Health and aging of urban American Indians.

Although half of the American Indian population resides off the reservation, mostly in the western states, research on the health of urban American Indians remains sparse. American Indians living in urban areas are not eligible for the federally mandated health care provided by the Indian Health Service and receive health care services in a variety of settings. This population is at high risk for many health problems, especially cardiovascular disease and diabetes mellitus. Social, cultural, and economic barriers that impede access to health care for this group, particularly for elders living in an urban setting, could be reduced if physicians improved their understanding of and communication with American Indian patients.


African-American culture and AIDS prevention. From barrier to ally.

African Americans make up an increasing proportion of persons with the acquired immunodeficiency syndrome (AIDS). I identify and describe cultural elements such as oral traditions, multiple naming, a collective identity, extended families, and sexuality influenced by myth and exaggeration that condition African Americans' reactions to AIDS prevention. I also offer suggestions on how these cultural elements can be used for effective AIDS prevention efforts in African-American communities.


Mental health and illness in Vietnamese refugees.

Despite their impressive progress in adapting to American life, many Vietnamese still suffer from wartime experiences, culture shock, the loss of loved ones, and economic hardship. Although this trauma creates substantial mental health needs, culture, experience, and the complexity of the American resettlement system often block obtaining assistance. Vietnamese mental health needs are best understood in terms of the family unit, which is extended, collectivistic, and patriarchal. Many refugees suffer from broken family status. They also experience role reversals wherein the increased social and economic power of women and children (versus men and adults) disrupts the traditional family ethos. Finally, cultural conflicts often make communication between practitioners and clients difficult and obscure central issues in mental health treatment. Rather than treating symptoms alone, mental health workers should acknowledge the cultural, familial, and historical context of Vietnamese refugees.


Dysphoria and somatization in Iranian culture.

Iranians express dysphoria through an undifferentiated term called narahati, meaning depressed, ill at ease, nervous, inconvenienced, or anxious. People try masking this emotion or express it in specific ways nonverbally, such as sulking or not eating. Two other dysphoric affects, sadness and anger, are not masked. Because of the social conception of persons being emotionally sensitive, the expression of narahati is guarded: expressing it not only could show that one is socially vulnerable, it could also make another sensitive empathic person narahat. The body is also sensitive, but to the physical world. Physical health is maintained by balancing a diet of "hot" and "cold" foods and avoiding exposure to cold and moisture. With the social and cultural problems brought on by revolution, war, immigration, and accommodation to a new society, Iranian refugees experience changes in family, role, status, finances, language, and other sociocultural ways of being that cause them to feel narahat and to express it verbally, nonverbally, or through somatization. Understanding Iranian conceptions of emotional and physical sensitivity will help clinicians in treating Iranian patients.


Working with refugee survivors of torture.

Numerous factors must be taken into account to best provide for the health and well-being of refugee patients in developed countries. One issue that is rarely considered is the awful and not uncommon occurrence of political torture. Large numbers of refugees and other displaced persons are survivors of political torture, and health care professionals must be prepared for this possibility when treating refugee patients. The effects of torture are pervasive, and we provide some practical considerations for health professionals who care for survivors of torture. Specific challenges include problems relating to exile and resettlement, somatic symptoms and pain, and the "medicalization" of torture sequelae.


This, that, and the other. Managing illness in a first-generation Korean-American family.

The use of Western medicine and of holistic traditional medicine and healing rituals is common in Korean-American families with a chronically ill member. I present a case as an example of the complexity of health management in first-generation Korean-American immigrants. Immigration and acculturation issues, Confucian-related sociocultural and psychological factors, and the psychiatric diagnosis of Western specialists all elicited family conflict leading to emotional and physiologic distress.


Use of traditional and modern health services by Laotian refugees.

Although refugee health care emerged as a special interest in the United States following the influx of almost a million Southeast Asians since 1975, few studies have been done of the influence of refugee traditions on the use of Western medical services. The illness patterns, medical beliefs, and health care behavior of a Southeast Asian refugee group, the Mien from Laos are described in this study. A cohort of 119 Mien refugees living in Richmond, California, was observed for a 6-month period. In-home interviews were undertaken about all episodes of ill health, including treatment and health care decisions. This study shows that the Mien integrate traditional healing beliefs and practices with the use of American health services. Such findings are important because the increasing cultural diversity in the United States, particularly in Western states, necessitates that health care professionals understand the importance of cultural factors for access to and the use of health care by all patients including refugees and other immigrant groups.


The effect of values and culture on life-support decisions.

Withdrawing life support is always difficult. When patients and health professionals are from different ethnic backgrounds, value systems that form the basis for such decisions may conflict. Many cultural groups do not place the same emphasis on patient autonomy and self-determination that Western society does and find the idea of terminating life support offensive. Although physicians should never assume patients will respond in a particular way because of their ethnic background, issues of life support should be discussed in a culturally sensitive way. African-American, Chinese, Jewish, Iranian, Filipino, Mexican-American, and Korean patients were surveyed about their views on life support. The findings reported here, although not meant to be definitive, should add to health professionals' understanding about diverse beliefs around life-and-death issues. By becoming aware of this diversity of beliefs, health professionals can avoid the damage to the physician-patient relationship caused by conflicting value systems.


Medical disclosure and refugees. Telling bad news to Ethiopian patients.

The strong value in American medical practice placed on the disclosure of terminal illness conflicts with the cultural beliefs of many recent refugees and immigrants to the United States, who often consider frank disclosure inappropriate and insensitive. What a terminally ill person wants to hear and how it is told are embedded in culture. For Ethiopians, "bad news" should be told to a family member or close friend of the patient who will divulge information to the patient at appropriate times and places and in a culturally approved and recognized manner. Being sensitive to patients' worldviews may reduce the frustration and conflict experienced by both refugees and American physicians.


Ethical dilemmas in a cross-cultural context. A Chinese example.

Considerable attention is now being given to ethical conflicts raised by such issues as the disclosure of diagnosis and prognosis, the role of the family in making medical decisions, and the withholding or withdrawing of treatment of terminally ill patients. Already complicated, these issues take on added complexity in contexts where medical professionals and patients have differing cultural beliefs and practices. Ethical dilemmas that develop in multicultural settings have been largely unaddressed. Through the analysis of a case involving the hospital admission and death of a Chinese woman with metastatic lung cancer, we examine some of these dilemmas and their effect on the patient, family, and physicians. Many issues were raised by this case regarding the relationships among ethnic background, bioethics, and medical care.


Older Russian emigrés and medical care.

Although emigration from the former Soviet Union is dramatically increasing nationwide, little information has been reported on the medical problems of these emigrés. For older emigrés in particular, the medical realities of aging, in combination with cultural expectations, make the United States' medical system an arena where the stresses of emigration are expressed and help is sought. We describe the influences of culture and aging on older emigrés' health and interaction with the American medical system. A qualitative, exploratory study was done of problems and issues in health care use by older Russian emigrés at the ambulatory medical clinic of Mount Zion Medical Center, San Francisco. Cultural expectations and beliefs about health, adaptive health behaviors learned in the former Soviet Union, the stresses of emigration, and the medical realities of aging can result in serious problems in the care and treatment of older Russian emigrés. Recommended solutions include educating emigrés and health care professionals, integrating mental health services into the primary care setting, and expanding supportive services in the community such as adult day health care.


Getting by at home. Community-based long-term care of Latino elders.

Although evidence suggests that the morbidity and mortality of Latino elders (of any Hispanic ancestry) are similar to those of non-Latino whites, Latinos have higher rates of disability. Little is known about influences on the use of in-home health services designed to assist disabled Latino elders. We examine the effects of various cultural and structural factors on the use of visiting nurse, home health aide, and homemaker services. Data are from the Commonwealth Fund Commission's 1988 national survey of 2,299 Latinos aged 65 and older. Mexican-American elders are less likely than the average Latino to use in-home health services despite similar levels of need. Structural factors including insurance status are important reasons, but acculturation is not pertinent. Physicians should not assume that Latino families are taking care of their disabled elders simply because of a cultural preference. They should provide information and advice on the use of in-home health services when an older Latino patient is physically disabled.


The French are different. French and American medicine in the context of AIDS.

Medicine has often been approached as a thing apart from culture, as a uniform Western science. Within the past 10 years, we have begun to recognize that medicine is a system of beliefs and practices intrinsically linked to its larger sociocultural context. Still, it is generally perceived as uniform across North America and Western Europe. My recent research on French and American medical perspectives on the acquired immunodeficiency syndrome (AIDS) challenges this view by exploring differences in the structure of health care, the physician-patient relationship, and the conceptualizations of disease, particularly AIDS. These differences are not specific to AIDS, but the disease serves to exemplify them and to act as a medium for expressing what makes French and American medicine distinct. Global epidemics such as AIDS require both international response and cross-cultural understanding.


Health policy and ethnic diversity in older Americans. Dissonance or harmony?

The rapid growth and diversity of the older population have long-term implications for health care policies in the United States. Current policies designed for a homogeneous population are increasingly obsolete. To ameliorate obstacles that handicap many ethnic minority elders and to provide equal access to adequate and acceptable health care, several factors need to be considered. Enhanced data collection and analytic techniques are needed. The effects of race or ethnicity must be separated from other biologic, environmental, socioeconomic, cultural, and temporal factors on health status and behavior. Health care professionals and organizations serving minority elders must continue to expand their advocacy efforts to articulate the findings and their concerns to policymakers. Policymakers must understand and acknowledge the implications of an increasingly diverse society and determine what will constitute adequate, accessible, and acceptable health care within continuing fiscal constrains. Program planning, implementation, and evaluation methods must be revised to meet future health care needs effectively and efficiently.


The business of preventing African-American infant mortality.

African-American women are twice as likely as women from other ethnic groups to have babies with low birth weights and to experience the loss of infant death. The problem is so endemic in black communities in Alameda County, California, that numerous programs have been developed over the past decade to reduce maternal risk factors and eliminate barriers to prenatal care. Despite these efforts, African-American ethnicity continues to be a major risk factor for infant mortality for reasons that are poorly understood. We take a critical look at 3 types of studies characteristic of infant mortality research: epidemiologic, studies that advocate prenatal care, and ethnomedical (cultural). We argue that the assumptions informing this research restrict the thinking about infant mortality and the political issues involved in how prevention programs are developed and structured. The persistent focus on maternal behavioral characteristics limits more in-depth analysis of the micropolitics of perinatal bureaucracies established in response to this ongoing crisis.


