Completeness of reporting of diagnosed HIV-infected hospital inpatients

To assess the completeness of human immunodeficiency virus (HIV) reporting among hospital inpatients whose records listed diagnostic codes for HIV infection but who did not meet the 1987 AIDS case definition, we conducted a statewide hospital study of admissions between January 1, 1986 and December 31, 1990. Of the 396 HIV-infected hospital inpatients identified, 313 (79%) had been reported to the State HIV Registry. HIV reporting was less complete for patients who were older and/or were blood product recipients. Of the 313 reported patients, 189 (60%) had been reported prior to their first hospital admission. Temporal improvements were noted in the completeness of HIV reporting among the hospital patients (1986: 65%; 1987: 81%; 1988: 64%; 1989: 82%; 1990: 86%; Chi square for linear trend 9.6, p < 0.01) and prior to their first hospital admission (1986: 31%; 1987: 34%; 1988: 49%; 1989: 64%; 1990: 72%; Chi square for linear trend 26.6; p < 0.01). Women were more likely than men to be reported prior rather than during or after their first hospital admission (71% vs. 55%; p < 0.01). Of the 155 patients with CD4+ T-lymphocyte test results, 41 had CD4+ counts < 200 mm3 and met the 1993 but not the 1987 AIDS case definition. In South Carolina most (79%) diagnosed, hospitalized, HIV-infected patients had been reported to the State HIV REgistry, with improvements in reporting occurring over time. Findings suggest that the 1993 AIDS case definition will improve our ability to monitor severe morbidity related to HIV.     

A shared genetic mechanism for melanotic encapsulation of CM-Sephadex beads and a malaria parasite, Plasmodium cynomolgi B, in the mosquito, Anopheles gambiae

Dialysis dose and malnutrition have a great impact on the clinical out come of chronic hemodialysis patients. The interrelationships between them, however, remain undefined. Thus, we performed a study to determine the effects of increasing the dialysis dose on serum albumin concentrations and mortality in hemodialysis patients. We examined urea kinetic modeling, biochemical nutritional indices, comorbid conditions, patient survival time, and annual mortality rate. Dialysis dose, measured by Kt/V, significantly increased from 1.3 +/- 0.3 in 1987 to 1.5 +/- 0.4 in 1990 and to 1.7 +/- 0.4 in 1993. Serum albumin level also increased from 3.8 +/- 0.4 g/dL in 1987 to 4.0 +/- 0.4 in 1990 and to 1.7 +/- 0.4 in 1993. In 1993, 76% of patients had Kt/V > or = 1.50 compared with 45% in 1990 and 28% in 1987, whereas 82% of patients had a serum albumin level > or 4.0 g/dL in 1993 compared with 58% in 1990 and 29% in 1987. Protein catabolic rate and hematocrit also increased from 1987 to 1993, but not serum cholesterol or triglyceride. The annual mortality rate declined from 16.1% in 1987 to 13.2% in 1990 and to 8.0% in 1993. The decrease in mortality appeared to be unrelated to differences in patient selection or comorbid conditions. Serum albumin levels, hematocrit, Kt/V, and protein catabolic rate were significantly related to patient survival after age, sex, and diabetic status had been adjusted. Furthermore, there was a positive correlation between Kt/Vs and serum albumin concentration (r = 0.216, P < 0.001). Thus it appears that increasing the dose of dialysis improves serum albumin levels and perhaps survival rate in hemodialysis patients as well.     

Mortality after deliberate self-poisoning. A prospective follow-up study of 587 persons observed for 5279 person years: risk factors and causes of death

