David C. Agerter

Evaluation of asymptomatic microscopic hematuria in adults : The American Urological Association Best Practice Policy-Part II : Patient evaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation, and follow-up

P I of this report (preceding article) addressed the definition, detection, prevalence, and etiology of asymptomatic microscopic hematuria. This section of the best practice policy (Part II) is intended to serve as guidance to urologists and primary care physicians with respect to the evaluation of adult patients who may have asymptomatic microscopic hematuria. Recommendations for a nephrology evaluation and for patient follow-up are provided.

A survey of family physicians and psychiatrists: Psychotropic prescribing practices and educational needs

The purpose of this study was to compare the psychotropic prescribing practices of family physicians and psychiatric physicians, and to assess their satisfaction with education about psychotropic prescribing. A survey was mailed to 461 active members of the Minnesota Psychiatric Society and to a randomized sample of 461 active members of the Minnesota Academy of Family Physicians. Major depression, panic disorder, and dementia with behavioral disturbance were selected for study. For each disorder, we asked for the estimated number of patients seen and treated as well as a list in order of preference of the three medications they most commonly use. Those surveyed were also asked about their level of satisfaction with the training they received in medical school, residency, and continuing medical education (CME) courses on the topic of psychotropic prescribing. The two physician groups reported similar prescribing practices for the single-drug treatment of depression. Family physicians more frequently prescribed minor tranquilizers and older generation psychotropics than did psychiatrists when treating panic disorder and dementia with behavioral disturbance. Patients with depression were the least likely to be referred to other health professionals. Neither physician group was satisfied with medical school education in this area; family physicians were less satisfied with residency training and in related CME courses than were psychiatric physicians. Additional study is needed to better understand interspecialty practice variation for commonly encountered psychiatric disorders. Medical education programs at all levels could better meet the reported needs of their graduates by providing more attention to prescribing psychotropic agents.

Septic sternoclavicular joint: a case report.

A 23-year-old man presented to our sports medicine clinic with a history of nontraumatic left anterior chest pain. Prior to presentation, a magnetic resonance image (MRI) had been performed that showed increased signal in the soft tissues around the sternoclavicular joint, primarily in the pectoralis major, and a small amount of fluid in the joint, thought possibly consistent with sympathetic effusion from a muscle tear. On examination, the patient was toxic appearing and had severe pain with virtually any left upper-extremity movement and with walking. There was swelling, redness, warmth, and tenderness over the left sternoclavicular joint. Vital signs were normal, but due to concerns of possible septic arthritis, he was admitted to the hospital. After discontinuation of prednisone and hydrocodone-acetaminophen that he had been receiving, the patient became febrile. Blood and sternoclavicular joint aspirate cultures grew methicillin-sensitive Staphylococcus aureus. On re-review of the MRI, subtle abnormal signal compatible with the patients joint infection was seen. The patient was treated with intravenous antibiotics and, eventually, surgical resection of the left sternoclavicular joint, proximal clavicle, and lateral manubrium with subsequent muscle flap. No predisposing factor for this infection was found. Septic sternoclavicular joint is rare, accounting for 1% of all septic joints. Infection or other unusual pathology should be suspected when clinical findings are not consistent with simple musculoskeletal injury.

Educational Links between Psychiatry and Family Practice

Psychiatrists increasingly are attentive to interactions with primary care physicians. Several studies point out that patients with mental health needs are first seen by their primary care clinicians [1,2]. While some of these patients receive fine care, others do not receive state of the art treatment; and, referral patterns from family physicians to psychiatric physicians are variable [3]. In some settings, the relationships between psychiatrists and generalists do not come naturally. Individual practice styles vary, as does convenience to high quality psychiatric care. In addition, some practitioners assign a low priority to the patient with a mental disorder [4]. Patient resistance to psychiatric service can be another complicating factor. The familiarity of clinicians in one specialty with those of another may have an impact on the likelihood of collaboration. Residencies are in a position to provide cross training in other specialties. Academic endeavors can further strengthen the bonds between the two groups. In our institution, where family practice and psychiatry had little interaction, the training directors developed four educational links between their programs. The first link resulted from psychiatry residents’ requests for rotations to family practice, coinciding with a national emphasis on primary care. Discovery of other partnership opportunities between the programs followed. Psychiatric training programs that want to improve collaboration with primary care departments in their home institutions may find it useful to explore local options to help achieve that goal, such as those described below.

