The Association between Educational Attainment and Patterns of Emergency Department Utilization among Adults with Sickle Cell Disease.

PURPOSE: Patients with low educational attainment may be at increased risk for unplanned health care utilization. This study aimed to determine what factors are related to emergency department (ED) visits in hopes of guiding treatments and early interventions. METHODS: At two medical centers in the Mid-Atlantic United States, 258 adults with sickle cell disease aged 19-70 years participated in a retrospective study where we examined whether education level is independently associated with ED visits after accounting for other socioeconomic status (SES) variables, such as pain and disease severity and psychosocial functioning. RESULTS: The data showed that patients without a high school education visited the ED three times as frequently as patients with post secondary education. Controlling for poverty and employment status decreased the effect of education on ED visits by 33.24 %. Further controlling for disease severity and/or psychosocial functioning could not account for the remaining association between education and ED visits, suggesting that education is independently associated with potentially avoidable emergency care. CONCLUSIONS: Early interventions addressing disparities in academic performance, especially for those children most at risk, may lead to improved long-term health outcomes in this population.

Photopsias are related in part to perceived stress and positive mood in retinitis pigmentosa.

PURPOSE: We measured the relationship between the occurrence of photopsias (spontaneous phosphenes), and retinitis pigmentosa (RP) subjects' level of vision, light exposure, and psychosocial factors to attempt to confirm RP patients' previous reports of these associations. METHODS: A total of 36 RP subjects self-administered PC-based binocular visual acuity, contrast sensitivity, and visual field tests at home twice a week, for 16 sessions in 2-3 months. After each session, subjects reported photopsias during the vision tests and completed questionnaires: Epworth Sleepiness Scale, Stanford Sleepiness Scale, Perceived Stress Scale, and Positive and Negative Affect Schedules. RESULTS: Across all subjects, photopsias occurred during 47% of sessions. Five (14%) subjects never noted photopsias, while five others noted photopsias at every session. Two-thirds of subjects experienced photopsias frequently (>20% of sessions). On average, the odds of noticing photopsias increased by 57% for every 1-point increase in mean perceived stress (OR = 1.57; 95% CI: 1.04, 2.4; P = 0.03) or reduced by 38% for every 1-point increase in positive mood (OR=0.62; 95% CI: 0.39, 0.98; P = 0.04), after adjusting for age, gender, and vision. Similarly, the odds of experiencing photopsias during a session increased by 16% for every 3-point increase in perceived stress and decreased by 17% for every 3-point increase in positive mood, after adjusting for age and gender (OR = 1.16; 95% CI: 1.01, 1.33; P = 0.048)(OR = 0.83; 95% CI: 0.73, 0.94; P = 0.004), respectively. Frequency of photopsias was not statistically significantly related to other factors measured. CONCLUSIONS: Increased photopsias appear to be related to times when subjects report increased perceived stress and/or decreased positive mood, rather than RP patients' age, level of vision, reported light exposure, or sleepiness.

The role of men in women's acceptance of an intravaginal gel in a randomized clinical trial in Blantyre, Malawi: a qualitative and quantitative analysis.

Survey questionnaires and focus group discussions were used to investigate the association between a female participant's acceptance and her perception of her male partner's acceptance of an intravaginal gel as a prototype microbicide. Women who perceived their male partners would accept using the gel were more likely to highly accept the gel as compared to women who perceived their male partners would not accept using the gel (OR=24.57; 95%CI: 16.49-36.61). Qualitative analysis supported a positive association between female acceptability and perceived male partner acceptability. Qualitative research reiterated this finding and also found that men and women had different approaches to assess gel acceptability. Women integrated perceptions of their partner's acceptance into their own acceptability and reported their partners had positive experiences. In contrast, men reported a more neutral experience with the gel and assessed the gel without overt consideration of their partner's experiences. These results indicate that female perceptions of male partner acceptability and actual male partner acceptability need to be considered when addressing female-controlled product acceptability and use.

