CONTEXT: Measurement of change in patients' health status is central to both clinical trials and clinical practice. Trials commonly use serial measurements by the patients at 2 points in time while clinicians use the patient's retrospective assessment of change made at 1 point in time. How well these measures correlate is not known. OBJECTIVE: To compare the 2 methods in measurement of changes in pain and disability. DESIGN: Longitudinal survey of patients starting new therapy for chronic arthritis in 1994 and 1995. Surveys were completed at baseline (before intervention) and at 6 weeks and 4 months. SETTING: Community health education program and university medical and orthopedic services. SUBJECTS: A total of 202 patients undertaking self-management education (n = 140), therapy with prednisone or methotrexate (n = 34), or arthroplasty of the knee or hip (n = 28). MAIN OUTCOME MEASURES: Concordance between serial (visual analog scale for pain and Health Assessment Questionnaire for disability) and retrospective (7-point Likert scale) measures, sensitivities of these measures, and their correlation with patients' satisfaction with the change (7-point Likert scale). RESULTS: When change was small (education group), serial measures correlated poorly with retrospective assessments (eg, r=0.13-0.21 at 6 weeks). With greater change, correlations improved (eg, r = 0.45-0.71 at 6 weeks). Average agreement between all pairs of assessments was 29%. Significant lack of concordance was confirmed in all 12 comparisons by McNemar tests (P = .02 to <.001) and by t tests (P = .03 to <.001). Retrospective measures were more sensitive to change than serial measures and correlated more strongly with patients' satisfaction with change. CONCLUSION: The 2 methods for measuring health status change did not give concordant results. Including patient retrospective assessments in clinical trials might increase the comprehensiveness of information gained and its accord with clinical practice.

Aged↗

PubMedDate not supplied

Pertussis complications in Germany--3 years of hospital-based surveillance during the introduction of acellular vaccines.

Between 1 November 1993 and 31 October 1996, admissions to paediatric departments for Bordetella pertussis complications were reported to a nationwide, hospital-based active surveillance system. The case definition included pertussis complicated by pneumonia, apnoea requiring assisted ventilation, seizures, encephalopathy or a combination of these. Two hundred sixteen cases of pertussis complications were registered. 57.4% of them were in infants, 50.9% of them less than 6 months old. There were five deaths, three previously healthy children died. At the time of hospital admission, 106 cases would have been eligible for at least three doses of pertussis vaccine, only four (3.8%) had received the recommended number of immunisations. From the second quarter of 1995, the reported number of cases declined. The decrease coincides with an improvement of pertussis vaccination coverage between 1992 and 1995 due to an increased use of acellular vaccines. The reduction of complicated pertussis was observed even in age-groups too young for the recommended vaccinations. The observed decrease could be due to the increase in vaccination coverage with interruption of the chain of transmission to the younger age-groups, to a cyclic decrease in pertussis cases, or to a combination of both. Continued surveillance will provide information on the epidemiological trend of hospitalisations for pertussis complications in the first European country to have introduced vaccination with acellular vaccines on a large scale.

Child↗

PubMedDate not supplied

Variability of diphenhydramine N-glucuronidation in healthy subjects.

The H1-antagonist diphenhydramine can undergo direct glucuronidation at its tertiary amino group with formation of a quaternary ammonium glucuronide. The intraindividual variability in the amount of N-glucuronide excretion in urine was investigated in two female volunteers who repeatedly took single doses of 25 mg diphenhydramine hydrochloride without and with concomitant administration of ascorbic acid or ammonium chloride for urine acidification. Another two female and four male subjects underwent single tests without and with additional ascorbic acid. Diphenhydramine N-glucuronide quantities in urine differed significantly among subjects and ranged between 2.7% and 14.8% of the dose within 8 h. Neither ascorbic acid nor ammonium chloride significantly influenced the quantity of N-glucuronide in urine, but ammonium chloride, that in contrast to ascorbic acid proved effective in lowering urinary pH, increased the excretion of the parent drug.

Adult↗

PubMedDate not supplied

[Lavage with exogenous surfactant in neonatal meconium aspiration syndrome].

