Stephen P. Merry

Dual-energy CT for the diagnosis of gout: an accuracy and diagnostic yield study

Objectives To assess the accuracy of dual-energy CT (DECT) for diagnosing gout, and to explore whether it can have any impact on clinical decision making beyond the established diagnostic approach using polarising microscopy of synovial fluid (diagnostic yield). Methods Diagnostic single-centre study of 40 patients with active gout, and 41 individuals with other types of joint disease. Sensitivity and specificity of DECT for diagnosing gout was calculated against a combined reference standard (polarising and electron microscopy of synovial fluid). To explore the diagnostic yield of DECT scanning, a third cohort was assembled consisting of patients with inflammatory arthritis and risk factors for gout who had negative synovial fluid polarising microscopy results. Among these patients, the proportion of subjects with DECT findings indicating a diagnosis of gout was assessed. Results The sensitivity and specificity of DECT for diagnosing gout was 0.90 (95% CI 0.76 to 0.97) and 0.83 (95% CI 0.68 to 0.93), respectively. All false negative patients were observed among patients with acute, recent-onset gout. All false positive patients had advanced knee osteoarthritis. DECT in the diagnostic yield cohort revealed evidence of uric acid deposition in 14 out of 30 patients (46.7%). Conclusions DECT provides good diagnostic accuracy for detection of monosodium urate (MSU) deposits in patients with gout. However, sensitivity is lower in patients with recent-onset disease. DECT has a significant impact on clinical decision making when gout is suspected, but polarising microscopy of synovial fluid fails to demonstrate the presence of MSU crystals.

Eight years of the Mayo International Health Program: what an international elective adds to resident education.

OBJECTIVE To examine the educational benefits of international elective rotations during graduate medical education. PARTICIPANTS AND METHODS We studied Mayo International Health Program (MIHP) participants from April 1, 2001, through July 31, 2008. Data from the 162 resident postrotation reports were reviewed and used to quantitatively and qualitatively analyze MIHP elective experiences. Qualitative analysis of the narrative data was performed using NVivo7 (QRS International, Melbourne, Australia), a qualitative research program, and passages were coded and analyzed for trends and themes. RESULTS During the study period, 162 residents representing 20 different specialties were awarded scholarships through the MIHP. Residents rotated in 43 countries, serving over 40,000 patients worldwide. Their reports indicated multiple educational and personal benefits, including gaining experience with a wide variety of pathology, learning to work with limited resources, developing clinical and surgical skills, participating in resident education, and experiencing new peoples and cultures. CONCLUSION The MIHP provides the structure and funding to enable residents from a variety of specialties to participate in international electives and obtain an identifiable set of unique, valuable educational experiences likely to shape them into better physicians. Such international health electives should be encouraged in graduate medical education.

Youth, unemployment, and male gender predict mortality in AIDS patients started on HAART in Nigeria

Abstract This retrospective study identifies risk factors for mortality in a cohort of HIV-positive adult patients treated with highly active antiretroviral therapy (HAART) in Jos, Nigeria. We analyzed clinical data from a cohort of 1552 patients enrolled in a HIV/acquired immune deficiency syndrome treatment program and started on HAART between December 2004 and 30 April 2006. Death was our study endpoint. Patients were followed in the study until death, being lost to follow-up, or the end of data collection, 1 December 2006. Baseline patient characteristics were compared using Wilcoxon Rank Sum Test for continuous variables and Pearson Chi-Square test for categorical variables to determine if certain demographic factors were associated with more rapid progression to death. The Cox proportional hazard multivariate model analysis was used to find risk factors. As of 1 December 2006, a total of 104 cases progressed to death. In addition to the expected association of CD4 count less than 50 at initiation of therapy and active tuberculosis with mortality, the patient characteristics independently associated with a more rapid progression to death after initiation of HAART were male gender, age less than 30 years old, and unemployment or unknown occupation status. Future research is needed to identify the confounding variables that may be amenable to targeted interventions aimed at ameliorating these health disparities.