Incidence of ocular complications in patients with multibacillary leprosy after completion of a 2 year course of multidrug therapy.

AIM: To evaluate the incidence of and risk factors for ocular complications in multibacillary (MB) leprosy patients following completion of 2 year, fixed duration, multidrug therapy (MDT). METHODS: Biannual eye examinations were conducted prospectively on a cohort of MB patients who had completed MDT and followed up for 5 years. The incidence of ocular pathology was calculated as the number of events per person year of event free follow up of patients who did not have the specific finding before completion of MDT. RESULTS: 278 patients had one or more follow up visits after completion of MDT. The incidence of lagophthalmos was 0.24%/patient year (95% CI 0.10% to 0.37%); corneal opacity, 5.35%/patient year (95% CI 4.27% to 6.70%); uveal involvement, 3.78%/patient year (95% CI 2.96% to 4.83%); and cataract that reduced vision to 6/18 or less, 2.4%/patient year (95% CI 1.77% to 3.26%). Overall, 5.65%/patient year (95% CI 4.51% to 7.09%) developed leprosy related ocular disease and 3.86%/patient year (95% CI 3.00% to 4.95%) developed leprosy related, potentially blinding ocular pathology during the period following MDT. Age and other disability also predicted incident eye disease. CONCLUSIONS: Every year, approximately 5.6% of patients with MB who have completed MDT can be expected to develop new ocular complications of leprosy, which often (3.9%) are potentially vision threatening. Because many of these complications cannot be detected without slit lamp examination, periodic monitoring, particularly of older patients and those with other disability, is recommended, in order to detect and treat ocular complications satisfactorily.

Incidence of ocular morbidity among multibacillary leprosy patients during a 2 year course of multidrug therapy.

AIM: To evaluate the incidence of and risk factors for ocular complications in multibacillary (MB) leprosy patients during their 2 year, fixed duration, multidrug therapy (MDT). METHODS: Periodic eye examinations were conducted prospectively on a cohort of 301 consecutive newly diagnosed MB patients every 6 months during their 2 year course of MDT. Incidence of ocular pathology was calculated as the number of events per person year of event free follow up of patients who did not have the specific finding at baseline. RESULTS: 292 (97%) patients had one or more follow up visits. The incidence of lagophthalmos was 1.2%/patient year (95% CI 0.5% to 2.8%); corneal opacity was 7.4%/patient year (95% CI 5.1% to 10.6%); uveal involvement was 5.1%/patient year (95% CI 3.3% to 7.8%), and cataract that reduced vision to 6/18 or less was seen in 4.3%/patient year (95% CI 2.7% to 6.9%) of patients. Overall, 23 individuals (5.8%/patient year, 95% CI 3.9 to 8.8) developed leprosy related potentially blinding pathology during the 2 years of MDT. CONCLUSIONS: Approximately 20% of patients with MB leprosy can be expected to develop ocular complications of leprosy during a 2 year course of MDT, many (11%) of which are potentially vision threatening. Ophthalmological monitoring to detect and treat ocular complications at defined intervals during MDT is indicated.

Measuring validity of self-reported symptoms among people with HIV.

Symptoms are important indicators of health and treatment for people with HIV. Symptoms are measured by patient self-report, but there has been little attention to what is the best method of elicitation. We compared three methods (presence, frequency, and bother) commonly used to measure HIV self-reported symptoms. CD4+ T lymphocyte count and health-related quality of life (HRQL) scales were used to test validity in 160 people with HIV. The average number of symptoms reported was 15.2 (standard deviation 8.4). Correlation coefficients of summary symptom scores using the three methods ranged from -0.30 to -0.36 with HRQL score and from -0.19 to -0.20 with CD4 count (p<0.05). Correlation coefficients of seven specific symptom items with CD4+ counts and HRQL scores for the same concepts were small to moderate (-0.08 to -0.58, p<0.05). For the three methods, the correlation coefficients in general tended to be greater with frequency or bother than presence. However, the differences among the three methods were not statistically significant. We conclude that no single method is superior to the others.

