Paediatric meningitis in the conjugate vaccine era and a novel clinical decision model to predict bacterial aetiology.

OBJECTIVES: The aims of this study were to assess aetiology and clinical characteristics in childhood meningitis, and develop clinical decision rules to distinguish bacterial meningitis from other similar clinical syndromes. METHODS: Children aged <16 years hospitalised with suspected meningitis/encephalitis were included, and prospectively recruited at 31 UK hospitals. Meningitis was defined as identification of bacteria/viruses from cerebrospinal fluid (CSF) and/or a raised CSF white blood cell count. New clinical decision rules were developed to distinguish bacterial from viral meningitis and those of alternative aetiology. RESULTS: The cohort included 3002 children (median age 2·4 months); 1101/3002 (36·7%) had meningitis, including 180 bacterial, 423 viral and 280 with no pathogen identified. Enterovirus was the most common pathogen in those aged <6 months and 10-16 years, with Neisseria meningitidis and/or Streptococcus pneumoniae commonest at age 6 months to 9 years. The Bacterial Meningitis Score had a negative predictive value of 95·3%. We developed two clinical decision rules, that could be used either before (sensitivity 82%, specificity 71%) or after lumbar puncture (sensitivity 84%, specificity 93%), to determine risk of bacterial meningitis. CONCLUSIONS: Bacterial meningitis comprised 6% of children with suspected meningitis/encephalitis. Our clinical decision rules provide potential novel approaches to assist with identifying children with bacterial meningitis. FUNDING: This study was funded by the Meningitis Research Foundation, Pfizer and the NIHR Programme Grants for Applied Research.

The effects of monensin on membrane lipids of cultured human skin fibroblasts.

We have investigated the effects of monensin, a monovalent cationophore, on the metabolism of neutral lipids, fatty acids, ceramide and phospholipids in cultured human skin fibroblasts. Treatment with 1 microM monensin for 18 h reduced the cellular cholesterol ester content to less than one-third of untreated cells, and incorporation of [3H]acetate into cholesterol ester was also reduced, to less than one-fifth. Concomitantly, a greater conversion of [3H]acetate into free cholesterol occurred. There was a moderate increase in free fatty acids, but no change in triacylglycerol content, although the content of the latter appeared to increase in the presence of fetal calf serum in the culture medium. Phosphatidylcholine decreased in content and phosphatidylserine increased among the phosphatides, but ceramide remained unchanged after monensin treatment. These findings suggest that monensin influences the metabolic interrelationships of structural lipids in fibroblasts.

Fluoride bioavailability from slow-release sodium fluoride given with calcium citrate.

Clinical pharmacology of slow-release sodium fluoride given with calcium citrate was examined in acute and long-term studies. Following a single oral administration of 50 mg slow-release sodium fluoride, a peak serum fluoride concentration (Cmax) of 184 ng/ml was reached in 2 h; thereafter, serum fluoride concentration declined with a T1/2 of 5.9 h. The concurrent administration of calcium citrate (400 mg calcium) gave an equivalent Tmax (time required to attain Cmax) and T1/2, but a lower Cmax of 135 ng/ml. The coadministration of a meal with fluoride also reduced Cmax but increased Tmax. The area under the serum concentration curve of slow-release sodium fluoride was reduced 17-27% by a meal or calcium citrate. Thus, calcium citrate reduced fluoride absorption and peak fluoride concentration in serum of slow-release sodium fluoride but did not affect the time required to reach peak concentration or the rate of subsequent decline. The effect of a meal was similar, except for a longer period required to reach peak serum concentration. During long-term administration of 25 mg slow-release sodium fluoride coadministered with 400 mg calcium as calcium citrate on a twice daily schedule, the trough level of serum fluoride could be kept between 95 and 190 ng/ml, believed to be the therapeutic window.

The Brigham integrated computing system (BICS): advanced clinical systems in an academic hospital environment.

The Brigham integrated computing system (BICS) provides nearly all clinical, administrative, and financial computing services to Brigham and Women's Hospital, an academic tertiary-care hospital in Boston. The BICS clinical information system includes a very wide range of data and applications, including results review, longitudinal medical records, provider order entry, critical pathway management, operating-room dynamic scheduling, critical-event detection and altering, dynamic coverage lists, automated inpatient summaries, and an online reference library. BICS design emphasizes direct physician interaction and extensive clinical decision support. Impact studies have demonstrated significant value of the system in preventing adverse events and in saving costs, particularly for medications.

Raising grandchildren from crack-cocaine households: effects on family and friendship ties of African-American women.

Changes in family and friendship networks of 71 African-American grandmothers raising grandchildren as a consequence of the crack-cocaine epidemic are examined. Despite continued strong social ties, many of the women reported decreased contact with family and friends other than confidantes and a decline in marital satisfaction. Implications of the findings for research, policy, and practice are discussed.

