Hospitalization decision in patients with community-acquired pneumonia: a prospective cohort study.

PURPOSE: To identify a low-risk subset of patients with community-acquired pneumonia that could safely be treated in the ambulatory setting; and to assess how clinicians make the hospitalization decision. PATIENTS AND METHODS: We performed a prospective, observational study of 280 ambulatory and hospitalized adults with clinical and radiographic evidence of pneumonia. Patients were followed to assess all potential morbid complications and 6-week mortality. Physicians responsible for managing these patients were surveyed to assess the reasons for treating in a hospital or ambulatory setting and the therapies that dictate hospitalization. RESULTS: Sixty-one percent (170 of 280) of patients did not have an indication for admission at presentation using modified Appropriateness Evaluation Protocol criteria (a severe vital sign abnormality, alteration in mental status, suppurative complication, arterial hypoxemia, severe laboratory abnormality, or an acute coexistent medical problem requiring admission independent of the pneumonia). Among these 170 patients, 38% had a complicated course defined as death within 6 weeks, development of a new suppurative or medical complication due to pneumonia, intensive care unit admission, persistent fever or use of intravenous fluids or oxygen beyond 3 days, hospitalization lasting more than 3 days, or subsequent hospitalization in patients initially treated in the ambulatory setting. Five predisposing factors for a complicated course were identified in logistic regression models. The odds ratio for age more than 65 years was 2.7; for comorbid illness, 3.2; for temperature more than 38.3 degrees C (101 degrees F), 4.1; for immunosuppression, 12.0; and for a high-risk etiology, 23.3. The risk of a complicated course increased linearly with the number of risk factors, from 12% with none to 100% with four or more factors (p less than 0.001). Physicians most often relied on the general clinical appearance of the patient when making the triage decision, and most commonly cited intravenous antibiotics and chest physical therapy as treatments requiring hospitalization. CONCLUSIONS: If validated, our findings could improve physicians' assessment of prognosis, and may identify a low-risk subset of patients with community-acquired pneumonia who could safely be managed in the ambulatory setting.

Discovery of 1,5-benzodiazepines with peripheral cholecystokinin (CCK-A) receptor agonist activity. 1. Optimization of the agonist "trigger".

Directed screening of compounds selected from the Glaxo registry file for contractile activity on the isolated guinea pig gallbladder (GPGB) identified a series of 1,5-benzodiazepines with peripheral cholecystokinin (CCK) receptor agonist activity. Agonist efficacy within this series was modulated by variation of substituents on the N1-anilinoacetamide moiety. Remarkably, a single methyl group confers agonist activity, with an N-isopropyl substituent providing optimal efficacy. Hydrophilic substituents on the anilino nitrogen abolish agonist activity or produce antagonists of CCK. In contrast, hydrophilic electron-donating groups at the para-position of the anilino ring enhance or maintain in vitro and in vivo agonist activity. Despite decreased affinity for the human CCK-A receptor, relative to CCK-8, some of these compounds are equipotent to CCK as anorectic agents in rats following intraperitoneal administration.

Automatic computer processing of digital 2-dimensional echocardiograms.

Quantitative studies of left ventricular function using 2-dimensional echocardiography have been limited because of a lack of computerized methods to automatically analyze the echocardiographic images. Previous computer efforts have been directed at digitizing the video output of the 2-D echocardiogram, but this digitizing method has significant limitations. A direct digitization method that produces improvement in signal-to-noise ratio and, subsequently, improved automatic detection of endocardial and epicardial borders, was developed. With definition of these edges, left ventricular global and regional analysis is possible frame by frame so that dynamic changes in cardiac function may be assessed throughout the cardiac cycle. Further technologic advances in 2-D echocardiographic acquisition and image processing should allow computer processing of 2-D echocardiographic data in real time.

Large-core needle biopsy of nonpalpable breast cancers. The impact on subsequent surgical excisions.

