Aclacinomycin A in the treatment of experimental proliferative vitreoretinopathy. Efficacy and toxicity in the rabbit eye

PURPOSE

Aclacinomycin A is an oligosaccharide anthracycline that, by contrast with daunomycin, lacks carcinogenicity. The authors evaluated the efficacy of aclacinomycin A in prevention of experimental proliferative vitreoretinopathy (PVR) and its toxicity on the rabbit retina.

METHODS

Dutch-belted rabbit were used to create a model for traction retinal detachment. Seven to 10 days after vitreous gas compression, 25,000 homologous fibroblasts were injected into the vitreous cavity. Subsequently, the eyes received either sham injections or doses of 6, 30, or 60 nmol of aclacinomycin A, respectively. The fundus findings were documented on days 7, 14, and 28 after the fibroblast injection. The toxicity studies were conducted according to the same protocol as was used for the efficacy evaluation but without the fibroblast injection. Simultaneous electroretinograms were recorded on days 0, 3, 7, and 14 from the right eyes that were injected with 30 or 60 nmol of aclacinomycin A and the left eyes that were sham injected. Morphologic studies were conducted on the eyes enucleated on days 3, 7, and 14 after drug exposure.

RESULTS

Intraocular administration of 30 nmol of aclacinomycin A on day 2 after fibroblast injection resulted in a detachment rate of 37.5% (controls, 100%; P < 0.01, by Fisher's exact test). Administration of 60 nmol of aclacinomycin A 3 days after fibroblast injection resulted in a detachment rate of 26.7% (controls, 100%; P < 0.0001). Six nanomoles of aclacinomycin A 3 days after fibroblast injection had no effect. No electroretinogram changes were present in eyes treated with 30 nmol of aclacinomycin A. Such recordings from eyes exposed to 60 nmol of aclacinomycin A demonstrated decreased a- and b-waves on day 3; these completely recovered by day 7. Morphologic studies of these eyes revealed no damage to the retina.

CONCLUSIONS

These results suggest that aclacinomycin A should be considered an alternative to daunomycin for treatment of human PVR because, in addition to its lack of carcinogenicity, it shows good efficacy and causes less retinal toxicity.

Likelihood ratios for continuous test results--making the clinicians' job easier or harder?

Clinicians' paradigms for considering diagnostic test results require decisions based on the actual test value. However, when the test result is reported on a continuous scale each possible outcome may not result in unique actions. To simplify decision making, clinicians often break down the continuous scale into dichotomous or ordered outcomes. Likelihood ratios, reported with the test outcome, help summarize the impact of diagnostic tests. Although commonly applied to dichotomous outcomes, likelihood ratios can also be applied to ordinal or continuous results. This application allows investigators to consider the effect of clinically simplifying continuous data into dichotomous or ordinal categories. The parameters of a simple logistic regression equation summarize continuous likelihood ratios, evaluate covariates, generate likelihood ratio lines, and help assess the statistical significance of more complex models. Having visually inspected likelihood ratio lines and considered statistical differences, the investigator should choose the test report format that best accounts the realities driving clinical decisions.

Role perceptions of divorcing parents

Using interview data from a convenience sample of 101 divorcing parents, we examined the gender roles of parents during the transition from marriage to divorce. We found that the women, who most often initiated divorce, were changing their roles and that this was related to marital dissatisfactions. Factor analysis indicated that real differences existed in how mothers and fathers perceived the co-parental relationship. Mothers saw the relationship as supportive at times and conflictual at times. Fathers tended to view the relationship as helpful only if it did not contain conflict. Improved communication in the coparental relationship after divorce seemed to be related to changes in traditional female and male roles.

Physician-related barriers to breast cancer screening in older women

Despite evidence that annual mammographic screening in women 50 years and older reduces mortality, surveys of physicians and patients have repeatedly demonstrated that annual screening mammography is not performed. The fundamental question addressed in this chapter is: If the assumption is made that the scientific evidence supports the use of mammography, what, then, are physician-related barriers to mammographic screening of elderly women? Using a model that classifies barriers to implementing prevention protocols into three categories (predisposing, enabling, and reinforcing factors), literature is reviewed to help identify reasons for low mammographic screening rates, especially in elderly women. This article concludes with a discussion of strategies that may help overcome barriers to mammographic screening in elderly women.