A follow-up study of mortality and factors associated with death from various causes were done on two unselected groups of patients surviving deliberate self-poisoning in 1978 and 1987. The persons were studied up to the end of 1993. In 1978 the group included 152 female and 101 male subjects and in 1987 the group included 190 female and 144 male subjects. By the end of 1993 a total of 37 (24%) of the female and 33 (33%) of the male patients admitted in 1978 had died (n.s.) and 18 (10%) of the female and 29 (20%) of the male patients admitted in 1987 had died (P < 0.01). The main causes of death were suicide and death from cardiovascular disease. The 5-year follow-up mortality more than doubled in males from 1978 to 1987 but decreased in females. In female subjects, the total follow-up mortality was 3.6 times the expected ratio, with a 95% confidence interval (95% CI of 2.7-4.6); in male subjects it was 5.0 times the expected ratio (95% CI = 3.8-6.4). The cause-specific mortality ratio was highest for deaths from suicide--in the female group it was 65.5 (39.4-102.3) times the expected and in the male group 41.5 (26.0-62.8)--and from accidental poisoning--for females 50.0 (6.1-180.6) times the expected and for males 66.7 (24.5-145.1). In the female group none of the variables examined reached significance as predictors for subsequent suicide or death from unnatural causes. In the male group being aged 30 years or more came out as a predictor for subsequent suicide [relative risk (RR) = 5.66 (1.05-30.37)], while imprisonment came out as a protective factor [RR = 0.08 (0.01-0.64)]. Significant predictors for death from unnatural causes were: having been convicted (but not been in jail) [RR = 34.01 (1.07-1078.15)] and a serious suicidal intent [RR = 138.62 (1.38-13,946.79)]. It is concluded that patients who survive deliberate self-poisoning are at increased risk of death. The predictors for death are not very specific and are considered difficult to apply in the clinical work with these patients.     

Evaluating functional outcome in patients with lower extremity sarcoma

The Short Form 36, The Toronto Extremity Salvage Score, and the 1987 and 1993 Musculoskeletal Tumor Society Rating Scales were compared as measures of functional status for patients with lower extremity sarcoma. The study included 97 patients with lower extremity sarcoma and evaluated each measure on the following measurement properties: conceptual framework; statement of the purpose; feasibility; breadth of content; depth of measurement; cross sectional and longitudinal reliability; and validity and responsiveness. The Short Form 36 represents patients' perceptions of their physical and mental health and is practical to use. However, the validity of the measure is questionable for the patients with sarcoma because the subscale structure could not be reproduced in the current data. The Toronto Extremity Salvage Score meets all standards of measurement with the exception of breadth of content as it measures only physical function. The 1987 and 1993 Musculoskeletal Tumor Society scales do not meet the standards of measurement. In choosing an outcome measure for the extremity sarcoma population, the Toronto Extremity Salvage Score has superior measurement properties when compared with the Short Form 36 or the 1987 and 1993 Musculoskeletal Tumor Society scales. The Toronto Extremity Salvage Score is a reliable and efficient measure for monitoring patients and for use in clinical trials.     

Dose escalation with repeated intrathecal injections of 131I-labelled MAbs for the treatment of central nervous system malignancies

OBJECTIVE: The 1987 American Rheumatism Association (ARA) criteria for rheumatoid arthritis (RA) were developed to discriminate between patients with established RA and those with another rheumatological disorder. Their ability to determine which patients presenting with early synovitis have "true" RA is not known. We evaluated whether the 1987 ARA classification criteria for RA in patients newly presenting with inflammatory polyarthritis (IP) predict persistent, disabling, or erosive arthritis. METHODS: We studied 486 patients with early IP referred to the Norfolk Arthritis Register. The 1987 ARA criteria were applied at baseline, and assessed for their ability to identify (1) patients referred to hospital for whom the diagnosis of RA was recorded by the hospital physician; (2) patients at 3 years with (a) persistent synovitis; (b) moderate or greater disability; and (c) erosions. RESULTS: At baseline, 323 (67%) patients satisfied the ARA criteria in the classification tree format. Exactly 50% of those referred to hospital were given a diagnosis of RA. By 3 years, 76% of the 486 patients had persistent disease, 36% had a Health Assessment Questionnaire score > or = 1, and 40% had erosions. The sensitivity of the criteria was good, ranging from 77 to 87% depending on the outcome. The specificities were poor, and thus the overall discriminatory ability showed little improvement over random probability. CONCLUSION:. Among patients newly presenting with IP, the 1987 ARA criteria for RA had a low ability to discriminate between patients who developed persistent, disabling, or erosive disease and those who did not. Alternative criteria are required for studies investigating early RA.     

