A study of various tests to detect asymptomatic urinary tract infections in an obstetric population.

OBJECTIVE: To compare rapid screening techniques for detecting asymptomatic urinary tract infections (AUTIs) in pregnant women. DESIGN: Comparison of results of the screening tests of urinalysis, urine dipstick, and Gram's staining with the results of standard urine culture at an initial prenatal visit. In follow-up visits, urine dipstick testing was compared with urinalysis. SETTING: Departments of Family Medicine and Obstetrics and Gynecology, Mayo Clinic, Rochester, Minn. PATIENTS: Pregnant women (1047) from the local community were screened for AUTI on initial and follow-up visits. METHODS: Initial prenatal urine was tested by using urine dipstick testing, urinalysis, Gram's staining, and urine culture. At each follow-up visit, urine specimens were tested by using urine dipstick and urinalysis. MAIN OUTCOME MEASURES: Sensitivity and specificity, incremental patient costs, and clinical outcomes were used to assess the effectiveness of the techniques. RESULTS: On initial visits, rapid screening tests for AUTI in pregnant women revealed the following: Gram's staining identified 22 of 24 patients with AUTI (sensitivity, 91.7%; specificity, 89.2%); urine dipstick, 12 of 24 (sensitivity, 50.0%; specificity, 96.9%); and urinalysis with presence of leukocytes, six of 24 (sensitivity, 25.0%; specificity, 99.0%). In follow-up visits, urine dipstick tests detected 19 infections and urinalysis, three (positive predictive value, 5% compared with 3%). CONCLUSIONS: Urine dipstick testing for nitrites identified half of all patients with urinary tract infections and was superior to urinalysis on follow-up visits. Although Gram's staining is more expensive, it was more accurate for AUTI than urinalysis or urine dipstick test for nitrites. Urinalysis was never the test of choice because it was more expensive and detected fewer positive cultures. Leukocyte measurement correlated poorly with AUTI.

Premenstrual syndrome. A practical approach to management.

Management of premenstrual syndrome (PMS) includes psychosocial as well as medical therapy. Nonmedical treatment involves patient education, physician and family support, stress reduction, and dietary changes. If these methods do not alleviate symptoms, drug therapy may be necessary. Because the exact cause of PMS is unknown, treatment is largely empirical. More research is imperative to improve therapy for patients with PMS.

The many faces of carpal tunnel syndrome.

Carpal tunnel syndrome, a common and well-described clinical disorder, usually has been considered a chronic disorder with a fixed set of symptoms and typically affecting middle-aged women. Because of the many variations in its initial clinical manifestations, however, its diagnosis at times can be difficult. In this review, we describe nonclassic manifestations of carpal tunnel syndrome and discuss the differential diagnosis, the importance of electrodiagnostic studies, and treatment modalities.

Breast problems.

This article deals with improving the clinical examination of breasts, benign breast disorders, and breast cancer. The early detection of cancer is emphasized.

New perspectives on rural EMT defibrillation.

In recent years, several studies have produced contradictory data regarding the impact of emergency medical technicians trained in defibrillation on hospital admission and dismissal survival rates in rural areas. Fourteen communities (service area populations, 4,000 to 36,000) in rural south-eastern Minnesota participated in a two-year crossover study to further define the factors necessary for success. Automatic external defibrillators were used to defibrillate and record patient rhythms in the treatment group and to only record in the control group. Although six of 36 patients (17%) in ventricular fibrillation who experienced a witnessed arrest survived in communities using automatic external defibrillators, compared with one of 27 (4%) in the control group, five of the six survivors were from a single large community with a 911 system, full-time emergency medical technicians, police first-responders, and a well-equipped emergency facility. Our data suggest that certain prerequisites, especially CPR prior to ambulance arrival and collapse to defibrillation times of less than ten minutes, are clearly essential to produce significant benefits from emergency medical technicians trained in defibrillation in rural communities.

HTN-APT: computer aid in hypertension management.

Hypertension-aid in physician treatment (HTN-APT) is an expert computer system that assists the physician in determining the best form of treatment for the individual hypertensive patient. The HTN-APT system aids the physician in managing the hypertensive patient by keeping a record of the patient's progress, allowing easy access to drug information, and generating recommendations and critiques about treatment options. The treatment recommendations are ranked by an analogue indication-contraindication scheme whereby each drug both singly and in combination is evaluated for patient suitability on the basis of more than 30 possible patient factors. When the computer-generated recommendations were evaluated by a group of family physicians, the HTN-APT system was found to make beneficial treatment recommendations without major judgmental error.

A study of out-of-hospital cardiac arrests in northeastern Minnesota.

Training in advanced cardiac life support and defibrillation and community programs in cardiopulmonary resuscitation (CPR) had limited success in resuscitating patients with cardiac arrest in the Arrowhead region of Minnesota. Factors associated with survival included advanced cardiac life support within 16 minutes, ambulance traveling less than 1 mile (less than 1.6 km), use of paramedics, CPR within four minutes, and a call for help within two minutes. The use of technicians trained in defibrillation was associated with a statistically significant increase in hospital admissions, but not in survivors. The study failed to confirm the findings of previous studies of resuscitation in some rural areas. It was consistent, however, with reports that associated poor survival in rural areas with poor response times. No victims of unwitnessed arrests survived. Of the hospital deaths, 80% were due to neurologic causes, and overall survival was low.

Cardiac arrest in the community. How to improve survival rates.

A coordinated community response to cardiac arrest can be successful if the response time to administration of cardiopulmonary resuscitation (CPR) is less than four minutes and to administration of advanced cardiac life support (ACLS) is less than eight minutes. Elements needed to achieve this goal include rapid access to the emergency medical system; widespread CPR training; rapid response of first responders trained in basic life support; rapid response time to ACLS, including resuscitation at the scene; and an evaluation system to determine the effectiveness of the response and then implementation of changes to prevent future mistakes. The response to cardiac arrest should be kept simple, and the community should work with the resources it possesses. Most communities already have the necessary elements and simply need to coordinate the effort into a reasonable approach. Perhaps with such an approach, 80% of deaths from sudden cardiac arrest could be prevented.

The Good Neighbor Rescue Program: utilizing volunteers to perform cardiopulmonary resuscitation in a rural community.

The Good Neighbor Rescue Program utilizes volunteers who pay for their basic life support training. Acting as first responders during cardiac emergencies, they become involved in the emergency care of seriously ill patients. In the program described, they participated in saving two lives during the first two years of the program. They reduced the time for trained help to arrive at the scene in 90 percent of the emergencies. The program requires coordination of existing resources within the rural community, is inexpensive, and is heavily dependent on volunteerism. The program complements the goals of providing basic life support to cardiac victims before the arrival of an ambulance and of providing advanced life support at the scene.