Attitudes, knowledge and practice regarding the anti-müllerian hormone test among general practitioners and reproductive specialists: A cross-sectional study.

OBJECTIVE: To describe clinicians' attitudes, knowledge and practice relating to the anti-müllerian hormone (AMH) test. DESIGN: Cross-sectional nationwide survey. SETTING: Australia. POPULATION OR SAMPLE: A total of 362 general practitioners (GPs), gynaecologists and reproductive specialists. METHODS: Clinicians were recruited through relevant professional organisations, with data collected from May 2021 to April 2022. MAIN OUTCOME MEASURES: Clinicians' attitudes, knowledge and practice relating to the AMH test, measured using multiple choice, Likert scales and open-ended items. RESULTS: Fifteen percent of GPs (n = 27) and 40% of gynaecologists and other specialists (n = 73) order at least one AMH test per month. Specialists reported raising the idea of testing most of the time, whereas GPs reported that patient request was more common. Half of clinicians lacked confidence interpreting (n = 182, 51%) and explaining (n = 173, 48%) an AMH result to their patients. Five percent (n = 19) believed the test was moderately/very useful in predicting natural conception/birth and 22% (n = 82) believed the same for predicting premature menopause, despite evidence that the test cannot reliably predict either. Forty percent (n = 144) had previously ordered the test to help with reproductive planning and 21% (n = 75) to provide reassurance about fertility. CONCLUSIONS: Clinicians reported use of AMH testing in clinical circumstances not supported by the evidence. With the proliferation of direct-to-consumer testing, efforts to support clinicians in the judicious use of testing and effectively navigating patient requests are needed.

Community awareness and use of anti-Müllerian hormone testing in Australia: a population survey of women.

STUDY QUESTION: What is the anti-Mullerian hormone (AMH) test usage, awareness, and perceived reasons for testing in a representative community sample of women in Australia? SUMMARY ANSWER: : Among women aged 18-55 years, 13% had heard about AMH testing and 7% had had an AMH test, with the top three reasons for testing including due to infertility investigations (51%), considering pregnancy and wanting to understand their chances (19%) or to find out if a medical condition had affected fertility (11%). WHAT IS KNOWN ALREADY: The growing availability of direct-to-consumer AMH testing has raised concerns about overuse, however as most AMH tests are paid for privately by consumers, data on test usage is not publicly available. STUDY DESIGN, SIZE, DURATION: National cross-sectional survey of 1773 women, conducted in January 2022. PARTICIPANTS/MATERIALS, SETTING, METHODS: Females aged 18-55 years were recruited from the representative 'Life in Australia' probability-based population panel and completed the survey online or by telephone. Main outcome measures included if and how participants had heard about AMH testing, whether they had ever had an AMH test, main reason for testing and test access. MAIN RESULTS AND THE ROLE OF CHANCE: Of the 2423 women who were invited 1773 responded (73% response rate). Of these, 229 (13%) had heard about AMH testing and 124 (7%) had had an AMH test. Testing rates were highest among those currently aged 35-39 years (14%) and associated with educational attainment. Almost all accessed the test through their general practitioner or fertility specialist. Reasons for testing were: part of an infertility investigation (51%), considering pregnancy and wanting to understand chances of conceiving (19%), finding out if a medical condition had affected fertility (11%), curiosity (9%), considering egg freezing (5%), and considering delaying pregnancy (2%). LIMITATIONS, REASONS FOR CAUTION: Although the sample was large and mostly representative, it was over-represented by people holding a university degree and under-represented by people aged 18-24, however, we used weighted data where possible to account for this. All data were self-reported so there is a risk of recall bias. The number of survey items was also restricted, so the type of counselling women received prior to testing, reasons for declining an AMH test or test timing were not measured. WIDER IMPLICATIONS OF THE FINDINGS: Whilst most women reported having an AMH test for appropriate reasons, about one third had it for reasons not supported by evidence. Public and clinician education about the lack of utility of AMH testing for women not undergoing infertility treatment is needed. STUDY FUNDING/COMPETING INTEREST(S): This project was supported by a National Health and Medical Research Council (NHMRC) Centre for Research Excellence grant (1104136) and Program grant (1113532). T.C. is supported by an NHMRC Emerging Leader Research Fellowship (2009419). B.W.M. reports research funding, consultancy and travel support from Merck. D.L. is the Medical Director of City Fertility NSW and reports consultancy for Organon, Ferring, Besins and Merck. The authors have no other competing interests. TRIAL REGISTRATION NUMBER: N/A.

