Impact of quality-of-care factors on pediatric intensive care unit mortality

OBJECTIVE

To determine the importance of the following care factors previously associated with hospital quality on survival from pediatric intensive care: size of the intensive care unit (ICU), medical school teaching status of the hospital housing the ICU, specialist status (pediatric intensivist), and unit coordination.

DESIGN

After a national survey, consecutive case series were collected at 16 sites randomly selected to represent unique combinations of quality-of-care factors.

SETTING

Pediatric ICUs.

PATIENTS

Consecutive admissions to each site.

MAIN OUTCOME MEASURE

Patient mortality adjusted for physiologic status, diagnosis, and other mortality risk factors.

RESULTS

There were 5415 pediatric ICU admissions and 248 ICU deaths. The ICUs differed significantly with respect to descriptive variables, including mortality (range, 2.2% to 16.4%). Analysis of risk-adjusted mortality indicated that the hospital teaching status and the presence of a pediatric intensivist were significantly associated with a patient's chance of survival. The probability of patient survival after hospitalization in an ICU located in a teaching hospital was decreased (relative odds of dying, 1.79; 95% confidence interval [CI], 1.23 to 2.61; P = .002). In contrast, the probability of patient survival after hospitalization in an ICU with a pediatric intensivist was improved (relative odds of dying, 0.65; 95% CI, 0.44 to 0.95; P = .027). Post hoc analysis indicated that the higher severity-adjusted mortality in teaching hospitals may be explained by the presence of residents caring for ICU patients.

CONCLUSION

Characteristics indicative of the best overall hospital quality may not be associated, or may be negatively associated, with quality of care in specialized care areas, including the pediatric ICU.

Seizure control following tumor surgery for childhood cortical low-grade gliomas

Detailed preoperative electroencephalographic (EEG) studies are now recommended for children with seizures and cortical tumors to define seizure foci prior to surgery. To develop a historical perspective for better evaluation of results from series reporting tumor removal combined with resection of seizure foci, the authors reviewed seizure outcome in 60 children with seizures and low-grade neoplasms treated consecutively since 1981 by surgical resection without concomitant EEG monitoring or electrocortical mapping. Forty-seven of the 60 tumors were totally or near-totally resected; 45 patients were seizure-free and two were significantly improved 1 year following surgery. Of the 50 children in this series with more than five seizures prior to surgery, 36 were seizure-free, two were significantly improved, and 12 were not improved. Factors associated with poor seizure control included a parietal tumor location, a partial tumor resection, and a history of seizures for more than 1 year prior to surgery. The children at highest risk for poor seizure control at 2 years had experienced seizures for more than 1 year prior to surgery and had undergone partial resection of their parietal low-grade glial tumors or gangliogliomas. In contradistinction, the best seizure control was seen in patients with totally resected low-grade gliomas or gangliogliomas who had experienced seizures for less than 1 year (concordance rates for being seizure-free ranged from 78% to 86%). Long-term seizure control remained excellent. These results suggest that seizure control can be obtained 2 years following tumor surgery in the majority of children with presumed tumors after extensive tumor resection without concomitant EEG monitoring or electrocortical mapping.

Recombinant alpha-interferon therapy in multiple myeloma

Three patients with multiple myeloma were treated with recombinant alpha-interferon (r IFN-alpha 2b Intron AR) along with combination chemotherapy i.e. melphelan and prednisolone. In one case it was given as an initial therapy, while the other two patients had refractory and relapsing disease respectively. IFN-alpha 2b was given in the dose of 2 x 10(6) Mu/m2 by subcutaneous injection thrice in a week for six months in two patients and for three months in one patient. All three patients experienced improvement in bone pains; partial response with reduction in the paraprotein level was seen in one patient; while there was no radiological, biochemical or haematological improvement in two patients. Side effects noted were flu like syndrome in all three patients and urticaria in one patient. They were treated symptomatically and did not require cessation of interferon therapy.

