Publications

This report describes a 48-year-old caucasian male with schizophrenia who developed hepatitis, hyperglycemia, pleural effusion, eosinophilia, hematuria and proteinuria early in clozapine treatment which resolved on drug discontinuation. The literature on similar cases is reviewed.

OBJECTIVE: To determine whether patient preferences for the use of coronary revascularization procedures differ between white and black Americans.

DESIGN: Cross-sectional survey.

SETTING: Tertiary care Department of Veterans Affairs hospital.

PATIENTS: Outpatients with and without known coronary artery disease were interviewed while awaiting appointments (n = 272). Inpatients awaiting catheterization were approached the day before the scheduled procedure (n = 80). Overall, 118 blacks and 234 whites were included in the study.

MEASUREMENTS AND MAIN RESULTS: Patient responses to questions regarding (1) willingness to undergo angioplasty or coronary artery bypass surgery if recommended by their physician and (2) whether they would elect bypass surgery if they were in either of two hypothetical scenarios, one in which bypass surgery would improve symptoms but not survival and one in which it would improve both symptoms and survival. Blacks were less likely to say they would undergo revascularization procedures than whites. However, questions dealing with familiarity with the procedure were much stronger predictors of a positive attitude toward the procedure use. Patients who were not working or over 65 years of age were also less interested in procedure use. In multivariable analysis race was not a significant predictor of attitudes toward revascularization except for angioplasty recommended by their physician.

CONCLUSIONS: Racial differences in revascularization rates may be due in part to differences in patient preferences. However, preferences were more closely related to questions assessing various aspects of familiarity with the procedure. Patients of all races may benefit from improved communication regarding proposed revascularization. Further research should address this issue in patients contemplating actual revascularization.

Despite the worldwide distribution and prevalence of Schizophyllum commune, an emerging basidiomycetous pathogen, human infections occur only rarely. We describe the first well-documented pulmonary infection caused by S. commune which disseminated to the brain of a 58-year-old patient undergoing empiric corticosteroid therapy. Magnetic resonance imaging scans revealed ring-enhancing masses. Histologic examination of biopsy tissue from lungs and brain showed hyaline, septate, branched hyphae with clamp connections. Cultures of the lung tissue grew S. commune, which produced numerous, characteristic flabelliform and medusoid fruiting bodies on Czapek's agar. The isolate was susceptible to amphotericin B (MIC, < 0.03 microgram/ml) and fluconazole (MIC, 8 micrograms/ml). Despite treatment with antifungal and antibacterial agents, the patient developed progressive pulmonary failure and bacterial sepsis and died.

BACKGROUND: Previous studies have found racial differences in the use of invasive cardiovascular procedures, which may be due in part to the greater financial incentives to perform such procedures in white patients. In Department of Veterans Affairs hospitals, direct financial incentives affecting use of the procedures are minimized for both patients and physicians.

METHODS: We conducted a retrospective analysis of the use of cardiovascular procedures among black and white male veterans discharged from Veterans Affairs hospitals with primary diagnoses of cardiovascular disease or chest pain during fiscal years 1987 through 1991. We used coded discharge data to determine whether cardiac catheterization, percutaneous transluminal coronary angioplasty, or coronary artery bypass grafting was performed during or immediately after such admissions. We used logistic-regression analysis to adjust for the primary discharge diagnosis, the presence of coexisting conditions, age, marital status, type of eligibility to receive care at Veterans Affairs hospitals, geographic region, and whether the hospital was equipped to perform bypass surgery. We classified the primary diagnosis as myocardial infarction, unstable angina, angina, chronic ischemia, chest pain, or "other" cardiovascular diagnosis.

RESULTS: After we adjusted for all the potential confounders, we found that white veterans were more likely than black veterans to undergo cardiac catheterization (odds ratio, 1.38; 95 percent confidence interval, 1.34 to 1.42), angioplasty (odds ratio, 1.50; 95 percent confidence interval, 1.38 to 1.64), and coronary artery bypass surgery (odds ratio, 2.22; 95 percent confidence interval, 2.09 to 2.36).

CONCLUSIONS: Even when financial incentives are absent, whites are more likely than blacks to undergo invasive cardiac procedures. These findings suggest that social or clinical factors affect the use of these procedures in blacks and whites.

Pneumocystis carinii infection of the liver is being reported with increasing frequency in patients with acquired immune deficiency syndrome (AIDS). The clinical picture typically resembles hepatitis. We report such an occurrence in a patient with persistent elevation of alkaline phosphatase and gamma-glutamyl transpeptidase with relatively normal transaminases who was found to have P. carinii on antemortem liver biopsy. The differential diagnosis of abnormal alkaline phosphatase and gamma-glutamyl transpeptidase in patients with AIDS should include P. carinii.