Patient-centredness, self-rated health, and patient empowerment: should providers spend more time communicating with their patients?

OBJECTIVE Patient-centred communication is often employed as a strategy for empowering patients. The purpose of this study was to investigate the relationship between a direct measure of patient empowerment, feeling that one is in control of ones own health and patient satisfaction with communication. DESIGN A cross-sectional survey of family medicine patients was used to test the theory that, in primary care patients, empowerment is related to satisfaction with several aspects of communication after adjusting for health status, age and gender. Interviews were completed with 680 adult patients for whom complete data were available. RESULTS Multiple logistic regression analysis revealed that being highly satisfied with overall communication [adjusted odds ratio (AOR)=2.08], explanations (AOR=2.04), listening (AOR=2.63), use of understandable words (AOR=2.41) and involvement in decisions (2.34) were positively associated with empowerment. Self-rated health was more strongly related to empowerment than satisfaction with communication in every model tested (AORs ranged from 2.8 to 3.0). CONCLUSIONS Reliance solely on patient-centred communication to promote empowerment may be insufficient as well as costly. Instead, improved one-to-one communication between patients and providers should be reserved for clinically complex and urgent situations. For other health matters, referral of patients to community health promotion and education programmes should be considered because this may offer a lower-cost approach to empowerment.

Rules of Engagement: The Principles of Underserved Global Health Volunteerism

The day begins at 7:00 AM with a layer of mosquito repellent and boiled coffee in a tin cup. Our medical clinic in the small village of Rancho Pedro along the Dominican Republic-Haiti border is a small hut composed of dilapidated wooden planks fastened together under a thatched reed roof. Patients with a variety of ailments line up daily outside the clinic door in anticipation of seeing a physician, often for the first time. Most patients have been waiting for hours, usually after enduring an overnight mountainous trek from a neighboring Haitian or Dominican village. Many of the medical problems encountered can be treated effectively with simple measures of wound debridement, bandages, analgesics, or antibiotics; however, some are more complex with no referral options. The work is intense but inspiring, rewarding but often frustrating as the limitations of our abilities quickly become apparent.

Validity of overall self-rated health as an outcome measure in small samples: A pilot study involving a case series

OBJECTIVE A single-item measure of overall self-rated health (SRH) commonly is used in population surveys, but has not been used in small pilot projects. The purpose of this study was to assess the validity of SRH in small samples. DESIGN We used data from a prospective, observational weight-loss project to compare change in SRH with change in body weight and physical activity (PA) (minutes) over 30 days (n = 34). Body mass index at baseline ranged from 25.5 to 50.4 (mean = 36.1, median = 34.6). SRH was self-assessed using the following question: How would you rate your health overall? Results An increase in weight was associated with a reduction in SRH (r = 0.37, P = 0.03). An increase in PA was associated with improved SRH (r = 0.39, P = 0.02). CONCLUSIONS A single-item SRH measure may be an efficient method for measuring programme outcomes, and may also be useful for comparing the relative effectiveness of different programmes in pilot projects and quality improvement studies.

Comparison of Clinical Risk Tools for Predicting Osteoporosis in Women Ages 50–64

