User acceptance of inter-organizational electronic medical records

This paper reports the findings of the first stage of an ongoing, longitudinal study into primary care practitioners’ views of an electronic medical records (EMR) system for maternity patients. All doctors and midwives holding maternity care contracts with a large urban hospital in New Zealand were sent a questionnaire soliciting their views on a planned EMR system linking the hospital and the primary care sectors.

The questionnaire was based on Davis’ technology acceptance model (TAM) [1]. The results show that while Davis’ two key factors of perceived ease of use and perceived usefulness were important to medical professionals, other features of the proposed system and the wider organizational environment also influenced the respondents’ willingness to utilize the proposed system.

Haemophagocytic lymphohistiocytosis in a patient with severe burns

Recently, increasing attention has been drawn to haemophagocytic lymphohistiocytosis as a potentially under-diagnosed condition in critically ill patients with severe sepsis. It is thought to be caused by a highly stimulated, but ineffective, immune system. We report the case of a patient suffering from major burns who, despite extensive investigations showing the absence of concurrent sepsis or infection, developed haemophagocytic lymphohistiocytosis refractory to treatment. We believe that this is the first report suggestive of haemophagocytic lymphohistiocytosis triggered by a burns injury.

The role of oxidative stress in viral infections

Oxidative stress is implicated as a pathogenic factor in a number of viral infections. Our work has shown that nutritionally induced oxidative stress exacerbates the pathogenesis of coxsackievirus B3 (CVB3) infection in mice. Of particular note, mice fed on a diet deficient in antioxidants developed myocarditis when infected with a normally benign strain of CVB3. This change in virulence was found to be due to changes in the viral genome. Immune functions of the oxidatively stressed mice were also altered. Another example of the effect of oxidative stress on a viral pathogen took place in Cuba in the 1990s. An epidemic of optic and peripheral neuropathy in the population occurred that was associated with a lack of dietary antioxidants and with smoking (a pro-oxidant). A coxsackie-like virus was isolated from the cerebrospinal fluid from 84% of patients cultured. Thus, oxidative stress can have profound effects, not only on the host, but on the pathogen as well.

An attempt to pinpoint the phylogenetic introduction of glutaminyl-tRNA synthetase among bacteria

Until recently it was believed that most Bacteria form Gln-tRNA(GLN) by the amidation of Glu-tRNA(GLN), only a few members of the gamma subdivision of Proteobacteria being able to charge tRNA(GLN) directly. We undertook a phylogenetic study in an attempt to determine at what point the changeover to the direct system may have occurred. To this end, we selected a number of representative Proteobacteria to see if we could find a division point. We constructed degenerate primers and conducted PCR analysis to identify which Bacteria had Gln-tRNA synthetase, on the one hand, and which had the amidotransferase system, on the other. At the same time, we surveyed data banks of completely sequenced microbial genomes, as well as those for genomes in the process of being sequenced. These combined efforts revealed four Proteobacteria in a phylogenetically intermediate position which have the genetic potential for both mechanisms. Perplexingly, however, three distantly related bacteria were also found to have both enzymes.

[The genomic characterization of the Cuban strain with a light cytopathic effect]

The genomic characterization of the strain of light cytopathic effect by nucleotide sequence is presented. It was possible to sequence 90% of the strain of light cytopathic effect. A close relationship with Coxsackie A9 was observed. The greatest mutations occurred in the region of the genome that codifies for the structural proteins. Therefore, it may be considered as a variant of Coxsackie A9 never reported before.

Evolutionary anomalies among the aminoacyl-tRNA synthetases

Unexpected relationships among the various aminoacyl-tRNA synthetases continue to be uncovered. The question arises - is this mainly the result of promiscuous exchange, or is the confusion really a reflection of the differential loss of past duplications? Phylogenetic analysis may yet provide the answer.

Specialists achieve better outcomes than generalists for lung cancer surgery

OBJECTIVE

A push toward care provided by generalists as opposed to specialists has occurred in the health-care marketplace despite a lack of provider specific outcome data. The objective of this study was to determine whether the outcome of patients undergoing lung cancer surgery is different between general surgeons (GSs) and thoracic surgeons (TSs).

DESIGN

Examination of data from a state-wide severity-adjusted administrative hospital discharge database.

SETTING/PARTICIPANTS

Patients undergoing lung cancer resection in all nonfederal acute care hospitals within South Carolina.

MAIN OUTCOME MEASURES

Mortality by specialty adjusted for case mix.

RESULTS

From 1991 to 1995, 1,720 resections for lung cancer were performed in South Carolina. One hundred thirty-seven cases were excluded because surgeons did not meet the predefined criteria for board certification, leaving 1,583 resections for analysis. One-half of lobectomies and nearly 60% of pneumonectomies were performed by GSs. Patients were similar in age, sex, gender, race, and the proportion in each severity of illness subclass. Mortality was significantly higher in patients who underwent lobectomy by GSs vs TSs (5.3% vs 3.0%; p<0.05) and in patients with extreme comorbidities (43.6% vs 25.4%; p=0.03) or age >65 years (7.4% vs 3.5%; p<0.05). Seventy percent of TSs performed > 10 cases in the series, whereas 75% of GSs performed <10 (p=0.05). Logistic regression analysis failed to identify any significant variable that might explain the mortality differences between TSs and GSs.

