Steven E. Reinert

Patients' Use of the Internet for Medical Information

AbstractOBJECTIVES: To determine the percentage of patients enrolled in a primary care practice who use the Internet for health information, to describe the types of information sought, to evaluate patients’ perceptions of the quality of this information, and to determine if patients who use the Internet for health information discuss this with their doctors. DESIGN: Self-administered mailed survey. SETTING: Patients from a primary care internal medicine private practice. PARTICIPANTS: Randomly selected patients (N=1,000) were mailed a confidential survey between December 1999 and March 2000. The response rate was 56.2%. MEASUREMENTS AND MAIN RESULTS: Of the 512 patients who returned the survey, 53.5% (274) stated that they used the Internet for medical information. Those using the Internet for medical information were more educated (P<.001) and had higher incomes (P<.001). Respondents used the Internet for information on a broad range of medical topics. Sixty percent felt that the information on the Internet was the “same as” or “better than” information from their doctors. Of those using the Internet for health information, 59% did not discuss this information with their doctor. Neither gender, education level, nor age less than 60 years was associated with patients sharing their Web searches with their physicians. However, patients who discussed this information with their doctors rated the quality of information higher than those who did not share this information with their providers. CONCLUSIONS: Primary care providers should recognize that patients are using the World Wide Web as a source of medical and health information and should be prepared to offer suggestions for Web-based health resources and to assist patients in evaluating the quality of medical information available on the Internet.

Effect of Fecal Microbiota Transplantation on Recurrence in Multiply Recurrent Clostridium difficile Infection: A Randomized Trial

