Differences in length of stay among hospitalized children with acute lymphoblastic leukemia

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Background: Acute lymphoblastic leukemia (ALL) is the most common malignancy among children in the United States. While age, race, and clinical complications have been associated with longer length of stay (LOS) among children with cancer, it is unknown what factors are related to LOS among children with ALL. We examined differences in LOS among hospitalized children with ALL. Methods: We used 2000, 2003, and 2006 data from the Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database (KID) which contains pediatric discharges from community, non-rehabilitation hospitals. We used negative binomial regression to determine factors related to LOS. Results: We found the following factors related to greater LOS among hospitalized children with ALL: Non-Hispanic blacks vs. non-Hispanic whites (Rate Ratio (RR) = 1.06, CI:1.03–1.10), Hispanics vs. non-Hispanic whites (RR = 1.07, CI:1.04–1.10), age < 1 year vs. age 1–5 years (RR = 1.93, CI:1.83–2.04), female vs. male (RR = 1.05, CI:1.03–1.07), lowest quartile of household income in patient's zip code vs. highest quartile (RR = 1.09, CI:1.06–1.12), Medicaid vs. private insurance (RR = 1.11, CI:1.09–1.14), children's hospital vs. non-children's (RR = 1.11, CI:1.08–1.14), Western region of United States vs. Northeast region (RR = 1.14, CI:1.11–1.17), emergency room admission vs. routine admission (RR = 1.23, CI:1.20–1.26), blood transfusion (RR = 1.64, CI:1.61–1.67), bone marrow transplant (RR = 7.64, CI:7.11–8.20), and neutropenia (RR = 1.22, CI:1.19–1.24). Conclusions: Race/ethnicity, age, sex, household income, insurance status, admission source, hospital type and region, transfusion, bone marrow transplant, and neutropenia were significantly associated with longer LOS. These factors may help identify children with ALL at risk for complications. Prophylactic treatment for clinical complications may reduce LOS.

No significant financial relationships to disclose.

Implementing rapid HIV testing in outreach and community settings: results from an advancing HIV prevention demonstration project conducted in seven U.S. cities

OBJECTIVES

The goals of this project were to assess the feasibility of conducting rapid human immunodeficiency virus (HIV) testing in outreach and community settings to increase knowledge of HIV serostatus among groups disproportionately affected by HIV and to identify effective nonclinical venues for recruiting people in the targeted populations.

METHODS

Community-based organizations (CBOs) in seven U.S. cities conducted rapid HIV testing in outreach and community settings, including public parks, homeless shelters, and bars. People with reactive preliminary positive test results received confirmatory testing, and people confirmed to be HIV-positive were referred to health-care and prevention services.

RESULTS

A total of 23,900 people received rapid HIV testing. Of the 267 people (1.1%) with newly diagnosed HIV infection, 75% received their confirmatory test results and 64% were referred to care. Seventy-six percent were from racial/ethnic minority groups, and 58% identified themselves as men who have sex with men, 72% of whom reported having multiple sex partners in the past year. Venues with the highest proportion of new HIV diagnoses were bathhouses, social service organizations, and needle-exchange programs. The acceptance rate for testing was 60% among sites collecting this information.

CONCLUSIONS

Findings from this demonstration project indicate that offering rapid HIV testing in outreach and community settings is a feasible approach for reaching members of minority groups and people at high risk for HIV infection. The project identified venues that would be important to target and offered lessons that could be used by other CBOs to design and implement similar programs in the future.

Self-reported syphilis and gonorrhoea testing among men who have sex with men: national HIV behavioural surveillance system, 2003-5

OBJECTIVES

The Centers for Disease Control and Prevention provides guidance on sexually transmitted disease (STD) testing specifically for men who have sex with men (MSM) in STD treatment guidelines to address increasing rates of gonorrhoea and syphilis among MSM in the USA. The guidelines recommend at least annual syphilis, gonorrhoea and chlamydia testing for sexually active MSM. The implementation of these guidelines was evaluated.

