Validity of an artificial neural network in predicting discharge destination from a postacute geriatric rehabilitation unit.

OBJECTIVE: To develop an artificial neural network (ANN) designed to predict discharge destination from postacute geriatric rehabilitation units. DESIGN: Nonconcurrent prospective study. SETTING: Postacute geriatric rehabilitation units: a 20-bed unit in a nonproprietary skilled nursing facility and a 40-bed unit in a suburban private facility. PATIENTS: Consecutive sample of 661 patients admitted between January 1995 and February 1999, including a derivation group of 452 patients and a validation group of 209 patients. INTERVENTIONS: A feed-forward, back-propagation neural network to predict discharge destination. MAIN OUTCOME MEASURE: Discharge destination from postacute geriatric rehabilitation. RESULTS: An ANN was trained on clinical pattern set derived from 452 patients and validated prospectively on 209 consecutive patients admitted to postacute geriatric rehabilitation units. The neural network achieved a sensitivity of 85.7% (95% confidence interval [CI], 83.7-89.4) and specificity of 94.1% (95% CI, 84.4-99.1) in identifying discharge destination with a corresponding area under the curve of 95.7% (95% CI, 92.1-98.3). CONCLUSION: An ANN can predict discharge to the community postacute rehabilitation with a high degree of accuracy. It could have particular value to predict return to the community for older adults with multiple comorbidities after an acute hospitalization.

Using admission characteristics to predict return to the community from a post-acute geriatric evaluation and management unit.

OBJECTIVE: To compare the Cumulative Illness Rating Scale (CIRS) and the Nursing Severity Index (NSI) as independent predictors of discharge outcome from a post-acute GEM unit and to define a multivariate model for predicting the same outcome. DESIGN: Retrospective chart review for the entire sample. The sample was split into two cohorts, a derivation cohort (n = 298) and a validation cohort (n = 154). SETTING: A 20-bed, post-acute GEM unit in a nonproprietary skilled nursing facility. PARTICIPANTS: All 452 patients admitted to the GEM from the unit's inception in December 1994 until January 1998. MEASUREMENT: Demographics, CIRS, NSI, functional status, and social support variables were measured using data available on admission to the GEM unit. The discharge outcome was dichotomized as return to the community or not. RESULTS: A total of 99.7% of the individuals in the derivation cohort were living in the community before the index hospitalization; 75.8% of patients in the derivation cohort returned to the community. The NSI, individual "severe" items from the CIRS, age, and social support were in the final logistic regression model fitted to the derivation cohort. A total of 87.7% of the observed discharge outcomes were predicted when the model was applied to the validation cohort and the calculated probability of return to the community. CONCLUSIONS: Variables for severity of illness, function, social support, and age combined into a logistic regression equation that predicted more than 80% of the dichotomized discharge outcome in the derivation cohort. The proportion of discharge outcomes that were predicted with the validation cohort remained high at 87.7%. The NSI and CIRS were each important to a model that is anticipated to refine the selection of geriatric patients for post-acute services.

Predictors of cervical cancer screening in Mexican American women of reproductive age.

Several barriers impede cancer prevention in the Mexican American population. This study identified sociocultural factors that could be used to increase screening rates for cervical cancer in women of reproductive age. A survey was conducted in 1991 of 366 Mexican American women ages 18 to 40 in Tucson, Arizona, to assess current compliance with cervical cancer screening guidelines and several psychological, social, and cultural variables. Women who had never been screened (13 percent of the sample) had a knowledge deficit, no gynecological care, and no sexual activity. Women not screened annually (16 percent) lacked preventive care, imperfectly understood the Pap test, had lower self-efficacy expectations for understanding physicians, experienced higher emotional stress about the test, and were older and less acculturated. Women who have never been screened require basic education on cancer and cancer screening and policy changes increasing access to care. For women with less routine screening, preventive care, supportive attitudes, and health care skills must be encouraged.

The clinical assessment of femoral stress fractures: a comparison of two methods.

In a prospective study among 667 recruits, the incidence of asymptomatic femoral stress fractures was compared using a new expanded stress fracture clinical examination (SFCA) versus an older stress fracture examination. There was a statistically significant difference (p = 0.0001) between the percentage of femoral stress fractures that were asymptomatic in the group evaluated by SFCA (26%) and those evaluated by the older stress fracture examination (80%). By using the SFCA, many of the femoral stress fractures previously classified as asymptomatic are in fact recognized as symptomatic.

