Document jKo1epwN6QKKZ0zebYbbMdE9

omnonisi Vol -*4 No. - correspondence 109 ifvraoano : i11ii w^nv..wm. /\ ' ooMTSonoM p"""9iai | : j11i1ii iiMi ii#i "__ Figure 1. Re-marking el the Inner Surface ol Sphygmomanometor Cull ter Proper Fit cumfcrcncc. this range should be shortened by 7.0 an. Patterns with Urge arms who arc "undertuffed" have systolic and diastolic readings that arc falsely elevated 5 to 10 nun H| on the average,1-4 leading to overDiagnosis and svcnreaiment of hypenenaton.1 The problem can be remedied bv re-marking, with an indelible marker, the right border of ihe ranee on a cult at a point where "5 per cent of the arm's circumference is covered by the bladder. This is most easily done by multiplying the bladder length by a/3, then marking a vertical line on the cuff at this distance from the left border of the cuff (Fig. I). Thus, when the cuff is applied snugly to the arm, one will know (without measurement) whether the cuff, sue it appropriate, if on closure the left cuff border meets a point to the left of the new line, the cuff it adequate: if the left border meets a point to the right of the new line, a larger cuff is required. Given the awkwardness of the older recommendations regarding cuff tiec. it is little wonder that most physicians and nurses do net employ objective criteria (manufacturer s markings or others) in se lecting a tat Sines adherence to the 1910 criteria can be easily ac complished and will save many large-armed patients from inappro priate antihypenensive treatment. Pittsburgh. PA 15219 Dt.vivts M. Mammae. M.D. Mercy Hospital of Pittsburgh I. Kirkcndall EM. Famleib M. Frei EA. at aL AHA Comamat Report: rcwfliintaOsusns for human bleed pressure dctoroumauoe by tphygmomanomnen. Circuituon. 1910: tilI46A-33A. Z. American Heart Association Recommendations for human blood praotun determination by tphyimomaaomciafs. Circulation. 1967; 34 9104. J. Simpson JA. Jammaoa G. Dickhaus DW, a si. Effaa of tut of cuff blsadcr on aecurscv of measurement of mdunci Mood prelaws. Am Hun J. 1963: 70:706-13. a. Nielson PE Janmche H. Tbs accuracy of auacuhstory mrmiumsni of 1*3:403-9. 3. liag GE Taking ibv blood prewar*. JAMA. 1969: J09-.I909-4. SPUTUM FOR OTOLOGIC DIAGNOSIS Off * LUNG CANCER Tt lit Editor: In a letter in the October I issue. Melamed and hit roiieatues reported that cytologic specimens obtained by pooling spui urn produced bv spontaneous coughing on the three mornings iter aerosol inouction contained identifiable cancer cells more fre quently than did specimen! obtained during induction itself. These authors mat na>e given the erroneous impression that the same ii true of ipec:.mens irom spontaneous coughing (pooled over three - ) recused independently of aerosol induction. Our caperi- cnee from a cooperative study that included the Johns Hopkins Medical Institutions and the Mayo Foundation may be relevant to the interpretation of the data of Melamed a ai. The design of their studs' and ours required that aerosol induc tion be performed at the initial visit, with sputum obtained during induction and on the nest three mornings, as outlined above. .This procedure was repeated annually. In addition, twice a year (at four and eight months;, a thrcc-moming pooled specimen was collected that was identical to the above post-induction specimen, except that .it was collected with no preceding induction. Our data show that the post-induction three-day pooled sputum added further diagnostic benefit to that obtained at the time of in duction. as in the study by Melamed et al. However, two thirds of all evtologically positive cases of cancer appearing after the initial screening (13 of 23) were detecied by the annual induction proce dure (induced sputum plus poet-induction three day pooled sputum), whereas only one third (eight of 23) were detected by the procedures at four or eight months with three-day pooled sputum that was not induced. These data dearly show' an advantage of per-' forming aerosol induction before obtaining a spontaneous-cough specimen