Biomedical subjects
Publications and source records attributed to M A Crouch.
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In a university-based family practice residency program, patients' computerized medical records were audited to determine how information about family health history was recorded. Family history items were listed on the problem lists for only 4.4 percent of all active patients and for only 2.7 percent of a systematic sample of 375 patients. A manual audit of 75 charts randomly selected from the systematic sample showed that the problem lists contained only 5.8 percent of the family history items reported by patients. Children's problem lists contained fewer family history items than did those of adults.
Audiotapes of the visits of 50 new patients with 20 family practice residents were analyzed to determine how aware the residents were of their patients' families. The same patients' opinions about family awareness were elicited by interviews. Residents exhibited only limited family awareness. Despite this, patients thought that the residents showed more interest in family matters than they usually expected from a family physician. Patients thought the physicians were most interested in their family situations when they asked more questions about family matters. Physicians were seen as least interested when they asked few family questions and when they were absent from the examination room for a relatively high proportion of the visit. Physicians were much less likely to discuss family matters with a patient during a short visit for an acute problem than during a longer visit for a chronic problem or for health maintenance. Most patients identified physician attitudes and behaviors as more important obstacles to the discussion of family matters than patient attitudes. Patients generally wanted substantially more help from their family physician for family problems than they expected to receive.
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The diagnostic and prognostic significance of plasma inactive creatine kinase B protein (CK-Bi) levels measured by radioimmunoassay was determined in various ischemic myocardial syndromes. In 120 stable angina patients free of pain at time of blood sampling, mean CK-Bi level was 114 +/- 42 (SD) micrograms-equiv/ml; 195 micrograms-equiv/ml (95% confidence interval) represented upper limit of normal. In seven coronary artery disease (CAD) patients atrial pacing induced ischemia was not associated with increased coronary sinus CK-Bi. Of 201 consecutive patients with suspected acute infarction (AMI), 45 developed ECG criteria of transmural AMI with concomitant increased plasma CK-Bi levels (498 +/- 133, range 372-718 micrograms-equiv/ml). Elevated CK-Bi levels in evolving transmural AMI were detected before raised CK enzyme activity. Elevated plasma CK-Bi levels also occurred in acute pericarditis and in unstable angina. In the 84 patients not developing ECG changes or elevated plasma CK activity, their plasma CK-Bi levels were also normal and no coronary events occurred in the next 6 months. The remaining 55 patients had nontransmural AMI, with 15 also having elevated plasma CK and CK-Bi levels, of whom six developed re-AMI in the next 3 months. In the other 40 nontransmural AMI patients, plasma CK-Bi levels (350 +/- 65 micrograms/equiv/ml, range 228 to 445) increased significantly without associated CK activity rise, and 24 developed re-AMI (three fatal) in the next 6 months. These data suggest that: (1) plasma CK-Bi protein radioimmunoassay measurement provides a sensitive means for detecting myocardial necrosis or inflammation and (2) elevated plasma CK-Bi levels in coronary disease patients during myocardial ischemic pain may afford identification of a CAD clinical subset at high risk of subsequent AMI.
Using a specific radioimmunoassay for enzymically inactive creatine kinase (EC 2.7.3.2) B protein (CK-Bi), we studied 139 patients with various malignancies. We found it to be increased in certain adenocarcinomas, including colorectal, lung, and prostate, as has also been reported for enzymically active CK-BB. Of 15 patients with leukemia or lymphomas with active disease, 12 also had increased values for CK-Bi in plasma. In these patients, concentrations of CK-Bi in plasma tended to correlate with disease activity, increasing with aggressive malignancy and decreasing on successful treatment. Thus, measurement of CK-Bi may constitute a sensitive means for detecting malignancy and, in certain subsets of patients, for monitoring therapeutic response.
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The treatment of choice for chronic, symptomatic bradycardia is the placement of a cardiac pacemaker. Individuals who refuse or cannot tolerate pacemaker insertion usually require pharmacologic therapy. Hydralazine, prazosin, anticholinergics, and sympathomimetic agents have been administered for this indication, but adverse effects and limited data hinder routine, long-term use. Theophylline has emerged as a reasonable alternative strategy. For the medical management of bradycardia in the elderly, the literature supports theophylline dosages between 400 and 600 mg/d (approximately 8 mg/kg/d) administered in divided doses. This dosage range should result in a steady-state serum concentration between 5 and 15 mg/L. While some investigators recommend potentially higher initial doses (up to 12 mg/kg/d), lower dosages are more appropriate in the elderly due to decreased theophylline clearance. Initial dosage titration may be indicated and prolonged therapy is expected on the basis of the common etiologies of bradycardia in this patient group. Patient specifics such as altered theophylline metabolism (e.g., smoking), drug interactions (e.g., ciprofloxacin), and concomitant disease states (e.g., hepatic disease, heart failure) should always be considered in theophylline dosage recommendations. Clinicians should adjust the theophylline dose on the basis of patient response, including heart rate and clinical symptomatology, as well as measurement of occasional theophylline concentrations, if deemed appropriate. Theophylline should be avoided in the bradycardia-tachycardia manifestations of sick sinus syndrome or when ventricular ectopy is frequent. Additional investigation will further define the role of theophylline in elderly patients with chronic, symptomatic bradycardia.