Lack of evidence of prolonged human immunodeficiency virus infection before antibody seroconversion.

Recently, considerable concern has been raised regarding the possibility that antibody-based screening tests for the human immunodeficiency virus (HIV) may fail to detect certain high-risk individuals for prolonged periods of time. It has been proposed that testing for HIV-related antigen may be a necessary procedure to detect such individuals. To address this issue, we longitudinally studied two groups of homosexual men: direct sexual partners of acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC) patients and individuals who ultimately sero-converted. There was no evidence of prolonged infection with HIV in the absence of detectable antibody in these two groups. It appears at this time that, even among subjects at very high risk for HIV infection, currently available antibody-based assays are sufficient to identify infected individuals.

Effects of HIV antibody test knowledge on subsequent sexual behaviors in a cohort of homosexually active men.

This study assesses the effects of HIV (human immunodeficiency virus) antibody testing on subsequent (one year) sexual behavior among 270 homosexual men at a Boston community health center, 21 per cent of whom were unaware of their test result. Except for the number of steady partners, the levels of all sexual activities of all groups of study participants declined over time. No effects of test awareness of antibody status were found on protective behavior for receptive anogenital contact. Elimination of unprotected insertive anogenital contact (by elimination of the practice or by condom use) was reported somewhat more often among seropositive men who became aware of their test result. Increased negative emotional reactions were reported by HIV seropositive men who were aware of their test result. These results suggest some behavioral impact of HIV antibody test knowledge in this cohort, but may not be generalizable to other populations.

Reliability of self-reported sexual behavior risk factors for HIV infection in homosexual men.

This study was undertaken to determine the reliability of self-reported sexual behavior using the test and retest technique when used with self-reported sexual behavior. The subjects were 116 asymptomatic homosexual men who participated in another study (an examination of behavioral and demographic determinants of HIV antibody status). The subjects were asked to complete two questionnaires. The first contained demographic and sexual behavior questions. The second, administered an average of 6 weeks later, used a subset of the questions in the first questionnaire. The reliability of the test-retest procedure was measured by the Kappa statistic, which assesses the proportion of agreement between two data items, accounting for the amount of agreement expected by chance. The highest degree of reliability as measured by Kappa was found with demographic information, smoking history, and sexual orientation. Self-reported sexual behaviors for the previous 6 months generally had the next highest degree of reliability as measured by Kappa. Questions examining change over the previous 5 years had the lowest reliability. Behavior changes during the time between questionnaires, subjectivity of the answer categories, and social desirability of the answers are three factors that may result in a lack of reliability in this self-reported sexual behavior questionnaire. This raises methodological concerns about the measurement of behavioral risk factors for AIDS and the ability to assess meaningfully subjective reports of behavioral change.

Correlation of enzyme-linked immunosorbent assays for serum human immunodeficiency virus antigen and antibodies to recombinant viral proteins with subsequent clinical outcomes in a cohort of asymptomatic homosexual men.

A cohort of asymptomatic homosexual men at a Boston community health center was screened for the presence of human immunodeficiency virus (HIV) serum antigen and antibodies to recombinant proteins containing portions of the envelope and the gag (core) gene products. Of 196 asymptomatic men screened, 149 were antigen-negative/antibody-negative, 41 were antigen-negative/antibody-positive, and six were antigen-positive/antibody-positive. All three men in whom the acquired immune deficiency syndrome (AIDS) developed over the next year were antigen-positive at enrollment. Although a larger portion of the men who were antigen-positive and did not demonstrate progression to AIDS after one year had thrush, zoster, or generalized lymphadenopathy, the associations were not statistically significant. Whereas all of the seropositive men had antibody to viral envelope antigens, about a quarter did not have detectable antibodies to recombinant core antigens. However, all of these men had detectable antibody to core antigens by Western blot. Titers to recombinant core and envelope antigens tended to be lower in the men with AIDS. HIV-infected persons who are more likely to have enhanced immuno-compromise may be identified by these newer tests, but further longitudinal studies will be necessary to fully understand their prognostic value.

Successful chemotherapy of transfusion babesiosis.

We describe babesiosis transmitted by transfusion. The infected blood donor was identified and a minimum period of infectivity of the donor's blood was established. We report a new modality for chemotherapy consisting of quinine plus clindamycin, and a new endemic focus for this zoonosis on Fire Island, New York. There are insufficient data to establish a reasonably safe period after which visitors and residents of Babesia-endemic foci can become blood donors. Screening of such persons by a rapid serologic test, such as the ELISA or immunofluorescent antibody tests, is suggested.

