Health care utilization among homeless adults prior to death.

This study characterizes health care utilization prior to death in a group of 558 homeless adults in Boston. In the year before death, 27 percent of decedents had no outpatient visits, emergency department visits, or hospitalizations except those during which death occurred. However, 21 percent of homeless decedents had a health care contact within one month of death, and 21 percent had six or more outpatient visits in the year before death. Injection drug users and persons with HIV infection were more likely to have had contact with the health care system. This study concludes that homeless persons may be underusing health care services even when they are at high risk of death. Because a subset of homeless persons had extensive health care contacts prior to death, opportunities to prevent deaths may have been missed, and some deaths may not have been preventable through medical intervention.

Risk factors for death in homeless adults in Boston.

BACKGROUND: Homeless individuals experience high mortality rates. Males, whites, and substance abusers are more likely to die, but other high-risk characteristics are unknown. OBJECTIVE: To identify demographic and clinical factors associated with an increased risk of death in homeless individuals. METHODS: We conducted a case-control study of 558 adults who were seen by a health care program for the homeless in Boston, Mass, and who died in 1988 to 1993. Age-matched paired controls were selected from among individuals seen by the program who were alive at the end of 1993. Predictive data were obtained by blinded review of medical records. Odds ratios (ORs) for death were calculated using logistic regression analysis models. RESULTS: In a multivariate analysis, the strongest risk factors for death were acquired immunodeficiency syndrome (OR, 55.8), symptomatic human immunodeficiency virus infection (OR, 17.7), asymptomatic human immunodeficiency virus infection (OR, 4.1), renal disease (OR, 18.4), a history of cold-related injury (OR, 8.0), liver disease (OR, 3.8), and arrhythmia (OR, 3.3). A history of substance abuse involving injection drugs (OR, 1.6) or alcohol (OR, 1.5) also increased the risk of mortality. Nonfluency in English was associated with a decreased risk of death (OR, 0.4). CONCLUSIONS: In a group of adults seen by a health care program for the homeless, specific medical illnesses were associated with the greatest risk of death. Substance abuse alone was less strongly associated with death. Interventions to reduce mortality among the homeless should focus on individuals with high-risk characteristics.

Causes of death in homeless adults in Boston.

BACKGROUND: Homeless persons have high mortality rates. OBJECTIVE: To ascertain causes of death in a group of homeless persons. DESIGN: Cohort study. PATIENTS: 17,292 adults seen by the Boston Health Care for the Homeless Program from 1988 to 1993. MEASUREMENTS: Cause-specific mortality rates adjusted for race and rate ratios that compare mortality rates in homeless persons with those in the general population of Boston. RESULTS: Homicide was the leading cause of death among men who were 18 to 24 years of age (mortality rate, 242.7 per 100000 person-years; rate ratio, 4.1). The acquired immunodeficiency syndrome was the major cause of death in men (mortality rate, 336.5 per 100000 person-years; rate ratio, 2.0) and women (mortality rate, 116.0 per 100000 person-years; rate ratio, 5.0) who were 25 to 44 years of age. Heart disease and cancer were the leading causes of death in persons who were 45 to 64 years of age. CONCLUSIONS: The most common causes of death among homeless adults who have contact with clinicians vary by age group. Efforts to reduce the rate of death among homeless persons should focus on these causes.

Rifampin preventive therapy for tuberculosis in Boston's homeless.

An epidemic of isoniazid (INH)- and streptomycin (SM)-resistant tuberculosis began among Boston's homeless population in 1984. Individuals with skin test conversions who agreed to preventive therapy received either INH, rifampin, or a combination of INH and rifampin. A total of 204 individuals with documented tuberculin skin test conversions who did not have active tuberculosis at the time of the clinical evaluation for their positive skin test were eligible for preventive therapy. Data on type and length of preventive therapy were obtained from the Tuberculosis Clinic and the Boston Tuberculosis Registry records at Boston City Hospital. The individuals were followed for development of active tuberculosis. Six of 71 (8.6%) individuals who received no therapy, 3 of 38 (7.9%) in the INH group, and none in the rifampin or rifampin plus INH groups (49 and 37 persons, respectively) developed active tuberculosis. Patients in the rifampin group were significantly less likely to develop tuberculosis than patients in the no therapy group (p = 0.04; odds ratio [OR] = 0.00, 95% confidence interval [CI] = 0.00-0.91). Treatment with any rifampin-containing preventive therapy (rifampin or rifampin plus INH) was effective (p < 0.01 ) in preventing development of active disease. The three INH failures were with organisms that were resistant to INH.

Cosmic ray and solar particle investigations over the South polar regions of the sun.

Observations of galactic cosmic radiation and anomalous component nuclei with charged particle sensors on the Ulysses spacecraft showed that heliospheric magnetic field structure over the south solar pole does not permit substantially more direct access to the local interstellar cosmic ray spectrum than is possible in the equatorial zone. Fluxes of galactic cosmic rays and the anomalous component increased as a result of latitude gradients by less than 50% from the equator to -80 degrees . Thus, the modulated cosmic ray nucleon, electron, and anomalous component fluxes are nearly spherically symmetric in the inner solar system. The cosmic rays and the anomalous nuclear component underwent a continuous, -26 day recurrent modulation to -80.2 degrees , whereas all recurring magnetic field compressions and recurring streams in the solar wind disappeared above approximately 55 degrees S latitude.

