Non-specific Indicators Research Articles

Ultrasonic indicators of ureteric reflux in the newborn

There is controversy over the value of ultrasonic screening for detection of vesicoureteric reflux (VUR) in babies. We scanned 300 newborn babies and identified 53 with a dilated renal pelvis or other minor abnormalities. Eventually, 9 of these were investigated by voiding cystourethrography and 3 (5 kidneys) proved to have VUR exceeding grade II. In 3 babies the reason for cystourethrography was persistent renal pelvis dilation; in 3 it was urinary tract infection; and in 3 it was a new ultrasonic sign observed early in the series—ballooning of the renal pelvis during voiding. Whereas persistent dilation of the renal pelvis was a non-specific indicator (absent in 2 of the 5 affected kidneys and present in 5 of those unaffected), ballooning was consistently seen in all 5 affected renal pelvises. This sign, easily obtained in a baby who has been sleeping, deserves prospective assessment for its value in screening.

Can quality care in psychiatry be purchased?

Is it feasible to purchase quality care in psychiatry through managed competition? Can representatives of the Swedish public choose wisely between tenders for care and hold the provider accountable? Yes, to a point. The parties can reasonably agree on a budget to serve a defined population, using professional guidelines and procedures for diagnosis, treatment, and follow-up. Such an agreement is likely to enhance the quality of care. It can be audited partly by means of nonspecific multiple indicators. Nevertheless, paying for specific patient outcomes has the propensity to upset the care ecosystem, inviting bias and corruption. Comparative field studies of the impact of specific outcome indicators are recommended before the reform cycling continues.

The Mystique of the Erythrocyte Sedimentation Rate: A Reappraisal of One of the Oldest Laboratory Tests Still In Use

The ESR is a commonly performed laboratory test with intriguing antecedents extending back to the classical period of Western medicine. Although this background was appreciated by the physicians who popularized the test in the early part of this century, it has been largely forgotten. There has always been a lack of consensus about the role of the ESR as a nonspecific indicator of inflammation and tissue injury. The usefulness of the sedimentation rate has decreased as new methods of evaluating disease have been developed. It remains helpful in monitoring certain inflammatory processes, particularly rheumatoid arthritis, and it is of great value in the diagnosis of temporal arteritis and polymyalgia rheumatica. The use of the ESR as a screening test to identify patients who have significant disease is not supported by the literature. The basic factors influencing the sedimentation rate were understood by the early decades of this century and the most satisfactory method of performing the test was introduced by Westergren in 1921. The complex nature of the factors influencing test outcome have precluded development of a reference method or of an easily implemented quality control program. Current interest in the methodology of the ESR focuses on the development of automated closed systems that allow determination of the sedimentation rate in the collection tube. These methods offer advantages of speed, safety, and uniform specimen handling. Systems utilizing sedimentation columns less than 200 mm in length may be less sensitive to changes at higher ESRs than the Westergren method. Laboratories should consider using a closed or a closed and automated system as their routine method for performing the ESR.

Pemphigus associated with nail dystrophy

Two patients suffering from pemphigus vulgaris were found to have nail dystrophies which antedated the onset of mucocutaneous lesions by many years. The nail changes improved substantially on treatment of the bullous disease. One patient had nail matrix histology consistent with pemphigus, and both had positive direct immunofluorescence with intercellular IgG in the matrix epithelium, as well as at other body sites. We propose that dystrophic nails, as a non-specific indicator of autoimmune disease, are a genuine and relevant finding in pemphigus.

Orbital Lymphoma Versus Reactive Lymphoid Hyperplasia

Computed x ray tomography (CT) studies of 40 patients with proptosis or periorbital swelling, in whom biopsy showed lymphoma in 23 and reactive lymphoid hyperplasia in 17, were analysed in an attempt to identify radiological differences between the two conditions. The results indicate that homogeneity of an orbital mass is a sensitive but non-specific indication of lymphoma, 75% of lymphomatous masses and only 23% of reactive lesions being homogeneous. Bone destruction was seen only in cases of lymphoma, but was rare. Other radiological features of the mass or the affected orbital structures did not allow discrimination of tumour from a reactive lesion.

Myasthenia gravis

To clarify the role of cell-mediated versus humoral immune effector responses in myasthenia gravis (MG), we examined the occurrence of inflammatory cells in muscle from 30 patients with MG, determined the site of accumulation of the cells (at or remote from end-plates), enumerated and immunophenotyped those cells at the end-plate, and evaluated the frequency of deposition of the complement membrane attack complex (MAC) at the end-plate. Seven of 30 patients had well-defined collections of mononuclear cells in muscle (lymphorrhages), but these were not topographically related to the end-plates. Twenty of 30 patients had inflammatory cells (mostly macrophages and T cells) at or near end-plates, but these cells were present at less than 10% of the end-plates, and only seldom was there more than one cell at any end-plate. None of the inflammatory cells penetrated the muscle fiber near the end-plate. All end-plates of all patients immunostained for MAC. The findings reconfirm that the predominant immune effector response in MG is humorally mediated. The lymphorrhages in muscle and other tissues are probably a nonspecific indicator of disturbed immune regulation in MG.

