Chest Diseases in Nursing Homes

Chest Diseases in Nursing Homes

Chest Diseases in Nursing Homes* OTTo L. AND N Glen Ellyn, Illinois Chicago, Illinois BETTAG, M.D., F.C.C.P.,** S. A. LEADER, M.D.,t OT TOO MANY...

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Chest Diseases in Nursing Homes* OTTo L. AND

N

Glen Ellyn, Illinois Chicago, Illinois

BETTAG, M.D., F.C.C.P.,**

S. A.

LEADER, M.D.,t

OT TOO MANY YEARS AGO, TUBERCU-

losis in mental and penal institutions was not deemed a health problem of great import. The fallacy of this thinking eventually was demonstrated by the fact that here was found the highest incidence of this disease. Great strides have been made in tuberculosis control in these facilities. In the state of Illinois they now are the safest places to be admitted with respect to tuberculosis, since a regular and continuing program of screening, including personnel, is in effect.! For 20 or more years, chest disease detection, especially tuberculosis, has been an accepted and productive program-although in varying degrees-in general and mental hospitals and penal institutions. With the inauguration of these programs, it was the general belief of those in the tuberculosis field that "all bases were pretty well covered" insof ar as institutions were concerned. ANOTHER SLEEPING DRAGON?

In the past decade, however, a new area of concentrated population has developed and we find ourselves faced with another potential facet of the problem of detection -hitherto untapped and for the most part ignored in the total health program (Fig.

approached 800 million dollars. With the number of beds increasing at the rate of 24,000 annually, this is one of the fastest growing medical and economic problems.! Nursing home residents are not necessarily aged. Many are younger persons who are, to varying degrees and for varying reasons, disabled. They now have surpassed the previous largest single segment of bed occupancy in the United States-the mentally ill and mentally retarded in public mental hospitals-reported last year ( 1963 ) as numbering 504,947. 3 Those in the field of chest diseases have bemoaned the apathy of the public toward case-finding. Yet within the past decade we may have permitted the growth of a sleeping dragon" in our midst. The lack of attention to the potential problem is underscored by the fact that upon thorough search of the medical literature we could not find a single reference to a previously published scientific paper on s the subject as it pertains to nursing homes. However, we are aware that screening studies have been made elsewhere. To

SAFEGUARD THESE CITIZENS

It is to Illinois' credit that its state health department has taken an interest in this important field. The rules and regulations of the Illinois Department of Public Health governing the operation of nursing homes have been amended at least three times in the past seven years. The most recent revised minimum standards and regulations which became effective February 1, 1962, require that every patient have a physical examination prior to or within 72 hours after admission. The physical examination shall include a statement dated and signed by the physician that the patient is free of communicable disease, including tuberculosis. Phvsical examinations also shall be given all'patients at least annually.'

1).

We refer to the nursing and convalescent homes and related facilities. To illustrate the magnitude of this dereliction, there are more than 23,000 such facilities in the United States with more than 600,000 beds. In 1962, nursing home construction ·Presented in part at the 55th annual meeting, Illinois Tuberculosis Association, Peoria, Illinois, April 22, 1964, and at the VIII International Congress on Diseases of the Chest, Mexico City, Mexico, October 11-15, 1964. **Medical Director, DuPage County Tuberculosis Sanatorium Board. t Associate Clinical Professor, Department of Radiology, University of Illinois Medical School.

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THE PROBLEM OF COMPLIANCE

According to the Illinois Hospital Association, Illinois nursing homes are operated primarily for profit. Ninety-two per cent of the nursing homes in the state, containing 81 per cent of the beds, fall into this category. The average size of a proprietary nursing home is 35 beds.' Obviously, it is unrealistic to expect homes of this size to maintain x-ray departments. At the same time, there also is reluctance on the part of the homes' owners to absorb the cost of x-raying or to pass it on to the resident patients. Regulations which cannot be met, regardless of how well-meaning, result in involuntary violators. The difficulty of adding screening examinations to detect possible active tuberculosis becomes evident when it is a fact that many Illinois nursing home patients are not receiving accepted medical care.' PROFILE OF DUPAGE COUNTY

