Evaluation of VIDAS Listeria monocytogenes II (LMO2) Immunoassay Method for the Detection of Listeria monocytogenes in Foods: Collaborative Study

A multilaboratory study was conducted to compare the VIDAS®Listeria monocytogenes II (LMO2) immunoassay and the standard cultural methods for the detection of Listeria monocytogenes in foods. Five food types—vanilla ice cream, brie cheese, cooked roast beef, frozen green beans, and frozen tilapia fish—at 3 levels were analyzed by each method. A total of 26 laboratories representing government and industry participated. In this study, 1404 test portions were analyzed of which 1152 were used in the statistical analysis. There were 448 positive by the VIDAS LMO2 assay and 457 positive by the standard culture methods. A χ2 analysis of each of the 5 food types, at the 3 inoculation levels tested, was performed. The resulting χ2 value, 0.36, indicates that overall, there are no statistical differences between the VIDAS LMO2 assay and the standard methods at the 5% level of significance.

Stress and working with addicts: a role for meditation?

Occupational stress is frequent among individuals whose work brings them into close contact with other people. One putative means of preventing or alleviating such stress is meditation (West, 1987). A six week course in meditation was recently held for staff in the Drug Dependence Service based at University College Hospital, London. The idea for the course came from the head of the unit who had personal experience of meditation. The course and its acceptability to staff are described below.

Effect of Intravenous Administration of Cobalt Chloride to Horses on Clinical and Hemodynamic Variables

Background

Cobalt chloride (CoCl₂) is administered to racehorses to enhance performance. The purpose of this study was to evaluate the clinical, cardiovascular, and endocrine effects of parenterally administered CoCl₂.

Objectives

To describe the effects of weekly intravenous doses of CoCl₂ on Standardbred horses.

Animals

Five, healthy Standardbred mares.

Methods

Prospective, randomized, experimental dose‐escalation pilot. Five Standardbred mares were assigned to receive 1 of 5 doses of CoCl₂ (4, 2, 1, 0.5, or 0.25 mg/kg) weekly IV for 5 weeks. Physical examination, blood pressure, cardiac output, and electrocardiography (ECG) were evaluated for 4 hours after administration of the first and fifth doses. Blood and urine samples were collected for evaluation of cobalt concentration, CBC and clinical chemistry, and hormone concentrations.

Results

All mares displayed pawing, nostril flaring, muscle tremors, and straining after CoCl₂ infusion. Mares receiving 4, 2, or 1 mg/kg doses developed tachycardia after dosing (HR 60–126 bpm). Ventricular tachycardia was noted for 10 minutes after administration of the 4 mg/kg dose. Increases in systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and mean arterial pressure (MAP) occurred after administration of all doses (4, 2, 1, 0.5, and 0.25 mg/kg). Profound hypertension was observed after the 4 mg/kg dose (SAP/DAP, MAP [mmHg] = 291–300/163–213, 218–279). Hemodynamics normalized by 1–2 hours after administration. ACTH and cortisol concentrations increased within 30 minutes of administration of all CoCl₂ doses, and cardiac troponin I concentration increased after administration of the 4 and 2 mg/kg doses.

Conclusions and Clinical Importance

The degree of hypertension and arrhythmia observed after IV CoCl₂ administration raises animal welfare and human safety concerns.

Simvastatin did not prevent nor restore ovariectomy-induced bone loss in adult rats

Current published results on whether statins have beneficial effects on bone metabolism have been conflicting so far. In order to further investigate if statins were promising candidates for the treatment for osteoporosis, we conducted a study in which rats were ovariectomized (OVX) at 6 months of age, allowed to lose bone for 60 days and followed by oral administration of simvastatin at the dose levels of 0.3-10 mg/kg/d for 60 days. PGE2 (6 mg/kg) was used as a positive control. Study endpoints included bone histomorphometry on the proximal tibial metaphysis (PTM) and the tibial diaphysis (TX), dual-energy X-ray absorptiometry on the right femur and micro computed tomography (ICT) on the 5th lumbar vertebra (LV). After 120 days of OVX, cancellous bone lost by 80% in the PTM and 18% in the LV accompanied by increased bone formation and resorption. Simvastatin at all dose levels did not affect bone volume, bone formation rate and bone erosion surface when compared to 120 day ovariectomized animals at all bone sites studied. By contrast, PGE2 restored cancellous and cortical bone area to sham control levels. In conclusion, this study demonstrated that unlike PGE2, oral administration of simvastatin did not have effects on cancellous or cortical bone formation and resorption; and consequently was not able to prevent further bone loss or restore bone mass in the osteopenic, OVX rats.

