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Biomedical subjects

S D Fihn

Publications and source records attributed to S D Fihn.

At least 73 records · Page 4Linked to original sources
PubMed1991

Status report on ambulatory care and education in the VA Western Region and western medical schools.

Since the initial 1988 Ambulatory Care and Education (ACE) conference, reported in the October 1989 supplement to Academic Medicine, the Western Region Veterans Health Administration and its 11 affiliated western medical schools have established several programs and related activities that implement strategic ACE recommendations. This report gives an update on the ACE Advisory Group; the Pilot Ambulatory Care and Education (PACE) Center at the VA Medical Center, Sepulveda, California; other innovative ambulatory care and education projects; the second ACE Development Conference; and future activities in the expanded Western Region of the Department of Veterans Affairs.

Ambulatory Care↗
PubMed1989

Association between bacterial vaginosis and acute cystitis in women using diaphragms.

We hypothesized that the increased vaginal fluid pH and altered vaginal microflora characteristic of bacterial vaginosis might predispose young women to introital colonization with Escherichia coli and to acute cystitis. To evaluate this hypothesis, we studied 291 women who presented with acute urinary symptoms for association of clinically defined bacterial vaginosis and vaginal conditions associated with this syndrome (increased vaginal fluid pH, absence of lactobacilli, and abnormal vaginal fluid gas-liquid chromatographic patterns) with E coli introital colonization and urinary tract infection. Escherichia coli introital colonization and urinary tract infection were both significantly more frequent among women with a high vaginal fluid pH, an absence of vaginal lactobacilli, or an abnormal vaginal fluid gas-liquid chromatographic pattern characteristic of bacterial vaginosis. Escherichia coli introital colonization was also more frequent in women with bacterial vaginosis. These associations and an association of bacterial vaginosis and E coli urinary tract infection were strong only among the 144 women who were diaphragm users. We conclude that bacterial vaginosis, or an altered vaginal microflora as reflected by an abnormal gas-liquid chromatographic pattern characteristic of bacterial vaginosis, is associated with E coli introital colonization and acute symptomatic urinary tract infection in women who use diaphragms.

Acute Disease↗
PubMed1989

Ambulatory care research in the VA: present status and recommendations for the future.

The growth of ambulatory care delivery in the Department of Veterans Affairs (VA) has been accompanied by increasing interest in and need for ambulatory care research. Results from a national survey of academic general internal medicine units suggest that those that share VA and university affiliation tend to be more successful than those that are unaffiliated. The VA must strive to improve the environment for ambulatory care research. Among other things, this will entail providing adequate protected time to ambulatory care faculty and developing a uniform ambulatory care database to facilitate longitudinal, population-based research. Extended fellowships in ambulatory care and faculty development programs for existing staff will be required to create a core of competent investigators. The VA must also provide increased funding to the Health Services Research and Development and Cooperative Studies programs. Special funding programs targeted to key areas such as quality assurance, medical education, and direct patient care should be established. In addition, the VA should seek to develop joint ventures with other funding agencies for innovative ambulatory care initiatives.

Ambulatory Care↗
PubMed1988

Utilization and yield of drug screening in the emergency department.

Emergency qualitative tests for drugs are commonly ordered during evaluation of cases of suspected drug overdose. We prospectively compared the utilization and yield of drug screens based on urine and of identical tests of gastric contents under actual clinical conditions in a busy metropolitan emergency department. During the 4.5-month study period, physicians ordered drug screening in 405 of 582 (70%) study cases. Screens of both types of body fluid were ordered in only 95 cases (16%), suggesting study physicians regarded these tests to be functionally equivalent. Drug screens of gastric fluid were favored in cases involving acute ingestion and in medically complicated cases requiring gastric lavage. Urine drug screens were favored in clinically stable cases with primarily thought or behavior disorders. In the 95 cases for which both drug screens were ordered, gastric screens in 18 cases detected 20 drugs not detected by urine drug screening. Urine screening, on the other hand, identified 74 drugs not found on gastric screening in 48 cases. Gastric drug screening also performed poorly in comparison to quantitative serum drug levels. Seventeen false-positive urine or gastric screens were noted as well. Despite significant technical limitations, physicians frequently order drug screens in our emergency department. Qualitative drug screening of gastric fluid may prove useful in cases involving acute ingestion, but samples of urine and serum must also be submitted for analysis if optimal test performance is to be achieved.

Acute Disease↗
PubMed1988

A general method of compliance assessment using centralized pharmacy records. Description and validation.

