Use of multiple-cause mortality data in epidemiologic analyses: US rate and proportion files developed by the National Institute for Occupational Safety and Health and the National Cancer Institute

The authors have created US mortality rates (age, sex, race, and calendar-time specific) and proportions, using multiple cause-of-death data, for the years 1960-1989. Multiple cause-of-death data include the usual underlying cause of death from the death certificate as well as contributory causes and other significant conditions. US multiple-cause rates and proportions enable the user to calculate the expected occurrences of disease on the death certificates of a cohort under study. There is an average of 2.66 causes and/or contributory conditions listed on US death certificates, increasing over time from 2.54 in the 1960s to 2.76 in the 1980s. The ratio of multiple-cause listings to underlying cause listings varies by disease, from low ratios for cancers to high ratios for diseases such as diabetes, arthritis, prostate disease, hypertension, pneumoconiosis, and renal disease. Use of these data is illustrated with two cohorts. Multiple-cause analysis (but not underlying cause analysis) revealed twofold significant excesses of renal disease and arthritis among granite cutters. For workers exposed to dioxin, neither multiple-cause nor underlying cause analysis indicated any excess of diabetes, an outcome of a priori interest. Good candidates for multiple-cause analysis are diseases that are of long duration, not necessarily fatal, yet serious enough to be listed on the death certificate.

Prolonged chemotherapy for localised squamous carcinoma of the oesophagus

We evaluated the feasibility of six courses of chemotherapy in 34 consecutive patients with localised squamous cell carcinoma of the oesophagus. All 32 evaluable patients first received at least two courses of chemotherapy. There were 18 patients with resectable carcinomas who underwent surgery and 14 patients with unresectable carcinomas who received definitive chemoradiotherapy. After two courses of 5-fluorouracil and cisplatin 21 (66%) of 32 patients had either a complete or major response. A median of five courses (range, 1-6 courses) was administered. 17 out of 18 (94%) patients with resectable carcinoma had a 'curative' resection (negative proximal, distal, and radial margins by histopathology in an en-block resection specimen) and 2 patients had a complete pathological response. The median survival duration of all patients was 28 months (range, 2-46+ months). The median survival duration of 14 patients with unresectable carcinoma was 23 months (range, 8-36+ months), and the median survival duration of 18 patients with resectable carcinoma has not been reached at a median follow-up of 24+ months (range, 10+ to 46+ months). No deaths occurred because of chemotherapy or chemoradiation therapy. Our data suggest that prolonged chemotherapy is feasible in patients with locoregional squamous carcinoma of the oesophagus. An ongoing controlled trial will determine the contribution of chemotherapy to patients' survival.

Respiratory pharmacology and the weaning patient: implications for critical care nursing

The process of weaning patients from mechanical ventilation may be facilitated by the appropriate selection and use of bronchodilators, mucolytics, steroids, and sedatives. This article discusses implications for the critical care nurse, focusing on the indications, applications, and evaluations of the drugs most commonly administered to patients prior to or during weaning from mechanical ventilation.

A survey of nosocomial respiratory viral infections in a children's hospital: occult respiratory infection in patients admitted during an epidemic season

OBJECTIVE

To define the extent of shedding of respiratory viruses and Mycoplasma pneumoniae among a population of pediatric patients admitted to the hospital during a winter epidemic period and to identify nosocomial infections within this population.

DESIGN

An open, prospective survey of patients admitted to three wards (General Medical, Respiratory Infectious, and Infectious Diseases) of a pediatric hospital during a defined three-month period.

PATIENTS

All patients with medical, respiratory, and infectious conditions admitted to three wards of the Adelaide Children's Hospital had nasopharyngeal aspirations performed at the time of admission with the purpose of documenting viral and M pneumoniae shedding. Patients were monitored daily for the development of symptoms of respiratory infection or new symptoms of respiratory disease. Such patients underwent a further nasopharyngeal aspiration for the purpose of diagnosing hospital-acquired infection.

RESULTS

Nasopharyngeal aspirations were obtained from 601 patients. Forty-seven percent of asymptomatic patients were positive for a respiratory virus or M pneumoniae, and 61% of patients with respiratory symptoms were also positive. Gastroenteritis patients shed viruses in 66% of cases. Respiratory symptoms were initially overlooked by admitting physicians but subsequently identified in 110 cases, and 46% of these were found to be positive for a respiratory virus or M pneumoniae. There were 18 possible hospital acquired infections among the 293 initially virus-negative patients. Multiple isolates were obtained from a substantial number of patients, especially those with respiratory symptoms.

CONCLUSIONS

A substantial proportion of all patients admitted to a pediatric hospital during winter represent a potential source of infection, and strict infection control measures should be enacted to limit the spread of these infections.