Trends in cigarette smoking in the United States. The changing influence of gender and race

Trends in the prevalence, initiation, and cessation of cigarette smoking are reported for the US population using weighted and age-standardized data from seven National Health Interview Surveys (1974 to 1985). The decline in prevalence was linear, with the prevalence for men decreasing at 0.91 percentage points per year to 33.5% in 1985 and the prevalence for women decreasing at 0.33 percentage points per year to 27.6% in 1985. For whites the rate of decline (percentage points per year) was 0.57, to 29.4% in 1985, and for blacks the decline was 0.67, to 35.6% in 1985. Smoking cessation increased among all gender-race groups from 1974 to 1985, with the yearly rate of increase (in percentage points per year) about equivalent for blacks (0.75) and whites (0.77), while it was higher in women (0.90) than in men (0.67). Smoking initiation decreased among young men (-1.03), while it remained about the same in young women (+0.11). Initiation decreased at a more rapid rate in blacks (-1.02) than in whites (-0.35). We conclude that smoking prevalence is decreasing across all race-gender groups, although at a slower rate for women than men, and that differences in initiation, more than cessation, are primarily responsible for the converging of smoking prevalence rates among men and women.

Donor-specific transfusions. Donor-recipient HLA compatibility, recipient HLA haplotype, and antibody production

HLA profiles of 25 donor-specific transfusion (DST) kidney donor-recipient pairs were analyzed for HLA antigen compatibility. Serum samples collected during and after DST were tested for cytotoxic antibodies against T and B lymphocytes of the donors and 30 normal individuals. Eleven recipients did not produce cytotoxic antibodies to the antigens of their DST donors, and eight produced cold and/or warm, broadly reactive B-cell antibodies. Six patients (24%) produced HLA-A, B, C, and/or DR antibodies. Three of these individuals produced antibodies after two immunizations, while others required three immunizations. Three of the 11 antibody nonproducers (17%) had not received previous transfusions, as compared to three of the eight antibody producers (43%). Comparison of HLA profiles revealed 22 percent of the HLA-A, B, DR identities between the transfusion donor and recipient in antibody nonproducers as compared to 9 percent of the HLA-A, B, DR identities in antibody producers. The HLA-A2, B40, DR4 haplotype and HLA-DRW6 antigen were more common among antibody producers than among nonproducers, who had an excess of the HLA-B8, DR3 haplotype. These results are consistent with the hypothesis that there may be high- and low-responder HLA haplotypes that control immunologic responsiveness to histocompatibility antigens.

The human sex ratio: increase in first-born males to parents with shared HLA-DR antigens

Maternal-fetal HLA-DR antigen sharing has been reported to affect the sex ratio of first-born. We therefore studied offspring sex ratios and birth orders in 66 families in which parents shared one or more HLA-DR antigens as compared to 61 families with no parental HLA-DR sharing. A significant excess of males was found among first-born children who were HLA-DR compatible with their mothers compared to first-born HLA-DR incompatible children of couples sharing HLA-DR antigens and couples not sharing HLA-DR antigens. Increased numbers of males may persist among children of higher birth orders in families where parents share both HLA-DR antigens, but not among couples sharing only one HLA-DR antigen. We hypothesize that the presence of the H-Y antigen in the male fetus may provide the necessary stimulus for a successful pregnancy in HLA-DR compatible pregnancies and may explain the excess of male births in the general population.

Factors responsible for successful HLA-DR typing of mononuclear cells from cord blood

Of 115 cord blood samples tested, both HLA-DR antigens were identified in 79% of fresh samples, 66% of older samples and 55% of freshly frozen samples. Because of weak reactions, one or two questionable antigens were present in 21% of fresh samples as compared to 34% of older samples and 45% of freshly frozen samples. Older samples showed lower cell viability, more extra reactions, and a high frequency of weak reactions. Comparison of cord blood DR antigens with parental DR antigens revealed that antigens were missed or inappropriately assigned in 5 known cases. This was more frequent with older blood samples. The critical factors in successful DR typing of cord blood samples were 1) dilution of cord blood samples with medium, 2) processing of the samples as soon as possible, and 3) overnight incubation to remove adherent cells.

