Accuracy of proband reported family history: the NHLBI Family Heart Study (FHS).

Proband-reported family histories are widely used in research and counseling, yet little is known about the validity of family history reporting. The Family Heart Study (FHS), a population-based study of familial cardiovascular disease, gathered family history information from 3,020 middle-aged probands in four U.S. communities. Probands reported on the history of coronary heart disease (CHD), diabetes, hypertension, and asthma among a total of 10,316 living relatives (9,186 siblings, 1,130 parents) and 2,685 spouses. Questionnaires were returned by 6,672 siblings, 901 parents, and 2,347 spouses, yielding response rates of 73, 79, and 87%, respectively. Utilizing the relatives' self-report as the standard, sensitivity of the proband report on their spouse, parent, and sibling was 87, 85, and 81% for CHD, 83, 87, and 72% for diabetes, 77, 76, and 56% for hypertension, and 66, 53, and 39% for asthma, respectively. Most specificity values were above 90%. Analyses using generalized estimating equations (GEE) were performed to evaluate differences in proband accuracy based on the proband's age, gender, disease state, center, and ethnicity. In multivariate models, age, gender, and disease status were significantly associated with the accuracy of proband's report of sibling disease history, but had little effect on the accuracy of their report on spouses or parents. In general, older probands were significantly less accurate reporters of disease than younger probands. These results demonstrate that CHD family history can be captured effectively based on proband reports, but suggest that additional family contacts may be helpful when working with older probands or with chronic diseases that have few recognized medical events or procedures.

Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study.

OBJECTIVE: To determine the independent contribution of admission delirium to hospital outcomes including mortality, institutionalization, and functional decline. DESIGN: Three prospective cohort studies. SETTING: Three university-affiliated teaching hospitals. PATIENTS: Consecutive samples of 727 patients, aged 65 years and older. MEASUREMENTS AND MAIN RESULTS: Delirium was present at admission in 88 (12%) of 727 patients. The main outcome measures at hospital discharge and 3-month follow-up were death, new nursing home placement, death or new nursing home placement, and functional decline. At hospital discharge, new nursing home placement occurred in 60 (9%) of 692 patients, and the adjusted odds ratio (OR) for delirium, controlling for baseline covariates of age, gender, dementia, APACHE II score, and functional measures, was 3.0, (95% confidence interval [CI] 1.4, 6.2). Death or new nursing home placement occurred in 95 (13%) of 727 patients (adjusted OR for delirium 2.1, 95% CI 1.1, 4.0). The findings were replicated across all sites. The associations between delirium and death alone (in 35 [5%] of 727 patients) and between delirium and length of stay were not statistically significant. At 3-month follow-up, new nursing home placement occurred in 77 (13%) of 600 patients (adjusted OR for delirium 3.0; 95% CI 1.5, 6.0). Death or new nursing home placement occurred in 165 (25%) of 663 patients (adjusted OR for delirium 2.6; 95% CI 1.4, 4.5). The findings were replicated across all sites. For death alone (in 98 [14%] of 680 patients), the adjusted OR for delirium was 1.6 (95% CI 0.8, 3.2). Delirium was a significant predictor of functional decline at both hospital discharge (adjusted OR 3.0; 95% CI 1.6, 5.8) and follow-up (adjusted OR 2.7; 95% CI 1.4, 5.2). CONCLUSIONS: Delirium is an important independent prognostic determinant of hospital outcomes including new nursing home placement, death or new nursing home placement, and functional decline-even after controlling for age, gender, dementia, illness severity, and functional status. Thus, delirium should be considered as a prognostic variable in case-mix adjustment systems and in studies examining hospital outcomes in older persons.

The Kidney Outcomes Prediction and Evaluation (KOPE) study: a prospective cohort investigation of patients undergoing hemodialysis. Study design and baseline characteristics.