Topographical analysis of cortical neuronal loss associated with disseminated selective neuronal necrosis and infarction after repeated ischemia

Hepatitis A virus (HAV) is a health problem in countries where seroepidemiology shows changes from hyperendemicity to intermediate endemicity. Throughout the last decade, we studied, in Bangkok, the seroprevalence of hepatitis A virus antibody (anti-HAV) among adolescents of different age groups. In 1996, 245 serum specimens from children aged between 10 and 19 were tested for anti-HAV by ELISA method. The results were compared to those obtained in 1987 and 1993 from students of the same age and attending the same school. Anti-HAV was detected in 31.4%, 14.6% and 12.7% of school children in the years 1987, 1993 and 1996, respectively. Each year, it was found that an increasing prevalence of anti-HAV was related to an increasing age. From 1987 to 1996, the age specific prevalence of anti-HAV was markedly decreased in younger children. The surveillance of the epidemiological trend of HAV infection is important for implementing preventive measures and for controlling the disease.     

Rheumatoid arthritis and risk of cancer

In the current study we linked data from the Danish Hospital Discharge Register and the Danish Cancer Registry to estimate cancer occurrence among more than 20,000 patients hospitalized at least once with rheumatoid arthritis during 1977-1987. During a follow-up interval of up to 15 years, we found increased risks of non-Hodgkin's lymphoma, Hodgkin's disease and lung cancer, while the risk of colorectal cancer was decreased. These findings were all in agreement with the results of previous studies from two other Nordic countries, which were based on a similar type of data. We also found an excess of non-melanoma skin cancer and a deficit of female breast cancer, of which only the breast cancer observation had been seen in an earlier study.     

The INK4a/ARF tumor suppressor: one gene--two products--two pathways

From 1987 to 1996 we operated on 263 patients for mitral insufficiency. Multiple valve operations were excluded, with the exception of tricuspid reconstruction for functional regurgitation. The perioperative mortality was 3%, while the late mortality rate during a mean follow-up period of 3.5 years amounted to 2% per patient year and 1.7% if only cardiac causes were considered. The prognosis for patients with rheumatic, endocarditic and ischemic valvular disease was much worse compared to that for a degenerative cause. The latter group consisted of 209 patients with an operative mortality of 1.4% and a late mortality rate per patient year of 1.4% and 0.9% for cardiac causes only. Further analysis showed a significant prognostic improvement for patients with a preoperative ejection fraction of more than 60% and a repairable valve.     

Surgical treatment of gastric adenocarcinoma: the role of lymph node dissection

In this retrospective study, 652 patients who had curative resections for gastric cancer from 1977 to 1991 were reviewed to evaluate improvements in gastric cancer surgery and the influence of the extent of lymphadenectomy on survival. The patients were grouped into three time periods: 1977 to 1981, 1982 to 1986 and 1987 to 1991. The percentage of patients with early gastric cancer increased from 17.7% during 1977 to 1981, to 24.3% during 1987 to 1991. The average number of dissected lymph nodes was 7.5 +/- 8.1 during 1977 to 1981 and 16.4 +/- 10.3 during 1987 to 1991, when more radical lymphadenectomy was adopted. Total gastrectomies increased from 10.9% to 25.9% in the same time periods while combined visceral resections increased from 26.7% to 38.1%. Operative mortality decreased from 5.0% to 1.7%. The overall 5-year survival rate increased from 34.8% to 59.4%. In subgroup analysis, significant improvement of the 5-year survival rate was noted in the following groups: patients with stage I, II and III tumors but not stage IV; both proximal and distally located tumors; tumors with or without lymph node metastases; T1 and T2 but not in T3 and T4 (cancer invasion beyond the serosa). The decreased surgical mortality in recent years suggests that curative resection with extensive lymph node dissection can now be safely performed. Radical gastrectomy with extended lymphadenectomy may be adopted in gastric cancer resection for better control of regional disease.     

