Effect of improved home ventilation on asthma control and house dust mite allergen levels.

BACKGROUND: The warm, humid environment in modern homes favours the dust mite population, but the effect of improved home ventilation on asthma control has not been established. We tested the hypothesis that a domestic mechanical heat recovery ventilation system (MHRV), in addition to allergen avoidance measures, can improve asthma control by attenuating re-colonization rates. METHODS: We conducted a randomized double-blind placebo-controlled parallel group trial of the installation of MHRV activated in half the homes of 120 adults with asthma, allergic to Dermatophagoides pteronyssinus. All homes had carpets steam cleaned and new bedding and mattress covers at baseline. The primary outcome was morning peak expiratory flow (PEF) at 12 months. RESULTS: At 12 months, the primary end-point; change in mean morning PEF as compared with baseline, did not differ between the MHRV group and the control group (mean difference 13.5 l/min, 95% CI: -2.6 to 29.8, P = 0.10). However, a secondary end-point; evening mean PEF, was significantly improved in the MHRV group (mean difference 24.5 l/min, 95% CI: 8.9-40.1, P = 0.002). Indoor relative humidity was reduced in MHRV homes, but there was no difference between the groups in Der p 1 levels, compared with baseline. CONCLUSIONS: The addition of MHRV to house dust mite eradication strategies did not achieve a reduction in mite allergen levels, but did improve evening PEF.

Prospective study of Candida endophthalmitis in hospitalized patients with candidemia.

To determine the frequency of endogenous Candida endophthalmitis in patients with candidemia, we prospectively evaluated 32 inpatients with fungemia by weekly indirect ophthalmoscopic examinations. Chorioretinitis compatible with Candida infection was found in 9 (28%) patients. Patient age, sex, underlying diseases, or hospital-acquired factors, such as presence of central venous or Foley catheters, bacteremia, use of multiple antibiotics, hyperalimentation, or surgery, did not distinguish between groups. Groups were also similar in number of sites colonized with yeast and species of Candida recovered. Patients with endophthalmitis tended to have more blood cultures positive for Candida (mean, 4.3) than the patients without endophthalmitis (mean, 2.8), but this trend did not reach statistical significance. Based on these results, we recommend periodic ophthalmoscopic examinations in all patients with documented candidemia.

Hospital survey of antimicrobial prophylaxis to prevent endocarditis in patients with prosthetic heart valves.

The American Heart Association (AHA) has published guidelines for use of prophylactic antibiotics to prevent bacterial endocarditis, but few data are available about physician compliance with these guidelines. A retrospective review was conducted of the use of prophylactic antibiotics in patients with prosthetic heart valves who were undergoing diagnostic or operative procedures or heart catheterization at three hospitals. Compliance with AHA recommendations was only 30 percent (14 of 46) for procedures considered high risk for patients with prosthetic heart valves. Six (23 percent) of 26 patients who underwent right or left heart catheterization received prophylactic antibiotics (not recommended by AHA). Antibiotics were given to 42 (74 percent) of 57 patients who underwent surgical procedures considered at low risk of bacteremia, but only 33 (58 percent) received antibiotics that cover organisms commonly present at the site of the procedure. The results indicate that clinicians frequently do not administer prophylactic antibiotics in patients with prosthetic heart valves who are undergoing invasive procedures or do not follow published AHA guidelines when antibiotics are administered.

Infectious complications in heart-lung transplant recipients.

Infectious complications were studied in 14 patients who received heart-lung transplants at Stanford University Medical Center from March 1981 to November 1983. Twenty-nine infections occurred in 12 patients: 18 bacterial, nine viral, and two fungal. Sixteen (89 percent) of the bacterial infections occurred in the lung. Because of frequent colonization of the lower respiratory tract, the specificity of transtracheal aspiration and bronchoscopy was low. Empiric broad-spectrum antibiotic therapy was usually successful, and no patient died of bacterial infection. Cytomegalovirus infection occurred in six and herpes simplex virus infection in three patients. Two patients had invasive candidiasis at postmortem examination. This series emphasizes the importance of infection, particularly of the lung, in causing morbidity and mortality in heart-lung transplant recipients.