PURPOSE: The purpose of the Kidney Outcomes Prediction and Evaluation (KOPE) study, was to more fully characterize the end-stage renal disease (ESRD) population with respect to social, psychological, and clinical characteristics, and to prospectively study the biomedical, social, and psychological factors that influence a range of ESRD outcomes in a large observational study of black and white patients on hemodialysis. This paper focuses on the KOPE study design as well as characteristics of patients at baseline. METHODS: KOPE was a prospective cohort investigation of patients treated at four dialysis centers in Forsyth County, North Carolina. Participants were interviewed at the dialysis centers, semi-annually over a 3 1/2 year period. Prevalent cases who were being treated with hemodialysis at the initiation of the study were enrolled into KOPE. Incident cases were subsequently enrolled as they presented to the participating units for hemodialysis. A total of 304 prevalent and 162 incident cases were enrolled into the study. The baseline health and sociodemographic characteristics of KOPE participants reported in this paper were obtained from medical records and Southeast Kidney Council data. Laboratory values taken within a 30-day interval around the baseline interview are also reported. RESULTS: KOPE participants differ from national statistics on race, age, and gender. Differences between KOPE participants and patients living in the region, but who did not participate in the study, can be explained by our recruitment criteria. CONCLUSIONS: KOPE will enable the characterization of the ESRD population, identification of factors related to poor outcomes, and identification of opportunities for interventions to prevent death and morbidity.

Chest X-ray changes in air space disease are associated with parameters of mechanical ventilation in ICU patients.

To assess relationships between parameters of mechanical ventilation (MV) and portable chest X-ray (CXR) measurements of lung length (LL) and severity of air space disease, a prospective, randomized, blinded comparison of 102 adults in a university hospital was performed. Each patient received two portable, supine CXRs on different MV breaths within 5 min of one another. Ventilator parameters were recorded. All 204 CXRs were randomly assorted and read independently by three radiologists. Air space disease was considered more severe with pressure support ventilation (PSV) breaths than with intermittent mandatory ventilation (IMV) breaths (p = 0.0003), and its extent correlated inversely with static compliance (p = 0.0001, r = -0.40). Among patients having CXRs on both IMV and PSV breaths, 15 of 67 (22%) had their overall degree of air space disease read differently by one category (mild, moderate, or severe). Increases in LL between the two CXRs were associated with increasing peak (p = 0.0038) or mean (p = 0.0065) airway pressure, tidal volume (VT) (p = 0.022), and VT per kilogram (p = 0.006). We conclude that lung volume changes during MV, typically not noted nor controlled for during portable chest radiography, may substantially alter the interpretation of air space disease and LL. Physicians monitoring intensive care unit (ICU) patients with daily CXRs should be aware of the variables influencing interpretation of portable CXRs of ICU patients.

High density lipoprotein cholesterol is associated with serum cortisol in older people.

OBJECTIVE: To determine the associations between serum cortisol and HDL cholesterol, other lipoprotein lipids and cardiovascular risk factors, carotid atherosclerosis, and clinical heart disease in older people. DESIGN: A cross-sectional, observational, ancillary study of the Cardiovascular Health Study (CHS). POPULATION: A total of 245 community-dwelling people, 65 to 89 years old, were recruited consecutively for a 2-month period from the CHS cohort in Forsyth County, North Carolina. METHODS: Cortisol was measured by radioimmunoassay in serum collected between 7:00 and 10:00 AM after an overnight fast. Cortisol levels were correlated with lipoprotein lipids, insulin, glucose, body mass index, waist-hip ratio, prevalent coronary heart disease, hypertension, diabetes, and carotid atherosclerosis by B-mode ultrasound. RESULTS: Serum cortisol was correlated negatively (r = -.24) with body mass index and waist-hip ratio (r = -.16) but was not related significantly to fasting insulin or glucose. Cortisol was not associated significantly with triglyceride and low density lipoprotein cholesterol but showed a positive correlation (r = .21) with high density lipoprotein cholesterol. The relationship between cortisol and high density lipoprotein cholesterol persisted after adjustment for gender, body mass index, waist-hip ratio, cigarette and alcohol use, triglyceride level, and diabetes. There was a trend toward a negative correlation between cortisol and measures of carotid atherosclerosis, but no significant relationship was indicated between cortisol and prevalent coronary heart disease, hypertension, or diabetes. CONCLUSION: Endogenous glucocorticoid levels correlated with HDL cholesterol levels and may play a role in the physiologic regulation of high density lipoprotein levels in older people.

Detection of postoperative sepsis in infants with the use of metabolic stress monitoring.

