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Biomedical subjects

J H Grossman

Publications and source records attributed to J H Grossman.

At least 19 recordsLinked to original sources
PubMed1999

Academic health centers can bridge the gulf between medicine and public health.

The authors review why the gulf between clinical medicine and public health has existed since the first schools of public health were established in 1916. They emphasize that academic health centers (AHCs) have the potential to bring together these two perspectives--as well as the health services perspective--to clarify what they offer and to find creative ways to build upon their combined strengths. The authors describe institutional approaches that can be taken to narrow the gulf, with examples from the initiatives of this type that are under way at The George Washington University Medical Center in Washington, D.C. For example, the authors state and discuss in detail that an AHC's medical, public health, and health services institutions should be physically and institutionally close; that collaboration between them requires well-structured interaction; that institutional structures are needed to ensure cooperation when internal competition is likely; and that collaboration is fostered by new opportunities and the potential for new resources. The authors conclude by stating that the future will require that the health education and prevention perspective of public health, the treatment perspective of medicine, and the financial and management perspective of health services be developed and integrated into the work of AHCs, and give examples of specific activities that would be possible with such integration.

Academic Medical Centers↗
PubMed1997

Comparison of pregnancy outcome between treated and untreated women with chlamydial cervicitis.

BACKGROUND: Maternal, fetal, neonatal, and infant outcome in treated versus untreated pregnant women with positive endocervical cultures for Chlamydia trachomatis is controversial. METHODS: One thousand three hundred fifty pregnant women registering consecutively on the staff clinic service were screened for chlamydia. The results of the antigen, but not the culture tests, were available for clinical management. RESULTS: Eighty one patients had positive chlamydia cultures, a prevalence rate of 5.1%. Fifty eight patients were not treated, 44 because of false-negative direct antigen tests. Twenty three patients were treated. Maternal complications including abortion, preterm rupture of membranes, preterm delivery, chorioamnionitis, and endometritis were similar in the two groups. Similarly, neonatal and infant complications including prematurity, conjunctivitis, and pneumonia were similar in the two groups. CONCLUSIONS: Our findings suggest that further prospective, controlled culture based studies are needed before recommending routine screening for chlamydia even in high risk populations.

Adolescent↗
PubMed1994

The value of amniotic fluid interleukin-6 determination in patients with preterm labor and intact membranes in the detection of microbial invasion of the amniotic cavity.

OBJECTIVES: Our purpose was to (1) determine the value of amniotic fluid interleukin-6 determination in the detection of microbial invasion of the amniotic cavity and (2) compare interleukin-6 to other rapid tests in the evaluation of preterm labor. STUDY DESIGN: Amniotic fluid interleukin-6 was determined quantitatively by enzyme-linked immunosorbent assay in 91 amniotic fluid specimens obtained by amniocentesis in 89 patients with preterm labor. Amniotic fluid cultures for aerobes, anaerobes, and mycoplasma species were performed. Receiver-operator characteristic curve analysis, logistic regression analysis, and Cox's proportional-hazards model were used to explore the relationship between several explanatory and outcome variables. Diagnostic index values of interleukin-6, glucose level, Gram stain, leukocyte esterase, and limulus amebocyte lysate assay for prediction of a positive amniotic fluid culture, preterm delivery, clinical infection, and neonatal sepsis were calculated. RESULTS: The prevalence of positive amniotic fluid cultures was 13% (12/89). The median interleukin-6 concentration in patients with positive cultures was 241.8 ng/ml, in contrast to 0.291 ng/ml in patients with negative cultures (p. < 0.005). Sensitivity and specificity of an interleukin-6 level > or = 6.17 ng/ml was 75% and 79%, in contrast to that of glucose, < or = 12 mg/dl (83% and 86%) for a positive amniotic fluid culture and sensitivity (p = 0.26, z test). All patients with an interleukin-6 level > 6.17 ng/ml were delivered preterm, in contrast to 85.2% of patients with a glucose level < or = 12 mg/dl. When all rapid tests and clinical parameters were considered simultaneously in the logistic model, only interleukin-6 maintained a significant relationship to preterm birth (odds ratio 35, p = 0.003). Cox's proportional analysis demonstrated a strong relationship between interleukin-6 and the amniocentesis-to-delivery interval after clinical variables were controlled for (hazard ratio 3.01, p < 0.00001). CONCLUSION: Amniotic fluid interleukin-6 determination may be a useful adjunct to our armamentarium of rapid tests to exclude infection and predict delivery in patients with preterm labor and intact membranes.

