Pneumococcal bacteremia in three community teaching hospitals from 1980 to 1989.

STUDY OBJECTIVE: To review the clinical and laboratory findings in a large number of patients with pneumococcal bacteremia in the 1980s and identify risk factors associated with increased mortality. DESIGN: Retrospective review of medical records identified by blood culture logbooks and ICD-9 codes. SETTING: Three community teaching hospitals affiliated with a medical school in northeastern Ohio. PATIENTS: 385 inpatients with pneumococcal bacteremia admitted between Jan 1, 1980 and Dec 31, 1989. MEASUREMENTS: Important clinical and laboratory information was abstracted from patients' medical records, compiled, computerized, and analyzed. MAIN RESULTS: The patients' mean age was 48 years. The overall mortality was 25 percent. The mortality increased with age, reaching 42 percent in patients over 65 years old. For these elderly patients, the mortality was higher (55 percent) for patients admitted from nursing homes than patients from the community (36 percent). Higher mortality was also associated with congestive heart failure (p = 0.001), alcoholism/cirrhosis (p = 0.02), diabetes mellitus (p = 0.05), and malignancy (p = 0.02). A platelet count less than 150,000/mm3, renal dysfunction (serum creatinine > 2 mg/dl), and the number of lobes involved were also associated with mortality. Patients receiving standard therapy (penicillin, ampicillin, erythromycin, or cephalosporins) had lower mortality. Of the previously specified risk factors for mortality, only age, whether standard therapy was administered, the number of lobes involved, and the serum creatinine level proved to be independent risk factors according to logistic regression. CONCLUSIONS: The overall mortality from pneumococcal bacteremia has not decreased during the past 40 years. Risk factors associated with increased mortality were identified. Prevention by immunization with polyvalent pneumococcal polysaccharide vaccine should be practiced more widely.

Tuberculosis. Cause of death in antibiotic era.

A five-year review (1979 to 1983) of 41 patients with active tuberculosis at the time of death was performed to determine the cause of death. Twenty deaths (49 percent) were directly attributed to tuberculosis. Overwhelming tuberculous disease was the cause of death for seven patients, and among them the majority had strikingly low serum levels of albumin. Ten patients died of either massive hemoptysis or respiratory failure. Only two patients died due to progressive drug-resistant disease in an area where drug resistance is common. The majority of patients (21/41; 51 percent) died of common medical problems unrelated to tuberculosis. Eleven patients died from cardiopulmonary disease (five pulmonary emboli, one respiratory failure due to chronic obstructive pulmonary disease, two acute myocardial infarctions, and two primary dysrhythmias). Three deaths were the result of gastrointestinal bleeding, and three patients died as a result of bacterial superinfection. Our data indicate that patients still die of tuberculosis in the era of effective antituberculosis therapy. It is imperative that clinicians are aware that pulmonary emboli, arteriosclerotic heart disease, bacterial superinfection, and gastrointestinal bleeding cause approximately 50 percent of the deaths among patients who have tuberculosis and that prompt recognition and treatment of those diseases might decrease the mortality from tuberculosis.

In vitro susceptibility of Mycobacterium avium complex to antibacterial agents.

In vitro agar dilution susceptibility studies were performed utilizing 20 isolates (24 against rifamycin) of Mycobacterium avium complex against several antimicrobial agents not routinely tested in the mycobacteriology laboratory. Thirteen strains were susceptible to gentamicin at 4 micrograms/ml, 20 to amikacin at 8 micrograms/ml, 18 to streptomycin at 8 micrograms/ml, 20 to kanamycin at 8 micrograms/ml, 20 to trimethoprim/sulfamethoxazole at 2 micrograms/ml, 12 to sulfisoxazole at 10 micrograms/ml, 14 to rifabutin at 1 microgram/ml. No activity was found with penicillin G, cephapirin, moxalactam, vancomycin, clindamycin, erythromycin, trimethoprim, or minocycline. This data suggests a potential use of trimethoprim/sulfamethoxazole, sulfisoxazole, amikacin, gentamicin, and kanamycin in the treatment of infections caused by this group of organisms.