CONCLUSION

Mortality is lower for lung cancer resection when the surgery is performed by a TS.

Viral isolation from cases of epidemic neuropathy in Cuba

OBJECTIVE

To investigate the possibility of a viral agent in the central nervous system of patients with epidemic neuropathy.

DESIGN

Virus isolation attempts, in cell cultures and suckling mice, from cerebrospinal fluid (CSF) of neuropathy patients and controls undergoing lumbar puncture for unrelated reasons. Serologic studies in patients, contacts, and controls.

SETTING

An epidemic of optic and peripheral neuropathy affected more than 50,000 people in Cuba in 1991 through 1993. Illness was associated with dietary limitations and increased physical demands accompanying the shortages of food and fuel experienced in Cuba since 1989. Most patients responded to parenteral vitamin therapy, and the epidemic began to subside when oral vitamin supplementation was begun for the entire Cuban population.

RESULTS

Coxsackievirus A9 (five isolates) and a similar, less cytopathic virus (100 isolates) were recovered from 105 (84%) of 125 CSF specimens from neuropathy patients. The strains with light cytopathic effect were antigenically related to Coxsackieviruses A9 and B4 by cross-neutralization and immunoblotting assays. Virus persisted in CSF of some patients for 1 to 12 months. Cerebrospinal fluid from patients and both types of virus from cell culture produced illness, including complete posterior flaccid paralysis, in newborn mice, and virus was reisolated from the mice. Mouse tissues and sural nerve biopsy specimens from patients were stained by immunoperoxidase and colloidal gold techniques using hyperimmune rabbit antisera against the virus with light cytopathic effect.

CONCLUSIONS

Coxsackievirus A9 or an antigenically related agent with a light cytopathic effect was present in CSF of 84% of 125 patients with epidemic neuropathy. The role of these agents, probably in combination with nutritional factors, in the pathophysiology of the disease requires further investigation.

Post-transplantation lymphoproliferative disorder in the Epstein-Barr virus-naïve lung transplant recipient

Post-transplantation lymphoproliferative disorder (PTLD) is a widely recognized and often catastrophic complication of organ transplantation. The incidence of PTLD after lung transplantation ranges from 6.2 to 9.4% and is two-fold higher than that seen after organ transplantation of other organs. Primary Epstein-Barr virus (EBV) infection is a major risk factor for PTLD, but the incidence of PTLD in EBV seronegative (EBV-) patients seems to vary with type of organ transplant. The goal of this study was to quantify the risk of PLTD based on pre-lung transplantation EBV serostatus in lung transplant patients. Pre- and post-lung transplant serostatus was defined in 80 patients, and our six cases of PTLD occurred in this group. Six of 94 lung transplant patients (6.4%) who survived > 1 mo developed PTLD. All cases of PTLD involved thoracic structures at presentation and occurred in the first post-operative year. Patients who were EBV- before lung transplant were much more likely to develop PTLD than those who were seropositive (EBV+) (five of 15 [33%] versus one of 60 [< 2%], p < 0.001). Consistent with the prevailing adult (donor) EBV+ rate (85%), two of our EBV-patients remained EBV-after lung transplant. Therefore, the rate of PTLD was 42% in those with primary EBV infection. As compared with EBV-patients that remained tumor-free, those who developed PLTD had similar levels of immunosuppressants and doses of anti-viral therapy. We conclude that PLTD occurs predominantly in EBV-naïve patients (risk approximately 1/3). EBV-patients should be monitored more closely after lung transplantation and, possibly, managed with lower immunosuppression. Our data also suggest that anti-viral therapy alone does not decrease the incidence of PTLD in high risk patients, PTLD can be successfully treated in most cases, and EBV-naïve patients should not be excluded from lung transplant because their risk of death from PTLD is < 15%.

Adult day services--the next frontier

Even within the home care industry, the benefits of adult day care services may not be recognized. Yet the market in the changing health care system is ripe for their expansion. For home care, adult day care represents a logical addition to services as well as a good business opportunity.