Clostridium difficile infection (CDI) is the most common health careassociated infection in U.S. hospitals, with approximately 453000 infections and 29000 deaths in 2011 (1). Antibiotics are frequently ineffective (2, 3), with recurrence rates of 15% to 35% after a first episode and up to 65% after treatment of a second recurrence (4, 5). Recurrences are clinically challenging and are typically treated with prolonged courses of antibiotics, which maintain and exacerbate intestinal dysbiosis (6). Fecal microbiota transplantation (FMT) restores the normal composition of gut microbiota and is recommended when antibiotics fail to clear the infection (3). However, the evidence for FMT rests largely on case series and several open-label clinical trials that have suggested cure rates of 81% to 100% in recurrent CDI (712). To date, there has not been an adequately controlled and blinded trial of FMT for CDI treatment. Furthermore, the optimal method for administering FMT has not been determined. Evidence suggests that colonoscopic delivery has advantages in terms of efficacy (9), safety (13), and patient acceptance and tolerability (14) compared with administration via the nasoenteric route. We therefore performed a double-blind, randomized, controlled study of colonoscopic FMT for treatment of recurrent CDI. Cure rates and adverse events (AEs) were compared between donor FMT and autologous FMT (given as a placebo) in patients who had at least 3 CDI recurrences. Methods Design Overview This prospective, dual-center, double-blind, randomized, controlled trial compared FMT using donor stool or the patients own stool administered by colonoscopy. Patients treated with autologous FMT whose CDI relapsed during the 8-week follow-up were offered FMT using donor stool. Those who underwent donor FMT and had relapse were offered repeated FMT using stool from a different donor. Patients were enrolled between 15 November 2012 and 10 March 2015 at 2 academic hospitals: Montefiore Medical Center in the Bronx, New York (NY), and The Miriam Hospital in Providence, Rhode Island (RI). Microbiome analyses on donor and patient fecal specimens were performed at the University of Minnesota in Minneapolis. The institutional review board at each center approved the study protocol (Supplement). A data and safety monitoring board monitored the trial using halting rules for serious, unexpected, and related adverse safety outcomes, and all authors performed data analysis. Supplement. Supplemental Information Study Population The study population comprised adult outpatients who had 3 or more documented CDI recurrences (defined as 3 unformed stools over 24 hours for 2 consecutive days and either a positive stool test result for C difficile or pseudomembranes on colonoscopy) and who did not maintain cure after a course of tapered or pulsed vancomycin or were unable to taper or discontinue vancomycin (or an alternative antibiotic with activity against CDI) without recurrent diarrhea requiring anti-CDI treatment. All patients had completed at least 10 days of vancomycin therapy for the most recent CDI and continued therapy until 2 to 3 days before the procedure. Major exclusion criteria included age 75 years or older; inflammatory bowel disease, irritable bowel syndrome (IBS), or chronic diarrheal disorder; any immunocompromised state or immunodeficiency; anaphylactic food allergy; previous FMT; untreated, in situ colorectal cancer; and inability to undergo colonoscopy. Donor Identification and Screening Patients were permitted to identify a donor or choose to be treated with stool from healthy volunteers who were recruited at each site. All prospective donors underwent a medical interview and physical examination and were excluded if they had a known communicable disease, features of the metabolic syndrome, a diarrheal disorder, an autoimmune or atopic disease, a tumor, a neurologic disorder, or chronic pain syndrome or if they had used antibiotics for any indication within 3 months. Potential donors also completed a modified AABB full-length donor history questionnaire, and those with risk factors for infectious agents were excluded (Supplement). Testing for HIV-1 and HIV-2 was performed within 2 weeks before donation for FMT. Other serologic and stool testing was performed within 1 month before FMT and included testing for hepatitis A, B, and C viruses; testing for Treponema pallidum; polymerase chain reaction (PCR) testing for detection of C difficile toxin; culture for enteric pathogens (Escherichia coli, Salmonella, Shigella, Yersinia, Campylobacter, Listeria monocytogenes, Vibrio parahaemolyticus, and V cholerae); testing for fecal Giardia and Cryptosporidium antigens; acid-fast stain for detection of Cyclospora and Isospora; ova and parasite testing; and enzyme immunoassay for detection of Rotavirus. Patients also had baseline testing for HIV-1 and HIV-2; hepatitis A, B, and C viruses; and T pallidum. Randomization and Interventions Donors took an osmotic laxative (magnesium hydroxide) the evening before and provided fresh stool the day of FMT. All donor specimens were transported on ice and processed within 6 hours of collection. Patients were given a standard bowel purge (sodium sulfate, potassium sulfate, and magnesium sulfate oral solution) the evening before the procedure. For patient convenience, sodium sulfate, potassium sulfate, and magnesium sulfate oral solution was substituted for the polyethylene glycol (PEG) bowel purge described in the study protocol. After initiating the preparation, patients were required to collect the first stool passed (for possible use in autologous FMT), transfer it to a clean container, and keep it either refrigerated or on ice. Within 1 hour before the scheduled FMT procedure, the nonblinded research assistant took possession of the stool specimens from both the donor and the patient. Patients were equally allocated to the donor and autologous FMT groups via block randomization by C difficile positivity at baseline, with stratification by study site. The protocol specified a dose of 100 g of stool diluted in 500 mL of nonbacteriostatic 0.9% normal saline immediately before the procedure, but the study relied on fresh stool, which has unpredictable weight and volume, and most provided specimens were less than 100 g. Because patients had discontinued use of vancomycin, had completed bowel lavage, and had been randomly assigned, we elected to use the lesser amount of fecal material. In those circumstances, available stool was weighed and suspended in a proportionately reduced volume of saline. A mean stool dose of 64 g (SD, 25 g; range, 20 to 100 g) was infused for donor FMT. Colonoscopies were performed within the endoscopy units of the study centers. Endoscopic findings and the depth of insertion were recorded. The study physician administered 300 mL of the fecal suspension through the instruments working channel into the furthest point reached (terminal ileum or cecum). After FMT, patients were transferred to the recovery area and encouraged to retain the stool for at least 1 hour. If they were unable to do so, the time of the first postprocedure bowel movement was recorded. Follow-up Patients were instructed to contact the clinical team if they had recurrence of diarrhea and were provided with a thermometer for daily oral temperature readings and a diary card to record solicited AEs for 7 days and unsolicited AEs for 30 days after transplantation. They were contacted by telephone 2 and 7 days after FMT and then biweekly for 8 weeks and questioned about stool form and frequency. All patients were seen in the clinic for follow-up 2 and 8 weeks after treatment, where they were assessed for infectious and gastrointestinal symptoms and underwent physical examination. They submitted stool specimens at baseline and at each post-FMT visit for C difficile PCR testing and microbiome analysis. All patients were contacted by telephone by a study representative 6 months after the last treatment to record any serious AEs (SAEs), new medical conditions or diagnoses, or changes in medical conditions or medications since the last study contact. End Points The primary efficacy end point was the rate of clinical cure in the intention-to-treat (ITT) population 8 weeks after FMT or at the time of early withdrawal. Clinical cure was defined as lack of CDI recurrence with maintenance of resolution (that is, <3 unformed stools per day) for 8 weeks without requirement for further antibiotics (metronidazole, vancomycin, or fidaxomicin). Because nucleic acid testing does not distinguish colonized patients from those with symptomatic disease (15), it cannot test for cure (2, 16); therefore, patients meeting the definition of clinical cure were considered to be cured regardless of the results of follow-up PCR testing of stool for C difficile. Safety end points were evaluated by review of SAEs, AEs, new medical conditions or diagnoses, or changes in medical conditions at the 6-month follow-up. Analysis of Fecal Microbiota Fecal microbiota was analyzed from patients at least 5 days before and 2 and 8 weeks after FMT, as well as from donor samples. DNA extraction, 16S ribosomal RNA gene amplification, and sequencing were performed by the University of Minnesota Genomics Center. Processing details are described in the Supplement, and data are archived in the Sequence Read Archive at the National Center for Biotechnology Information under BioProject accession number SRP066964. Taxonomic assignments were made against the Ribosomal Database Project using mothur software, version 1.34.0 (17). Alpha and beta diversity of bacterial communities were evaluated using the same software. Shannon indices and abundance-based coverage estimate parameters were calculated to assess alpha diversity. Differences in beta diversity and abundances of genera were performed using analysis of similarity and KruskalWallis analysis, respectively (18). Statis

