CHICAGO—Extremely low-birth-weight (ELBW) infants who have an infection during their hospitalization following birth are more likely to have adverse neurodevelopmental outcomes than those infants who do not have an infection, according to a study in the November 17 issue of JAMA.

Infections are known to be a frequent complication among ELBW (14.2 ounces to 35.3 ounces) preterm infants, and are associated with short-term illness and increased risk of death, according to background information in the article.

Barbara J. Stoll, M.D., of the Emory University School of Medicine, Atlanta, and colleagues conducted a study to determine if neonatal (during the first 120 days of life) infections are associated with adverse neurodevelopmental and growth abnormalities in early childhood.

The study included infants, born 1993-2001, who were enrolled in a very low-birth-weight registry at academic medical centers participating in the National Institute of Child Health and Human Development Neonatal Research Network. Neurodevelopmental and growth outcomes were assessed at a comprehensive follow-up visit at 18 to 22 months (from conception) and compared by infection group. Eighty percent of survivors completed the follow-up visit and 6,093 infants were studied. Registry data were used to classify infants by type of infection: uninfected (n = 2,161), clinical infection alone (negative infection requiring 5 days or more of antibiotics; n = 1,538), sepsis (positive blood cultures requiring 5 days or more of antibiotic treatment; n = 1,922), sepsis and necrotizing enterocolitis (inflammation involving both the small intestine and the colon; n = 279), or meningitis with or without sepsis (n = 193).

The majority of ELBW survivors (65 percent) had at least 1 infection during their hospitalization after birth. The researchers found that compared with uninfected infants, those in each of the 4 infection groups were significantly more likely to have adverse neurodevelopmental outcomes at follow-up, including cerebral palsy (40-70 percent increased odds), low Bayley Scales of Infant Development II scores on the mental development index (30-60 percent increased odds) and psychomotor development index (50 percent to 2.4 times increased odds), and vision impairment (30 percent to 2.2 times increased odds). Infection in the neonatal period was also associated with impaired head growth, a known predictor of poor neurodevelopmental outcome.

CHICAGO—A 10-ppb (parts per billion) increase in daily ozone levels is associated with an increase in the number of deaths in large U.S. urban communities, according to an article in the November 17 issue of JAMA.

"Exposure to ...ozone is widespread in the United States," according to background information in the article. "Short-term exposure to ozone has been linked to adverse health effects, including increased rates of hospital admissions and emergency department visits, exacerbations of chronic respiratory conditions (e.g., asthma), and decreased lung functioning." Information on an association between ozone and death rates has been inconclusive.

Michelle L. Bell, Ph.D., from the School of Forestry and Environmental Studies, Yale University, New Haven, Conn., and colleagues investigated the effect of short-term (daily and weekly) exposure to ozone on death rates in the United States. Using information from the National Morbidity, Mortality, and Air Pollution Study (NMMAPS), the researchers estimated the average of deaths associated with short-term ozone exposure for 95 large urban communities (which includes 40 percent of the U.S. population) from 1987 to 2000.

The researchers found that a 10-ppb (parts per billion) increase in the previous week's ozone was associated with a 0.52 percent increase in the daily death rate, with a 0.64 percent increase in cardiovascular and respiratory-related deaths. People aged 65 to 74 years old experienced a slightly higher increase in the death rate, at 0.70 percent. Results were significant when adjusted for particulate matter, weather, seasonality, and long-term trends.

The authors state: "...a 10-ppb increase in daily ozone would correspond to an additional 319 annual premature deaths for New York City and 3,767 premature deaths annually for the 95 urban communities, based on mortality data from 2000. This value is probably an underestimate of the total mortality burden from such an increase in ozone because it accounts for only the short-term effects."

CHICAGO—Computer-based standing orders are more effective than computerized reminders to physicians in increasing influenza and pneumococcal vaccine administration for hospitalized patients, according to an article in the November 17 issue of JAMA.

According to background information in the article, few medical interventions rival influenza and pneumococcal vaccines in their ability to reduce illness and save costs and lives. Yet in the past, among individuals older than 65 years, as many as 34 percent have not received their annual influenza vaccine and 38 percent have not received their annual pneumococcal vaccine. Computerized reminder systems increase influenza and pneumococcal vaccination rates, but computerized standing order systems have not been previously evaluated.

Paul R. Dexter, M.D., of Wishard Memorial Hospital and Indiana University School of Medicine, Indianapolis, and colleagues compared the effects of computerized standing orders for influenza and pneumococcal vaccines in a randomized trial using the computerized physician reminder system as a control. The trial included 3,777 general medicine patients discharged from 1 of 6 study wards during a 14-month period (November 1, 1998, through December 31, 1999) composed of 2 overlapping influenza seasons at an urban public teaching hospital.

The hospital's computerized physician order entry system identified inpatients eligible for influenza and pneumococcal vaccination. For patients with standing orders, the system automatically produced an order directing a nurse to administer the vaccine at time of discharge. For patients with reminders, the computer provided reminders to physicians that included vaccine orders during routine order entry sessions.

During the approximately 6 months of the influenza season, 50 percent of all hospitalized patients were identified as eligible for influenza vaccination. Twenty-two percent of patients hospitalized during the entire 14 months of the study were found eligible for pneumococcal vaccination. The researchers found that patients with standing orders received an influenza vaccine significantly more often (42 percent) than those patients with reminders (30 percent). Patients with standing orders received a pneumococcal vaccine significantly more often (51 percent) than those with reminders (31 percent).

HIGHER OZONE LEVELS LINKED TO INCREASE IN MORTALITY IN STUDY OF 95 U.S. CITIES