Synthesis of carbon-13-labeled tetradecanoic acids

The synthesis of tetradecanoic acid enriched with 13C at carbons 1, 3, or 6 is described. The label at the carbonyl carbon was introduced by treating 1-bromotridecane with K13CN (90% enriched) to form the 13C-labeled nitrile, which upon hydrolysis yielded the desired acid. The [3-13C]tetradecanoic acid was synthesized by alkylation of diethyl sodio-malonate with [1-13C]1-bromododecane; the acid was obtained upon saponification and decarboxylation. The label at the 6 position was introduced by coupling the appropriately labeled alkylcadmium chloride with the half acid chloride methyl ester of the appropriate dioic acid, giving the corresponding oxo fatty acid ester. Formation of the tosylhydrazone of the oxo-ester followed by reduction with sodium cyanoborohydride gave the labeled methyl tetradecanoate which, upon hydrolysis, yielded the desired tetradecanoic acid. All tetradecanoic acids were identical to unlabeled analogs as evaluated by gas-liquid chromatography and infrared or NMR spectroscopy. These labeled fatty acids were used subsequently to prepare the correspondingly labeled diacyl phosphatidylcholines.

Effect of bleomycin-radiotherapy combination in management of head and neck squamous cell carcinoma

Twenty-five patients with head and neck squamous cell carcinoma were treated with bleomycin-radiotherapy protocol, 15 mg bleomycin I.V. on alternate days followed by radiation within half an hour. The average total dose of bleomycin was 150 mg. Radiotherapy was given daily. Two patients were lost to follow-up very early in the course of the treatment and were removed from the study for statistical purposes. Thirty-six patients with head and neck squamous cell carcinoma who were treated with radiotherapy alone during the same period were used as controls. The patients were followed for two years. The incidence of response rate did not differ significantly between regimens; however the incidence of side effects with bleomycin-radiotherapy, 82.61%, is significantly more than that of radiotherapy alone (52.78%). Median survival time (MST) of those responding to bleomycin-radiotherapy protocol was seven months and 12 days and for radiotherapy responders was six months. Neither the response rate nor the MST improve significantly after pretreatment with bleomycin. On the contrary, the incidence of side effects increased significantly.

Triamterene nephrolithiasis complicating dyazide therapy

A case of triamterene nephrolithiasis is reported in a man after 4 years of hydrochlorothiazide-triamterene therapy for hypertension. The stone passed spontaneously and was found to contain a triamterene metabolite admixed with uric acid salts. Factors affecting triamterene nephrolithiasis are discussed and 2 previously reported cases are reviewed.

Granulomatous hepatitis due to Mycobacterium scrofulaceum: report of a case

A rare case of hepatic granulomatosis due to Mycobacterium scrofulaceum is presented. The prolonged clinical course before liver biopsy was characterized by a disproportionate rise in alkaline phosphatase, moderate hepatomegaly, tiredness, and low-grade fever. Liver biopsy confirmed primary liver granulomatosis in the absence of evidence of pulmonary or systemic involvement. The patient was treated with INH, rifampin, and cycloserine with amelioration of clinical symptoms and return of serum alkaline phosphatase levels to normal.

Evaluating statistical analyses and reproducibility of microbial mutagenicity assays

The NCI/NTP has completed the first phase of a 4-laboratory study on the reproducibility of testing chemicals for mutagenicity in the Salmonella/microsome assay. This paper is a report of the statistical analysis of some of that data. This analysis involved (1) identifying and removing spurious data; (2) determining the adequacy of the remaining data in making a decision on the mutagenicity of the test chemical; (3) performing the statistical tests; and (4) interpreting the results. Using this procedure, 7 approaches were used to determine the mutagenicity of a test. These approaches were the (1) 2-fold rule, (20 modified 2-fold rule, (3) one-way analysis of variance (homogeneity test), (4) test for linear trend, (5) combination of 3 and 4, (6) 97.5th percentile threshold rule and (7) confidence interval threshold rule. The conclusions drawn by each rule were compared to the microbiologists' interpretation, and the results of these comparisons were presented. In addition, the strengths and weakness of each rule were discussed. The reproducibility of the assay in this study was examined, and a discussion of the significance of these results was presented.