Detection and evaluation of intracranial aneurysms with 16-row multislice CT angiography

AIM

The aim of this study was to assess the usefulness of 16-row multislice CT angiography (CTA) in evaluating intracranial aneurysms, by comparison with conventional digital subtraction angiography (DSA) and intraoperative findings.

METHODS

A consecutive series of 57 patients, scheduled for DSA for suspected intracranial aneurysm, was prospectively recruited to have CTA. This was performed with a 16-detector row machine, detector interval 0.75 mm, 0.5 rotation/s, table speed 10mm/rotation and reconstruction interval 0.40 mm. CTA studies were independently and randomly assessed by two neuroradiologists and a vascular neurosurgeon blinded to the DSA and surgical findings. Review of CTA was performed on workstations with an interactive 3D volume-rendered algorithm.

RESULTS

DSA or intraoperative findings or both confirmed 53 aneurysms in 44 patients. For both independent readers, sensitivity and specificity per aneurysm of DSA were 96.2% and 100%, respectively. Sensitivity and specificity of CTA were also 96.2% and 100%, respectively. Mean diameter of aneurysms was 6.3mm (range 1.9 to 28.1 mm, SD 5.2 mm). For aneurysms of less than 3 mm, CTA had a sensitivity of 91.7% for each reader. Although the neurosurgeon would have been happy to proceed to surgery on the basis of CTA alone in all cases, he judged that DSA might have provided helpful additional anatomical information in 5 patients.

CONCLUSION

The diagnostic accuracy of 16-slice CTA is promising and appears equivalent to that of DSA for detection and evaluation of intracranial aneurysms. A strategy of using CTA as the primary imaging method, with DSA reserved for cases of uncertainty, appears to be practical and safe.

Why we should eliminate the due date: a truth in jest

We currently use flawed calculations to set a woman's due date based on menstrual periods to determine gestational age. We use the estimated gestational age to make management decisions based on our patients' individual needs. This principle is in contrast to our patients' use of dating to set an estimated date of confinement. This date is seen as a very specific point in time. Patients and their families plan on that date and become distressed when the expected date is not met. Given that many patients are induced electively, that many will have their delivery dates changed, and that many will have delivery dates adjusted for medical reasons, and most importantly given that dating is inaccurate and unreliable, we propose eliminating the due date. We propose giving patients a calculated assigned week of delivery at 32 weeks. An assigned week of delivery allows for individualization of obstetric care based on the needs of our patients, their support systems, and hospital staffing. We believe an assigned week of delivery will improve obstetric practice and patient satisfaction.

ADEPT: Addition of the AT1 receptor antagonist eprosartan to ACE inhibitor therapy in chronic heart failure trial: hemodynamic and neurohormonal effects

BACKGROUND

Persistent activation of the renin-angiotensin-aldosterone-system (RAAS) is known to occur in patients with chronic heart failure (CHF) despite treatment with angiotensin-converting enzyme inhibitor (ACE) therapy. When added to ACE inhibitors, angiotensin II type 1 (AT1) antagonists may allow more complete blockade of the RAAS and preserve the beneficial effects of bradykinin accumulation not seen with AT1 receptor blockade alone.

METHODS

Thirty-six patients with stable New York Heart Association class II-IV CHF receiving ACE inhibitor therapy were randomly assigned in a double-blind manner to receive either eprosartan, a specific competitive AT1 receptor antagonist (400 to 800 mg daily, n = 18) or placebo (n = 18) for 8 weeks. The primary outcome measure was left ventricular ejection fraction (LVEF) as measured by radionuclide ventriculography, and secondary measures were central hemodynamics assessed by Swan-Ganz catheterization and neurohormonal effects.

