Biomedical subjects

Stephan D Fihn

Publications and source records attributed to Stephan D Fihn.

58 records · Page 4Linked to original sources

PubMed2002

Using quality of life to predict hospitalization and mortality in patients with obstructive lung diseases.

STUDY OBJECTIVES: Condition-specific measures of quality of life (QOL) for patients with COPD have been demonstrated to be highly reliable and valid, but they have not conclusively been shown to predict hospitalization or death. OBJECTIVE: We sought to determine whether a brief, self-administered, COPD-specific QOL measure, the Seattle Obstructive Lung Disease Questionnaire (SOLDQ), could accurately predict hospitalizations and death. DESIGN: Prospective cohort study. SETTING: Patients enrolled in the primary care clinics at seven Department of Veterans Affairs (VA) medical centers participating in the Ambulatory Care Quality Improvement Project. PATIENTS: Of 24,458 patients who completed a health inventory, 5,503 reported having chronic lung disease. The 3,282 patients who completed the baseline SOLDQ were followed for 12 months. MEASUREMENTS: Hospitalization and all-cause mortality during the 1-year follow-up period. RESULTS: During the follow-up period, 601 patients (18.3%) were hospitalized, 141 (4.3%) for COPD exacerbations, and 167 patients (5.1%) died. After adjusting for age, VA hospital site, distance to the VA hospital, employment status, and smoking status, the relative risk of any hospitalization among patients with scores on the emotional, physical, and coping skills scales of the SOLDQ that were in the lowest quartile, when compared to the highest quartile, were 2.0 (95% confidence interval [CI], 1.5 to 2.6), 2.5 (95% CI, 1.9 to 3.4), and 1.9 (95% CI, 1.5 to 2.5), respectively. When hospitalizations were restricted to those specifically for COPD, the odds ratio (OR) for the lowest quartile of physical function was 6.0 (95% CI, 3.1 to 11.5). Similarly, patients in the lowest quartile of physical function also had an increased risk of death (OR, 6.8; 95% CI, 3.3 to 13.8). When adjusted for comorbidity (OR, 0.8; 95% CI, 0.5 to 1.2), long-term steroid use (OR, 2.8; 95% CI, 1.6 to 4.9), and prior hospitalization for COPD (OR, 4.5; 95% CI, 2.2 to 9.2), patients having baseline SOLDQ physical function scores in the lowest quartile had an odds of hospitalization for COPD that was fivefold higher than patients with scores in the highest quartile (OR, 5.0; 95% CI, 2.6 to 9.7). CONCLUSIONS: Lower QOL is a powerful predictor of hospitalization and all-cause mortality. Brief, self-administered instruments such as the SOLDQ may provide an opportunity to identify patients who could benefit from preventive interventions.

Aged↗

PubMed2002

Diabetes and the risk of acute urinary tract infection among postmenopausal women.

OBJECTIVE: To examine whether the presence of diabetes alters the risk of acute urinary tract infection (UTI) in postmenopausal women. RESEARCH DESIGN AND METHODS: A case-control study of the Group Health Cooperative of Puget Sound (GHC), a staff-model nonprofit health maintenance organization in Washington State, was conducted. Subjects were women aged 55-75 years who had been members of GHC for at least 1 year and who had had an acute symptomatic UTI within the preceding month. Laboratory files were used to identify women with a urine culture that grew > or =10(5) colonies of a urinary pathogen. Medical records were reviewed to confirm the presence of acute, clinically symptomatic UTI. Control subjects were randomly selected from the GHC enrollment file, screened to remove women with recent UTI, and frequency matched to cases by age within 2 years. An interviewer ascertained self-reported clinician-diagnosed diabetes. Diagnosis of diabetes was confirmed by the GHC diabetes registry. A subsample of women underwent measurement of postvoid residual bladder volume (n = 748) and culture of vaginal flora (n = 454). RESULTS: Of the 901 case and 913 control subjects, diabetes was reported in 13.1 and 6.8%, respectively. The health plan diabetes registry confirmed the diagnosis in 92% of women who self-reported the condition. The age-adjusted odds ratio (OR) for UTI in relation to self-reported clinician-diagnosed diabetes was 2.2 (95% CI 1.6-3.0). Adjustment for frequency of sexual intercourse and history of UTI had little effect on this estimate. Compared with nondiabetic women, higher UTI odds were seen in subjects who used oral hypoglycemic agents (OR 2.9 [95% CI 1.7-5.1]) and insulin (2.6 [1.5-4.6]) but not in subjects with untreated diabetes or diabetes treated by lifestyle changes (1.3 [0.7-2.3]). No significant difference was seen in the OR for UTI in diabetic women with disease of shorter duration (<10 years, OR 1.9) or longer duration (> or =10 years, OR 2.6) or in relation to HbA(1c) level. Similar microbiologic pathogens were seen in diabetic and nondiabetic women. No significant differences were seen by diabetes status in mean postvoid residual bladder volume or vaginal flora. CONCLUSIONS: Diabetes under pharmacologic treatment is associated with increased risk of clinically apparent UTI in postmenopausal women.

