A predictive model for the management of community-acquired pneumonia.

BACKGROUND: Understanding what determines the prognosis of community-acquired pneumonia (CAP) is especially important for decisions on hospitalization and antimicrobial therapy. The objective of the present study was to compare the predictability of mortality in our patients to that of the pneumonia patient outcomes research team (PORT) study. PATIENTS AND METHODS: Data of 320 patients admitted with CAP were retrospectively evaluated and classified according to the published scheme. RESULTS: One-month mortality was 14.4%; 1-year mortality was 27.8%, two-thirds from new episodes. Univariate logistic regression risk factors for the 1-month mortality rate included leukocytosis, anemia, hypoalbuminemia, elevated blood urea nitrogen, >or= two comorbidities, tachycardia, tachypnea, acidosis, stupor, age > 65 years and high serum lactic dehydrogenase. These variables, except the last two, plus pleural effusion and bilateral infiltration were also risk factors for 1-year mortality. In the multivariate models, eight of these factors were significant risk factors, four for 1-month mortality and six for 1-year mortality. Our model for prediction of 1-month mortality had a sensitivity of 65%, specificity of 95% and accuracy of 91%. CONCLUSION: Agreement between predictions by our model and the published model was considerable, showing that most patients in the low score groups should not have been hospitalized.

Validation of birth certificate data. A study of women in New Jersey's HealthStart program.

PURPOSE: This study assesses the accuracy of 1989-1992 birth certificate data from New Jersey for a group of high-risk women. METHODS: Birth records were linked to data on women who participated in HealthStart, a program of enriched prenatal care for pregnant women on Medicaid. Concordance was assessed for all variables common to the two data sets. RESULTS: The birth records had accurate reporting of birth-weight, demographic characteristics, and most methods of delivery. Prenatal care use was over-reported, and alcohol, tobacco, transfer status, medical risk factors, obstetric procedures, as well as complications of labor and delivery were underreported. CONCLUSIONS: While many variables are reported very accurately on birth certificates, other measures must be used cautiously. Analyses using birth certificate data, particularly those focusing on high-risk women, need to take the low levels of sensitivity for many risk factors into consideration.

Prevalence of hypothyroidism and diabetes mellitus in elderly kibbutz members.

UNLABELLED: The aim of this study was to determine the prevalence of hypothyroidism and diabetes mellitus (DM) in elderly (aged 65-92 years) kibbutz members in Northern Israel. METHOD: The medical records of 1096 elderly (642 females and 454 males) residing in 11 kibbutzim were reviewed for data regarding thyroid function tests (TSH and FT4) and fasting blood glucose. Fasting blood glucose levels above 7.8 mmol/l was considered diagnostic for diabetes mellitus. RESULTS: The prevalence of hypothyroidism was 14% (9.7% in males and 18.2% in females) and that of DM was 11.5% (12.1% in males and 11.1% in females). In 74% of the diabetics the diagnosis was made after the age of 60 years. Distribution of treatment modalities in diabetics was as follows: diet only 42%. oral hypoglycemic agents 52% and Insulin 6%. Subclinical hypothyroidism (serum TSH levels above 4.5 mU/L with normal FT4 levels) was detected in 38% of all the hypothyroid subjects. CONCLUSION: The data suggest that diabetes mellitus and primary hypothyroidism are common disorders in elderly subjects. DM in the elderly can usually be handled with diet and oral hypoglycemic drugs. Since the clinical features of hypothyroidism in the elderly are often atypical, we suggest that elderly subjects should be screened for hypothyroidism.

Psychosocial factors and the timing of prenatal care among women in New Jersey's HealthStart program.

CONTEXT: Helping high-risk pregnant women obtain prenatal care early is the main policy goal of most U.S. publicly funded programs aimed at reducing the incidence of low birth weight and infant mortality It is therefore crucial to understand the factors that influence when women initiate prenatal care. METHODS: The effects of psychosocial and demographic risk factors on the timing of entry into prenatal care were estimated using data on roughly 90,000 Medicaid recipients who participated in New Jersey's HealthStart prenatal care program. RESULTS: Overall, 37% of women began prenatal care in the first trimester. Multivariate logistic regression indicated that women who lived in poor housing conditions and those who smoked, drank or used hard drugs had a reduced likelihood of entering care early (odds ratios, 0.8-0.9), while those who had clinical depression or who experienced domestic violence or abuse had elevated odds of early entry (1.1-1.2). The risk factor with the greatest impact on the timing of prenatal care was the wantedness of the pregnancy; women whose pregnancy was unwanted had dramatically reduced odds of entering care early (0.4). Separate analyses of women of varying racial and ethnic backgrounds demonstrated the differential effects of risk factors, the importance of including ethnicity with race and the universal impact of wantedness across racial and ethnic groups. CONCLUSIONS: Entry into prenatal care for at-risk women is affected by factors from multiple domains. It is important for prenatal programs to recognize the complexity of the issue as well as the barriers that different subgroups of women face.

