Fluctuations In Severity Research Articles

Idiopathic edema: Pathogenesis, clinical features, and treatment

Previously published findings are reviewed and new data are presented relating to the clinical features, pathophysiology, and treatment of the idiopathic edemas, a group of disorders diagnosed by exclusion of the known causes of edema. The disorders occur almost exclusively in women, show diurnal (postural), not “cyclic” fluctuations in severity, often cause discomfort and occasionally pain, and may be aggravated by prolonged orthostasis, hot environments, menses, and some drugs. Among the pathophysiologic factors known to be important in edema formation, in general: (1) Hypoproteinemia is more commonly the result than the cause of idiopathic edema; (2) elevated capillary hydrostatic pressure is seldom the primary cause, except perhaps in rare cases of occult congestive heart failure; (3) changes in tissue pressure may limit the progression of, but do not initiate, the edema; (4) changes in capillary wall permeability and (5) changes in capillary diffusion area, perhaps because of excessive dilatation of precapillary sphincters appear to be of importance; (6) abnormalities of lymphatic flow are not demonstrable; and (7) the upright posture is an important contributor to the excessive transudation in over 80% of the patients studied (“orthostatic edema”) but not in the remaining minority of patients (“nonorthostatic edema”). By balance studies with constant diets and by an abbreviated “posture test”, it has been shown that (A) the majority of patients with “orthostatic edema” have excessive orthostatic sodium (Na) retention that results from an excessive orthostatic fall in glomerular filtration rate, frequently associated with excessive renal tubular reabsorption of the subnormal filtered Na load because of orthostatic hyperaldosteronism, and (B) about 30%–40% of patients with orthostatic edema have “orthostatic water retention”, demonstrable by an inability to excrete more than 55% of a 20 ml/kg water load during 4 hr in the upright posture. In most of these patients but not in most other types of edema, orthostatic excretion of the water load is restored to normal by ethanol (a known inhibitor of vasopressin release). Improvement in orthostatic renal excretion by external compression of the legs and persistence of excessive orthostatic changes in leg volume despite restricted Na intake support microscopic evidence that a capillary “leak” may be the primary cause of most orthostatic edemas. Reduced dopamine excretion has been reported and linked to the causation of some types of idiopathic edema. Obesity is often associated with edema that differs from other idiopathic edemas in that it usually disappears with caloric restriction and weight loss. In occasional patients, undue sensitivity to heat may play a role as important as that of posture. Treatment of idiopathic edema includes avoidance of excessive salt intake, reduction of the duration of standing and sitting, and administration of conventional diuretics, preferably at 7 or 8 p.m., followed by recumbency for several hours before sleep. Hyperaldosteronism has responded to subtotal adrenalectomy (which is not recommended) and constitutes a strong indication for the use of spironolactone, which facilitates recumbent excretion of Na retained in the upright posture. Sympathomimetic amines (ephedrine, phenylephrine, and preferably dextroamphetamine) are the only agents that will usually significantly reduce the excessive weight gain from morning to evening (the hallmark of orthostatic edema), perhaps by preventing excessive capillary pooling and transudation. They have been used safely, effectively, and without loss of their efficacy, for up to 20 yr in several patients. Elastic stockings and garments are occasionally useful and regular exercise, especially swimming, may be beneficial.

Relationship between bronchial reactivity, airway caliber, and severity of asthma.

Indices of bronchial reactivity were obtained in 11 asthmatic subjects. These were based on the responses of specific airway conductance to timed cumulative doses of methacholine aerosol. The relationship of bronchial reactivity both to initial airway caliber and to current severity of asthma was then assessed. There was no correlation between initial airway caliber and the degree of bronchial reactivity for the group. Furthermore, a subject's bronchial response to methacholine, when expressed as a percentage of initial specific airway conductance, remained stable, even in the presence of moderate fluctuations in initial specific airway conductance. There was also no correlation between bronchial reactivity and severity of asthma for the group. Each subject's bronchial responses remained stable, even in the presence of moderate fluctuations in severity of asthma. These data confirm that a simple relationship between intrinsic bronchial reactivity and the severity of clinical asthma is not apparent.

Tropical splenomegaly syndrome in New Guinea. I. Natural history.