RESULTS

There was no change in LVEF with eprosartan therapy (mean relative LVEF percentage change [SEM] +10.5% [9.3] vs +10.1% [5.0], respectively; difference, 0.4; 95% confidence interval [CI], -20.8 to 21.7; P =.97). Eprosartan was associated with a significant reduction in diastolic blood pressure and a trend toward a reduction in systolic blood pressure compared with placebo (-7.3 mm Hg [95% CI, -14.2 to -0.4] diastolic; -8.9 mm Hg [95% CI, -18.6 to 0.8] systolic). No significant change in heart rate or central hemodynamics occurred during treatment with eprosartan compared with placebo. A trend toward an increase in plasma renin activity was noted with eprosartan therapy. Eprosartan was well tolerated, with an adverse event profile similar to placebo, whereas kidney function remained unchanged.

CONCLUSIONS

When added to an ACE inhibitor, eprosartan reduced arterial pressure without increasing heart rate. There was no change in LVEF after 2 months of therapy with eprosartan.

alpha-adducin and angiotensin I-converting enzyme polymorphisms in essential hypertension

This study focused on two genes that have previously been implicated in hypertension and may influence renal sodium handling, adducin, and angiotensin I-converting enzyme (ACE). We compared their polymorphic frequencies and interaction in patients with essential hypertension (n=128) and individually age- and gender-matched normotensive control subjects. The alpha-adducin G460W polymorphism was genotyped by DNA amplification and restriction digestion. The ACE I/D polymorphism was assayed by a triple-primer method, with a "nested" polymerase chain reaction primer situated completely within the insertion sequence of the I: allele. The distributions of genotypes and alleles for the two polymorphisms were not significantly different between the case and control populations, and the cross-classification of cases by alpha-adducin and ACE genotype gave a distribution similar to that of control subjects. We have previously reported that the distributions of genotypes for two linked polymorphisms in the aldosterone synthase gene (one in the steroidogenic factor-1 [SF-1] binding site and the other an intronic conversion [IC]) were significantly different between this cohort of essential hypertensives and matched control subjects. The cross-classification of cases by alpha-adducin and SF-1, alpha-adducin and IC, ACE and SF-1, and ACE and IC genotype gave a distribution similar to that of control subjects. Hence, no evidence was found to suggest an association between either the alpha-adducin G460W or the ACE I/D polymorphism and hypertension in a careful case-control study. Furthermore, the alpha-adducin G460W, ACE I/D, and aldosterone synthase SF-1 and IC polymorphisms do not appear to interact in our hypertensive population.

A multicentre, randomized, double-blind, placebo-controlled trial of naltrexone in the treatment of alcohol dependence or abuse

The opioid antagonist, naltrexone, is reported, in single centre studies, to improve the clinical outcome of individuals with alcohol dependence participating in outpatient psychosocial programmes. This is the first multicentre controlled study to evaluate the efficacy and safety of naltrexone as adjunctive treatment for alcohol dependence or abuse. Patients who met criteria for alcohol dependence (n = 169) or alcohol abuse (n = 6) were randomly assigned to receive double-blind oral naltrexone 50 mg daily (n = 90) or placebo (n = 85) for 12 weeks as an adjunct to psychosocial treatment. The primary efficacy variable was time to first episode of heavy drinking; secondary efficacy assessments included time to first drink, alcohol consumption, craving, and changes in the serum biological markers gamma-glutamyl transferase (GGT), and aspartate and alanine aminotransferases. Compliance was assessed by tablet counts and, in the naltrexone-treated group, by measurement of urinary concentrations of 6-ss-naltrexol. Forty-nine (58%) patients randomized to placebo and 53 (59%) randomized to naltrexone did not complete the study. In intention-to-treat analyses, there was no difference between groups on measures of drinking. The median reduction from baseline of serum GGT (P: < 0.05) and the reductions in alcohol craving (Obsessive and Compulsive Drinking Scale: OCDS) were greater in the naltrexone group (P: < 0.05), from approximately half-way through the study. Of 70 patients (35 placebo; 35 naltrexone) who met an a priori definition of compliance (80% tablet consumption, attendance at all follow-up appointments), those allocated to naltrexone reported consuming half the amount of alcohol (P: < 0.05), had greater median reduction in serum GGT activity (P: < 0.05), and greater reduction in alcohol craving (OCDS total score: P: < 0.05; Obsessive subscale score: P: < 0.05), compared to patients in the placebo group. Use of naltrexone raised no safety concerns. Naltrexone is effective in treating alcohol dependence/abuse in conjunction with psychosocial therapy, in patients who comply with treatment.

Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI

CONTEXT

Issues of cost and quality are gaining importance in the delivery of medical care, and whether quality of care is better in teaching vs nonteaching hospitals is an essential question in this current national debate.

OBJECTIVE

To examine the association of hospital teaching status with quality of care and mortality for fee-for-service Medicare patients with acute myocardial infarction (AMI).

DESIGN, SETTING, AND PATIENTS

Analysis of Cooperative Cardiovascular Project data for 114,411 Medicare patients from 4361 hospitals (22,354 patients from 439 major teaching hospitals, 22,493 patients from 455 minor teaching hospitals, and 69,564 patients from 3467 nonteaching hospitals) who had AMI between February 1994 and July 1995.

MAIN OUTCOME MEASURES

Administration of reperfusion therapy on admission, aspirin during hospitalization, and beta-blockers and angiotensin-converting enzyme inhibitors at discharge for patients meeting strict inclusion criteria; mortality at 30, 60, and 90 days and 2 years after admission.

RESULTS

Among major teaching, minor teaching, and nonteaching hospitals, respectively, administration rates for aspirin were 91.2%, 86.4%, and 81.4% (P<.001); for angiotensin-converting enzyme inhibitors, 63. 7%, 60.0%, and 58.0% (P<.001); for beta-blockers, 48.8%, 40.3%, and 36.4% (P<.001); and for reperfusion therapy, 55.5%, 58.9%, and 55.2% (P =.29). Differences in unadjusted 30-day, 60-day, 90-day, and 2-year mortality among hospitals were significant at P<.001 for all time periods, with a gradient of increasing mortality from major teaching to minor teaching to nonteaching hospitals. Mortality differences were attenuated by adjustment for patient characteristics and were almost eliminated by additional adjustment for receipt of therapy.

CONCLUSIONS

In this study of elderly patients with AMI, admission to a teaching hospital was associated with better quality of care based on 3 of 4 quality indicators and lower mortality. JAMA. 2000;284:1256-1262

Venous thromboembolism and oral contraceptive use: a methodological study of diagnostic suspicion and referral bias

BACKGROUND

In studies of oral contraceptive oral contraceptive use and risk of venous thromboembolism, bias related to heightened diagnostic suspicion and preferential referral of oral contraceptive users has been an issue. The aim of our study was to determine the presence and potential impact of diagnostic suspicion and referral bias.

METHODS

We conducted a case/non-case study in 21 regional study centers in Germany and, in parallel, a conventional case-control study using the same cases but randomly selected population controls from the same areas. Women with symptoms compatible with venous thromboembolism were included in the study between 1994 and 1999, and classified as cases or non-cases (first reference group) according to the diagnostic work-up (case/non-case study). A second reference group consisted ofpopulation controls (conventional case-control study as an internal comparison for the case/non-case study): 606 cases, 462 non-cases and 2942 population controls aged 15-49 years. Adjusted unconditional regression analyses were performed.

RESULTS

Adjusted odds ratios for venous thromboembolism in oral contraceptive users were systematically higher in the classical case-control study compared to the case/non-case approach (using the same cases) across all subgroup analyses (e.g. for idiopathic cases, the odds ratio was 67% higher in the case-control study: 4.33 (95% confidence interval (CI) 3.27-5.74) versus 2.60 (95% CI 1.75-3.88)). We found a significantly increasing trend of oral contraceptive use in four categories of increasingly sophisticated diagnostic tests that were applied to 1067 women with a suspicion of venous thromboembolism, irrespective of the outcome. Stratified analysis showed the diagnostic level to be a confounder.