Negative results of randomized clinical trials published in the surgical literature: equivalency or error?

HYPOTHESIS: We hypothesized that review of randomized controlled clinical trials (RCTs) with nonstatistically significant or "negative" results published in the surgical literature do not have appropriate statistical power to demonstrate equivalency between treatment arms. DATA SOURCES AND STUDY SELECTION: The MEDLINE database was searched to obtain reports of all RCTs with negative results published in 3 surgical journals from 1988 to 1998. Manual review of one year (1997) of publications for each journal was performed to validate our search strategy. Equivalency was evaluated using the Two One-Sided Tests Procedure and post hoc power calculations. DATA SYNTHESIS: Ninety reports of RCTs with negative results were identified in the surgical literature between 1988 and 1998. The manual review of 1997 showed a 100% retrieval rate for our search strategy. After applying the Two One-Sided Tests Procedure, 35 reports (39%) met the criteria for demonstrating equivalency. The other 55 reports (61%) contained at least a 10% absolute difference in the 90% confidence interval of Delta. Using the power calculation method, only 22 (24%) articles had a power greater than.80 to detect a 50% difference in therapeutic effect. Only 29% of the reports included a formal sample size calculation and these studies were more likely to demonstrate equivalency than those without a sample size estimate (P<.01). CONCLUSIONS: Many reports from negative RCTs published in the surgical literature lack sufficient statistical power to establish that clinically important differences are not present. Surgeons should perform appropriate sample size calculations when designing RCTs and recognize the utility of confidence intervals when reporting negative results.

The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma, II: characteristics of patients enrolled and not enrolled. COMS Report No. 17.

OBJECTIVES: To describe characteristics of patients evaluated for the Collaborative Ocular Melanoma Study (COMS) randomized clinical trial of iodine 125 brachytherapy for choroidal melanoma by enrollment status, and to compare characteristics of patients enrolled with those of patients with tumors of eligible size who did not enroll in order to assess the extent to which findings from the clinical trial can be generalized to future patients. METHODS: For all patients diagnosed with choroidal melanoma and evaluated for the clinical trial at COMS centers from November 1986 through July 31, 1998, selected data were transmitted to the COMS Coordinating Center, Baltimore, Md, where they were integrated and analyzed. Data included ophthalmic and medical history, examination findings, and visual acuity measurements recorded prior to enrollment; standardized A- and B-scan echographic examination findings; and wide-angle fundus photographs and fluorescein angiograms. RESULTS: Of 8712 patients with choroidal melanoma, 5046 had tumors of eligible size; of these, 2882 (57%) were eligible for enrollment, and 1317 (46% of eligible patients, 26% of patients with tumors of eligible size) enrolled. Most differences between eligible and ineligible patients corresponded to eligibility and exclusion criteria. However, ineligible patients were older and had thicker tumors than eligible patients. Eligible patients who enrolled were slightly older and had larger tumors than those who did not enroll. Nearly half (48%) of enrolled patients had choroidal melanoma with the apex located temporal to the fovea, compared with 40% of eligible patients not enrolled and 29% of ineligible patients. CONCLUSIONS: This trial was designed to yield internally valid treatment comparisons through random assignment to treatment at time of enrollment. Information from this and other studies document that enrolled patients were similar to other patients with choroidal melanoma who were treated with 125I brachytherapy. These findings support the external validity of the trial and applicability of treatment findings to all patients who meet the criteria used to judge eligibility for the trial.

The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma, III: initial mortality findings. COMS Report No. 18.

