James F. Jekel

The Diagnostic Accuracy of Kernig's Sign, Brudzinski's Sign, and Nuchal Rigidity in Adults with Suspected Meningitis

To determine the diagnostic accuracy of Kernigs sign, Brudzinskis sign, and nuchal rigidity for meningitis, 297 adults with suspected meningitis were prospectively evaluated for the presence of these meningeal signs before lumbar puncture was done. Kernigs sign (sensitivity, 5%; likelihood ratio for a positive test result [LR(+)], 0.97), Brudzinskis sign (sensitivity, 5%; LR(+), 0.97), and nuchal rigidity (sensitivity, 30%; LR(+), 0.94) did not accurately discriminate between patients with meningitis (>/=6 white blood cells [WBCs]/mL of cerebrospinal fluid [CSF]) and patients without meningitis. The diagnostic accuracy of these signs was not significantly better in the subsets of patients with moderate meningeal inflammation (>/=100 WBCs/mL of CSF) or microbiological evidence of CSF infection. Only for 4 patients with severe meningeal inflammation (>/=1000 WBCs/mL of CSF) did nuchal rigidity show diagnostic value (sensitivity, 100%; negative predictive value, 100%). In the broad spectrum of adults with suspected meningitis, 3 classic meningeal signs did not have diagnostic value; better bedside diagnostic signs are needed.

Comparison of frequencies of atrial fibrillation after coronary artery bypass grafting with and without the use of cardiopulmonary bypass.

This study compared the incidence of postoperative atrial fibrillation in a group of 34 patients undergoing coronary artery bypass graft surgery without the use of cardiopulmonary bypass and cardioplegia with a control group of 747 patients undergoing coronary artery bypass graft surgery using cardiopulmonary bypass and standard cardioplegia. A trend toward a lower incidence of postoperative atrial fibrillation was found in the group that underwent coronary artery bypass graft surgery without the use of cardiopulmonary bypass (n = 0.06).

Internists’ attitudes towards terminal sedation in end of life care

Objective: To describe the frequency of support for terminal sedation among internists, determine whether support for terminal sedation is accompanied by support for physician assisted suicide (PAS), and explore characteristics of internists who support terminal sedation but not assisted suicide. Design: A statewide, anonymous postal survey. Setting: Connecticut, USA. Participants: 677 Connecticut members of the American College of Physicians. Measurements: Attitudes toward terminal sedation and assisted suicide; experience providing primary care to terminally ill patients; demographic and religious characteristics. Results: 78% of respondents believed that if a terminally ill patient has intractable pain despite aggressive analgesia, it is ethically appropriate to provide terminal sedation (diminish consciousness to halt the experience of pain). Of those who favoured terminal sedation, 38% also agreed that PAS is ethically appropriate in some circumstances. Along a three point spectrum of aggressiveness in end of life care, the plurality of respondents (47%) were in the middle, agreeing with terminal sedation but not with PAS. Compared with respondents who were less aggressive or more aggressive, physicians in this middle group were more likely to report having more experience providing primary care to terminally ill patients (p = 0.02) and attending religious services more frequently (p<0.001). Conclusions: Support for terminal sedation was widespread in this population of physicians, and most who agreed with terminal sedation did not support PAS. Most internists who support aggressive palliation appear likely to draw an ethical line between terminal sedation and assisted suicide.

Suicide attempts in a population pregnant as teen-agers.

PREGNANCY, childbearing, and motherhood are normal biological events rather than disease processes, but even in the mature married woman they disturb the usual pattern of social life. For the teen-age girl, particularly if unmarried, pregnancy and the events which follow are especially likely to cause difficulty for the individual, those immediately associated with her, and society. Other authors1-3 have reviewed some of the problems associated with teenage pregnancies, such as disrupted education, welfare dependency, and increased fertility. A review of the medical records of 105 pregnant females 17 years of age or younger admitted to the Yale-New Haven Hospital for delivery during 1959 and 1960 suggested an additional potential difficulty -the possibility of suicide-threatened, attempted, or actually committed. This study revealed that 14 of the young mothers were known to have made subsequently one or more self-destructive attempts or threats serious enough to require care or to be reported to a physician at the hospital. The study population received its obstetrical care in the period before the emphasis on programs for teen-age mothers. Some were patients of private physicians, but the majority were seen by obstetrical residents, medical students, and staff physicians in the general obstetrical clinic.4 As a group they were offered no special social services, although in individual cases the need was so obvious that a social worker was assigned. They were excluded from school when their condition became apparent and limited educational alternatives were provided.5 Today in New Haven, and in many other cities throughout the United States, such girls are being offered programs that include unified medical care, augmented social services, and special educationafl provisions. It is hoped these programs will make a significant difference in the life of these young mothers and their children. Some reports are already indicating lower rates of medical complications among mothers and infants8 and decreases in early school terminations.1 Studies now under way may show that the attention being

Changes in age and sex specific tonsillectomy rates: United States, 1970-1977

National estimates of tonsillectomy rates were generated from the Hospital Discharge Survey for the years 1970 and 1977. A comparison of the rates over the seven-year period revealed significant declines in T&A for all age and sex categories and in tonsillectomy alone for males aged 20 through 29. It was also observed that sex differences found in 1970 persisted in 1977. (Am J Public Health 1982; 72:488-491.)

Influenza Outbreaks in Nursing Homes: How Effective Is Influenza Vaccine in the Institutionalized Elderly?