AIDS among the homeless of Boston: a cohort study.

We wanted to compare demographics, risk behaviors, AIDS-defining diagnoses, and survival between homeless and housed persons with AIDS in Boston from 1983 to 1991. Our retrospective cohort study used chart review to identify homeless AIDS cases and data from the Massachusetts AIDS Surveillance Program for comparison of homeless and nonhomeless cases. Seventy-two homeless and 1,536 nonhomeless Boston residents were reported to have AIDS between Jan. 1, 1983, and July 1, 1991. Homeless persons with AIDS were more likely to be African American or Latino (81 vs. 39%, p < 0.0001) and have i.v. drug use as a risk behavior (75 vs. 19%, p < 0.0001). The AIDS-defining diagnoses among the homeless were more commonly disseminated Mycobacterium tuberculosis (9 vs. 2%, p < 0.0001) and esophageal candidiasis (17 vs. 9%, p < 0.01). These differences were not seen when the populations were stratified by i.v. drug use. No significant difference in survival between the homeless and nonhomeless cohorts was found. Homeless individuals with human immunodeficiency virus are significantly different than housed persons, and at greater risk of invasive opportunistic infections. Appropriate clinical strategies can be developed to provide needed care to homeless persons with HIV.

Nontuberculous respiratory infections among the homeless.

In contrast to the extensive studies of pulmonary tuberculosis among homeless persons, virtually no data are available on nontuberculous respiratory infections in this population. This article reviews the literature on pulmonary infections and homelessness. The clinical experience of the Boston Health Care for the Homeless Program is detailed, with emphasis on the role of multidisciplinary teams of physicians, nurses, and case workers in the integration of hospital- and shelter-based clinics necessary to provide primary care to a fragmented and transient population. The shelters facilitate the transmission of airborne pathogens, and homeless persons are often debilitated and susceptible hosts. Outbreaks of specific respiratory infections are examined, including pneumococcal pneumonia, Haemophilus influenzae type b pneumonia, and influenza.

Extracorporeal membrane oxygenation for neonatal respiratory failure. A report of 50 cases.

From February 1985 through June 1987, 50 newborn infants in whom maximal ventilator therapy failed (80% predicted mortality) were treated with extracorporeal membrane oxygenation (ECMO) according to the following inclusion criteria: arterial oxygen tension less than 50 torr (alveolar-arterial oxygen gradient greater than 630 torr) for 2 hours or arterial oxygen tension less than 60 torr (alveolar-arterial oxygen gradient greater than 620 torr) for 8 hours. Criteria for exclusion from ECMO therapy included birth weight less than 2000 gm, gestational age less than 35 weeks, presence of intracranial hemorrhage, presence of other major congenital anomalies including cyanotic heart disease, and high levels of ventilatory support for more than 7 days. Mean birth weight was 3.28 +/- 0.56 kg, mean gestational age was 39.6 +/- 1.7 weeks, and mean age at the start of ECMO was 48.6 +/- 36.9 hours. Meconium aspiration, usually associated with persistent pulmonary hypertension, was the most common cause of pulmonary failure (62%). Mean pre-ECMO arterial oxygen tension during maximal ventilatory and pharmacologic support was 34.5 +/- 14.5 torr. Mean ventilatory support immediately before the institution of ECMO was as follows: peak inspiratory pressure 46.8 +/- 9.9 cm H2O, positive end-expiratory pressure 4.6 +/- 1.6 cm H2O, and intermittent mandatory ventilation rate 101.0 +/- 22.7 breaths/min with all patients receiving an inspired oxygen fraction of 1.0. Lung management to prevent pulmonary atelectasis during ECMO consisted of moderate levels of positive end-expiratory pressure (mean 10.3 +/- 2.6 cm H2O, range 8 to 14 in 94% of patients. Other mean ventilator parameters during ECMO were as follows: peak inspiratory pressure 22.8 +/- 1.6 cm H2O, intermittent mandatory ventilation rate 11.8 +/- 2.9, and inspired oxygen fraction 0.21. The overall long-term patient survival rate was 90%. Mean values for arterial blood gases and ventilator settings immediately after the discontinuation of ECMO were as follows: oxygen tension 78.4 +/- 22.1 torr, pH 7.39 +/- 0.10, carbon dioxide tension 37.4 +/- 10.7 torr, peak inspiratory pressure 25.2 +/- 3.9 cm H2O, positive end-expiratory pressure 5.6 +/- 1.2 cm H2O, and intermittent mandatory ventilation rate 41.3 +/- 12.6 with an inspired oxygen fraction of 0.42 +/- 0.17. Despite slightly higher levels of ventilator support (peak inspiratory pressure 46.8 versus 45.0 cm H2O, not significant) mean pre-ECMO oxygen tension was significantly lower than that reported from the National ECMO Registry (34.5 versus 42.0 torr, p less than 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)