OBJECTIVES: To report initial mortality findings from the Collaborative Ocular Melanoma Study (COMS) randomized clinical trial of iodine 125 brachytherapy vs enucleation for treatment of choroidal melanoma. METHODS: Patients were evaluated for eligibility at 43 participating clinical centers in the United States and Canada. Eligible consenting patients were assigned randomly at the time of enrollment to enucleation or 125I brachytherapy. Patients were examined at specified intervals after enrollment for data collection purposes. Findings presented herein are based on data received by September 30, 2000. Data for each patient were analyzed with the treatment group to which the patient was assigned randomly at the time of enrollment. RESULTS: During the 11(1/2)-year accrual period, 1317 patients enrolled; 660 were assigned randomly to enucleation and 657 to 125I brachytherapy. Only 2 patients in the enucleation arm were found to have been misdiagnosed when histopathology was reviewed centrally. All but 17 patients (1.3%) received the assigned treatment. Adherence to the brachytherapy protocol was excellent, with 91% of patients treated per protocol. Based on time since enrollment, 1072 patients (81%) had been followed for mortality for 5 years and 416 (32%) for 10 years. A total of 364 patients had died: 188 (28%) of 660 patients in the enucleation arm and 176 (27%) of 657 patients in the brachytherapy arm. The unadjusted estimated 5-year survival rates were 81% and 82%, respectively; there was no clinically or statistically significant difference in survival rates overall (P =.48, log-rank test). The adjusted estimated risk ratio for 125I brachytherapy vs enucleation was 0.99 (95% confidence interval [CI], 0.80-1.22). Five-year rates of death with histopathologically confirmed melanoma metastasis were 11% and 9% following enucleation and brachytherapy, respectively; after adjustment, the estimated risk ratio was 0.91 (95% CI, 0.66-1.24). CONCLUSIONS: Mortality rates following 125I brachytherapy did not differ from mortality rates following enucleation for up to 12 years after treatment of patients with choroidal melanoma who enrolled in this COMS trial. The power of the study was sufficient to indicate that neither treatment is likely to increase or decrease mortality rates by as much as 25% relative to the other.

Effect of pre-loading oral glucosamine HCl/chondroitin sulfate/manganese ascorbate combination on experimental arthritis in rats.

The therapeutic effect of a nutritional supplement consisting of a combination of glucosamine hydrochloride (FCHG49), purified sodium chondroitin sulfate (TRH122), and manganese ascorbate (GCM)3 was investigated in the rat model of collagen-induced autoimmune arthritis (CIA). The GCM compound was mixed with a palatable nutritional paste (Nutri-cal [NC]). Oral administration of the NC/GCM compound was initiated in 26 rats 10 days before immunization and continued until the day of sacrifice. One group of 12 control rats was given no oral agents; a second group of 12 control rats received NC only. Evaluations included arthritis index (AI) scoring by three independent evaluators, histologic index (HI) scoring of lesions, T-cell proliferation, and serological studies for antibody classes and subclasses. Both the AI and HI criteria showed a statistically significant reduction in the prevalence of CIA in rats pretreated with the NC/GCM (54%) compared to the combined control groups (96%, chi2 analysis P = 0.001). Rats fed the NC/GCM also exhibited a significant decrease in the severity of autoimmune arthritis in both the AI and HI compared to control Group 2 (immunized-NC) (chi2 analysis P < 0.05). Histological studies verified the decreased incidence of arthritis in the NC/GCM group compared to control Group 2. GCM treatment failed to alter T-cell proliferation and antibody production to bovine type-II collagen, indicating that its effects are not due to alteration of the antigen-specific immune response.

Income-based disparities in outcomes for patients with chronic kidney disease.