A season in the life of a migrant farm worker in California.

There is an erroneous but widespread belief that in the past few decades California agriculture has become increasingly mechanized and reduced its need for migrant labor. Steeply increasing demand, however, for specialty fruit and vegetable crops, which are labor-intensive, has actually increased the need for migrant workers, who come mainly from Mexico. A case study of a young migrant describes the dismal work, economic, and living conditions such workers typically endure and the possible health consequences of those conditions.


Occupational health problems among migrant and seasonal farm workers.

Migrant and seasonal farm workers are one of the most underserved and understudied populations in the United States. The total US population of such farm workers has been estimated at 5 million, of whom about 20% live or work in California. Farm workers perform strenuous tasks and are exposed to a wide variety of occupational risks and hazards. Low socioeconomic status and poor access to health care also contribute to existing health problems in this population. Potential farm work-related health problems include accidents, pesticide-related illnesses, musculoskeletal and soft-tissue disorders, dermatitis, noninfectious respiratory conditions, reproductive health problems, health problems of children of farm workers, climate-caused illnesses, communicable diseases, bladder and kidney disorders, and eye and ear problems. Few epidemiologic studies exist of these occupational health problems. No comprehensive epidemiologic studies have assessed the magnitude of occupational health problems among migrant and seasonal farm workers and their dependents. Although the migratory nature of this population makes long-term studies difficult, the development of standardized data collection instruments for health consequences and scientific assessment of farm work exposures and working conditions are vital to characterize and reduce the occupational health risks in farm workers.


[Nephrotic syndrome with mesangial hyperplasia and an unfavorable outcome].

In a group of 109 children with the nephrotic syndrome caused by mesangial hyperplasia 5 cases with unfavourable outcome were observed. The follow-up was from 3 years to 11 years. In all children no remissions of the syndromes were obtained after treatment with prednisone, methylprednisolone pulses, immunosuppressants. They had hypertension poorly responding to hypotensive drugs, and chronic renal failure developed with early progression to terminal renal failure. In three children subjected to renal transplantation the signs of the nephrotic syndrome returned, in two of them biopsy of the renal graft demonstrated evidence of mesangial hyperplasia, and in one case vascular rejection and extracapillary proliferation of cells with presence of semilunar hyperplasia.


[Intermediate lymphocytic lymphoma].

The characteristic features are presented of intermediate lymphocytic lymphomas which have suggested the pathomorphological and clinical peculiarity of this disease entity. They occur in two forms: diffuse and nodular which are two phases in the development of the disease. The phenotypic and karyotypic characteristics of these lymphomas resemble those of chronic lymphocytic leukaemia, but their more malignant course is similar to that of centrocytic lymphomas.


[Effect of lead on thyroid function].

Lead in organic and inorganic compounds is a health risk factor leading after high-grade exposure to poisoning. It can accumulate in the organism and exert toxic effects, especially on the haemopoietic system and nervous system. Its action includes damage to cell membranes and disorders of the oxidoreductive processes in the cells. Hypothyroidism occurring in subjects with occupational exposure to lead may evidence a negative effect of the element on thyroid function.


[A case of esophageal pemphigus].

A case of oesophageal pemphigus was observed in a man aged 76. Attention is called to the rarity of this disease and resulting diagnostic difficulties.


[A case of Hashimoto struma coinciding with limited scleroderma].

In a female patient aged 43 years severe hypothyroidism was caused by Hashimoto struma. She had also cutaneous changes suggestive of collagen disease. On the basis of clinical manifestations, laboratory investigations and histological examinations coexistence was diagnosed of two autoimmunological diseases. Stress is laid on diagnostic difficulties and choice of management.


[The effect of hormones on the gastrointestinal mucosa].

Proliferative effects of hormones on the gastrointestinal mucosa are discussed according to literature data. There are presented the trophic effects of gastrin, cholecystokinin, secretin, enteroglucagon, somatostatin, growth hormone, thyroxine, peptide YY, epidermal growth factor and submaxillary growth factor.


[Different course of myocardial infarction in old age].

For the assessment of the peculiarities of acute myocardial infarction in patients aged over 60 years 100 patients with this disease treated at the Department of Internal and Occupational Diseases, Silesian Medical Academy were compared with 100 patients aged below 60 years. The location of myocardial infarction was similar in both groups. In the younger group premature ventricular beats were more frequent while in the older group supraventricular or ventricular tachycardia and left bundle branch block were more frequent. The death rate was much higher in the older group.


[Conservative treatment of arterial occlusion with streptokinase administered intra-arterially].

The effectiveness of conservative treatment of the occlusion of peripheral arteries with streptokinase administered intra-arterially was assessed in 16 cases. In 11 cases the blood flow in the extremity was returned (68.7%). Good therapeutic results were obtained in properly selected cases.


[Effect of hemodialysis on somatosensory evoked potentials of medium and long latency].

In 16 patients with terminal renal failure aged from 21 to 74 years maintained on haemodialysis programmes for 2 to 60 months somatosensory evoked potentials were studied after stimulation of the median nerve immediately before and after haemodialysis. The central conduction time, the P 45-N 60, P 100-N 140-P 200 complexes and the P 300 wave were evaluated. The results were compared with those in 16 healthy volunteers aged 20 to 66 years. In the patients on haemodialyses the evoked somatosensory potentials of medium and long latency differed statistically significantly from those in the control group, but not direct effect of haemodialysis on these potentials was found.


[Allergic reactions to teniposide (VM-26) in children with neoplasms].

Allergic reactions of dramatic intensity were observed in 5 children treated with Teniposide (VM-26) for acute lymphoblastic leukaemia and histiocytosis X. In the further treatment this drug was replaced with epoxide, a cytostatic agent which is also a podophyllin derivative but in other chemical formulation. In none of these patients the allergic reaction returned.


[Morphologic appearance of intestinal microvilli in children with coeliac disease and secondary malabsorption syndromes after gluten-free diet and gluten challenge].

The glycocalyx and the structure of the microvilli were analysed in electron microscopy in 122 children with coeliac disease and secondary syndromes of malabsorption. Slight differences were noted in glycolayx structure between both groups of children. In children with coeliac disease its reduction was noted (after gluten challenge). Changes were observed also in the structure of the microvilli. They were lower and often with abnormal shape in coeliac disease, while they were high and of normal structure in secondary malabsorption syndromes.


[Changes in the visual system of children with subacute sclerosing panencephalitis].

The results of ophthalmological examinations were compared in 20 children aged 6 to 13 years with SSPE. The examinations in the first phase of the disease demonstrated fundus changes with presence of choked disc in 4 cases, papilloedema in 4 cases, uveitis in 1 case, retrobulbar optic neuritis in 1 case (in this case ophthalmological changes developed 4 months prior to the onset of typical neurological sings.


[Clinical suspicion of inborn errors of metabolism].

A number of inherited metabolic disorders are diagnosed by means of the nationwide newborn screening programme, usually before the first clinical signs occur. As for the rest of the varied metabolic disorders, knowledge and intuition of the paediatrician is a prerequisite for selection of patients for further metabolic investigation (selective screening procedure). Clinical symptoms of the most important metabolic diseases can be classified according to their pathophysiological background as: "intoxication type, energy deficiency type, storage type, neurodegenerative type". Especially in the first year of life, clinical features are unspecific: psychomotoric retardation, muscular hypotonia, cerebral convulsions, recurrent vomiting, sepsis-like conditions. In these cases indication for metabolic screening is broad. Especially in older children some clinical symptoms can be specific for a metabolic disorder: distinctive odour of urine, changes in hair, skin or eyes, organomegaly, skeletal changes. Recently, Reye-like syndrome, stridor, macrocephaly and vague, cerebral ischaemic episodes have been described in association with a metabolic defect. In conclusion, experience has shown that only a small number of metabolic disorders will be diagnosed from the typical clinical picture alone. In most cases a selective screening procedure leads to diagnosis because initial symptoms are unspecific.


[Differential diagnosis and therapy of various forms of hyperphenylalaninemia: facts and fiction].

The various conditions which can lead to elevated blood phenylalanine (PHE) levels must be differentiated promptly in the neonatal period so that the correct treatment can be implemented as soon as possible. In order to exclude the rare tetrahydrobiopterin (BH4) deficiency, it is advisable to perform a BH4 loading test and to determine the renal excretion of pterins, as well as the dihydropteridine reductase activity in erythrocytes. The practical consequence of differentiating the various types of PHE hydroxylase deficiency is that with both phenylketonuria (PKU; PHE greater than 20 mg/dl) and hyperphenylalaninemia (HPA) with PHE levels above 15 mg/dl a diet restricted in PHE is initiated, whereas HPA infants with PHE levels below 8 mg/dl are fed normally. In the case of PHE concentrations between 8 and 15 mg/dl standardized protein intake can be used to decide whether a diet restricted in PHE or only a restriction of protein intake has to be instituted. Optionally a protein challenge can be performed at the age of six months in order to evaluate the individual PHE tolerance. Psychometric investigations of PKU patients after diet discontinuation at different ages, as well as animal studies are in favour of a diet-for-life. The diet in PKU patients is known to lead to some side effects such as bony changes and amino acid imbalance, as well as deficiency of selenium and carnitine. Finally, great efforts have to be made in order to avoid the increasing danger of PHE embryofetopathy in the offspring of PKU mothers (maternal PKU).


[25 years Austrian screening program for inborn errors of metabolism at the Vienna University].

The results are presented by the Austrian screening program for inborn errors of metabolism, which is one of the oldest and most comprehensive in the world. At present, the program comprises screening for the following diseases: phenylketonuria, galactosemia, homocystinuria, maple syrup urine disease, hypothyroidism, biotinidase deficiency. The results of the program with regard to diagnosed cases are presented: in total, 747 carriers of various inborn errors of metabolism have been detected by means of the Screening Program and were referred for therapy where appropriate.


[Long-term results in children with classical galactosemia].