METHODS

Data from the 2003-5 MSM cycle of the National HIV Behavioural Surveillance System were used. The proportion of sexually active HIV-negative MSM reporting syphilis and gonorrhoea testing during the previous year was determined and multivariate logistic regression was used to identify factors associated with testing.

RESULTS

Of 10 030 MSM, 39% and 36% reported having been tested for syphilis and gonorrhoea in the previous year, respectively. Four factors were associated with syphilis and gonorrhoea testing, respectively: age 18-24 years versus > or =45 years (odds ratio (OR) 2.2, 95% CI 1.8 to 2.5; OR 2.7, 95% CI 2.3 to 3.2), black versus white race (OR 1.3, 95% CI 1.1 to 1.4; OR 1.4, 95% CI 1.2 to 1.6), private insurance versus no insurance (OR 1.3, 95% CI 1.1 to 1.4; OR 1.3, 95% CI 1.1 to 1.4) and disclosing male-male sex to a healthcare provider (OR 2.2, 95% CI 2.0 to 2.5; OR 2.1, 95% CI 1.9 to 2.3).

CONCLUSIONS

Syphilis and gonorrhoea testing among MSM was low, despite specific testing recommendations in the STD treatment guidelines. To increase STD testing among MSM, healthcare providers should assess the risks of STD for male patients through routine enquiries about sexual activity.

Screening for skin cancer: an update of the evidence for the U.S. Preventive Services Task Force

BACKGROUND

Skin cancer is the most commonly diagnosed cancer in the United States. The majority of skin cancer is nonmelanoma cancer, either basal cell cancer or squamous cell cancer. The incidence of both melanoma and nonmelanoma skin cancer has been increasing over the past 3 decades. In 2001, the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against routine screening for skin cancer by using whole-body skin examination for early detection of skin cancer.

PURPOSE

To update the evidence of benefits and harms of screening for skin cancer in the general population.

DATA SOURCES

MEDLINE and Cochrane Library searches from 1 June 1999 to 9 August 2005 for English-language articles; recent systematic reviews; reference lists of retrieved articles; and expert suggestions.

STUDY SELECTION

English-language studies were selected to answer the following key question: Does screening in asymptomatic persons with whole-body examination by a primary care clinician or by self-examination reduce morbidity and mortality from skin cancer? Randomized, controlled trials and case-control studies of screening for skin cancer were selected. One author selected English-language studies to answer the following contextual questions: Can screening with whole-body examination by primary care clinicians or by self-examination accurately detect skin cancer? Does screening with whole-body examination or by self-examination detect melanomas at an earlier stage (thinner lesions)?

DATA EXTRACTION

All studies for the key question were reviewed, abstracted, and rated for quality by using predefined USPSTF criteria.

DATA SYNTHESIS

No new evidence from controlled studies was found that addressed the benefit of screening for skin cancer with a whole-body examination by a physician. One article of fair quality, which reanalyzed data from a 1996 study identified for the 2001 report for the USPSTF, provides limited but insufficient evidence on the benefit of skin self-examination in the reduction of morbidity and mortality from melanoma.

LIMITATIONS

Direct evidence linking skin cancer screening to improved health outcomes is lacking. Information is limited on the accuracy of screening by physicians or patients using real patients and lesions.

CONCLUSION

The limited evidence prevents accurate estimation of the benefits of screening for skin cancer in the general primary care population.

Functional reconstitution of purified chloroquine resistance membrane transporter expressed in yeast

