RESUMO
The aim of this study was to define predictors of survival for women and men after AIDS diagnosis. We examined health care delivery and drug therapy in the year before AIDS diagnosis for continuously enrolled New York State Medicaid beneficiaries with AIDS in 1988-1990. We examined the association of these factors with survival after AIDS diagnosis. Of 1,077 women and 1,871 men, 60% of both gender groups were drug users. In both risk groups, women had more outpatient visits than men but were equally likely to visit an AIDS specialist. In those who were not drug users, men were twice as likely as women to receive either zidovudine or Pneumocystis carinii pneumonia prophylaxis. No difference appeared among drug users. Survival after AIDS diagnosis was similar by gender for those who were not drug users (RR = 1.09; 95% CI = 0.90-1.33). In drug users, women had a slightly lower risk of death than men (RR = 0.84; 95% CI = 0.72-0.98). Risk of death after AIDS diagnosis was higher for persons starting zidovudine earlier in both risk groups. Among drug users, women received more ambulatory care and survived slightly longer than men. Among those who were not drug users, survival was similar by gender even after adjusting for differences in care.
Assuntos
Síndrome da Imunodeficiência Adquirida/mortalidade , Atenção à Saúde/estatística & dados numéricos , Zidovudina/uso terapêutico , Síndrome da Imunodeficiência Adquirida/complicações , Síndrome da Imunodeficiência Adquirida/terapia , Adolescente , Adulto , Algoritmos , Assistência Ambulatorial/estatística & dados numéricos , Análise de Variância , Distribuição de Qui-Quadrado , Estudos de Coortes , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Estudos Longitudinais , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , New York/epidemiologia , Pneumonia por Pneumocystis/prevenção & controle , Modelos de Riscos Proporcionais , Fatores de Risco , Fatores Sexuais , Transtornos Relacionados ao Uso de Substâncias/complicações , Análise de Sobrevida , Estados UnidosRESUMO
We studied the prognostic significance of electroencephalograms recorded serially at 2- to 4-day intervals during the acute neonatal course of 119 near-term infants with severe respiratory failure treated by venoarterial extracorporeal membrane oxygenation (ECMO). A poor prognosis was defined as early death (n = 27), an abnormally low developmental assessment score (n = 14), or cerebral palsy (n = 14) at 12 to 45 months of age. The only electroencephalographic abnormalities that were significantly related to a poor prognosis were burst suppression (B-S) and electrographic seizure (ES). The 30 infants with two or more recordings of B-S or ES, when compared with the 58 neonates without such electroencephalographic abnormalities, had an odds ratio for a poor prognosis of 6.6 (95% confidence limits, 2.2 to 20.2). The 31 infants with a single ES or B-S recording did not have a significantly increased risk for a poor prognosis. Cardiopulmonary resuscitation immediately before ECMO (n = 8) and the lowest systolic blood pressure before or during ECMO were significantly related to the occurrence of ES or B-S recordings. There was no significant predilection of ES for either cerebral hemisphere. We conclude that in near-term neonates with respiratory failure, serial electroencephalographic recordings are of predictive value, and may facilitate clinical care including the decision to initiate or to continue ECMO.
Assuntos
Eletroencefalografia , Oxigenação por Membrana Extracorpórea , Insuficiência Respiratória/fisiopatologia , Insuficiência Respiratória/terapia , Doença Aguda , Reanimação Cardiopulmonar , Intervalos de Confiança , Humanos , Recém-Nascido , Morbidade , Razão de Chances , Valor Preditivo dos Testes , Prognóstico , Análise de Regressão , Explosão Respiratória/fisiologia , Insuficiência Respiratória/complicações , Insuficiência Respiratória/mortalidade , Fatores de Risco , Espasmos Infantis/etiologia , Espasmos Infantis/fisiopatologia , Taxa de Sobrevida , Fatores de TempoRESUMO
We examined patterns of ambulatory care in the year before diagnosis of acquired immune deficiency syndrome (AIDS) for 5,720 persons infected with human immunodeficiency virus (HIV) who were continuously enrolled in the New York State Medicaid program and diagnosed in 1984-90. For 3,175 persons followed > or = 6 months after AIDS, we also examined the change between the year before AIDS diagnosis and the 6 months afterward in the predominant provider who was seen most frequently and at least twice. Approximately 75% of the population had a predominant provider identified. Of this group, 43% of the patients had a generalist as their predominant provider before AIDS diagnosis, falling to only 25% after diagnosis. The proportion with an AIDS specialist predominant provider increased from 22% before AIDS diagnosis to 39% afterward (P < 0.001). Patients with a generalist predominant provider before AIDS diagnosis had higher odds of switching providers and of hospitalization after AIDS diagnosis than patients with an AIDS specialist predominant provider. If generalists are to be encouraged to manage patients with advanced HIV disease, a better understanding of factors contributing to these outcomes is needed.