Traditionally, the inner area of the city of Chicago--second largest city in the United States -has served as the point of entry for immigrants and migrants moving to the urban setting. The level of socioeconomic and cultural stability improves and the incidence of tuberculosis decreases in relation to the distance from the center of the city.' DuPage county is one of 102 counties in Illinois, located on the outskirts of Chicago. It is the state's most rapidly growing county, with a population of approximately onethird million. The per capita income at last census was the highest in the state and tenth highest in the nation. There are 25 villages and five cities, the largest having 37,000 population. All but eight of the towns have less than 10,000 population. The last census reported 312,200 native white, 677 Negro, 212 Japanese, 123 Chinese, 86 Filipino, 69 Indian and 92 from other races. The estimated average age of DuPage residents is 28 years,lO

A COUNTy-WIDE PROGRAM The DuPage County Tuberculosis Sanatorium Board initiated in August, 1962 a chest x-ray screening program for all residents of nursing and convalescent homes. Several factors entered into the inauguration of the survey. Although ambulatory patients in the two largest homes were screened through the mobile unit of the DuPage County Tuberculosis Association, there was the problem of x-raying those patients who were nonambulatory. From this evolved a pilot study to include all the nursing, convalescent and retirement homes of the county. After preliminary discussions with various groups, the project was crystalized in

PEOPLE LIVE

LONGER~ (65 and over)

Courtesy TIME; copyright Time. Inc. 1962

FIGURE

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August, 1962 at a county-wide meeting sponsored by the sanatorium board and coordinated with the DuPage County Health Department, the county tuberculosis association and the health and tuberculosis committee of the county board of supervisors. Attending were representatives of nursing homes and homes for the aged of the county involving a potential total population of approximately 800. Also present were officials from the state and regional health offices, the Illinois Public ~~id Commission, the Illinois Tuberculosis Association and the Tuberculosis Institute of Chicago and Cook County, as well as administrators of the county's hospitals. Although it was not nor is it the intent or desire of the DuPage County Tuberculosis Sanatorium Board to assume the responsibilities of the nursing homes, it generally was agreed that the official agency should cooperate with these facilities in assisting them in their initial endeavors of meeting the new health standards. To enforce such regulations without consideration of the problem of meeting them would have been and is grossly unfair to the nursing homes. Cooperation of all concerned would result in diligent and, at the same time, humane enforcement. THE SURVEY IS LAUNCHED

The program was launched in September, 1962 after the sanatorium board purchased a portable x-ray unit. Ideally, nursing home x-ray screening requires a light portable unit capable of 50 M.A., 85 to 90 K.V., with a timer operating at onetenth of a second or less. However, using a used 100-pound portable unit (General Electric) with an output of 12 M.A., 70 to 80 K.V., with a timer operating at from .3 to .5 of a second has resulted in satisfactory 14 x 17 films. Routine chest x-ray films are best obtained at a distance of six feet. With our equipment it has been necessary to take films at four feet. These have been quite adequate. When the patient is bedfast it may be necessary to take the film even closer than four feet.

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When possible, posteroanterior views are preferable, but it has been found easier to take the films in the anteroposterior position. This distorts and magnifies the cardiac outline, but does not materially affect lung findings. Lead apron and lead gloves should be provided for attendants who assist the technician in positioning the patient. Films may be developed at a central locale so no dark room is required at the nursing home. Interpretation was by a radiologist with clinic experience. Films were re-read by a chest physician. All positive films were reviewed in conference. Seventeen of the 18 nursing facilities of the county participated in the survey. One already had an x-ray screening program in effect. In the period of September, 1962 to April, 1964, a total of 1190 x-ray films were made on 663 residents, although some of these subsequently were re-x-rayed on the second and third survey. Because of pathology, 208 persons required multiple x-ray examinations. The medial cost per patient was $7.51. FINDINGS

