Use of a direct fluorescent antibody test for detecting Chlamydia trachomatis cervical infection in women seeking routine gynecologic care

We determined the sensitivity, specificity, and predictive value of a direct fluorescence test for Chlamydia trachomatis infection compared with culture of the endocervix in women seeking routine gynecologic care. Of 527 patients seen in a hospital-based practice, 23 (4.4%) had a positive culture for C. trachomatis. The overall sensitivity of the direct test was 70%, and the specificity was 98%. When five or more endocervical cells were present on the direct test slide, the sensitivity increased to 92%, and the specificity decreased to 96% (P less than .05). When the presence of any columnar epithelial cells, five or more elementary bodies, or both was used as the criteria for accepting specimens, the sensitivity and specificity of the direct test were 80% and 96%, respectively. However, 44% of the specimens would be rejected if these criteria were used. The overall probability that an individual with a positive direct test would have a positive culture was 62%.     

Lipids, vascular disease, and dementia with advancing age. Epidemiologic considerations

Elevated plasma lipid and lipoprotein levels are associated with an increased risk of cardiovascular disease in middle-aged men and women. It is still not clear, however, whether lipid and lipoprotein abnormalities continue to be risk factors for cardiovascular disease in the elderly population. It is not even clear what normal lipid values are in the elderly, and whether diet or drug therapy should be advised on the basis of lipid values established in middle-aged populations. Ischemic heart disease does remain the leading cause of death in the elderly, and there is now preliminary evidence from epidemiologic studies that relative elevations of levels of lipid and lipoprotein fractions in an elderly population might be associated with an independent and increased risk of coronary heart disease, stroke, and possibly dementia. Intervention studies are about to begin that will assess various lipid-and lipoprotein-modifying therapies and their ability to reduce vascular disease risk in the elderly.     

Prevalence, incidence and prognosis of recognized and unrecognized myocardial infarction in persons aged 75 years or older: The Bronx Aging Study

The prevalence, incidence and prognosis of recognized and unrecognized Q-wave myocardial infarction (MI) was assessed in an 8-year prospective study of 390 community-based subjects (age 75 to 85 years at entry, mean 79 years). Subjects were studied at baseline and with annual follow-up electrocardiographic (ECG) exams. At baseline, 7.9% had a history of MI without ECG evidence, 6.4% had ECG evidence of Q-wave MI without clinical history, 4.1% had both clinical history and ECG evidence and 81.5% had neither history nor ECG evidence (control subjects). After an average follow-up period of 76.2 months, the total mortality rate was 5.9/100 person-years for subjects with some evidence of MI at baseline versus 3.9 in the control group (p = 0.059). The incidence of cardiovascular disease in subjects with evidence of MI was 8.8/100 person-years versus 4.7 among control subjects (p = 0.002). During the follow-up period, 115 new Q-wave MIs occurred (50 unrecognized, rate 2.4/100; 65 recognized, rate 3.2/100). There was no difference in mortality and morbidity outcome between subjects with recognized and unrecognized MIs. Those with only a history of MI at baseline had a threefold greater risk of a new MI (recognized and unrecognized) than the control group (p = 0.003). Unrecognized Q-wave MI is a common occurrence in the "old old" with subsequent morbidity and mortality prognosis comparable to that of recognized MI. History of MI alone in this age group is also associated with an increased risk of MI, suggesting the need for better diagnostic markers of myocardial ischemia in the old.     

Is multiple SNP testing in BRCA2 and BRCA1 female carriers ready for use in clinical practice? Results from a large Genetic Centre in the UK

BRCA1 and BRCA2 are major breast cancer susceptibility genes. Nineteen single nucleotide polymorphisms (SNPs) at 18 loci have been associated with breast cancer. We aimed to determine whether these predict breast cancer incidence in women with BRCA1/BRCA2 mutations. BRCA1/2 mutation carriers identified through the Manchester genetics centre between 1996 and 2011 were included. Using published odds ratios (OR) and risk allele frequencies, we calculated an overall breast cancer risk SNP score (OBRS) for each woman. The relationship between OBRS and age at breast cancer onset was investigated using the Cox proportional hazards model, and predictive ability assessed using Harrell's C concordance statistic. In BRCA1 mutation carriers we found no association between OBRS and age at breast cancer onset: OR for the lowest risk quintile compared to the highest was 1.20 (95% CI 0.82–1.75, Harrell's C = 0.54), but in BRCA2 mutation carriers the association was significant (OR for the lowest risk quintile relative to the highest was 0.47 (95% CI 0.33–0.69, Harrell's C = 0.59). The 18 validated breast cancer SNPs differentiate breast cancer risks between women with BRCA2 mutations, but not BRCA1. It may now be appropriate to use these SNPs to help women with BRCA2 mutations make maximally informed decisions about management options.     