Use of absorbable mesh as an aid in abdominal wall closure in the emergent setting

A surgeon has many options available to aid in the closure of abdominal wall defects in the elective setting. In the emergent setting, active infection or contamination increases the likelihood of infection of permanent prosthetic material and limits the surgical options. In such settings, we have used absorbable mesh (Dexon) as an adjunct to fascial closure until the acute complications resolve. To evaluate the effectiveness of this technique, we reviewed the outcome of such closures in 26 critically ill patients. Between July 1987 and June 1993, 26 patients were identified who had placement of absorbable mesh as part of an emergent laparotomy at a major urban trauma center. Through a retrospective chart review, the incidence of complications and outcome of the closure were tabulated. Seven patients were initially operated on for trauma. Two of the patients had mesh placement at their initial procedure secondary to fascial loss from trauma. The remainder of the patients hd mesh placement during a subsequent laparotomy for complications related to their initial procedure. Indications for these laparotomies included combinations of wound dehiscence, intra-abdominal abscess, anastomotic disruption, and perforation. Mesh placement in patients with intra-abdominal infection created effectively open abdominal wounds that allowed continued abdominal drainage, but required extensive wound care. Despite the absorbable nature of the mesh and often prolonged hospital stay in these ill patients, none of them required reoperation for dehiscence, recurrence of intra-abdominal abscess, or infection of the mesh.(ABSTRACT TRUNCATED AT 250 WORDS)     

Flavone acetic acid enhances accumulation of IL-2 activated NK cells within established metastases

OBJECTIVE: In 1995, we presented our experience in hysteroscopic resection of hemorrhagic submucous fibroids in 196 patients. The objective of the present work was to analyze functional outcome three years later. PATIENTS: One hundred ninety-six patients with abnormal uterine bleeding were treated between 1987 and 1993. Equipment, techniques, characteristics of the procedures and early results were detailed in the previous article. RESULTS: With a mean follow-up of 73 months (range 50,104), results were: 13.8% of the patients were lost to follow-up; 68.4% had symptomatic improvement and failure was observed in 17.8% (subsequent hysterectomy in 12.7%). Forty-nine patients had repeat resection in this series; 61 became menopausal after surgery, and 21 were taking hormone replacement therapy with good results. CONCLUSION: Developed as an alternative to hysterectomy, operative hysteroscopy has proven to be a safe and effective procedure. This treatment modality appears to give satisfactory long-term results, with a low rate of complications.     

The microbiological profile of nosocomial infection in a respiratory intensive care unit

In 1987, in the Respiratory Intensive Care Unit of Santa Maria Hospital we developed a nosocomial surveillance program with specially created software that provides knowledge of NI in the ICU at any moment. The information gathered along the time is particularly useful in the correlation of the risk factors, the most frequent microorganisms and in the institution of empiric antibiotic therapy. Out of 2528 patients admitted in our ICU for the last 6 years (87/92), 10% had bacteriologically identified NI. Almost (93%) of them had occurred in mechanically ventilated patients, which corresponds to 20.7% NI in those patients. The gram-negative appeared in 63.37%, with the predominance of Enterobacteriaceae. From the gram-positives the most frequent were Staphylococcus spp. Their meticiline resistance was worrisome. NI patients had significantly higher severity and therapeutic intervention scores. Mechanical ventilation period was 4 fold higher and mortality 2.5 times higher in the patients with this complication.     

Polymyalgia rheumatica in biopsy proven giant cell arteritis does not constitute a different subset but differs from isolated polymyalgia rheumatica

OBJECTIVE: To assess clinical and laboratory features that may be useful in differentiating isolated polymyalgia rheumatica (PMR) from PMR associated with biopsy proven giant cell arteritis (GCA); and in differentiating biopsy proven GCA associated with PMR from GCA without manifestations of PMR. METHODS: Clinical records of patients with PMR and biopsy proven GCA diagnosed at Hospital Xeral, Lugo, Spain from January 1987 through May 1997 were reviewed. Patients with a positive temporal artery biopsy were categorized into 2 different subgroups according to the presence or absence of associated PMR. The patients with biopsy proven GCA associated with PMR were compared with a group of patients with isolated PMR (not associated with GCA). RESULTS: From a total of 108 biopsy proven patients with GCA, 45 had associated PMR. Apart from a predominance of women and a longer delay to diagnosis, patients with PMR associated with GCA did not differ from the patients with GCA without PMR manifestations. In comparing patients with isolated PMR (n=117) with patients with PMR associated with GCA, we observed that PMR associated with GCA was a more severe disease, with significant abnormality in most laboratory variables, including constitutional syndrome, higher elevation of erythrocyte sedimentation rate and platelet counts, and lower values of hemoglobin. CONCLUSION: In both isolated PMR and PMR associated with GCA we observed a predominance of women. While there are no differences in the type of polymyalgia symptoms in patients with isolated PMR versus PMR associated with GCA, severe abnormalities associated with the inflammatory response in PMR may have prognostic value for more severe disease, which may be linked to the presence of GCA.     