Prevalence and Significance of Electroencephalographic Abnormalities in Patients with Suspected Organic Mental Syndromes

To determine the prevalence of electroencephalogram (EEG) abnormalities at different levels of cognitive impairment and to assess the possible diagnostic usefulness of the test. Combined prospective assessment of subjects receiving EEGs and retrospective chart review of symptoms and medications. Academic geriatric psychiatry service. 350 adults age 50 and above; 312 were patients being evaluated for possible organic mental syndrome and 38 were normal controls. All subjects had EEGs and Mini-Mental State Examinations (MMSE) performed at the time of the EEG. EEGs were rated for the presence and type of abnormality, and subjects were stratified according to the severity of impairment. Charts were reviewed by a person blinded to EEG results to determine clinical diagnosis and medications received. Abnormal EEGs were significantly more common among all patients (67%) in the study than among controls (11%), and the prevalence of abnormality increased with increasing impairment. Many demented patients with equivocal impairment (42%), and most with mild-to-moderate impairment (65%) had abnormal EEGs. An abnormal EEG was not indicative of dementia even when clear cognitive impairment was present, since patients with depression frequently also had abnormal EEG results. These findings suggest that the EEG is a moderately sensitive but non-specific indicator of brain dysfunction in the elderly. The significance of abnormalities among patients with equivocal impairment should be more fully assessed by longitudinal follow-up to determine if greater cognitive impairment develops.

Clinical and Serologic Evaluation of Neonates for Congenital Syphilis: A Continuing Diagnostic Dilemma

Neonates born to women with reactive serologic tests for syphilis were studied; the total of 116 included 18 who were symptomatic, 60 asymptomatic but possibly infected, and 38 asymptomatic and probably uninfected. The fluorescent treponemal antibody-absorption (FTA-ABS) 19S IgM test and an IgM capture ELISA for Treponema pallidum, both treponema-specific assays, and the reverse enzyme-linked immunospot (RELISPOT), which detects immunoglobulin-secreting cells and is a nonspecific indicator of infection, were evaluated. Sensitivities among symptomatic neonates were 88% (IgM ELISA), 73% (FTA-ABS), and 78% (RELISPOT). Specificities ranged from 97% to 100%. A major problem has been the inability to identify which asymptomatic but possibly infected neonate is really uninfected. Among 41 such babies who had all three tests done, 93% were negative by all assays, suggesting they were uninfected or recently infected. Strategies to accurately identify the truly uninfected asymptomatic newborn would prevent the unnecessary hospitalization of all at-risk infants, resulting in improved quality of care and reduced costs.

Growth deficit in survivors and non-survivors: Biological mortality bias in subadult skeletal samples

Linear growth of the long bones has and continues to be used by osteologists as a non-specific indicator of health. Studies of past populations use cross-sectional mortality samples to construct human skeletal growth profiles as a means of inferring the overall health of the population from which the skeletal series was drawn. Although all studies recognize that the growth profiles derived from skeletal samples may not be representative of the “true” path followed by the children who survived to adulthood, only recently have there been attempts to quantitatively examine this problem. This paper addresses the issue of biological mortality bias in subadult skeletal samples, focusing specifically on reduced or retarded linear growth. We begin with an overview of the general opinion on the subject within the osteological literature. A review of the child survival literature examines the interrelationships between malnutrition, morbidity, mortality, and linear growth, considering both indirect and direct studies of survivor–non-survivor growth data. This literature suggests that mortality samples are potentially biased, with linear growth of survivors often greater than that of non-survivors. The issues of stunting (the process of becoming small) and stunted growth (being small) are discussed with respect to biological mortality bias. It is concluded, that while the potential for such a bias exists within subadult skeletal collections, the effects are likely to be small at the aggregate level and error introduced by other methodological considerations (ageing, unknown sex, sample size, preservation, quality of excavation) is likely to outweigh any such error in interpretations of past population health. © 1993 Wiley-Liss, Inc.

Certified sick leave as a non-specific morbidity indicator: a case-referent study among nurses.