A total of 674 chest abnonnalities or pathologic conditions was detected among the 663 persons x-rayed. The predominant abnonnalities were arteriosclerosis of the aorta (236) and cardiac enlargement ( 168), with various types of pulmonary pathology the next most frequently seen. Thirty-five residents had pneumonia. One case was diagnosed as inactive tuberculosis. Seven had findings suggestive of active tuberculosis. Four of these were kept under observation in the nursing homes and the inflammatory lesions were subsequently found to be nontuberculous. Three of the seven were hospitalized with two diagnosed active tuberculosis and one as being inactive (Fig. 2). It has been said that "tuberculosis has shifted to old people. However, no one has adduced evidence or has demonstrated such shifting. An accurate statement is that tuberculosis has remained among old people."u

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IMPLEMENT THE X-RAY SURVEY

Although the chest x-ray screening project unquestionably had merit for its revelation of chest pathology other than tuberculosis, the question arises as to the need for continuous x-ray screening as a detection tool. An effort to answer this question was made in February, 1964 when the study was implemented by a tuberculin and histoplasmin testing project, and at the same time there was an attempt to correlate the x-ray findings with possible tuberculosis and histoplasmosis etiologies. The county's 16 nursing homes and the two homes for the aged, one a contract life care home and the other operated as a notfor-profit corporation under the auspices of a religious group, were asked to cooperate. All responded enthusiastically except one nursing home which does its own tuberculin testing and the home for the aged under the auspices of the religious group. The tests were administered and interpreted by the sanatorium board's technicians. The histoplasmin,* strength of 11000, was injected into the right arm. Puri-

fied protein derivative,* strength of .005, 250 international units of tuberculin, was injected in the left arm. This is equivalent to 1-40 Old Tuberculin and is 250 times stronger than first strength. It is 50 times stronger than second strength. The tests were interpreted after 72-hour intervals. The dual testing averaged $2.1 7 per patient. Of course, it would have been desirable to start with the weakest strength and gradually work up to the greatest strength. Because of nursing home settings, personnel limitations, et cetera, it appeared that the most practical way of achieving an index reaction was the method used. Despite the strength of the tuberculin, the number of severe reactors was relatively small. RESULTS

A total of 533 patients were tested and recorded, in other words 81 per cent participation. There were 58 per cent positive reactors to tuberculin. An additional 5 per cent had questionable positive reactions varying from 3 to 9 mm. *Supplied by Parke, Davis and Company.

CHEST X-RAY FINDINGS SEPTEMBER 1, 1962 - MARCH 31, 1964

ARTERIOSCLEROSIS OF THE AORTA

236

CARDIAC ENLARGEMENT

179

PULMONARY ABNORMALITIES - OTHER THAN TUBERCULOSIS

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MISCELLANEOUS FINDINGS - HIATUS HERNIAS, ANEURISMS, ETC.

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SKELETAL DEFORMITIES TUBERCULOSIS - ACTIVITY UNDETERMINED

TOTAL EXAMINED - 663

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TOTAL ABNORMALITIES - 614

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There were 17.7 per cent positive histoplasmin reactors, with an additional 1.3 per cent with questionable positive reactions varying from 3 to 9 mm. Reactors both to tuberculin and histoplasmin were 13.33 per cent. There are those who believe skin testing in the aged is of little value because of the high percentage of positive reactors or the loss of sensitivity with age. The reactions averaged 15 to 40 mm., with a few exceptions. Nineteen tuberculin reactions exceeded 50 mm. Nine histoplasmin reactions exceeded 50 mm. There was no significant correlation between the size of reactions and age, physical status and activity of patient. The average age of persons tested was 79 (78.75). One patient, age 100, had a positive tuberculin reaction measuring 73 x 100 mm. The truly positive reactions were essentially the same type as those found in persons receiving tuberculin tests in the sanatorium board clinic. Only in the questionable reactors was the edema not as pronounced. It was the belief that had the same amount of redness occurred in persons tested in the clinic there would have been accompanying edema. Tuberculin testing may have a place in this type of facility if chest x-ray screening is financially impractical. This would depend on the locale, whether urban or rural, the strength of tuberculin used and the accuracy of administration and interpretation. As the incidence of the disease declines in a given area, the importance of the tuberculin reactor register will increase. 11 However, this is not without possible pitfalls since clinical tuberculosis may be present in some with questionable or negative tuberculin reactions. THE NEED FOR BETTER EQUIPMENT