CONCLUSION

In our population-based study with the possibility of internal comparison, we found clear evidence that diagnostic suspicion and referral bias does play an important role in case-control studies of venous thromboembolism risk among oral contraceptive users. This underlines the importance of making an effort to avoid this bias when designing a new study.

Venous thromboembolism and combined oral contraceptives: does the type of progestogen make a difference?

Venous thromboembolism (VTE) is rare in young women but is associated with the use of combined oral contraceptives (OCs). In 1995 and 1996, three studies showed a difference in the risk of VTE with third-generation OCs containing the progestogens, desogestrel or gestodene, compared with earlier formulations. However, the subsequent MediPlus study did not show any difference in the risk of VTE between users of third- and second-generation OCs. To re-examine the risks of VTE with various OCs, a nested case-control study was undertaken using the General Practice Research Database (GPRD). This study identified 293 cases and selected up to four controls matched for year of birth, practice, and event date. Adjustment for confounding variables included: body mass index, smoking, asthma, diastolic blood pressure, and a proxy for recent illness. The new analysis of the GPRD showed that there was no statistically significant difference in the risk of VTE among users of third-generation OCs compared with second-generation OCs containing levonorgestrel 150 microg plus ethinylestradiol 30 microg. Important associations with idiopathic VTE included: age, obesity, smoking, recent concurrent illness, and asthma. Thus, any difference previously noted between OCs containing desogestrel or gestodene and levonorgestrel are likely to be due to the healthy-user effect, prescribing bias and inadequate control of known confounding variables, such as age and obesity.

Mycobacterium chelonae sepsis associated with long-term use of an intravenous catheter for treatment of hyperemesis gravidarum. A case report

BACKGROUND

Of the 1-2% of pregnant women who develop hyperemesis, the great majority are managed successfully with antiemetics and, when needed, short courses of parenteral medications. Only rarely will chronic parenteral therapy be necessary. Such therapy may be associated with significant complications.

CASE

A 38-year-old woman, gravida 3, para 1, induced abortion 1, with a history of hyperemesis in her first pregnancy, developed recurrent hyperemesis at 9 weeks' gestation. After four admissions and a 5.45-kg weight loss at 12 weeks' gestation, a Groshong catheter was placed in the left subclavian vein. The patient was then managed with home droperidol infusions and intravenous hydration as needed. At 30 weeks' gestation she developed tender, erythematous nodules over her legs and right arm. Culture from a biopsy of the nodules grew Mycobacterium chelonae, as did the catheter tip. M chelonae is a ubiquitous, opportunistic, nontuberculous (atypical) mycobacterium. The patient responded slowly to clarithromycin. At 37 weeks she delivered a healthy, 4,080-g, male infant. Three months postpartum the nodules continued to resolve slowly on clarithromycin.

CONCLUSION

When chronic parenteral therapy is required for hyperemesis gravidarum, attention must be given to potential complications. Indwelling catheters should be removed as soon as possible.

Preeclampsia into eclampsia: toward a new paradigm

OBJECTIVE

This study was undertaken to characterize aspects of the natural history of eclampsia.

STUDY DESIGN

A retrospective analysis was performed on the records of patients with eclampsia who were delivered at two tertiary care hospitals.