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Heparin is one of the most frequently prescribed medications in the United States; yet, a significant number of patients receiving heparin develop heparin-induced thrombocytopenia and thrombosis syndrome. This detailed case report demonstrates the significant role nurses play in early detection and prevention of the numerous multisystem complications of this heparin toxicity.
Because more than one-half of adult Americans have total blood cholesterol levels that often contribute to atherosclerotic blockage of their coronary arteries, routine random screening of all adults and high-risk children for hypercholesterolemia is recommended. Reduced intake of saturated fat and cholesterol can lower total and low-density lipoprotein (LDL) cholesterol by 10-20 percent, while several medications lower total and LDL cholesterol by 15-40 percent. A highly effective cholesterol-lowering medication, lovastatin, has been recently marketed. The efficacy and long-term safety of ingesting large amounts of omega-3 fatty acids in fish oil supplements are unproven. Hypercholesterolemia is a family problem transmitted between generations by various combinations of genetic factors and learned behaviors. The family physician can be most effective by working with entire families to detect and treat hypercholesterolemia early in life to prevent serious consequences of prolonged cholesterol elevation.
The visits of 50 new patients seeing 20 family practice residents were audiotaped. Analysis of transcripts of all conversation involving family-related content showed that the resident physicians used a high control interviewing style consisting mostly of closed-end questions and declarative statements. They rarely asked open-end questions. After eliciting family information, the residents missed numerous opportunities to express empathy or concern verbally. The physicians seldom connected family information obtained during the visit with the patient's ongoing or potential health problems. Of 12 patients reporting a life-threatening familial illness in a close relative, only one received any relevant patient education. The closed style of interviewing appeared to interfere with the physicians' gathering and responding to family information.
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Two depression inventories were used to screen 377 family practice patients. One, the Self-Rating Depression Scale (SDS), assesses major symptomatology; it is the depression inventory most frequently used in family practice. The other, the Depression Adjective Checklist (DACL), assesses mood only and has not been previously reported in the family medicine literature. Forty-one percent of the patients who completed the SDS rated themselves at least mildly depressed; 37% scored in the same range on the DACL. Four percent of the patients scored in the severe depression range on the SDS, while 15% scored in the severe depression range on the DACL. Residents treating these patients, however, failed to diagnose depression in more than 85% of the patients who had rated themselves as at least mildly depressed on either inventory. The residents also failed to diagnose depression in more than 70% of those who had rated themselves as severely depressed. Teaching and research implications are discussed.
STUDY OBJECTIVES: To determine if alpha1-acid glycoprotein (AAG) concentrations are altered in patients with atrial fibrillation and flutter (AFF), and to establish if fluctuations in AAG change the free fraction of quinidine. DESIGN: Prospective, controlled, nonrandomized. SETTING: Tertiary care medical center and outpatient clinics. PATIENTS: Thirty patients with AFF and 16 matched controls. INTERVENTIONS: Serial blood samples were collected from patients with AFF at baseline and for 28 days after cardioversion. The control group received no treatment and a single blood sample was obtained. MEASUREMENTS AND MAIN RESULTS: Concentrations of AAG were measured by Laurell-Rocket immunoelectrophoresis. Quinidine concentrations were determined by fluorescence polarization immunoassay using the Abbott TDx system. Baseline AAG concentrations in patients with AFF (122 +/- 55 mg/dl) were significantly increased compared with the control group (62 +/- 28 mg/dl, p<0.0005). Concentrations of AAG remained elevated after conversion to sinus rhythm and did not significantly change over the study period, regardless of method of cardioversion (p>0.2). In patients with AFF, the free fraction of quinidine at the highest AAG concentration was 8.5 +/- 2.3%. This was significantly reduced compared with the value in the control group (12.5 +/- 3.0%, p<0.05) as well as that in patients with AFF at the lowest AAG concentration (11.0 +/- 2.5%, p<0.05). Overall at the highest AAG concentration, patients with AFF had a relative reduction in the quinidine free fraction by 32% compared with controls. Regression analysis showed an indirect relationship between serum AAG concentration and the unbound fraction of quinidine (r=0.56) CONCLUSIONS: Concentrations of AAG are increased in patients with AFF and remain elevated for at least 28 days after cardioversion. Elevated AAG concentrations significantly reduce the free fraction of quinidine.
We conducted a prospective, nonrandomized study in healthy volunteers to determine if racial differences exist in orosomucoid (ORM) and its variants, and to examine quinidine and lidocaine binding to the protein. Total ORM serum concentrations were measured by Laurell-Rocket immunoelectrophoresis. Allele types were determined by isoelectric focusing and immunoblotting. Total and unbound quinidine and lidocaine concentrations were measured with standard fluorescence polarization immunoassays after ultrafiltration. The frequency of the common ORM alleles was similar between 38 Caucasians and 67 African-Americans. Mean total ORM concentration was significantly lower in Caucasians (57.3 +/- 25.4 vs 73.2 +/- 33.9 mg/dl, p=0.01). However, more Caucasians took oral contraceptives, which may have decreased ORM concentrations. Quinidine unbound fraction (UF) was related to ORM phenotype. The highest UF was found with ORM 1-S (p=0.009). There were no significant relationships between ORM phenotype and lidocaine UF. Overall, African-Americans had higher ORM concentrations than Caucasians. Quinidine binding showed significant relationships to specific ORM variants.