The need for development of better diagnostic, more economical and lighter equipment by the x-ray industry becomes abundantly clear. Although several countries have portable x-ray equipment available, these have not attained the ideal of purpose. Equipment deficiencies too often ne-

cessitate multiple x-ray films, making the cost of a screening program too expensive to maintain on a continuing basis. Even the initial cost of such equipment is prohibitive for the average-size nursing home. This program has stimulated study by the Joint Committee on Chest X-ray of the American College of Radiology and the American College of Chest Physicians. OTHER PROGRAMS

Other agencies have demonstrated concern for tuberculosis in residents of nursing homes and related facilities by initiating programs. In 1956, in the Cook County Institutions, Oak Forest, Illinois, 2104 residents 60 years of age or over were tuberculin tested (Mantoux) with 1-1000 (10 I.T.V.) Old Tu berculin. .t\pproximately 76 per cent were positive. 13 In a tuberculosis and chest consultation program started in 1957 in the Jewish Homes for the i\ged, Chicago, three large homes have been carefully screened and studied. Tuberculosis has remained a constant medical problem among the aged. In 1962, using standard fixed x-ray equipment, 1276 chest films were taken of 851 residents. Fifty-five cases of tuberculosis were diagnosed with seven proved to be active. 14 The Tuberculosis Institute of Chicago and Cook County selected 24 nursing homes and homes for the aged for survey in a demonstration project from December, 1961 to March, 1962. Two thousand and twenty-two ambulatory and nonambulatory residents were x-rayed, resulting in 82 tuberculosis suspects, six of whom were active cases. 15 On February 20, 1963, the following resolution concerning chest x-ray films and screening procedures in the respective facilities was adopted by the Chicago Board of Health and added to the Municipal Code of Chicago. Be it resolved that: 1. All patients shall have a chest x-ray within 90 days prior to or within 72 hours after admission to the home.

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2. All ambulatory patients shall have an annual chest x-ray examination. 3. All nonambulatory patients shall have a 24-hour sputum test annually. 4. Records showing satisfactory evidence of a chest x-ray for ambulatory patients, or a sputum test where indicated for nonambulatory patients, shall be maintained for all patients in the home. 5. All positive findings shall be reported immediately to the Board of Health. For the past six years, mobile unit x-ray screening has been done by the Suburban Cook County Tuberculosis Sanitarium District at nursing homes with more than 100 ambulatory patients and employees. Bed patients with chest symptoms have had sputum analyses. In October, 1963, portable (Serend 20) chest x-raying of nonambulatory residents was begun. In the first 1000 patients so studied, the yield of four active cases was unexpectedly low. ls WHAT IS THE STANDARD?

Certainly, the 1000 or so nursing homes and related facilities in Illinois with over 40,000 resident-patients are faced with a problem which must be met. A decision must be reached as to what constitutes an acceptable method of tuberculosis detection. Should all new admissions be required to have chest x-rays? Is tuberculin testing, with chest x-ray films of the positive reactors, the answer? In senile and uncooperative residents are neg a t ive findings on examinations of 24-hour sputa reasonable assurance of the lack of active tuberculosis? Collection of satisfactory sputum specimens is difficult with some patients even though they have pathologic bronchial secretion. Emphysema, bronchitis and/or bronchiectasis, prevalent in the aged, may be reservoirs for atypical acid-fast bacilli. The administrative confusion caused by the original reporting of these as positive on smear and culture-later to be ruled out by identification and sen sit ivit y studies-is obvious. Should the required subsequent annual examination include a chest x-ray film

or would tuberculin testing adequately protect the patient, the other residents, the employees of the facility and the public? There is no precedent in this field for use as a prototype. The responsible agencies must decide on a standard for detection of tuberculosis--one that is practical from the nursing home's standpoint and, at the same time, reliable as a screening device. SUMMARY