Clinical evaluation for sinusitis. Making the diagnosis by history and physical examination

OBJECTIVE

To identify the most useful clinical examination findings for the diagnosis of acute and subacute sinusitis.

DESIGN

Prospective comparison of clinical findings with radiographs.

SETTING

General medicine clinics at a university-affiliated Veterans Affairs Medical Center.

PATIENTS

Two hundred forty-seven consecutive adult men with rhinorrhea (51%), facial pain (22%) , or self-suspected sinusitis (27%) (median age, 50 years; median duration of symptoms, 11.5 days).

MEASUREMENTS

Patients were examined by a principal investigator (86%) or by a staff general internist, internal medicine resident (postgraduate year 2 or 3), or physician assistant, all blinded to radiographic results. All examiners recorded the presence or absence of 16 historical items, 5 physical examination items, and the clinical impression for sinusitis (high, intermediate, or low probability). The criterion standard was paranasal sinus radiographs (4 views), which were interpreted by radiologists blinded to clinical findings.

RESULTS

Thirty-eight percent of patients meeting entrance criteria had sinusitis. Sensitivity, specificity, and likelihood ratios were measured for clinical items. Logistic regression analysis showed five independent predictors of sinusitis: maxillary toothache (odds ratio, 2.9), transillumination (odds ratio, 2.7), poor response to nasal decongestants or antihistamines (odds ratio, 2.4), colored nasal discharge reported by the patient (odds ratio, 2.2), or mucopurulence seen during examination (odds ratio, 2.9). THe overall clinical impression was more accurate than any single finding: high probability (likelihood ratio, 4.7, intermediate (likelihood ratio, 1.4), low probability (likelihood ratio, 0.4).

CONCLUSIONS

General internists, focusing on five clinical findings and their overall clinical impression, can effectively stratify male patients with sinus symptoms as having a high, intermediate, or low probability of sinusitis.

A method for assessing drug therapy appropriateness

This study evaluated the reliability of a new medication appropriateness index. Using the index, independent assessments were made of chronic medications taken by 10 ambulatory, elderly male patients by a clinical pharmacist and an internist-geriatrician. Their overall inter-rater agreement for medication appropriateness (ppos) was 0.88, and for medication inappropriateness (pneg) was 0.95; the overall kappa was 0.83. Their intra-rater agreement for ppos was 0.94 overall, for pneg was 0.98 overall while the overall kappa was 0.92. The chronic medications taken by 10 different ambulatory elderly male patients were independently evaluated by two different clinical pharmacists. Their overall inter-rater agreement for ppos was 0.76, and for pneg was 0.93, while the overall kappa was 0.59. This new index provides a reliable method to assess drug therapy appropriateness. Its use may be applicable as a quality of care outcome measure in health services research and in institutional quality assurance programs.

Blood pressure measurements in the nursing home: are they accurate?

To examine the accuracy of blood pressure (BP) measurements in the nursing home, a trained observer (physician) and nursing home staff (NHS) measured BP for 146 nursing home residents on two separate occasions. Using the physician as the reference standard for measuring BP, the NHS: 1) significantly underestimated systolic BP; 2) significantly overestimated diastolic BP; and 3) had a high frequency of terminal digit preference for zero. These errors resulted in the NHS misclassifying hypertension in 21% of patients.

Relative frequency of nosocomial pathogens at a university hospital during the decade 1980 to 1989

BACKGROUND

We compared the relative frequency of pathogens isolated from 1985 to 1989 (N = 4358) with those isolated from 1980 to 1984 (N = 5290) in a university hospital to determine trends in the relative importance of pathogens causing nosocomial infection.

METHODS

Our study was based on surveillance data prospectively obtained between 1980 and 1989 from a 600-bed university hospital. Statistically significant trends occurring from 1980 to 1984 to 1985 to 1989 were determined by chi 2 tests with Bonferroni corrections (i.e., p less than [0.05/17]).