Malaria is one of the major parasitic diseases. Current treatment of malaria is seriously hampered by the emergence of drug resistant cases. A once-effective drug chloroquine (CQ) has been rendered almost useless. The mechanism of CQ resistance is complicated and largely unknown. Recently, a novel transmembrane protein, Plasmodium falciparum chloroquine resistance transporter (PfCRT), has fulfilled all the requirements of being the CQ resistance gene. In order to elucidate the mechanism how PfCRT mediates CQ resistance, we have cloned the cDNA from a CQ sensitive parasite (3D7) and tried to express it in Pichia pastoris (P. pastoris) but with unsuccessful results due to AT-rich sequences in the malaria genome. We have therefore, based on the codon usage in P. pastoris, chemically synthesized a codon-modified pfcrt with an overall 55% AT content. This codon-modified pfcrt has now been successfully expressed in P. pastoris. The expressed PfCRT has been purified with immuno metal affinity chromatography (IMAC) and then reconstituted into proteoliposome. It was found that proteoliposomes have a saturable, concentration and time-dependent CQ transport activity. In addition, we found that proteoliposomes with resistant PfCRT(r) (K76T or K76I) showed an increased CQ transport activity compared to liposomes with lipid alone, or proteoliposomes reconstituted with sensitive PfCRT(s) (K76) protein. This activity could be inhibited by nigericin and decreased with the removal of Cl(-). This work suggests that PfCRT is mediating CQR in P. falciparum by virtue of its changes in CQ transport activity depending on pH gradient and chloride ion in the food vacuole.

Production of human type I collagen in yeast reveals unexpected new insights into the molecular assembly of collagen trimers

Substantial evidence supports the role of the procollagen C-propeptide in the initial association of procollagen polypeptides and for triple helix formation. To evaluate the role of the propeptide domains on triple helix formation, human recombinant type I procollagen, pN-collagen (procollagen without the C-propeptides), pC-collagen (procollagen without the N-propeptides), and collagen (minus both propeptide domains) heterotrimers were expressed in Saccharomyces cerevisiae. Deletion of the N- or C-propeptide, or both propeptide domains, from both proalpha-chains resulted in correctly aligned triple helical type I collagen. Protease digestion assays demonstrated folding of the triple helix in the absence of the N- and C-propeptides from both proalpha-chains. This result suggests that sequences required for folding of the triple helix are located in the helical/telopeptide domains of the collagen molecule. Using a strain that does not contain prolyl hydroxylase, the same folding mechanism was shown to be operative in the absence of prolyl hydroxylase. Normal collagen fibrils were generated showing the characteristic banding pattern using this recombinant collagen. This system offers new opportunities for the study of collagen expression and maturation.

Nutritional and pulmonary function assessment in chronic obstructive pulmonary disease: Effects of nutritional supplementation

We found that with oral supplementation by a liquid soy-based protein hydrolysate in malnourished COPD patients (BMI <= 20), it possible to increase weight over a 6-week period, and body water and an index of muscle mass (MAMC), but not total body nitrogen (TBN judged by Nitrogen Index) which identifies a particular challenge for nutrition support in COPD patients. There was no associated improvement in pulmonary function but we found that better nourished COPD patients (BMI > 20) had some pulmonary function advantage; it is suggested that TBN may need to improve with nutrition support for pulmonary function to improve.

Absence of alpha-1-antitrypsin (Pi Null Bellingham) and the early onset of emphysema

BACKGROUND

Alpha-1-antitrypsin is the body's major inhibitor of human neutrophil elastase, a powerful proteolytic enzyme capable of degrading the common tissue components. There are over 70 genetic variants of alpha-1-antitrypsin, with the Z allele being of greatest clinical relevance. Individuals homozygous for this allele (approximately one in 2500 in Caucasians) have low serum alpha-1-antitrypsin levels (10-20% of normal) and are predisposed to emphysema, especially if they smoke. Much rarer are mutations which result in the complete or almost complete absence of alpha-1-antitrypsin in the serum.

AIM

To determine the cause of complete absence of alpha-1-antitrypsin in a patient who at age 27 years had both emphysema and idiopathic cardiomyopathy.

METHODS

Molecular biology techniques were used to sequence the alpha-1-antitrypsin gene. Allele specific amplification was used to show the presence of the mutations in other family members.

RESULTS

Investigation showed that the proband was homozygous for the Pi Null Bellingham variant of alpha-1-antitrypsin due to the mutation Lys 217 (AAG) to Stop (TAG). His grandmother was heterozygous for Pi Null Bellingham and the additional rare variant P Lowell, Asp 256 (GAT) to Val (GTT), a variant that also results in alpha-1-antitrypsin deficiency.