Arthroscopic débridement for osteoarthritis of the knee.

BACKGROUND The role of arthroscopic débridement in the treatment of osteoarthritis of the knee remains to be defined, and few clinical and radiographic characteristics have been quantitatively associated with the outcome. The hypothesis of this study was that the outcome of arthroscopic débridement for osteoarthritis of the knee is associated with preoperative clinical and radiographic features and intraoperative characteristics and that there are subsets of patients who are more and less likely to respond favorably to the treatment. METHODS We performed a cross-sectional study of a consecutive cohort of 122 patients who underwent arthroscopic débridement for the treatment of osteoarthritis of the knee that had been unresponsive to anti-inflammatory therapy. One hundred and ten patients were followed for a mean of thirty-four months. Pain was assessed with the pain domain of the Knee Society scoring system. Radiographs were scored with the Kellgren-Lawrence method, and limb alignment and the widths of the medial and lateral joint spaces were measured. The severity of cartilage lesions was scored intraoperatively with a modified Noyes grading system. Specific methods of data collection and analysis were incorporated to minimize bias. RESULTS Fifty-two (90%) of fifty-eight knees with mild arthritis, normal alignment, and a joint space width of > or = 3 mm were improved after arthroscopic débridement. Conversely, only five (25%) of twenty knees with severe arthritis, limb malalignment, and a joint space width of < 2 mm had substantial relief of symptoms. Of seventy-two patients who had improvement, forty-four (61%) had it within six months after the arthroscopy. The severity of the lesion was highly predictive of the clinical outcome both in patients with mild arthritis and in those with severe arthritis. CONCLUSIONS The severity of the arthritis, as assessed preoperatively with radiography and intraoperatively by rating the severity of cartilage lesions, influences the clinical outcome of arthroscopic débridement of an osteoarthritic knee. Knees with severe arthritis fare poorly, whereas those with mild arthritis fare well. We could not predict the outcome for knees with moderate arthritis. We believe that these observations are relevant for establishing indications for arthroscopy in patients with osteoarthritis of the knee and may be useful for designing studies with a more rigorous experimental design.

Windsurfing injuries: results of a paper- and Internet-based survey.

