Publications

The U.S. Preventive Services Task Force (USPSTF) recently issued guidelines on screening for vitamin D deficiency. The guidelines were based on randomized trials of vitamin D deficiency screening and treatment, as well as on case-control studies nested within the Women's Health Initiative. The USPSTF concluded that current evidence is insufficient to assess the benefits and harms of screening for vitamin D deficiency in asymptomatic adults. Compared with placebo or no treatment, vitamin D was associated with decreased mortality; however, benefits were no longer seen after trials of institutionalized persons were excluded. Vitamin D treatment was associated with a possible decreased risk for at least 1 fall and the total number of falls per person but not for fractures. None of the studies examined the effects of vitamin D screening versus not screening on clinical outcomes. In this Grand Rounds, 2 prominent endocrinologists debate the issue of screening for vitamin D deficiency in a 55-year-old, asymptomatic, postmenopausal woman. They review the data on which the USPSTF recommendations are based and discuss the potential benefits and risks, as well as the challenges and controversies, of screening for vitamin D deficiency in primary care practice.

PURPOSE

We sought to determine whether frailty affects the type of pelvic organ prolapse surgery performed and the odds of postoperative complications.

MATERIALS AND METHODS

This is a retrospective cohort study of women who underwent obliterative and reconstructive surgery for pelvic organ prolapse in ACS (American College of Surgeons) NSQIP® (National Surgical Quality Improvement Program) from 2005 to 2013. We quantified frailty using NSQIP-FI (Frailty Index) and applied logistic regression models predicting the type of procedure (colpocleisis) and the odds of postoperative complications.

RESULTS

We identified a total of 12,731 women treated with pelvic organ prolapse repair, of which 5.3% were colpocleisis procedures, from 2005 to 2013. Among women undergoing colpocleisis, the average age was 79.2 years and 28.5% had a NSQIP-FI of 0.18 or higher, indicating frailty. Women undergoing colpocleisis procedures had higher odds of being frail (NSQIP-FI 0.18 vs 0 OR 1.9, 95% CI 1.4-2.6) and were older (age 85+ vs less than 65 years OR 486.4, 95% CI 274.6-861.7). For all types of pelvic organ prolapse procedures, frailty increased the odds of complications (NSQIP-FI 0.18 vs 0 OR 2.8, 95% CI 1.8-3.0), after adjusting for age and type of pelvic organ prolapse procedure.

CONCLUSIONS

For pelvic organ prolapse surgery, age rather than frailty is more strongly associated with the type of procedure performed. However, frailty is more strongly associated with postoperative complications than age. Furthermore, incorporating frailty into preoperative decision making is important to improve expectations and outcomes among older women considering pelvic organ prolapse surgery.

BACKGROUND

Nucleic acid amplification tests (NAATs) have been used as a diagnostic tool for tuberculosis (TB) in the United States for many years. We sought to assess NAAT use in TB patients in California during a period of time when NAAT availability increased throughout the world.

METHODS

We conducted a retrospective review of surveillance data from 6051 patients with culture-confirmed pulmonary TB who were reported to the California TB registry during 2010-2013.

RESULTS

Only 2336 of 6051 (39%) TB patients had a NAAT for diagnosis before culture results. Although 90% (N = 2101) with NAAT had positive test results, 9% (N = 217) had falsely negative NAAT results, and 0.8% (N = 18) had indeterminate NAAT results. The median time from specimen collection to TB treatment initiation was shorter when NAAT was used (3 vs 14 days, < .0001), and patients with a positive NAAT result initiated treatment earlier than patients with a falsely negative result (1 vs 11 days from NAAT report, < .0001). We confirmed the increased sensitivity of NAAT compared with acid-fast bacilli (AFB) smear microscopy in our study population; 92 of 145 AFB smear-negative patients had positive NAATs. Median time from specimen collection to NAAT result report differed by health jurisdiction, from 1 to 11 working days.

CONCLUSIONS

Increased use of NAATs in diagnosis of pulmonary TB could decrease the time-to-treatment initiation and consequently decrease transmission. However, differential use and access to NAAT may prevent full realization of NAAT benefits in California.