Galactosemia due to uridyl-transferase deficiency was detected in 47 patients between 1/1/1967 and 31/12/1988. The condition took a fulminant course in 31 patients and 10 infants in this group died between the 6th and the 18th day of life. The determination of uridyl-transferase in 36 patients confirmed the diagnosis. Exchange blood transfusion was undertaken in 25 infants because of hyperbilirubinemia, septicemia or neurological symptoms. 5 of the 31 children had a cataract. In most cases the lactose-free diet was commenced in the 2nd week of life. 27 patients were followed up with respect to somatic and intellectual development. Gonadal function was investigated in 5 patients; hypergonadotropic hypogonadism was found in the 4 girls.


[Vasoactive drugs with an effect on the prostaglandin system].

The balance between prostaglandin (PG)I2, a potent vasodilator and inhibitor of platelet aggregation mainly produced by endothelial cells, and thromboxane (TX)A2, a vasoconstrictor and inducer of platelet aggregation and adhesion synthesized predominantly by platelets, seems to be relevant for the regulation of vessel tone and platelet aggregation. PGE2 has vasodilating properties, too. Thus, substances affecting the biosynthesis of PG and TX may have prophylactic and therapeutic, but also detrimental effects with regard to hypertension and atherosclerosis. A mechanism of action which is related to the PG system is discussed for a number of antihypertensive agents, e.g. propranolol, angiotensin converting enzyme inhibitors, furosemide and cicletanine. The vasoprotective effect of inhibition of platelet cyclooxygenase by acetylsalicylic acid is well known. Calcium antagonists, dipyridamole, estradiol, aprotinin and interferon have also been reported to possibly exert beneficial effects on PG/TX levels, while cyclosporin A and streptokinase have shown undesirable interactions with the PG system.


[Risk factors of atherosclerosis--primary examination of Vienna employees].

In the course of an atherosclerosis intervention study, a basic medical check-up of 2105 out of 4800 employees of a Viennese banking house was carried out (37.1 +/- 11.0 years, 54.6% females). Apart from liver and kidney function parameters, an extensive lipid status was determined, the blood pressure was measured, and a cardiovascular-centered case history ascertained. The mean cholesterol level in females was 208.3 +/- 54 mg/dl and that in males was 226.8 +/- 61.1 mg/dl. The HDL-cholesterol level in males was 43.8 +/- 11.9 mg/dl; that in females (54.9 +/- 13.4 mg/dl) was significantly higher. The mean value of LDL-cholesterol in the entire group was 141.6 +/- 51.4 mg/dl and it was significantly higher in males, as well as in participants with known hypertension. 33.4% of the persons stated that they smoked. The obtained data will serve not only to discover potential interrelations between the individual risk factors of atherosclerosis in Austria, but also in particular as a basis for interventional strategies on the part of the company's medical services.


Risk factors for atherosclerosis in female type II diabetic patients with incipient diabetic nephropathy.

Risk factors for atherosclerosis were investigated in a group of 17 female Type II diabetic patients with microalbuminuria-urinary albumin excretion (UAE) in the range of 30-300 mg/day, and in a control group including 15 Type II diabetic females with UAE less than 30 mg/day. Significantly increased mean concentrations of total and LDL-cholesterol were measured in the group with microalbuminuria (p less than 0.05). Also mean levels of some other cardiovascular risk factors (systolic blood pressure, fibrinogen, apolipoprotein B, triglycerides and uric acid) were higher in the group of patients with microalbuminuria, although the differences in comparison to the control group did not reach the level of statistical significance. In the multiple stepwise regression analysis log transformed UAE values correlated significantly with three independent factors--uric acid (p less than 0.01), fibrinogen (p less than 0.05), and systolic blood pressure (p less than 0.05). It is concluded that a slight increase in the levels of a number of cardiovascular risk factors observed in incipient diabetic nephropathy suggests an additive effect favouring atherogenesis.


[Development of arterial revascularization of the myocardium at the Linz general hospital. Personal experiences with 1000 patients].

Arterial revascularization of the myocardium, particularly the use of the internal mammary artery (IMA) as a bypass graft in coronary artery surgery has become an established procedure over the past decade. From March 1986 to June 1991, of 2070 patients who underwent coronary heart surgery at our department, revascularization of the myocardium was performed with an IMA graft in 1000 cases, whereby the percentage increased from 10.4% in 1986 to 75.0% in 1991 (p less than 0.01). The range of indications gradually widened throughout the period, age no longer being a contradiction today. One reason for this development is the substantial improvement in IMA preparation technique. No increase was found in rethoracotomy rate or in the rate of perioperative infarctions. The mean age of patients receiving an IMA graft increased from 55.2 years (1986) to 64.7 years (1991) and therefore reflects the change in ranges of indication. 54 IMA jump grafts were anastomosed, in 30 cases bilateral IMAs were used and the IMA was implanted as a free graft twice. In the future these successful results with the implementation of IMA grafts will lead to a further displacement of the saphenous vein as main bypass material.


[Snuff aspiration as a cause of recurrent pulmonary infiltrations in a 60-year-old patient with chronic renal failure].

Pulmonary infiltrations associated with renal failure demand several diagnostic procedures to exclude autoimmune disorders affecting both organ systems or to find an infectious cause of the disease. We report the case of a 60 year-old man with chronic renal failure and recurring pulmonary infiltrations. On admission to hospital all diagnostic parameters for systemic vasculitis, infectious or neoplastic disease were negative, including the histological report on transbronchial biopsies. Eventually, follow-up biopsies taken 3 months later showed vegetable fibres and necrosis due to intensive snuff abuse during the previous months. After the patient stopped taking snuff the pulmonary infiltrations improved quickly. Uraemic neuropathy, which may have facilitated aspiration, as well as the reduced pulmonary and systemic defence mechanisms due to chronic renal failure probably contributed to a considerable degree to the development of pulmonary infiltration.


[Report of 111 patients with multiple cancers of the first medical department of the Vienna-Lainz nursing home 1981-1987].

After a short synopsis of the literature we describe 111 patients with multiple primary cancer and compare these patients with 804 patients with solitary cancer admitted over the same period. Patients who developed primary cancer at a younger age are more prone to developing a second cancer than patients who developed cancer first at an older age. This concerns younger women with breast or genital cancer, who are much more likely to develop a second cancer than older women; nevertheless these women have a more favourable prognosis. As the great majority of patients were already over 70 at the time of diagnosis of the second cancer, the prognosis of geriatric diseases has become of considerable significance. We present a detailed investigation of the interrelations between the first and second cancer, also between oncological and geriatric diseases.


[Successful treatment of HIV-associated pneumocystis carinii pneumonia with dapsone plus trimethoprim].

Standard treatments of HIV-associated Pneumocystis carinii pneumonia (PCP) consist of high dose intravenous or oral cotrimoxazole or intravenous pentamidine. Both treatment modalities are associated with a high incidence of side effects which strengthen the need for alternative therapies. Since April 1987 we have used the combination of dapsone plus trimethoprim (DP+TMP) as primary treatment for PCP in patients who could be managed on an outpatient basis. We report the results of an analysis of the efficacy and toxicity of this treatment in 20 episodes of PCP in 18 patients. PCP was diagnosed by identification of the pathogens in bronchoalveolar lavage specimens. Chest X-ray revealed bilateral involvement in 11 and unilateral in 7 cases and no infiltration in one patient. Treatment over three to four weeks was successful in 14 of 20 PCPs (70%). In six cases (30%) treatment was changed to another regimen after a mean of seven days due to a maculopapular rash (n = 2), haematotoxic side effects (n = 2), persistent fever (n = 1) and for unexplained reasons (n = 1). Less severe side effects not causing a change in treatment were a slight to moderate neutropenia (n = 10), a moderate elevation of liver enzymes (n = 2) and a well tolerated rash (n = 2). The success rate of DP+TMP was in the same range as it is known for the standard regimens, whereas the rate of severe side effects appears to be lower. The results suggest that in AIDS patients DP+TMP may be used as first line treatment of PCP which is not severe enough for hospitalisation.


[Biochemical and immunohistochemical detection of epidermal growth factor receptor in breast and ovarian tissue].

The epidermal growth factor receptor (EGFR) was assessed in 52 breast and 46 ovarian biopsies by the radio ligand binding assay and/or the immunoperoxidase technique. A direct comparison of the two methods was undertaken in 27 breast and 32 ovarian biopsies. The results of both methods correlated positively (r = 0.59) in malignant tumours (n = 34), but not in benign lesions (n = 16) nor in normal tissues (n = 9). The different results may be explained by the fact that different aspects were measured by the two methods, while the biochemical assay assessed the receptor binding capacity, the immunohistochemical method detected an EGFR epitope. Since the histochemical method allows the localization of EGFR positive cells and the biochemical assay gives a quantitative measure, both methods together give more information on the receptor situation. A comparison of the results of these methods used simultaneously, rather than alternating one method with another improves the degree of accuracy of evaluation.


[Risk factors for the development of diabetic retinopathy in patients with insulin-dependent diabetes mellitus treated with continuous subcutaneous insulin infusion].

During a one year observation period, the retinal status, glycosylated hemoglobin levels (HbA1), hypoglycemias, lipid values, blood pressure and clinical abnormalities of IDDM (insulin dependent diabetes mellitus) patients treated by CSII (continuous subcutaneous insulin infusion) were documented. In 70 (out of n = 81) patients 137 retinal follow-up examinations were performed and evaluated. In 86.1% of those patients, CSII appeared to have a positive influence on their retinal status. In 14.6% (8.6% with background retinopathy + 5.8% with proliferative retinopathy) improvement of a pre-existing retinopathy could be seen. The diabetes duration itself seemed to have no influence on development or progression of diabetic retinopathy, but elevation of HbA1 or serum triglyceride levels, as well as elevated systolic blood pressure leaded (on a medium term base) to statistically significant deterioration or development of retinopathy. In addition, hypoglycemias and impaired renal function have to be seen as risk factors potentiating each other. Besides the treatment of cardiovascular risk factors, getting normal HbA1 values while avoiding hypoglycemia must be the major aim in therapy management to prevent microangiopathy. In certain cases, even patients with severe retinopathy might benefit from CSII. When blood sugar levels are carefully lowered during the first months, no deterioration of the retinal status is seen in patients with long-term metabolic decompensation.


