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* Objective: To evaluate the effects of long-term intravenous infusion of prostacyclin on exercise capacity, hemodynamics, and survival in patients with primary pulmonary hypertension. * Design: Open, multicenter, uncontrolled trial. * Setting: Four referral centers. * Patients: 18 patients with primary pulmonary hypertension: 1 New York Heart Association (NYHA) class II patient, 13 NYHA class III patients, and 4 NYHA class IV patients. * Interventions: Continuous intravenous prostacyclin administered by portable infusion pumps. All patients were treated with anticoagulant agents. * Measurements and Main Results: With the 6-minute walk used to evaluate exercise capacity, patients could walk on average more than 100 meters farther after prostacyclin therapy was initiated (distance at 6 months, 370 [+ or -] 119 meters compared with 264 [+ or -] 160 meters at baseline; P < 0.001; distance at 18 months, 408 [+ or -] 138 meters; P = 0.02 compared with baseline). Hemodynamics were improved at 6 months: The cardiac index increased 18% (95% CI, 0.1% to 36.7%; P = 0.02), and mean pulmonary artery pressure and total pulmonary resistance decreased 9% (CI, 1.4% to 15.7%; P = 0.03) and 26% (CI, 6.1% to 46.3%; P = 0.02), respectively, compared with baseline. The improvements in cardiac index and total pulmonary resistance were maintained at 12 months (27% increase (CI, 1.3% to 51.9%; P = 0.05] and 32% decrease [CI, 9.7% to 53.6%; P = 0.02] compared with baseline, respectively). Survival was improved in NYHA class III and IV patients who received continuous prostacyclin (n = 17; follow-up, 37 to 69 months) when compared with historical controls who received standard therapy (National Institutes of Health Primary Pulmonary Hypertension Registry, n = 31, P = 0.045). Kaplan-Meier estimates of 1-, 2-, and 3-year survival rates for the patients treated with prostacyclin were 86.9%, 72.4%, and 63.3%, respectively, compared with 77.4%, 51.6%, and 40.6% for the historical control group (hazard ratio, 2.9 [CI, 1.0 to 8.0; P = 0.045]). Serious complications attributable to the drug and delivery system included two deaths and seven episodes of nonfatal sepsis in three patients. * Conclusions: Continuous intravenous prostacyclin resulted in sustained clinical and hemodynamic improvement and probably in improved survival in patients with severe primary pulmonary hypertension. Despite potentially serious complications, long-term prostacyclin may be especially helpful in seriously ill patients awaiting transplantation., Continuous intravenous prostacyclin treatment may prolong survival in patients with severe pulmonary hypertension. Pulmonary hypertension is elevated pressure in the pulmonary artery which leads to heart failure. If medical treatment is not effective, patients may require heart-lung or lung transplants. Prostacyclin is a vasodilator, or agent that expands the blood vessels. Eighteen patients with severe pulmonary hypertension received continuous prostacyclin infusion from a portable pump into a catheter implanted into a vein. The prostacyclin dose started at 2 to 8 nanograms per kilogram (ng/kg) of body weight, but increased respective to hemodynamic measurements until the average dose at three years was 53 ng/kg. Hemodynamic measurements, including cardiac index and pulmonary resistance, improved by one year. Four patients died during the study, two from disease progression and two from complications of the infusion therapy. Eight patients had transplantation, and six were still receiving prostacyclin, from 50 to 69 months after initiation of the study.

Objective: To determine the prevalence of measles seronegativity among infants younger than 6 months and to ascertain their serologic response to measles vaccine. Design: Cross-sectional measles antibody survey during the 1989 measles epidemic in Chicago, Ill. Setting: Inner-city perinatal center. Participants: Two hundred three infants younger than 6 months who had been admitted to the neonatal intensive care unit at birth; 130 (64%) of these infants were premature. Transplacental antibody transfer was evaluated in a subset of 89 mother-newborn pairs. Intervention: Administration of measles monovalent vaccine to seronegative infants. Measurements/Results: Measles IgG antibody was measured using indirect fluorescent assay. At birth, 19 (38%) of 50 neonates born at less than 3 7 weeks' gestation had antibody titers that were twofold to fourfold lower than those of their mothers compared with three (8%) of 39 neonates born at more than 37 weeks' gestation (P, Whether a child has immune protection against measles at age six months or younger depends primarily on gestational age at birth, chronological age, and mother's age at the time of the birth. During a 4-month period of 1989, a group of 203 infants admitted to neonatal intensive care at Cook County Hospital in Chicago were evaluated for measles immune status. This was during a measles outbreak, and immunization was being recommended for infants six months and older. At birth, 38% of preterm newborns lacked immunity versus 8% of full-term newborns. At birth, 4% of newborns lacked immunity versus 74% of infants four to five months old. Mothers of 88% of infants lacking immunity were born after 1963, when mass immunization against measles began. When infants lacking immunity were immunized, 79% developed immunity.