Malaria and Borrelia co-infection.

Severe anemia requiring blood transfusion may complicate falciparum malaria, but is rare in nonfalciparum malaria. We present a case of a young man with high fever, severe hemolytic anemia, and a blood film containing massive co-infection with Plasmodium vivax and with Borrelia. The possible importance of the co-infection on the magnitude of hemolysis will be discussed.

[Cryptococcal meningitis following cryptococcal pneumonia in an immunocompetent].

Cryptococcal meningitis (CM) is common in the immunocompromised (especially due to AIDS), but also occurs in immunocompetent subjects. CM can complicate cryptococcal pneumonia (CP) not only in the immunocompromised but also in the immunocompetent. We describe a healthy 26-year-old man who developed a prolonged lung infection. Diagnosis of cryptococcal pneumonia was established from bronchoscopic washings. He recovered spontaneously, so no antifungal treatment was given. 4 months later he was admitted with cryptococcal meningitis and was treated successfully with amphotericin B. An extensive immunologic study revealed no abnormalities. Since CM can complicate cryptococcal pneumonia, it is recommended that patients with CP be followed, even if recovery is apparently complete.

[Ferritin levels in adult Still's disease].

Adult-onset Still's disease (AOSD) is characterized by a spiking fever and diverse clinical findings; the diagnosis is often delayed for months or even years. The only positive laboratory finding is neutrophilic leukocytosis. Since 1987, the diagnostic importance of elevated serum ferritin levels has been discussed in numerous papers, but is not yet among the diagnostic criteria for AOSD. We describe a case in which the finding of extreme hyperferritinemia enabled prompt diagnosis and treatment.

[Brucellosis presenting as acute abdomen].

Usually symptoms of brucellosis are nonspecific and characterized by a wide range of complaints. Although the disease in Israel is almost exclusively food borne (caused by Brucella melitensis in unpasteurized goat milk products) so the main route of infection is the gastrointestinal tract, but gastrointestinal complications are rare, and only sporadic cases of ileitis or colitis have been described. We present a 43-year-old woman with an acute abdomen, probably due to diverticulitis. It was diagnosed only after blood cultures were positive for Brucella melitensis. We believe that its protean manifestations should be considered in addition to the other bizarre presentations of this disease, important in our region.

Prenatal care, birth outcomes and newborn hospitalization costs: patterns among Hispanics in New Jersey.

CONTEXT: With the influx of Latin American immigrants to the United States and the relatively high fertility of Hispanic women, the importance of understanding patterns of birth outcomes within the heterogeneous Hispanic community is growing. METHODS: Vital statistics data linked with hospital discharge files for single, liveborn infants delivered in New Jersey to state residents in 1989 and 1990 are used to examine the effects of maternal birthplace and Hispanic ethnicity on early initiation of prenatal care, low birth weight, infant mortality and newborn hospital costs. Multivariate analyses control for a range of demographic, economic, behavioral and medical factors. RESULTS: White women of Puerto Rican descent have a significantly higher risk than both non-Hispanic whites and other Hispanic whites of having a low-birth-weight baby. However, their infants do not have an increased risk of mortality, and newborn hospitalization costs are not elevated for this group. Mexican-born white women begin prenatal care later than their U.S.-born counterparts, but do not have worse birth outcomes. The sharpest contrasts are not among Hispanics but between non-Hispanic black and non-Hispanic white women born in the same place. CONCLUSIONS: Ethnicity and birthplace affect prenatal care and birth outcomes but are probably not as significant as racial differences. Poor outcomes without elevated newborn costs may indicate less access to high-quality neonatal care among some ethnic groups.

PIP: Vital statistics data linked with hospital discharge files for single, live-born infants delivered in New Jersey (US) in 1989-90 were used to examine the effects of Hispanic ethnicity on prenatal care utilization, low birth weight, infant mortality, and newborn hospitalization costs. The findings indicate that disparities by race may be at least as important as variations in birthplace and ethnicity. Puerto Rican White women who gave birth in New Jersey were twice as likely, relative to their US-born non-Hispanic White counterparts, to have a low-birth-weight infant and to have an infant who died in the first year of life. In addition, their newborn hospitalization costs were 25% higher than those of US-born non-Hispanic White women. Women of Puerto Rican descent, regardless of whether they were born in the US, initiated prenatal care later than all other Whites, except the infants born in Mexico, and their infants had the highest rates of low birth weight and mortality among all Whites. Although the multivariate results indicated that ethnic Puerto Rican Black women begin prenatal care earlier and have better birth outcomes than non-Hispanic Blacks, the descriptive statistics showed that Puerto Rican Blacks and Whites have similar levels of prenatal care use and birth outcomes. Enhanced understanding of the sources of these racial disparities is important for the design of policies to improve birth outcomes. Poor outcomes without concomitant increases in hospitalization costs may be a sign of low access to high-quality neonatal care.