CONCLUSION

Patients with complete absence of alpha-1-antitrypsin develop premature emphysema not having smoked or after only minimal exposure, and much earlier than the more common Pi Z individuals who have the usual form of alpha-1-antitrypsin deficiency.

Asthma requiring mechanical ventilation. A low morbidity approach

STUDY OBJECTIVE

There is considerable uncertainty about the clinical features, respiratory physiology, and optimal management of patients with asthma requiring mechanical ventilation. Furthermore, the ventilatory and pharmacologic management of asthma requiring mechanical ventilation remain controversial. We hypothesized (1) that there are clinically identifiable and pathophysiologically different subgroups presenting with asthma requiring ventilation; (2) that lower dose steroid therapy (< 400 mg/d intravenous hydrocortisone) is adequate; (3) that permissive hypercapnia is safe; (4) that prolonged paralysis is generally unnecessary; and (5) that clinical outcome would be favorable in patients treated with this approach.

DESIGN

Review of medical records and intensive care charts and statistical analysis of findings.

SETTING

ICU of tertiary institution.

PATIENTS

Thirty-five consecutive cases of life-threatening asthma requiring mechanic ventilation.

RESULTS

Three clinical subgroups of ventilation-requiring asthmatics could be identified. Those presenting with steady deterioration (10), those with unstable asthma followed by a sudden "dip" (16), and those with a sudden unexpected dip (9). Patients in the first group had a significantly lower PaCO2 (p < 0.01) at presentation, but required ventilation for longer periods. Those in the second group had a significantly higher PaCO2 (p < 0.01) and required ventilation for a shorter period. Those in the third group had an intermediate PaCO2 level before intubation and the shortest period (p < 0.01) of mechanical ventilation. Five patients experienced their sudden dip after ingesting aspirin. Ten cases received "high" dose hydrocortisone therapy (mean: 980 mg/24 h), and 25 received lower dose hydrocortisone (mean: 341 mg/24 h). No differences in illness severity at presentation or outcome could be detected between these two groups. Mean duration of ventilatory support was 36 h and mean duration of the ICU stay 52.1 h. Muscle relaxation was used in 12 patients for a mean period of 11.1 h. One patient was brain dead on arrival. All others survived.

CONCLUSIONS

Life threatening asthma is an endpoint for several different clinical patterns of disease. No major clinical advantage could be found in our group of patients when high-dose steroids were used. Long-term use of muscle relaxants and prolonged mechanic ventilation are rarely needed in the management of patients with life-threatening asthma and excellent results can be achieved with a relatively simple management strategy.

Fibreoptic bronchoscopy in the critically ill: a prospective study of its diagnostic and therapeutic value

AIM

A prospective study was undertaken to assess the diagnostic value and therapeutic usefulness of fibreoptic bronchoscopy in the critically ill.

METHOD

Fifty-six bronchoscopies were performed in fifty patients. Biochemical, radiological, microbiological and clinical assessments were made before and after each procedure.

RESULTS

Eighteen fibreoptic bronchoscopies were performed for therapeutic indications (32.1%) of which ten (55.6%) yielded a useful outcome. Thirty-eight bronchoscopies were for diagnostic purposes (67.8%) of which 22 (57.9%) were clinically useful. Broncho-alveolar lavage was performed in twenty-eight cases (50%) and it led to a clinically useful diagnosis in 17 (60.7%). There was no major complication. A subgroup of patients was defined (persistent left lower lobe collapse or consolidation following thoracic or abdominal surgery) in whom fibreoptic bronchoscopy usually did not yield a useful outcome.

CONCLUSION

The use of fibreoptic bronchoscopy in the Intensive Care Unit, in combination with the technique of broncho-alveolar lavage, results in a clinically useful outcome in the majority of cases. Fibreoptic bronchoscopy is an effective and safe diagnostic and therapeutic tool in critically ill patients.

