The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases.

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Comparison of Alzheimer's disease risk factors in white and African American families.

The associations between alcohol, smoking, and head injury and the risk of AD in 443 African American and 2,336 white participants in the MIRAGE Study were evaluated. Alcohol had a modest protective effect in whites (odds ratio [OR] = 0.82, 95% CI = 0.68 to 0.99), with a similar trend in African Americans (OR = 0.88, 95% CI = 0.54 to 1.4). Head trauma increased the risk of AD in whites (OR = 2.3, 95% CI = 1.8 to 3.0) and African Americans (OR = 2.9, 95% CI = 1.2 to 7.0). Smoking was not associated with AD risk in whites (OR = 0.88, 95% CI = 0.73 to 1.1) or African Americans (OR = 1.0, 95% CI = 0.69 to 1.5). These risks were similar across subsets stratified by the presence or absence of the APOE epsilon4 allele.

Documented arterial gas embolism after spinal epidural injection.

We report the case of a 90-year-old man with syncope, arrhythmia, cardiac ischemia, and neurologic deficit after undergoing spinal epidural injection for control of pain related to post-herpetic neuralgia. The diagnosis of arterial gas embolus was made after air was identified in the left ventricle of the heart on an abdominal computed tomographic scan. Emergency physicians should consider and rapidly diagnose this rare but potentially fatal complication of spinal epidural puncture.

Firearm presence in households of patients with Alzheimer's disease and related dementias.

OBJECTIVE: Attention has recently been drawn to the potential dangers of firearm use among patients with dementia. However, little is known about the actual prevalence of firearms in households with demented family members. This study seeks to determine the prevalence and loaded status of firearms in households with a demented family member in a sample of outpatients at a University memory disorders clinic. DESIGN: Utilizing a cross-sectional design, subjects underwent a structured NINCDS-ADRDA criteria comprehensive evaluation to assess dementia and were also administered a questionnaire to assess level of mood disturbance. Family members were administered a behavioral checklist and surveyed about the number and loaded status of firearms in the patient's household. SETTING: The study took place in an outpatient Medical University memory disorders clinic in the Southern United States. PATIENTS: Subjects were 106 consecutive outpatients referred for symptoms suggestive of dementia. MAIN OUTCOME MEASURES: Firearm presence was coded as "present," "not present," and "unsure." In cases where firearms were present, the number and loaded status were collected. Other outcome measures included the Clinical Dementia Rating of each patient, the Yesavage Mood Inventory, and the Revised Memory and Behavior Problems Checklist. RESULTS: A high prevalence of firearm prevalence in households with demented family members was revealed (60.4%). Gun ownership was equally prevalent in households regardless of the severity of the dementia (chi-square, P = .426), severity of behavioral disturbance (ANOVA P = .88), or depressive symptoms (ANOVA P = .37). In households with firearms, 44.6% of the families reported that the guns were kept loaded; 38% reported that they did not know whether the guns were loaded. Only 16.9% of the families reported that guns were maintained in an unloaded state. CONCLUSIONS: This study suggests that many family members living in households in which there are demented patients do not take appropriate action to remove or unload firearms in their households, regardless of the severity of dementia, behavioral disturbance, or depression. These findings suggest that clinicians need to ask families specifically about the presence of firearms and advocate for their removal.

The sensitivity and specificity of forecasting high-cost users of medical care.