Using chart reviews to assess residents' performances of components of physical examinations: a pilot study.

PURPOSE: To evaluate chart review as a method of assessing residents' performances of physical examinations in an ambulatory care setting. METHOD: In 1992, nurse authors at the Affiliated Hospitals at Canton of the Northeastern Ohio Universities College of Medicine assessed whether 22 internal medicine residents performed ten components of the physical examination by interviewing patient volunteers immediately after the patients' examinations. A total of 89 patient interviewees were included in the analysis; these patients were all new outpatients who had been scheduled for initial visits to obtain complete histories and physical examinations. Charts for the same patients were then retrospectively reviewed. The residents and faculty were blinded to both the chart reviews and the interviews. Statistical methods used were Pearson correlational analysis and variance-component analysis. RESULTS: The interviews and chart reviews showed 81% agreement in component performance. Completeness of the physical examination (whether measured by chart review or interview) did not correlate with other standard methods of resident evaluation, and completeness did not show a significant association with characteristics of the residents and patients. Two of the 22 residents assessed were identified as having completeness scores so low as to be unsatisfactory. CONCLUSION: That residents were identified as failing to perform examination components suggests that chart reviews, especially when independently verified by patient interviews, may be a useful evaluation tool for identifying inadequate performance of components of the physical examination and may identify the need for remediation.

Relevance of routine admission electrocardiograms for psychiatric patients.

OBJECTIVE: To make clinically relevant recommendations for electrocardiogram (ECG) testing among psychiatric patients, the study examined the practice of ordering ECGs for this population. METHODS: The records of 4,045 patients consecutively admitted for psychiatric care to seven community teaching hospitals over one year were examined. The frequency of ECG orders was documented, and abnormal ECG results were grouped into two categories: relevant to psychiatric treatment (ischemia or conduction defects) and incidental to treatment (minor abnormalities and screening abnormalities). For those with abnormalities, additional cardiac follow-up data were recorded. Associations between ECG results and patients' characteristics were analyzed. RESULTS: ECGs were performed for 2,857 (71 percent) of first admissions, of which 2,225 (78 percent) showed neither relevant nor screening abnormalities. Eighteen percent of those tested had relevant abnormalities, most commonly a first-degree atrioventricular block or some evidence of a myocardial infarction. ECG screening abnormalities were found for another 4 percent, primarily left ventricular hypertrophy (3 percent), but no follow-up occurred for 46 percent of these patients. Among patients under 40 years of age, 8 percent had relevant abnormalities, and 3 percent had screening abnormalities. Among patients without apparent cardiac risk, 10 percent had relevant and 3 percent had screening abnormalities. More than half the patients who had a second or third admission during the year had a repeat ECG, even when previous ECGs were normal. CONCLUSIONS: Routine ECG is not an effective treatment or screening tool in this population, and substantial cost savings could result from more selective testing, particularly among young patients, those at low risk, and those with repeat admissions.

Adrenal hemorrhage: a complication of anticoagulant therapy--a case history.

A seventy-five year-old woman developed adrenal hemorrhage and acute adrenal insufficiency while receiving anticoagulant therapy. Abdominal CT scan was consistent with bilateral adrenal hemorrhage and was an important contribution to diagnosis and therapy. Acute adrenal hemorrhage should be suspected in patients, especially the elderly, who have recently begun anticoagulant therapy and develop upper abdominal pain followed by decreased sensorium, high fever, hypotension, and hyponatremia. Any consideration of the diagnosis of sepsis with shock in a recently anticoagulated elderly hospital patient should suggest the possibility of acute adrenal hemorrhage. Abdominal CT scan and a cosyntropin stimulation test should be performed to confirm the diagnosis. Failure of diagnosis has generally been associated with death in most patients, whereas prognosis in patients treated with corticosteroids is excellent.