Feeling Younger, Rehabilitating Better: Reciprocal and Mediating Effects between Subjective Age and Functional Independence in Osteoporotic Fracture and Stroke Patients.

INTRODUCTION: The current study aimed to find reciprocal effects between subjective age and functional independence during rehabilitation from osteoporotic fractures and stroke and whether these effects can be mediated by indicators of well-being. METHODS: Participants were 194 older adults (mean age = 78.32 years, SD = 7.37; 64.8% women) who were hospitalized following an osteoporotic fracture or stroke. Participants completed measures of subjective age and well-being (i.e., optimism, self-esteem, and life satisfaction) several times during rehabilitation. Functional Independence Measure (FIM) was completed by nursing personnel at admission and at discharge. RESULTS: Younger subjective age at admission predicted higher FIM scores at discharge. The reverse effect, that is, of FIM scores at admission on subjective age at discharge, was nonsignificant. Optimism during hospitalization mediated the effect of subjective age on subsequent FIM scores while self-esteem and life satisfaction did not. Sensitivity analyses further showed that the effect of subjective age on FIM was significant for both fracture and stroke patients. DISCUSSION: The findings highlight the effect of subjective age on rehabilitation outcomes among osteoporotic fractures and stroke patients and suggest several potential mechanisms behind this effect. Rehabilitation outcomes following osteoporotic fractures or strokes could improve if subjective age and an optimistic outlook are taken into consideration.

Anti-Mullerian hormone (AMH) test information on Australian and New Zealand fertility clinic websites: a content analysis.

OBJECTIVES: The anti-Mullerian hormone (AMH) test has been promoted as a way to inform women about their future fertility. However, data consistently show the test is a poor predictor of natural fertility potential for an individual woman. As fertility centre websites are often a primary source of information for reproductive information, it is essential the information provided is accurate and reflects the available evidence. We aimed to systematically record and categorise information about the AMH test found on Australian and New Zealand fertility clinic websites. DESIGN: Content analysis of online written information about the AMH test on fertility clinic websites. SETTING: Accredited Australian and New Zealand fertility clinic websites. METHODS: Data were extracted between April and June 2020. Any webpage that mentioned the AMH test, including blogs specifically about the AMH test posted since 2015, was analysed and the content categorised. RESULTS: Of the 39 active accredited fertility clinics' websites, 25 included information about the AMH test. The amount of information varied widely, and embodied four overarching categories; (1) the utility of the AMH test, (2) who the test is suitable for, (3) possible actions in response to the test and (4) caveats and limitations of the test. Eight specific statements about the utility of the test were identified, many of which are not evidence-based. While some websites were transparent regarding the test's limitations, others mentioned no caveats or included persuasive statements actively promoting the test as empowering for a range of women in different circumstances. CONCLUSIONS: Several websites had statements about the utility of the AMH test that are not supported by the evidence. This highlights the need for higher standards for information provided on fertility clinic websites to prevent women being misled to believe the test can reliably predict their fertility.

Cumulative live birth rates for women returning to ART treatment for a second ART-conceived child.