The search for chest diseases, especially tuberculosis, in general and mental hospitals and penal institutions, has been accepted and productive. Nursing and convalescent homes and related facilities have been an interesting but somewhat forgotten facet of the total health treatment program. There are more than 23,000 such facilities in the United States with more than 600,000 beds. In 1962, nursing home construction approached 800 million dollars. With the number of beds increasing at the rate of 24,000 annually this is one of the fastest growing medical and economic problems. Only recently the health standards for these homes attracted indicated attention. The state of Illinois revised minimum standards and regulations for nursing homes which became effective February 1, 1962, and require that every patient have a physical examination prior to or within 72 hours after admission. The physical examination shall include a statement dated and signed by the physician that the patient is free from communicable diseases, including tuberculosis. Physical examinations also shall be given all patients at least annually. Most nursing homes are too small to maintain x-ray departments. There also is reluctance on the part of the homes' owners to absorb the cost of x-raying or to pass it on to the resident patients. DuPage county is one of 102 counties in Illinois, located on the outskirts of Chicago. It is the state's most rapidly growing county, with a population of approximately onethird million. The DuPage County Tuberculosis Sanatorium Board initiated in August 1962 a

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chest x-ray screening program for all residents of nursing and convalescent homes of the county. The data compiled from approximately 1000 resident patients show the importance of continuous studies and detecting unknown tuberculosis, pneumonia, malignancies, cardiovascular diseases, et cetera. It also points up the difficulties encountered in using roentgenographic equipment and the need for development of better diagnostic, more economical and lighter equipment bv the x-rav industrv. The .study em'phasizes' the need for a standard for detection of tuberculosis--one that is practical from the nursing home's point of view and, at the same time, reliable as a screening device. RESUMEN

La exploraci6n de enfermedades del pecho, especialmente tuberculosis en hospitales generales y mentales ha sido aceptada y productiva. Asilos para convalecientes y facilidades relacionadas han sido interesantes pero mas 0 menos facetas olvidadas en el programa total del tratamiento de la salud. Hay mas de 23,000 de esas facilidades en los Estados Unidos con mas de 600.000 camas. En 1962 la construcci6n de asilos a tca~l6 800 miHones de dolares. Con el numero de camas aumentando mas 0 menos 24,000 al ano, este es uno de los problemas medicos y econ6micos que van cresciendo mas rapidamente. Solamente ahora pronto los "standards" de saIud en esas instituciones atrajeron la atenci6n necesaria. EI estado de Illinois revis6 los "standards" minimos y las regulaciones para los asilos que fueron efectivas en Febrero 1, 1962, y requieren de cada paciente un examen fisico completo antes 0 durante las primeras 72 horas de la admisi6n en el hospital. EI examen fisico debe incluir una declaraci6n firmada y con fecha por el medico, que el paciente no tiene enfermedades contagiosas, incluyendo tuberculosis. Examenes fisicos tambien deben ser hechos en pacientes por 10 menos anualmente. La mayor parte de los asi los son demasiado pequenos para mantener departamento de rayos X. Tambien hay resistencia de los duefios de los asilos de absorber el costo de tomar rayos X, 0 pasar el costo a los pacientes hospitalizados. El DuPage County es uno de los 102 counties en Illinois, localizado en las afueras de Chicago. Es uno de los counties en el estado de Illinois que esta cresciendo mas rapidanlente, con una poblaci6n aproximadamente de un tercio de milIon.

EI Directorio del Sanatorio de Tuberculosis del County de DuPage inici6 en Agosto de 1962 un programa de detectar tOOos los pacientes de los asilos y asilos para convalecientes en el county. Los hechos compilados en aproximadamente 1000 pacientes muestra la importancia de estudios contInuos y descubrimiento de casos de tuberculosis no aparentes, pneumonias, tumores malignos, enfermedades cardiovasculares, etc. Tambien muestra las dificultades encontradas usando equipo radiografico y la necesidad de desarrollar mejores diagn6sticos y equipo menos pesado por la industria radiografica. La investigaci6n muestra la necesidad de un standard para la detecci6n de tuberculosis que sea practico desde el punto de vista de los asilos y al mismo tiempo seguro como un instrumento de detecci6n. RESUME