The impact of income on outcomes for patients with end-stage renal disease (ESRD), who are largely relieved of structural and financial barriers to care, is poorly understood. We conducted a prospective cohort study of 3,165 patients who developed ESRD in the early 1990s to examine whether low-income patients with ESRD have poorer health outcomes than their socioeconomically advantaged counterparts, and, if so, to determine whether greater health insurance can reduce this disparity. We found that increasing neighborhood income was associated with decreased mortality and an increased likelihood of placement on the renal transplant waiting list. The presence of private insurance coverage in addition to Medicare improved rates of listing for transplantation in a graded manner, with the greatest effect among those living in neighborhoods below the 10th percentile of income, but had no effect on socioeconomic disparities in mortality. Our results suggest that low-income patients with ESRD experience persistent financial barriers to transplantation that can be addressed with greater health benefits. However, they also experience higher mortality that is caused by personal and/or environmental factors that differ by social class. Clinicians, researchers, and policymakers must address these social, cultural, psychologic, and environmental determinants of health to improve the survival of patients with ESRD.

Cause-specific mortality coding. methods in the collaborative ocular melanoma study coms report no. 14.

Ascertainment of cause of death is often sought in clinical trials in which mortality is an outcome of interest. Standardized methods of coding all-cause and disease-specific mortality were developed and evaluated in the Collaborative Ocular Melanoma Study randomized trial of pre-enucleation radiation of large choroidal melanoma. All available clinical and pathologic materials documenting events prior to each reported death were reviewed systematically by a Mortality Coding Committee (MCC) to determine whether melanoma metastasis or local recurrence was present at the time of death. A level of certainty was assigned based on availability of local or central review of pathology materials. The outcome of the mortality coding protocol was evaluated both by assessing agreement between the judgment of the MCC and the presumed cause of death reported by the clinical center and, for a subset of patients, by assessing agreement between the MCC classification and the cause of death reported on the death certificate. As of July 31, 1997 (the cutoff date for the initial mortality report), 435 (95%) of 457 deceased patient files had been reviewed. The MCC classified 269 patients (62%) as dead with melanoma metastasis, 22 (5%) as dead with another malignant tumor, and 92 (21%) as dead with a malignant tumor of uncertain origin. Thirty-eight patients (9%) died with no evidence of malignancy; in 14 cases (3%), the presence or absence of malignancy could not be established due to lack of clinical information. Fair agreement (kappa = 0.34) was observed between the determinations of the MCC based on detailed review of materials and the cause of death reported on the death certificate, but death certificates alone underestimated the proportion of deaths due to metastatic choroidal melanoma. Detailed mortality coding identified difficulties associated with accurate reporting of cause-specific mortality in patients with choroidal melanoma.

Hospitalization rates in an urban cohort after the introduction of highly active antiretroviral therapy.

OBJECTIVE: Previous studies have shown a decrease in hospitalization rates associated with the introduction of highly active antiretroviral therapy (HAART). To evaluate hospitalization rates and patterns in discharge diagnoses that changed between 1995 and 1998 and to examine risk factors for hospitalization in HIV-positive patients, we conducted a cohort study. PATIENTS AND METHODS: All inpatient hospitalizations of 2,151 HIV-positive patients enrolled in our university-based HIV clinic between January 1, 1994 and December 31, 1998 with a CD4 count within a 6-month calendar semester were examined to evaluate hospitalization rates, discharge diagnoses, and intensive care department use. Negative binomial regression was used to assess the effect of various risk factors on hospitalization. RESULTS: Hospitalization rates decreased between 1995 and 1996 but increased between 1997 and 1998. In multivariate regression, female gender (incidence rate ratio [IRR], 1.45; p <.001), injection drug use (IRR, 1.36; p <.001), and having received no antiretroviral therapy were strong predictors of total hospitalization. White race, low CD4 count, and no antiretroviral treatment were strong predictors of hospitalization for an opportunistic infection. Female gender (IRR, 1.45; p <.001), African-American ethnicity (IRR, 1.22, p =.05), no antiretroviral treatment, and low CD4 counts were predictive of higher hospitalization rates for nonopportunistic infection-related diagnoses. Intensive care department-use was associated with white ethnicity (IRR, 1.86; p =.028), heterosexual transmission of HIV (IRR, 1.90; p =.009), no antiretroviral treatment, and low CD4 count at enrollment. CONCLUSIONS: Our data indicate that hospitalization rates decreased between 1995 and 1997 after introduction of HAART, but that they then increased between 1997 and 1998, particularly for diagnosed nonopportunistic infections. If these trends continue, it indicates that patients may be developing previously unseen comorbidities and that HAART may have reached or exceeded a threshold in its effectiveness in reducing the clinical morbidity that results in hospital admission.