[Surgical treatment of glossopharyngeal neuralgia].

Glossopharyngeal neuralgia is a rare disease which is characterized by severe paroxysmal pain attacks in the distribution of the 9th cerebral nerve. Although uncommon, the condition has to be considered in the differential diagnosis of various craniofacial neuralgias. The purpose of this study was to describe 3 cases of glossopharyngeal neuralgias and to discuss its diagnosis and therapy. Various surgical therapeutic procedures have been described, including neurotomy of the glossopharyngeal nerve in the frontal neck, thermocoagulation of Andersch's ganglion, and para-pontine neurotomy (Dandy). Because of its good results and low incidence of recurrences, microvascular decompression (Jannetta) is considered the procedure of choice.


Cerebral palsy: improved outcome by early detection of latent failure of psychomotor development in infants.

A prospective cohort study was performed to evaluate the results of a new screening system for latent psychomotor disturbances in infancy developing into cerebral palsy (CP). The system has been based on an early diagnosis within the first 2 months of life with a subsequent follow-up. All liveborn children were screened and suspect cases were immediately referred to detailed neurological examination. With the new screening system implemented within 1988 to 1989, the incidence of cerebral palsy in the area could be halved as compared to 1980 to 1986 (0.26% vs. 0.52% of liveborn children respectively). Out of 4,166 liveborn children, 527 newborns had to be referred to neurologic examination, thereof 460 required follow-up and 228 had to be treated. In only 11 of the children CP was diagnosed at the age of 15 months. 8 of the CP children presented signs of serious neurologic disturbance at birth and were considered as "requiring high-tech use". A latent psychomotor disturbance developing slowly into CP during the first year of life occurred but in 3 children, 2 of them having relatively favorable prognosis; this group was termed as "requiring skilled clinical organization". Premature children (under 37 weeks of gestational age) had an 82% share on our recent CP patients.


[Does a supportive "muscle corset" prevent spinal complaints?].

By strengthening trunk muscles, we hope to prevent back pain. The logic behind this argument is, however, fragmentary. The scientific evidence for the effectiveness of such measures is conflicting. Rigorous trials provide little indication as to the correctness of the above thesis. Thus further research on this important matter is necessary. Until it is available, primary prevention programs based on trunk strengthening exercise are lacking a scientific basis.


Differentiated thyroid carcinoma in children and adolescents.

From 1936 to 1990, 89 children and adolescents (72 girls and 17 boys) were treated for differentiated thyroid carcinoma at the University of Michigan Medical Center; 58 of these patients were first reported in 1971. Thirty (34%) patients had previously received external irradiation to the head and neck, although only 1 (3%) patient of the last 33 patients seen had this history. Patients first presenting from 1971 to 1990 had less advanced disease than those seen earlier. Also, during this time period, the rate of initial palpable cervical adenopathy fell from 63% to 36%, local infiltration of primary cancer from 31% to 6%, and initial pulmonary metastases from 19% to 6%. The incidence of cervical nodal metastases has remained 88% for 54 years. Papillary or the follicular variant of papillary carcinoma was found in 93% of all patients. Seventy-nine (89%) patients had total or completion total thyroidectomy. Surgical management of lymphatic metastases varied from regional excision of nodes to radical neck dissection. The overall rate of permanent accidental recurrent laryngeal nerve palsy and hypoparathyroidism was 4.5%, although neither has occurred in a child or adolescent undergoing surgery at the center in the past 25 years. The most recent 33 patients had a low rate of local/regional persistence or recurrence. Cervical nodal persistence occurred in 21%; there were no thyroid recurrences. Eighty-two percent of patients received 131I. The long-term mortality rate was 2.2%. We continue to advocate total thyroidectomy, cervical lymph node dissection, and postoperative 131I therapy as the most conservative treatment regimen for children with differentiated thyroid carcinoma.


Causes of failed primary exploration and technical aspects of re-operation in primary hyperparathyroidism.

Hypercalcemia was corrected in 62 (90%) of 69 patients after re-operation for primary hyperparathyroidism during a mean follow-up of 6.3 years. Failed primary exploration was mainly due to inadequate visualization of the pathological parathyroid glands, often in association with misleading or absent peroperative histology. Other causes included seeding of parathyroid adenoma tissue, truly recurrent adenomas, and recurrent hyperplasia, especially in patients with multiple endocrine neoplasia type 1. A considerable number of parathyroid glands missed at the primary operations were subsequently found in essentially normal positions. Ectopic superior glands were most frequently positioned para-esophageally or retro-esophageally, while abnormally placed inferior glands were generally situated within or close to the thymus. Glands in 3 patients were dissected from around the large vessels in the mediastinum. Concomitant thyroid procedures during the primary operation yielded few abnormal parathyroids and made the re-exploration considerably more difficult. We suggest a semilateral approach and caudal identification of the recurrent laryngeal nerve to reduce the hazards of difficult parathyroid re-operations. Mediastinal exploration may require total removal of the thymus and careful dissection of the middle mediastinum.


Mutational activation of RAS and GSP oncogenes in differentiated thyroid cancer and their biological implications.

Activating mutations of ras-genes (Kirsten-ras, Harvey-ras, N-ras) and genes encoding for the alpha subunit of G-proteins (Gs, Gi2, Gi3, Go, Gz) were assessed in 32 differentiated thyroid cancer (DTC) tissues from German (n = 22) and American (n = 10) patients. Gs-protein (GSP) and/or ras mutations were found in 69% of all tissues with a heterogeneous distribution pattern. An increased prevalence could be demonstrated in metastatic (8 of 9 mutation positive) when compared to localized disease (13 of 23 mutation positive) (p less than 0.001) and in patients greater than 50 years of age (16 of 18 mutation positive), when compared to younger patients (6 of 14 mutation positive) (p less than 0.001). No activating mutations were found on H-ras and K-ras genes nor on genes encoding for the alpha subunits of Gi2, Gi3, Go, and Gz. Differentiated thyroid cancer tissue from German patients revealed a higher prevalence for GSP mutations (73%) than did DTC from American patients (20%) (p less than 0.001). We demonstrated a high frequency of ras and GSP mutations in DTC and suggest that these mutations may contribute to our basic understanding of this disease and might initiate a new search for more rational and individualized therapeutic approaches in patients with DTC.


Outcome of long standing solitary thyroid nodules.

We investigated the outcome of long standing palpable solitary thyroid nodules by surveying 441 patients and examining 140 patients who had untreated thyroid nodules for 15 +/- 4.5 years. In our clinical survey, the most common outcome was disappearance of the thyroid nodule (38.3%). Also a significant number of patients (36.3%) underwent surgery in other hospitals. Five (1.1%) patients died of thyroid cancer. When thyroid nodules were re-examined, most nodules indeed decreased in size or disappeared; however, 13% of nodules increased in size. Ultrasound of the nodules showed that most solitary nodules were multiple and partially cystic and solid. There was an increased incidence of calcification in long standing nodules. Thyroid cancer was found by fine needle aspiration biopsy in 26.3% of enlarging nodules and 6.4% of nodules without changing size. The risk of cancer decreased when the size of the nodule decreased. A total of 15 patients with suspicion of malignancy underwent surgery. Surgical procedures were lobectomy, near total thyroidectomy, or resection of nodules with or without modified neck dissection. Seven patients had papillary carcinoma and 2 patients with benign cytology had microscopically evident papillary carcinoma. In our study, the majority of palpable solitary thyroid nodules tended to decrease in size; these nodules do not require treatment. Enlarging solid nodules are a definite risk for thyroid cancer. If the size of the nodule remains the same, judicious approach with fine needle aspiration biopsy is needed.


Follicular tumors of the thyroid gland: diagnosis, clinical aspects and nuclear DNA analysis.

From 1985 to 1990, 169 patients underwent surgery for follicular thyroid tumors at the Department of Surgery, Karolinska Hospital, Stockholm, Sweden. Nine of the patients had tumors which were diagnosed as follicular carcinoma, 4 of whom had recurrences in the neck region. In 6 of the patients the carcinomas were diagnosed as widely invasive and in 3 patients as minimally invasive. Of the 160 patients with follicular adenomas, 21 adenomas were of oxyphil type ("Hürthle" adenomas), 17 adenomas were diagnosed as "atypical", and 6 adenomas were classified as being both "atypical" and having oxyphil cell differentiation. The nuclear DNA content was measured with image cytometry and/or flow cytometry. Six of the 9 carcinomas were euploid and 3 were aneuploid. In the adenoma group, 32 (20%) were aneuploid. Thus 38% of all adenomas showed atypical cellular features, oxyphil cell differentiation, and/or aneuploid nuclear DNA pattern. None of the patients with adenomas have shown any sign of recurrence. In the present prospective study, the nuclear DNA content could not discriminate between a benign and a malignant follicular tumor, and was of limited value in predicting prognosis in the patients with follicular carcinoma. Still, the best way to establish a diagnosis and to predict prognosis is to surgically remove the follicular tumor for a proper histopathological examination.


Recurrent renal hyperparathyroidism and DNA analysis of autografted parathyroid tissue.

In spite of recent therapeutic advances, severe overt secondary hyperparathyroidism due to chronic renal failure necessitates parathyroidectomy and recurrent hyperparathyroidism is one of the most significant problems in this patient population. In the present study, the incidence of recurrent hyperparathyroidism was evaluated in relation to the histopathological features. Image cytometric DNA analysis was performed to estimate the proliferative potential of parathyroid tissue. The study comprised 248 patients who underwent parathyroidectomy from 1973 to 1991. The frequency of recurrent hyperparathyroidism after subtotal parathyroidectomy was 4 (21.1%) of 19 patients, the rate of graft-dependent recurrence after removal of residual parathyroid tissue with forearm autograft was 2 (50%) of 4 patients. The frequency of graft-dependent recurrence after total parathyroidectomy with forearm autograft was 16 (7.5%) of 212 patients. The frequency of recurrence was significantly higher (p less than 0.01) when nodular hyperplastic parathyroid tissue was autografted (17 of 68 patients, 25%) than when diffuse-hyperplastic tissue was grafted (1 of 105 patients, less than 1%). All 58 specimens subjected to image cytometric DNA analysis showed a diploid nuclear pattern cytometrically. However, the relative number of scattered cells that displayed cytometric nuclear DNA values outside the main diploid histogram peak was significantly greater (p less than 0.01) in nodular hyperplastic tissue before being autografted and in parathyroid tissue removed at re-operation performed for recurrence than in diffuse hyperplastic tissue. These clinical findings and results of DNA analysis clearly indicated that nodular hyperplastic parathyroid tissue has a higher growth potential, and it is concluded that to prevent graft-dependent recurrence, the nodular type of hyperplastic tissue should not be autografted.