A case-referent study assessed the association between medically certified sick leave from work and some occupational characteristics--namely, two work load indices (nurse patient ratio and patients' average duration of stay) and hospital and care unit. Study participants were nurses from seven general hospitals in Québec City who had been employed for at least six months at the time of study. Cases (n = 184) experienced at least one episode of medically certified sick leave for a diagnosis "most likely to be related to work load" between 1 January 1984 and 31 May 1987. Referents (n = 1165) were chosen from subjects who had no such leave, whatever the medical reason, and were matched to cases by the incidence density sampling method. Occupational data were collected from employment records and administrative files. Analysis was by multiple logistic regression. Significant associations were found between sick leave and nurse-patient ratio among head nurses, patient's duration of stay, and one hospital. Sick leave was more frequent among full time permanent nurses and among those on night and evening schedules. These associations were independent of age, duration of service in this hospital or in the actual job assignment, and care unit. This study supports the relevance of using sick leave as a non-specific indicator of health out-comes.

Freon and Hypertension

To the Editor. —In Questions and Answers in the January 22/29, 1992, issue of JAMA , a New Jersey physician asked whether a single Freon exposure at work could have caused subsequently observed hypertension. 1 The responders, reasonably, were doubtful of a causative relationship, but did not refer to a published description of an extensive experience with blood pressure surveillance as a nonspecific indicator of workplace intolerance to chemicals, in use from the late 1930s until the early 1950s. Periodic blood pressure surveillance to detect chemical toxic effects was established in 1937 by DuPont in its explosives factories. 2,3 Several other explosives manufacturers, including Hercules and American Cyanamid, also used the system for a time. Blood pressure surveillance was applied to workers exposed to lead, hydrogen sulfide, sulfur dioxide, carbon monoxide, a number of solvents, sulfides, aromatic and aliphatic nitro compounds, and chlorinated hydrocarbons (Freon was not mentioned by name). 2

C-reactive protein--a characteristic feature of health control in swine.

In this study 120 weaned female piglets were clinically examined and porcine C-reactive protein (CRP) concentration determined in blood serum by means of a competitive enzyme ligand assay. CRP values were put into relation to clinical (catarrh, diarrhoea, inflammation and fever) and pathomorphological findings. It was found, that CRP values are clearly elevated during infections with fever and inflammatory processes, but not in the case of catarrh and diarrhoea. The pathomorphological investigations of some animals with clinical findings revealed changes in lungs, bowels and liver. Special attention has to be paid to the fact that, as in man, CRP is an acute phase reactant, and therefore a sensitive, but non-specific indicator for infections and inflammation processes. Serum CRP screening seems to be a good means for the supervision of the general state of health in pigs.

Orbital lymphoma versus reactive lymphoid hyperplasia: an analysis of the use of computed tomography in differential diagnosis.

Computed x ray tomography (CT) studies of 40 patients with proptosis or periorbital swelling, in whom biopsy showed lymphoma in 23 and reactive lymphoid hyperplasia in 17, were analysed in an attempt to identify radiological differences between the two conditions. The results indicate that homogeneity of an orbital mass is a sensitive but non-specific indication of lymphoma, 75% of lymphomatous masses and only 23% of reactive lesions being homogeneous. Bone destruction was seen only in cases of lymphoma, but was rare. Other radiological features of the mass or the affected orbital structures did not allow discrimination of tumour from a reactive lesion.

A new influenza surveillance system in France: The Ile-De-France ?GROG?. 2. Validity of indicators (1984?1989)

The evaluation of the validity of the GROG's indicators is based on the first five years of activity, four of which being epidemic ones. A virological criterion for identifying epidemics is used as the gold standard. For each non-specific indicator, the ratio of epidemic weeks to non-epidemic weeks is outlined. Therefore we can define four epidemic situations in relation with the strains circulating and the non-specific indicators. Influenza A epidemics, which are known as a mortality problem can also be described according to its impact upon morbidity. As a result, it is possible to set up a sensitive and specific surveillance system for early detection of influenza epidemics. This objective is achieved by combining both the weekly collection of virological data as well as the collection of other available indicators either in routine practice or as provided by a network of sentinel practitioners. Such detection can pave the way for an improvement in preventive measures against the harmful effects on health of influenza epidemics.

Production of interleukin-1β and tumour necrosis factor-α in patients with benign or malignant ovarian tumours

To assess the role of interleukin-1 beta (IL-1 beta) and tumour necrosis factor alpha (TNF alpha) in the physiological host defence mechanisms against malignancies, the production of these cytokines in sera, ascitic and cyst fluids and in the tumour tissues of patients with benign or malignant ovarian tumours was studied. IL-1 beta was found neither in the sera nor in the ascitic fluids of these patients. It was also virtually absent from the cyst fluid samples. However, a mean value of 790 pg IL-1 beta/g tumour was found. Like IL-1 beta, TNF alpha was virtually absent in the serum samples. It was, however, detectable in the ascitic and cyst fluids and tumour tissues. The TNF alpha concentrations were highest in the tumour tissues, with a mean level of 328 pg/g tumour. When comparing the level of IL-1 beta and TNF alpha in patients with benign tumours to that seen in patients with malignant tumours, no differences in production were observed, regardless of the origin of the test samples. Our results indicate the production of IL-1 beta and TNF alpha in patients with ovarian tumours. More importantly, the finding that the production of these cytokines in patients with benign tumours is similar to that in patients with malignant tumours supports the conclusion that the production of these cytokines is more a nonspecific indicator of an inflammatory process than a specific response to a malignant process.