RESULTS

Overall an increased frequency of isolation occurred for Candida and other yeasts and for Haemophilus species. A decreased frequency was noted for Proteus species, non-Bacteroides anaerobes, and Serratia species. Comparison of 1985 to 1989 with 1980 to 1984 revealed that the most significant change in nosocomial pathogens was the marked increase in infections with yeast, principally Candida species. Candida and other yeast infections increased 40%, from 7.6% (rank, 5) to 10.6% (rank, 3) of all pathogens isolated. Increases, which occurred in urine, blood, and wound isolates, were especially marked among surgical patients. In addition, a significant increase was noted among blood isolates in the isolation of yeast other than Candida albicans.

CONCLUSIONS

We conclude that Candida and other yeasts are being isolated increasingly as causative agents of nosocomial infection.

Physicians' attitudes and practices regarding treatment of HIV-infected patients

We conducted a statewide survey to identify physicians' experiences, attitudes, and practices related to HIV-infected patients. A random sample, stratified by medical specialty (primary care, surgery, emergency medicine), was drawn. Physicians were concerned about contagion and inadequate knowledge to care for HIV-infected patients; 40% reported refusing or referring new HIV-infected patients. Differences across medical specialty and respondents' interest in various medical education topics to remedy knowledge deficits are discussed.

Comparing proxy and patients' perceptions of patients' functional status: results from an outpatient geriatric clinic

OBJECTIVE

To compare ratings of patients referred for geriatric evaluation and their proxies with respect to patients' ability to perform activities of daily living.

DESIGN

Retrospective chart audit.

SETTING

University-based Outpatient Geriatric Clinic.

PATIENTS

Elderly medicine patients referred to a university-based outpatient geriatrics clinic for the first time.

MAIN OUTCOME MEASURES

Modified Katz Physical Activities of Daily Living (PADL) and Instrumental Activities of Daily Living (IADL).

RESULTS

With regard to PADLs, patients were generally rated as independent by both patients (91%) and proxies (87%); for IADLs, ratings of independence by both patients (68%) and proxies (51%) were significantly lower. Concordance between patient and proxy ratings was significantly (P less than 0.001) greater for PADLs (92%) than for IADLs (82%). When disagreement occurred, patients consistently rated themselves as more independent than their proxies, especially for IADLs. Moreover, concordance between patients and proxies regarding IADLs was significantly (P less than 0.001) worse for patients who had scores below 24 on the Folstein Mini-Mental State Examination (72%) compared with those scoring 24 or higher (95%).

CONCLUSIONS

Patient and proxy ratings were concordant when rating patients' ability to perform PADLs. Moreover, concordance was extremely high on IADLs when patients' Folstein scores were 24 or higher. Concordance with respect to IADLs was relatively poor only among patients with Folstein scores below 24. In that case, patients had a more optimistic view of their independence, compared with their proxies.

The effect of combined daunorubicin and triamcinolone acetonide treatment on a refined experimental model of proliferative vitreoretinopathy

Prior studies have shown that intravitreal daunorubicin (9-15 nmol) and triamcinolone acetonide (2 mg) are effective individually in preventing retinal detachment in experimental proliferative vitreoretinopathy. This report compares the efficacy of the combination of daunorubicin (15 nmol) and triamcinolone acetonide (2 mg) with that of daunorubicin alone in a refined experimental model of proliferative vitreoretinopathy. The degree of retinal detachment in each treatment group was graded, with the unequivocal absence or presence of retinal detachment used as an indicator of treatment success or failure. Both treatments (daunorubicin alone and in combination with triamcinolone acetonide) effectively prevented retinal detachment. However, there was no significant difference in the rate of retinal detachment between the two treatment groups. These results indicate that combination therapy with daunorubicin/triamcinolone is no more effective at preventing retinal detachment than daunorubicin alone.

Transparent polyurethane film as an intravenous catheter dressing. A meta-analysis of the infection risks

OBJECTIVE

To obtain a quantitative estimate of the impact on infectious complications of using transparent dressings with intravenous catheters.

DATA SOURCES

Meta-analysis of all studies published in the English literature, including abstracts, letters, and reports that examined the primary research question of infection risks associated with transparent compared with gauze dressings for use on central and peripheral venous catheters. Studies were identified by use of the MEDLINE database using the indexing terms occlusive dressings, transparent dressings, and infection and by review of referenced bibliographies.