BACKGROUND: Meconium aspiration syndrome is a disease in near term infants which requires invasive techniques to decrease mortality. Lavage of the tracheobronchial tree with exogenous surfactant has been shown to be effective in animal studies. We studied the effectiveness of this technique in newborn infants and compared them with a historical control group. PATIENTS AND METHODS: From 1987 to 1998, we treated 18 neonates with meconium aspiration syndrome. In 11 babies a lavage with bovine derived diluted surfactant was carried out immediately after admission. In 7 infants of the control group only the meconium was suctioned or a lavage with saline performed. There were no differences between both groups concerning other therapeutic interventions like high frequency ventilation or inhalative NO. The control group contained significantly more outborn patients compared with the lavage group. Criteria of effectiveness were change in oxygenation index (OI), duration of mechanical ventilation and oxygen supplementation greater than 30 %. In addition, the two groups were compared for incidence of death, need for ECMO, and air leaks. RESULTS: One infant of the lavage group died, one had to be transferred to ECMO (no significant difference). There was a significant decrease in OI after surfactant lavage from 22 at admission to 5.1 one day later (p=0.007), whereas in the control group, OI did not change significantly over time (15.8 to 11.4). There were no differences in the duration of mechanical ventilation or oxygen supplementation. CONCLUSIONS: In our study, lavage with exogenous surfactant had only a short-term effect in decreasing OI in neonates with meconium aspiration. Larger numbers of patients need to be investigated to demonstrate an improvement in long-term outcome.

Bronchoalveolar Lavage↗

PubMedDate not supplied

[Sudden death of twins: botulism because of contamination by pap vegetables].

Botulism is caused by the blockage of the neural transmission in the cholinergic synapses by botulinum neurotoxin (BoNT) which is produced by Clostridium botulinum or other Clostridia. The classic form of botulism occurs after the ingestion of food contaminated by BoNT. The course of the infection can be asymptomatic, mild with subtle paralysis ("failure to thrive") oder severe with generalized paralysis ("floppy infant"). Infected infants can also die sudden and unexpectedly. These deaths often are attributed to Sudden Infant Death Syndrome (SIDS), unless a thorough postmortem examination reveals Botulism. The rate of fatal Botulism falsely attributed to SIDS is not known, because it is difficult in most cases to show the causal relationship between contamination, disease and death. We report the sudden and unexpected simultaneous death of twins of 22 months which could be attributed to Botulism. Contamination of food, colonization of the gut by Clostridia and infection with specific pathomorphological changes could be proven. The initial suspicion of infanticide could be excluded. lt could be shown, that Botulism is a potential cause of simultaneous unexpected deaths in twins.

Botulinum Toxins↗

PubMedDate not supplied

[High-frequency oscillating ventilation in premature infants under 1500 gram birth weight].

In 58 premature infants with a birthweight < 1500 g High-Frequency-Oscillating-Ventilation (HFOV) was initiated within the first 48 hours of life. Indications for HFOV were: no response to surfactant application (N = 41), respiratory distress syndrome without surfactant application (N = 9), pulmonary interstitial emphysema (N = 8). Mean gestational age of the enrolled patients was 27.6 weeks (24-32) and mean birthweight was 964 g (490-1450). 23 infants died, 5 from non-pulmonary causes. Of the remainder 2 had B-Strept.-septicemia, 1 lunghypoplasia, and 1 patient died on the 70th day of life from chronic lung disease. There were no statistical differences between survivors and nonsurvivors in gestational age, birthweight, umbilical pH, 1 min APGAR score or time on conventional ventilation prior to HFOV. Alveolar-arterial-O2-difference dropped in the group of surviving patients from x487 mm Hg (sd +/- 60) to 252 mm Hg (sd +/- 89) after 6 hours (p < 0.0001) and in the nonsurvivors from x517 mm Hg (sd +/- 74) to x373 mm Hg (sd +/- 106) (p = 0.002). Oxygenationindex fell from x25 (sd +/- 10) to x5 (sd +/- 1.5) in the survivors and from 25 (sd +/- 11) to x9 (sd +/- 5.5) in the nonsurvivors within 6 hours (p < 0.0001). Mean airway pressure could be lowered in survivors from x7.6 cm H2O (sd +/- 0.6) to 5.3 cm H2O (sd +/- 0.8) and in nonsurvivors from x8.6 cm H2O (sd +/- 0.6) to 5.7 cm H2O (sd +/- 0.9) (p = 0.0002). The promising results of HFOV as a rescue therapy require a controlled study for its use as a primary mode of ventilation in premature infants.

Female↗

PubMedDate not supplied

A new rating scale for the assessment of the alcohol-withdrawal syndrome (AWS scale).