for the detection and diagnosis of lung cancer, at least in a screening situation. Baltimore. MD 21205 John K. F*ost. M.D. WiusoT C Ball. Jn., M.D. Moaroiv L Levin. M.D.. D P.H. Muwk S. Tockmak, M.D.. Pm.D. Ytnta S. Esoiam, M.D. PaAaooH K. Gl'PTa, M.D. The Johns Hopluns Medical Institutions The above letter was referred to the authors of the letter in ques tion, who offer the following reply: Tt lit Edam: As described in our previous letter, we compared aerosol-induced and three-day pooled spontaneous-cough sputumcollection techniques in an initial screening of men enrolled in a lung-cancer detection program. In the detection of cancer present as enrollment (prevalence cases) the three-day pooled spontaneous sputum was of greater diagnostic value. Dr. Frost and his colleagues suggest that the three-dav pooled spontaneous specimen obtained after aerosol induction mav be a better sample than such a specimen produced without aerosol in duction. This is an important issue, and these authors' data on cytotogically detected lung cancers appearing after initial screen ing (incidence cases) support this view OQij 669q ,< rtS rti ^zvsnoois i 'a IK. THE NEW ENGLAND JOURNAL OF MEDICINE Jan |4. 19s. Taei# t. Cytologic Diagnosis of Lung Cantor (Incioanea Casos) Or Souium Sampling. V. 4* ChMN PutfkQW > SbBFUhti TK%*U thr resolution needed to differential* infarcted from nomnfarctro components of tne imocardiai region ai risk Ms prediction .> tnat miarcr using with isotopes will require either eesriopmrn: of newer raoiophamtaceuticait or a quantum jump in singie-pnoion lomoerapnic instrumentation. iNffiae ifssiisioumoi ' J. A. Bunco. M.D # f Negative Cancsr Sutpcmi Modern* atypu Canon 1 Moocraisaiypu MoOusitaispu 1 Cancer Cancer 1 Caoetr Suspaoous 1 Cancer Not dom ti-rsv posiusci <rm4 from i(w ikt Utrm lii *% aimM lAOMkUaM. Inf4<i FMM MOMMaOM *#*(* UM Nl1 JMwl (UMUML fWW*W * UM pTMMl M* Pr U ejt Roxbun Veterans Administration Hm Koxburs. MA 02132 Medical Center 1. Berger HJ. Zarr. IL. Nuclear caroiotpfs. N Engl) Med. 1911.30**99- W*. !. 2. Bianco JA, The saga of tcmugrapfiv in acute myocardial infarction. J Nad Med. I*l. :: *J9u:. 3. Rctmcr KA. Jenningi RB. The "wavefront phenomenon" of myocardv al ischemic cell oeaih. II. Transmu/ai progrtsaion of necrosis within the framework of iKhcmic bco sue ims ocardium ai risk i ana collateral flow Lab Invest. 19*9 at>633-aa 4. kronenOerg MU. Euinger UR. ilson GA. ei al. A comparison of radunractr sno biocnemicai meihoos for the quanuuuen of eapenmenui mfarci weight m sure relationships. 1 Nucl Mad. 1979. 20.22a-3l. i " c therefor* reviewed all our cvtologKills detected cam of lung suitrcr appearing after the initial serrening (incidence cam i There !. Berger H3. Gantehalk A. Zaret BL. Dual radionuclide study of acute myocardial infarction comparison of thallium.201 and technctium-99m uannous pyrophosphate imaging in man Ann Intern Med. 1971.11.145- were la tuch cam (Table I In two thirds of the cam appearing after imnaJ examination, cancer ai detected in the three-das 6. Buie LM. Rarkey RU Siokeley EM. ct al. Rsihophytiolory of tacfiMsi- puuled iputum specimen produced without aerosol induction 11ir>c results are confident nth our earlier lindmgi on the initial examination (prevalence cam) and diflcr from those reported bv Frost et al. This apparent difference may result from the small sue of the um-99m tunnous psrophoiphaic and ihallium-201 umugraphs of acute, anterior myocardial infarcti in dogs. J Clin Invest. 197*. 