STUDY SELECTION

Seven of the 15 studies (47%) of central venous catheters and seven of 12 studies (58%) of peripheral catheters met our inclusion criteria for analysis. All studies used a prospective cohort design, utilized hospitalized patients, and reported at least one of our defined outcomes.

EXTRACTION

Data for each study were abstracted independently by three investigators. At least three studies were used in the analysis of each outcome.

DATA SYNTHESIS

Applying a Mantel-Haenszel chi 2 analysis, use of transparent dressings on central venous catheters was significantly associated with an elevated relative risk (RR) of catheter tip infection (RR = 1.78; 95% confidence interval [CI], 1.38 to 2.30). Catheter-related sepsis (RR = 1.69; 95% CI, 0.97 to 2.95) and bacteremia (RR = 1.63; 95% CI, 0.76 to 3.47) were both associated with an elevated RR. Use of transparent dressings on peripheral catheters was associated with an elevated RR of catheter-tip infection (RR = 1.53; 95% CI, 1.18 to 1.99) but not phlebitis (RR = 1.02; 95% CI, 0.86 to 1.20), infiltration (RR = 1.12; 95% CI, 0.92 to 1.37), or skin colonization (RR = 0.99; 95% CI, 0.90 to 1.09).

CONCLUSION

The results demonstrated a significantly increased risk of catheter-tip infection with the use of transparent compared with gauze dressings when used with either central or peripheral catheters. An increased risk of bacteremia and catheter sepsis associated with the use of transparent compared with gauze dressings for use on central venous catheters was suggested.

Generic versus disease specific health status measures: comparing the sickness impact profile and the arthritis impact measurement scales

Health services researchers frequently must choose between a generic health status measure, such as the Sickness Impact Profile (SIP) and a disease specific health status measure, such as the Arthritis Impact Measurement Scales (AIMS). In a longitudinal study of patients with knee or hip osteoarthritis, we examined the extent to which these 2 measures provide similar information. We found the SIP and AIMS to be significantly (p less than 0.001) correlated for physical (0.75-0.76) and total health (0.70-0.73). Correlations for psychological health were statistically significant, albeit modest (0.37-0.40). We conclude that, for most dimensions, investigators will obtain similar information using either well validated instrument.

Two-year trends in physical performance following supervised exercise among community-dwelling older veterans

The extent to which exercise can delay the normal decline in physical performance associated with aging is unknown. We examined the impact of 2 years of supervised exercise on cardiovascular fitness, flexibility, and strength in a group of elderly (age 65-74) veterans. Seventy-five patients exercised 3 days/week for 90-minute sessions emphasizing aerobic, flexibility, and strength development. Thirty-six (47%) completed 2 years of a voluntary supervised exercise program (n = 16-25 with complete data). Over a 2-year follow-up period, cardiovascular outcome variables improved significantly: metabolic equivalents increased 20% (7.4 +/- 2.2 to 9.0 +/- 2.4, P less than 0.001) and submaximal heart rate decreased 7% (131.4 +/- 14.8 to 121.0 +/- 18.5 beats/minute, P = 0.06). Resting heart rate decreased 8% (68.5 +/- 8.0 to 63.6 +/- 8.4 beats/minute, P = 0.02) but this difference did not reach statistical significance. Flexibility, measured by hamstring length, improved 11% (57.5 +/- 15.1 to 64.0 +/- 11.1 degrees, P = 0.02). Strength variables did not improve. The study indicates that improvements in cardiovascular function and flexibility achieved by the elderly in the early stages of an exercise program can be maintained for at least 2 years.