Open lung biopsy in patients with acute leukemia.

The results of open lung biopsy in 15 patients with acute leukemia, pulmonary infiltrates, neutropenia, and fever were reviewed. The patients averaged 26 hospital days of neutropenia and 20 hospital days of fever before open lung biopsy, and all patients received broad-spectrum antibacterial agents (mean 17 days) before open lung biopsy. Nine (67 percent) received amphotericin B prior to open lung biopsy (mean 22 days). Open lung biopsy yielded a specific clinically helpful diagnosis in six patients, but only two of these patients survived the hospitalization during which open lung biopsy was performed. Open lung biopsy detected fungus in four patients and leukemic infiltrates in two patients. Management was appropriately modified in these patients. In nine patients, a specific diagnosis of the pulmonary infiltrate was not obtained by open lung biopsy. Antimicrobial regimens were not changed substantially for these patients. In six patients, the results of open lung biopsy may have been misleading. Two patients had pulmonary fungal diseases at autopsy, undetected by open lung biopsy eight days and five weeks prior to death. Another patient had invasive aspergillosis and one had cytomegalovirus pneumonitis not detected by open lung biopsy. Two patients had false-positive preliminary histologic reports of pulmonary infection. On the basis of this experience, in this specific population of patients, open lung biopsy was often of little help in directing medical therapy or influencing clinical outcome.

Open lung biopsy in patients with non-Hodgkin's lymphoma and pulmonary infiltrates.

Patients with non-Hodgkin's lymphoma (NHL) are at increased risk for pulmonary infection with opportunistic pathogens associated with diminished cell mediated immunity. Open lung biopsy (OLB) frequently is recommended for diagnosis of pulmonary infiltrates in patients with NHL, but its usefulness for patient management and outcome has not been evaluated for patients with NHL. We reviewed the results of 20 consecutive OLB in 19 patients with previously diagnosed non-Hodgkin's lymphoma at Stanford University Medical Center during a nine-year period. Fifteen patients had known active lymphoma at time of OLB, and no patient had granulocytopenia. Ten of the 20 OLBs yielded specific diagnoses. A greater proportion of patients with stage I or II disease had specific diagnoses than patients with more advanced NHL. Five of 14 patients considered to have had a life threatening illness at the time of OLB had specific diagnoses from OLB vs five of six patients considered clinically stable. Chest roentgenograms that had discrete masses or nodules correlated with ability to establish a specific diagnosis by OLB. For patients in whom the results of OLB were nonspecific, management appeared unaffected by the OLB. The OLB in NHL appeared most useful for detecting recurrent NHL in clinically stable patients with discrete nodules or masses on chest roentgenogram. Pneumocystis pneumonia was the only infection identified by OLB.

EuroQol: health-related quality of life measurement. Results of the Swedish questionnaire exercise.

The EuroQol Group, which currently comprises 7 centres in 5 countries, has been testing the feasibility of jointly developing a standardised non-disease-specific instrument for describing and valuing health-related quality of life. The instrument employs a visual analogue scale of the 'thermometer' type to allow respondents to rank a number of health states. As part of the Swedish IHE's contribution to the EuroQol Group's work, questionnaires were sent to 1000 people randomly selected to provide a representative sample of the Swedish population aged 16-84 years. 349 persons responded and 208 provided sufficient information for detailed analysis. From these 208 it proved possible to derive health status information in a quantitative form. The most interesting result was that the health state valuations from this survey indicated a striking similarity with those of EuroQol studies in Frome (England) and Bergen op Zoom (The Netherlands). The lessons learned from undertaking the survey are briefly discussed. The Swedish IHE is encouraged by the exercise to continue to play its part in the continuing developments of the EuroQol methodology.

The economics of preventing and treating pressure ulcers: a pilot study.