Inter-rater reliability of the Johns Hopkins Highest Level of Mobility Scale (JH-HLM) in the intensive care unit

BackgroundThe Johns Hopkins Highest Level of Mobility (JH-HLM) scale is used to document the observed mobility of hospitalized patients, including those patients in the intensive care unit (ICU) setting.ObjectiveTo evaluate the inter-rater reliability of the JH-HLM, completed by physical therapists, across medical, surgical, and neurological adult ICUs at a single large academic hospital.MethodsThe JH-HLM is an ordinal scale for documenting a patient’s highest observed level of activity, ranging from lying in bed (score = 1) to ambulating >250 feet (score = 8). Eighty-one rehabilitation sessions were conducted by eight physical therapists, with 1 of 2 reference physical therapist rater simultaneously observing the session and independently scoring the JH-HLM. The intraclass correlation coefficient was used to determine the inter-rater reliability.ResultsA total of 77 (95%) of 81 assessments had perfect agreement. The overall intraclass correlation coefficient for inter-rater reliability was 0.98 (95% confidence interval: 0.96, 0.99), with similar scores in the medical, surgical, and neurological ICUs. A Bland–Altman plot revealed a mean difference in JH-HLM scoring of 0 (limits of agreement: ?0.54 to 0.61).ConclusionThe JH-HLM has excellent inter-rater reliability as part of routine physical therapy practice, across different types of adult ICUs.     

Confidential clinician-reported surveillance of adverse events among medical inpatients

BACKGROUND: Although iatrogenic injury poses a significant risk to hospitalized patients, detection of adverse events (AEs) is costly and difficult. METHODS: The authors developed a confidential reporting method for detecting AEs on a medicine unit of a teaching hospital. Adverse events were defined as patient injuries. Potential adverse events (PAEs) represented errors that could have, but did not result in harm. Investigators interviewed house officers during morning rounds and by e-mail, asking them to identify obstacles to high quality care and iatrogenic injuries. They compared house officer reports with hospital incident reports and patients’ medical records. A multivariate regression model identified correlates of reporting. RESULTS: One hundred ten events occurred, affecting 84 patients. Queries by e-mail (incidence rate ratio [IRR]=0.16; 95% confidence interval [95% CI], 0.05 to 0.49) and on days when house officers rotated to a new service (IRR=0.12; 95% CI, 0.02 to 0.91) resulted in fewer reports. The most commonly reported process of care problems were inadequate evaluation of the patient (16.4%), failure to monitor or follow up (12.7%), and failure of the laboratory to perform at test (12.7%). Respondents identified 29 (26.4%) AEs, 52 (47.3%) PAEs, and 29 (26.4%) other house officer-identified quality problems. An AE occurred in 2.6% of admissions. The hospital incident reporting system detected only one house officer-reported event. Chart review corroborated 72.9% of events. CONCLUSIONS: House officers detect many AEs among inpatients. Confidential peer interviews of front-line providers is a promising method for identifying medical errors and substandard quality. This research was supported in part by the CareGroup Center for Quality and Value. Preliminary data were presented at the Second Annenberg Conference on Enhancing Patient Safety and Reducing Errors in Health Care, Rancho Mirage, Calif, November 8–10, 1998, and an extended abstract published in the conference proceedings.     

Utility of pulmonary hypertension for the prediction of heart failure following acute myocardial infarction

Pulmonary hypertension (PH) is usually perceived as a complication of established heart failure (HF) rather than as a predictor of HF or a marker of subclinical HF. PH may develop because of cardiac alterations that result in increased filling pressures after acute myocardial infarction (AMI). We hypothesized that PH might be a useful marker to predict the risk of HF after AMI. We studied 1,054 patients with AMI. Pulmonary artery systolic pressure (PASP) was estimated using echocardiography at the index admission and PH was defined as a PASP >35 mm Hg. The primary end point was readmission for HF at 1 year. PH was present in 471 patients (44.6%) and was strongly associated with age, decreased ejection fraction, advanced diastolic dysfunction, and moderate/severe mitral regurgitation (p <0.0001 for all comparisons). Area under the receiver operating characteristic curve was significantly higher for estimated PASP (0.74 ± 0.02) compared to other echocardiographic parameters (p = 0.02 to 0.0003). After adjustments for clinical and echocardiographic variables in a Cox model, PH was associated with a hazard ratio of 3.10 for HF (95% confidence interval 1.31 to 2.57, p <0.0001). After adding estimated PASP to a model containing clinical and echocardiographic risk factors, net reclassification improvement was 0.21 (95% confidence interval 0.11 to 0.31, p <0.0001). In conclusion, PASP integrates the severity of multiple hemodynamic determinants of increased left atrial pressures that lead to an increase in pulmonary venous pressure. In AMI, PH at the index admission is a useful marker in unmasking latent subclinical HF and predicting the development of overt HF.