Nosocomial infection rate as a function of human immunodeficiency virus type 1 status in hemophiliacs

As part of a prospective cohort study initiated in 1983, the human immunodeficiency virus type 1 (HIV-1) status has been periodically determined for patients with clotting disorders (hemophilia A or B, von Willebrand's disease, miscellaneous). The University of North Carolina Hospitals has conducted comprehensive surveillance for nosocomial infections (NI) using modified Centers for Disease Control criteria since 1980 and entered this information in a computerized data base. Cross-matching of our NI data base and hemophiliac/HIV-1 study data base for the time period 1980-1989 revealed that 13 NI occurred in 11 patients during 659 hospitalizations (5,723 hospital days). NI rates per 100 admissions (per 1,000 hospital days) by HIV-1 status were as follows: HIV-1 negative = 0.91 (1.18), HIV-1 positive pre-AIDS = 1.65 (1.84), and AIDS = 6.67 (6.48). NI occurred with a similar frequency in HIV-1 positive pre-AIDS hemophiliacs and HIV-1 negative hemophiliacs (Fisher's exact test, p greater than 0.10). However, NI occurred more frequently in hemophiliacs with AIDS versus HIV-1 positive or negative hemophiliacs (Fisher's exact test, p less than 0.05). We conclude that HIV-1 infection does not appreciably alter the risk of developing a NI, but that patients who have progressed to AIDS are at significantly increased risk of developing a NI per hospital day or per hospitalization.

An evaluation of a brief health status measure in elderly veterans

OBJECTIVE

To examine the feasibility of a brief 36-item health status measure in elderly male veterans, by comparing it with the 136-item Sickness Impact Profile.

DESIGN

Cross-sectional study in which all subjects completed both measures in a random order.

SETTING

Durham VAMC General Medicine and Geriatrics Clinics.

PATIENTS

Convenience sample of 25 male veterans aged 65 and older (mean age = 73.5 years; 68% white; 68% currently married; mean annual income = $7,000).

MAIN OUTCOME MEASURES

Two well-validated health status measures, the Sickness Impact Profile and the SF-36.

RESULTS

The SF-36 took less time to administer than the Sickness Impact Profile in both the Geriatrics Clinic (mean: 15 vs 33 minutes) and General Medicine Clinic (mean: 14 vs 21 minutes). Although SIP scores consistently displayed a more optimistic picture of respondents' health compared with the SF-36, the two instruments were highly correlated: overall functioning (r = 0.73), physical functioning (r = 0.78), and social functioning (r = 0.67).

CONCLUSIONS

These two measures provide a similar ranking of elderly male veterans' health status. The significantly shorter administration time of the SF-36 is an attractive feature for both researchers and clinicians interested in assessing health status.

Use of antimicrobial drugs in adults before and after removal of a restriction policy

The effects on the quantity and quality of antimicrobial drug use of removing an antimicrobial restriction policy are reported. Monthly totals for the number of courses of antimicrobial therapy and expenditures based on grams used were obtained from pharmacy records on adult inpatients for a portion (July-December 1987) of the restriction policy term and for the six months (July-December 1988) immediately after the policy ended. Data were obtained for nine restricted drugs and for three that were never restricted. Retrospective drug-use reviews were conducted for ceftazidime and imipenem-cilastatin. For the restricted agents, the total number of courses of therapy increased by 158% after the restriction policy was removed, and total expenditures increased by 103%. There were no significant changes in the number of courses of therapy or cost for the unrestricted antimicrobials. In the postrestriction period, ceftazidime and imipenem-cilastatin were used more often in patients who were less critically ill. Inappropriate use of imipenem-cilastatin occurred significantly more often after the restrictions were removed. Other factors potentially affecting the use of antimicrobials, such as patient age and the incidence of nosocomial infections, did not differ substantially between the two periods. The removal of an antimicrobial restriction policy resulted in increased use of and higher expenditures for previously restricted agents, as well as an increase in the inappropriate use of at least one agent.

X-linked hypophosphatemic rickets without "rickets"

Wrist and knee radiographs from children with X-linked hypophosphatemic rickets were analyzed and compared with those from normal children and children with established rickets to assess whether radiographically apparent rickets is a consistent abnormality in X-linked hypophosphatemia. The absence or presence of rickets was correctly identified in 94.8% of wrist and knee films from normal and positive controls. In contrast, patients with X-linked hypophosphatemia exhibited rachitic abnormalities in only 5 of 11 wrist and 13 of 15 knee radiographs. As a result, 4 patients within this study group had rickets at the knee and not at the wrist, whereas 5 displayed classic defects at both sites. Perhaps more important, 2 patients, aged 3.8 and 5.2 years, displayed no evidence of rickets in either wrist or knee films, although relatives exhibited demonstrable rachitic abnormalities. Our data indicate that radiographically detectable rickets is a variable abnormality of X-linked hypophosphatemia and does not provide an unambiguous index for the diagnosis of this disease.

