Frederick J. Wenzel

Immunofluorescent studies in patients with farmer's lung

Abstract Pulmonary tissues from patients with farmers lung have been studied with the use of fluorescein-labeled globulins from patients with this disease and with fluorescein-labeled antisera specific for IgG, IgA, IgM and C3 complement. Immunoglobulins of all three classes were found in the plasma cells and lymphocytes. The walls of the bronchioles appeared rich in antigen, staining well with the fluorescein-labeled globulins isolated from patients with the disease. Fixed C3 complement was present in the histiocytes, suggesting the antecedent presence of antigen-antibody complexes. No histologic or immunologic evidence of vasculitis could be found. These findings suggest further investigation of the hypothesis that at least part of the pathogenesis of farmers lung may involve a cytotoxic type II reaction. In this event, antigen adsorbed to the cells reacts with antibody in the presence of complement, causing cellular destruction. The presence or absence of a delayed component is still uncertain.

Pulmonary embolectomy: Review and current status

D ISCUSSIONS regarding pulmonary embolectomy are traditionally opened with a reference to Dr. Trendelenburg. I The controversy stimulated by this procedure has resulted in continued and considerable accrual of information regarding massive pulmonary embolism. Dialogue remains heated, both in the literature and from the speakers podium. Many authors, myself included, owe Dr. Trendelenburg a great debt; how many of our patients have such an obligation remains debatable. The Congress of German Surgeons in 1908 indeed must have been a stellar event. There were reports of the benefit of early ambulation as it affects thrombotic and embolic phenomena, technique of transplantation of the thyroid gland and bone, intravenous novocaine for anesthesia of the extremities, successful transnasal hypophysectomy for acromegaly, use of positive and negative atmospheric pressure for intrathoracic operations, and the description and use of an intraoperative gastroscope. It was in this setting that Trendelenburg reported his technique for pulmonary embolectomy. Although none of the patients upon whom he operated survived, the technique still bears his name. Kirschner, 2 a student of Trendelenburg, in 1924 reported the first success utilizing the procedure. In this country the first such success was reported in 1958 by Steenburg? Temporary inflow occlusion of the circulation, and tourniquet occlusion of the inferior and superior vena cava, was first used to do embolec-

Impact of Membership in an Enrolled, Prepaid Population on Utilization of Health Services in a Group Practice

Members of prepaid group-practice medical-care plans are believed to use more ambulatory, but fewer inpatient, services than populations served by fee-for-service practitioners. It is not known whether these differences are attributable to the prepayment aspects of the plan or to other circumstances. We studied the impact on use of services of only one factor-prepayment at the Marshfield Clinic, Wisconsin--with all other factors, including group practice, held constant. The findings were derived from the experience one year before, and two years after, the initiation of the prepaid program. Results showed that prepayment alone resulted in significant increases in both inpatient and ambulatory care (about 100 per cent in ambulatory-care visits, 75 per cent in hospital discharges, and 60 per cent in hospital days). These increases were far greater than comparable increases in the fee-for-service population served by the Clinic.

Serum immunoglobulin levels in farmer's lung disease

Abstract The serum concentrations of the five major classes of immunoglobulins were measured in 27 farmers lung patients and compared with a group of normals and a group of patients with diffuse lung disease, but no precipitins to our antigen panel. The mean IgG and IgA levels in the sera of the farmers lung patients were found to be significantly higher than that of the normal group. In addition, the IgG level of the farmers lung group was also significantly higher than the group with negative precipitin tests. The remaining immunoglobulin classes, IgM, IgD, and IgE, were not remarkably different from normal in either diffuse lung disease group.

Cholecystectomy Peer Review: Measurement of Four Variables

Process and outcome analyses were carried out on a group of patients who had uncomplicated cholecystectomy. The postoperative length of stay and patient satisfaction were also measured. A random sample of 80 charts was selected from 222 eligible records for process analysis. Outcome was evaluated in 218 of the 222 eligible patients against explicit criteria. More patients were in the symptomatic and back-to-work group than expected. The peer consensus was that these results were not related to the surgical procedure or specifically related to gallbladder disease. Ninety-five per cent of the patients assessed care as good or excellent, and 90 per cent felt the length of postoperative stay was satisfactory. When the patients were divided according to surgeon, significant differences in the length of postoperative stay were found in the 154 patients without common bile duct exploration. After the findings were presented to the surgeons through an educational program, changes occurred which resulted in a decrease of nearly one day in the postoperative hospitalization.

Can the Frequency of Myocardial Infarction Be Reduced during Coronary Artery Operations

A prospective experiment was carried out in 56 patients undergoing coronary artery revascularization to determine whether those having a glucose-insulin-potassium (GIK) perfusion during the procedure would have fewer myocardial infarctions (MI) compared with patients given a control perfusion of Normosol-R. Six patients (11%) developed an MI, defined as a 24-hour creatine phosphokinase MB isoenzyme value of 100 IU per liter or greater. Four (13%) had control perfusions and 2(8%) had GIK perfusion. One MI in a double-graft recipient who had GIK perfusion occurred because of a technical surgical error; therefore, the corrected MI rate was 13% in control patients compared with 4% for the GIK group. These data, as well as the more frequent spontaneous defibrillation in patients who had GIK perfusion, suggest that GIK was of benefit.

Quadruple Coronary Artery Bypass Grafting

In our last 150 consecutive revascularization operations, 30 patients (20%) have had 4 or more bypass grafts. One patient died after quadruple grafting (mortality, 3%). Twenty-two (75%) of the survivors have been rehabilitated to active work status and 25 (86%) were considered by their cardiologists to have improved function postoperatively by New York Heart Association criteria. Preoperatively 15 patients (50% of the group) had either a markedly diminished ejection fraction (EF) or extreme elevation in left ventricular end-diastolic pressure (LVEDP) or both. Complete revascularization, with resection of ventricular aneurysms when present, can be carried out successfully in a high-risk group of patients. Elevated LVEDP or diminished EF per se is not a valid contraindication to myocardial revascularization.

Adrenal cortical activity in depression

Summary We have presented a pilot study of ten depressed patients as well as preliminary data from another study which suggests alternations in the diurnal pattern of steroid excretion in depression. We found evidence that the patients own rating of his affect may be an accurate predictor of increased adrenal cortical activity. Limitations of the rating instruments are apparent, and it is suggested that further studies be conducted to investigate correlations of the patients rating of his depression with that of an observer and with adrenocortical activity.