Assuntos
Síndrome da Imunodeficiência Adquirida/terapia , Assistência Ambulatorial/estatística & dados numéricos , Medicina de Família e Comunidade/estatística & dados numéricos , Infecções por HIV/terapia , HIV-1 , Hospitalização/estatística & dados numéricos , Medicina/estatística & dados numéricos , Especialização , Adolescente , Adulto , Assistência Ambulatorial/classificação , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Modelos Logísticos , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , New York , Razão de Chances , Avaliação de Resultados em Cuidados de Saúde , Valor Preditivo dos Testes , Índice de Gravidade de Doença , Estados UnidosRESUMO
OBJECTIVE: To determine risk factors for the development of bronchopulmonary dysplasia (BPD) after treatment with extracorporeal membrane oxygenation (ECMO). DESIGN: Retrospective case-control study. SETTING: Tertiary care level 3 neonatal intensive care unit. PARTICIPANTS: Seventy-three newborns treated with ECMO for severe respiratory failure during a 5-year period, who survived until day of life 28, and who did not have pulmonary hypoplasia as the initial cause for respiratory failure. INTERVENTIONS: None. MAIN OUTCOME MEASURE: The presence of BPD after treatment with ECMO, which was defined as oxygen and/or ventilatory requirements at day of life 28, with characteristic abnormalities seen on chest x-ray film. RESULTS: The age at ECMO initiation was significantly greater for patients with BPD compared with patients without BPD (mean +/- SD, 135 +/- 68 hours vs 50 +/- 37 hours; P < .001). There was an 11.5-fold increased risk for the development of BPD if ECMO was initiated at greater than 96 hours of age. The primary diagnosis of respiratory distress syndrome imparted a 5.2-fold increased risk for the development of BPD. Patients with BPD required ECMO significantly longer than patients without BPD (203 +/- 73 hours vs 122 +/- 51 hours; P < .001). CONCLUSION: These results demonstrate that delayed use of ECMO in treating neonatal respiratory failure is associated with an increased risk for the development of BPD and a longer duration of ECMO therapy.
Assuntos
Displasia Broncopulmonar/epidemiologia , Displasia Broncopulmonar/etiologia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Insuficiência Respiratória/terapia , Fatores Etários , Gasometria , Displasia Broncopulmonar/diagnóstico por imagem , Displasia Broncopulmonar/terapia , Estudos de Casos e Controles , Feminino , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Modelos Logísticos , Masculino , Oxigenoterapia , Radiografia , Respiração Artificial , Insuficiência Respiratória/sangue , Insuficiência Respiratória/mortalidade , Fatores de Risco , Taxa de Sobrevida , Fatores de TempoRESUMO
OBJECTIVE: Right common carotid artery (RCCA) ligation after extracorporeal membrane oxygenation by venoarterial bypass may contribute to lateralized cerebral injury. Reconstruction of this artery after extracorporeal membrane oxygenation has proved feasible but has not been evaluated for neurologic outcome in any substantial series of infants. METHODS: We evaluated RCCA reconstruction in 47 infants treated with ECMO and compared their cerebrovascular and neuroanatomic imaging findings, electroencephalograms, and developmental outcomes with those of 93 infants who had no reconstruction. SUMMARY RESULTS: Color Doppler blood flow imaging revealed that carotid artery patency was usually obtained after RCCA reconstruction. Right internal carotid and bilateral anterior and middle cerebral arterial blood flow velocities were generally higher, and were more symmetrically distributed in infants with reconstructed RCCA. Electroencephalography did not disclose an increased risk of deterioration or marked abnormalities in infants after reconstruction, nor were neuroimaging findings consistent with an increased number of either focal or generalized abnormalities. Neurodevelopmental follow-up revealed no differences in the incidence of delays between those with a reconstructed RCCA and those with a ligated RCCA during the first year of life. CONCLUSIONS: Reconstruction of the RCCA after extracorporeal membrane oxygenation may facilitate normal distribution of cerebral blood flow through the circle of Willis, and may augment both left and right middle cerebral artery blood flow immediately after decannulation. The long-term consequences of either ligation or reconstruction of the RCCA will require careful scrutiny, however, before either course is recommended routinely.