Non-Hodgkin's lymphoma of the thyroid: is more than biopsy necessary?

Whereas excisional surgery and radiotherapy have resulted in a favorable outcome when non-Hodgkin's lymphoma of the thyroid (NHLT) is confined to the thyroid gland, controversy persists over the potential advantage of aggressive debulking in favor of diagnostic biopsy alone when disease cannot be completely resected. Our aims in this study were to delineate the present role of surgery in NHLT in pre-operative staging, the impact of the extent of resection on achieving complete remission and cause-specific survival, and patterns of failure. All 62 patients who underwent primary surgery for NHLT at the Mayo Clinic between 1965 and 1989 were analyzed. By postoperative staging, 50 patients were stage IE or IIE. Overall survival was 53% and 46% at 5 and 10 years; 80% for stage IE confined to the thyroid, 58% for stage IE-extrathyroid, 50% for stage IIE, and 36% for stages IIIE and IVE. Complete remission was achieved in 88% of patients who underwent diagnostic biopsy plus adjuvant therapy alone compared to 85% for patients in whom debulking plus adjuvant therapy was used. There was no difference in cause-specific survival in these two groups or in cause-specific survival in two subgroups who achieved complete remission. Relapse after complete remission occurred in 12 (26%) of 46 patients, only 2 of whom survived long-term after salvage therapy. The role of surgery in NHLT is diminishing and advances that will increase complete remission and relapse-free survival will not likely involve more aggressive surgical resections.


Dynamics of parathyroid hormone release and serum calcium regulation after surgery for primary hyperparathyroidism.

Analysis of 14 patients with primary hyperparathyroidism (HPT) prior to and during the first year after parathyroid surgery disclosed that the operation was associated with rapid reductions of intact serum parathyroid hormone (PTH) and total serum and ionized plasma calcium values. A decreased urinary calcium excretion, a gradual elevation of renal calcium reabsorption, a transient reduction of serum calcitriol, and a late increase in 25-hydroxycholecalciferol values were also noted. Dynamic tests of parathyroid function by EDTA infusion and an oral calcium load revealed a sigmoidal relationship between serum PTH and calcium levels, and that parathyroid surgery induced considerable changes in both the position and slope of the dose-response curve. It was also apparent that PTH release was submaximally stimulated event at periods of hypocalcemia. The findings substantiate that adjustments of PTH release to acute alterations of serum calcium occur along the prevailing dose-response relationship, while stimuli being maintained for longer periods of time induce compensatory shifts in the position and slope of this curve. It is further suggested that unknown factors with PTH-like function may participate in the calcium regulation after surgery for primary HPT.


Unilateral neck exploration for primary hyperparathyroidism: analysis of a controversy using a mathematical model.

Most endocrine surgeons explore both sides of the neck and identify all parathyroid glands when operating on patients with primary hyperparathyroidism. Others, however, advocate the unilateral approach, i.e., if an adenoma and a normal gland are identified, the contralateral side is not explored. We analyzed the strategy of the unilateral approach using a mathematical model to determine the variables that influence the probability of missing a tumor on the unexplored side of the neck. Assuming the frequency of single adenoma is 80%, hyperplasia 14%, double adenomas 4%, triple adenomas 1%, and carcinoma 1%, and the probability of missing a tumor on the explored side is 5%, we found that: 1. Only 41% of the patients treated by the unilateral approach undergo unilateral exploration. This is increased to 62% when a localization study with a sensitivity of 80% is used pre-operatively. 2. The probability of missing a tumor on the unexplored side of the neck parallels the prevalence of multiple adenomas. Half of the patients with triple adenomas and two-thirds of the patients with double adenomas will have a missed tumor when treated by the unilateral approach. 3. Patients who undergo unilateral exploration have an additional 7% to 8% probability of missing a tumor that would have been found if bilateral exploration is performed. This risk is lowered to 2% by a pre-operative localization study that is 80% sensitive. 4. A prospective study will require 684 patients, randomized to the unilateral or bilateral approach, to have an 80% statistical power (alpha = 0.05, beta = 0.20) of detecting a difference between a 5% and a 10% risk of missing a tumor.


Adrenal cortical carcinoma in Norway, 1970-1984.

Adrenal cortical carcinoma is a rare and highly malignant tumor. This retrospective study includes 99 patients (57 males and 42 females) reported to The Cancer Registry of Norway during the 15 year period from 1970 to 1984. The age adjusted incidence was 1.5 per million per year. Eighty-one patients were diagnosed with adrenal cortical carcinoma when still alive. In 18 cases the diagnosis was first made at autopsy. Median age at diagnosis was 54 years (range 2-88 years) with a slight male predominance. Information about initial symptoms was available in 67 patients, of whom 26 patients (18 females and 8 males) presented with clinically functioning tumors, the Cushing syndrome and virilization being most frequently encountered. Only 28 (35%) of 81 patients diagnosed when still alive had tumors confined to the adrenals. Half of the patients had distant metastases, with lungs and liver being the most frequent sites. Sixty-one patients underwent surgery; 51 patients had a radical or debulking operation and 10 patients had laparotomy with tumor biopsy. After a complete follow-up for at least 6 years (range 6-21 years), only 9 patients were still alive. Early stage (Stage I and II) and curative resection had a significant impact on the outcome of this disease. To improve prognosis, early diagnosis and radical surgery, if feasible, are needed.


Hürthle cell (oxyphilic) papillary thyroid carcinoma: a variant with more aggressive biologic behavior.

The latest World Health Organization International Classification defines papillary thyroid carcinoma by its "follicular cell differentiation...as well as characteristic nuclear changes". However the oxyphilic (Hürthle cell) papillary carcinoma have nuclei which generally resemble the nuclei seen in oxyphilic follicular carcinomas, and such oxyphilic papillary tumors may behave more aggressively than typical papillary cancers. To further characterize these rare tumors, we identified during a 32-year period 22 patients with oxyphilic papillary cancer and compared them with 1,084 patients with typical papillary cancers and 57 patients with oxyphilic follicular cancers treated by the Mayo surgical group during the same time period. Although typical papillary and oxyphilic papillary cancers were comparable with regards to patient age, tumor size and extent, TNM stage, and prognostic score (AGES), there were significant differences. Compared to typical papillary tumors, oxyphilic papillary cancers had fewer neck nodal metastases at primary diagnosis (5% vs 40%, p less than 0.0001), were more often DNA non-diploid (71% vs 21%, p less than 0.001), and after 10 postoperative years had higher rates of both tumor recurrence (28% vs 11%, p less than 0.0001) and cause-specific mortality (1.7% vs 4%, p less than 0.0005). In these four important respects the oxyphilic papillary cancers more resembled the oxyphilic follicular cancers. For oxyphilic follicular cancers, the frequency of initial neck nodal metastases was 7% (cf 5%); 83% of the oxyphilic follicular tumors were non-diploid (cf 71%), and at 10 years postoperatively the tumor recurrence and cause-specific mortality rates were 28% and 18%, insignificantly different from 28% and 17% seen with the oxyphilic papillary cancers.(ABSTRACT TRUNCATED AT 250 WORDS)


Adrenalectomy in primary aldosteronism: a long-term follow-up study in 52 patients.

From 1975 to 1989, 52 patients with primary aldosteronism underwent adrenalectomy. There were 16 men and 36 women. The average age was 42.5 years, ranging from 28 years to 70 years. They were all hypertensive, with average pre-operative diastolic pressures varying from 105 to 140 mm Hg (median 117 mm Hg). The subjective symptoms most frequently reported were headache (71%) and asthenia (53%). In all patients except two, serum potassium concentration was 3.3 mEq/L (median 2.7 mEq/L) at the time of diagnosis. Plasma aldosterone concentration was elevated in all patients, 48 +/- 5.3 ng/mL in the recumbent position and 52.6 +/- 6.0 ng/mL in the upright position. The operations carried out were 50 unilateral and 2 bilateral adrenalectomies. In 4 patients a transperitoneal approach was employed and in the remaining 48 patients an extraperitoneal flank incision was used. The histological findings were 47 adenomas (with dimension ranging from 1 to 4.5 cm), unilateral macronodular hyperplasia in 2 patients, an adenoma plus controlateral hyperplasia in 1 patient, bilateral hyperplasia in 1 patient, and unilateral hyperplasia in 1 patient. After long-term follow-up (median 77 months, range 13 to 189 months), 15 patients remained hypertensive (diastolic blood pressure up to 100 mm Hg). In 9 of these patients the hypertensive illness had been present for more than 5 years prior to operation. In the remaining 37 (71%) patients, the arterial pressure returned to normal and in almost half of the patients this result was evident one or two days after operation.


Solid cell nests of the thyroid gland: precursor of mucoepidermoid carcinoma?

Solid cell nests (SCN) are found within the thyroid parenchyma on routine clinical pathological examinations, but their histogenesis and clinical significance are still obscure. From November 1987 to May 1991, a total of 3,260 patients underwent thyroid surgery at Ito Hospital and SCN were noted in 42 (1.3%) patients. Serial sections of the specimens from these patients were studied morphologically and immunohistochemically. The location and growth pattern of SCN within the thyroid parenchyma were distinct from those of hyperplastic C-cells. SCN were located in the isthmus lobe in 1 patient and even in the pyramidal lobe in 3 patients. In another patient neoplastic proliferation of SCN was observed. Immunohistochemically, SCN were negative for neuron-specific enolase, chromogranin A, and S-100 protein. These findings strongly suggest that SCN are of endodermal origin and that they may be closely related to mucoepidermoid carcinoma of the thyroid gland.