La recherche a propos des maladies des poumons et du coeur specialment de tuberculose a ete bien acceptee par les institutions mentales et penales. Malgre ce pregres les maisons de retrait et les maisons de convalescence ont ete oubliees. Aux ttats Unies il y a plus que 23,000 institutions de cette sorte avec une capacite totale de 600,000 lits. En 1962 la construction des maisons de convalescence a coute approximativement 800 millions de dollars. On a estime que Ie nombre des lits augmente par 24,000 chaque annee et par consequent il est un des problemes financiels et medicaux des plus pressant. Seulement recemment on a commence a payer attention a cettes institutions. En 1er de Fevrier 1962 l'£tat d'Illinois a entrepris une revision des standards minimaux, reglant la fonction de maisons de retrait, et depuis lors on demande que chaque malade ait un examen general avant ou durant les premieres 72 heures apres son entree a Ia Maison de convalescence. Une declaration datee et signee par Ie medecin doit affinner que Ie patient ne souffre pas de maladies communicables y compris la tuberculose. L'examen physique est arrange reegulierement une fois par annee. La plupart des maisons de convalescence sont trop petites pour maintenir undepartment radiologique. Aussi les proprietaires de cettes maisons ne sont pas d'accord au point de vue d'arrangement financiel. lIs ne veulent pas payer les depens et its ne desirent pas avoir leur patients payer pour la radiographie. Le comte de DuPage est un parmi 102 comtes d'Illinois, situe aux faubourgs de Chicago. Son developpement au point de vue de population est formidable, ayant a present approximativement un tiers de million d'habitants. Le conseil de tuberculose du comte de DuPage a lance au mois d'Aotit 1962 un programme pour la decouverte radiographique des maladies des

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poumons et du coeur parmi les residants des maisons de convalescence. Les infornlations accumulees d'approximativement mille residants montrent l'importance de continuer cette etude pour la decouverte des cas de tuberculose, des pneumonies, des maladies du couer et des vaisseaux. cancer, etc. Aussi on signifie les difficultes encontrees a l'usage de l'equipage radiographique et de meme on presente la necessite pour l'amelioration des moyens diagnostiques. En general l'etude Inarque l'importance d'avoir un modele pour la decouverte de tuberculose, qui soit pratique pour les maisons de convalescence et en meme tenlps confiant comme un moyen diagnostique. ZUSAMMENFASSUNG

Das Aufsuchen von Thoraxerkrankungen, besonders Tuberkulose in allgemeinen Krankenhausern, Irreanstalten und Gefangnissen wurde schliesslich angenommen aud erscheint produktiv zu seine Sanatorien dagegen sowie Rekonvaleszentenheime und a h n I i c h e Anstalten, obwohl auch interessant, sind inzwischen ins Vergessen geraten. Die Anzahl dieser Institutionen in den Vereinigten Staaten ist grosser als 23,000 und enthalt 600,000 Bette. Die Konstruktionskosten dieser Heime naherte sich im Jahre 1962 der Summe von 800 Millionen Dollars. Der jahrliche Anstieg dieser Anstalten betragt 24,000 Bette und stellt ein formidables finanzielles und medizinisches Problem dar. Der Staat von Illinois hat neulich die minimum Erfordemisse und Regulationen fiir solche Rekonvaleszenthenheime iiberpriift und infolgedessen muss seit dem ien Februar von 1962 jeder Patient, der in eine seiche Anstalt eingeliefert wird, innerhalb der ersten 72 Stunden nach Einlieferung einer allgemeinen Unter suchung unterzogen werden. Diese U ntersuchung soIl zugleich eine Bescheinigung enthalten die datiert und vom zustandigen Arzt unterschrieben sein soli; diese Bestatogung soil darauf hinweisen, dass der betreffende Patient an keinen ansteckenden Krankheiten leidet, einschliesshlich der Tuberkulose. Jeder Patient muss einer allgemeinen Untersuchung jahrlich unterzogen werden. Die meisten Rekonvaleszentenheime sind aber zu klein urn iiber einen Rontgenapparat zu verfiigen. Es ist auch eine allgemeine Abneigung unter den Eigentiimem von solchen Rekonvaleszenteheimen sich den Unkosten der regularen rontgenologischen U nter such ungen auszusetzen oder ihre Patienten-Einwohner damit zu belasten. DuPage Bezirk ist einer von 102 Bezirken in Illinois, situiert in den Vororten von Chicago. Er ist cler am schnellsten wachsencle Bezirk, mit einer Bevolkerung von ungeHihr ein Drittel Million von Einwohnern.

