National Data Sources on the Care and Outcomes of Patients with Community Acquired Pneumonia

Despite improved understanding and treatment of community acquired pneumonia (CAP), variations in clinical practice and patient outcomes still exists, resulting in excess healthcare dollars spent and decreased patient satisfaction. The use of treatment and outcomes research data can help providers improve their methods and standardize techniques to control costs and provide the best care for their patients. To better understand the utility and capabilities of this research, this article will compare several administrative and clinical databases. Two, data sources in particular, the EPI-Q Inc. CAP-Compare database and the University HealthSystem Consortium's (UHC) CAP Benchmarking Program contain clinical and utilization data specific to CAP. In addition there are several government and non-government sponsored data sources that include administrative data on many diagnosis including CAP. These include: Healthcare Benchmarking Systems International's EXPLORE database, the Center for Healthcare Industry Performance Studies database, the National Center for Health Statistics'--National Hospital Discharge Survey, and the Medicare Provider Analysis and Review data files.     

Patient satisfaction with health care providers in South Africa: the influences of race and socioeconomic status.

OBJECTIVE: The first democratic government elected in South Africa in 1994 inherited huge inequalities in health status and health provision across all sections of the population. This study set out to assess, 4 years later, the influence of race and socioeconomic status (SES) on perceived quality of care from health care providers. DESIGN: A 1998 countrywide survey of 3820 households assessed many aspects of health care delivery, including levels of satisfaction with health care providers among different segments of South African society. RESULTS: Fifty-one percent (n = 1953) of the respondents had attended a primary care facility in the year preceding the interview and were retained in the analysis. Both race and SES were significant predictors of levels of satisfaction with the services of the health care provider, after adjusting for gender, age, and type of facility visited. White and high SES respondents were about 1.5 times more likely to report excellent service compared with Black and low SES respondents, respectively. CONCLUSION: In South Africa, race and SES are not synonymous and can no longer be considered reliable proxy indicators of one another. Each has distinct and significant but different degrees of association with client satisfaction. Any assessment of equity-driven health policy in South Africa should consider the impacts of both race and SES on client satisfaction as one of the indicators of success.     

Effects of exogenous sphinganine, sphingosine, and sphingosine-1-phosphate on relaxation and contraction of porcine thoracic aortic and pulmonary arterial rings.

Fumonisin mycotoxicosis in pigs causes a decrease in mean aortic pressure, an increase in mean pulmonary arterial pressure, and increases in serum concentrations of sphinganine (3.2 microM) and sphingosine (1.4 microM). To determine a causal relationship between the hemodynamic changes and sphingolipid alterations, we examined the in vitro effects of sphinganine, sphingosine, and sphingosine-1-phosphate on porcine aortic and pulmonary arterial rings. Both sphinganine and sphingosine relaxed un-contracted and phenylephrine-contracted aortic rings at > or = 10 microM and > or = 1 microM, respectively. Sphingosine (> or = 10 microM) relaxed un-contracted and phenylephrine-contracted pulmonary arterial rings, whereas sphingosine-1-phosphate (10 microM) contracted pulmonary arterial rings. Sphingosine (3 microM) also impaired the contractile response of pulmonary artery rings to 60 mM KCl. The results suggested that the systemic hypotension caused by fumonisin is mediated, in part, by increases in serum sphinganine and sphingosine concentrations, and the pulmonary hypertension is mediated, in part, by increased sphingosine-1-phosphate concentrations.     

Brain trauma in aged transgenic mice induces regression of established abeta deposits

Traumatic brain injury (TBI) increases susceptibility to Alzheimer's disease (AD), but it is not known if TBI affects the progression of AD. To address this question, we studied the neuropathological consequences of TBI in transgenic (TG) mice with a mutant human Abeta precursor protein (APP) mini-gene driven by a platelet-derived (PD) growth factor promoter resulting in overexpression of mutant APP (V717F), elevated brain Abeta levels, and AD-like amyloidosis. Since brain Abeta deposits first appear in 6-month-old TG (PDAPP) mice and accumulate with age, 2-year-old PDAPP and wild-type (WT) mice were subjected to controlled cortical impact (CCI) TBI or sham treatment. At 1, 9, and 16 weeks after TBI, neuron loss, gliosis, and atrophy were most prominent near the CCI site in PDAPP and WT mice. However, there also was a remarkable regression in the Abeta amyloid plaque burden in the hippocampus ipsilateral to TBI compared to the contralateral hippocampus of the PDAPP mice by 16 weeks postinjury. Thus, these data suggest that previously accumulated Abeta plaques resulting from progressive amyloidosis in the AD brain also may be reversible.     