A pilot economic evaluation of a projected pressure ulcer prevention policy was carried out in a 252-bed geriatric unit in Glasgow. The aim was to set up a framework for evaluating and comparing the costs and benefits of current care and a potential prevention programme. Data were collated from prevalence and incidence studies. Prevalence results showed that 41% of the patient population suffered pressure damage to some extent and incidence data showed that 45% of these were potentially preventable. Evaluation of the costs and benefits shows that the prevention programme would be cost-effective. The cost would be between 17,606 Pounds and 28,669 Pounds but the benefits would range from 305,506 Pounds to 342,510 Pounds. The authors conclude that economic appraisal is feasible.

Cost of selected health institutions in the Central Region 1972-1973.

An account is given in the paper of a costing exercise conducted at four institutions in the Central Region, using 1972/1973 data. Attention is initially drawn to the conceptual and practical difficulties involved in the collection and interpretation of data. Detailed estimates for each institution-Cape Coast hospital, Saltpond hospital, Swedru health centre and Kissi health post are then presented. Finally a tentative suggestion for a supplementary statistical system covering institutional cost is broached.

Willingness to pay in arthritis: a Danish contribution.

OBJECTIVE: To explore the use of willingness-to-pay (WTP) methods with respect to an antagonist of tumour necrosis factor as an antirheumatic drug. METHODS: One hundred and fifteen rheumatoid arthritis (RA) patients at a tertiary care centre in Odense, Denmark were interviewed using two WTP approaches, the contingent ranking and double-bounded (closed-ended) methods. RESULTS: The average closed-ended WTP value was DKr581 and the average contingent ranking WTP was DKr643. There were no statistically significant differences in the WTP estimates between the two methods. CONCLUSION: It is feasible to use these methods with arthritis patients. If, as suggested in a number of recent reviews, a major effort is to be put into undertaking economic appraisals of arthritis programmes, then this should include more cost-benefit studies using WTP approaches of the kind illustrated in this paper.

Clinical efficacy and levels of ciprofloxacin in tissue in patients with soft tissue infection.

The clinical efficacy of ciprofloxacin was evaluated with 21 patients with soft tissue infection due mainly to gram-negative aerobic bacteria. Clinical cure was noted in 16 patients (76%), and clinical improvement was noted in the remaining 5 patients (24%). In addition, levels of ciprofloxacin were measured in the sera and tissues of 11 patients. Mean concentrations in tissue averaged 1.75 times the levels in serum. Ciprofloxacin should provide serum and soft tissue concentrations above the MICs for most gram-negative aerobic bacteria.

Role of serology in the diagnosis of toxoplasmic lymphadenopathy.

Serologic results obtained in 92 cases of toxoplasmic lymphadenopathy diagnosed by lymph node biopsy were reviewed, and guidelines for serologic diagnosis of this disease were established. When tests were first performed within six months of onset of lymphadenopathy, single high titers of IgG toxoplasma antibodies (suggestive of acute infection) were found with the Sabin-Feldman dye test and the direct agglutination test in 93% and 76% of cases, respectively. Observations of significant rises in titer were uncommon because of the late acquisition of sera. Within the first six months after the onset of lymphadenopathy, IgM toxoplasma antibody was demonstrable by the double-sandwich IgM enzyme-linked immunosorbent assay in 88% of cases and by the IgM-immunofluorescent antibody test in 78%. Twenty percent of patients who had serum samples drawn more than 12 months after onset lymphadenopathy still had IgM toxoplasma antibodies demonstrable by the enzyme-linked immunosorbent assay. No patient first tested six or more months after onset of lymphadenopathy was positive in the IgM-immunofluorescent antibody test. These results provide the basis for recommendations on the use of serologic tests for the diagnosis of acute toxoplasmic lymphadenopathy.

Comparison of a new rapid test (TestPack Rotavirus) with standard enzyme immunoassay and electron microscopy for the detection of rotavirus in symptomatic hospitalized children.