RESULTS

Fifty-three pregnancies complicated by eclampsia were identified. Thirty-seven of the women were nulliparous. The mean age was 22 years (range, 15-38 years). Mean gestational age at the time of seizures was 34.2 weeks' gestation (range, 22-43 weeks' gestation). Twenty-eight women had antepartum seizures (53%); 23 of the 28 had seizures at home. Nineteen women had intrapartum seizures (36%). Eight of these women had seizures while receiving magnesium sulfate, and 7 had therapeutic magnesium levels. Six women had postpartum seizures (11%), 4 >24 hours after delivery. Headache preceded seizures in 34 cases. Visual disturbance preceded seizures in 16 cases. The uric acid level was elevated to >6 mg/dL in 43 women. There were no maternal deaths or permanent morbidities. There were 4 perinatal deaths. Two patients had intrauterine fetal deaths at 28 and 36 weeks' gestation. These mothers had seizures at home. One infant died of complications of prematurity at 22 weeks' gestation and one died of respiratory complications at 26 weeks' gestation. There were 4 cases of abruptio placentae, 1 of which resulted in fetal death. Of the 53 cases of eclampsia, only 9 were potentially preventable. One of these was that of a woman who was being observed at home. The other 8 women were hospitalized and had hypertension and proteinuria. Only 7 women could be considered to have severe preeclampsia before seizure (13%), and 4 of these 7 women were receiving magnesium sulfate.

CONCLUSIONS

Eclampsia was not found to be a progression from severe preeclampsia. In 32 of 53 cases (60%) seizures were the first signs of preeclampsia. In this series eclampsia appeared to be more of a subset of preeclampsia. Only 9 cases of eclampsia were potentially preventable with current standards of practice. Our paradigm for this disease, as well as our approach to seizure prophylaxis, should be reevaluated.

Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction

BACKGROUND

There are few reports describing the combined influence of the race and sex of a patient on the use of reperfusion therapy for acute myocardial infarction.

METHODS

To determine the relation of race and sex to the receipt of reperfusion therapy for myocardial infarction in the United States, we reviewed the medical records of 234,769 Medicare patients with myocardial infarction. From these records we identified 26,575 white or black patients who met strict eligibility criteria for reperfusion therapy. We then performed bivariate and multivariate analyses of prevalence ratios to determine predictors of the use of reperfusion therapy in four subgroups of patients categorized according to race and sex: white men, white women, black men, and black women.

RESULTS

Among eligible patients, white men received reperfusion therapy with the highest frequency (59 percent), followed by white women (56 percent), black men (50 percent), and black women (44 percent). After adjustment for differences in demographic and clinical characteristics, white women were as likely as white men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.98 to 1.03). Likewise, black women were as likely as black men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.89 to 1.13). However, black women were significantly less likely to receive reperfusion therapy than white men (prevalence ratio, 0.90; 95 percent confidence interval, 0.82 to 0.98), as were black men (prevalence ratio, 0.85; 95 percent confidence interval, 0.78 to 0.93).

CONCLUSIONS

After adjustment for differences in clinical and demographic characteristics and clinical presentation, differences according to sex in the use of reperfusion therapy are minimal. However, blacks, regardless of sex, are significantly less likely than whites to receive this potentially lifesaving therapy.

Endothelial dysfunction in renal transplant recipients maintained on cyclosporine

BACKGROUND

Hypertension is almost universal following renal transplantation and may contribute to the already poor cardiovascular prognosis of this group. Cyclosporine-induced hypertension is a particular problem and has variously been attributed to increased sympathetic nerve activity, salt and water retention, and increased circulating endothelin levels. However, the effects of cyclosporine on the L-arginine/nitric oxide (NO) system in vivo in humans are unknown. In this present study, we examined basal and stimulated NO production from the vascular endothelium in cyclosporine-treated renal transplant recipients using the technique of forearm venous plethysmography.

METHODS

In study 1, stimulated NO production was assessed in 9 cyclosporine-treated renal transplant recipients (CsA), 7 azathioprine-treated renal transplant recipients (AZA), and 12 controls, using carbachol (an endothelium-dependent vasodilator) and sodium nitroprusside (an endothelium-independent vasodilator). In study 2, basal NO production was assessed in 9 cyclosporine-treated patients and 11 controls using L-NMMA (inhibits NO synthase), with norepinephrine as a control vasoconstrictor. Drugs were infused into the nondominant forearm through a sterile 27-gauge needle, and changes in forearm blood flow (FBF) were measured using venous occlusion plethysmography.