Reducing racial disparities in transplant activation: whom should we target?

Several studies have documented that blacks with end-stage renal disease (ESRD) are less likely than whites to be placed on the waiting list for a renal transplant. We examined trends in access over time to determine whether publication of these reports resulted in a reduction in disparity and identified those blacks who were most affected to focus future interventions. Three nationally representative groups of adult patients with ESRD (first dialysis in 1986 to 1987, 1990, or 1993) were followed up longitudinally to ascertain the date of first placement on the renal transplant waiting list. Cox proportional hazards models were used to characterize the magnitude of racial disparities in access to the waiting list with adjustment for clinical and sociodemographic factors. Lower rates of placement on the waiting list for blacks than whites persisted after adjustment for differences in both sociodemographic characteristics and health status (relative hazard [RH], 0.68; 95% confidence interval [CI], 0.59 to 0.79). The gap between blacks and whites did not narrow over time (blacks versus whites: 1986 to 1987 group, RH, 0.71; 95% CI, 0.59 to 0.86; 1990 group, RH, 0.69; 95% CI, 0.54 to 0.91; 1993 group, RH, 0.57; 0.43 to 0.77) and was greatest for the youngest and healthiest black patients, who were 50% and 40% less likely to be listed than corresponding whites, respectively. Interventions targeted toward young and healthy blacks, who are most likely to benefit from transplantation, are urgently needed to narrow black-white differences in transplant activation.

Double-blind placebo-controlled trial of fluconazole to prevent candidal infections in critically ill surgical patients.

OBJECTIVE: To evaluate the prophylactic use of enteral fluconazole to prevent invasive candidal infections in critically ill surgical patients. SUMMARY BACKGROUND DATA: Invasive fungal infections are increasingly common in the critically ill, especially in surgical patients. Although fungal prophylaxis has been proven effective in certain high-risk patients such as bone marrow transplant patients, few studies have focused on surgical patients and prevention of fungal infection. METHODS: The authors conducted a prospective, randomized, placebo-controlled trial in a single-center, tertiary care surgical intensive care unit (ICU). A total of 260 critically ill surgical patients with a length of ICU stay of at least 3 days were randomly assigned to receive either enteral fluconazole 400 mg or placebo per day during their stay in the surgical ICU at Johns Hopkins Hospital. RESULTS: The primary end point was the time to occurrence of fungal infection during the surgical ICU stay, with planned secondary analysis of patients "on-therapy" and alternate definitions of fungal infections. In a time-to-event analysis, the risk of candidal infection in patients receiving fluconazole was significantly less than the risk in patients receiving placebo. After adjusting for potentially confounding effects of the Acute Physiology and Chronic Health Evaluation (APACHE) III score, days to first dose, and fungal colonization at enrollment, the risk of fungal infection was reduced by 55% in the fluconazole group. No difference in death rate was observed between patients receiving fluconazole and those receiving placebo. CONCLUSIONS: Enteral fluconazole safely and effectively decreased the incidence of fungal infections in high-risk, critically ill surgical patients.

Predictors of repeat Chlamydia trachomatis infections diagnosed by DNA amplification testing among inner city females.