Assessing independence in community living

Community health professionals are frequently faced with the dilemma of assessing "independence in community living" in individuals with physical limitations. However, the validity of standardized assessment of "independence in community living" continues to be limited. Standardized assessment tools are unable to capture the true meaning of "community living" and "independence" being articulated through the Independent Living Movement by people who have physical limitations. We use examples from our experience with the Community Living Skills Project in Nova Scotia to highlight three limitations of standardized assessment of individuals in light of the Independent Living Movement's interpretation of "independence in community living". Standardized assessments were unable to attend to and integrate the complexities of interactional elements, individual differences and the concept of "independence" as personal control and mutual dependence. We conclude that individual assessment requires tools with greater sophistication than those currently available. This discussion is important since individual assessment guides decisions which have far reaching effects on people's lives and on the demands placed on limited health and social services.

New developments in the Life Table Analysis System of the National Institute for Occupational Safety and Health

In the 1970s, the National Institute for Occupational Safety and Health developed a Life Table Analysis System to analyze occupational cohort studies. We have updated the original system by adding two new features: direct standardization with a test for linear trend, and analyses by lagged exposure (either duration of exposure or cumulative exposure). We have also updated US reference rates through 1989. The updated systems and documentation (version F) are available upon request. In collaboration with the National Cancer Institute, we have also developed multiple cause-of-death rate files, which consider contributory as well as underlying cause. These files (also available upon request) will enable investigators to derive the expected prevalence of diseases at death, which can then be compared with the observed prevalence in an exposed cohort. Work is currently underway to produce a personal computer version of the Life Table Analysis System.

Evaluation of pre- and postoperative chemotherapy for resectable adenocarcinoma of the esophagus or gastroesophageal junction

Thirty-five consecutive patients with resectable adenocarcinoma of the esophagus or gastroesophageal junction were treated with two preoperative and three or four postoperative chemotherapy courses consisting of etoposide, fluorouracil, and cisplatin (EFP) to evaluate the rate of curative resection, clinical and pathologic response, toxic effects, and survival. One hundred thirty-seven courses with a median number of five courses (range, one to six) were administered. Preoperative EFP resulted in 17 (49%) major responses, including six patients who did not have carcinoma cells in the repeat endoscopic biopsy specimens and cytologic brushings. Among 32 patients who had surgery, 25 (78%) had curative resection, one patient had a complete pathologic response, and one had microscopic carcinoma in the resected specimen. Six patients had microscopic carcinoma at the resection margins and received postoperative radiotherapy. At a median follow-up of 20 months, the projected survival of 35 patients is 23 months (range, 6 to 33+). Fifteen patients died of their carcinomas, and 15 patients were alive (median follow-up, 20+ months; range, 15+ to 33+ months) with no evidence of relapse. There were no deaths related to chemotherapy, surgery, or radiotherapy. EFP-induced toxic reactions were moderate. Our data suggest that multiple courses of EFP are feasible. Future strategies for this disease should consider prolonged chemotherapy with regimens that result frequently in pathologic complete responses.

Thyroid adenoma following treatment of acute lymphocytic leukemia

Sequelae of the treatment of children with acute lymphocytic leukemia (ALL) include multiple effects on the endocrine system, especially as it relates to growth and puberty. Thyroid dysfunction, and in particular, the occurrence of thyroid neoplasia, has been only rarely described. We report the development of benign thyroid neoplasms in two patients 9 years following the diagnosis and treatment of ALL. Both patients were clinically and biochemically euthyroid with noncystic "cold" nodules found on thyroid scan. In light of these observations, and along with previous reports of malignant thyroid neoplasia in children with ALL, long-term careful observation of children successfully treated for ALL is indicated.

Perioperative care of the liver transplant patient

1. Communication among team members on the liver transplant team is crucial; individual responsibilities must be considered while problem solving is shared as a team. 2. A major goal of the OR nurse is to maintain the patient's skin integrity; proper patient positioning and protection is essential. 3. Constant awareness of blood and blood product availability is urgent.

Criteria mapping: a method of quality assurance

Criteria mapping is a flexible and responsive method of chart audit that allows the simultaneous assessment of both the process and the outcome of care by means of health record abstraction. This method of audit is particularly suited to occupational therapy because it includes branching to reflect the sequential judgments of therapists and does not penalize the clinician for omitting unnecessary procedures. The purpose of this study was to determine the utility and reliability of the criteria mapping process in evaluating the quality of care for a self-care disability in an acute care setting. Three occupational therapists and one independent abstractor evaluated 12 charts twice. Intraobserver reliability calculated with intraclass correlation coefficients was .77 for the therapists and .65 for all observers. Interobserver reliability was .73 for the therapists and .72 for all observers. The criteria map provided comprehensive and relevant information about each chart. This paper discusses the implications of these findings for the ongoing monitoring of the quality of care in occupational therapy.

Primary health care through a community based smoking-cessation program

The International Conference on Primary Health Care, meeting in Alma-Ata, in the Soviet Union, September 12, 1978, expressed the need for urgent action by all governments, all health and development workers and the world community, to protect and promote the health of all people of the world. The world was caught by the phrase which emerged from this conference, "Health For All by the Year 2000" and many have examined the articles of the Alma-Ata declaration and tried to implement them in their corner of the world. This paper describes a community-based smoking-cessation program which was implemented in the province of Nova Scotia, Canada, during the years 1980-1984. Primary to this project was the belief that people have the right and the duty to participate individually and collectively in planning and implementing their health care. This paper describes one community's effort in putting this belief into practice.