Objective: The objective of this study was to compare the performance of the US Preventive Services Task Force (USPSTF) recommended WHO Fracture Risk Assessment Tool (FRAX) threshold score of 9.3% (calculated without femoral neck bone density) with the Simple Calculated Osteoporosis Risk Estimate (SCORE), Osteoporosis Self-Assessment Tool (OST), and the Osteoporosis Risk Assessment Instrument (ORAI) to identify osteoporosis in younger women. Methods: We conducted a retrospective review of women ages 50 to 64 years who underwent dual-energy radiographic absorptiometry (DXA) at our institution over a 6-month period. Scores for the FRAX, ORAI, OST, and SCORE tools were calculated using various thresholds: FRAX ≥9.3%, SCORE ≥6, OST <2, and ORAI ≥9. Sensitivity, specificity, and area under the receiver-operating characteristic curve for detection of densitometric osteoporosis by DXA for each tool were compared. Results: A total of 290 women were identified. Of these, 284 (97.9%) were white, and the mean ± standard deviation age was 56.6 ± 3.4 years. Fifty (17.2%) had osteoporosis of the lumbar spine and/or femoral neck on DXA. Sensitivity, specificity, and area under the receiver-operating characteristic curve for identifying densitometric osteoporosis at the femoral neck and/or spine were 36%, 73%, and 0.55 for FRAX; 74%, 42%, and 0.58 for SCORE; 56%, 69%, and 0.63 for the OST; and 52%, 67%, and 0.60 for the ORAI, respectively. Conclusions: DXA screening based on the USPSTF–recommended FRAX threshold score of 9.3% has a low sensitivity to identify densitometric osteoporosis in women ages 50 to 64. Lowering the threshold score would increase sensitivity but would also increase the number of women sent for screening DXA. Use of the validated SCORE tool would improve sensitivity to identify osteoporosis in this age group.

Physical limitations and self-rated overall health in family medicine patients

Objective: To assess how physical limitations relate to self-rated health among family medicine patients after adjustment for severity of illness. Design: A telephone survey of family medicine patients, linked with medical record information. Setting: A large family medicine department in Rochester, Minnesota, USA. Subjects: Self-ratings of health were linked to medical records for 804 adult patients. Results: Adjusting for severity and other confounders using multiple logistic regression analysis revealed that having physical limitations was inversely and independently related to good self-rated health (adjusted odds ratio = 0.20, P<0.001). Odds ratios also were lower for high severity of illness (adjusted odds = 0.43). Morbidly obese patients and patients older than 65 years of age also had reduced odds of good self-rated health. Conclusions: In our sample of family medicine patients, part of the disparity in health status experienced by people with physical limitations is attributable to greater severity of illness, age and obesity.

A patient-centered decision rule for referral of patients to weight-loss programs.

Background The obesity epidemic threatens to shorten life expectancy and reduce the quality of life for large segments of the population. The purpose of this study was to develop a decision rule for referral to a weight-loss program on the basis of the relationship between body mass index (BMI) and self-rated overall health. Methods We employed a patient satisfaction survey of family medicine patients treated in Mayo Clinic in Rochester, Minnesota, linked with medical record information, to test the theory that, in primary care patients, BMI exhibits an inverse and independent relationship with overall self-rated health after adjusting for age, gender, marital status, and cigarette smoking. Interviews were linked to medical records for 679 adult patients. Results Adjusting for age and other confounders using multiple logistic regression analysis revealed that overweight (BMI = 25–30 kg/m2) was not a risk factor for poor self-rated health and only BMI above 35 kg/m2 was significantly related to poor overall health (adjusted odds ratio = 0.33, confidence interval = 0.17–0.64, P = .0012). Conclusions Quality improvement programs should monitor whether obesity is being addressed in clinical settings. A patient-centered decision rule for addressing obesity could involve referral of patients whose BMI is above 35 kg/m2 to weight management programs, monitoring of patients whose BMI scores are between 30 and 35 kg/m2, and encouragement of patients whose BMI is above 25 kg/m2 to avoid weight gain.

Self-assessed disability and self-rated health among rural villagers in Peru: a brief report.

CONTEXT Risks for poor self-rated overall health in rural areas of developing nations have not been thoroughly investigated. PURPOSE The objective of this study was to assess potential risk factors for poor self-rated health among rural villagers in Peru. METHODS A door-to-door survey of villagers residing in the Pampas Grande region in Peru, which is in the Andes Mountains, yielded complete data for 337 adults. FINDINGS Adjusting for age and gender using multiple logistic regression analysis revealed that having self-reported disabilities was inversely and independently related to good self-rated health (OR 0.48 [95% CI, 0.26-0.88]). Joint pain also was related to self-rated health (OR 0.23 [95% CI, 0.13-0.41]). CONCLUSIONS Increasing access to affordable, effective analgesics may reduce this disparity. Health agencies should consider these actions as possible planning priorities for the region.