A new rating scale for the quantitative assessment of the alcohol-withdrawal syndrome (AWS) was developed from the CIWA-A scale by item analysis based on the data from 132 alcoholic patients. The clinical evaluation of this AWS scale in a second sample of 256 alcoholic patients showed that it adequately assessed the course and severity of the AWS. The AWS scale provides data for a rational strategy of therapy for the AWS by rating mental and somatic symptoms on different scales. In particular, the mental subscale allows prediction of a complicated AWS. Subjects with an AWS score > or = 10 at admission have a higher risk of becoming delirious than those with a lower score (46.6% vs 2.8%; P < 0.001). In order to minimize the prescription of drugs with abuse potential, such as diazepam and clomethiazole, a structured treatment programme of in-patient alcohol detoxification based on the AWS score was also developed. The comparison revealed that, in the second sample, which was treated following this protocol, the number of cases given medication was lower and the amount of clomethiazole prescribed per patient was less.

Adult↗

PubMedDate not supplied

Comparison of cage and mast with the alcohol markers CDT, gamma-GT, ALAT, ASAT and MCV.

Many alcoholics deny abuse. To screen greater samples for alcohol dependence, short questionnaires, e.g. the CAGE or MAST are often applied. Frequently laboratory parameters [i.e. 'alcohol markers', such as carbohydrate-deficient transferrin (CDT), gamma-glutamyl transferase or mean corpuscular volume of erythrocytes] are used to support the diagnosis of long-standing heavy alcohol consumption. In this study, the self-ratings (CAGE and MAST) were compared with the above laboratory parameters in an unselected sample of 204 patients admitted to a general hospital. The sensitivities, specificities, and positive (PPV) as well as negative predictive values of the CAGE, the MAST, and the alcohol markers were calculated along with the reported alcohol consumption or the ICD-10 diagnosis as standard. According to recent harmful alcohol consumption levels (women >225 g/week: men >350 g/week), the sensitivities and the PPVs were rather low in all tests (sensitivity <60%; PPV <50%). With the ICD-10 diagnosis as standard, the CAGE and MAST showed a rather high specificity (>95%) and PPV (about 90%). CDT revealed the best PPV of all alcohol markers (60%). However, the sensitivity of the CAGE, MAST, and the alcohol markers for the ICD-10 diagnosis was rather poor (<60%). This low sensitivity impedes the usefulness of these questionnaires and alcohol markers as screening tests for alcoholism in general hospitals.

Adult↗

PubMedDate not supplied

Cotton-wool spots.

A series of 24 consecutive patients presenting with a fundus picture characterized by a predominance of cotton-wool spots, or a single cotton-wool spot, is reported. Excluded were patients with known diabetes mellitus. Etiologic conditions found included previously undiagnosed diabetes mellitus in five patients, systemic hypertension in five patients, cardiac valvular disease in two patients, radiation retinopathy in two patients, and severe carotid artery obstruction in two patients. Dermatomyositis, systemic lupus erythematosus, polyarteritis nodosa, leukemia, AIDS, Purtscher's retinopathy, metastatic carcinoma, intravenous drug abuse, partial central retinal artery obstruction, and giant cell arteritis were each found in one patient. In only one patient did a systemic workup fail to reveal an underlying cause. The presence of even one cotton-wool spot in an otherwise normal fundus necessitates an investigation to ascertain systemic etiologic factors.

Adult↗

PubMedDate not supplied

The effect of dehydration on parotid salivary gland function.

Dehydration is common in the elderly, and has been traditionally linked with salivary hypofunction. This study examined the effect of dehydration on parotid salivary flow rates. Twelve young and 12 older healthy subjects abstained from food and fluid intake for 24 hrs (dehydration) and then underwent i.v. rehydration proportional to the amount of weight lost. Unstimulated and stimulated parotid flow rates, weight, hematocrit and hemoglobin values were assessed at baseline and 24 hrs, and 1 hr after completion of rehydration. All subjects experienced decreases in weight and increases in hematocrit and hemoglobin during dehydration. I.v. fluids caused weight gain and decreased hematocrit and hemoglobin, demonstrating that subjects were metabolically rehydrated. During dehydration, unstimulated flow rates decreased in young (p < 0.001) and older (p < 0.001) subjects, and stimulated flow rates decreased in young (p > 0.05) and older (p = 0.03) subjects. While flow rates increased with rehydration, they remained lower than baseline levels. No age or gender differences were detected for salivary data. These findings suggest that dehydration may cause decreased parotid flow rates, independent of age in healthy adults.

Adult↗

PubMedDate not supplied

Proposal for a new scoring system in international interhospital air transport.

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APACHE↗