RESULTS

In study 1, sodium nitroprusside caused a similar dose-dependent increase in FBF in all groups. However, the median (range) percentage increase FBF to carbachol (3 micrograms/min) was markedly reduced in the CsA patients (188.8; 72.5 to 385.1) compared with AZA patients (378.1; 124.0 to 548.9; P = 0.042) and to controls (303.8; 124.8 to 813.3; P = 0.028). In study 2, the maximum percentage reduction in FBF to L-NMMA (4 mumol/min) was less pronounced in CsA patients (-19.5; -4.7 to -63.1) compared with controls (-39.5; -15.7 to -52.8; P = 0.056), and while controls vasoconstricted to the maximum dose of norepinephrine (240 pmol/min) as expected (-26.9; -1.4 to -38.6), CsA patients as a group tended to vasodilate (7.9; -36.8 to 92.6; P = 0.02).

CONCLUSION

These data demonstrate impaired stimulated and basal NO production in CsA patients, indicating endothelial dysfunction. This may predispose patients to atherosclerosis and may be involved in the etiology of post-transplant hypertension.

The art and science of chart review

BACKGROUND

Explicit chart review was an integral part of an ongoing national cooperative project, "Using Achievable Benchmarks of Care to Improve Quality of Care for Outpatients with Depression," conducted by a large managed care organization (MCO) and an academic medical center. Many investigators overlook the complexities involved in obtaining high-quality data. Given a scarcity of advice in the quality improvement (QI) literature on how to conduct chart review, the process of chart review was examined and specific techniques for improving data quality were proposed.

METHODS

The abstraction tool was developed and tested in a prepilot phase; perhaps the greatest problem detected was abstractor assumption and interpretation. The need for a clear distinction between symptoms of depression or anxiety and physician diagnosis of major depression or anxiety disorder also became apparent. In designing the variables for the chart review module, four key aspects were considered: classification, format, definition, and presentation. For example, issues in format include use of free-text versus numeric variables, categoric variables, and medication variables (which can be especially challenging for abstraction projects). Quantitative measures of reliability and validity were used to improve and maintain the quality of chart review data. Measuring reliability and validity offers assistance with development of the chart review tool, continuous maintenance of data quality throughout the production phase of chart review, and final documentation of data quality. For projects that require ongoing abstraction of large numbers of clinical records, data quality may be monitored with control charts and the principles of statistical process control.

RESULTS

The chart review module, which contained 140 variables, was built using MedQuest software, a suite of tools designed for customized data collection. The overall interrater reliability increased from 80% in the prepilot phase to greater than 96% in the final phase (which included three abstractors and 465 unique charts). The mean time per chart was calculated for each abstractor, and the maximum value was 13.7 +/- 13 minutes.

CONCLUSIONS

In general, chart review is more difficult than it appears on the surface. It is also project specific, making a "cookbook" approach difficult. Many factors, such as imprecisely worded research questions, vague specification of variables, poorly designed abstraction tools, inappropriate interpretation by abstractors, and poor or missing recording of data in the chart, may compromise data quality.

Titration of vasodilator therapy in chronic heart failure according to plasma brain natriuretic peptide concentration: randomized comparison of the hemodynamic and neuroendocrine effects of tailored versus empirical therapy

BACKGROUND

Most patients with chronic heart failure (CHF) receive the same dose of angiotensin-converting enzyme (ACE) inhibitors because there is currently no measure of treatment efficacy. We sought to determine whether titration of vasodilator therapy according to plasma brain natriuretic peptide (BNP) concentration may be of value in the individual optimization of vasodilator therapy in CHF.

METHODS AND RESULTS

Twenty patients with mild to moderate CHF receiving stable conventional therapy including an ACE inhibitor were randomly assigned to titration of ACE inhibitor dosage according to serial measurement of plasma BNP concentration (BNP group) or optimal empirical ACE inhibitor therapy (clinical group) for 8 weeks. Only the BNP-driven approach was associated with significant reductions in plasma BNP concentration throughout the duration of the study and a significantly greater suppression when compared with empiric therapy after 4 weeks [-42.1% (-58.2, -19.7) vs -12.0% (-31.8, 13.8), P =.03]. Both treatment strategies were well tolerated and associated with favorable neurohormonal and hemodynamic effects; however, in comparison between groups, mean heart rate fell (P =.02) and plasma renin activity rose (P =.03) in the BNP group when compared with the clinical group.

