Medical Inspection – Health Blog

The most surprising finding of this investigation was that most neonates with respiratory symptoms were not classifiable by standard diagnostic criteria for textbook pulmonary disorders, even applying the broadest definitions. To our knowledge, this is the first attempt to classify acute respiratory disorders in the newborn in three decades in North America. Interestingly, similar to the findings of Hjalmarson in Sweden 21 years ago, a large proportion of infants with respiratory symptoms fail to meet any diagnostic criteria for the respiratory conditions as defined in standard textbooks. Nevertheless, they are ill and in many cases present with frank respiratory failure.

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During the one year enrollment period, there were 2805 live-born infants weighing at least 500 grams born without major anomalies in our hospital. We excluded 19 live-born infants from the study because of birth weights below 500 grams (15 infants) or congenital anomalies (four infants). Three were excluded for incomplete data. Of the study population, some 584 (21%) developed one or more respiratory signs in the first day, 90% of them within the first hour. The respiratory distress persisted beyond six hours in 474 (81%) of the symptomatic neonates and 400 (68%) were admitted to the neonatal intensive care unit. There were 19 deaths among these infants in the first five days of life, 12 in infants with RDS, giving an overall five-day mortality rate of 32/1000 for all infants with respiratory symptoms and a five-day case fatality rate of 111/1000 for the subset with RDS. Additional early neonatal deaths occurred in our inborn population over the study period: one infant with holoprosencephaly and all 15 infants with birth weights below 500 grams.

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We prospectively studied all infants born at Cook County Hospital, a tertiary perinatal center serving a low-income population, over a 12-month period. About 50-60 % of deliveries had significant perinatal risk factors such as preterm labor, preeclampsia or other significant medical or social problems (E. Swift, MD, personal communication). The birth population was 58% African American and 31% Latino. The rate of low birth weight (<2500 grams) for 1995 was 16.8 % overall, with the black rate over twice as high as that for Hispanic infants (21.9% versus 9.7%). All live born infants weighing at least 500 grams and assessed to be at least 22 weeks gestation who displayed signs of respiratory disturbance within 24 hours of birth were evaluated from November 1994 to November 1995. Neonates who were judged to be pre-viable and who were not resuscitated, were excluded. Previable was defined by being less than 500grams and 22 weeks gestation.

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Experience suggests that many newborn infants with acute respiratory disorders do not fit classic diagnostic patterns. There also is considerable variation among authors about which particular diagnostic criteria should be relied upon to define common disorders, such as respiratory distress syndrome (RDS), also known as hyaline membrane disease (HMD). In 1962, Miller classified patients having RDS based on oxygen therapy, grunting, and respiratory rate but used no radiographic criteria for diagnosis, despite the fact that Donald and Steiner had described the reticulogranular or ground glass pattern now regarded as the “classic” radiographic picture of RDS in 1953. In a review of 39 pediatric and neonatology textbook and articles in 1991, Teji and David found the presence of a reticulogranular pattern on chest film the most widely agreed upon criterion for establishing the diagnosis of RDS, with 70% of authors in agreement.Clearly, diagnostic criteria evolve over time with our understanding of the features, pathophysiology and treatment of diseases.

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This pattern of missed opportunities has contributed to continued under-utilization of vaccinations among adults despite initiatives to improve vaccination levels. In 1990, the National Coalition for Adult Immunization issued the Standards for Adult Immunization, endorsed by the National Foundation for Infectious Diseases, the CDC, the NMA, and other agencies. Beginning in 1994, national and state-based campaigns were initiated by the Health Care Financing Administration to increase influenza and pneumococcal coverage among Medicare beneficiaries. In 1994, the National Vaccine Advisory Committee recommended the following to improve adult immunization: 1) improve public and provider education; 2) institute major changes in clinical practice; 3) increase financial support by public and private insurers; 4) improve surveillance of vaccine-preventable diseases and vaccine production and delivery; and 5) provide support for research on vaccine-preventable diseases, new and improved vaccines, immunization practices, and international programs for adult immunization. The Department of Health and Human Services subsequently issued an Adult Immunization Action Plan outlining a proposal for collaboration among federal agencies, state and local agencies, health professional organizations, purchasers and providers of health-care, vaccine companies, and the public, to increase adult vaccination levels.

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Several reasons have been given to explain under-utilization of vaccines among adults. First, some members of the public and health care providers do not perceive adult vaccine-preventable diseases as a significant public health problems. Second, there are unnecessary fears among patients and providers concerning adverse events following vaccination. Third, unlike childhood immunization, adult immunization indications are selective, with different target groups for different vaccines. Fourth, there are no statutory requirements for adult immunization. Fifth, there are no comprehensive vaccine-delivery systems in the public and private sectors. Sixth, there are limited reimbursement levels for vaccination services and a lack of coverage for adult immunization by third party payers. Seventh, there is a failure to establish organized vaccination programs in settings (e.g. workplace) where adults congregate. Finally, there are missed opportunities to vaccinate adults during contacts with health care providers.

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Influenza Vaccine

The Influenza vaccine has reduced death, hospitalization, and clinical illness in years when vaccine and epidemic strains are similar. Influenza vaccine is up to 90 percent effective in preventing illness in young, healthy adults. Among institutionalized, high-risk older persons, those vaccinated experience a 30 percent to 40 percent reduction in incidence of illness; a 50 percent-60 percent reduction in hospitalization; and up to 80 percent reduction in death.

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