STUDY QUESTION: What are the success rates for women returning to ART treatment in the hope of having a second ART-conceived child. SUMMARY ANSWER: The cumulative live birth rate (LBR) for women returning to ART treatment was between 50.5% and 88.1% after six cycles depending on whether women commenced with a previously frozen embryo or a new ovarian stimulation cycle and the assumptions made regarding the success rates for women who dropped-out of treatment. WHAT IS KNOWN ALREADY: Previous studies have reported the cumulative LBR for the first ART-conceived child to inform patients about their chances of success. However, most couples plan to have more than one child to complete their family and, for that reason, patients commonly return to ART treatment after the birth of their first ART-conceived child. To our knowledge, there are no published data to facilitate patient counseling and clinical decision-making regarding the success rates for these patients. STUDY DESIGN, SIZE, DURATION: A population-based cohort study with 35 290 women who commenced autologous (using their own oocytes) ART treatment between January 2009 and December 2013 and achieved their first treatment-dependent live birth from treatment performed during this period. These women were then followed up for a further 2 years of treatment to December 2015, providing a minimum of 2 years and a maximum of 7 years of treatment follow-up. PARTICIPANTS/MATERIALS, SETTING, METHODS: Cycle-specific LBR and cumulative LBR were calculated for up to six complete ART cycles (one ovarian stimulation and all associated transfers). Three cumulative LBR were calculated based on the likelihood of success in women who dropped-out of treatment (conservative, optimal and inverse probability-weighted (IPW)). A multivariable logistic regression model was used to predict the chance of returning to ART treatment for a second ART-conceived child, and a discrete time logistic regression model was used to predict the chance of achieving a second ART-conceived child up to a maximum of six complete cycles. The models were adjusted for patient characteristics and previous and current treatment characteristics. MAIN RESULTS AND THE ROLE OF CHANCE: Among the women who had their first ART-conceived live birth, 15 325 (43%) returned to treatment by December 2015. LBRs were consistently better in women who recommenced treatment with a previously frozen embryo, compared to women who underwent a new ovarian stimulation cycle. After six complete cycles, plus any surplus frozen embryos, the cumulative LBR was between 60.9% (95% CI: 60.0-61.8%) (conservative) and 88.1% (95% CI: 86.7-89.5%) (optimal) [IPW 87.2% (95% CI: 86.2-88.2%)] for women who recommenced treatment with a frozen embryo, compared to between 50.5% (95% CI: 49.0-52.0%) and 69.8% (95% CI: 67.5-72.2%) [IPW 68.1% (95% CI: 67.3-68.9%)] for those who underwent a new ovarian stimulation cycle. The adjusted odds of a second ART-conceived live birth decreased for women ≥35 years, who waited at least 3 years before returning to treatment, or who required a higher number of ovarian stimulation cycles or double embryo transfer to achieve their first child. LIMITATIONS, REASONS FOR CAUTION: Our estimates do not fully account for a number of individual prognostic factors, including duration of infertility, BMI and ovarian reserve. WIDER IMPLICATIONS OF THE FINDINGS: This is the first study to report success rates for women returning to ART treatment to have second ART-conceived child. These age-specific success rates can facilitate individualized counseling for the large number of patients hoping to have a second child using ART treatment. STUDY FUNDING/COMPETING INTEREST(S): No funding was received to undertake this study. R. Paul and O. Fitzgerald have nothing to declare. D. Lieberman reports being a fertility specialist and receiving non-financial support from MSD and Merck outside the submitted work. C. Venetis reports being a fertility specialist and receiving personal fees and non-financial support from MSD, personal fees and non-financial support from Merck Serono and Beisins and non-financial support from Ferring outside the submitted work. G.M. Chambers reports being a paid employee of the University of New South Wales, Sydney (UNSW) and Director of the National Perinatal Epidemiology and Statistics Unit (NPESU), UNSW. The Fertility Society of Australia (FSA) contracts UNSW to prepare the Australian and New Zealand Assisted Reproductive Technology Database (ANZARD) annual report series and benchmarking reports. TRIAL REGISTRATION NUMBER: NA.

The distribution of immune cells and macrophages in the endometrium of women with recurrent reproductive failure I: Techniques.

Recurrent miscarriage affects approximately 1% of the population and in half of these cases no cause is found. Abnormally functioning immunocompetent cells, including natural killer (NK) cells, in the endometrium, are thought to be responsible for many such cases and treatment trials including oral prednisolone and intravenous immunoglobulins are now underway. Despite these encouraging developments, there is neither adequate standardization of counting uterine NK cells nor consensus as to what constitutes an abnormal level. To address this issue, immunohistochemistry was used to examine the presence and distribution of selected immune cells and macrophages in the endometrium from 222 women who had a routine endometrial biopsy for investigation of recurrent miscarriage or IVF failure, at various stages of the menstrual cycle, and accessioned prospectively over a 7-month period. Biopsies were examined by H+E and immunostained for CD8(+) T-cells, CD163(+) macrophages, CD56(+) NK cells, and CD57(+) cells. Cell numbers (expressed as immunopositive cells per mm(2)) were determined in the stroma of the functional layer of endometrium and the relative concentrations of some cell types (CD163(+) macrophages, CD56(+) NK cells) were expressed as a percentage of all stromal cells. Routine H+E sections revealed 12 patients with focal "endometritis" without plasma cells. CD8(+) T-cells showed focal perivascular aggregates in most instances, and non-random but scattered cells in all cases, with a twofold increase in the luteal phase. CD163(+) cells were distributed evenly throughout the superficial endometrial stroma and also present as single or clustered macrophages within the lumens of superficial glands, mostly in the luteal phase. CD56(+) NK cells showed "diffuse" but variable distribution throughout the functional layer and perivascular aggregates of various sizes in two thirds of cases. Raw cell counts were low and relatively stable in the proliferative phase, but increased somewhat during the first half of the secretory phase, while in the second half of secretory phase they increased six to tenfold. Percentage counts rose from approximately 5% of stromal cells in the early part of the secretory phase of the cycle to over 35% in premenstrual endometrium. CD57(+) cells were present in very low numbers in most cases. The study illustrates the complexity and variability of immune cell infiltration of endometrium. We stress the need for strict counting protocols and attention to histological criteria if any immunological perturbations potentially responsible for recurrent reproductive failure are to be identified. Reference ranges for individual cell types are only valid for individual "days" of a normalized menstrual cycle.