Aortoesophageal fistula and double aortic arch: two important points in management

Two children with double aortic arch and aortoesophageal fistula (AEF) are reported to warn of this lethal complication of double aortic arch and to stress important points in the diagnosis and management. A review of the records of 30 children with double aortic arch disclosed two patients who had AEF. The first patient had respiratory distress and repair of a vascular ring (double aortic arch) at 5 weeks of age. At 9 weeks of age, because of difficulty with tracheal extubation, aortopexy was performed. Ten days later, profuse upper gastrointestinal bleeding required control by a Sengstaken-Blakemore (SB) tube. Thoracotomy and repair AEF was accomplished successfully under cardiopulmonary bypass. The second patient had hepatomegaly and Pseudomonas sepsis. Endotracheal and nasogastric intubation was necessary, and subsequently the double aortic arch was demonstrated by magnetic resonance imaging (MRI). On the 48th day of hospitalization, life-threatening upper gastrointestinal hemorrhage required insertion of an SB tube. Cardiopulmonary bypass allowed successful repair of the AEF. Both children are alive, after 3 and 2 years (respectively). These patients demonstrate that AEF must be diagnosed clinically (no imaging technique is effective); its history and physical presentation are typical. The SB tube is effective for controlling the hemorrhage until cardiopulmonary bypass can be performed to allow repair.

Nasal cytokine production in viral acute upper respiratory infection of childhood

Children in a day care center underwent serial nasal lavages in order to assess nasal cytokine expression during acute upper respiratory infections (URI). Interleukin (IL)-1 beta, IL-8, IL-6, and tumor necrosis factor-alpha (TNF-alpha) were markedly elevated in nasal lavage fluid during acute URI compared to baseline, and all except TNF-alpha decreased significantly by 2-4 weeks later. Cytokine patterns in respiratory syncytial virus-positive and -negative illnesses did not differ significantly. A subgroup of children also underwent superficial mucosal biopsy under the inferior nasal turbinate. During acute URI, biopsy cells (90%-95% epithelial) showed increased transcripts for IL-1 beta, IL-8, and IL-6 in 7 of 9 subjects, suggesting that epithelial cells may be one source of cytokines during acute URI. The results show that inflammatory cytokines are elevated in nasal secretions during acute URI in preschool children. Thus, cytokines are likely to participate in regulation of respiratory virus-induced inflammation.

International models. Home care in Belgium

The Belgian health care system blends national health insurance with private service providers. This small nation's home care system is clearly and simply organized, providing an example that other countries may wish to follow.

A strong association between mefloquine and halofantrine resistance and amplification, overexpression, and mutation in the P-glycoprotein gene homolog (pfmdr) of Plasmodium falciparum in vitro

Stepwise selection for increased mefloquine resistance in a line of Plasmodium falciparum in vitro resulted in increased resistance to halofantrine and quinine, increased sensitivity to chloroquine, and amplification and overexpression of the P-glycoprotein gene homolog (pfmdr1). A point mutation (tyrosine to phenylalanine) noted at amino acid 86 in pfmdr1 in the mefloquine-resistant line W2mef was amplified in more resistant lines derived from it by in vitro selection pressure with mefloquine. Conversely, lines selected for increased chloroquine resistance exhibited a revertant phenotype that was sensitive to mefloquine and halofantrine. These lines also demonstrated increased sensitivity to quinine, loss of amplification of pfmdr1, loss of the mefloquine/halofantrine phenylalanine-86 mutation, and selection for a tyrosine-86 mutation previously associated with chloroquine resistance. These findings provide strong evidence for pfmdr1 mediating cross-resistance to halofantrine and mefloquine in P. falciparum in vitro.

Derivation of highly mefloquine-resistant lines from Plasmodium falciparum in vitro

Serial passage of a multidrug-resistant clone of Plasmodium falciparum in concentrations of mefloquine hydrochloride ranging from 30 to 2,400 ng/ml resulted in the derivation of increasingly resistant parasite lines in vitro. Parasite lines isolated in mefloquine concentrations greater than 300 ng/ml demonstrated increased vacuolization, enhanced pigment production, and increased growth rates as compared with the progenitor clone, W2-mef. Although microdilution incorporation assays demonstrated that the 50% inhibitory concentration (IC50) of mefloquine were similar for all lines, the IC90, IC95, and IC99 levels were significantly increased. Growth rate assays performed in 5% hematocrit suspensions demonstrated different levels of mefloquine resistance among these lines. Under these conditions the most resistant line, Mef 2.4, grew efficiently in approximately 10-fold higher concentrations of mefloquine than the progenitor clone W2-mef. Analysis of drug susceptibility profiles to mefloquine hydrochloride, chloroquine diphosphate, quinine sulfate, and halofantrine hydrochloride indicated that selection for high levels of mefloquine resistance had resulted in significant increases in resistance to halofantrine and increased sensitivity to chloroquine. The phenotypic changes demonstrated in the most resistant line, Mef 2.4, reflect a multidrug resistant-like phenotype, and appear to mimic changes recently reported in drug susceptibility profiles of recrudescent isolates following mefloquine treatment failures in Thailand.

The evolution of home care in The Netherlands

As the Netherlands strives to reform its entire health care delivery system, home care is perhaps the one sector where the opportunity for innovation is the greatest. Home care is evolving from a low-technology, noncompetitive, and simply regulated field to an arena in which technology, market forces, and increasing regulatory complexity characterize its growth.