Amniocentesis↗
PubMed1993

Cytobrush versus swab endocervical sampling for the detection of obstetric chlamydial infection.

Timely detection and treatment of chlamydial infections during pregnancy is an important public health issue. Exfoliated, infected cells must be present for successful detection of endocervical infection. We compared samples obtained using a cytobrush versus a Dacron-tipped applicator swab for tissue culture isolation of Chlamydia trachomatis from the cervices of 605 pregnant women. The prevalence of chlamydial infection was 5.1%. Cytobrush and Dacron-tipped swab sampling were equally accurate; each detected 80% of all chlamydial infections identified. There were no clinically significant obstetric complications following cytobrush sampling. Bacterial contamination was present in one third more samples obtained using the cytobrush than those obtained using the swab (p = .0001). Culture-independent diagnostic methods such as immunoassays may be preferable for diagnosis of chlamydial infection when cytobrush samples are processed from such clinical specimens.

Cervix Uteri↗
PubMed1993

Comparison of cytobrush and cotton swab for Papanicolaou smears in pregnancy.

Papanicolaou smears obtained using cytobrush or cotton swabs were compared in 222 pregnant women. There were no complications attributable to the cytobrush. Endocervical cell yields obtained with the brush were 70.9% compared to 41.9% with the swab (P = .0001). There was no difference between use of the swab and the brush in the prevalence of dysplasia (19 cases) nor was there any difference in the prevalence of dysplasia in the smears that contained endocervical and/or metaplastic cells (17/181 = 8.6%) compared to those not containing these cell types (2/24 = 8.3%). This study suggests that use of the cytobrush in pregnancy warrants further study because of the frequency with which smears are reported as inadequate because they lack endocervical and/or metaplastic cells.

Analysis of Variance↗
PubMed1992

Evaluation of rapid diagnostic tests in the detection of microbial invasion of the amniotic cavity.

OBJECTIVE: We sought to determine and compare the value of several rapid diagnostic tests in the detection of intraamniotic infection. STUDY DESIGN: Gram stain, intraamniotic glucose level determination, leukocyte esterase assay, and the Limulus amebocyte lysate assay were performed on 144 amniotic fluid specimens retrieved by transabdominal amniocentesis in 136 patients with preterm premature rupture of the membranes or preterm labor. Diagnostic indices for a positive amniotic fluid culture and the development of clinical infection were calculated for each rapid test. Receiver-operator characteristic curves were generated to help select the optimal glucose level and combination of tests to detect intraamniotic infection. RESULTS: The greatest sensitivity for predicting either a positive culture or subsequent clinical infection in preterm labor patients and in predicting clinical infection in patients with preterm premature rupture of the membranes was demonstrated by a low glucose level. The Gram stain provided the greatest positive predictive value in patients with preterm labor. Combining the Gram stain and measurement of intraamniotic glucose levels did not improve sensitivity above glucose alone or positive predictive value above Gram stain alone. CONCLUSION: Leukocyte esterase determination and Limulus amebocyte lysate assay are insensitive indicators of intraamniotic infection. Selection of Gram stain or glucose level measurement alone or in combination as an appropriate screen for intraamniotic infection will depend on the clinicians' false-positive rate threshold.

Adult↗
PubMed1992

The future of health care.