OBJECTIVE: To compare the subsequent surgical therapy for women with nonpalpable breast cancers diagnosed by large-core needle biopsy (LCNB) vs those diagnosed by surgical excision after wire localization. DESIGN: Retrospective review of cases and results. SETTING: Secondary referred care. PATIENTS: A total of 677 women diagnosed as having breast cancer by LCNB (n = 67) or by surgical excision after wire localization (n = 610). RESULTS: Women in the LCNB group underwent an average of 1.25 surgical procedures and women whose breast cancers were diagnosed by surgical excision after preoperative wire localization underwent an average of 2.01 surgical procedures (P < .001). CONCLUSIONS: Large-core needle biopsy decreases the number of surgical procedures in women diagnosed as having nonpalpable breast cancers. Increased implementation of this technique will substantially decrease the costs of surgical therapy in these patients.

Breast ultrasound.

Ultrasound is second in importance only to mammography in the evaluation of breast abnormalities. The ability of US to diagnose benign simple cysts accurately has spared innumerable women from needless biopsies and aspirations. When a suspicious solid abnormality is detected by ultrasound, it readily provides convenient, inexpensive, accurate imaging guidance for interventional procedures. Future studies of US as a screening tool must weigh potential benefits against the potential risks because of increased biopsies performed for false-positive results.

The psychocultural roots of genocide. Legitimacy and crisis in Rwanda.

In April 1994, the small east African nation of Rwanda became the site of one of the most violent episodes of the 20th century. Over the course of just 100 days, an embattled authoritarian state organized the slaughter of at least 850,000 Rwandans. Briefly, worldwide attention was riveted. But clichés about "age-old tribal hatreds" soon dominated discussion, conveying the impression that this was simply the latest episode in an unending cycle of violence. The truth, however, is quite different. The April genocide was in many ways unique. It was neither tribal nor age-old, and it is hardly fated to recur. Indeed, the author's premise is that if this genocide is grasped in all its psychocultural novelty and complexity, a point of Archimedean leverage can be found for interventions to avert tragedies in the future.

Image-guided core breast biopsy of ductal carcinoma in situ presenting as a non-calcified abnormality.

OBJECTIVE: Ductal carcinoma in situ (DCIS) typically presents as calcifications which are detected mammographically. Our aim was to evaluate the less common presentations of ductal carcinoma in situ diagnosed by image-guided core biopsy and correlate with histopathologic diagnoses. METHODS AND MATERIAL: Imaging and histopathologic findings were retrospectively reviewed in 11 patients with ductal carcinoma in situ diagnosed at core biopsy that presented as noncalcified radiographic abnormalities. RESULTS: Mammography showed non-calcified, circumscribed nodules, ill-defined nodules and architectural distortion. In two patients, no mammographic abnormality was detected. Sonography showed circumscribed, round or oval, solid masses; irregular, heterogeneous masses; and a tubular structure. Histopathologic diagnoses included multiple architectural subtypes and ranged from low to high nuclear grade. CONCLUSION: Although image-guided core biopsy diagnosis of ductal carcinoma is typically made when sampling calcifications, DCIS can be diagnosed following biopsy of non-calcified masses or distortion. There is no correlation between histopathologic subtype and radiologic appearance.

The correction of angular deformities of long bones by osteotomy-osteoclasis.

The correction of angular deformities of long bones by incomplete osteotomy, followed three weeks later by manual osteoclasis, overcomes the problem of secondary displacement sometimes seen after correction by complete osteotomy and makes internal fixation unnecessary. This paper presents an experience of twenty-six operations in eighteen patients. In all cases the deformity was corrected with excellent cosmetic and functional results. Complete bony union was achieved and there were no problems with displacement at the osteotomy site. Four cases are described in detail to illustrate use of the technique in different clinical situations.

Imaging features of nonmyxomatous primary neoplasms of the heart and pericardium.

We present the imaging findings in 13 patients with nonmyxomatous primary neoplasms of the heart and pericardium. Ten patients had abnormal chest films. While echocardiography was useful for determining origin of the tumor, CT (computed tomography) and MRI (magnetic resonance imaging) were better at delineating extent of disease. The radiographic appearance of these rare neoplasms of the heart and pericardium is varied. Cross-sectional imaging plays a crucial role in the surgical planning and management of these patients.

Mercury Measurement and Its Control: What We Know, Have Learned, and Need to Further Investigate.

