Richard L. Hughes

Fiber Size and Energy Metabolites in Five Separate Muscles from Patients with Chronic Obstructive Lung Disease

The purpose of this study was to examine whether morphologic abnormalities in human respiratory muscles are related to increased airway obstruction. 43 patients who were undergoing thoracotomy for suspected neoplasm had biopsies taken from one or more of the following muscles: external intercostal (EXT), internal intercostal (INT), diaphragm (DIA), latissimus dorsi (LAT), and quadriceps femoris (LEG). Mean FEV1/FVC was 65% of predicted (range 43–90%). 21 of the 43 patients had a malignancy. Atrophy of type I fibers was found in 27% of respiratory and 11 % of nonrespiratory muscles. Type II fiber atrophy was more common, being found in 58% of all muscles studied. The degree of type II fiber atrophy correlated significantly with the amount of weight loss, but not with age or the presence of malignancy. A unique and significant relationship was found between type II fiber atrophy in the INT (an expiratory muscle) and all measured indices of airway obstruction. This relationship did not exist in the DIA, EXT, or LAT, ordinarily considered muscles of inspiration. The percentage of type I and type II fibers bore no relationship to indices of airway obstruction. Depletion of muscle metabolites was common to all muscles and could not be related to airway obstruction or fiber atrophy. These data suggest that fiber atrophy and metabolite depletion occur commonly in both respiratory and nonrespiratory muscles in patients with stable obstructive lung disease. These changes probably reflect a generalized disease process and may predispose to muscle fatigue. Whether or not airway obstruction produces fiber atrophy in expiratory muscles requires further investigation.

Training house officers to be cost conscious: Effects of an educational intervention on charges and length of stay

Two annual cost-containment educational programs, featuring involvement of respected senior physicians, lectures, comparative feedback, chart reviews, and small group discussions, were designed to reduce interns’ generated costs in a private and a VA university hospital affiliated with Northwestern University Medical School. To evaluate the impact of this randomized educational intervention, hospital data on inpatient charges and length of stay (LOS) were collected for 12 common medical diagnoses and adjusted by the Severity of Illness Index. Interns who were randomized to the program were found to have significantly lower per patient costs and LOS than control group interns at both hospitals. These reductions in resource use and LOS were not associated with differences in patients’ residual impairment on discharge, the incidence of inpatient complications, or the percentage of deaths and readmissions within 30 days. Our results suggest that the current hospital cost-containment environment may be far more conducive to physician cost-containment education than indicated by the earlier literature.

Effects of dietary protein on theophylline pharmacokinetics and caffeine and aminopyrine breath tests

The effects of low‐ and high‐protein diets on theophylline kinetics and the time course of changes in 13C‐labeled caffeine and aminopyrine CO2 breath tests were examined in six young men. With a low‐protein diet, mean theophylline clearance fell 21% (P < 0.04) and the t1/2 rose from 8.0 to 10.6 hours (P < 0.02). With a high‐protein diet, mean theophylline clearance rose 26% (P < 0.004) and the t1/2 shortened to 7.4 hours (P < 0.03). Theophylline volume of distribution and protein binding did not change. Renal clearance of theophylline was lowered during the low‐protein diet. Theophylline clearance correlated with caffeine breath test values during the low‐ (r = 0.73) and high‐ (r = 0.70) protein diets. Theophylline clearance correlated less well with the aminopyrine breath test values during the low‐ (r = 0.47) and high‐ (r = 0.55) protein diets. Thus dietary protein significantly influenced theophylline clearance, but the caffeine and aminopyrine breath tests showed a differential response to this important environmental factor.

Longer Hospitalization at Veterans Administration Hospitals Than Private Hospitals: Verification and Additional Insights

Utilizing 1,297 male patients under the primary care of an identical group of house officers and under treatment between 1985 and 1987 for ten common medical diagnoses, length of hospitalization was compared between a private sector (n = 481) and Veterans Administration (VA) (n = 816) facility, both affiliated with the same medical school. All patients were rated by the Horn Severity of Illness Index. After researchers controlled for diagnosis, severity of illness, age, race, and physician, results in this study indicate that an additional 3.2 days of hospitalization were associated with the VA facility. This finding is consistent with earlier reports of inappropriate hospitalization at the VA hospital and suggests that VA facility planners need to evaluate whether longer lengths of stay (LOS) are merited.

A Path Analysis of Medical School and Residency Performance Implications for Housestaff Selection

The selection and subsequent performance of 212 internal medicine residents was examined byfactor analysis andpath analysis. A three-factor solution accountedfor most of the variance among the nine selection variables. These three factors, labeled Board Scores, Faculty Evaluations, and Academic Distinction, were then combined with in-training residencyperformance evaluations and composite scores on the ABIM certifying examination to produce a comprehensive path model of house staff selection and performance. The Academic Distinction factor emerged as the strongest predictor of residency performance,; the Faculty Evaluationsfactor was also a significant component of the model. Standardized test scores correlatedpoorly with clinicalperformance. The data suggest that increased attention to the content of letters of reference could substantially improve their predictive validity. Other means of reporting subjective evaluations may also be needed to increase the stature of noncognitive attributes in house staff selection decisions.

Potential Effects of Nutritional State on Pulmonary Function in Cystic Fibrosis

ABSTRACT. There are a number of observations which suggest that malnutrition and decreasing pulmonary function are parallel phenomena in chronic lung disease. Causality for either has not been established. A potential link between the two may he the diminishing function of respiratory muscles which accompanies weight loss. Data from adult patients with chronic obstructive lung disease are presented which suggest that respiratory muscle fibers progressively atrophy, not hypertrophy, in the face of increasing airway obstruction. This lack of compensation is probably nonspecific since nonrespiratory muscles demonstrate the same trend. This observation may explain some of the impaired respiratory muscle function which has been documented in patients with chronic lung disease. There are no morphologic data available for older patients with cystic fibrosis, but the processes which impair muscle function may prove to he similar in both groups of patients. The effect of malnutrition on respiratory muscle fiber size remains to be determined.

Impairment of theophylline clearance by a hypocaloric low-protein diet in chronic obstructive pulmonary disease

The effect of a hypocaloric, low protein diet on theophylline kinetics was studied in a 70-year-old man with chronic obstructive pulmonary disease who lost 6.2 kg of weight. Total systemic clearance, unbound clearance, and intrinsic hepatic clearance fell dramatically. Theophylline elimination half-life rose from 8.4 to 17.1 h. Therefore, a diet deficient in both calories and protein can significantly impair theophylline clearance and prolong theophylline elimination half-life.