Aged↗

PubMed2002

Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking.

OBJECTIVE: This study describes primary care discussions with patients who screened positive for at-risk drinking. In addition, discussions about alcohol use from 2 clinic firms, one with a provider-prompting intervention, are compared. DESIGN: Cross-sectional analyses of audiotaped appointments collected over 6 months. PARTICIPANTS AND SETTING: Male patients in a VA general medicine clinic were eligible if they screened positive for at-risk drinking and had a general medicine appointment with a consenting provider during the study period. Participating patients ( N = 47) and providers ( N = 17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus. INTERVENTION: Intervention providers received patient-specific results of positive alcohol-screening tests at each visit. MEASURES AND MAIN RESULTS: Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol-related discussions with most coded as questions (24%), information giving (23%), or facilitation (34%). Advice, reflective listening, and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers offered alcohol-related advice during 21% of visits. Sixteen percent of patient utterances reflected "resistance" to change and 12% reflected readiness to change. On average, Intervention providers were more likely to discuss alcohol use than Control providers (82.4% vs 39.6% of visits; P =.026). CONCLUSIONS: During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not give explicit alcohol-related advice. Discussions about alcohol occurred more often when providers were prompted.

Alcohol Drinking↗

PubMedDate not supplied

Does this woman have an acute uncomplicated urinary tract infection?

CONTEXT: Symptoms suggestive of acute urinary tract infection (UTI) constitute one of the most common reasons for women to visit clinicians. Although the clinical encounter typically involves taking a history and performing a physical examination, the diagnostic accuracy of the clinical assessment for UTI remains uncertain. OBJECTIVE: To review the accuracy and precision of history taking and physical examination for the diagnosis of UTI in women. DATA SOURCES: We conducted a MEDLINE search for articles published from 1966 through September 2001 and manually reviewed bibliographies, 3 commonly used clinical skills textbooks, and contacted experts in the field. STUDY SELECTION: Studies were included if they contained original data on the accuracy or precision of history or physical examination for diagnosing acute uncomplicated UTI in women. One author initially screened titles and abstracts found by our search. Nine of 464 identified studies met inclusion criteria. DATA EXTRACTION: Two authors independently abstracted data from the included studies. Disagreements were resolved by discussion and consensus with a third author. DATA SYNTHESIS: Four symptoms and 1 sign significantly increased the probability of UTI: dysuria (summary positive likelihood ratio [LR], 1.5; 95% confidence interval [CI], 1.2-2.0), frequency (LR, 1.8; 95% CI, 1.1-3.0), hematuria (LR, 2.0; 95% CI, 1.3-2.9), back pain (LR, 1.6; 95% CI, 1.2-2.1), and costovertebral angle tenderness (LR, 1.7; 95% CI, 1.1-2.5). Four symptoms and 1 sign significantly decreased the probability of UTI: absence of dysuria (summary negative LR, 0.5; 95% CI, 0.3-0.7), absence of back pain (LR, 0.8; 95% CI, 0.7-0.9), history of vaginal discharge (LR, 0.3; 95% CI, 0.1-0.9), history of vaginal irritation (LR, 0.2; 95% CI, 0.1-0.9), and vaginal discharge on examination (LR, 0.7; 95% CI, 0.5-0.9). Of all individual diagnostic signs and symptoms, the 2 most powerful were history of vaginal discharge and history of vaginal irritation, which significantly decreased the likelihood of UTI when present (LRs, 0.3 and 0.2, respectively). One study examined combinations of symptoms, and the resulting LRs were more powerful (24.6 for the combination of dysuria and frequency but no vaginal discharge or irritation). One study of patients with recurrent UTI found that self-diagnosis significantly increased the probability of UTI (LR, 4.0). CONCLUSIONS: In women who present with 1 or more symptoms of UTI, the probability of infection is approximately 50%. Specific combinations of symptoms (eg, dysuria and frequency without vaginal discharge or irritation) raise the probability of UTI to more than 90%, effectively ruling in the diagnosis based on history alone. In contrast, history taking, physical examination, and dipstick urinalysis are not able to reliably lower the posttest probability of disease to a level where a UTI can be ruled out when a patient presents with 1 or more symptoms.

Acute Disease↗