Elderly patients undergoing mechanical ventilation in and out of intensive care units: a comparative, prospective study of 579 ventilations.

INTRODUCTION: Many mechanically ventilated elderly patients in Israel are treated outside of intensive care units (ICUs). The decision as to whether these patients should be treated in ICUs is reached without clear guidelines. We therefore conducted a study with the aim of identifying triage criteria and factors associated with in-hospital mortality in this population. METHODS: All mechanically invasive ventilated elderly (65+) medical patients in the hospital were included in a prospective, non-interventional, observational study. RESULTS: Of the 579 ventilations, 283 (48.9%) were done in ICUs compared with 296 (51.1%) in non-ICU wards. The percentage of ICU ventilations in the 65 to 74, 75 to 84, and 85+ age groups was 62%, 45%, and 23%, respectively. The decision to ventilate in ICUs was significantly and independently influenced by age (Odds Ratio (OR) = 0.945, P < 0.001), and pre-hospitalization functional status by functional independence measure (FIM) scale (OR = 1.054, P < 0.001). In-hospital mortality was 53.0% in ICUs compared with 68.2% in non-ICU wards (P < 0.001), but the rate was not independently and significantly affected by hospitalization in ICUs. CONCLUSIONS: In Israel, most elderly patients are ventilated outside ICUs and the percentage of ICU ventilations decreases as age increases. In our study groups, the lower mortality among elderly patients ventilated in ICUs is related to patient characteristics and not to their treatment in ICUs per se. Although the milieu in which this study was conducted is uncommon today in the western world, its findings point to possible means of managing future situations in which the demand for mechanical ventilation of elderly patients exceeds the supply of intensive care beds. Moreover, the findings of this study can contribute to the search for ways to reduce costs without having a negative effect on outcome in ventilated elderly patients.

Respiratory viruses in adults with community-acquired pneumonia.

BACKGROUND: Use of nucleic acid amplification techniques has increased the identification of respiratory viruses (RVs) in adult patients with community-acquired pneumonia (CAP). The objectives of the present study were to identify RV in patients with CAP using three different sampling methods and to compare CAP virus proportions and types with two comparison groups. METHODS: The study population included 183 adult patients with CAP, 450 control subjects, and 201 patients with nonpneumonic lower respiratory tract infection (NPLRTI). Each participant was sampled by oropharyngeal swab, nasopharyngeal swab, and nasopharyngeal washing, and the samples were tested for detection of 12 RVs by multiplex TaqMan Hydrolysis probe-based real-time polymerase chain reaction (Integrated DNA Technology; Coralville, IA). RESULTS: At least one RV was identified in 58 patients with CAP (31.7%) compared with 32 (7.1%) in control subjects and 104 (51.7%) in patients with NPLRTI (P < .01 and P < .01, respectively). Coronaviruses were identified in 24 (13.1%) patients with CAP, compared with 17 (3.8%) in control subjects, and 21 (10.4%) patients with NPLRTI. Respiratory syncytial virus was identified in 13 (7.1%), four (0.9%), and seven (3.5%); rhinovirus in nine (4.9%), nine (2.0%), and 15 (7.5%); and influenza virus in eight (4.4%), two (0.4%), and 63 (31.3%) patients with CAP, control subjects, and patients with NPLRTI, respectively. CONCLUSIONS: The proportion of RV involvement in CAP is higher than previously reported. The proportion of RV identified in healthy subjects is significantly lower than in CAP, but it is not zero and should be weighed when interpreting corresponding proportions among patients.