OBJECTIVES: This study compares the ability of 3 risk-assessment models to distinguish high and low expense-risk status within a managed care population. Models are the Global Risk-Assessment Model (GRAM) developed at the Kaiser Permanente Center for Health Research; a logistic version of GRAM; and a prior-expense model. GRAM was originally developed for use in adjusting Medicare payments to health plans. METHODS: Our sample of 98,985 cases was drawn from random samples of memberships of 3 staff/group health plans. Risk factor data were from 1992 and expenses were measured for 1993. Models produced distributions of individual-level annual expense forecasts (or predicted probabilities of high expense-risk status for logistic) for comparison to actual values. Prespecified "high-cost" thresholds were set within each distribution to analyze the models' ability to distinguish high and low expense-risk status. Forecast stability was analyzed through bootstrapping. RESULTS: GRAM discriminates better overall than its comparators (although the models are similar for policy-relevant thresholds). All models forecast the highest-cost cases relatively well. GRAM forecasts high expense-risk status better than its comparators within chronic and serious disease categories that are amenable to early intervention but also generates relatively more false positives within these categories. CONCLUSIONS: This study demonstrates the potential of risk-assessment models to inform care management decisions by efficiently screening managed care populations for high expense-risk. Such models can act as preliminary screens for plans that can refine model forecasts with detailed surveys. Future research should involve multiple-year data sets to explore the temporal stability of forecasts.

Chest radiographs in the pediatric emergency department for children < or = 18 months of age with wheezing.

There are no widely accepted predictors of pneumonia in wheezing infants and toddlers who present to the emergency department (ED). A 10-month retrospective review of ED visits of wheezing children < or = 18 months of age revealed the following chest radiograph (CXR) results: normal (21%), findings consistent with uncomplicated bronchiolitis or asthma (61%), focal infiltrates (18%), and other abnormalities (< 1%). Patients with focal infiltrates on CXR were more likely to have the following: a history of fever (p = 0.03, OR 2.1, 95% CI 1.0, 4.4), temperature > or = 38.4 degrees (p = 0.01, OR 2.5, 95% CI 1.1, 5.8) or crackles on examination (p < 0.0005, OR 3.9, 95% CI 1.7, 9.0). Selective use of CXRs has the potential to save health care dollars and limit unnecessary radiation.

Emergency department presentations of Lyme disease in children.

OBJECTIVE: To review the clinical characteristics and diagnostic evaluation of children with Lyme disease evaluated in an emergency department (ED) in an endemic area. DESIGN: A retrospective review of the demographic, historical, clinical, and laboratory data of pediatric patients with a final diagnosis of Lyme disease. SETTING: The pediatric ED of an urban university hospital. PARTICIPANTS: Children with Lyme disease evaluated during the three-year period from 1992 to 1994. RESULTS: Twenty-nine children ranging in age from three to 19 years who were diagnosed with Lyme disease subsequent to a visit to a pediatric ED were identified. Four patients had early localized disease with erythema migrans and varying degrees of systemic symptoms. Ten had early disseminated Lyme disease, with multiple erythema migrans, neurologic involvement (including three patients with pseudotumor cerebri), or carditis. Fifteen cases of late Lyme disease with arthritis were identified. Recognition of Lyme arthritis proved particularly difficult; seven children were initially diagnosed as having septic arthritis, six of whom underwent arthrotomy. Marked elevations of the erythrocyte sedimentation rate and synovial fluid white blood cell counts were observed in these patients, making it difficult to distinguish Lyme disease from septic arthritis on the basis of laboratory findings. CONCLUSION: Lyme disease is an infrequent, often difficult, diagnosis in children who present to an ED. Early disseminated and late disease predominate; classic erythema migrans is uncommon in the ED in comparison with other ambulatory venues. Diagnosis of Lyme arthritis may be difficult; exposure in an endemic area and clinical findings may help distinguish it from septic arthritis. Overall, underdiagnosis of Lyme disease may actually be more of a problem than overdiagnosis in the ED setting. Recognition of Lyme disease by emergency medicine practitioners requires familiarity with its epidemiology and its multiple manifestations.

The geographic variation in stroke incidence in two areas of the southeastern stroke belt: the Anderson and Pee Dee Stroke Study.