Medical therapy of Mycobacterium avium-intracellulare pulmonary disease.

Fifty-four patients meeting strict criteria for invasive pulmonary disease caused by Mycobacterium avium-intracellulare complex have been treated and followed at San Antonio State Chest Hospital during the past 15 yr. Chemotherapy with standard antituberculosis drugs was successful in effecting sputum conversion in 32 (59%) of the 54 patients. Regimens containing 2 drugs were successful in only 1 of 10 patients. If 3 or more drugs were given, 91% of those with moderately advanced cavitary disease and 64% of those with far advanced disease responded. There was no correlation between sputum conversion and use of a drug to which the organism exhibited susceptibility in vitro. No particular drug or combination of drugs was uniquely effective.

Recognition of depression by internal medicine residents.

We studied the ability of internal medicine residents to recognize depressive symptoms in a population of lower socio-economic primary care patients. Four hundred twenty patients completed the short form of the Beck Depression Inventory (BDI). Simultaneously, the resident caring for the patient estimated the degree of depression for each patient. One-fourth of the patients scored at or above the moderately depressed level on the BDI and the residents rated 23 percent of their patients as at least moderately depressed. However, the accuracy of the residents' assessment of his or her individual patient was poor (correlation = 0.42, sensitivity = 0.46, specificity = 0.84). Patients with a prior history of psychiatric disorder scored higher on the BDI and were given higher ratings of depression. No other pre-existing medical condition was significantly associated with a higher or lower BDI score. The amount of alcohol consumed and the amount smoked, were both associated with higher BDI scores. Residents varied in their sensitivity to their patients' BDI scores. Some showed high agreement with BDI scores, others low. There were no specific resident characteristics (e.g. year of training, resident gender) that could explain this variability. Patients with a history of depression were given lower resident ratings compared to other patients and patients with a history of depression were given lower resident ratings than predicted by their BDI scores. Residents' ability to accurately diagnose and treat depression in the underprivileged primary care patient can be facilitated by the institution of depression screening in the ambulatory clinic.

Drug-resistant Mycobacterium tuberculosis in Korean isolates.

Tuberculosis is a common disease in developing countries. An increasing incidence of resistance to isoniazid (INH) and streptomycin in organisms isolated from patients who contracted their disease in these countries, particularly in the Far East, is well recognized. This drug resistance has led to the recommendation of empirically beginning a regimen in patients with tuberculosis from the Far East of INH, ethambutol, and rifampin. This report documents the increasing incidence of resistance in isolates from Korea to ethambutol and rifampin in addition to INH and streptomycin. It suggests that the empiric use of INH, ethambutol, and rifampin in this group of patients could potentially lead to resistance to all of these drugs because of a significant amount of multidrug resistance. A regimen of INH, rifampin, pyrazinamide, and capreomycin is suggested as appropriate initial therapy in these patients based on the in vitro sensitivity data presented and initial clinical experience.

Immunogenetic analysis of human tuberculosis.

An investigation was undertaken to determine if susceptibility and/or immune response to Mycobacterium tuberculosis was associated with histocompatible leukocyte antigen (HLA) phenotype frequencies of class I or II antigens. Comparisons of the HLA phenotypes of 51 Mexican-American patients with tuberculosis and 54 healthy subjects who differed in their skin-test reactivity to purified protein derivative (PPD) revealed that HLA-DR3 was significantly decreased in patients with tuberculosis, compared with healthy persons who were tuberculin skin-test positive. Although no association was observed between HLA phenotype and skin test reactivity to PPD in tuberculous patients, we did observe an increase in the HLA-A9-B40 phenotype in patients who manifested a strong in vitro proliferative response to PPD, whereas the HLA-B14-DR1 phenotype was increased in patients who exhibited a low proliferative response to this antigen.