overall DNA content per organ did not change, but the amounts of protein and RNA relative to DNA decreased significantly. It is therefore inferred that thyroid deficiency affects the size of the cells in brain and cerebellum rather than their total number. Conversely, the cell population of the liver was only a quarter of that in the control. There was a small but significant decrease in the hepatic protein and RNA content in the hypothyroid animal. The activities of the following enzymes which served as markers for subcellular fractions in homogenates of cerebral cortex were determined: lactate dehydrogenase for the supernatant, glutamate dehydrogenase for the mitochondrial and glutamate decarboxylase for the synaptosomal fractions. When the activities were expressed on a fresh weight basis a significant decrease by comparison with the control values was observed only in the case of glutamate decarboxylase (—15 per cent at the age of 17–32 days); when the activities were based on DNA content all values were reduced, probably as a result of the general decrease in cell size. Pyrimidine metabolism of brain and liver, studied after the administration of [6-¹⁴C]-orotic acid, was not affected in either tissue by neonatal thyroidectomy. A small but significant reduction in the incorporation of labelled pyrimidine nucleotides in liver RNA was observed, but no significant decrease in the incorporation in cerebral RNA was found in the hypothyroid rats.     

Cardiac screening procedures

Seven per cent of a sample group of civil service employees were found to have diagnosable heart disease. The diagnosis was made on the basis of a complete physical examination and history taken by a specialist in internal medicine and/or heart disease. In addition a questionnaire form related to symptoms of heart disease was filled out by the patient, and various laboratory tests were made. As a technique in cardiac case-finding, the electrocardiogram was the best single device. Of all the cases of heart disease in this survey 65 per cent were detected from tracings obtained by using all 12 leads, and 57 per cent if only the three standard limb leads were taken; but of the presumably normal persons, 13 per cent would be erroneously suspected of possible heart disease by this technique. Heart disease was detected in 50 per cent of the diagnosed cases on the basis of answers to three of the questions in the questionnaire. Eighteen per cent of normal persons would also have been suspected of having heart disease by this case-finding device. Although the survey reported did not develop a simple cardiac case-finding technique, the data presented indicated that a questionnaire history-form, if judiciously used and evaluated, may be of value to physicians who examine large numbers of patients who are unwilling to submit to a complete cardiac evaluation.     

GERIATRIC PATIENTS IN A MENTAL HOSPITAL

An intensive study was made of men 55 years of age and over admitted to Napa State Hospital with either senile or arteriosclerotic brain disease. A ward treatment program, combining both the medical and psychiatric approaches, was applied to one-half of such patients admitted to a state hospital, with the aim of determining what, if any, effect this program would have on the course of the illnesses.Special laboratory studies showed: (a) Serial electroencephalograms and hospital adjustment ratings appeared to be positively correlated with the patients'' clinical course; (b) In 35 per cent of cases the electrocardiographic tracings at the time of admittance were within normal limits; (c) A “pathological level” of blood bromides was found in only one of 340 consecutive admissions in this age group.Sociopsychiatric study of 100 consecutively admitted patients revealed that: (a) 35 per cent of the patients were from the middle, and 65 per cent from the lower classes of society; (b) Only 59 per cent were admitted because of activities specifically psychotic. (c) 63 per cent needed admittance to this state hospital for observation and diagnosis, but only 44 per cent needed to stay for care and treatment; (d) In 88 per cent, specific emotional stresses were present just preceding and coincident with the clinical appearance of the organic brain syndrome.     