BACKGROUND AND PURPOSE: South Carolina and the southeastern United States have maintained the highest stroke mortality in the country. The Anderson and Pee Dee Stroke Study is an assessment of cerebrovascular disease incidence in 2 geographically defined communities in the stroke belt. METHODS: Strokes were identified in the Anderson and Pee Dee areas of South Carolina. All hospitalized and out-of-hospital deaths occurring during 1990 among the residents of these 2 areas were included. Strokes were classified by an independent panel of neurologists using a standard protocol that included specific criteria for stroke and subtypes. RESULTS: The overall age-adjusted stroke incidence rates (per 100 000 population) were significantly higher in the Pee Dee population (293.1) compared with Anderson (211.2). The geographic differences were more dramatic in the younger age groups of 35 to 64 years. Likewise, incidence rates for blacks were nearly twice the rates for whites. The rates in the Pee Dee were higher than the rates from other studies in the United States and other parts of the world. Although the stroke subtypes did not vary between the 2 regions, race-sex differences were identified. CONCLUSIONS: High stroke incidence and disease rates persist for all 4 race-sex groups in the Southeast and reflect similar risks as mortality rates. However, geographic variability in stroke rates suggests that the pattern of disease in the region is not so much a "belt" of increased stroke in contiguous areas but rather more a "necklace" of different levels of risk. These results should be useful in the identification of factors associated with this geographic enigma.

Airbag injuries in infants and children: a case report and review of the literature.

Airbags have saved an estimated 2620 lives as of November 1997. However, airbags also have caused a number of injuries and deaths and have received a lot of publicity from the NHTSA and the media as a result. The majority of the injuries have occurred when seat belts and shoulder harnesses were not used properly in conjunction with airbags. This article describes an injury that apparently occurred despite use of an age-appropriate, state-of-the-art child protection seat.

Building health plan databases to risk adjust outcomes and payments.

OBJECTIVES: To highlight the types and sources of data on medical risk and outcomes routinely collected by managed care organizations over time; to summarize the quality and consistency of these data; and to describe some of the difficulties that arise in collecting, pooling, and using these data. DESIGN: Synthesis of the experiences of two risk-adjustment modeling projects in assembling large volumes of demographic, diagnostic, and expense data from several health maintenance organizations (HMOs) over multiple years. SETTING: Six large HMOs from the Northwest, North Central, and Northeast regions of the USA. INTERVENTIONS: Health plans were approached to participate in a risk-adjustment study, presented with an extensive variable-by-variable data request, and, if willing to participate, asked to specify a desired process for extracting, copying, and transferring selected variables to the study site for purposes of research. Depending on local circumstances, three different approaches were used: (i) health plan staff obtained the data and organized them into the requested study format; (ii) study staff were provided access to health plan data systems to perform the extractions directly; and (iii) health plans hired contract programmers to perform the extractions under the direction of the study team. Key measures of risk and cost were extracted and merged into analysis files. MAIN OUTCOME MEASURES: Complete and consistent eligibility maps, demographic information, inpatient and outpatient diagnoses, and total health plan expense for each enrollee. RESULTS: We have been successful in collecting and integrating complete utilization, morbidity, demographic, and cost data on total memberships of five large HMOs as well as a subset from a sixth HMO, all for multiple years. CONCLUSION: While HMOs vary greatly in the quality and comprehensiveness of their data systems, these attributes have been improving across the board over time. Automated health plan data systems represent potentially valuable sources of data on health risks and outcomes and can be used to benchmark disease management programs and risk adjust capitation payments and medical outcomes.

Effectiveness of a continuum of care using brief and partial hospitalization for agitated dementia patients.