Teenage pregnancy.

The pediatrician's role in teenage pregnancy is multifaceted. The problem is a sociologic phenomenon with medical consequences. The pregnant teenager actually represents three patients: the mother, the baby, and the adolescent herself. Prepregnancy nutrition can be improved through pediatric education and advice. Sex education can be improved through the advocacy of pediatricians, who can discuss postponing parenthood until the end of adolescence with many of their patients. Services to prevent pregnancy can be offered by pediatricians. Unfortunately, in Oklahoma it is illegal to dispense contraceptives to minors without parental consent. Pediatricians should work to gain acceptance of laws modeled after the American Academy of Pediatrics' health care for minors policy. Lastly, support services to promote proper parenthood and establishment of families can be developed with pediatric input. The entire problem must be viewed in the context of current social patterns, an understanding of adolescent development, the significance of peer pressures, and the biological changes that make it possible for children to bear children.

PIP: This discussion of teenage pregnancy focuses on the following: the scope of the problem; identification of the pregnant teenager; causes of teenage pregnancy (biologic factors, the role of peers, societal influences, and contraception); the teenage father; complications of pregnancy; nutrition in teenage pregnancy (protein requirements, vitamins, minerals, and trace minerals); the options for a pregnant teenager; and prevention. Of much concern is the 61% increase in the total number of births to females aged 15 and younger in the U.S. between 1960 and 1977. Teenage pregnancy is not a new problem, yet in the last 20 years several factors have influenced the awareness of the problem and its consequences. Furstenberg identifies several reasons for increased attention devoted to teen pregnancy: an increase in the teenage population; more awareness of population control; more liberal teenage sexual behavior, coupled with a disdain for early marriage, and resulting in increased illegitimate birth; and governmental concern regarding socioeconomic conditions vis-a-vis teenage parenthood and poor educational, vocational, and social stability. Experience shows that the pregnant teenager is unlikely to have completed growth tasks, particularly the acquisition of independent thinking and a mature understanding of self. There is a significant population of females aged 12.5-15 years who biologically and physically are close to being mature women and are capable of becoming pregnant. That population grows larger monthly throughout the schoolage years. Repeatedly, teenagers encountered in practice, clinics, and an outreach educational project have reported that peer pressure is their single greatest motivator in regard to sexual behavior. In the last 20 years, the concept in advertising has been sex and an attitude of acceptance toward sexuality. If society acquiesces to the constant exposure of its young people to sex, it needs to provide a support system that enables the adolescent to deal effectively with sex. Adolescents frequently deny that they can become pregnant, and consequently they fail to even consider contraception. The potential teenage father needs to be prepared by education and counseling for either appropriate delay of his role as a father or coping with its premature occurrence. It appears that with the exception of preeclampsia and a small bony pelvis in the adolescent, the majority of complications of teenage pregnancy are more a function of lack of prenatal care than they are of maternal age. Factors related to nutrition that place the adolescent at risk during pregnancy include low prepregnancy weight, insufficient weight gain, obesity, existing medical complications, dietary faddism, pica, and low income or ethnic variances.

Volatilization of 1,2-dibromo-3-chloropropane (DBCP) from soils.

The volatilization of DBCP from soils, as affected by the soil characteristics and application techniques, was studied in a laboratory experiment. The volatilization rate of DBCP applied in water was higher from sandy and silty loam soils than from clay soil. Water added after DBCP application acted as a soil cover, decreasing the volatilization rate. The results obtained with DBCP application in hexane to air-dry soils, indicate that adsorption could be an important factor in reducing the volatilization losses. Diffusion coefficients were calculated from the volatilization parameters, by using a simplified relationship between volatilization losses and diffusion through soil.

[Phagocytosis in patients with splenectomy]. / Fagocitosis en pacientes esplenectomizados

Phagocytosis was evaluated in nine patients with splenctomy undergoing renal transplant, eight renal transplanted patients without splenectomy, three immunodepressed patients with terminal renal failure, four patients with splenectomy and six healthy volunteers. For phagocytosis evaluation, neutrophils adhered to glass were used. They were cover with 4% latex and albumin containing culture medium with or without phagocytosis stimulating tetrapeptide extracted from IgG in each case. Phagocytosis was decreased in all groups studied. Immunodepressed patients showed the highest diminishment of phagocytosis and patients with splenectomy and immunodepression the lesser. It was speculated that such a finding is due to a decrease of tetrapeptide in serum.