Identification of respiratory viruses in adults: nasopharyngeal versus oropharyngeal sampling.

The optimal method for identifying respiratory viruses in adults has not been established. The objective of the study was to compare the sensitivities of three sampling methods for this purpose. One thousand participants (mean age, 63.1 +/- 17.8 years) were included. Of these, 550 were patients hospitalized for acute febrile lower respiratory tract infections and 450 were controls. Oropharyngeal swabs (OPS), nasopharyngeal swabs (NPS), and nasopharyngeal washings (NPW) were obtained from each participant and were tested for 12 respiratory viruses by a multiplex hydrolysis probes-based quantitative real-time reverse transcription-PCR. Patients were defined as positive for a specific virus if the virus was identified by at least one sampling method. In all, 251 viruses were identified in 244 participants. For the detection of any virus, the sensitivity rates for OPS, NPS, and NPW were 54.2%, 73.3%, and 84.9%, respectively (for OPS versus NPS and NPW, P < 0.00001; for NPS versus NPW, P < 0.003). Maximal sensitivity was obtained only with sampling by all three methods. The same gradation of sensitivity for the three sampling methods was found when influenza viruses, coronaviruses, and rhinoviruses were analyzed separately. The three sampling methods yielded equal sensitivity rates for respiratory syncytial virus. We conclude that nasopharyngeal sampling has a higher rate of sensitivity than oropharyngeal sampling and that the use of NPW has a higher rate of sensitivity than the use of NPS with a rigid cotton swab for the identification of respiratory viruses in adults. Sampling by all three methods is required for the maximal detection of respiratory viruses.

How do older ventilated patients fare? A survival/functional analysis of 641 ventilations.

BACKGROUND: The outcome of mechanical ventilation in elderly patients should be evaluated by integrating survival rates with functional state over time after the ventilation episode. OBJECTIVES: The aim of this study was to measure the survival rate and functional state of elderly ventilated patients and to present an integrated analysis of both outcome measures. METHODS: This is a prospective observational, noninterventional study of 641 invasive medical ventilations of elderly (65+ years) patients in medical wards and intensive care units. The functional state, by the Functional Independence Measure scale, was measured before hospitalization, at discharge from the hospital, and 1 year later. RESULTS: Survival rates at the end of hospitalization and 3, 6, and 12 months later were 33%, 28%, 25%, and 22%, respectively. According to a combined survival/functional analysis, only 11% of all ventilated elderly patients were doing well (Functional Independence Measure scale score, >or=90) a year after the hospitalization. The rates for this condition ranged from 23% for acute exacerbation of chronic obstructive pulmonary disease to 0% for stroke and hospital-acquired pneumonia. CONCLUSIONS: In elderly patients treated with mechanical ventilation, the outcomes in the period immediately after ventilation and later on are poor. In this group of patients, functional outcomes should be integrated with survival analysis for a meaningful assessment of the outcomes of treatment with mechanical ventilation to provide patients, families, practitioners, and society with reliable information on which life or death decisions can be based.

What next for preimplantation genetic screening (PGS)? Experience with blastocyst biopsy and testing for aneuploidy.

Blastocysts more commonly have a normal karyotype than cleavage-stage embryos do. Moreover, blastocysts have also made a metabolic transition from catabolism and recycling of the oocyte's reserves and resources, processes that fuel the first 3 days of cleavage. Although not all blastocysts are karyotypically equal, it is still to be determined to what extent a mosaic karyotype might be a normal feature among embryos, both at the cleavage stage and the blastocyst stage--and when looking for karyotypic abnormalities by embryo biopsy might help the chance of implantation rather than harm it. It is also still impractical to look at all the chromosomes that can, through their aneuploidy, stand in the way of successful embryonic and fetal development. We report a randomized clinical trial of blastocyst biopsy followed by preimplantation genetic screening (PGS) for aneuploidy using 5-colour FISH. The trial was suspended and then terminated early when we were unable to show an advantage for PGS. If we are correct in assuming that mitotic non-disjunction is common by the stage of the blastocyst (and that it is much less ominous than meiotic non-disjunction), then further studies of effective PGS of blastocysts for aneuploidy require methods of analysis that cover all the chromosomes and can differentiate the triallelic and monoallelic states of meiotically derived aneuploidies from the biallelic state of mitotic aneuploidies.