Future changes in patient care to curb costs and refocus on health versus medical care are discussed, and efforts at the New England Medical Center (NEMC) to measure patient outcomes and reorganize the delivery of care are described. Medical care is not the only determinant of an individual's health; lifestyle choices and the community also play important roles. The rate of increase in the cost of medical care must be contained. The future of health-care reform will be predicated on packages for the administration of care; for any given condition, all of the elements of medical care would be combined so that clinical and functional outcomes are achieved at a given price (episode-of-illness pricing). The success of medical care should be determined on the basis of the patient's ability to function, not on clinical indicators alone. Also, the prices for new generations of drugs should be determined on whether the new drugs improve patients' quality of life. Health-care professionals in hospitals should not be divided according to their specialties; instead, they should compose multidisciplinary teams that can care for patients over time. NEMC is developing a process and structure in which various health-care professionals work together to design health-care plans that cover a full episode of illness. The future of health care will also be influenced by global trends, including international medical-care inflation, standardization of process and outcome measurements, and a shift in emphasis from medicine to health. The health-care industry is in transition as this country searches for the best way to improve the health and functioning of each citizen.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost Control↗
PubMed1992

Management and therapy of human immunodeficiency virus-infected pregnancies in maternal-fetal medicine fellowship training programs.

OBJECTIVE: To determine attitudes and practices of obstetricians in maternal-fetal medicine fellowship programs regarding the management of human immunodeficiency virus (HIV) infection and the use of zidovudine during pregnancy. METHODS: We sent a questionnaire to the directors of all 78 approved maternal-fetal medicine fellowship programs. The responses, reflecting the consensus of the staffs of each program, were obtained and tabulated. RESULTS: Although their programs annually provide care for more than 2100 pregnant women infected with HIV, less than 25% of all maternal-fetal medicine fellowship directors reported that their patients participate in multicenter studies of HIV infection complicating pregnancy. Nearly two-thirds of the infected women are excluded from such multicenter studies. More than 70% of all program directors believe that zidovudine should be offered to symptomatic pregnant women infected with HIV; one-half question whether zidovudine poses short-term fetal risks. Nevertheless, nearly half of all HIV-infected pregnant women they manage are excluded from trials of zidovudine therapy during pregnancy. CONCLUSIONS: Many HIV-infected pregnant women who receive care in clinics of maternal-fetal medicine fellowship programs are excluded from multicenter studies. Consideration should be given to creating a national registry for this important, currently unreported, clinical resource.

Clinical Trials as Topic↗
PubMed1992

Pathfinder direct fluorescent antigen test for diagnosing maternal chlamydial infections. An evaluation.

Chlamydia trachomatis is a frequent cause of genital infections in young women. Chlamydial infections may adversely affect perinatal outcome. We compared the Pathfinder direct fluorescent antigen (DFA) test for chlamydial infections to tissue culture isolation in an obstetric population. Among 984 samples, 152 (15.4%) were inadequate for evaluation using the Pathfinder DFA test. Among 783 evaluable specimen pairs, the sensitivity, specificity, and positive and negative predictive values of the Pathfinder, as compared to tissue culture isolation, were 25%, 97.5%, 32.1% and 96.4%, respectively. On the basis of that experience, we do not recommend the Pathfinder DFA test as a clinical screening device for detecting chlamydial infections complicating pregnancy.

Chlamydia Infections↗
PubMed1992

TORCH infections. Diagnosis in the molecular age.

TORCH agents cause a varied spectrum of disease. Advances in ultrasound, invasive perinatal procedures and molecular diagnostics have allowed in utero evaluation. Infected fetuses, especially those which are sonographically abnormal, may be treated in utero depending upon the pathogen and attendant pathophysiology. Subclinical perinatal infections may lead to later childhood deficits. Such infected fetuses may benefit from early diagnosis and prompt initiation of rehabilitative measures.

Abbreviations as Topic↗
PubMed1991

Diagnosis of chlamydial infection in pregnant women using the Testpack Chlamydia diagnostic kit.

We compared the performance of Testpack Chlamydia to tissue culture isolation for detection of endocervical chlamydia in an obstetric clinic population at high risk for infection. Among 227 evaluable patients, 30 tissue culture-confirmed chlamydial infections were found (13.2%). The sensitivity, specificity, and positive and negative predictive values of Testpack compared with tissue culture isolation were 66.7, 95.4, 69.0, and 94.9%, respectively. This test can be performed on a desktop within 30 minutes by staff with limited laboratory experience and no special equipment. Based upon our preliminary experience, we believe that Testpack Chlamydia offers promise as a screening device for the detection of endocervical chlamydial infections in high-risk obstetric populations.

Chlamydia Infections↗