[Purpura--an unusual presentation of Takayasu arteritis].

Takayasu arteritis is an uncommon vasculitis, often referred to as aortic arch syndrome. It is most prevalent in young women. Physical findings such as the combination of pulseless arms and carotid bruits suggest the diagnosis. Associated skin manifestations such as pyoderma gangrenosum and erythema nodosum have been described. We present a 27-year-old woman with diffuse purpuric eruption and Takayasu arteritis. This appears to be the first description of such an association.

[Acute effusive-constrictive pericarditis in influenza A].

Constrictive pericarditis may complicate the course of several viral infections, mainly Coxsackie virus group B, as well as in rheumatoid disease, radiation and neoplasm. Perimyocardial involvement during influenzal infections is usually mild and does not progress to constriction or tamponade. A single case of cardiac tamponade caused by influenza A was reported in 1986. We report a case of acute effusive-constrictive pericarditis due to influenza A infection. Corticosteroids resulted in some benefit, but did not relieve constriction, which required extensive pericardiectomy.

Maternal age and birth outcomes: data from New Jersey.

The effects of maternal age on low birth weight, newborns' hospital costs and infant mortality were estimated based on individual 1989 and 1990 vital statistics records from New Jersey that were linked with uniform billing hospital discharge records. Results of multivariate analyses show a U-shaped relationship between maternal age and low birth weight among whites, with the youngest (younger than 15) and oldest (aged 40 and older) mothers being at higher risk than 25-29-year-olds; older teenagers were not at any significantly increased risk. Among blacks, however, 15-19-year-olds faced significantly lower risks of delivering low-birth-weight babies than did black women aged 25-29. Both black and white mothers in their 30s were significantly more likely to deliver a low-birth-weight baby than women aged 25-29 of the same race. The multivariate analysis also showed that newborn hospitalization costs increased with maternal age among both blacks and whites. The seemingly poorer birth outcomes of teenage mothers appear to result largely from their adverse socioeconomic circumstances, not from young maternal age per se.

PIP: This study compared birth outcomes among Black and White adolescents aged under 15 years, 15-17 years, and 18-19 years, in New Jersey. Data were obtained from vital statistics records for 1989 and 1990, and hospital discharge records from the New Jersey Department of Health. Hospital discharge records included insurance status and newborn costs. Adolescent data was compared to data among women aged 20-40 years. The 3 models run separately for each race were ones that allowed for the gross effects of age, controls for medical and behavioral risk factors only, and controls for socioeconomic status. Birth outcomes included infant mortality, low birth weight (LBW), and newborn costs. Findings indicate a complex set of relationships between maternal age, comparison groups, birth outcomes, and mediating factors. The analysis among White adolescents supports the common perception that teenage mothers are at higher risk of unfavorable birth outcomes and higher hospital costs than women in their 20s, but not all older women. Teenagers aged under 15 years had the highest risk of delivering a LBW infant compared to women aged 15-19 years, followed by mothers aged 40 years and older and women aged 35-39 years. Newborn costs among White and Black teenagers were lower than costs to older women. One caveat is that many teenagers are not at any increased risk of adverse birth outcomes, and unobserved determinants of adverse outcome could be related to prenatal care, smoking, or alcohol use. Black teenagers had a significantly reduced risk of having an LBW compared to 25-29 year olds. Poorer outcomes are attributed to adverse socioeconomic conditions. White teenagers aged under 15 years had the most unexplained risk. Risk of infant mortality increased with the increasing age of the mother, particularly among Black women. Rates of LBW among Black women aged 15-19 years were 3 times higher than among Whites.

The effects of enriched prenatal care services on Medicaid birth outcomes in New Jersey.

This paper uses a health production function framework to evaluate the race-specific effects of participation in New Jersey's HealthStart program on birthweight and newborn hospitalization costs in 1989 and 1990. HealthStart provides enriched prenatal and health support services to pregnant women on Medicaid. The program also attempts, through outreach, to attract women into care earlier. For blacks, the results indicate increased birthweights, lower newborn hospitalization costs and reduced rates of low birthweight and very low birthweight for those participating in HealthStart. There is no evidence, however, that the HealthStart program was associated with improved birth outcomes or lower costs for whites.