Mortality rates in patients with burns; a report of experience at San Francisco City and County Hospital, 1943-1956

A review was made of the cases of 93 patients with burns covering more than 20 per cent of the body surface who were treated at the San Francisco City and County Hospital, University of California Service, between 1943 and 1956. The mortality rate increased from 40 per cent during 1943-1947 to 69 per cent during 1952-1956. A significant change in survival time was noted: During 1943-1947, 69 per cent of the deaths occurred within 48 hours of admission; during 1952-1956, only 19 per cent of the deaths occurred within the first 48 hours. In the period 1943-1947 the majority of deaths resulted from shock in the immediate post-burn period; in the later years of the study the major cause of death was infection. No patient more than 50 years of age who had burns of more than 25 per cent of the body surface survived. Only one patient with burns involving more than 45 per cent survived. No patient who had a blood culture positive for bacteria survived. The use of antibiotics had no effect on the incidence of infection. Elderly patients, children and alcoholics were less able to resist the effects of infection. The lowest mortality rate was in the age group of 15 through 35 years.     

ACUTE GALLBLADDER DISEASE—Experiences with 103 Consecutive Cases

One hundred and three cases of acute cholecystitis in patients ranging in age from 19 to 88 years were reviewed. Operation was done in all cases. Seventy per cent of the patients were women.Primary cholecystectomy was done in 72.8 per cent of the series. Primary cholecystostomy was performed in the remainder, and one-fourth of these patients had a secondary cholecystectomy. No specific time, with relation to interval after onset of symptoms, was chosen for operation.Jaundice was present in 14.5 per cent of patients at the time of admittance to hospital. Serum amylase was above normal in five of 27 patients on whom this determination was carried out. All five were women.The gallbladder was perforated in 13 cases. Common duct exploration was done in 25 cases and in 12 of them stones were found.The morbidity rate for the series was 11.6 per cent; the mortality rate 9.7 per cent.     

SEIZURE PROBLEMS IN 250 CEREBRAL PALSIED ADULTS

Seizures occurred at some time in 81 (or 32 per cent) of an unselected, consecutive series of 250 cerebral palsied persons between the ages of 16 and 52 years, an incidence similar to that reported by other investigators in groups of cerebral palsied persons who were mainly children.The incidence of seizures of any kind after 16 years of age in the present series was 10 per cent as compared with 0.5 per cent in the general population. Half of the 10 per cent had more than six convulsions despite drug therapy, and the other half had fewer than six.Of thirty-six who had convulsions in the neonatal period, only four had seizure problems as adults, even though most showed moderate to severe physical handicap after age 16.Data on the small group of paraplegics in the present study, all spastics, were in accord with reports by other investigators with regard to decreased incidence of seizures in cerebral palsied patients with normal upper extremities. Of the thirteen (5 per cent of the 250) whose seizure problems continued to be clinically significant in adult life, ten had had frequent seizures in childhood. Eight were hemiplegic. There appeared to be no relationship between the severity of physical handicap and the incidence of seizures after age 16.     

MORTALITY RATES IN PATIENTS WITH BURNS—A Report of Experience at San Francisco City and County Hospital, 1943-1956

A review was made of the cases of 93 patients with burns covering more than 20 per cent of the body surface who were treated at the San Francisco City and County Hospital, University of California Service, between 1943 and 1956.The mortality rate increased from 40 per cent during 1943-1947 to 69 per cent during 1952-1956. A significant change in survival time was noted: During 1943-1947, 69 per cent of the deaths occurred within 48 hours of admission; during 1952-1956, only 19 per cent of the deaths occurred within the first 48 hours. In the period 1943-1947 the majority of deaths resulted from shock in the immediate post-burn period; in the later years of the study the major cause of death was infection.No patient more than 50 years of age who had burns of more than 25 per cent of the body surface survived. Only one patient with burns involving more than 45 per cent survived.No patient who had a blood culture positive for bacteria survived. The use of antibiotics had no effect on the incidence of infection. Elderly patients, children and alcoholics were less able to resist the effects of infection.The lowest mortality rate was in the age group of 15 through 35 years.     