Objective: Although the Global Deterioration Scale has been widely used since its publication in 1982, its stages are based on implicit assumptions about the linearity, temporality, and interdependence of cognitive, functional, and behavioral impairment in Alzheimer's disease. The authors evaluated the validity of these assumptions and tested the hypothesis that psychopathology and functional impairment would occur in earlier stages than the Global Deterioration Scale predicts. Method: The analyses were based on data on 324 patients with Alzheimer's disease who were selected from a registry of such patients. Data analyses included 1) descriptive statistics on the frequency of psychiatric symptoms and difficulties with activities of daily living and 2) logistic regression, with symptoms and functional impairment as independent variables, to test for significant changes in patients' status between stages of the Global Deterioration Scale. Results: More than 50% of the patients at stage 2 displayed psychopathology, and 32% had two or more symptoms. The significant increase in psychiatric symptoms occurred between stages 3 and 4, not between stages 5 and 6 as predicted by the Global Deterioration Scale. Impairment in functional status was observed at all stages, and significant increases occurred between stages 3 and 4 as well as between stages 5 and 6. Conclusions: Psychiatric symptoms and functional impairment occur earlier than predicted by the Global Deterioration Scale, and the rate of change is also different from that specified in the scale. Separate scales to describe cognitive, clinical, and functional status may be the best way to describe the illness until better multidimensional instruments are developed.

Adult Population Estimates Obtained from Measurements of Chest Roentgenograms from the NHANES II Survey Stuart Rich, M.D., F.C.C.P.;(*1) Eva Chomka, M.D.;(*1) Lawrence Hasara, M.D.;(*1) Kimberly Hart, R.N.;(*1) Terence Drizd, B.S.;[unkeyable] [...]

The National Trauma Data Bank (NTDB) was developed as a convenience sample of registry data from contributing trauma centers (TCs), thus, inferences about trauma patients may not be valid at the national level. The NTDB National Sample was created to obtain nationally representative estimates of trauma patients treated in the US level I and II TCs.

The Illinois Trauma Registry (ITR) was developed as the principal evaluative tool for the comprehensive set of medical programs known as the Illinois Trauma System. In order to determine the completeness of case reporting to the ITR, a 10 per cent sample of traumatic injuries was drawn at 33 hospitals designated as Trauma Centers. An attempt was then made to link the cases found at the Trauma Centers with those in the ITR; theoretically, all cases found in the Trauma Center should appear in the ITR. Analysis reveals that the ITR is drastically underreported; for all 33 Trauma Centers combined, only 36.9 per cent of the cases appeared in the ITR. On an individual hospital basis, completeness ranged from 0.0 per cent (eight hospitals) to 83.3 per cent. Inclusion in the ITR is significantly associated with the categorization of hospital emergency capability, the method of patient transport to the hospital, the mechanism of injury and subsequent admittance to the intensive care unit. Of particular interest for evaluative studies is the marginally significant difference between the case fatality rate as reported in the ITR (5.0 per cent) and that found in the hospital (2.8 per cent). Guidelines are suggested to improve the development, management and data quality of future registries.

The Illinois Trauma System has served as a prototype for many of the advanced emergency medical services systems developed during the past decade. The Illinois Trauma Study uses a cross-sectional research design to assess the trauma patient utilization patterns at hospitals in Illinois. Data were collected from 33 Trauma Centers and 43 nonsystem hospitals for the time interval July 1973–June 1974. Results indicated that 45.5 per cent of patients admitted with specified trauma conditions were hospitalized at Trauma Centers. When adjustment is made for differences in the size of hospitals, a 50 per cent excess in patient capture is found at Trauma Centers. This excess utilization found in Trauma Centers for this sample of trauma victims was not found among all patients admitted to these hospitals. Factors found to be associated with high Trauma Center use are race (high use among nonwhites), injury severity, evening admission to hospital and vehicular injury. Also, approximately two thirds of trauma patients that were admitted to intensive care units or transferred from other hospitals were hospitalized at Trauma Centers.