Prevalence of cognitive dysfunction and hypothyroidism in an elderly community population.

Cognitive function was assessed in 801 elderly subjects (aged 65-92 years) using the Mini Mental State Examination (MMSE). The mean (+/- SD) MMSE score in the age group 65-70 years was 27.8 +/- 5.6, and the score declined to 22.3 +/- 7.8 at the age 85-90 (P = 0.001). Abnormal MMSE scores (less than 24) were found in 5.2% of the subjects aged 65-70 and gradually increased with age to 35.5% in the age group of 85-90. Serum thyroid-stimulating hormone (TSH) levels were determined in 751 subjects. Elevated TSH (> 4.5 mIU/l) were detected in 112 people (14%). The prevalence of hypothyroidism was higher in females (18.2%) than in males (9.7%). MMSE scores in 39 patients (14 males and 25 females) with untreated hypothyroidism were compared to the scores of 570 euthyroid elderly controls (235 males and 335 females). The mean +/- SD MMSE scores were 27.0 +/- 2.1 in hypothyroid males vs. 26.0 +/- 4.7 in male controls and 25.0 +/- 7.7 in hypothyroid females vs. 25.0 +/- 6.6 in female controls. The scores in the hypothyroid patients were not significantly different from the controls. Our data suggest that: a) the average cognitive performance declines with age; b) the percentage of subjects with abnormal MMSE scores increases with age, and is higher in females than in males; c) the prevalence of hypothyroidism in the elderly population is 14% and is higher in females (18%) than in males (10%); and d) mild untreated hypothyroidism is not associated with cognitive impairment.

Cyclosporin A blocks 6-hydroxydopamine-induced efflux of Ca2+ from mitochondria without inactivating the mitochondrial inner-membrane pore.

Oxidative stress causes Ca(2+)-loaded mitochondria to release Ca2+. The mechanism of this efflux is unclear, but it appears to be associated with the opening of a pore in the mitochondrial inner membrane. Pore opening depolarizes the mitochondria, letting solutes enter the mitochondrial matrix, causing swelling. Cyclosporin A (CsA) prevents opening of this pore. The neurotoxin 6-hydroxydopamine (6HD) autoxidizes, producing free radicals, which cause oxidative stress. In this paper it is shown that 6HD-induced efflux from Ca(2+)-loaded mitochondria was prevented by CsA. The 6HD-induced Ca2+ efflux was not accompanied by mitochondrial swelling, depolarization of the mitochondrial inner membrane or movement of radiolabelled sucrose into the mitochondrial matrix. In agreement with others [Schlegel, Schweizer and Richter (1992) Biochem. J. 285, 65-69], these findings suggest that the mitochondrial pore remained closed during pro-oxidant-induced Ca2+ efflux. However, the implication that CsA blocks pro-oxidant-induced Ca2+ efflux by some mechanism other than inactivating the mitochondrial pore, suggests that the interaction of CsA with mitochondria may be more complex than is currently supposed.

Seroprevalence of antibodies against Toxoplasma gondii among two rural populations in northern Israel.

The prevalence of antibodies against Toxoplasma gondii was measured in two rural populations in northern Israel--Jewish kibbutz members and Arab villagers. The respective prevalences in these two populations were 22.2% and 55.8% (P < 0.001). No correlation was found between the presence of antibodies and sex, occupation, contact with cats, a history of fever and/or lymphadenopathy, eye disease, abortions or delivery of children with congenital malformations. In contrast to Jewish children who were not found to have antibodies in the first decade of life, 20.5% of Arab children tested positive. A gradual increase in the prevalence of antibodies with age was seen in both groups, with the Jews reaching a prevalence of 42.6% at age 60+ and the Arabs reaching 74% at age 40. The difference between the two groups probably stems from different eating habits, namely ingestion of raw meat and unpasteurized milk and milk products.

Seroprevalence of antibodies against Toxoplasma gondii among recently immigrating Ethiopian Jews.

Sera from 144 Ethiopian immigrants who arrived in Operation Solomon, 1991, living in three absorption centers in the Jezreel Valley were tested for antibodies against Toxoplasma gondii. Antibodies were found in 34% of the test group, with a rise in prevalence with age from 0% in the first decade to 46% in the > 40 age-groups. The prevalence in the Ethiopians was higher than in Jewish kibbutz members (22.8%) and lower than in Arab villagers (55.8%). During the reproductive years (age 20-39) the rate of seroconversion is 1% per year, and screening of pregnant Ethiopian women for antibodies to T. gondii should be considered.