PERFORATED PEPTIC ULCER—Selective Gastric Resection in Emergency Treatment

In a series of 240 cases of perforated peptic ulcer prior to 1952 there was a total mortality of 17 per cent. This included cases treated conservatively as a planned procedure or because of other morbid conditions and undiagnosed cases, all ending in death.In cases treated by simple suture, mortality was 2.6 per cent for patients under 50 years of age and 17 per cent for those over 50, the rate rising very steeply with each decade over 50.From 1953 through 1959 selective gastric resection was carried out, the operation being done in all cases of perforated gastric ulcers, of chronic duodenal ulcers and of perforations associated with hemorrhage.During this period 303 perforated ulcers were treated, with a mortality of 15.5 per cent. Patients with associated morbid conditions and those admitted moribund and died, or died undiagnosed were again included.In this series also the mortality increased steeply from age 50 onward.Gastric resection was carried out in 148 cases of perforated peptic ulcer with a mortality of 6 per cent. In 105 cases under 60 years of age there were no deaths but in those over 60 the mortality rate was 21.8 per cent. Results in the patients who had resection, as determined after three years of observation, compared favorably with the results in patients who were treated by suture.The mortality of perforated ulcers in females was higher than in males.Emergency gastric resection has a definite place in the treatment of perforated peptic ulcer.     

Motor Neuron Disease in the Rocky Mountain Region

We saw 166 patients with motor neuron disease over a ten-year period, 116 with amyotrophic lateral sclerosis–111 sporadic and 5 familial–and 50 with progressive muscular atrophy. The age at onset varied widely, with the youngest mean onset occurring in the familial group. The most common presenting symptoms were leg or arm weakness and difficulty speaking or swallowing; fewer patients reported cramping, fasciculation, or fatigue. Mean survival time was less in familial cases, women, older patients, and in those with difficulty speaking and swallowing. A total of 50% of all patients were alive after four years; 13% were alive after ten years. Previous reports on the natural history of motor neuron disease may be overly pessimistic in suggesting that survival time rarely exceeds two years.     

The natural history of childhood asthma to adult life.

A randomly selected group of 331 children who had started to wheeze in childhood and a control group of 77 children were prospectively studied clinically and physiologically from 7 to 21 years of age. Most subjects improved during adolescence and about 55% of those whose wheezing had started before 7 years and stopped before adolescence remained wheeze free. Forty-five per cent of subjects who had apparently ceased to wheeze at 14 years had minor recurrences of wheezing between 14 and 21 years of age. Fewer than 20% of those with persistent symptoms in childhood had become totally wheeze free during adolescence, although there was amelioration in symptoms. Girls did less well during adolescence than boys, so that there was no longer an increased preponderance of boys with increasing severity of asthma. Normal growth was achieved in all grades despite the persistence of symptoms in many cases. At 21 years of age features of airways obstruction were often found during an interval phase, especially in those who had more persistent symptoms.     

Severe euthyroid cardiac disease; technique for treatment with radioiodine

It is possible to safely lower the basal metabolism of patients suffering from severe cardiac disease by administering multiple small doses of radioiodine in order to achieve symptomatic relief. From the present study, multiple small doses of I(131) appeared to be as effective as single or multiple large doses of this material and complications such as thyroiditis, temporary thyrotoxicosis and bone marrow depression were almost always avoided. No damage to the parathyroid glands or the recurrent laryngeal nerve was observed. No radiation sickness developed after therapy.A scintigram of the thyroid gland was useful in determining the size, shape and function of the thyroid gland before and during radioiodine treatment and helped to determine the need for additional treatment. In order to prevent the distressing symptoms of the myxedema state, desiccated thyroid was administered when necessary. In the series of 278 euthyroid patients with severe cardiac disease who were treated with radioactive iodine, results were excellent in 35 per cent of cases and good in 44 per cent. In 21 per cent there was no improvement.     