Retrospective analysis of prognostic factors affecting the thyroid functional status after subtotal thyroidectomy for Graves' disease.

To determine the factors causing thyroid dysfunction after surgery for Graves' disease, we studied 321 patients who underwent subtotal thyroidectomy during the 7-year period from 1981 to 1987. Thyroid functional status was evaluated biochemically and the patients were divided into four categories: recurrent hyperthyroidism, euthyroidism, latent hypothyroidism, and hypothyroidism. The following factors were analyzed: sex, age at onset of the disease, indication for surgery, serum titer of antimicrosomal hemagglutination antibody (MCHA), weight of resected thyroid tissue, size of remnant thyroid relative to body surface area, pathological findings of lymphoid follicles, and lymphocytic infiltration in the thyroid tissue. Probabilities of failure (recurrent hyperthyroidism and hypothyroidism) were estimated by the Kaplan-Meier method. Prognostic factors for failure were identified by using Cox's proportional hazards model. The incidence of hyperthyroidism and hypothyroidism 5 years after subtotal thyroidectomy was 16.2% and 9.6%, respectively. Significant factors for hyperthyroidism were relatively large thyroid remnant, high serum titer of MCHA (greater than or equal to 1:3200), and age at onset of the disease less than 20 years. The significant factor for hypothyroidism was severe lymphocytic infiltration. The level of postoperative thyroid stimulating hormone (TSH)-binding inhibition immunoglobulins (TBII) in patients with recurrence was significantly higher than in patients in remission. It is reasonable to determine the amount of remnant thyroid tissue in relation to patient body surface area. Although subtotal thyroidectomy can induce immunological remission by reduction of antigen, if the remission disappears, that is if TBII increases, recurrence of hyperthyroidism may develop even in patients without the unfavorable factors.


Serum chromogranin A in the diagnosis and follow-up of neuroendocrine tumors of the gastroenteropancreatic tract.

Hormonally active neuroendocrine tumors may easily be diagnosed by elevated serum levels of their specific peptides and hormonal products, but there are no reliable markers for neuroendocrine tumors without hormonal activity. Chromogranin A (CgA), a secretory protein of neuroendocrine cells, has recently been characterized as a valuable tissue marker in hormonally active and non-functioning neuroendocrine tumors. This study analyzes the role of CgA as a serum marker for different neuroendocrine tumors. Thirty-three patients with neuroendocrine tumors of the stomach (n = 7), the ileum (n = 18), and the pancreas (n = 8) were investigated. Serum CgA levels were analyzed by radioimmunoassay at the time of diagnosis and during follow-up under different therapeutic regimens. Serum CgA was elevated in 30 (91%) patients. Mean CgA serum levels varied with tumor location (pancreas: 7068 +/- 3008 ng/ml, ileum: 5381 +/- 1740 ng/ml, stomach: 529 +/- 179 ng/ml, x +/- SEM ng/ml) but did not differ between functioning and non-functioning tumors. Eight of 10 patients treated with either somatostatin or interferon-alpha showed changes of CgA concentrations corresponding to tumor growth. We conclude that CgA is a useful broad-spectrum tumor marker in gastroenteropancreatic neuroendocrine tumors. Its determination is especially recommended in tumors without hormonal activity.


The incidence of bilateral well-differentiated thyroid cancer found at completion thyroidectomy.

The purpose of this study was to evaluate the surgical outcome of completion thyroidectomy in patients with presumed unilateral well-differentiated thyroid cancer (WDTC). The medical records of all patients having had unilateral thyroid lobectomy for WDTC, who subsequently underwent completion thyroidectomy, were reviewed. From 1980 to 1991, 60 patients with WDTC underwent completion thyroidectomy. Forty-seven patients had presumed unilateral WDTC, with no evidence of residual disease prior to their completion thyroidectomy. Twenty-five (53%) of these patients were found to have residual neoplastic disease in the neck. In 20 (43%) of 47 patients, a focus of cancer was found in the remaining thyroid lobe and in 5 additional patients no cancer was found in the contralateral lobe, however, unsuspected nodal disease was found. The remaining 13 of the 60 patients presented with either regional recurrence (n = 12) or distant metastases (n = 1) at the time of their completion thyroidectomy. All (92%) but 1 of these 13 patients had cancer in the remaining thyroid lobe. Multifocal disease in the primary lobe was associated with bilateral thyroid cancer (p less than 0.01). Complications were infrequent; transient hypocalcemia occurred in 5 (8%) patients, permanent hypoparathyroidism occurred in 1 (1.7%) patient, and transient recurrent laryngeal nerve palsy occurred in 3 (5%) patients. Residual WDTC was found in 37 (62%) of 60 patients undergoing completion thyroidectomy. Multifocal disease in the primary resected lobe was associated with a high incidence of contralateral thyroid cancer. Completion thyroidectomy is a safe procedure and may prevent the development of regional recurrence by eliminating an unsuspected focus of cancer.


Long-term effects of parathyroidectomy for primary hyperparathyroidism on arterial hypertension.

The prevalence of arterial hypertension in primary hyperparathyroidism (PHPT) is higher than in the general population. With the aim of determining the evolution of hypertension associated with PHPT, we analyzed a group of 56 patients followed for a mean of 60 months (range 10-101 months) after successful parathyroidectomy for PHPT. The study group consisted of 16 men and 40 women. The mean age was 49 +/- 12 years (range 18-73 years). None of the patients had renal impairment. Two hypertensive patients died during the follow-up from complications related to their hypertension. Twelve (21.8%) patients were hypertensive before parathyroid surgery (systolic greater than 160 mmHg and/or diastolic greater than 90 mmHg). Pre-operative midregion serum parathyroid hormone concentration was higher in the hypertensive patients than in normotensive patients (2.7 +/- 2.4 vs 0.82 +/- 0.4 mu iEq/l, p = 0.018). Pre-operative creatinine clearance was lower in the hypertensive patients than in normotensive patients (65.4 +/- 27.5 vs 86.7 +/- 26 ml/min, p = 0.002). There were no significant differences between normotensive and hypertensive patients in age, sex, body weight, clinical manifestations, weight of parathyroid tissue removed, and calcium metabolism, or in plasma concentrations of magnesium, uric acid, cholesterol, proteins, or albumin. During follow-up, none of the patients with pre-operative hypertension became normotensive, whereas 32% of the patients who were normotensive preoperatively developed clinical hypertension. The global prevalence of postoperative hypertension was thus 48%. The patients that developed hypertension after parathyroidectomy were followed for a longer period than the normotensive patients (76 +/- 17 vs 53 +/- 10 months, p = 0.005), had a lower postoperative creatinine clearance (74 +/- 28 vs 90 +/- 25 mg/min, p = 0.07), and higher cholesterol levels (6.2 +/- 1.5 vs 5.5 +/- 0.9 mmol/L, p = 0.08).(ABSTRACT TRUNCATED AT 250 WORDS)


Prognostic factors in parathyroid cancer: a review of 95 cases.

The clinical course, histopathology, and tumor DNA distribution patterns were analyzed in 95 patients with parathyroid cancer. The median follow-up was 6 years (range 1-25 years). Eighteen patients received a benign diagnosis at their first operation. The initial procedure was tumor resection in 42 patients and tumor resection plus partial or total thyroidectomy in 40 patients. Forty patients developed recurrent disease and 36 patients underwent 1 to 9 re-operations. Cervical recurrence and lung metastases were most commonly encountered. The median time from the first operation to recurrence was 33 months (range 1-228 month). Twenty-one patients died of parathyroid cancer a median of 28 months following discovery of their first recurrence. The histopathological reevaluation confirmed unequivocal parathyroid cancer, i.e., infiltration and/or metastases, in 41 cases. Fifty-four cases lacked these criteria but showed various forms of atypia. Image cytometry demonstrated tumor aneuploidy in 26 of 39 cases with definite cancer by histological criteria, compared to the 13 of the 52 with equivocal histological diagnosis. Twelve patients with aneuploid tumors and 7 patients with euploid tumors died of parathyroid cancer. In a multivariate analysis, patients treated with extensive surgery, i.e., tumor resection and unilateral or bilateral thyroidectomy, had a longer survival and a longer relapse-free period. Other factors of importance for survival were age and histopathology. Histopathology and an aberrant nuclear DNA content were important factors for the time to recurrence. We conclude that histopathology alone is unable to confirm a cancer diagnosis in the absence of infiltration and/or metastases. Because recurrence may occur late, patients should be followed closely. Even repeated surgical interventions have proven beneficial.


Survival rates and prognostic factors in adrenocortical carcinoma.

In the last 12 years, 41 patients with adrenocortical carcinoma were operated on at Cochin Hospital. There were 29 females and 12 males having an average age of 42 +/- 17 years. Seven of them underwent repeat operation for local recurrence after an average interval of 22 months. Eighty per cent of the tumors had secretory activity while 20% did not. Adrenalectomy and lymphadenectomy were performed on all patients. Thirteen (32%) patients underwent extensive resection because of invasive cancer. The same procedure was performed on 7 patients undergoing re-operation. Operative mortality was 4% (2 of 48 patients). Twenty-four patients died of cancer with an average survival time of 22 months (range 2-86 months) and 15 (37%) patients were still alive, 4 of them with metastases, with an average survival time of 51 months. Curative resection for the 31 patients with local (n = 21) or regional disease (n = 10) allowed a 5 year actuarial survival rate of 45%. The 5 year actuarial survival rate for patients undergoing repeat surgery was 33%. Only 1 of the 10 patients with metastases, and who had an impressive response to OP'DDD, was alive 2 years after the operation. The other 9 patients died within 3-4 months after operation. We found that neither patient characteristics or tumor characteristics were of significant prognostic value. There was no overall prolongation of survival in patients receiving OP'DDD. However 4 patients with metastases occurring in the course of their disease experienced an impressive response with OP'DDD and a relatively long survival.


The role of epinephrine, norepinephrine, and dopamine in blood pressure disturbances in patients with pheochromocytoma.