Rehabilitation outcome following hip fracture surgery in elderly diabetics: a prospective cohort study of 224 patients.

PURPOSE: To characterize the course and outcome of rehabilitation following hip fracture (HF) in elderly diabetic patients. METHOD: A non-interventional prospective cohort study of 224 elderly diabetic patients who were hospitalized for rehabilitation, compared to 738 non-diabetic patients. Stepwise multiple regression was used to assess the relative contribution of the variables to the variance of the rehabilitation outcome. RESULTS: The absolute efficacy of rehabilitation was lower in diabetics vs. non-diabetics (28.8 +/- 20.0 vs. 31.8 +/- 18.4, respectively, p = 0.04). This difference was caused by a significantly lower pre-event Functional Independence Measure (FIM) (112 +/- 17 vs. 115 +/- 14, p = 0.002) and a significantly higher rate of prior stroke with motor impairment (16% vs. 7%, p < 0.0001). No significant difference was found between the study groups for various rehabilitation-related complications, including mortality. None of the 12 specific variables associated with diabetes or its complications was significantly and independently associated with the outcome of rehabilitation among diabetics. CONCLUSIONS: The outcome of rehabilitation in elderly diabetic patients following HF is significantly worse than in non-diabetics. This result stems from the poor pre-event functional state of these patients. The results of this study can help to predict the outcome of rehabilitation in elderly diabetic patients who are candidates for rehabilitation following surgical repair of HF.

Naso- and oropharyngeal potential respiratory pathogens in adults with nonpneumonic lower respiratory tract infection.

The objective of this prospective study was to determine positive isolation rates for potential respiratory pathogens (PRPs) in the naso- and oropharynx of adults hospitalized for nonpneumonic lower respiratory tract infection (NPLRTI), compared with patients with community-acquired pneumonia (CAP) and healthy controls. The study population was 315 non-chronic obstructive pulmonary disease adults hospitalized with febrile lower respiratory tract infection (158 NPLRTI and 157 CAP) and 450 control subjects. Each participant was sampled by oropharyngeal swab, nasopharyngeal swab, and nasopharyngeal washings that were tested by conventional bacteriologic methods to identify PRP. At least 1 of the samples was positive for at least 1 of the 3 PRP bacteria in 55 NPLRTI patients (35%) compared with 51 CAP patients (33%) (NS) and 100 controls (22%) (P = 0.003 compared with NPLRTI and P = 0.02 compared with CAP). Samples were positive for Streptococcus pneumoniae in 14 NPLRTI patients (9%) compared with 29 CAP patients (19%) (P = 0.02) and 16 controls (4%) (NPLRTI P = 0.015, CAP P < 0.0001). The corresponding rates for Haemophilus influenzae were 23 (15%), 16 (10%), and 60 (13%) (NS for all 3 comparisons), and for Moraxella catarrhalis, 28 (18%), 25 (16%), and 48 (11%), respectively (NPLRTI versus controls, P = 0.03, NS other comparisons). We conclude that the rate of positive naso/oropharyngeal isolates for at least 1 of the 3 PRP bacteria in NPLRTI patients is similar to the corresponding rates for CAP patients and is higher in both groups than in controls.

Nasopharyngeal versus oropharyngeal sampling for isolation of potential respiratory pathogens in adults.

The optimal methodology for the identification of colonization by potential respiratory pathogens (PRP) in adults is not well established. The objectives of the present study were to compare the sensitivities of sampling the nasopharynx and the oropharynx for identification of PRP colonization and to compare the sensitivities of samples from the nasopharynx by swab and by washing for the same purpose. The study included 500 participants with a mean age of 65.1 +/- 17.8 years. Of these, 300 patients were hospitalized for acute febrile lower respiratory tract infection and 200 were controls. Each participant was sampled by oropharyngeal swab (OPS), nasopharyngeal swab (NPS), and nasopharyngeal washing (NPW). The samples were tested by conventional bacteriological methods to identify Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. OPS detected colonization by S. pneumoniae in 30% of the subjects compared with 89% by NPS and NPW (P < 0.000001). The corresponding rates for H. influenzae were 49% and 64%, respectively (no significant difference [NS]), and for M. catarrhalis were 72% and 46%, respectively (P < 0.0004). NPS identified 61% of the cases of colonization with S. pneumoniae, compared with 76% by NPW (NS). The corresponding rates for H. influenzae were 31% and 56%, respectively (P < 0.04), and for M. catarrhalis were 39% and 33%, respectively (NS). We conclude that the sensitivities of nasopharyngeal and oropharyngeal sampling for identification of PRP colonization in adults are different for each of the three bacteria in this category. The combined results of sampling from both sites are necessary to obtain a true picture of the rate of colonization. NPW is superior to NPS.