1m August 1962 fiihrte das DuPage Besirk Tuberkulose Sanatorium Direktorat ein Rontgen Program ein, wodurch aile Einwohner der Rekonvaleszentenheime sowie ahnliclier Anstalten im obengenannten Bezirke einer rontgenologischen Untersuchung des Thorax unterzogen wurden. Die Resultate der Untersuchung von ungeHihr 1000 Patienten-Einwohnem zeigt die Wichtigkeit solcher Studien in der Entdeckung von Tuberkulose, Lungenentziindunzen und Geschwulsten, Kreislaufstorungen, U.S.W. Es weist auch daraumin welchen Schwierigkeiten man begegnet in Gebrauch von Rontgenapparaturen, U.S.W. Diese Arbeit betont die Notwendigkeit eines Standards zur Entdeckung der Faile von Tuberkulose, der von den Rekonvaleszentenheimen fiir praktisch und zugleich zuversichtlich als diagnostisches Mittel betrachtet \verden kann. ADDENDUM: A report has since been published of a chest x-ray sunoey of the nursing homes of Massachusetts made in 1962 and a special followup study by the local health department of 39 (7 per cent) tuberculosis suspects in nursing homes in Brookline, Massachusetts, (KAHN, G. AND TAUBEN, HAUS, L. J.: "X-ray Screening for Tuberculosis in Nursing Home Patients," Amer. Geriatrics Soc., 12 : 5, 1964). ACKNO'VLEDGMENTS: We acknowledge the following staff members of the DuPage County Tuberculosis Sanatorium Board: Victor Kucas, R.T., Technician, for x-raying the nursing home residents; Mesdames Ethel Voigt, R.T., Chief Technician, and Iva P. Morrison, R. T., and Lee Anne Park, R.T., Technicians, for administration and interpretation of the tuberculin and histoplasmin tests; Miss Elizabeth E. Roe, B.S., Supervisor of Special Services, for coordination of the program; Mrs. Jackie M. Winston, Executive Assistant, for journalistic assistance on the manuscript; D. C. Cannavos, M.D., Clinic Physician, for translations of the summary. REFERENCES

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BETTAG, O. L.: "Facts and Foolishness-Tuberculosis," Proc. lnst. Med. Chicago, 9: 2, 1952. ERcoLANo, A. S.: "How the Nursing Home Industry is Meeting the Needs of the Aged," Paper presented at the Mid-America Nursing Home Convention, Chicago, November 25, 1963. The AMA News: March 30, 1964. "The Sleeping Dragon," Dis. Chest, 42 :657, 1962. (Statement prepared by the Joint Committee on Chest X-ray of the American College of Radiology and the American College of Chest Physicians). Correspondence between the DuPage County Tuberculosis Sanatorium Board and American College of Chest Physicians, April 6, 1964 ; American Medical Association, March 16, 1964; American Nursing Home Association, May 1, 1964; American Public Health Association, April 6, 1964 ; National Tuberculosis Association, May 13, 1964. Illinois Department of Public Health: Minimum Standards, Rules, Regulations for Nurs-

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ing Homes, Div. 5, Sec. 1; Div. 7, Sec. 1, February 1, 1962. Illinois Hospital Ass 0 cia t ion: Report, 24: 6, 1963. KRAMER, C. H. AND SONDAG, R. F.: "Medical Care of Nursing Home Patients: An Overview," Report of survey of Illinois nursing homes presented at the 16th annual meeting of the Gerontological Society, Boston, November 7. 1963. BETTAG, O. L.: "Environment Links in Tuberculosis and Mental Hospital Admissions," Paper presented at the VI International Congress on Chest Diseases, Vienna, Austria, September 1, 1960. DuPage County League of Women Voters Council: Know DuPage County! pp. 1-2, 1962. MYERS, J. A. AND HARTIG, H.: "Tuberculosis Lingers as the Life Span Lengthens-Part I," Geriatrics, 14: 709, 1959.