CONCLUSIONS

Plasma BNP concentration may be chronically reduced by tailored vasodilator therapy in CHF. Furthermore, titration of vasodilator therapy according to plasma BNP was associated with more profound inhibition of the renin-angiotensin-aldosterone system and significant fall in heart rate when compared with empiric therapy.

Clinical information for research; the use of general practice databases

General practice computers have been widely used in the United Kingdom for the last 10 years and there are over 30 different systems currently available. The commercially available databases are based on two of the most widely used systems--VAMP Medical and Meditel. These databases provide both longitudinal and cross-sectional data on between 1.8 and 4 million patients. Despite their availability only limited use has been made of them for epidemiological and health service research purposes. They are a unique source of population-based information and deserve to be better recognized. The advantages of general practice databases include the fact that they are population based with excellent prescribing data linked to diagnosis, age and gender. The problems are that their primary purpose is patient care and the database population is constantly changing, as well as the usual problems of bias and confounding that occur in any observational studies. The barriers to the use of general practice databases include the cost of access, the size of the databases and that they are not structured in a way that easily allows analysis. Proper utilization of these databases requires powerful computers, staff proficient in writing computer programs to facilitate analysis and epidemiologists skilled in their use. If these structural problems are overcome then the databases are an invaluable source of data for epidemiological studies.

Measurement of mammography rates for quality improvement

To determine the best source of high-quality data related to mammography rates, a study was undertaken to compare chart audit and claims data from the Health Care Financing Administration's Ambulatory Quality Improvement Project. Because claims data captured a higher percentage of mammograms than chart audit data in this study, quality improvement projects should consider utilizing claims data only to ascertain mammography rates.

Effects of timely antibiotic administration and culture acquisition on the treatment of urinary tract infection

The purpose of this study was to assess the timeliness of initial antibiotic administration and culture acquisition for Medicare patients discharged with a principal diagnosis of urinary tract infection. The main outcome measurement was reduced length of stay. Data were collected retrospectively from 24,389 randomly selected discharged Medicare patients from September 1, 1994, to August 31, 1995. Only 61% of the cases as urinary tract infection had adequate criteria to confirm the diagnosis. Of these cases, antibiotics were administered within 4 hr after presentation in 40.9% patients. Urine cultures within 24 hr of presentation were noted more frequently (94%)than blood cultures (66%). Urine cultures obtained before antibiotic administration were noted more frequently (82%) than were blood cultures (58%). Timely antibiotic administration and the acquisition of urine cultures in the first 24 hr of hospitalization were independently associated with shorter length of stay.

Sexual abuse and the subsequent development of alcohol problems

The literature on sexual abuse and alcohol problems has been reviewed. Various methodological issues are relevant in determining whether there is merely an association or also a causal relationship. These include the definition of sexual abuse, the degree and timing of abuse, the methods of data collection, sample selection, the presence or absence of control groups, possible recall bias, difficulties with prospective studies for this subject, and the definition of alcohol misuse or dependence. Results with community and victim samples are conflicting, but studies on samples of problem drinkers suggest an association between severe alcohol problems and previous sexual abuse, at least in women. The association may be especially strong for earlier and more severe forms of sexual abuse. Possible mechanisms for an association were examined and are: (1) sexual abuse as a cause of alcohol misuse; (2) alcohol misuse predisposing people to sexual assault; (3) sexual assault and alcohol misuse both resulting from another factor; (4) sexual abuse predisposing to other conditions associated with alcohol misuse; and (5) an artefactual association. Regardless of the role of sexual abuse in causing alcohol problems, the available evidence suggests that victims of sexual abuse may present to services with more problematical patterns of drinking and more concurrent psychiatric disorder.