Inpatient rehabilitation outcome after hip fracture surgery in elderly patients: a prospective cohort study of 946 patients.

OBJECTIVE: To identify the factors associated with inpatient rehabilitation outcome after surgical repair of hip fracture in elderly patients. DESIGN: A noninterventional prospective cohort study. SETTING: Geriatric inpatient rehabilitation center in a tertiary university medical center in southern Israel. PARTICIPANTS: Patients (N=946) aged 65 years of age or older who were hospitalized for rehabilitation after surgery for hip fracture. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional studies by the FIM instrument and a broad spectrum of clinical, demographic, and social variables. Stepwise multiple regression was used to assess the relative contribution of the variables to the variance of the percentage change in the FIM score during the course of rehabilitation in relation to the severity of the functional impairment at its inception. RESULTS: Eight variables were significantly and independently associated with rehabilitation outcome. Prefracture FIM scale (standardized regression coefficient in multiple regression [beta]=.261, P<.001), serum albumin at discharge (beta=.222, P<.001), Folstein Mini-Mental State Examination (beta=.174, P<.001), visual impairment (beta=-.089, P=.002), dyspnea at mild exertion (New York Heart Association class III) (beta=-.080, P=.005), age (beta=-.080, P=.007), poststroke motor impairment (beta=-.072, P=.011), and decreased serum folic acid (beta=-.055, P=.047). The total percentage of the explained variance of the primary rehabilitation outcome measure accounted for by these 8 variables (adjusted R(2)) was 31.9%. CONCLUSIONS: The outcome of rehabilitation of elderly patients after surgical repair of hip fracture is associated with 4 clinical and nutritional correctable parameters. The other 4 variables that are associated with the process cannot be corrected but may help predict outcomes and adjust expectations.

Rehabilitation following stroke in patients aged 85 and above.

To assess the course and results of rehabilitation following stroke in the oldest old, we conducted a prospective study to compare 45 patients 85 years and above and 220 consecutive patients aged 75 to 84 years who were hospitalized for rehabilitation following stroke. Functional status was measured and compared by the Functional Independence Measuretrade mark(FIM) scale and successful rehabilitation was defined as FIM > 80 at discharge. Eighteen patients in the 85+ group (40%) underwent successful rehabilitation compared with 115 (52%) in the 75 to 84 group (not significant). No significant differences were found between the groups in any other parameters that measure success and/or efficacy of rehabilitation, but in all these parameters, without exception, there were lower values in the 85+ group. No differences in the length of rehabilitation and complications rates were found between groups. We conclude that although the success rate for rehabilitation following stroke is lower in the oldest old, it appears that the effort invested in rehabilitating patients in this group is no less justified than in younger elderly patients.

Visual and hearing impairment in elderly patients hospitalized for rehabilitation following hip fracture.

In a prospective study, we assessed the prevalence and significance of visual and hearing impairment in 896 patients who were hospitalized for rehabilitation following hip fracture. Visual impairment was defined as visual acuity equal to worse than 6/60 in the better of the two eyes. Hearing impairment was defined as mean decibel level equal to or higher than 60 in the better of the two ears. Visual impairment was found in 210 patients (23.4%) and hearing impairment was found in 231 patients (25.8%). Simultaneous visual and hearing impairment was seen in 72 patients (8%). In univariate analysis, the absolute efficacy of rehabilitation was significantly lower in patients with visual impairment compared to those without (p = 0.00001) and in patients with hearing impairment compared to those without (p = 0.002). However, in multivariate analysis, visual, but not hearing, impairment was found to be independently associated with the absolute efficacy of rehabilitation (p = 0.001). In light of these results, we propose that in the first phase of rehabilitation, patients' visual acuity needs to be optimized.

Rehabilitation following hip fracture surgery: a comparative study of females and males.