Postoperative vomiting following strabismus surgery in paediatric outpatients: spontaneous versus controlled ventilation

The study was designed to compare the frequency and severity of postoperative vomiting in paediatric out-patients receiving controlled ventilation (IPPV) or breathing spontaneously (SV) during anaesthesia for strabismus repair. One hundred and twenty unpremedicated children (ages 2-12 years) were studied in a randomized fashion. After intravenous induction of anaesthesia and tracheal intubation, patients breathed halothane 1-1.5 per cent inspired and N2O 66 per cent in O2 spontaneously (n = 60), or received IPPV, halothane 0.5-1 per cent, N2O 66 per cent, and pancuronium 0.05 mg.kg-1, which was reversed with neostigmine and atropine (n = 60). The incidence of vomiting with SV was 50 per cent (95 per cent confidence limits: 34.5-65.5 per cent) compared with 40 per cent (24.5-55.5 per cent) with IPPV (p greater than 0.25). Patients in the SV group experiencing emesis had longer operations than those not vomiting (mean +/- SEM = 1.5 +/- 0.1 vs 1.2 +/- 0.1 hours, p less than 0.005). This was not the case with IPPV. There was no correlation between age, sex, duration of surgery, or number of extraocular muscles repaired, and frequency or severity of vomiting or time to discharge. No significant advantage was afforded by IPPV over SV in the present study.

Human immunodeficiency virus (HIV) infection in children

HIV infection in pediatric patients is a multisystem chronic disease that manifests as a clinical spectrum from asymptomatic infection through symptomatic infection with opportunistic infections and malignancies. The hematopoietic system is involved early in the systemic manifestations of this disease. The hematologic abnormalities seen are most probably a reflection of persistent viral infection, inflammation, and immune dysregulation, and may be complicated by secondary infections, chronic disease, drug toxicities, and nutritional deficiencies. Anemia and lymphopenia are commonly found in adult AIDS patients. Although both are also seen in pediatric patients, lymphopenia is much less common. Atypical lymphocytes with plasmacytoid characteristics have been identified in both adults and children. Pediatric bone marrow evaluation has shown an increase in plasma cells and plasmacytoid lymphocytes. Besides these findings, adult marrow findings include an increase in reticulum and lymphocytes appearing in a diffuse or aggregate pattern.

Functional changes in vascular amputee patients: evaluation by Barthel Index, PULSES profile and ESCROW scale

This study evaluated the changes made by 60 peripheral vascular amputees from one month prior to admission to six months after attending a rehabilitation hospital. The Barthel index, PULSES profile, and ESCROW profile were used to measure functional status, social support, and rehabilitation progress. Statistical analysis consisted of t-tests to determine significant differences between the means of scores at varying intervals, and analysis of variance was added to determine interactions between amputation level, age, and sex as related to functional change. Amputees showed significant gains in Barthel scores from admission to discharge; this was attributed to rehabilitation intervention. They showed a significant decrease by the PULSES profile over the study period, indicating a decrease in independence from their premorbid function. Changes in ESCROW scores showed patients to have a greater need for social supports as they moved from admission to discharge. Age was a significant factor in mobility at discharge as measured by the Barthel index. As measured by the PULSES profile, men did better than women at six months follow-up. Unexpected results were that neither amputation level nor the presence or absence of diabetes mellitus had a significant impact on functional status as measured. The lack of significant differences by amputation level may be due to factors of age and sex, as well as to more depression in the below-knee group.

Mucoid anaplastic hepatoblastoma. A case report

A case of an unusual type of hepatoblastoma in a 5-month-old male infant is described. The tumor showed the following unusual features as compared with the epithelial and mixed types of hepatoblastoma: (1) The tumor cells presented a primitive anaplastic appearance without any resemblance in terms of cytologic features or arrangement to embryonal or fetal liver. (2) Abundant mucoid material containing acid mucopolysaccharide was present giving a slimy, gelatinous, gross appearance to the tumor and its metastases. (3) Well-defined tubular structures were present in some foci within the tumor parenchyma. (4) The tumor resulted in a rapidly fatal course, with metastases to the lungs and widespread peritoneal seeding despite complete surgical resection of the primary tumor. Yolk sac carcinoma and undifferentiated (embryonal) sarcoma of the liver were considered in the differential diagnosis. On electron microscopic examination, the tumor cells showed cytoplasmic features and junctional complexes consistent with their epithelial origin. Alpha-fetoprotein in the blood, which was markedly elevated prior to surgery, returned to a normal level postoperatively. Hepatoblastoma with the combination of features described above has not been previously reported. Because of the two striking and easily recognizable features viz. total lack of differentiation of tumor cells and presence of abundant mucoid material, the authors designated the tumor as mucoid anaplastic hepatoblastoma.