Abstract The course of the tropical splenomegaly syndrome has been observed for periods of up to 6 1 2 years in 75 adults living in the Upper Watut Valley of New Guinea. During this time there were 27 deaths, 2 from septicaemia and another 8 from similar fulminating febrile illnesses. The mortality rate in those with Grade V splenomegaly was 57%, almost 3 times that of the remainder. Serial hospital assessment of 26 subjects demonstrated progression of the disease, characterized by further enlargement of the spleen and a fall in haemoglobin concentration in 9; increases in splenic red cell pool, in plasma volume and in serum IgM concentration were sometimes, but not invariably, associated. In none of the total group of 75 subjects was a decrease in spleen size observed. Thus the natural history of the tropical splenomegaly syndrome is that of a progressive disease with a high mortality in the fully developed case. Periodic fluctuations in the clinical severity of the disorder are frequently seen and are largely related to the occurrence of episodes of acute haemolysis; however, spontaneous remission has not been observed.

Gamma-globulin in treatment of acne and psoriasis.

Evaluation of new agents in the treatment of acne and psoriasis is fraught with difficulty. This is evidenced by the number of new medicaments which have been introduced with enthusiasm to be cast aside later as valueless. Two factors have been mainly responsible: first, normal fluctuation in severity of these particular disorders and, second, lack of adequate controls in most investigations. During recent years γ-globulin has been utilized by several investigators in the management of acne. Shaffer and co-workers 1 reported on 4 patients with severe pustular and cystic acne who had been resistant to conventional therapy; after 2 injections of 10 cc. of poliomyelitis immune globulin in successive weeks there was temporary improvement in 2 cases and no change in the other 2. Sutton and Asel 2 used γ-globulin in dosage of 2 cc. at approximately weekly intervals, in addition to standard therapy, for 19 patients with acne. Results

Effect of the Vitamin B Complex in Diabetes Mellitus1

Because members of the vitamin B complex are concerned in carbohydrate metabolism, it has been suggested that they might have an ameliorating effect in diabetes mellitus. Clinical trials (1) with thiamine hydrochloride have been disappointing, but in experimental diabetes, Chaikoff and Kaplan (2) have shown that the administration of whole vitamin B complex prolongs the life of depancreatised dogs. We have, therefore, tried the vitamin B complex in clinical diabetes, but without benefiting the condition. METHODS Assessing the effect of a therapeutic measure in diabetes is difficult because of the great fluctuations in severity which many patients manifest. Elderly diabetics, in particular, often may take 20 to 30 units of insulin daily less than their true requirement, and only gradually over weeks develop marked glycosuria. The effect of infections is likewise well-known. It is possible that serial glucose tolerance tests would be the most accurate criterion for judging the condition of a diabetic, but s...

Recent developments in plant diseases in the United States

The present summary of information regarding certain diseases in the United States through the season of 1940 is in large part a continuation of one published earlier in this journal (23) which contained information up to and including 1935. As in the earlier paper, the choice of diseases to be included has been determined by the present interest of the disease due to its recent appearance in this country or to marked fluctuations in extent or severity, and by the completeness or reliability of available information regarding its incidence. Miss Jessie I. Wood, who collaborated in the preparation of the earlier paper, has aided in this one with numerous valuable suggestions. Much of the material here summarized is, of course, taken from the Plant Disease Reporter. For economy and convenience, references to this publication are made merely by volume and page, italicized, in parentheses inserted in the text.

A Preliminary Report on the Occurrence and Distribution of the Common Bacterial and Fungous Diseases of Crop Plants in Illinois

The next important step in the study of plant diseases is concerned with epidemiology—the fluctuation in severity and abundance from year to year exhibited by all diseases. An explanation of the causes underlying these fluctuations promises things of the greatest importance to the growers of our crops in the improvement of control measures and the regulation of times and methods of their application.

PROPHYLACTIC INOCULATION AGAINST RESPIRATORY INFECTIONS

In attempting to lessen the incidence and to reduce the severity of infections of the respiratory tract by vaccination, it is essential to consider the wide range of bacterial flora, the relative prevalence of each species, as well as the fluctuations in incidence and severity of these infections with changes in season. The well-defined tendency of bacteria of the same species to localize differently in different epidemics indicates peculiar infecting and antigenic powers. The short duration of immunity to infections following attacks adds greatly to the difficulty. However, owing to the high incidence and high mortality rate from infections of the respiratory tract during the present epidemic, a painstaking effort to raise the resistance of individuals by inoculation with appropriate vaccines appeared to be strongly indicated. In considering prophylactic inoculations in this epidemic of influenza, we put aside the debated question as to the cause of the initial symptoms and