PURPOSE: To compare patient, fracture and rehabilitation variables between male and female patients during the rehabilitation period immediately following surgical repair of hip fracture (HF). METHODS: A prospective cohort study was conducted in a rehabilitation geriatric ward in a tertiary university hospital in southern Israel. The study group consisted of 808 elderly patients, 65 years of age or older, selected for hospitalized rehabilitation following surgery for HF. The measurements included functional studies by the Functional Independence Measure (FIM) scale, mental status by Folstein Minimental Test and Clock Drawing Test, Geriatric Depression Screening Scale (GDS), demographic and social parameters, laboratory tests, length of rehabilitation, complications and mortality during rehabilitation. RESULTS: Six hundred and fourteen patients (76%) were women and 194 (24%) were men. The mean age ( +/- SD) of the women was 78.4 +/- 7.1 years and of the men was 77.8 +/- 7.5 (NS). There were no significant differences between women and men in terms of the anatomic site of the fracture or the type of surgery, the complication rate or mortality during rehabilitation, the length of time needed for rehabilitation, the framework to which the patient was discharged, FIM values before the HF, on admission and at the end of rehabilitation, or the difference between FIM scores at these last two points in time. CONCLUSIONS: In selected elderly patients with HF gender does not affect variables associated with hip fracture, the rehabilitation process immediately following the fracture, or the results of rehabilitation.

Diagnosis of ambulatory community-acquired pneumonia. Comparison of clinical assessment versus chest X-ray.

OBJECTIVES: When evaluating patients with respiratory tract infections (RTI), physicians have to judge and decide whether the patient has pneumonia or not. This decision is usually made by clinical assessment alone and/or by performing a chest X-ray. The aim of this study was to determine the reliability of physicians' judgements relating to the presence of pneumonia in RTI patients by clinical assessment alone compared with chest X-ray. DESIGN: A prospective, clinical study. SETTING: Primary care clinics and a university hospital in southern Israel. SUBJECTS: Two-hundred-and-fifty ambulatory patients with febrile RTI were included in a prospective study. On the basis of a medical interview and physical examination alone physicians were asked to make judgements relating to the study question, and these judgements were compared with the results of chest X-rays. RESULTS: Physicians' judgements of pneumonia had a sensitivity of 74% (49-90%), a specificity of 84% (78-88%), a negative predictive value of 97% (94-99%) and a positive predictive value of only 27% (16-42%), compared to the results of chest X-ray. CONCLUSION: We conclude that the ability of physicians to negate X-ray confirmed pneumonia by clinical assessment in febrile adult RTI patients is good, but that their ability to successfully predict this condition is poor.

Infectious aetiologies in elderly patients hospitalised with non-pneumonic lower respiratory tract infection.

OBJECTIVE: to identify the infectious aetiologies of non-pneumonic lower respiratory tract infections in hospitalised elderly patients, and to characterise the patients in terms of demographic, clinical and therapeutic variables. DESIGN: a prospective, non-interventional, purely serologically based diagnostic study. SETTING: a tertiary university hospital in southern Israel. SUBJECTS: 133 elderly patients hospitalised for non-pneumonic lower respiratory tract infections. METHODS: paired sera were obtained for each of the hospitalisations and were tested using immunofluorescence or enzyme immunoassay methods to identify 13 different pathogens. Only significant changes in antibody titers or levels between the paired sera were considered diagnostic. RESULTS: at least one infectious aetiology was identified in 77 patients (58%). At least one of seven viral aetiologies was identified in 52 patients (39%). A bacterial aetiology was identified in 27 patients (20%) including Streptococcus pneumoniae in 24 (18%). An atypical bacterium was found in 27 patients (20%) including Mycoplasma pneumoniae in 15 (11%) and Legionella spp. in nine (7%). More than one aetiology was found in 23 patients (17%). One hundred and twenty nine patients (96%) suffered from serious chronic co-morbidity. One hundred and twenty one patients received antibiotics during their hospitalisation, 106 (80%) with a beta-lactam and 42 (31%) with another antibiotic. CONCLUSIONS: non-pneumonic lower respiratory tract infection is caused in hospitalised elderly patients by a broad spectrum of aetiological agents, primarily respiratory viruses with a significant, though lesser, prevalence of classical and atypical bacteria. Despite this distribution of aetiologies, most patients are treated with beta-lactam antibiotics. The indication for antibiotic therapy in these patients and the choice of antibiotic preparation should be addressed in further studies.