Causes of low utilization of amniocentesis by women of advanced maternal age

Abstract

The objectives of this study were to determine current usage of amniocentesis by women of advanced maternal age in a southwestern Ohio county and to determine potential usage levels by surveying women not utilizing the procedure to understand their reasons. For women age 35 and older giving birth in Hamilton County, Ohio, the estimated percentage using amniocentesis was 3.9 in 1978, 7.6 in 1979, and 13.3 in 1980. Approximately comparable statewide utilization rates were 7.0, 11.5, and 17.2 respectively. A telephone survey during the summer of 1980 of 81 Hamilton County women age 35 and older recently giving birth to a normal baby found four main reasons why they did not utilize amniocentesis: (1) they did not feel at an increased risk (29.6 per cent); (2) they had never heard of the test (24.7 per cent); (3) they were opposed to abortion (21.0 per cent); and (4) no one suggested they have the test done (19.8 per cent). Their physicians reported that 81 per cent of these women had received prenatal counseling. Thus, of those counseled, over two‐thirds apparently missed at least one essential message of the counseling they were presumably provided. These findings, coupled with 47.7 per cent of women who knew about amniocentesis saying they would most likely use it if they became pregnant again and their physician recommended it, indicate that utilization of prenatal diagnosis by at least 50 per cent of women age 35 and older is likely with greater public education and greater support of the procedure by obstetricians.     

Risk of death due to chronic chagasic cardiopathy

In this longitudinal study 5,710 people were included. The inclusion criteria were two positive serological results for Trypanosoma cruzi infection, 15 and 50 years old and no other demonstrable disease at the time of study. In the five year follow up 1,117 patients were lost. The follow up involved yearly evaluation of serology, clinical examination, X-ray of thorax, and ECG, for 4,593 patients and 263 were contacted at home because they did not assist for their clinical consultant. Time average of follow up was 5.3 years. Eighty nine (1.5%) of the 4,593 patients died during the follow-up period, 63 (71%) by cardiac insufficiency (CI) and 26 (29%) by severe ventricular arrhythmias. Diagnosis of cardiomegaly was present in all the patients with diagnosis of CI and in 15 (5%) of the patients with diagnosis of arrhythmias. The ECG alterations of these patients show 61 right bundle branch block (RBBB), associated or not with left anterior hemiblock (LAHB), 47 pathological Q wave and 70 primary repolarization alterations; 61 had polyfocal ventricular arrhythmia. The death rate was similar in the sexes and was more frequent between 40 and 50 years of age. Information on 1,380 recuperated patients shows that 15 died with no previous symptoms and without medical assistance and were interpreted as sudden death. The latest ECG in three follow-up of these patients indicates (before death) that only one had normal study and 14 presented 12 RBBB; 9 LAHB; 7 isolated ventricular arrhythmia; 10 repolarize alterations; 2 pathological Q wave, 10 patients of them with RBBB and repolarize alterations. In all the cases we had people between 35 and 43 years old, 9 men and 6 women. This study shows that in Chagas disease is possible to differentiate two risk groups. A low risk death group that have normal ECG and clinical evaluation during the follow up, and a high risk group associate ECG with RBBB and primary alterations of repolarization and/or inactivation zones with not annual clinical evaluation.     

CONGENITAL HEART DISEASE—Comments Regarding Incidence and Natural History

The incidence of congenital heart disease is approximately 1 per cent of all live births. Approximately 60 per cent of patients who die of congenital heart disease do so at less than two years of age. Very few patients with such lesions live beyond 45 years at the very most. In about 70 per cent of patients who are born with cardiac anomalies, the lesions are either of kinds that are already being operated upon successfully or for which operations are now being attempted and often are helpful.     

Congenital heart disease; comments regarding incidence and natural history

The incidence of congenital heart disease is approximately 1 per cent of all live births. Approximately 60 per cent of patients who die of congenital heart disease do so at less than two years of age. Very few patients with such lesions live beyond 45 years at the very most. In about 70 per cent of patients who are born with cardiac anomalies, the lesions are either of kinds that are already being operated upon successfully or for which operations are now being attempted and often are helpful.     