Closure of U.S. community hospitals during the years 1976-1980 is analyzed by describing the distributional patterns of closings among hospitals classified by certain institutional characteristics bed size, number of facilities and services, ownership, teaching status, location in a Standard Metropolitan Statistical Area (SMSA) or in a non-SMSA, and location in one of the nine United States Census Divisions. The method of Cox regression analysis is used to show that each of these institutional characteristics is independently, and significantly, associated with closure, and to estimate the strength of the association. On the basis of this analysis, a theoretic model is constructed for estimating the relative probability of closure for any community hospital with a given set of these institutional characteristics.

This study examines a large number of demographic, hospital, patient volume, and medical factors that may influence in-hospital mortality due to trauma. The authors use data from the 1977 and 1978 National Hospital Discharge Survey to assemble a case-control data set of severe injuries (n 336). Cases are defined as “deaths from trauma,” and control subjects are “injured survivors.” Control subjects are frequency-matched to cases on the basis of overall severity, site of the most severe anatomic injury, and age. The analysis estimates the relative risk of mortality associated with different levels of the risk factors by the odds ratio. The unadjusted results indicate a significant impact of the following variables sex (with males at higher risk), average severity of hospital case mix, number of severe trauma patients treated at a hospital (with high-volume hospitals at increased risk), ischemic heart disease and other forms of heart disease, malignant neoplasms, influenza and pneumonia, and emergency tracheotomy or tracheostomy. After adjustment using multiple logistic regression, the single significant risk factor is the presence of ischemic heart disease and other forms of heart disease. The implication of this finding is that hospitals exhibit little difference in mortality from severe trauma after adjustment for patient mix characteristics. Possible explanations for this result are tendered.

Previous reports have documented normal values for serum carnitine in children with RS. We have performed sequential analyses of serum carnitine in 14 children with RS. Eight were in stage III, five in stage IV, and one in stage II coma, (NIH Cons. Dev. Conf.,1981). The series was subdivided into three groups. A)survival without neurologic sequelae; B)survival with sequelae; C)died.Results: compared to controls, Mean±S.E. Comparison of inter-group means: A vs. B, p<.05; A vs. C, p<.05; B vs. C, NS.Elevation of serum carnitine persisted for 44-48 hours in three patients with stage III or IV RS. Sequential monitoring of serum values may be helpful in predicting patient outcome. The wide variation in serum carnitine levels in children with RS may reflect varying degrees of severity of hepatocyte injury.

Oloske, D. (Hematology/Oncology Section, U. of Chicago, Chicago, IL 60637), H. M. Golomb, M. D. Farber, and P. S. Levy. A case-control inquiry into the etiology of hairy cell leukemia. Am J Epklemlol 1985;121:675–83. A case-control study was conducted to investigate the etiology of hairy cell leukemia. Forty-five individuals with histologically confirmed hairy cell leukemia comprised the cases. Three neighborhood controls were selected on the basis of age (±5 years), race, sex, and residence at the time of the interview for each case. There was no association found for cigarette smoking, alcohol or coffee consumption and hairy cell leukemia. With respect to occupational risk factors, employment in woodworking or in farming was of borderline significance. Re ported exposure to organic chemicals in the workplace was significantly greater among both sexes of the cases than among their respective matched controls (relative risk (RR) = 3.10). Other variables found to be significantly associated with hairy cell leukemia wore farm birthplace (RR = 4.20), anemia (RR = 4.29), migraine (RR = 4.80), Infectious mononucleosis (RR = 9.00), and routine use of aspirin (RR = 3.41) or tranquilizers (RR = 4.50). No association between radiation and hairy cell leukemia was detected.

This book, written by and directed to physicians, presents the basic concepts of epidemiology with conciseness, clarity, and numerous examples from clinical medicine. The authors approach the topic of clinical epidemiology by applying epidemiologic principles and methods to problems encountered in clinical medicine. They believe that knowledge of these principles can help a clinician not only in the evaluation of clinical literature but also in patient care.The book consists of 12 chapters, each covering a broad epidemiologic concept. Among the major topics included are problems in clinical measurements; sensitivity, specificity, and predictive accuracy of diagnostic tests; measurement of disease occurrence and etiology; and assessment of prognosis and of treatment efficacy. The text has interspersed numerous tables and attractive diagrams and figures, and the authors make effective use of tables to summarize their discussions.Major strengths of this book are its clarity, the attractiveness of its presentation, and its avoidance