Evolution of diagnostic and therapeutic criteria in Graves' disease in Spain. Comparison of the results of 2 surveys in 1987 and 1995

BACKGROUND: To assess the new diagnostic and therapeutic trends for hyperthyroidism due to Graves' disease in Spain and the differences with respect to a previous study performed in 1987. METHODS: A questionnaire about a typical clinical case of hyperthyroidism due to Graves' disease and 10 variations to it, in which different diagnostic and therapeutic options are exposed. These questionnaires were mailed to 70 Spanish units of endocrinology during 1995, and 51 participated finally in the study. The results are compared with those obtained in Spain with a similar study in 1987. RESULTS: Thyrotropin (98%) and free thyroxine (88%) were the most used tests for diagnosis of Graves' disease, with a significant decrease (p < 0.001) in the use of total T4 and total T3 in comparison with the results of the questionnaire performed in 1987. The measurement of antibodies against thyrotropin receptor (TSH-R-Ab) was the most frequently used immune marker for the diagnosis (78%), with significant differences (p < 0.001) with respect to questionnaire in 1987. The use of anti-thyroperoxidase antibodies (anti-TPO-Ab) (36%) in diagnosis of this disease, significantly increased (p < 0.05) with respect to 1987. Antithyroid drugs were the most frequent initial treatment (98%) with significant differences (p < 0.001) in use of radioiodine (24%) as treatment of choice in elderly patients respect to 1987. Surgery was mainly used for large-size goiters (33%) and radioiodine for recurrences after medical (61%) or surgical (80%) treatment. Antithyroid drugs were the most frequent treatment for children and for recurrences during gestation. CONCLUSIONS: In Spain, the measurements of TSH, FT4 and TSH-R-Ab are the main diagnostic test of hyperthyroidism. Antithyroid drugs are still the treatment of choice in typical case of hyperthyroidism due to Graves' disease, in recurrences during gestation and children. Surgery is only used for large goiters and radioiodine is the treatment of choice in recurrences after medical or surgical treatment.     

Entry into clinical trials in breast cancer: the importance of specialist teams. Scottish Breast Cancer Focus Group and Scottish Cancer Therapy Network

The aim of this study was to identify the factors influencing entry of women with invasive breast cancer into clinical trials in Scotland. Women diagnosed during 1987 and 1993 were identified from cancer registry data records and their case notes reviewed. Entry into clinical trials was recorded, along with clinical and demographic data for 4688 patients. In 1987, the proportion of women entering clinical trials was 12.3% and, allowing for shorter follow-up, this appeared unchanged in 1993. Patients seen by surgeons with a high case load and those referred to an oncologist were approximately seven times and three times, respectively, more likely to enter a clinical trial (P < 0.0001). The area of Scotland (Health Board) where the woman was first treated also influenced study entry (P < 0.0001), whereas social deprivation had no effect (P = 0.93). Older women, especially those over 80 years of age, were less likely to enter studies (P = 0.05). Extending the management of patients by specialist multidisciplinary teams should increase recruitment into clinical trials and help to identify better treatments for women with breast cancer.     

Hospitalization of patients infected with active TB in New York State, 1987-1992: the effect of the HIV epidemic

Hospital discharge records were used to study the relationship between human immunodeficiency virus (HIV) epidemic and hospitalized patients with tuberculosis in New York State from 1987 through 1992. The discharges of patients coinfected with HIV and tuberculosis increased by 270%, rising from 1,573 in 1987 to 5,825 in 1992. This constitutes an increase from 19.8 to 49.1% of all discharges of patients with tuberculosis. Discharges of tuberculosis patients who were not infected with HIV decreased slightly during this time, going from 6,359 to 6,039. Postdischarge treatment plans, HIV prevention, HIV testing, and HIV educational programs for the tuberculosis population require special consideration, given the significant rise of HIV in the tuberculosis-infected population.     