OBJECTIVE To describe the frequency, pattern, and mechanism of windsurfing injuries. METHODS A 24-question multiple-choice paper-based survey was distributed to windsurfers at beaches in the United States and the Dominican Republic, and an identical survey was placed on the Internet. RESULTS Two hundred ninety-four surveys in all were completed describing 339 acute and 150 chronic injuries. The foot, knee, chest wall, and ankle were the most commonly injured body parts. Sprains (26.3%) were most common, followed by lacerations (21.2%), contusions (16.2%), and fractures (14.2%). Direct injury from the windsurfing apparatus resulted in 64.5% of the acute injuries, and 12% were caused by contact with the ocean floor. The maneuvers most likely to result in injury were jumping, high-speed falls, and catapult falls. There was no statistically significant difference between the Internet- and paper-based surveys regarding anatomic distribution of injuries or type of injury. The incidence of injuries requiring medical care in study participants was estimated to be one injury per 1000 days sailed. CONCLUSIONS Sprains, lacerations, and contusions to the lower extremity are the most common windsurfing injuries. Equipment modifications are suggested that may decrease the risk of injury.

Impact of Interpretation Method on Clinic Visit Length

AbstractOBJECTIVE: To determine the impact of interpretation method on outpatient visit length. DESIGN: Time-motion study. SETTING: Hospital-based outpatient teaching clinic. PARTICIPANTS: Patients presenting for scheduled outpatient visits. MEASUREMENTS AND MAIN RESULTS: Over a 6-week study period, a research assistant recorded the following information for consecutive patient visits: patient age, gender and insurance type; type of interpreter used (none, hospital interpreter, telephone interpreter or patient-supplied interpreter); scheduled visit length; provider type (nurse practitioner; attending physician; resident in postgraduate year 1, 2 or 3, or medical student); provider gender; amount of time the patient spent in the examination room with the provider (provider time); and total time the patient spent in the clinic from check-in to checkout (clinic time). When compared to patients not requiring an interpreter, patients using some form of interpreter had longer mean provider times (32.4 minutes [min] vs 28.0 min, P<.001) and clinic times (93.6 min vs 82.4 min, P=.002). Compared to patients not requiring an interpreter, patients using a telephone interpreter had significantly longer mean provider times (36.3 min vs 28.0 min, P < .001) and clinic times (99.9 min vs 82.4 min, P=.02). Similarly, patients using a patient-supplied interpreter had longer mean provider times (34.4 min vs 28.0 min, P<.001) and mean clinic times (92.8 min vs 82.4 min, P=.027). In contrast, patients using a hospital interpreter did not have significantly different mean provider times (26.8 min vs 28.0 min, P=.51) or mean clinic times (91.0 min vs 82.4 min, P=.16) than patients not requiring an interpreter. CONCLUSION: In our setting, telephone and patient-supplied interpreters were associated with longer visit times, but full-time hospital interpreters were not.

Prognostic value of stress-gated Tc-99m sestamibi SPECT after acute myocardial infarction

Stress-gated technetium-99m (Tc-99 m) sestamibi single-photon emission computed tomography (SPECT) is used to risk stratify patients after acute myocardial infarction (AMI). In clinical practice, results of this test are used primarily to identify patients with myocardial ischemia for intervention. The value of this test to risk stratify patients with AMI not at high ischemic risk has not been addressed. More than 1-year follow-up was undertaken in 124 patients who underwent predischarge gated Tc-99m sestamibi SPECT studies and who did not undergo subsequent revascularization. Clinical variables and test-derived variables were evaluated to predict cardiac death, recurrent AMI, and hospitalization for unstable angina, congestive heart failure, or coronary revascularization. Independent predictors by multivariate analysis for cardiac death or recurrent AMI were a history of prior AMI (relative risk [RR] = 5.32, confidence interval [CI] 2.17 to 12.96), a low exercise capacity (RR = 6.84, CI 1.99 to 23.48), and left ventricular (LV) ejection fraction (EF) <40% (RR = 2.63, CI 1.04 to 6.38). The incidence of cardiac death or recurrent AMI was 29.8% in patients with a low exercise capacity versus 4.5% in those with good exercise capacity, and 38.1% in patients with LVEF <40% versus 9.4% in those with LVEF >40%. Independent predictors of cardiac death, AMI, or hospitalization for unstable angina, congestive heart failure, or revascularization were a history of prior AMI (RR = 2.24, CI 1.11 to 4.50) and LVEF <40% (RR = 3.13, CI 1.64 to 5.95). Among patients followed after AMI without revascularization Tc-99m sestamibi SPECT can identify a high-risk subset. The strongest independent predictors are poor exercise capacity and LVEF < 40%.