Observer variability of Osler's maneuver in detection of pseudohypertension

Pseudohypertension in the elderly occurs when blood pressure is overestimated because of inelastic, sclerotic arteries. Osler's maneuver (OM), the palpability of a pulseless artery, is recommended as a non-invasive test to detect pseudohypertension, despite limited data concerning its reproducibility. We assessed the maximum achievable inter-and intra-observer agreement of OM among 6 examiners: cardiologists, geriatricians and general internists. Each examiner performed OM twice on 65 elderly hypertensive men attending the general medicine and geriatric clinics. The inter-observer agreement for brachial and radial examinations was 79 and 70%, while intra-observer agreement was 82 and 75%, respectively. After adjusting for chance agreement the kappa values for inter-observer agreement for brachial and radial arteries were 0.38 (95% confidence interval (CI): 0.21-0.55) and 0.37 (0.28-0.46), respectively. Similarly, the kappa values for intra-observer agreement were 0.45 (95% CI: 0.35-0.55) and 0.49 (0.39-0.59). Kappa values never exceeded 0.6 in any time period, suggesting no training effect. OM cannot be recommended as a screening test for pseudohypertension given this low inter- and intra-observer agreement.

Likelihood ratios with confidence: sample size estimation for diagnostic test studies

Confidence intervals are important summary measures that provide useful information from clinical investigations, especially when comparing data from different populations or sites. Studies of a diagnostic test should include both point estimates and confidence intervals for the tests' sensitivity and specificity. Equally important measures of a test's efficiency are likelihood ratios at each test outcome level. We present a method for calculating likelihood ratio confidence intervals for tests that have positive or negative results, tests with non-positive/non-negative results, and tests reported on an ordinal outcome scale. In addition, we demonstrate a sample size estimation procedure for diagnostic test studies based on the desired likelihood ratio confidence interval. The renewed interest in confidence intervals in the medical literature is important, and should be extended to studies analyzing diagnostic tests.

Breast cancer screening in older women: practices and barriers reported by primary care physicians

Annual mammography, in combination with clinical breast examinations, can reduce mortality from breast cancer. However, surveys of both patients and physicians suggest that mammography is underutilized. This study examined whether physicians' reported breast cancer screening practices and barriers to mammography varied with patients' age. Data from 576 primary care physicians (internal medicine, family/general practice, and obstetrics/gynecology) who participated in a mailed statewide survey were analyzed. Physicians reported screening elderly women significantly less often than younger women, regardless of family history of breast cancer. With the exception of medical specialty, physicians' demographic and practice characteristics were not associated with reported screening practices. However, physicians' knowledge and beliefs about breast cancer in older women were associated with reported screening practices. When analyzing barriers to ordering mammography, cost to the patient was viewed as a barrier for women of all ages, and pain was viewed as a greater barrier for younger women; otherwise, physicians consistently believed that their elderly patients faced considerably more barriers compared with younger women. Further investigation is required to examine why primary care physicians report age-related differences in both breast screening and barriers to mammography.

Bacterial indicators of risk of diarrhoeal disease from drinking-water in the Philippines

Inadequate measures of water quality have been used in many studies of the health effects associated with water supplies in developing countries. The present 1-year epidemiological-microbiological study evaluated four bacterial indicators of tropical drinking-water quality (faecal coliforms, Escherichia coli, enterococci and faecal streptococci) and their relationship to the prevalence of diarrhoeal disease in a population of 690 under-2-year-olds in Cebu, Philippines. E. coli and enterococci were better predictors than faecal coliforms of the risk of waterborne diarrhoeal disease. Methods to enumerate E. coli and enterococci were less subject to interference from the thermotolerant, non-faecal organisms that are indigenous to tropical waters. Little difference was observed between the illness rates of children drinking good quality water (less than 1 E. coli per 100 ml) and those drinking moderately contaminated water (2-100 E. coli per 100 ml). Children drinking water with greater than 1000 E. coli per 100 ml had significantly higher rates of diarrhoeal disease than those drinking less contaminated water. This threshold effect suggests that in developing countries where the quality of drinking-water is good or moderate other transmission routes of diarrhoeal disease may be more important; however, grossly contaminated water is a major source of exposure to faecal contamination and diarrhoeal pathogens.