Border crossing for hospital care and its implications for the use of statewide data

A major concern of researchers using state data sets for population-based analyses and market share studies in the health care sector is the potential bias caused by 'border crossing'--patients receiving care out of state. By using the Health Care Financing Administration (HCFA) discharge abstract files for 1987 and 1988, we found that 'border crossing' is not a serious problem for the two large states we examined. Only 4.4% of New York patients and 2.15% of California patients received care out of state. At the county and zip code level, 'border crossing' is more frequent but tends to be concentrated in areas adjacent to other states. Even excluding all zips with more than 10% of patients crossing the 'border' results in a small loss of patients (2.2% for New York and 1.0% for California).     

Progression of asbestosis predicts lung cancer

STUDY OBJECTIVES: To explore whether the progression of asbestosis correlates with the risk of lung cancer among patients with asbestosis. DESIGN: A group of 85 asbestosis patients (78 men and 7 women) were radiographically followed up between 1979 and 1987. Two or three posteroanterior radiographs taken from each patient in 1978 to 1979, 1983 to 1984, and 1986 to 1987 were classified according to the International Labour Office 1980 classification and were used to divide the patients into progressors and nonprogressors. Follow-up for cancer was done automatically through the files of the Finnish Cancer Registry from the time of determination of the progression status to December 31, 1994. Predictors of lung cancer risk were studied with a logistic regression model, and the standardized incidence ratio (SIR) was calculated for lung cancer. RESULTS: Of the 24 male patients with progressive small opacity profusion, 11 (46%) developed lung cancer, as opposed to 5 (9%) of the 54 male patients without progression. The SIR for lung cancer was 37 (95% confidence interval, 18 to 66) for the progressors and 4.3 (1.4 to 9.9) for the nonprogressors. In both groups, all the lung cancer cases occurred among smokers or ex-smokers. None of the seven female patients showed progressive small opacity profusion. One of them developed lung cancer. In the logistic regression model including all 85 asbestosis patients, radiographic progression of small opacity profusion (p=0.0009) and current smoking (0.0021) were significant predictors of lung cancer morbidity. CONCLUSIONS: Asbestosis patients with radiographic progression of small opacity profusion over a few years are at a higher risk of lung cancer than those with a less aggressive course of the disease. The progression of pulmonary fibrosis may be an independent risk factor that, in addition to smoking history and the intensity of asbestos exposure, could be used to estimate lung cancer risk.     

Epidemiology of Serratia marcescens between 1987 and 1995 at Vall d'Hebron Hospital

BACKGROUND: Nosocomial infection have a relative high prevalence, which is necessary to reduce in order to improve the quality of patient care. The aims of this work is to study the behaviour of Serratia marcescens in our hospital as between 1987 and 1995. METHODS: Between February 1987 and March 1995 we detected 679 isolates of Serratia marcescens in 504 patients. We used serotype as first marker and phagotype as second, and evaluation of PGFE as a discriminator of doubtful strains was done. RESULTS: 35.8% of the strains were from the respiratory tract, 37.2% from urinary tract; and 11.7% were isolated in blood culture, among them 23.3% came form children younger than 7 years. We noticed a tendency to decrease the number of isolates along the studied period. The most frequent serotypes were O:6, O:3 and O:2; representing the 36.0% of the total. Serotypes O:6;14, O:4, O:5, O:11 and polyagglutinables accounted for 37% of the total. The frequency was variable from year to year, and the predominant serotypes were different in every one of the hospitals in which the center is divided. A 60% of the patients were hospitalized in the General Hospital Vall d'Hebron building, in ICU (20%) and in chirurgical services (25%). Ninety-six patients had more than one isolate, 91 of them (94.8%) can be classified by phenotypic test. The PFGE is discriminatory in three of the five unclassificable isolates. In more than 35% of the patients the strains isolated along the time are different. The 66.7% of the patients acquired Serratia strains in the same admission, and in some cases with few days of difference. We detected 17 cross infections, predominantly in ICUs. With PFGE we could discriminate isolates which produced cross infections between patient who are not in the same hospital. CONCLUSIONS: Although the prevalence of Serratia marcescens is diminishing, it is able to produce crossed infections that, in general, affected few patients. The serotype and phagotype discriminate 94.8% of isolates. The PFGE is high discriminatory and reproducible, only 6.8% of the 44 strains tested by this method can not be typed.