Self-Confidence in and Perceived Utility of the Physical Examination: A Comparison of Medical Students, Residents, and Faculty Internists

BACKGROUND AND OBJECTIVESLittle is known about the differences in attitudes of medical students, Internal Medicine residents, and faculty Internists toward the physical examination. We sought to investigate these groups’ self-confidence in and perceived utility of physical examination skills.DESIGN AND PARTICIPANTSCross-sectional survey of third- and fourth-year medical students, Internal Medicine residents, and faculty Internists at an academic teaching hospital.MEASUREMENTSUsing a 5-point Likert-type scale, respondents indicated their self-confidence in overall physical examination skill, as well as their ability to perform 14 individual skills, and how useful they felt the overall physical examination, and each skill, to be for yielding clinically important information.RESULTSThe response rate was 80% (302/376). The skills with overall mean self-confidence ratings less than “neutral” were interpreting a diastolic murmur (2.9), detecting a thyroid nodule (2.8), and the nondilated fundoscopic examination using an ophthalmoscope to assess retinal vasculature (2.5). No skills had a mean utility rating less than neutral. The skills with the greatest numerical differences between mean self-confidence and perceived utility were distinguishing between a mole and melanoma (1.5), detecting a thyroid nodule (1.4), and interpreting a diastolic murmur (1.3). Regarding overall self-confidence, third-year students’ ratings (3.3) were similar to those of first-year residents (3.4; p = .95) but less than those of fourth-year students (3.8; p = .002), upper-level residents (3.7; p = .01), and faculty Internists (3.9; p < .001).CONCLUSIONSSelf-confidence in the physical exam does not necessarily increase at each stage of training. The differences found between self-confidence and perceived utility for a number of skills suggest important areas for educational interventions.

Effect of discontinuing cholinesterase inhibitor therapy on behavioral and mood symptoms in nursing home patients with dementia

BACKGROUND Cholinesterase inhibitors (CHEIs) ameliorate some types of behavioral symptoms in patients with Alzheimers disease. However, there has been little previous study of the outcomes associated with discontinuing these medications. OBJECTIVE The primary aim of this study was to evaluate the extent to which discontinuing CHEI therapy affected behavioral and mood symptoms in a cohort of nursing home residents with a diagnosis of dementia compared with residents receiving longer-term CHEI therapy. METHODS This was a retrospective cohort study using Rhode Island Medicaid prescription claims and the Minimum Data Set (MDS). Participants were Rhode Island nursing home residents aged > or =60 years with a diagnosis of Alzheimers disease or non-Alzheimers dementia, treated with CHEI monotherapy, and enrolled in the Medicaid program between January 1, 2004, and December 31, 2005. The discontinuation cohort (CHEI-DC) was selected by identifying residents who received 3 to 9 months of uninterrupted CHEI therapy. The continuation cohort (CHEI-CONT) was prescribed continuous CHEI therapy for >9 months. Changes in scores on the Aggressive Behavior Scale (ABS) and the Depression Rating Scale (DRS) for CHEI-DC residents were compared with changes in scores for CHEI-CONT residents. Secondary outcomes included change over time for individual behavioral symptoms and indicators of cognitive and functional status coded on the MDS. RESULTS The final matched sample (N = 178) included 62 CHEI-DC cases and 116 CHEI-CONT controls. More than half of the cohort was aged > or =85 years, and the sample was predominantly female. A diagnosis of Alzheimers disease was documented in 40.3% of the CHEI-DC patients and in 46.5% of the CHEI-CONT patients. Behavioral worsening, indicated by an increase in the estimated mean monthly point change in ABS score, occurred in the CHEI-DC group (0.08; 95% CI, 0.01 to 0.16) but not in the CHEI-CONT group (-0.01; 95% CI, -0.06 to 0.04), and the between-group difference was significant (0.09; 95% CI, 0.01 to 0.18). There were no significant between-group differences in the mean monthly point change in mood symptoms on the DRS (0.04; 95% CI, -0.03 to 0.12). For the secondary outcomes, the mean monthly MDS point change for frequency of repetitive verbal behaviors indicated that CHEI-DC patients exhibited significantly more episodes of repetitive questioning (0.17; 95% CI, 0.05 to 0.29) and repetitive health complaints (0.16; 95% CI, 0.04 to 0.27) compared with CHEI-CONT residents. Continued use of CHEIs was associated with more time spent in leisure-related activities over the study period (-0.26; 95% CI, -0.50 to -0.02), with the CHEI-DC group spending less time in activities (0.11; 95% CI, 0 to 0.23); the between-group difference was also significant (0.37; 95% CI, 0.10 to 0.65). CONCLUSION Results of this retrospective analysis suggest that, compared with longer duration of CHEI therapy, discontinuation of CHEIs in these nursing home residents with dementia was associated with some adverse behavioral changes and decreased time spent engaging in leisure-related activities.