Fifty-six patients with pheochromocytoma underwent surgery during the 9-year period from 1981 to 1990. These patients were divided into two groups according to whether the dominant plasma concentration was of epinephrine or norepinephrine. Plasma levels of the catecholamines were stratified into three grades at 5 and 10 times the normal upper limit. Pre-operative disturbances of blood pressure, sustained or paroxysmal, and normal blood pressure were highly correlated with the dominantly secreted catecholamine and its plasma concentration. Thirteen patients with high plasma norepinephrine levels (greater than or equal to 10 times normal) had sustained hypertension while 18 patients with moderate to high plasma epinephrine levels (greater than or equal to 5 times normal) had paroxysmal hypertension. In the majority of normotensive patients (12 of 14), plasma catecholamine levels were less than 10 times the upper normal limit. Urinary excretion of dopamine and size of the tumor were analyzed according to these patient groups. In the norepinephrine dominant group, urinary dopamine excretion tended to be proportional to the plasma epinephrine levels and when the patients were normotensive, urinary dopamine excretion decreased. In norepinephrine-secreting patients, urinary dopamine tended to be inversely correlated with the plasma norepinephrine level; however dopamine did not prevent the hypertensive action of norepinephrine. Tumor size showed no correlation with the plasma levels of catecholamine in the moderate to high plasma catecholamine groups. We conclude that the plasma catecholamine type and its level are the most important factors in determining the patterns of blood pressure disturbances of patients with pheochromocytoma.


A template for health information.

The Template for Health Information is a software package for microcomputers developed by the National Task Force on Health Information of Statistics Canada. The Template software provides a conceptual framework for the collection, analysis and utilization of health information for policy planning and management uses. This framework involves interactions between a population of individuals, their external environment, and sets of potential health-affecting interventions. The Template is seen as a pedagogical device for incorporating the many perspectives of different health constituencies. A floppy diskette is provided with the article to demonstrate the potential of the Template.


Single and multigland disease in primary hyperparathyroidism: clinical follow-up, histopathology, and flow cytometric DNA analysis.

Two-hundred seventy-four patients with primary hyperparathyroidism had selective removal of enlarged parathyroid glands. Biopsies were taken from all parathyroid glands. Normal-size glands were not resected irrespective of their histological appearance. After a mean follow-up of 13.5 years the rates of persistent and recurrent hyperparathyroidism were, respectively, 3.6% and 0.7%. Transient and permanent hypoparathyroidism occurred in 24% and 2.5% of the patients. The microscopic appearance of enlarged glands and of biopsies taken from normal-size glands were reviewed by two pathologists. Normal parathyroid glands were distinguished from abnormal glands fairly accurately (sensitivity 93%, specificity 80%). Microscopic classification of abnormal parathyroid glands as adenomas or hyperplastic glands correlated poorly with the gross classification as single or multigland disease. Flow cytometric DNA analysis of paraffin embedded parathyroid tissue showed significant differences for DNA index, % S-phase and % G2M (p less than 0.001). Differentiating single from multigland disease by means of DNA analysis was not possible. In conclusion, removal of only enlarged parathyroid glands results in acceptable rates of persistent and recurrent hyperparathyroidism. Biopsies should only be taken sparingly to prevent transient and permanent hypoparathyroidism. Microscopic examination and flow cytometric DNA analysis can differentiate normal from abnormal parathyroid glands but are unable to differentiate abnormal glands into single or multigland disease.


Primary hyperparathyroidism in Austria: results of an 8-year prospective study.

Serum calcium determinations in 45,217 hospitalized patients during an 8 year period revealed sustained hypercalcemia in 124 (0.3%) patients. Further clinical and biochemical investigations established primary hyperparathyroidism (PHP) in at least 40 (32%) patients, an incidence of PHP of 89.6 +/- 41.5 per 100,000 patients per year. The incidence of PHP in males and females was 31.5 and 124.2 per 100,000, respectively. The highest incidence was found in females greater than 66 years of age (268.8 per 100,000). Nineteen (48%) patients showed classical symptoms of PHP, 14 (35%) patients were minimally symptomatic, and 7 (17%) patients were asymptomatic. The incidence and symptomatology of PHP in Austria is nearly the same as in other countries. Because of the multiple actions of parathyroid hormone in the body, PHP can cause debilitating symptoms but too often it remains undiagnosed clinically. Routine calcium determinations are very important and PHP must always be considered in the differential diagnosis, especially in minimally symptomatic patients.


The value of measurement of ras oncogenes and nuclear DNA analysis in the diagnosis of Hürthle cell tumors of the thyroid.

Hürthle cell tumors (HCT) remain difficult to treat because some which appear non-malignant on light microscopy later metastasize. In order to improve diagnostic accuracy, the value of ras mutations and nuclear DNA analysis was determined in 65 patients with HCT. Rapid nuclear DNA cytometry (MicroTICAS system) was performed. Mutations of H-ras, K-ras, and N-ras genes were analyzed by oligonucleotide probe hybridizations to polymerase chain reaction (PCR) amplified DNA. HCT were classified by light microscopy as benign (n = 22), intermediate (n = 30), and malignant (n = 13). After a mean follow-up of 7 years, 1 (4.5%) of 22 benign tumors and 4 (13%) of 30 intermediate tumors had metastasized, leading to tumor death in 3 of these 5 patients. Six of the 13 cancers diagnosed by light microscopy also resulted in tumor-related deaths. Aneuploidy was found in 83% of all Hürthle cell cancers, including 3 (60%) of the 5 cancers not diagnosed microscopically. However, 49% of non-malignant HCT also demonstrated aneuploidy. A nuclear area of less than 55 square microns was found in 83% of all Hürthle cell cancers and in 100% of those cancers not diagnosed by light microscopy. However, 47% of non-malignant HCT also demonstrated a "small" nuclear area. Aneuploidy correctly identified 8 of 9 cancers that resulted in tumor death and each of 3 other tumors that developed metastases. However, 1 patient with a diploid tumor died of metastatic cancer. A nuclear area of less than 55 square microns identified each cancer that resulted in a tumor death.(ABSTRACT TRUNCATED AT 250 WORDS)


Surgery for hyperthyroidism: hemithyroidectomy plus contralateral resection or bilateral resection? A prospective randomized study of postoperative complications and long-term results.

Fifty consecutive patients undergoing surgical treatment for hyperthyroidism were randomized to have either bilateral subtotal resection (n = 23) or hemithyroidectomy plus contralateral resection (n = 27). No significant differences in operating time or intra-operative bleeding were found. No postoperative bleeding and no temporary or persistent recurrent laryngeal nerve paralysis occurred. Four patients who underwent bilateral resection and 2 patients who had hemithyroidectomy resection needed temporary calcium supplementation, and the serum calcium concentrations were slightly lower during the first few postoperative days in the patient undergoing hemithyroidectomy/resection. No persistent hypocalcemia occurred in either of the groups. At follow-up 3-4 years (mean 3.6 years) postoperatively, 1 patient in the bilateral resection group developed recurrent hyperthyroidism; no patients in the hemithyroidectomy/resection group developed recurrent hyperthyroidism. Twelve (44%) patients in the hemithyroidectomy/resection group and 8 (35%) patients in the bilateral resection group needed thyroxine supplementation because of a rise in thyroid stimulating hormone concentration combined with clinical signs of hypothyroidism that developed during follow-up. Hyperthyroidism can be treated by hemithyroidectomy plus contralateral resection without increasing the risk of complications. The results also suggest that when using this method, a slightly larger thyroid remnant should be left to avoid an increase in the incidence of hypothyroidism postoperatively.


Trends in cancer mortality sex ratios in Europe, 1950-1989.

A study was carried out to analyse trends in cancer mortality sex differentials. This study compared age-standardized sex ratio values for mortality from 18 cancers (or groups of cancers), and total cancer mortality over the period 1950-1989 in 24 European countries, for 4 age groups (all ages, 20-44 years, 45-64 years, and 65 years and over). For lung cancer and other tobacco-related neoplasms, appreciable rises in sex ratio values were observed until the late 1970s, particularly in Southern and Eastern Europe, before levelling off in recent years, particularly among the younger age groups. In the late 1980s, the range of variation in overall age-standardized sex ratios for lung cancer was between 2 and 3 in the United Kingdom and in Nordic countries, and around or over 10 in Southern Europe. In young adults, the decline in sex ratio values observed in Denmark and Sweden (unity), and in other Nordic countries and in the United Kingdom (around or below 2) reflects a levelling of lung cancer in young males and an increase in young females. This clearly indicates that young women are a priority target group for smoking control interventions in Europe. Appreciable cohort effects were also observed for stomach cancer: rises in sex ratio values were greater in, or restricted to, middle- and older age groups, whereas in the young there was some tendency towards a levelling in sex differentials. The overall sex ratio values for stomach cancer were around 2 in most areas of Europe in the late 1980s. For intestinal cancer, sex ratio values showed some tendency to rise, reaching a level of 1.3-1.7 in the late 1980s; steady rises were also registered in sex ratio values for melanoma (skin cancer), reaching 1.5-1.8 in the late 1980s in most countries. These upward trends which were minor or inconsistent at younger ages in several countries became progressively stronger with advancing age. Sex ratio values were below unity for cancers of the gallbladder and the thyroid. Sex ratio values tended to rise also for leukaemia (from 1.2-1.5 to 1.5-1.7), but showed no noticeable trend for lymphomas or myeloma. The overall sex ratio values for total cancer mortality in the 1950s were between 1.2 and 1.4 in most European countries. Thereafter, they rose appreciably in several countries, reaching 1.9 in Czechoslovakia, Italy and Poland, and 2.3 in France.(ABSTRACT TRUNCATED AT 400 WORDS)


The evolving demography of aging in the United States of American and the former USSR.