Based on the available evidence of health effects, the U.S. Environmental Protection Agency (EPA) has been evaluating the need to regulate mercury releases to the environment. In response to the congressional mandates in The 1990 Clean Air Act Amendments (CAAA), the EPA has issued the Mercury Study Report and the Study of Hazardous Air Pollutant Emissions from Electric Utility Steam Generating Units Report. In spite of the enormous effort represented by these reports, as well as the efforts of both the U.S. Department of Energy (DOE) and the Electric Power Research Institute (EPRI), in conducting the field measurement programs that form the basis for these reports, a definitive answer on the need for mercury regulation has not been found. However, the EPA, as well as other regulatory agencies and health researchers, have suggested a "plausible link" between anthropogenic sources emitting mercury and the methylation, bioaccumulation in the food chain, and adverse health effects in humans and wildlife.

Mercury Measurement and Its Control: What We Know, Have Learned, and Need to Further Investigate.

The U.S. Department of Energy (DOE), through the Federal Energy Technology Center (FETC), manages the largest funded program in the country for developing (1) an understanding of mercury emissions, (2) measurement of these emissions, and (3) control technology (-ies) for these emissions for the U.S. coal-fired electric generating industry. DOE has initiated, or has collaborated with other government and industrial organizations in, these and other efforts relating to mercury and other hazardous air pollutants (HAPs), also known as air toxics. One of DOE's first reports on trace elements in coal was conducted from 1976 through 1978 by researchers at DOE's Pittsburgh Energy Technology Center (PETC, now FETC) and the Pittsburgh Mining Operations of the Department of the Interior's Bureau of Mines. The report was completed less than two years after DOE was formed, and 13 years before Title III of the 1990 Clean Air Act Amendments was enacted (Cavallaro et al., March 1978).

The performance of integrated transconductance amplifiers as variable current sources for bio-electric impedance measurements.

Multiple applied current impedance measurement systems require numbers of current sources which operate simultaneously at the same frequency and within the same phase but at variable amplitudes. Investigations into the performance of some integrated operational transconductance amplifiers as variable current sources are described. Measurements of breakthrough, non-linearity and common-mode output levels for LM13600, NE5517 and CA3280 were carried out. The effects of such errors on the overall performance and stability of multiple current systems when driving floating loads are considered.

The radiological diagnosis of posttraumatic effusion of the elbow joint and its clinical significance: the 'displaced fat pad' sign.

Alterations occur in the radiological appearance of the soft tissues after injury to the elbow joint. These are due to displacement of the intra-articular fat pads by capsular distension when an effusion is present. A prospective study of 89 consecutive elbow injuries was undertaken in an attempt to assess the usefulness and reliability of these changes in the diagnosis of minor elbow injuries and the assessment of their clinical progress. In 61 elbows (69 per cent) there was no radiological evidence of an effusion and no evidence of bony injury. All quickly returned to normal. In 28 elbows (31 per cent) radiological evidence of an effusion was present. Twenty-three (80 per cent) of these were also found to have a fracture in, or adjacent to the elbow joint. In 9 elbows the fracture could not be seen on the initial radiographs. Because of the presence of an effusion, repeat radiographs were taken and a fracture discovered. The presence of an effusion was associated with an increase in the time required for full recovery.

The Mennen plate in periprosthetic hip fractures.

We would like to report five patients with periprosthetic hip fractures, treated with a Mennen plate, as we felt there were contraindications to revision surgery in these patients. Their average age was 79.1 years. All patients were uncomfortable in Thomas splint traction and more comfortable after surgery; they required an average of 2 units of blood to be transfused; they were partially weight-bearing with a caliper in an average of 9 weeks, home in an average of 10 weeks, and the average time to clinical or radiological union was 4.8 months. We considered a reasonable level of mobility was regained after surgery and would recommend Mennen plate fixation for periprosthetic fractures in those patients perhaps too frail for revision.

A preliminary investigation of temperature distribution in the prostatic urethra during Thermex II thermotherapy.

In a random group of five patients undergoing thermotherapy with Thermex II (Direx Systems), the temperature in the region of the external sphincter was measured using a modified Thermex catheter. In all five patients the measured temperature exceeded 44.5 degrees C for more than half the duration of treatment. Further temperature mapping studies and studies on the assessment of sphincter function after Thermex II thermotherapy are in progress.