We compared a new, rapid, qualitative test for rotavirus (TestPack Rotavirus; Abbott Laboratories, North Chicago, Ill.) with another enzyme immunoassay (Pathfinder Rotavirus; Kallestad Laboratories, Inc., Austin, Tex.) and electron microscopy to determine its clinical utility in a population of symptomatic hospitalized children. In the first part of the study, 100 frozen stool samples were tested. The results after resolution with a blocking reagent showed a sensitivity of only 50% and a specificity of 88% for TestPack Rotavirus. In the second part of the study, we tested TestPack Rotavirus on 100 fresh, unfrozen samples. The results (sensitivity/specificity) were as follows: TestPack Rotavirus, 95/90%; Pathfinder Rotavirus, 84/98%; direct electron microscopy, 63/100%. Although it was not as sensitive or specific as immune electron microscopy, TestPack Rotavirus was more sensitive than direct electron microscopy or Kallestad Pathfinder Rotavirus. TestPack Rotavirus represents a rapid, qualitative method for the detection of rotavirus in stools of symptomatic children.

Detection of Toxoplasma gondii antigens by a dot-immunobinding technique.

A sensitive assay for the detection of antigens of Toxoplasma gondii by spotting samples directly onto nitrocellulose paper was developed. The sensitivity ranged from 10 to 40 pg of antigen diluted in phosphate-buffered saline and 40 to 130 pg of antigen diluted in normal mouse serum, normal human serum, or human cerebrospinal fluid. T. gondii antigen in serum samples taken from mice infected with T. gondii was detectable by day 2 of infection. Antigen was also detectable in cerebrospinal fluid samples taken from four of six infants congenitally infected with T. gondii and in serum samples from two of these infants.

Encephalitis caused by Coxiella burnetii.

Acute infection with Coxiella burnetii usually results in a self-limited illness, but it can occasionally cause chronic endocarditis or hepatitis. Headache is a common presenting symptom of acute infection with this agent, but specific neurological abnormalities are rare. We report the case of a patient with acute Q fever that caused frank encephalitis. We also review the literature on central nervous system disease attributable to C. burnetii.

Clinical spectrum in 107 cases of toxoplasmic lymphadenopathy.

Lymphadenopathy is the most frequent clinical manifestation of acute acquired infection with Toxoplasma in the immunocompetent individual. One hundred seven cases of histologically verified toxoplasmic lymphadenitis were reviewed in an effort to determine the usual modes of clinical presentation and the incidence of extranodal disease. Toxoplasmic lymphadenitis most frequently involved a solitary lymph node in the head and neck regions, without systemic symptoms or extranodal disease and with a benign clinical course. However, serious extranodal disease did occur in some patients and included myocarditis, pneumonitis, encephalitis, chorioretinitis, and transmission of the infection to the fetus. Case histories are presented to illustrate important points with respect to clinical presentation, complications, and diagnosis.

Costs of managing patients at a Canadian rheumatic disease unit.

Financial and other costs of managing 194 inpatients and 433 outpatients referred to the rheumatology service of a Canadian general teaching hospital during 1978 were assessed. The tax financed institutional cost/outpatient visit was $102, compared to $112/inpatient day, which was 62% of the hospital's $180 cost/inpatient day. Hospital financial costs represent 78% of RDU outpatient costs and 85% of substantially lower than per diem rates. Our findings caution against relying solely on hospital data in assessing total economic costs of any diagnostic subset of patients.

Open trial of imipenem/cilastatin therapy for serious bacterial infections.

Imipenem is a new beta-lactam antibiotic with a wide spectrum of activity against gram-positive and gram-negative aerobic and anaerobic bacteria. The efficacy and toxicity of this drug, when administered parenterally in combination with the dehydropeptidase I inhibitor cilastatin, were studied in 41 hospitalized patients with serious infections. Clinical cure was achieved in 26 (79%) of the 33 patients who could be evaluated and microbiologic cure in 23 (85%) of the 27 patients who could be evaluated. Adverse clinical or laboratory reactions were observed in seven (17%) of the 41 patients. Thus, imipenem/cilastatin was highly effective in the treatment of a wide variety of serious bacterial infections.