OBJECTIVES: To evaluate the ability of serial protein metabolic monitoring to detect postoperative injury due to serious bacterial infection in infants by comparing changes observed in these protein parameters with more conventionally accepted indexes of infection. DESIGN: Retrospective review of infants whose postoperative course was complicated by bacterial infection compared with a matched cohort of infants in whom bacterial infection did not develop postoperatively. SETTING: Neonatal and pediatric intensive care units at the Wake Forest University Medical Center, Winston-Salem, NC. PATIENTS: Critically ill infants (N = 40) recovering from major surgical intervention. MAIN OUTCOME MEASURES: Serum C-reactive protein, prealbumin, and tumor necrosis factor concentrations were compared with the white blood cell count, immature-total neutrophil ratio, and body temperature obtained within 24 hours before and following the new onset of culture-established postoperative bacterial infection in 13 infants. These infants were compared with a matched cohort of 27 infants in whom postoperative bacterial infection did not develop. RESULTS: Only C-reactive protein (P = .0001) and prealbumin (P = .0003) levels were significantly altered in association with the onset of serious bacterial infection (paired t test). The C-reactive protein levels were clearly superior to all other variables in predicting postoperative infection (at cutoff point > 6.0 mg/dL; sensitivity, 92%; specificity, 96%). The predictive power of prealbumin level was lower, but acceptable (at cutoff point < or = 9.0 mg/dL; sensitivity, 85%; specificity, 74%). CONCLUSIONS: Monitoring of serial protein metabolic stress with C-reactive protein and prealbumin levels in infants following operations is more effective than the white blood cell count, immature-total neutrophil ratio, or temperature in detecting serious postoperative infections.

Estimating incidence and diagnostic error rates for bivariate progressive processes.

Estimating the times until incidences of bivariate progressive processes that are categorical is a common problem in ophthalmology, audiology, pulmonary medicine, and other fields of medical research. We consider study designs in which diagnoses of subject's bivariate status are performed repeatedly across time and when diagnosis is subject to error. In such situations, error confounds the interpretation of the time until an event. A composite model is proposed for parameterizing both the incidence and error distributions, which allows for correlation between sites with respect to both incidence and diagnostic error. An EM algorithm is described for this model, which allows categorical covariates for both incidence and error. The methodology is applied to two examples. The first represents a situation in which bivariate incidence and error can reasonably be assumed symmetric: prospective data concerning the development of ocular lens opacities in a large pharmaceutical clinical trial. The second example represents a situation in which bivariate incidence and error may not be symmetric: clinical evaluations of sexual maturation status with respect to two different anatomical indices in the Cooperative Study of Sickle Cell Disease. The methodology described in this paper is used, in each case, to estimate incidence, characterize error rates, and assess bivariate correlations.

Serum fructosamine as a screening test for diabetes in the elderly: a pilot study.

OBJECTIVE: To determine the value of serum glycated protein, measured as serum fructosamine, as a screening test for diabetes in the elderly. DESIGN: Cross-sectional pilot study. SETTING: Ambulatory research clinic in university setting. PATIENTS: One hundred fifty-seven consecutive community-dwelling participants in the Cardiovascular Health Study, average age 71.8 + 5 (mean +/- SD, range 65-88 years). MEASUREMENTS: Serum fructosamine levels (first and second generation assay) were obtained. All subjects who did not have a diagnosis of diabetes were given a 75-g glucose tolerance test (GTT). RESULTS: Twenty-six subjects (17%) (10 previously diagnosed, 16 undiagnosed and asymptomatic) had diabetes mellitus, and 38 subjects (24%) had impaired glucose tolerance by history or by the GTT (WHO criteria). Only the 16 asymptomatic diabetics were included in the analysis for the pilot study. There was a significant difference in the fasting fructosamine level between non-diabetics and asymptomatic diabetics for the first generation (2.06 +/- .21 vs 2.53 +/- .49 mMol/L, P < 0.0015) and second generation assay (221 +/- 27 vs 269 +/- 48 mMol/L, P < 0.0012). Receiver operator curves were constructed to evaluate the test characteristics of serum fructosamine. Using a point of > or = 2.3 mMol/L for the first-generation assay, the sensitivity to detect asymptomatic diabetes was 75%, specificity 83%, and positive predictive value 35%. To detect both diabetes and impaired glucose tolerance using a cutpoint of > or = 2.3 mMol/L, the sensitivity was 24%, specificity 95%, and positive predictive value 68%. Employing a cut point of 250 muMol/L for the second generation assay, the sensitivity to detect diabetes was 81%, specificity 87%, and positive predictive value 43%. However, to detect diabetes and glucose intolerance using the second generation assay, the sensitivity was 39% and specificity was 86%. CONCLUSION: This study demonstrated that a single measurement of either first or second generation fructosamine showed promise as a screening test for diabetes, but not impaired glucose tolerance, in older people.