Central nervous system anoxic-ischemic insult in children due to near- drowning

An analysis of admission and follow-up CT examinations of the brains of 17 children who had nearly drowned (15 of whom were comatose and two of whom were conscious on admission) indicated that a normal initial CT scan is common in the majority of comatose patients, a severe neurologic outcome may develop in spite of a normal initial CT examination, and abnormal initial or follow-up CT findings indicate the strong but not inevitable probability of a severe neurologic outcome. We conclude that when there is no head trauma, an initial CT examination is not necessary. Prediction of the clinical outcome cannot be made on the basis of the initial CT findings.     

Persistent progesterone production associated with autoimmune oophoritis. A case report

A woman with autoimmune oophoritis was found to have luteal phase progesterone levels throughout a six-month period of amenorrhea. The common presentation of amenorrhea or metrorrhagia, despite the presence of a corpus luteum, in women with autoimmune oophoritis might result from this chronic progesterone production. A clinical picture consistent with a persistent corpus luteum may be a very early sign of autoimmune oophoritis.     

Identifying priority health conditions, environmental data, and infrastructure needs: a synopsis of the Pew Environmental Health tracking project

In this article we describe the methodologic approaches of the Pew Environmental Health Commission at the Johns Hopkins Bloomberg School of Public Health used to identify priority environmental health conditions and develop recommendations to establish a national environmental public health tracking network. We present the results of a survey of public health and environmental practitioners to uncover state and local health tracking needs and priorities. We describe the steps that combined the findings from the state and local health tracking survey and a review of the state of the science on environmental impacts on health to identify priority health end points. Through an examination of national health and health care databases, we then describe trends and public health effects of those diseases that may be linked to the environment. Based on this analysis, respiratory diseases and neurologic diseases are recommended as priorities for tracking. Specific end points recommended for tracking include asthma and chronic respiratory diseases, and chronic neurodegenerative diseases such as multiple sclerosis. Based on trends in reported prevalence, consideration should also be given to developmental disabilities, reproductive disorders, and endocrine/metabolic disorders. Strengthening of current efforts to track cancer and birth defects should also be included as components of a nationwide health tracking network. Finally, we present the recommendations for environmental public health tracking. These recommendations provided the groundwork for the development of the Centers for Disease Control and Prevention's National Environmental Public Health Tracking Progam that now includes 21 states, three cities, and three academic centers throughout the nation.     

Smallpox vaccine: problems and prospects

Smallpox justifiably is feared because of its morbidity and mortality. Wide-spread population-level susceptibility to smallpox exists, and the only effective tool against the virus is a live, attenuated vaccine that is highly reactogenic and controversial. A significant minority of the population has contraindications that prevent preexposure use of this vaccine. Newer, safer, and equally immunogenic vaccines must be developed and licensed. Several live, attenuated vaccines are in clinical trials. Although these vaccines may prove to be less reactogenic, they still may not be administered safely to a significant portion of the population because they contain live, attenuated viruses. Newer vaccines will be needed if routine preexposure vaccination is to be instituted universally. The idea of a subunit or peptide-based vaccine is appealing, because it obviates potential safety concerns. It may be possible to use a more-attenuated, live vaccine strain for a large segment of the population on a preexposure basis and accept the morbidity and mortality that would result from its use on a postexposure basis, if necessary. The need for widespread population-level protection against variola infection is apparent. The use of the new biology tools to predict or define who might experience serious reactions to the smallpox vaccine and why these reactions occur is an area ripe for additional research. The reason why an individual develops postvaccinal encephalitis remains unknown, and the development is unpredictable and untreatable. In the future, if the mechanism behind such adverse events is defined, it may be possible to screen persons who are likely to experience such events. Although the authors remain proponents for use of the vaccine in alignment with the CDC vaccination program and recommendations, the previous concerns indicate that new knowledge must be gained and shared. Further research on attenuated vaccines and nonliving or peptide vaccines with equal efficacy should remain the goal, as it is apparent that smallpox vaccine once again will become part of the vaccinologist's and public health official's armamentarium in the decades to come.     