Presynaptic NMDA receptor subunit immunoreactivity in GABAergic terminals in rat brain

N-methyl-D-aspartate (NMDA) receptors are commonly found post-synaptically; they mediate fast excitatory neurotransmission in the central nervous system. In this study, we provide immunocytochemical data supporting the existence of presynaptic NMDA receptors in GABAergic terminals using polyclonal antisera raised against the C-terminus of the NMDAR1 subunit. At the light microscope level, rich plexuses of NMDAR1-positive varicose fibers were found in various nuclei in the basal forebrain (bed nucleus of stria terminalis, septum, parastrial nucleus, vascular organ of the lamina terminalis), thalamus (paraventricular nucleus, midline nuclei), and hypothalamus (parvocellular paraventricular nucleus, arcuate nucleus, preoptic nucleus, suprachiasmatic nucleus). In the brainstem, labeled fibers were much less abundant and were confined to the ventral tegmental area, periaqueductal gray, parabrachial nucleus, and locus coeruleus. At the electron microscope level, NMDAR1-immunoreactive terminals examined in the bed nucleus of stria terminalis, parvocellular paraventricular hypothalamic nucleus, and arcuate nucleus formed symmetric synapses, contained darkly stained large dense-core vesicles, and displayed gamma-aminobutyric acid (GABA) immunoreactivity. Terminals with similar ultrastructural features were found in the paraventricular thalamic nucleus. These findings demonstrate the existence of NMDAR1 subunit immunoreactivity in subsets of GABAergic terminals, which raises questions about the potential roles and mechanisms of activation of presynaptic NMDA heteroreceptors in the rat central nervous system. The pattern of distribution and ultrastructural features of these boutons suggest that they may arise from local GABAergic projections interconnecting a group of brain structures mediating stress responses and/or other endocrine, autonomic, and limbic functions.     

Ictal spiking patterns recorded from temporal depth electrodes predict good outcome after anterior temporal lobectomy

PURPOSE: Investigators have shown that the presence of ictal spiking (IS) recorded from temporal depth electrodes is associated with mesial temporal sclerosis (MTS). We investigated the relation of IS to seizure control and pathology after anterior temporal lobectomy (ATL). METHODS: All patients undergoing intracranial ictal monitoring from a single institution since 1989 were identified. Those who did not undergo ATL or had postoperative follow-up of <1 year were excluded. All received at a minimum bilateral temporal depth electrodes. Ictal recordings were reviewed for the presence of IS, and the proportion of seizures with IS was determined for each patient. Outcome was determined by using Engel's classification. Surgical specimens were reviewed for pathology. Statistics used were chi2, Fisher exact test, and Wilcoxon rank sum. RESULTS: Forty patients with 571 seizures were reviewed. In 292 seizures from 32 patients, IS was seen. Outcomes were 24 class I (22 with IS), five class II (four with IS), three class III (one with IS), seven class IV (four with IS), and one lost to follow-up (with IS). Pathologic review revealed 25 with MTS, 22 of whom had IS. The presence of IS was associated with class I outcomes (p = 0.04), but not MTS (p = 0.06). Patients with class I outcomes had a significantly greater proportion of seizures with IS (mean, 0.58 +/- 0.3) compared with other outcomes (mean, 0.30 +/- 0.3, p = 0.02). CONCLUSIONS: The presence of IS and higher proportion of seizures with IS correlated with good seizure outcome after ATL. This information may be used in preoperative counseling.     

Comparison of internal radiation doses estimated by MIRD and voxel techniques for a "family" of phantoms

The aim of this study was to use a new system of realistic voxel phantoms, based on computed tomography scanning of humans, to assess its ability to specify the internal dosimetry of selected human examples in comparison with the well-established MIRD system of mathematical anthropomorphic phantoms. Differences in specific absorbed fractions between the two systems were inferred by using organ dose estimates as the end point for comparison. A "family" of voxel phantoms, comprising an 8-week-old baby, a 7-year-old child and a 38-year-old adult, was used and a close match to these was made by interpolating between organ doses estimated for pairs of the series of six MIRD phantoms. Using both systems, doses were calculated for up to 22 organs for four radiopharmaceuticals with widely differing biodistribution and emission characteristics (technetium-99m pertechnetate, administered without thyroid blocking; iodine-123 iodide; indium-111 antimyosin; oxygen-15 water). Organ dose estimates under the MIRD system were derived using the software MIRDOSE 3, which incorporates specific absorbed fraction (SAF) values for the MIRD phantom series. The voxel system uses software based on the same dose calculation formula in conjunction with SAF values determined by Monte Carlo analysis at the GSF of the three voxel phantoms. Effective doses were also compared. Substantial differences in organ weights were observed between the two systems, 18% differing by more than a factor of 2. Out of a total of 238 organ dose comparisons, 5% differed by more than a factor of 2 between the systems; these included some doses to walls of the GI tract, a significant result in relation to their high tissue weighting factors. Some of the largest differences in dose were associated with organs of lower significance in terms of radiosensitivity (e.g. thymus). In this small series, voxel organ doses tended to exceed MIRD values, on average, and a 10% difference was significant when all 238 organ doses were considered as a single group. In 12 comparisons of effective dose, the mean voxel to MIRD ratio was 1.07 (range 0.72-1.32). It was shown for the majority of cases that, whereas some large differences in SAF values exist, differences in source organ and effective dose values between the MIRD and voxel methods were largely accounted for by the respective organ mass differences. The reasons for various organ dose differences with the selected radiopharmaceuticals are discussed. Taking biological variation into account, there is reasonable agreement between the two methods but some significant differences exist that warrant further investigation. More extensive comparisons involving a wide variety of voxel phantoms are required to establish whether realistic voxel phantoms should eventually replace the MIRD system.