In the United States of America and in the republics of the former USSR, the elderly (persons aged 60 and over) will comprise the same proportion of their respective societies by the year 2000, namely 17%. In both countries, this population subgroup is growing at a faster rate than the rest of the population and living longer, although there are now more differences than similarities between the two countries in respect of the elderly, as summarized below. Similarities. In both countries today, the age group 50 years and over represents 26% of the total population, and by the year 2000 it is expected that 17% of the population will be 60 years and over. Diseases of the circulatory system and neoplasms are the major causes of death in both countries. Life expectancy beyond retirement age (i.e. the number of years a person is expected to live after having retired) is about the same in both, but this is due to the statistical fact that in the former USSR women are expected to have an extra year of life expectancy compared to their United States counterparts, while men are expected to live 2.5 years less beyond retirement than their United States counterparts. Differences. Mortality rates in the former USSR are higher than those in the United States. Life expectancy for men in the former USSR is 6.5 years below the figure for United States males. By age 65, the differences are 2.7 years for women and 2.4 years for men. Today, the proportion of the population having reached retirement age is larger in the former USSR than in the United States (17% vs 15%) because of lower retirement age in the former USSR. By the year 2000, these figures are expected to be 19% and 25%, respectively. Men make up 27% of the pension-age population in the former USSR against 41% in the United States. Life expectancy at birth could increase by 4 years for men in the former USSR if they had the same mortality rates from diseases of the circulatory and respiratory systems as their United States counterparts. Similarly, women in the former USSR would gain 4 years of life from these two causes alone. Older women are more likely to be married in the United States than in the former USSR, and this difference increases with age: at age 65, 25% of the former USSR's women are married versus 41% in the United States.


Percutaneous ethanol injection treatment of autonomously functioning single thyroid nodules: optimization of treatment and short term outcome.

Twenty-five patients with solitary autonomous thyroid nodules (15 nontoxic, 10 toxic) received percutaneous ethanol injection treatment (PEIT) under sonographic guidance in 4-7 sessions (1-2 weekly). To test different doses, smaller nodules (volume less than 15 mL) were given 0.75-2.8 mL ethanol/mL nodular tissue while larger nodules received 0.5-1 mL/mL. Except for 1 patient who developed hyperpyrexia, no relevant adverse effects were observed. A slight, asymptomatic increase in serum thyroid hormone levels was observed in both groups during the treatment. Three months after treatment, a biochemical and clinical remission of hyperthyroidism was observed in 8 of 10 patients with toxic nodules. A significant increase of TSH level was seen in both groups (p less than 0.01). Significant shrinkage of volume (p less than 0.001) as well as structural alterations of nodules were consistently recorded at sonography. A linear relationship (r = 0.98; p less than 0.0001) between pretreatment volume and volume reduction was found both for large and small nodules, thus suggesting that even limited ethanol doses may be therapeutically effective. A recovery of extranodular parenchyma activity at scintiscan occurred in 16 (64%) of 25 patients. These data confirm that PEIT is effective in obtaining functional ablation and in inducing remission of hyperthyroidism. Adverse effects are infrequent. In spite of the small patient sample, a 0.5-1 mL ethanol dose per each mL of tissue appears as effective as larger doses and seems appropriate for treatment.


Analysis of mortality data from the former USSR: age-period-cohort analysis.

The objective of this article is to review research on age-period-cohort (APC) analysis of mortality and to trace the effects of contemporary and historical factors on mortality change in the former USSR. Several events in USSR history have exerted a lasting influence on its people. These influences may be captured by an APC model in which the period effects measure the impact of contemporary factors and the cohort effects the past history of individuals which cannot be attributed to age or stage in the life cycle. APC models are extensively applied in the study of mortality. This article presents the statistical theory of the APC models and shows that they belong to the family of generalized linear models. The parameters of the APC model may therefore be estimated by any package of loglinear analysis that allows for hybrid loglinear models.


Some problems of medicodemographic development in the former USSR.

The republics of the former USSR show great diversity in life expectancy, and in morbidity and disability prevalence rates. The diversity in life expectancy is strongly influenced by the different age, sex and cause-specific mortality rates obtaining in each republic. These in turn are determined by environmental, climatic and topographic features, as well as by social and economic development and lifestyle, including nutritional habits. In addition, large urban and rural differences are noted which may be partly accounted for by the restricted access to and low quality of health care in rural areas. Mortality, morbidity and disability rates have also shown unfavourable trends between 1965 and 1989 in many of the republics. The authors suggest further research to elucidate observed mortality, morbidity and disability differentials and trends, viz. analyses using finer breakdown of the population; examination of risk-factor-pattern data for mortality and morbidity by social groups and regions; the collection of data on health and demographic problems of ethnic minorities; greater use of socioeconomic development indicators at the regional level; surveys of individual opinions on perceived health, health requirements and quality of care received; and the development of appropriate medicodemographic models for analytic and forecasting purposes.


Economic aspects of health.

This study described in this article was undertaken to assess the possibility of getting a general picture of the public health situation to be used in such economically oriented models as cost-benefit, cost-effectiveness and cost-utility. Problems of data bases encountered in this assessment of various republics, regions and administrative entities are also considered. New mathematicodemographic statistical models and a family of potential factographic automated information reference systems (FAIRS) based on these models and designed to be utilized in projects, programmes and regional systems of public health are analysed.


Data needs for health policy in an aging population (including a survey of data available in the United States of America).

The development of a coordinated, systematic and responsive data base is essential for governments to make informed decisions for policy development and planning, to assess the impact of these decisions, and to operate their programmes effectively. One of the most significant challenges is the development of data systems capable of satisfying the multiple needs for data, and providing the data required for evaluating the impact of health programmes, while keeping the respondent burden reasonable. The United States of America is fortunate in having well-developed systems of data collection by national surveys for demographic, social and economic characteristics of the population, morbidity and mortality, health expenditures, and use of health and long-term care services. Current survey and administrative record data sets are described. Policy issues in health care for aging populations require the use of multiple data sets which may require modification of or addition to existing surveys and administrative records. Recommendations are made for an extension of the data bases already in existence and on the expansion of analytical capacity to address health policy issues for the elderly.


Primary hyperparathyroidism in younger and older patients: symptoms and outcome of surgery.

Two-hundred and fifty patients undergoing initial exploration for primary hyperparathyroidism were analyzed for differences in clinical presentation, biochemical status, pathology, and outcome of surgery. In patients less than 60 years of age (younger patients, n = 119) the most common preoperative symptoms and signs were fatigue (40.3%), bone pain (33.6%), renal stones (31.0%), hypertension (27.7%), and psychiatric illness (27.7%). In patients greater than or equal to 60 years of age (older patients, n = 131) the most frequent symptoms and signs were hypertension (46.6%), fatigue (35.1%), bone pain (30.5%), muscle weakness (28.2%), and joint pain (22.9%). Renal stones were 2.6 times more common (p less than 0.001, chi 2) in younger patients and hypertension 1.7 times more common (p less than 0.05, chi 2) in older patients. There was no significant difference in the preoperative and postoperative laboratory values typically associated with primary hyperparathyroidism. Double adenomas were more common in older (9.2%) than in younger patients (2.5%, p less than 0.05, chi 2). Surgical cure was obtained in 98.8% of patients, and after parathyroidectomy 83% of the younger and 82% of the older patients experienced substantial relief of pre-operative symptoms. Specific questioning revealed most patients to be symptomatic and older patients appear to receive the same clinical and metabolic benefits from parathyroidectomy as younger patients.


An overview of relevant data sources in the former USSR for studies in demographic trends, aging and noncommunicable disease problems.

This article provides an overview of health data available in the former USSR. It is not all-inclusive in terms of chronic diseases covered or in details of data collection activities carried out. However, several broad conclusions can be drawn: There is a system of population and mortality data collection which covers the former USSR and which can be disaggregated to smaller administrative areas. The system is being exploited by population specialists, demographers, medical demographers and epidemiologists, both nationally and internationally, both for analytical purposes and as part of health monitoring systems. A national-level data-collection system for morbidity and disability, based on delivery of health services, is in place and is exploited by both health researchers and health planners. The shortcomings of such a health service-based statistical system are well recognized. Further standardization or calibration of measures of total and cause-specific morbidity and disability measures should be examined. A potential calibration tool is the 1988-1993 health examination and interview survey covering a representative (but highly clustered) sample of the former USSR population. The possibilities of greater standardization of measurement procedures used in this survey should also be investigated. In certain disease areas, e.g. cardiovascular diseases, cancer, rheumatic diseases and gerontology, clinical and epidemiological studies involving international collaboration have been carried out. This has resulted in the use of internationally accepted disease definitions, diagnostic procedures, and of clinical and laboratory standardization of demographic, social and biological measurements. Participation in multilateral or bilateral studies should be encouraged in research in disease areas where these types of programmes have not yet been instituted.(ABSTRACT TRUNCATED AT 250 WORDS)


Epidemiology and aging: how gerontology has changed noncommunicable disease epidemiology in the United States of America.

Epidemiology is a continuously evolving discipline that has been greatly enriched by addressing the health problems of the elderly. In the United States of America, this has resulted in a large national data resource of functional and health measures on older populations, heretofore not available. In this article, suggestions are made for research priorities in the next 10 years in the epidemiological study of the elderly. They include: (i) a special emphasis on enhancing analytical methods, particularly for complex longitudinal data; (ii) an effort to understand the impact of the physiochemical environment on older persons, both in the household and workplace setting; (iii) the identification of new ways to determine early life exposures among older persons, so that hypotheses about early influences on aging processes can be tested; and (iv) a general effort to include function status and other geriatric measures as a routine part of the clinical record, so that secondary research on such records can be more conveniently performed.


Forecasting health: data needs and implications for model structure.

An agenda for analysing data on the health and functioning of the elderly must indicate new types of data to be collected, innovations in data collection strategies and new methods for analysis and forecasting. The required research agenda is broad and will require inputs from investigators in a number of disciplines. The data and methods required will need to be developed in order to reflect national, regional and local variations in the health phenomena under study; they will also have to be responsive to these variations. In the end, however, if the investment is to be most useful, it must be integrated into simulation and forecasting models, the mechanics of which are based on individual-level processes and not on the elements of the service system.


Resource allocation problems and health services for the elderly.

The provision of appropriate health support services for the elderly has increased in importance because of the trend towards aging populations in Europe and other developed regions. Health service resource allocation models and their roles in health service systems, which are also changing to reflect changing needs for the elderly, are discussed in this article. Different types of economic and health care delivery systems are examined, particularly those leading towards decentralization, consumer participation and "deinstitutionalization". A promising resource allocation approach--the "balance-of-care" approach--is described in some detail. This and other potential approaches make it possible to identify areas which hold promise for crossnational research.