During the 1984-1985 influenza season, outbreaks of influenza A (H3N2) occurred in three Connecticut nursing homes. Influenza vaccination rates were 67% (96 out of 144), 35% (30 out of 85) and 69% (332 out of 483), respectively. The relative risk of illness for vaccinated compared to unvaccinated residents was 1.8 (95% confidence interval, 0.6, 5.9), 1.6 (95% confidence interval, 0.8, 3.0) and 1.1 (95% confidence interval, 0.8, 1.7) for each of the three nursing homes, respectively. In the third outbreak, 22 vaccinated residents without clinical illness had a geometric mean titer of hemagglutination-inhibition (HI) antibody of 20. Although low, this titer was significantly higher than that of nine unvaccinated residents without clinical illness (12, p less than .05); only three (14%) vaccinated residents had HI titers of greater than or equal to 40. These results suggest that levels of HI antibody in vaccinated residents were not protective at the time of the third outbreak, four to five months after vaccination. In general, the study of vaccine effectiveness in nursing homes is limited by sample size and statistical power. Despite these limits, the retrospective investigation of influenza outbreaks in nursing homes is often the only practical way to evaluate influenza vaccine effectiveness in the elderly on a yearly basis.

Infection control practitioners and committees in skilled nursing facilities in Connecticut

All skilled nursing facilities (SNFs) in Connecticut were surveyed and more than 71% responded to a Centers for Disease Control-funded project, a component of which is reported herein. The study describes the infection control practitioner (ICP), assistance provided ICPs from external sources, and infection control committees. Almost all ICPs received some training in infection control and worked in the field for an average of 3 1/2 years. Both the number of hours devoted to infection control and the percentage of time spent by the ICP on infection control activities increased with the size of the facility. More than one half of the ICPs in SNFs have relationships with hospital ICPs. The majority of SNF infection control committees met quarterly. The chairperson most often was a physician, although ICPs held this office in almost one third of the reporting SNFs. We conclude that ICPs in Connecticut SNFs have increased in number and that they devote more time and effort to infection control than in previous years.

Variations in Maximum Amplitude of Facial Expressions between and within Normal Subjects

Definitive proof of efficacy of preventions and therapeutic interventions, and of risk factors in lower motor neuron facial paralyses continue to be confounded by the lack of repeatable quantitative measures of outcome. Clinical and research experience with human facial expression repeatedly demonstrates wide variations between subjects. To our knowledge, little information is available to isolate and describe the differences in dynamic facial expression between and within normal subjects. The purpose of this study is to use a statistical model to analyze the components of the observed variations of maximum amplitude measurement of image change during normal human subject facial expressions. Seventeen consecutive normal adult human subjects with no current or past evidence of facial nerve or ear disease were studied. Videotapes of command facial expressions were taken using specific and standardized conditions. The tapes were analyzed using a new computer-assisted image-change analysis program capable of generating dimensional data for the maximum amplitude of expression. These data were statistically analyzed using a General Linear Model with Nested variables to isolate and define component variations and errors. The General Linear Model predicted 88% of the observed total variation (p < 0.05).* A model performance this high suggests that most of the important independent variables were being studied. The major component of the variations was the difference among (between) subjects. Seventy-seven percent of the predicted variation was due to this difference (p < 0.05). Little of the variation (1%) seemed to be within-subjects. Test-retest agreement was acceptable. Most of the data were tightly clustered about the mean and there was no stochasticly significant difference between test-retest (p = 0.1187). We are encouraged by these results. They suggest the potential value of this and other dimensional techniques applied to facial expression. This study demonstrates that a computer-assisted image-change analysis program is capable of generating dimensional data that can be statistically analyzed in order to isolate and define component variations and errors.

Infant feeding patterns during the first year of life in Denmark: Factors associated with the discontinuation of breast-feeding

We prospectively studied 500 infants born consecutively in a university-affiliated community hospital in Copenhagen, Denmark, over the first 12 months of life using a detailed monthly mailed questionnaire (overall response rate = 73%) which focused on feeding practices and illnesses. Seventy-seven percent of respondents breast-fed their infants at 1 month of life compared to 19% at 12 months of life. Analysis of breast-feeding behavior using survival analysis showed that 50% of the mothers who breast-fed since the first month of their infants life were still breast-feeding at 7 months of life. Also, there was a greater than two-fold increase in the rate of discontinuation of breast-feeding for infants in daycare compared to infants not attending daycare (RR = 2.08, 95% CI = 1.43, 3.01). Discontinuation of breast-feeding was not significantly associated with the number of children in the family or with social class. These results give insight into infant feeding patterns in a developed country and suggest that: (1) breast-feeding is the dominant method of feeding during the infants first year of life, and (2) the rate of discontinuation of breast-feeding is increased by the entry of these infants into daycare.

Infection control practices in Connecticut's skilled nursing facilities.

Questionnaires were sent to all skilled nursing homes in Connecticut as part of a larger study of nosocomial infections, infection risks, and infection control programs. This article describes surveillance practices, isolation practices, control measures, and employee health activities of skilled nursing homes in Connecticut. The overwhelming majority of skilled nursing homes used written criteria to determine nosocomial infections, and all undertook surveillance; the majority did surveillance at least weekly and 21% did on a daily basis. The most frequent source of information for reporting infections were microbiology reports and information from the charge nurse. Three fourths of the skilled nursing homes stated that the responsibility of reporting communicable disease is that of the infection control practitioner. Two thirds of the skilled nursing homes stated that they had policies on the reporting of isolation practices, including the refusal or acceptance of patients with infections; 38% had residents under isolation precautions. Of all the patient care control measures, only that of changing urinary catheters on a routine basis was associated with facility size. More than 90% of facilities reported having an employee health program, but the benefit was limited.