12 ISBISTER, J. L.: "The Tuberculin Reactor Registers in Monroe, Michigan," Paper presented at National Tuberculosis Association's Conference of Executives of Constituent Associations, Dallas, January 22-24, 1964. 13 CHESROW, E. J. AND NOVAK, J. B.: "Tuberculin Testing of the Aged," Dis. Chest, 32: 217,1957. 14 SNYDER, M. M.: Report of the Tuberculosis Control Program in Jewish Federation Homes for the Aged, Chicago, 1962. 15 The Tuberculosis Institute of Chicago and Cook County: Summary of Findings of X-ray Screening Project, December 11, 1962. 16 Letter from E. A. Piszczek, Field Director, Suburban Cook County Tuberculosis Sanitarium District, Forest Park, Illinois, April 10, 1964. For reprints, please write Dr. Bettag, 526 Crescent Boulevard, Glen Ellyn, Illinois.

ARTERIOGRAPHIC DIAGNOSIS OF THORACIC OUTLET SYNDROMES The remarkable diagnostic accuracy of arterIography in the differentiation of various syndromes such as the scalenus anticus. the pectoralls minor. the cervical rib. the hyperabduction. and the costoclavicular. combined lesions. and Intrinsic arterial disease Is evaluated In the study of 135 patients. The Importance of muscle tonus In aggravation of symptomatology is stressed. Arteriography Is recognized as the only modaUty to diagnose combined lesions resulting in compression of the subclavian artery. The safety and slmpllclty of the arterlographlc examination Is stressed. Blood flow studies utillzlng

radioactive materials may be used for further assessment of the hemodynamic significance of such lesions. Impainnent of flow in anyone of the vessels of the brachiocephallc group results in a disturbance of the hemodynamic equllibrium of the entire brachiocephallc supply area and causes the development of various "steal" systems. such as the "vertebral steal," the "Internal mammary steal," and the "intercostal and thyrocervical steal syndrome." LANG. E. K.: "Arteriographic Diagnosis of the Thoracic Outlet Syndromes," Radiology, 84,296, 196'.

GIANT CELL AORTITIS A case of glant-eell aortitis developing in a 3O-yearold woman, with resultant ascending aortic aneurysm and aortic incompetence on the basis of dllatation of the valvular annulus, Is presented. The microscopic appearances are those of granulomatous or giant-cell aortitis or mesoaortltis. There are characteristic areas of "Infarction" with loss of elastic tissue, the essential feature of this process. Aneurysm formation and diffuse dllatatlon leading to aortic Incompetence results from this elastica destruction. The

Intimal fibrocellular thickening Is secondary to the underlying Inflammation and destruction. Successful surgical correction was accompllshed by excision of the aneurysm and aortic valve and Insertion of a Teflon graft and a Starr-Edwards prosthetic aortic valve. AUSTEN. W. G. AND BLENNERHASSETT, }. B.: "Giant-cell Aortitis Causing an Aneurysm of the Ascending Aorta and Aortic Regurgitation." New Engl. J. Mtd., 272:80, 1965.

STUDIES OF ADRENOCORTICAL FUNCTION IN CONTINUOUS ASTHMA The adrenal function In 34 patients with continuous asthma has been assessed. No patient had previously received corticosteroid or corticotrophin therapy at any time. Twenty-three patients had a diminished response to ACTH stimulation and 11 patients had a normal response. Thus, there Is evidence that in the

majority of these patients. the adrenal cortex was not functionally nonnal. ROBSON, A. O. AND KILBORN, }. R.: "Studies of Adrenocortical Function in Continuous Asthma," Tho,.ax, 20:93, 1965.