RESUMEN

The usefulness of the sputum Gram's stain is controversial. This meta-analysis was designed to evaluate the sensitivity and specificity of the sputum Gram's stain in community-acquired pneumococcal pneumonia. Using a predetermined protocol, articles were discovered through a MEDLINE search (1966 to 1993) and the examination of bibliographies and were graded for quality by three blinded reviewers. Information on the reference standard, blinding, stain interpreter, control for antibiotic use, and definition of a positive test was collected. We found 12 articles containing 17 test characteristics to evaluate. The number of patients in each study ranged from 16 to 404. Sputum culture was the most common reference standard (10 of 17 estimations). Sensitivity ranged from 15% to 100% and specificity from 11% to 100%. Test characteristics varied markedly among studies and appeared related partly to the test interpreter. The sputum Gram's stain may yield misleading results in community-acquired pneumonia, as its sensitivity and specificity vary substantially in different settings. A practitioner electing to use the study should be well trained and use a specific definition for a positive test.

Asunto(s)

RESUMEN

There are 36 reports in the English-language literature of Kawasaki disease in adults. We present two additional cases, in one of which retinal vasculitis developed, a previously unreported complication antemortem. We report the first use of intravenous gamma globulin in the United States for treatment of adult-onset Kawasaki disease and review the pertinent literature.

Asunto(s)

RESUMEN

OBJECTIVE: To determine initial patient acceptance of a cardiopulmonary resuscitation/do-not-resuscitate orders (CPR/DNR) information sheet intended to facilitate early discussion of CPR preferences. DESIGN: Attitudinal survey of adults after reading a CPR/DNR information sheet. SETTING: Inpatient wards and outpatient clinics of a tertiary care military teaching hospital. PATIENTS: 230 English-reading, mentally competent, volunteer patients (95%) of 243 eligible patients completed questionnaires. Mean age was 51.5 +/- 17 years; 122 (53%) patients were men; 103 (45%) were inpatients. Self-reported diagnoses were: cancer, 42 (18%); HIV disease, 22 (10%); other medical conditions, 87 (38%); pre- and postoperative cases, 35 (15%); and unknown, 44 (19%). RESULTS: 56% of the patients had previously thought about CPR options. 10% of the patients had actually discussed preferences with their physicians. 90% of the patients desired discussion with their physicians and other health care providers. 91% of the patients reported feeling better or no change after reading the information. 78% of the patients agreed that the information sheet would be helpful in discussing their preferences and most thought the information should be routinely given to all patients. CONCLUSIONS: Written information about CPR options was perceived as helpful and acceptable to most patients surveyed. Since a few patients initially reported feeling worse after reading the CPR/DNR information sheet, written information should not be used alone but may facilitate initial communication and discussion.

Asunto(s)

RESUMEN

HIV-infected individuals in both early and late stages of HIV disease were evaluated over 2 years to assess temporal trends and determinants of disease progression. The Walter Reed (WR) staging system was used to categorize patients into an early-stage cohort (WR Stages 1 and 2, N = 1183) and a late-stage cohort (WR Stage 5, N = 260) based on the initial clinical evaluation. Progression was defined as the occurrence of Stage 5 disease or beyond for the early cohort and Stage 6 disease or beyond for the late cohort. The cumulative incidence of progression was 15.7% (137 events) for the early-stage cohort, and 53.7% (85 events) for the late-stage cohort. Baseline CD4+ T lymphocyte (T4) count was the most significant marker of progression: 26% of WR Stage 1 or 2 patients with T4 lymphocytes below 500/mm3 progressed, compared with 12% with T4 lymphocytes at or above 500/mm3. In late-stage individuals, 83% with T4 lymphocytes under 200/mm3 progressed, compared with 27% with T4 lymphocytes at or above 200/mm3. Older age was associated with progression in both early- and late-stage groups. Differences in the rates of disease progression were not significant between blacks and whites or between men and women. Two-year rates of progression among the late-stage patients dropped from 78 to 47% between 1986 and 1988. This contrasted with progression rates in the early-stage cohort, which remained stable: 18% for those entering follow-up in 1986 and 17% for those entering follow-up in 1988. These data indicate a significant slowing of HIV disease progression rates and mortality rates among individuals with late-stage disease that is temporally associated with the increased availability and use of therapies. With control of T4 lymphocyte count, age, and calendar time, neither gender nor race was significantly associated with progression in either early- or late-stage patients.

Asunto(s)

RESUMEN

A collection of statistical analysis procedures is applied to the task of estimating relative market shares among different healthcare plans under the offering of multiple options. The results are developed into an interactive spreadsheet for estimating market shares when consumer perceptions of plan features are modified through product redesign or communications strategies.

Asunto(s)

RESUMEN

Healthcare providers of multiple option plans may be confronted with special market segmentation problems. This study demonstrates how cluster analysis may be used for discovering distinct patterns of preference for multiple option plans. The availability of metric, as opposed to categorical or ordinal, data provides the ability to use sophisticated analysis techniques which may be superior to frequency distributions and cross-tabulations in revealing preference patterns.

Asunto(s)

RESUMEN

A 33-year-old black woman with advanced acquired immunodeficiency syndrome (AIDS) presented with rapidly progressive muscle weakness and serologic and radiologic evidence of central nervous system Toxoplasma infection. Muscle biopsy revealed an inflammatory infiltrate predominantly composed of macrophages and T suppressor/cytotoxic cells. Human immunodeficiency virus major core protein (p24) was also detected in macrophages and damaged muscle cells around the inflammatory infiltrates. The patient improved clinically with glucocorticoid therapy for polymyositis and pyrimethamine and clindamycin therapy for toxoplasmosis.

Asunto(s)

RESUMEN

Invasive mycotic infections are becoming more commonplace in immune-compromised hosts. Aspergillus species is the most commonly encountered fungal genus in our environment causing paranasal sinus fungal infection. Aspergillus paranasal sinus infections in the healthy host are readily treated and controlled. In the immune-compromised host this common organism can rapidly become fatal even if recognized and treated appropriately. We present a case history of a patient who died from her disease despite radical surgery and antifungicidal therapy. Recent methods for early diagnosis will be reviewed. Only one other case has been reported in the literature of a patient developing fulminant aspergillosis sinusitis while receiving amphotericin B.

Asunto(s)

RESUMEN

A patient with Crohn's disease who required placement of a right external jugular vein central catheter for total hyperalimentation is presented. Catheter-induced thrombosis and catheter-associated bacteremia and sepsis subsequently developed. Following the description of the case is a brief discussion of the complications inherent in central line placement, the mechanisms by which thrombosis and sepsis occur, and the measures that can be taken to decrease the incidence of thrombosis and sepsis in central line placement. The management of central venous thrombosis and sepsis is medical and not surgical in nature, and consists of catheter removal, antibiotics, and anticoagulation.

Asunto(s)

Asunto(s)