Biophysical properties of a major membrane phospholipid, dielaidoylphosphatidylethanolamine, found in an Escherichia coli fatty acid auxotroph

Dielaidoylphosphatidylethanolamine, a principal lipid component of membranes of Escherichia coli fatty acid auxotrophs enriched in elaidic acid, has been studied by paramagnetic resonance, fluorescence, and calorimetric methods. EPR measurements with perdeutero-di-tert-butylnitroxide and 2,2,6,6-tetramethyl piperidine-1-oxyl indicate that, when dispersed in aqueous media, this phospholipid undergoes an abrupt order leads to disorder transition at 37.5 degrees C and 36.5 C, respectively. A similar transition temperature is suggested by experiments with 9-doxyl-dimyristoylphosphatidylethanolamine (DEPE). cis- and trans-Parinaric-acid fluorescence polarization measurements indicate that the midpoint of this transition occurs at 34.0 degrees C and 35.5 degrees C, respectively. Differential scanning calorimetry of DEPE revealed a single, sharp endotherm at 38.5 degrees C with increasing temperature; two exotherms of similar magnitude were observed at 36.5 degrees C and 34.5 degrees C upon cooling. This double transition was not observed by any of the other methods. From these results we conclude that the major structural transition at 30-31 degrees C observed previously with 5-, 12-, and 16-doxyl stearate in intact E. coli membranes is due to the DEPE present (Morrisett, J.D., Pownall, H.J., Plumlee, R.T., Smith, L.C., Zehner, Z.E., Esfahani, M., and Wakil, S.J. (1975) J. Biol. Chem. 250, 6969-6976).

A convenient synthesis of phosphatidylcholines: acylation of sn-glycero-3-phosphocholine with fatty acid anhydride and 4-pyrrolidinopyridine

A high-yield synthesis of saturated, unsaturated, and short chain phosphatidylcholines from sn-glycero-3-phosphocholine is described. The procedure offers advantages over other reported procedures for the synthesis of phosphatidylcholine in that the large-scale synthesis and purification can be achieved in a minimum time. The procedure utilizes 4-pyrrolidinopyridine as a catalyst and moderate amounts of fatty acid anhydride (2 mol eq. of fatty acid anhydride per mol of OH) in a 1:1 mixture of benzene-dimethylsulfoxide (DMSO) at 40 degrees--42 degrees C (oilbath) for 2--5 hr. At the end of the reaction, the phosphatidylcholine can be purified in the usual manner or by using a Waters Prep LC/500 with a radially compressed silica gel column eluted with chloroform-methanol-water 60:30:4. At a flow rate of 200 ml/min, the phospholipid elutes in 10--15 min, depending on the chain length and unsaturation.

Antimicrobial activity of chlormerodrin

A radiochemical study for antimicrobial activity of chlormerodrin was performed using some commonly occurring nonpathogenic and pathogenic microorganisms. Chlormerodrin concentrations of 15-35 and 20-45 microgram/ml of the culture medium were microbiostatic and microbicidal, respectively. The microbiostatic effect was reversible in the presence of cysteine, an amino acid containing a sulfhydryl group.

Structure of some cyclohexyl compounds as related to their ability to stimulate plant growth

Aqueous solution, 10 mm, of cyclohexanecarboxylic, cyclohexylacetic, cyclohexylpropionic, cyclohexylbutyric acids (all components of naphthenic acid); cis-1,2-, and trans-1, 4-cyclohexyldicarboxylic acids; 3-cyclohexene-1-carboxylic and cyclohexylsulfamic acids; and cyclohexyl mercaptan were applied to 14-day-old bush bean plants, Phaseolus vulgaris L. cv. Top Crop. Only cyclohexanecarboxylic and cyclohexylacetic acid resulted in a statistically significant (P = 0.05) increase in pod production per plant in all experiments. The stimulation by the first four monocarboxylic acids decreased as the number of methylene groups in the side chain increased from 0 to 3. The effective compounds possessed an H-saturated 6-carbon ring with a single carboxyl group attached directly to the ring or separated from it by no more than one methylene group.