OBJECTIVE: To describe the epidemiology of prevalent and incident chlamydia infection in order to assess the appropriate interval for chlamydia screening; and to identify risk factors predictive of infection and repeat infections. DESIGN: Prospective longitudinal study of a consecutive sample of 3860 sexually active females aged 12-60 years tested for C. trachomatis by polymerase chain reaction in Baltimore City clinics during 11,904 patient visits over a 33 month period. RESULTS: Chlamydia prevalence, incidence, and frequency to diagnosis of infection varied by age. Among 2073 females < 25 years, chlamydia infection was found in 31.2%. The median times to first and repeat incident infections were 7.0 months and 7.6 months, respectively. Among 1787 females > or = 25 years, chlamydia infection was found in 9.6%. Median times to first and repeat incident infections were 13.8 months and 11.0 months, respectively. Age < 25 years yielded the highest risk of infection. CONCLUSIONS: Since a high burden of chlamydia was found among mostly asymptomatic females < 25 years in a spectrum of clinical settings, we recommend chlamydia screening for all sexually active females < 25 years at least twice yearly.

A simplified cyclic adenosine monophosphate-mediated sweat rate test for quantitative measure of cystic fibrosis transmembrane regulator (CFTR) function.

OBJECTIVE: Sweat production is stimulated by both cholinergic and beta-adrenergic pathways in the sweat gland secretory coil. beta-Adrenergic pathway-mediated sweating is absent in cystic fibrosis (CF) because cyclic adenosine monophosphate (cAMP)-mediated chloride transport through the cystic fibrosis transmembrane regulator (CFTR) is disrupted. We report the development of a rapid, reproducible, macroscopic, and quantitative methodology to test the hypothesis that beta-adrenergic sweat rate discriminates among 3 different CFTR phenotypes-CF, heterozygote CF carriers, and non-CF. STUDY DESIGN: Intradermal injection of a mixture of 50 micromol/L isoproterenol, 5 mmol/L aminophylline (to potentiate the beta-adrenergic stimulation), and 140 micromol/L atropine (to block potential cholinergic stimulation) in lactated Ringer's solution was performed in duplicate on one forearm. A single injection of 0.5 mmol/L methacholine to stimulate sweat production by the cholinergic pathway was performed on the other forearm. Sweat rate was determined as the amount of sweat collected on filter paper over 20 minutes. RESULTS AND CONCLUSIONS: Median cAMP-mediated sweat rates were 1.45 mg/20 min (CF, n = 29), 2.55 mg/20 min (CF heterozygote carriers, n = 30), and 3.65 mg/20 min (non-CF, n = 30) and were significantly different in all 3 groups (P =.0001, Kruskal-Wallis test). Methacholine-stimulated sweat rates were similar for all 3 groups. The cAMP-mediated sweat rate test may be a useful endpoint for studies of new agents to increase the function of CFTR.

The diagnostic value of fungal surveillance cultures in critically ill patients.

BACKGROUND: Heavy fungal colonization is a known risk factor for fungal infection, yet the value of fungal surveillance cultures is uncertain. METHODS: To evaluate the utility of fungal surveillance cultures in predicting fungal infections, we evaluated surveillance fungal cultures over a three month period in a prospective, cohort study conducted at a university medical center with a large tertiary referral population. We enrolled 172 patients in the Oncology Center and the medical and surgical intensive care units at Johns Hopkins Hospital. RESULTS: Surveillance cultures from five sites were obtained twice weekly and evaluated for prediction of subsequent fungal infection. Infections were prospectively defined and evaluated by a panel of clinicians. Test characteristics were assessed. Of 159 eligible patients, 14 (9%) developed invasive fungal infections. Having two or more surveillance sites positive in a single day had an odds ratio of 8.2 (1.1-358.0) (p = 0.03), a negative predictive value of 0.98, sensitivity of 0.92, and a likelihood ratio of 1.6 for a fungal infection. In a multiple logistic regression model and Kaplan-Meier analysis, fungal burden was strongly and independently associated with infection (p < 0.05). CONCLUSIONS: Surveillance cultures are helpful in determining fungal colonization but do not have a high positive predictive value for fungal infection in a broad population of intensive care unit patients. However, fungal infection is more likely in heavily colonized patients, and surveillance cultures show that fungal infection is extremely unlikely in patients without fungal colonization.