Prevalence,natural history,and relationship of wheezy bronchitis and asthma in children. An epidemiological study

Three randomly selected groups of 7-year-old schoolchildren in Melbourne with mild wheezy bronchitis, with moderate wheezy bronchitis, and with asthma were compared with a control group, and the patients followed up until 10 years of age. Comparison showed that if there was any significant difference between the study groups and the controls it was usually present in all these study groups. It was considered that children with wheezy bronchitis and asthma were from the same population with the same underlying basic disorder, and that there was a wide spectrum in various aspects of the natural history of the disorder.About 11% of all children aged 10 years had had some asthmatic episodes. Seventy per cent. of these children ceased having asthma before 10 years of age, while about 30% (3·7% of the whole community) continued to have episodes. There was a highly significant correlation between early age of onset, the frequency of episodes in the first year of symptoms, and the persistence of asthmatic episodes up to 10 years of age.Ten per cent. of all children with asthmatic episodes continued to have symptoms as severely at 10 years as at an earlier period. In this group the onset of symptoms was almost always before 3 years of age, there was a high frequency of episodes in the first year of symptoms, and boys and girls were affected in the ratio of 7:3.     

Epidemiological survey of rhinosporidiosis in Kanyakumari district of Tamil Nadu

One hundred and twelve nasal polyps received along with full history from three different hospitals of Kanyakumari district of Tamil Nadu during the period 1983–1987 were found positive for rhinosporidiosis on histopathological examination. Among the four taluks (countries) the majority of the cases (41.1 per cent) came from Agastheeswaram, followed by Kalkulam (28.6 per cent), Thovalai (17.0 per cent) and Vilavancode (13.3 per cent). The 11–20 years age group found to be highly susceptible (60 per cent). There was no sex prepondence in contracting the disease as the cases were evenly distributed between both sexes. These findings exhibited the endemic nature of the disease in Kanyakumari district.Unreported cases to an extent of 9 to 40 per cent were encountered during the ENT disease diagnostic camps conducted in nine high incidence villages. Further 8 more cases were detected in addition to cases attended in the hospitals and ENT camps when a complete enumeration of cases was undertaken in Pallam village. Thus the actual number of cases found in the district need a stratified random sampling.     

SEVERE EUTHYROID CARDIAC DISEASE—Technique for Treatment with Radioiodine

It is possible to safely lower the basal metabolism of patients suffering from severe cardiac disease by administering multiple small doses of radioiodine in order to achieve symptomatic relief.From the present study, multiple small doses of I¹³¹ appeared to be as effective as single or multiple large doses of this material and complications such as thyroiditis, temporary thyrotoxicosis and bone marrow depression were almost always avoided. No damage to the parathyroid glands or the recurrent laryngeal nerve was observed. No radiation sickness developed after therapy.A scintigram of the thyroid gland was useful in determining the size, shape and function of the thyroid gland before and during radioiodine treatment and helped to determine the need for additional treatment. In order to prevent the distressing symptoms of the myxedema state, desiccated thyroid was administered when necessary.In the series of 278 euthyroid patients with severe cardiac disease who were treated with radioactive iodine, results were excellent in 35 per cent of cases and good in 44 per cent. In 21 per cent there was no improvement.     

Cerebrovascular Occlusive Disease—Experience with Panarteriography in 300 Consecutive Cases

Three hundred patients with cerebrovascular occlusive disease have had cerebral angiographic examination at the Veterans Administration Hospital, San Francisco, in the last five years. The present technique consists of preliminary visualization of the aortic arch and the major extracranial branches, followed by selective study of the subclavian and carotid arteries as necessary for evaluation of the intracranial circulation.Nine major complications occurred (an over-all incidence of 3 per cent). Two patients died after angiography and seven had major neurologic deficits persisting for more than 24 hours. Three of these patients had permanent damage, but four recovered completely.One-third of the patients had extracranial disease and one-third had intracranial disease. No significant lesion was found in the remainder. In the 212 patients with lesions, multiple lesions were common, the average number being three. Six patients had brain tumors and five had aneurysms.The mechanism of the stroke could be ascertained readily in most of the patients, but the extent of the disease and the resulting symptoms varied considerably. Several patients with occlusion of most of the cerebral vessels had minimal symptoms, while others had catastrophic symptoms but only minimal findings at arteriography.