Long-term assessment of lung function in survivors of severe ARDS

STUDY OBJECTIVES: To investigate the long-term outcome of lung function in survivors of severe ARDS after modern treatment strategies including lung protective mechanical ventilation and prone positioning maneuvers. DESIGN: Follow-up cohort study. SETTING: University hospital pulmonary division and level 1 trauma center. PATIENTS: Sixteen survivors of severe ARDS (from 1992 to 1994) with a lung injury score > or = 2.5. MEASUREMENTS: The follow-up study (from 1995 to 1996) included interview, physical examination, chest radiographs, static and dynamic lung volumes, diffusion capacity of the lung for carbon monoxide (DLCO), blood gas analysis, and cardiopulmonary exercise testing (CPET). RESULTS: The mean +/- SD interval between hospital discharge and functional assessment was 29.5 +/- 8.7 months (range, 15.0 to 40.7 months). In approximately one half of the patients, mild abnormalities in static and dynamic lung volumes were found. In 25% (4 of 16 patients), lung function was obstructive; in 25% (4 of 16 patients), lung function was restrictive; and in 6.3% (1 of 16 patients), a combined obstructive-restrictive pattern was revealed. DLCO was impaired in 12.5% (2 of 16 patients); gas exchange during exercise was impaired in 45.5% (5 of 11 patients). CONCLUSIONS: Residual obstructive and restrictive defects as well as impaired pulmonary gas exchange remain common after severe ARDS. CPET is a very sensitive measure to evaluate residual impairment of lung function after ARDS. Using CPET, reduced pulmonary gas exchange can be detected in many patients with normal DLCO.     

Trends in antibiotic use and cost and influence of case-mix and infection rate on antibiotic-prescribing in a long-term care facility

BACKGROUND: Antibiotic use and cost indicators have been developed specifically for the long-term care facility (LTCF) setting. Approximately 50% of the variation in these indicators was explained by the variation in infection rate. The objectives of this study were to further assess the utility of the antibiotic use and cost indicators in a different LTCF and to determine the correlation of case-mix and these indicators. METHODS: Antibiotic use and cost indicators were collected monthly by unit (N = 10) and by physician (N = 6) at a 433-bed LTCF in Syracuse, New York, from February 1999 to September 2001. Indicators included incidence (number of antibiotic courses per 1000 resident care-days) of antibiotic use, antibiotic utilization ratio ([AUR]; ratio of the number of antibiotic-days to the number of resident care-days), cost per antibiotic-day, and cost per resident care-day. Case-mix variation was measured with the case-mix index (CMI) of the Resource Utilization Group II system. Simple linear and multilinear regression analyses were used to evaluate correlations of continuous variables. RESULTS: Among the 10 units or 6 physicians, there was a significant difference in the average values for all indicators. Correlation between unit- or physician-specific CMI and antibiotic use or cost indicators or infection rate was poor. However, there was a significant positive correlation between unit- or physician-specific infection rate and incidence of antibiotic use, AUR, and cost per resident care-day but not cost per antibiotic-day. With use of multilinear regression analysis to control for CMI and cost per antibiotic-day, infection rate was a significant predictor of incidence of antibiotic use (R2 = 0.65; P <.001) and AUR (R2 = 0.78; P <.001). CONCLUSIONS: This study provides further evidence that the antibiotic use and cost indicators developed specifically for LTCFs can detect significant variation among units within a facility and among physicians. However, there was no correlation between CMI and antibiotic use or cost indicators. After controlling for case-mix variation and cost per antibiotic-day, variation in infection rate explained most of the variation in incidence of antibiotic use and AUR.     

Pulse-inversion contrast harmonic imaging: ultrasonographic assessment of cerebral perfusion

Pulse-inversion contrast harmonic imaging is a new ultrasonographic technique that can assess brain perfusion. In an adult with moyamoya disease and multiple recurrent strokes, this method detected subtle hemispheric differences in temporal-lobe perfusion, presumably due to neovascularisation, which were not shown by xenon-computed tomography or magnetic resonance perfusion imaging.