Atherosclerosis and Liver Function Tests in Coronary Angiography Patients.

OBJECTIVE Elevated aminotransferase levels indicating liver function, even in the normal range, have attracted great concern as potential novel markers of cardiovascular risk assessment. We hypothesized the possibility that liver function test variations in the normal range might be meaningfully associated to coronary artery disease (CAD). METHOD Eighty-eight patients were randomly selected from those who underwent coronary angiography from June 2010 to June 2011 after applying to the outpatient cardiology clinic in Gulhane Military Medical Academy. According to the results of angiographies, patients were classified into three groups as normal, non-critical (< 50% involvement in coronaries), and critical (≥ 50% involvement in coronaries). In addition to angiographic intervention, measurements of serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) concentrations, albumin and the other serum parameters were performed in all patients. RESULTS The patient groups of CAD were balanced (28 critical cases, 30 non-critical cases and 30 normal cases). Mean age was 51.93 ± 9.3 (range 32-65) years and 19.3 per cent (n = 17) were females. Multiple linear regression analysis of all three liver function tests explained a significant portion of the variance, but adjusted r-squares were small (AST = 0.174, ALT = 0.242, albumin = 0.124). Albumin was significantly higher for patients with critical CAD than for patients with no CAD (beta = 3.205, p = 0.002). Non-critical CAD was not significantly different from no CAD for any of the dependent variables. Mean AST was significantly higher for patients taking aspirin (beta = 0.218, p = 0.049), as was mean ALT (beta = 0.264, p = 0.015). CONCLUSION Alanine aminotransferase and AST may not be associated with angiographically determined coronary atherosclerosis. Albumin may be more sensitive to demonstrate the burden of atherosclerosis. These results indicate that the association between the liver function tests and coronary atherosclerosis may be more complex than generally appreciated.

Simulated application of US cardiology guidelines for statin use to hospital patients in Turkey.

Objectives: Simulate the application of the new cardiology prevention guideline on statin use in an angiography clinic sample taken from a hospital in Turkey. Methods: Taking statins was used as a quality indicator. All cases (323) included in the sample met criteria for taking statins upon arrival in the angiography clinic. The study population was divided into 3 groups: critical coronary artery disease (CAD) (>50%), noncritical (<50%), or individuals with normal coronary arteries. Patient risk factors were tested for association with taking statins using multiple logistic regression analysis. Results: Only 20.2% of patients were taking statins when they were accepted for coronary angiography. Patients with critical CAD and noncritical CAD had higher odds of receiving statins than persons with no CAD [odds ratio (OR) = 12.9, P < .001 and OR = 3.5, P = .025, respectively]. Patients receiving angiographic interventions for stent control were more likely to be on statins than patients with angina (OR = 5.298, P = 0.004). Compared to those not taking the treadmill test, both those with positive and those with negative results had reduced odds of receiving statins (OR = 0.260, P = .002, and OR = 0.130, P = .002, respectively). Both former and current smokers had lower odds of receiving statins than persons who had never smoked (OR = 0.148, P < .001, and OR = 0.161, P = .001). Patients taking aspirin were at risk of not being on statins (OR = 0.238, P = .001). Conclusions: Most of the patients in this study were not taking statins comparing according to US guidelines. Patients who exhibited risk factors for a cardiovascular event but who had not been diagnosed with CAD were at risk for not being on statins.