Assuntos
Artéria Carótida Primitiva/cirurgia , Circulação Cerebrovascular , Oxigenação por Membrana Extracorpórea , Velocidade do Fluxo Sanguíneo , Encéfalo/diagnóstico por imagem , Artéria Carótida Primitiva/diagnóstico por imagem , Artéria Carótida Primitiva/fisiologia , Artérias Cerebrais/diagnóstico por imagem , Artérias Cerebrais/fisiologia , Desenvolvimento Infantil , Ecoencefalografia , Eletroencefalografia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Seguimentos , Humanos , Recém-Nascido , Doenças do Sistema Nervoso/etiologia , Insuficiência Respiratória/terapia , Tomografia Computadorizada por Raios XRESUMO
Surviving preterm infants of less than 34 weeks' gestation who were selected on the basis of serial cranial ultrasonographic findings during their nursery course had repeated neurologic and developmental examinations during late infancy and early childhood that established the presence (n = 46) or absence (n = 205) of spastic forms of cerebral palsy. Of the 205 infants without cerebral palsy, 22 scored abnormally low on standardized developmental testing during early childhood. The need for mechanical ventilation beginning on the first day of life (n = 92) was significantly related to gestational age, birth weight, Apgar scores, patent ductus arteriosus, grade III/IV intracranial hemorrhage, large periventricular cysts, and the development of cerebral palsy. In the 192 mechanically ventilated infants, vaginal bleeding during the third trimester, low Apgar scores, and maximally low PCO2 values during the first 3 days of life were significantly related to large periventricular cysts (n = 41) and cerebral palsy (n = 43), but not to developmental delay in the absence of cerebral palsy (n = 18). The severity of intracranial hemorrhage in mechanically ventilated infants was significantly associated with gestational age and maximally low measurements of PCO2 and pH, but not with Apgar scores or maximally low measurements of PO2. Logistic regression analyses controlling for possible confounding variables disclosed that PCO2 values of less than 17 mm Hg during the first 3 days of life in mechanically ventilated infants were associated with a significantly increased risk of moderate to severe periventricular echodensity, large periventricular cysts, grade III/IV intracranial hemorrhage, and cerebral palsy. Neurosonographic abnormalities were highly predictive of cerebral palsy independent of PCO2 measurements.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Encefalopatias/etiologia , Paralisia Cerebral/etiologia , Desenvolvimento Infantil , Recém-Nascido Prematuro , Respiração Artificial/efeitos adversos , Encefalopatias/sangue , Encefalopatias/diagnóstico por imagem , Dióxido de Carbono/sangue , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/etiologia , Paralisia Cerebral/sangue , Pré-Escolar , Cistos/diagnóstico por imagem , Cistos/etiologia , Ecoencefalografia , Humanos , Lactente , Recém-Nascido , Doenças do Prematuro/sangue , Doenças do Prematuro/diagnóstico por imagem , Doenças do Prematuro/terapia , Insuficiência Respiratória/sangue , Insuficiência Respiratória/terapia , Fatores de RiscoRESUMO
In this study of 249 preterm infants of less than 34 weeks' gestation, the relationships between maximal serum total bilirubin concentrations during the neonatal period, neonatal cranial ultrasonographic abnormalities, and severe neurodevelopmental sequelae are described. The subjects, who were selected on the basis of serial cranial ultrasonographic findings, had repeated neurologic and developmental examinations during late infancy and early childhood that established the presence (n = 45) or absence (n = 204) of spastic forms of cerebral palsy. Of the 204 subjects without cerebral palsy, 23 scored abnormally low on standardized developmental testing during early childhood. All but seven of the subjects with cerebral palsy had grade III/IV intracranial hemorrhage or moderate to severe periventricular echogenicity or both, ultrasonographic abnormalities that probably reflect a disruption in the blood-brain barrier as well as extravasation of blood into brain tissue; however, analysis of the data did not suggest that these cranial ultrasonographic abnormalities increased either the maximum serum bilirubin concentration during the neonatal period or the susceptibility of the subjects to neurologic damage from hyperbilirubinemia. Also, there was no evidence to suggest that bilirubinemia in the range studied (2.3 to 22.5 mg/100 mL total serum bilirubin) was causally related to cerebral palsy, early developmental delay, or the development of periventricular cysts in this population of preterm infants.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Bilirrubina/sangue , Paralisia Cerebral/epidemiologia , Deficiências do Desenvolvimento/epidemiologia , Doenças do Prematuro/diagnóstico por imagem , Recém-Nascido Prematuro/crescimento & desenvolvimento , Índice de Apgar , Peso ao Nascer , Hemorragia Cerebral/diagnóstico por imagem , Pré-Escolar , Humanos , Lactente , Recém-Nascido , Doenças do Prematuro/diagnóstico , Icterícia Neonatal/diagnóstico , Leucomalácia Periventricular/diagnóstico por imagem , Fatores de Risco , UltrassonografiaRESUMO
In rural communities in the Ecuadorian Highlands, gastrointestinal disease is the leading cause of death. This paper proposes a model of the world view that specifies the factors that condition illness or health and a traditional taxonomy that relies on certain criteria to categorize three classes of diarrhea. These determine whether ethnomedical or medical treatment will be used to 'cure' a child. The three illness classes: diarrhea produced by supernatural forces, by humoral imbalances, and by 'infection' differ etiologically. The ambient air and its temperatures, the constitution, humoral state and overt personality characteristics (character) of the individual, and the predelictions of the evil spirits that seek to sap their vital essence all figure in the origins of illness. The model of the world view is related to a folk taxonomy, which, it is asserted, provides a charter for families' responses to child illness, that more often than not, are appropriate under the economic conditions they suffer.