Community-acquired pneumonia in adults.

The incidence and mortality rates of community-acquired pneumonia (CAP) continue to rise as patients age. The clinical presentation of CAP is variable; therefore, diagnosis can be challenging. Clinicians must rely on a careful history and physical examination when choosing empirical antibiotic treatment. Using current guidelines, this article discusses the pathogenesis, clinical presentation, differential diagnosis, prognosis, and treatment of adults with CAP in the primary care setting.

Utility of lactate dehydrogenase vs radiographic severity in the differential diagnosis of Pneumocystis carinii pneumonia.

STUDY OBJECTIVES: In patients with HIV infection, serum lactate dehydrogenase (LDH) level is commonly stated to be more elevated in Pneumocystis carinii pneumonia (PCP) than in non-PCP. We hypothesized that LDH level reflects radiographic extent and severity of pneumonia rather than P carinii infection specifically and therefore is not useful in the differential diagnosis of lung infections in AIDS. DESIGN: We compared radiographic features and LDH values in 93 sequential patients with HIV infection and a new hospital admission for pneumonia (53 PCP and 40 non-PCP) after excluding all patients with other potential causes for elevated LDH levels. The chest radiograph was graded using a quantitative scale (0 to 24) to assess radiographic extent and severity of pneumonia by two independent observers in blinded fashion. The relationship between radiographic score and hospital admission LDH level was analyzed by linear regression and Bayesian analysis was applied to different LDH ranges to calculate the clinical value of LDH measurements. SETTING: Tertiary care teaching hospital and regional AIDS referral center. RESULTS: Mean LDH level was higher in the PCP group (1.217 +/- 88 U/L compared with 776 +/- 55 U/L; p < 0.001), as was mean radiographic score (12.4 +/- 0.6 for PCP compared with 6.3 +/- 0.5 for non-PCP; p < 0.001). For the whole sample of 93, LDH level was significantly related to chest radiographic score (r = 0.43, p < 0.0001). Significant overlap occurred between the two groups at all levels of LDH such that no cutoff level could be established that impacted significantly on posttest probability of PCP, whereas a radiographic score of > 12 yielded a 96% posttest probability of PCP. CONCLUSIONS: Serum LDH level reflects the degree of radiographic abnormality and is elevated in both PCP and non-PCP pneumonia to an extent that limits its utility in differentiating the two processes in hospitalized patients. The extent of radiographic involvement more clearly distinguishes the two conditions.

Calcium and colorectal epithelial cell proliferation in ulcerative colitis.

In persons at higher risk for colon cancer (e.g., those with sporadic adenoma or ulcerative colitis), compared to those at lower risk, colonic epithelial cell proliferation kinetics are altered. We have shown previously that calcium supplementation appears to normalize the distribution of proliferating cells without affecting the proliferation rate in the colorectal mucosa of sporadic adenoma patients. In a pilot randomized, double-blind, placebo-controlled, clinical trial conducted concurrently with our previously published sporadic adenoma trial, we tested whether calcium supplementation can also modulate cell proliferation kinetics in patients with ulcerative colitis. Ulcerative colitis patients (n = 31) were randomized to placebo or 2.0 g of supplemental calcium daily. Colorectal epithelial cell proliferation was determined by immunohistochemical detection of proliferating cell nuclear antigen labeling of cells in "nonprep" rectal biopsies taken at randomization and after 2 months treatment. All biopsies were scored by one reviewer. Differences in mean follow-up minus baseline labeling index (LI; the proportion of colon crypt epithelial cells that were labeled) and in the phi(h) (proportion of labeled cells that were in the upper 40% of the crypts) were compared with analysis of covariance. Pill-taking adherence was 97%. Biopsy-scoring reliability was high (r = 0.89). The pooled baseline LI and phi(h) were 6.3% and 5.6%, respectively. The LI in the calcium group decreased by 0.5% (proportionately, 3%) more than in the placebo group (P = 0.91). Similarly, the phi(h) in the calcium group decreased by 0.3% (proportionately, 10%) more than in the placebo group (P = 0.85). This pilot study does not suggest that 2.0 g of calcium as calcium carbonate daily can substantially normalize either the rate or distribution of proliferating cells over a 2-month period in the colon crypts of patients with ulcerative colitis; a more definitive answer to the question of whether calcium may be effective would require a study with a larger sample size and/or other study design modifications.

The impact of companion animals in later life and considerations for practice.

Interaction with companion animals, or pets, is increasingly recognized as a contributor to well-being in later life. This article focuses on the actual impact of animal companionship on older adults' (institutionalized and community dwelling) physical, social, and psychological health. Considerations for practice are discussed, with particular emphasis on professionals' recognizing the effect of multiple life-course factors that may moderate the therapeutic value of companion animals. Such factors include older persons' health, financial status, housing situation, and current and previous attitudes and attachments to pets.