The prescription refill records of centralized pharmacies are a potential source of information about patient compliance with long-term medications. We developed a method for assessing compliance in such settings and validated our measures using pharmacy data and clinical information from patients with seizure disorders and hypertension. For patients taking the anticonvulsant medication phenytoin, compliance with the drug correlated significantly with mean plasma phenytoin level. For patients on antihypertensive medications, compliance with the treatment regimen correlated with control of diastolic blood pressure. Many patients (15% in the phenytoin validation, and 33% in the blood pressure validation) obtained substantial oversupplies of medications; for these patients, the direct relationship between compliance and drug effect was not evident. A majority of seizure patients with "subtherapeutic" mean plasma phenytoin levels were identified as noncompliant using our measures. We conclude that our method of assessing compliance in obtaining medications is feasible in "managed care" settings, appears to be a valid correlate of drug effects, and may be useful in research and patient care.

Computers↗
PubMed1988

Trimethoprim-sulfamethoxazole for acute dysuria in women: a single-dose or 10-day course. A double-blind, randomized trial.

STUDY OBJECTIVE: To compare single-dose and 10-day treatment regimens of trimethoprim-sulfamethoxazole in women with acute dysuria, urgency, or urinary frequency. DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: Student health center at a major university. PATIENTS: Consecutive sample of 255 young women including 216 with a bacteriologically documented urinary tract infection. INTERVENTION: Single-dose treatment (trimethoprim, 320 mg and sulfamethoxazole, 1600 mg) given to 116 women and 10-day treatment (trimethoprim, 160 mg and sulfamethoxazole, 800 mg, twice daily) given to 125 women. Women with a history of sulfonamide allergy were given trimethoprim alone: 10 received single-dose treatment (200 mg) and 5 received 10-day treatment (100 mg, twice daily). MEASUREMENTS AND MAIN RESULTS: The rates for resolution of symptoms at 3 days, 13 days, and 6 weeks after entry into the study were not significantly different between treatment groups. Among women with urinary tract infections, cumulative crude rates of recurrence in the single-dose and 10-day treatment groups, respectively, were 24% compared with 5% at 13 days after entry (P = 0.0002; 95% confidence interval [CI] for difference in proportions, 10%, 28%) and 32% compared with 21% at 6 weeks after entry (P = 0.07; 95% Cl, -2%, 24%). Factors independently associated with lower cure rates were a history of a urinary tract infection within the previous 6 weeks (adjusted odds ratio [OR], 3.8; 95% Cl, 1.4 to 10.6) and presence of 10(5) bacteria/mL or greater in an initial midstream culture (adjusted OR, 2.9; 95% Cl, 1.2 to 7.0). After controlling for these factors, the risk of failure after single-dose treatment was not statistically significantly different from 10-day treatment at 6 weeks (adjusted OR, 1.6; 95% Cl, 0.8 to 3.2; P = 0.21). Compared to 10-day treatment, single-dose treatment less effectively eradicated Escherichia coli from the vaginal flora (P less than 0.001) and led more often to early same-strain recurrences (P = 0.003). Meaningful adverse effects occurred in 12% of women given single-dose treatment compared with 25% of women receiving 10-day treatment (P = 0.009). CONCLUSIONS: Compared with single-dose treatment, 10-day treatment yields a superior cure rate at 2 weeks after the start of treatment, but by 6 weeks the advantage of longer treatment no longer exists. This effect may be explained by the lesser effectiveness of single-dose treatment in eradicating vaginal E. coli, resulting in more frequent same-strain recurrences within 2 weeks of treatment.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1987

Impact of drug screening in suspected overdose.

We studied how emergency qualitative drug screens were ordered and used during the evaluation of 405 consecutive adult patients presenting to a metropolitan emergency department with suspected drug intoxication. Physicians completed a two-part questionnaire outlining diagnosis, diagnostic certainty, suspected drug(s), and management plans immediately following initial evaluation and again at the time of ED disposition. Screen results were reviewed prior to ED disposition in 361 (89%) cases. We found that qualitative drug screens were associated with substantial changes in diagnostic certainty, as measured by changes in probability estimates and changes in absolute mean log-likelihood ratios. In 196 cases for which all data were recorded prospectively, drug screens excluded a diagnosis of drug intoxication or specifically suspected drugs in 81 cases (41%), but identified previously unsuspected drugs in only 21 cases (11%, P less than .001). Management changes followed qualitative drug screen results in 16 of 361 cases overall (4.4%), but seven of these were also associated with diagnostic quantitative serum drug levels. Potentially critical interventions were begun in two cases following positive screens but delayed in another due to a falsely negative screen. Guidelines for more efficient test utilization are proposed.

Emergencies↗
PubMed1987

Diagnosis of bacteriuria in men: specimen collection and culture interpretation.