Reducing barriers to reach more women for breast cancer services results of consumer focus groups.

In 1999, approximately 19,000 women in California were diagnosed with breast cancer and 4600 died. Early detection, education and treatment are critical services in combating the disease. In 1999, 42 low income women, 40 years and older participated in focus groups throughout California. Focus group results revealed valuable information regarding barriers to breast cancer early detection services.

Design of an easy-to-use physician order entry system with support for nursing and ancillary departments.

The Brigham Integrated Computing System (BICS) provides a broad range of clinical and administrative data-management functions for Brigham and Women's Hospital (BWH), a 720-bed major urban teaching hospital. We describe here the development of an inpatient order-entry system (BICS-OE) which is fully integrated into the BICS clinical environment. BICS-OE uses direct entry of orders by physicians to improve order response time and minimize transcription problems. BICS-OE includes a number of novel features to enhance its acceptance by physician users and its benefit to clinical practice in the hospital. Dual-mode input gives users a choice of full-screen assistance with ordering, or an intelligent text mode which provides rapid entry of orders by direct typing. An automated primary/on-call coverage by direct typing. An automated primary/on-call coverage list directs patient alerts and cosigning requests to the proper physician. Variable order sets allow a large group of orders to be stored and entered rapidly, even when some of the orders may change for different conditions. Multitasking allows the user to check prior orders and labs while concurrently entering new orders. The system permits a wide range of order checking and alerts.

Zinc diffusion through lipid bilayers.

Zinc diffusion across liposome bilayers was measured for a set of phosphatidylcholines. These lipids were sonicated to form small unilamellar vesicles in the presence of the metallochromic indicator antipyrylazo III. This chelator sequentially forms two complexes with zinc ion. The rate constant for the first complex formation is shown to increase linearly with zinc concentration. The slope of this line, a [Zn2+]-independent, second-order rate constant, varies with changes in phosphatidylcholine properties. The rate constant is little affected by changes in fluidity as estimated from the reduced temperature [Tr = (Texperimental-Tc)/Tc]. In contrast, the rate constant is directly dependent on lipid oxidation as measured by either a thiobarbituric acid test or a spectrophotometric determination of conjugate dienes. We estimate that zinc diffusion stimulated by lipid oxidation can approach rates observed in hepatocyte zinc transport.

A very large PC LAN as the basis for a hospital information system.

Brigham and Women's Hospital is converting its financial, administrative and clinical information systems from a mini-computer environment to a platform based on MUMPS and a network of several thousand personal computers. This article describes the project rationale and status and provides an overview of the architecture of the new system. The initial results of the project indicate that the personal computer network can provide large amounts of processor power and storage at costs per unit of power and storage that are several times less expensive than the minicomputer environment. The performance of the converted Accounts Payable system indicates that the architecture can deliver acceptable performance.

Response to a trial of physician-based inpatient order entry.

Our group has developed a physician-operated inpatient order-entry system (BICS-OE). Mindful of the problems inherent in bringing a radical cultural change such as this to the hospital, we conducted two pilots of the system prior to its full implementation. Physicians and nurses both identified a number of benefits from the use of OE. Physicians reported a number of areas where OE use was difficult or could be improved; nurses reported fewer problems. Based on the pilot trials, we modified the interface and some data constructs. These changes have enhanced the usefulness of OE in patient care in our hospital, and can serve as a model to others developing order entry.

Clinical computing in a teaching hospital.

This report describes a hospital-wide clinical computing system that permits physicians, nurses, medical students, and other health workers to retrieve data from the clinical laboratories; to look up reports from the departments of radiology and pathology; to look up demographic data and outpatient visits; to look up prescriptions filled in the outpatient pharmacy; to perform bibliographic retrieval of the MEDLINE data base; to read, write, retract, edit, and forward electronic mail; and to request delivery of a patient's chart. During a one-week study period, from 300 video display terminals located throughout the hospital, 818 patient care providers used a common registry of 539,000 patients to look up clinical and laboratory data 16,768 times; 477 other hospital workers used the patient registry 46,579 times. In a separate study of 586 health care providers, 470 (80 per cent) indicated that they used computer terminals "most of the time" to look up laboratory results; in contrast, 48 (8 per cent) preferred printed reports. Of 545 hospital workers, 440 (81 per cent) indicated that the computer terminals definitely or probably made their work more accurate, and 452 (83 per cent) indicated that terminals enabled them to work faster. The large amount of use by clinicians and their judgment that the computer has been so helpful to them suggests that a reliable, comprehensive, and easy-to-use computer system can contribute substantially to the quality of patient care.