Duodenal Hematoma

Enterogastric reflux occurs in normal and abnormal conditions. When pronounced, it is a nonspecific indicator of pathology. There are relatively few published reports discussing enterogastric reflux as a prominent finding on cholescintigraphy. A unique case of pronounced enterogastric reflux from an obstructing duodenal hematoma is presented.

Structural genitourinary defects detected in utero.

Fetal genitourinary anomalies are detected with increasing frequency due to the large numbers of fetuses that undergo screening ultrasonography (US) for nonspecific indications. One hundred seventy-seven patients were evaluated for fetal urinary abnormalities over a 2-year period. Fetal hydronephrosis accounted for 154 (87%) of the cases, with the remaining diagnoses including multicystic dysplastic kidney, autosomal recessive polycystic kidney disease, and renal agenesis or hypodysplasia. Ureteropelvic junction obstruction was the most common postnatal anatomic abnormality (29%), with a large number of cases of prenatally diagnosed hydronephrosis resolving either prenatally (33%) or postnatally (24%). Prenatal US findings were retrospectively analyzed with regard to the degree of hydronephrosis at different stages of gestation. Data showed that there is a gradual rise in anteroposterior renal pelvic diameter during gestation and that there is a correlation between this diameter and the ultimate renal outcome in regard to surgical repair. This information can provide guidance in making recommendations to parents and physicians.

Interferon- in Endocervical Secretions of Women Infected with Chlamydia trachomatis

Although interferon-gamma has been associated with control of chlamydial infections in mice, no direct evidence links it to human chlamydial infections. Therefore, interferon-gamma was assayed by ELISA in endocervical secretions and plasma of women cultured for Chlamydia trachomatis. Women with positive endocervical chlamydial cultures had increased levels of interferon-gamma in endocervical secretions (6.7 +/- 2.8, mean +/- SE, n = 47) compared with uninfected women (1.4 +/- 0.4, n = 52) (P = .002). Interferon was also present in secretions of women with gonorrhea. Higher levels were seen in secretions from older women with positive chlamydial cultures. Interferon levels in secretions did not correlate with simultaneous plasma levels, the number of organisms recovered in tissue culture, or clinical correlates of inflammation. These data suggest that interferon-gamma is present at the site of chlamydial infection; however, further experiments are needed to determine whether interferon is specifically involved in protection or is a nonspecific indicator of inflammation.

The Preceramic Period Site of Paloma, Peru: Bioindications of Improving Adaptation to Sedentism

The nature of the adjustments made by the steadily increasing population of central coastal Peru in the Middle through Late Preceramic time periods can be examined by careful study of bioindicators. Nonspecific indicators of stress (NSIS) preserved in human remains provide independent evidence for validating paleodemographic hypotheses. If life expectancy improves over a period of time, one expects diminished indication of nonspecific stress. Decreasing stress over time also may imply increasing fertility in precontraceptive peoples, which, along with declining mortality, would lead to population growth. However, the converse does not follow; populations may grow over time whether responding to increasing, stable, or decreasing stress. Other factors, such as changing subsistence strategies or hybrid vigor, also may be useful in explaining diminished indications of either nonspecific stress or population increase. The complex relations among (a) population structure and density (PSD), (b) nonspecific indicators of stress, and (c) diet have not yielded deductions that could form a universal set of expectations. However, several kinds of adaptation that are distinct with respect to population growth and health status are considered and illustrated with analyses of 201 skeletons from the preagricultural village of Paloma in central coastal Peru.

Delta Sleep Ratio

Slow wave sleep abnormalities have long been described in depression but were considered to be nonspecific indicators of psychopathology. Computerized techniques, including amplitude frequency measures and spectral analyses, are permitting new approaches to the examination of delta sleep. Early studies suggested that many depressed patients demonstrate lower delta wave intensity during the first non-rapid eye movement period than the second one. This finding, prominent in middle-aged depressed patients, has led to an examination of the ratio between the first and second non-rapid eye movement periods. This delta sleep measure seems to be a more robust predictor of recurrence than rapid eye movement latency. Analysis of data on 74 patients in a long-term maintenance treatment study for a minimum of 24 months demonstrates that the delta sleep ratio can predict survival time following discontinuation of drug treatment. Individuals with a high delta sleep ratio remain clinically remitted five times longer than those with a low delta sleep ratio.