Epidemiology of tuberculosis in North Carolina, 1966 to 1986: analysis of demographic features, geographic variation, AIDS, migrant workers, and site of infection

We analyzed all cases of tuberculosis reported in North Carolina between 1966 and 1986, and related the incidence rate of tuberculosis (per 100,000 population) to age (0 to 4 years, 7.59; 5 to 14 years, 3.44; 15 to 24 years, 6.30; 25 to 44 years, 15.92; 45 to 64 years, 33.85; greater than 65 years, 51.54), race (white 9.03, nonwhite 47.40), and gender (male 25.49, female 11.25). Over the 21-year study period the annual number of cases declined from 1,248 to 711 (43%), and the incidence rate from 25.56 to 11.25 (56%). Although the incidence rate of tuberculosis fell for all subgroups, nonwhites continued to have an incidence rate 3.2 to 22.5 times higher than whites, depending on age. The standardized morbidity ratio (SMR) (by age, race, and gender) of tuberculosis in the eastern region of North Carolina was nearly twice that of the western region and unexplainable by its demographics. Between 1983 and 1986 only a small percentage of cases of tuberculosis in North Carolina were accounted for by migrant farm workers (1.7% to 2.7%) and patients with the acquired immunodeficiency syndrome (less than 1%). Tuberculosis is increasingly a disease of the elderly, especially nonwhite men. Tuberculosis is a geographically and demographically focal disease in North Carolina, and preventive strategies should be appropriately targeted.

Multiple nosocomial infections. An incidence study

Prospective surveillance for nosocomial infections was performed for a five-year admission cohort (1980-1984) at North Carolina Memorial Hospital. One or more nosocomial infections developed in 2,662 patients (2.6%) from 102,206 patients at risk; greater than or equal to 2 nosocomial infections developed in 775 of these 2,662 patients (29.1%), and greater than or equal to 3 nosocomial infections in 304 of 775 patients with greater than or equal to 2 infections (39.2%). Hospital stay was significantly prolonged for infected compared with never-infected patients (38.1 vs. 7.9 days, p less than 0.0001) and for multiply-infected versus once-infected patients (57.9 vs. 30.0 days, p less than 0.0001). Total nosocomial infections numbered 4,031 with 2,144 multiple infections (53%); the average number of nosocomial infections per infected patient was 1.5 (4,031 infections in 2,662 patients). Among all nosocomial infections, 64% of bacteremias, 55% of respiratory infections, 55% of surgical wound infections, and 40% of urinary tract infections occurred in patients with multiple nosocomial infections. Surgical patients had 56% of multiple infections. Intensive care unit patients had significantly more multiple infections than non-intensive care unit patients. Nosocomial infections in intensive care unit patients were 71% multiple nosocomial infections. The probability of developing multiple infections was 11 times greater after the first infection occurred. This emphasizes the need to prevent initial nosocomial infections and to identify risk factors for multiple nosocomial infections. Determining risk factors for multiple nosocomial infections could focus infection control efforts on a subpopulation of patients who acquire over 50% of all nosocomial infections and who have significantly prolonged and costly hospital stays.

Do nursing diagnoses affect functional status?

1. Nurses in this study often made diagnoses pertaining to physiological or physical problems rather than psychosocial problems. One diagnostic category, "impaired home maintenance management," was consistently used incorrectly, suggesting a need for careful clinical training of nursing staff in diagnostic reasoning. 2. Patients who had a greater number of nursing diagnoses had greater improvements in function during the hospital stay. One explanation is that more nursing diagnoses may lead to more independent nursing actions, resulting in improvements in functional abilities. 3. Functional status on admission measured by the Katz ADL was the most powerful predictor of functional status at discharge. The scale can readily be used by nurses to document basic functioning and to quickly identify patients needing or coordinated discharge planning. 4. Institutionalized had a higher mean number of nursing diagnoses than those who were discharged to their own homes. The most powerful predictor of institutionalization was the Katz ADL score.