Bacteriologic criteria for diagnosing urinary tract infections in men have not been well defined. For determination of the bacterial colony count in voided specimens that most accurately reflects bladder bacteriuria, culture results were compared for voided urine and bladder urine (obtained by suprapubic aspiration and urethral catheterization) from men with various genitourinary problems. Bladder bacteriuria was found in 36 (47.3%) of 76 sets of specimens from 66 individuals. Culture results of bladder specimens showed excellent agreement with those of clean-catch midstream-void and uncleansed first-void specimens (weighted kappa = 0.924 and 0.906, respectively). The criterion for clean-catch midstream-void specimens that best differentiated sterile from infected bladder urine was growth of greater than or equal to 10(3) cfu of one predominant species/ml; this definition had a sensitivity of 0.97 and a specificity of 0.97. Uncleansed first-void specimens were equally sensitive (0.97) but less specific (0.91-0.92) in detection of bacteriuria. Pyuria (greater than or equal to leukocytes/mm3) and irritative genitourinary symptoms showed modest correlations with bladder bacteriuria.

Bacteria↗
PubMed1986

Diaphragm use and urinary tract infections: analysis of urodynamic and microbiological factors.

To investigate how diaphragm use predisposes to urinary tract infection we studied 22 women who experienced 1 or more urinary tract infections while using a diaphragm and 21 who used a diaphragm and did not have a urinary tract infection. For women with and without a prior urinary tract infection the mean peak urine flow rate was significantly less with than without a diaphragm. However, the mean decrease in peak urine flow rate with a diaphragm was not significantly greater for women with a prior urinary tract infection. There also was no significant increase in time to peak flow with the diaphragm in place. Women who reported a sensation of obstruction to voiding with a diaphragm demonstrated a significant decrease in peak urine flow rate and this finding was particularly apparent in those with a history of urinary tract infection in whom the peak urine flow rate decreased by an average of 10.0 ml. per second. Current users of a diaphragm with a history of urinary tract infection had heavier growth of coliform organisms from cultures of the vagina and urethra, and significantly more episodes of infection than women without such a history (p equals 0.03 and 0.05, respectively). We conclude that use of a diaphragm can cause urinary obstruction in some women but that the obstruction is of relatively small magnitude and does not correlate with the acquisition of a urinary tract infection. Changes in vaginal flora associated with diaphragm use may be of greater importance.

Adult↗
PubMed1985

Association between diaphragm use and urinary tract infection.

We conducted independent case-control and retrospective cohort investigations to assess the relationship between diaphragm use and urinary tract infection (UTI). In the former, we compared diaphragm use and vaginal flora among 114 women with acute UTI and 85 women with acute urinary tract symptoms and no UTI. In the latter study, we ascertained the incidence of UTI in 192 diaphragm users and 182 women taking oral contraceptives during a mean follow-up of 9.4 months. Both studies demonstrated a significantly increased risk of UTI in diaphragm users: relative odds were 2.0 in the case-control study and the relative risk was 2.5 in the retrospective cohort study. Vaginal colonization with Escherichia coli was significantly greater in diaphragm users. The incidence of UTI in the cohort study was 26.6 per 1,000 patient-months for diaphragm users and 8.9 per 1,000 patient-months for women taking oral contraceptives. The increased risk of UTI in diaphragm users could not be attributed to differences in age, parity, sexual activity, or previous UTI.

Adolescent↗
PubMed1984

Establishing the cause of genitourinary symptoms in women in a family practice. Comparison of clinical examination and comprehensive microbiology.

We conducted a prospective study comparing the diagnostic yield of standard clinical examinations and of comprehensive microbiological studies in establishing the etiology of genitourinary (GU) symptoms and the prevalence of GU tract infections in 204 women seen in a university-based family practice. Two thirds were initially seen with GU symptoms and one third were seen for routine examinations. In each case we obtained demographic and historical information, a physical examination, and a variety of laboratory tests, including research procedures not commonly available. Diagnoses considered were urinary tract infection and sterile pyuria; trichomonal, yeast, and nonspecific vaginitis; and GU tract infection with Neisseria gonorrhoeae, Chlamydia trachomatis, or herpes simplex virus. Using strategies commonly employed in practice, we reached a diagnosis in only 34% of symptomatic women, a figure rising to 66% when selected, nonroutine laboratory examinations were added.

Adolescent↗
PubMed1984

Should single-phase radionuclide bone imaging be used in suspected osteomyelitis?

The records of 69 patients who had 86 delayed, static radionuclide bone images for suspected osteomyelitis were studied to determine the effects of this procedure on diagnosis and treatment. Sensitivity, specificity, and positive predictive value were lower than reported in several other studies. When osteomyelitis was unlikely, imaging was either negative or falsely positive and rarely affected treatment. In 46 cases where osteomyelitis was more likely, imaging potentially changed therapy in 19 but was unhelpful or misleading in 15. One third of the interpretations were "equivocal" and these were incorrect four times more often than "definite" readings. Two false-positive images led to unnecessary surgeries, and one patient with negative images died with unrecognized osteomyelitis. Static-phase images with "definite" interpretations, particularly when negative, are specific, but "equivocal" studies may lead to diagnostic and therapeutic errors. When osteomyelitis is improbable, imaging rarely changes diagnosis or therapy.

Adolescent↗