The development of a urinary tract infection is associated with increased mortality in trauma patients.

BACKGROUND In October 2008, Medicare and Medicaid stopped paying for care associated with catheter-related urinary tract infections (UTIs). Although most clinicians agree UTIs are detrimental, there are little data to support this belief. METHODS This is a retrospective review of trauma registry data from a Level I trauma center between 2003 and 2008. Two proportional hazards regressions were used for analyses. The first predicted acquisition of UTI as a function of indwelling urinary catheter use, adjusting for age, diabetes, gender, and injury severity. The second predicted hospital mortality as a function of UTI, covarying for age, gender, chronic obstructive pulmonary disease, congestive heart failure, hypertension, diabetes, pneumonia, and injury severity. RESULTS After excluding patients who stayed in the hospital <3 days and those with a UTI on arrival, 5,736 patients were included in the study. Of these patients, 680 (11.9%) met criteria for a UTI, with 487 (71.6%) indwelling urinary catheter-related infections. Predictors of UTI included the interaction between age and gender (p = 0.0018), Injury Severity Score (p = 0.0021), and indwelling urinary catheter use (p < 0.001). The development of a UTI predicted the risk of in-hospital death as a patients age increased (p = 0.002). Similar results were seen when only catheter-associated UTIs are included in the analysis. CONCLUSIONS Indwelling urinary catheter use is connected to the development of UTIs, and these infections are associated with a greater mortality as the age of a trauma patients increases.

Are Dropped Osteoarticular Bone Fragments Safely Reimplantable in Vivo

BACKGROUND There are limited data detailing the appropriate management of nondisposable autologous osteoarticular fragments that have been contaminated by the operating room floor. The goal of the present study was to perform a comprehensive, three-phase investigation to establish an appropriate intraoperative algorithm for the management of the acutely contaminated, but nondisposable, autologous osteoarticular bone fragment. METHODS Phase I of the study was performed to quantify the rate of contamination and microbial profile of human osteoarticular fragments that were dropped onto the operating room floor (n = 162). Phase II was performed to assess the feasibility and optimal means of decontaminating 340 similar fragments that underwent controlled contamination with bacteria that were identified in Phase I; decontamination was performed with use of cleansing agents that are routinely available in an operating room. Phase III was performed to assess the effect of each decontamination process on fragment chondrocyte viability through histologic evaluation. RESULTS The contamination rate in Phase I was 70%. Coagulase-negative Staphylococcus was the most commonly cultured organism. In Phase II, varying exposure time to the chemical agents did not make a significant difference in decontamination rates. Mechanical scrubbing was superior to mechanical saline solution lavage (zero of fifty-six cultures compared with twenty of fifty-six cultures were positive for coagulase-negative Staphylococcus; p < 0.001). As a whole, bactericidal agents were found to be more effective decontaminating agents than normal saline solution. Povidone-iodine and 4% chlorhexidine gluconate were the most effective decontaminating agents, with none of the twenty-eight specimens that were decontaminated with each agent demonstrating positive growth on culture. Phase III demonstrated that the groups that were treated with normal saline solution and povidone-iodine retained the greatest number of live cells and the least number of dead cells. Mechanical scrubbing significantly decreased chondrocyte viability as compared with a normal saline solution wash (p < 0.05). CONCLUSIONS The majority of osteochondral fragments that contact the operating room floor produce positive bacterial cultures. Five minutes of cleansing with a 10% povidone-iodine solution followed by a normal saline solution rinse appears to provide the optimal balance between effective decontamination and cellular toxicity for dropped autologous bone in the operative setting.