57:1301-22. * Lee JT. Idckcr RE. Reimer KA Myocardial infarct sue and location in relation to the coronary vascular tied ai nit in man. Circulation. IMI: aa:52b-34. sample in both studio or from some other statistical artifact. For example, the results reported by these authors would be expected if the number of specimens obtained Irom the total population at an nual examinations exceeded the numocr submitted by mad at four BICLANIDES and the erythrocyte insulin RECEPTOR and eight months. We i s-- wtm inn rl of the value of aerosol induction for cat- Irrtiou sputum rytntngy in a screening program lor King cancer. Tt lie Edam- Despite my reservations about the validity of usings labeled hormone with a high concentration and Jow specific activi ty in a radioreceptor assay. I found it remarkable that the dramatic New York. NY 10021 Mvaox K. Mtusu. M.D. MCHAMSUO B ZASIAN. M.B B.S. Wanda Lazowsxi. CT. (A.S.C.F.) Nltmonil Sloan-Ketienng Cancer Center increase in the numbers of insulin receptors reported bv Hollt ct al. should have occurred when erythrocytes were incubated with met formin in vitro (September 3 issue i.1 L'niike other cells studied in vitro, peripheral ervthroeytes have not been demonstrated to have a capacity for tnr complete svntnestt of new proteins or receptors. Thus, the nature of tne direct effect of biguanidcs on the red-cell in Y un-town Heights. XY 10590 BrrrvJ. Fuhixcu. Pm.D. IBM Thomas J Watson Research Center sulin receptor is open to conjecture Conceivably, such agents may liter the age distribution of red eel!i or in some way uncover insu lin-binding sues that have become buried or nonfunctional as the cell has aged However, before any firm conclusions are drawn from the data presented bv Holle et al.. it should be emphasized PYROPHOSPHATE IMAGING FOR INFARCT SIZING that a major bioeflect of biguanidcs at the level of the insulin recep tors on other cell tvpcs. particularly those of target tissues, has yet Tt the Edatr The timely overview of nuclear cardiology by Berger to be demonstrated. and Zaret (October I issue)' will surely assist physicians when they are toimdenng the use of tracer techniques m cardiac disorders. I h. - recently w ritten an editorial on scintigraphy for mvotardial in- Betfinds. SID 20205 RoaaxT F. Dons. M.D . Pn.D. National Inslituin of Health tartuon. in which I expressed skepticism about the applicability of pvruphosphair imaging for the measurement of infarct sue.1 First of ail. pvrophosphate cannot be employtd (or assessment of inirrvmiions aimed at salt aging the heart from myocardial iitfarenor. Although myocardial infliction is complete within three to six hours after cessation of the coronary blood supply.' rodiophof- I. Rolls A. Msngcts U\ Drayer M. Kdhnau J. RMgtr HU Bifuamde irtatnmi incrusts the number of insulin-racspior on Human enkrseyta N Engl J Msd. 19*1. 305:5*3-6. 1 Dons RF. Condi |_ Corden F Tbs insulin rucspior is sn sgs dspsnd m snttgrtl componunt of tbs human tryuuocyu moabrnn*. 3 Bmi Chon. IMI: 25*.2f*:-7. phaic scanning is nor optimal until 36 hours after the onset of iimptorm.' "secondly, expenmental data have established that cardiac uptake if pvrophosphate. because of a peculiar (low dependency, is max The above letter was referred to the authors of the article in ques tion. who offer the following reply: im*; in the outer regions of the formed infarct, where histologic damage ranges from light to severe.* In fact, in both patients' and dues.1 infarct sue computed from pyrophosphate scans is consis tent iv larger than that derived from thallium images Ideally, these two nuclear scintiscans should shew concordant sizes of the infarct. finally, an acute infarct imuaJiy involves the subendocardial user and subsequently spreads toward the subepicardial myocar dium Nature spontaneouslv salvages 10 to 45 per cent of the traitsmur-J imocardiai thickness, largely because of the availability of To lie Edute We agree with Dr. Dons that studin with different ceil tvpes are needed before the phenomena occurring on ersihrocytes can be generalized as a principal mode of bifuamde action. However, we believe that our findings fit -- better than am other mechanisms proposed so far -- tne clinically and pharmacological ly observed effects of biguanidcs Biguanidcs are known 10 influence biologic membranes: their antidiabetic action is entirely cxtrapancrcatic and depends on the presence of insulin. In particular, obese hypennsulmemic diabetics vuhef.it jrdial collateral flow 1' No current tomographic device has seem to benefit from biguamd* therapy DOW 06699