Medical examiners and manner of death.

An experimental study of medical examiners in Alberta, Canada, produced manner of death determinations from simulated cases (vignettes) in order to examine interexaminer variation in certification judgments. Characteristics of medical examiners such as experience, residence, and religious background were investigated. The influence of victim characteristics was also examined, including race, age, gender, marital status, cause of death, and the presence of alcohol. Experience, residence, and religion of examiner were found to be related to judgments as were gender, medical cause of death, and the presence of alcohol.

Significance of nitroglycerin-induced hypotension with inferior wall acute myocardial infarction.

Up to 60% of patients with inferior wall acute myocardial infarction (AMI) develop hypotension. In many cases, profound hypotension is precipitated by the administration of nitroglycerin. To test the hypothesis that this hypotensive response to nitroglycerin may be related to right ventricular (RV) involvement, we compared 20 patients with electrocardiographic and enzyme-documented inferior wall AMI and marked hypotension (greater than 30 mm Hg decrease in systolic blood pressure, with symptoms) after nitrate administration, to 20 patients with documented inferior AMI, but without hypotension after administration of nitroglycerin. The presence of RV involvement was determined by electrocardiographic criteria of 1 mm of ST-segment elevation in at least 2 right precordial chest leads. Fifteen of the 20 patients who demonstrated a marked hypotensive response to nitroglycerin had evidence of RV involvement, while in 18 of the 20 patients without hypotension after nitrates there was no evidence of RV involvement. In a separate analysis of 28 patients with documented RV involvement in an inferior AMI, 20 developed hypotension in response to nitrates. Thus, in the setting of an inferior AMI, a marked hypotensive response to nitrates suggests the presence of RV involvement. Moreover, hypotension after nitrate administration may be anticipated in patients with known RV infarction, and in such patients, nitrates should be administered carefully.

Experimental chemotherapy-induced skin necrosis in swine. Mechanistic studies of anthracycline antibiotic toxicity and protection with a radical dimer compound.

The reactivity of antitumor anthracycline and mitomycin C antibiotics with the oxomorpholinyl radical dimers, bi(3,5,5-trimethyl-2-oxomorpholin-3-yl) (TM3) and bi(3,5-dimethyl-5-hydroxymethyl-2-oxomorpholin-3-yl) (DHM3), was studied in vitro. The oxomorpholinyl radical reduced daunorubicin to a quinone methide intermediate that reacted with solvent to form 7-deoxydaunorubicinone. The solvolysis reaction followed first order kinetics, and the reactivity rate constants (k2) measured for seven anthracycline analogues ranged from 2 X 10(-2) s-1 to 8.0 X 10(-4) s-1. The chemical reactivity of each anthracycline quinone methide correlated with the total skin toxicity caused by the respective parent anthracycline following injection into swine skin. Microscopic examination of experimental lesions in swine skin resemble those observed in humans after inadvertant chemotherapy extravasation. Hydrocortisone sodium succinate was not effective for the treatment of doxorubicin-induced skin necrosis, whereas DHM3 was effective for the treatment of skin necrosis caused by all seven anthracyclines and by the quinone containing antibiotic, mitomycin C.

Towards the development of a systematic approach to suicide prevention: the Alberta model.

The author outlines a model recently adopted by the Province of Alberta to provide suicide prevention, intervention and postvention services. Based on the proposals of a Provincial Task Force, the model features interrelated programs of outreach, education and training, research, and fund-raising. It is designed to make use of community resources in an efficient and coordinated manner, attacking the problem on several fronts.

Death styles among Canada's Indians.

Data are examined from a prospective study of Native mortality on 35 reserves and colonies in the province of Alberta, Canada. Native Indian deaths tend to occur at a younger age than others, to be multiple events and to occur in non-hospital settings with others present. In almost half the cases death resulted from accident, suicide or homicide. Though circumstances of weather and physical isolation, as well as human negligence and carelessness resulted in some deaths, the majority of violent deaths were associated with the heavy use of alcohol.

A sensitive dual wavelength microspectrophotometer for the measurement of tissue fluorescence and reflectance.

The construction of a microscope photometer using prefabricated elements is described. To illuminate the tissue, a Leitz Ultropac is applied. To enlarge the wavelength range, its illuminating glass lens is replaced by an Acryl glass zonal lens. Two separate light channels with separate lamps, monochromators and photomultipliers allow the measurement of fluorescence excitation and emission spectra as well as of reflection spectra. By chopping the light, light pulses and dark currents are measured 8.33 times a second. By an integration circuit the signal-to-noise ratio for small signals is improved. The instrument allows us to detect the increase of 4 ng/ml NADH (solution of pH 7.38) in an area of 0.2 mm2.