Clinical spectrum of cryptogenic organising pneumonitis

Cryptogenic organising pneumonitis (bronchiolitis obliterans organising pneumonia) is an uncommon condition that often responds to steroids. It is characterised clinically by constitutional symptoms, pathologically by intra-alveolar organising fibrosis, and radiologically by patchy pulmonary infiltrates. Its full clinical spectrum and course are only partially described and understood. Six patients are described, seen over three years, with considerably diverse clinical and radiological presentations (two had diffuse lung infiltrates, two had peripheral lung infiltrates, and two had localised lobar involvement) and with very varying severity of disease (two with a life threatening illness, three with appreciable subacute constitutional symptoms, and one with mild symptoms). It is concluded that cryptogenic organising pneumonitis can present in various ways. A set of diagnostic criteria are proposed which will help in the recognition of this syndrome, which is probably underdiagnosed.

Talking about death: patterns of lay and professional change

For the past thirty years, researchers have surveyed attitudes of providers and patients to the disclosure of the diagnosis and prognosis to the dying cancer patient. Though the lay population has expressed the wish to know over time, a change in provider attitudes is apparent: physicians are now more likely to inform their dying patients of the truth than before. This trend is viewed against a number of precipitating factors: changes in perception of the impact of disclosure and changes in the basic ethical norms related to disclosure with new cohorts of younger physicians reflecting these changes. These correlate with changes in underlying social structure brought about in part by the shift to chronic disease as the paradigm for medical care. With increasingly bureaucratized health care delivery, the physician must collaborate with others who may hold different judgments about what ought to be disclosed. Some nurses not only find it right to disclose, but also in their professional interest. In such settings, honesty may be necessary to avoid conflicting messages to the patient. These shifts may signal underlying shifts in the sick role and in the medical professional role with the patient more active and more knowledgeable in medical decisions and the physician serving as a source of information and counsel.

Cystic fibrosis--immunological reactions to A. fumigatus and common allergens

Immunological studies of forty-three patients with cystic fibrosis showed that positive prick tests to at least one common allergen were obtained in 70%, to multiple allergens in 28% and to A. fumigatus in 50%. Specific IgE antibodies against these allergens were found in the appropriate subjects. In spite of this evidence of type 1, IgE, sensitization none of the patients had a history of infantile eczema. Intracutaneous tests with A. fumigatus extract gave types 1 and 3 reactions in sixteen patients (37%), only seven of whom were among the sixteen (37%) who gave positive precipitin tests. Raised levels of total serum IgG and IgA were found as compared with healthy controls and asthmatic subjects. No differences were found in total serum IgM and IgD levels. The high incidence of allergy to A. fumigatus in cystic fibrosis is confirmed.

Response of blood gas tensions to aminophylline and isoprenaline in patients with asthma

Aminophylline and isoprenaline, two drugs widely used in the management of asthma, have a pulmonary vasodilator action as well as a bronchodilator action. If regional pulmonary vasoconstriction in poorly ventilated parts of the lungs is a significant compensatory phenomenon in asthma, the effects of administration of these agents on gas exchange would depend on the relative magnitudes of bronchodilator action and pulmonary vasodilator action in the individual patient. If vasodilator action were greater than bronchodilator action in significant portions of the lungs, maldistribution of ventilation-blood flow ratios would increase and arterial oxygen tension might fall. In 40 patients with chronic asthma, arterial blood gas tensions, minute ventilation, alveolar-arterial oxygen tension gradient, physiological dead space/tidal volume ratio, and oxygen consumption were measured before and at intervals up to 20 to 40 minutes after the administration of various agents: in 13 patients, 250 mg. of aminophylline intravenously; in 16 patients, six deep inhalations of 1% isoprenaline aerosol; in 11 patients, after various control procedures. There were no significant changes following the control procedures. Administration of both aminophylline and isoprenaline was followed by increases of F.E.V._1·0 and increases of minute ventilation. Despite these changes, five patients in each group showed a fall of arterial Po₂ of 5 mm. Hg or more. This was accompanied by an increase of alveolar-arterial oxygen tension gradient. It was concluded that the decreases of arterial blood Po₂ resulted from reversal of pre-existing, compensatory, regional pulmonary vasoconstriction by the pulmonary vasodilator action of each drug in some subjects.