OBJECTIVE: A behavioral intensive care unit was originally designed as a 21-day inpatient program for treating agitation among demented patients, one of the most common behavioral disorders in this group. Due to the need to dramatically reduce length of stay and create alternative care environments, the original model was modified into an integrated continuum of care blending inpatient and outpatient care and partial hospitalization that reduced hospitalization from 21 to an average of seven days. This quasiexperimental study compared the effectiveness of the inpatient and continuum-of-care programs and conducted cost analyses. METHODS: Subjects were inpatients diagnosed with both dementia and agitation. Outcomes of 68 patients treated in the inpatient program were compared with those of 110 patients treated in the continuum of care. The primary outcome measure was patients' score on the Cohen-Mansfield Agitation Inventory, which provides a total agitation score and scores on three factors describing agitated behavior--physically aggressive behavior, verbally aggressive behavior, and nonaggressive behavior. RESULTS: A statistically significant reduction in agitation was found for patients treated in both programs, with no significant difference in outcome between programs. Patients in both programs showed significant improvements in physical aggression, verbal aggression, and nonaggressive behavior. The cost-effectiveness analysis revealed clear advantages for the continuum-of-care program, especially in the area of aggressive behaviors. CONCLUSIONS: The data suggest that the restructured program is an effective and economically feasible intervention.

Unawareness of cognitive deficit in Alzheimer disease and related dementias.

The objective of this study was to determine whether unawareness of cognitive deficit is disease-specific. One hundred thirty-two patients were studied, grouped according to diagnosis of definite or probable Alzheimer disease, vascular dementia, geropsychiatric control, or geriatric control. Diagnosis was the independent variable, and unawareness of cognitive deficit was the dependent variable. The Mini-Mental State Examination score was used as a dementia severity covariate. Analysis of covariance was significant (F = 8.0, p < 0.0001). Follow-up mean comparisons showed the Alzheimer disease group to have significantly greater unawareness of cognitive deficit than all other groups. The vascular dementia group had significantly greater unawareness of cognitive deficit than the two control groups. These results support the premise that, independent of dementia severity, unawareness of cognitive deficit is disease specific.

Children and adults in cardiopulmonary arrest: are advanced life support guidelines followed in the prehospital setting?

STUDY OBJECTIVE: To compare the proportions of children and adults in whom advanced life support (ALS) guidelines for prehospital management of cardiopulmonary arrest. METHODS: We conducted a retrospective cross-sectional study of an urban EMS system and an urban ED. We studied 141 consecutive patients (47 children and 94 adults, matched by date of presentation) in cardiopulmonary arrest who were transported to the pediatric and adult EDs by ALS-trained prehospital providers (paramedics) between January 1992 and July 1995. We reviewed ambulance trip reports and ED records to determine when and which interventions were performed in the prehospital setting. Significance of differences between the groups was determined with Fisher's exact test and Student's t test. RESULTS: In 47 children (median age, 1 year; range, 2 days to 15 years) and 94 adults (median age, 67 years; range, 16 to 95 years), pulselessness was documented at the time of the initial response of the ALS provider. Basic life support was performed in all patients. Among the 21 children and 7 adults who were not intubated, intubation was attempted in 13 children (62%) and in 6 adults (86%) (P = .26). Among the 29 children and 16 adults in whom intravascular access was not established, unsuccessful attempts to establish access were made in 1 child (3%) and in 15 adults (94%) (P = .0001). Among the 30 children and 91 adults who were intubated, in whom intravascular access was established, or both, epinephrine was not administered to 12 children (40%) and 6 adults (7%) (P < .0001). CONCLUSION: In our study population endotracheal intubation, intravascular access, and administration of epinephrine were attempted and performed significantly less frequently in children than in adults. Given the relative infrequency with which ALS providers encounter children in cardiopulmonary arrest, they need additional training to maintain their skills.

Perinatal social work and the high risk obstetrics patient.

Even under the most favorable conditions, pregnancy and childbirth may tax the family's ability to cope. If there are problems with the pregnancy, these coping capacities may be further stressed. This article examines the common high risk obstetrical problems, frequently seen emotional reactions to the treatment of those problems, and social work assessment and intervention with families.

Perinatal social work and the family of the newborn intensive care infant.

The birth of a premature and/or sick infant challenges even the most stable, intact families. If the baby is admitted to the Newborn Intensive Care Unit (NICU), the family is further challenged by the environment in which the infant is being treated. This article examines the most frequent causes for admission to NICU, common family reactions to such a birth and admission, social work assessment and intervention used in work with families of such patients.