General Clinic Population Research Articles

High-pitch prospective ECG-triggered helical coronary computed tomography angiography in clinical practice: image quality and radiation dose.

High-pitch prospective ECG-triggered helical (PTH) protocols for coronary computed tomography angiography (CCTA) have demonstrated adequate image quality (IQ) in small-scaled studies and highly selected patients. Clinical applicability in a general clinical population is uncertain. This study evaluated the implementation of a PTH protocol in a routine clinical cohort, focusing on IQ and radiation dose. The local scientific board approved the retrospective analysis and all patients signed an informed consent statement for usage of their data. In consecutive patients suspected of coronary artery disease CCTA was performed using a dual source 128-slice scanner. All patients with a regular heart rate <65bpm underwent a PTH CCTA. IQ for each coronary segment was graded (1=absence of artifacts to 4=non-evaluable). In 664 (80.4%) of 826 included patients [mean age±standard deviation (SD) 57±11, 65% female, mean body mass index (BMI)±SD 27±9kgm(-2)] PTH CCTA was acquired whereas in 162 (19.6%) a non-PTH sequence was used. Reasons for not performing a PTH protocol were persistent high heart rate (41.6%) or heart rate irregularity (58.4%). Mean±SD heart rates for PTH and non-PTH CCTA were 55±5 and 65±9bpm, respectively, p<0.001. In the PTH group 92% of the segments were of diagnostic quality (score 1-3), versus 87% in the non-PTH group (p=0.055). Per patient, mean IQ score was 1.19 and 1.21 respectively (lower is better; p=0.012). Effective dose (including topogram, test bolus, and coronary calcium score), as calculated with a conversion factor of 0.014mSvmGy(-1)cm(-1) was 1.6±0.6 and 4.7±2.6mSv for the PTH and the non-PTH group respectively, (p<0.001). Performing high-pitch PTH sequences on a routine basis is feasible in the majority of patients with high IQ and significant reduction in radiation dose.

Prevalence of primary hyperparathyroidism in a referred sample of fibromyalgia patients

The objective of this study is to determine the prevalence of primary hyperparathyroidism in a referred sample of fibromyalgia patients. Consecutively, referred patients with confirmed fibromyalgia (FM group) had measurements of serum levels of vitamin D, alkaline phosphatase, total calcium, magnesium, phosphate, creatinine, total protein, albumin, and parathyroid hormone. The same measurements were also conducted in a group of patients with widespread pain (WP group) who did not meet the 2010 Modified ACR criteria for fibromyalgia and a group with localized musculoskeletal pain (MSK group). A case of primary hyperparathyroidism was defined as a subject whose results showed any of the following: (1) parathyroid hormone levels above 6.8 pmol/L; (2) an ionized calcium above 1.25 mmol/L; or (3) both elevated, in the presence of normal range creatinine, alkaline phosphatase, vitamin D, phosphate, and magnesium. The mean age and the proportion of subjects who met the case definition of primary hyperparathyroidism were calculated for all groups. There were 125 subjects in the FM group, 127 in the WP group, and 138 in the MSK group. The prevalence rates of primary hyperparathyroidism were 6.4, 5.5, and 6.1%, respectively, for these groups. Comparison of these prevalence rates to published figures for general clinical and non-clinical populations reveals no differences. The prevalence of primary hyperparathyroidism in fibromyalgia patients is not different than that in other patients with WP or those with localized pain, nor is it likely different than that seen in the general population.

NLA Task Force on Statin Safety--2014 update.

1933-2874/$ see front matter 2014 http://dx.doi.org/10.1016/j.jacl.2014.03 Statins are the most widely prescribed class of medications in the United States and their benefits for lowering lowdensity lipoprotein cholesterol (LDL-C) and reducing the risk for coronary heart disease (CHD) are well documented. Statins have been the cornerstone of pharmacotherapy for the management of high blood cholesterol levels virtually since their development. The American Heart Association /American College of Cardiology 2013 guidelines recently expanded the number of individuals eligible for statin therapy by recommending it for those with: (1) clinical atherosclerotic cardiovascular disease (ASCVD), (2) LDL-C $190 mg/dL, (3) type 2 diabetes and age between 40 and 75 years with LDL-C 70 to 189 mg/dL, and (4) an estimated 10-year risk of ASCVD $7.5% and age 40 to 75 years. Considering only those who qualify according to their estimated 10-year risk of ASCVD, it has been reported that of the 101 million people in the United States age 40 to 79 years who do not have cardiovascular disease, 33 million have an estimated 10-year risk of ASCVD $7.5%, and another 13 million have a risk between 5% and 7.4%. Using crude global estimates, 920 million people worldwide would be expected to be

G415(P) A Re-audit of Vitamin supplementation levels in paediatric allergy and general paediatric populations – Any better now than in 2009?

Introduction:Vitamin D deficiency and rickets are increasing in the United Kingdom, despite national guidance to supplement all children <5 years of age. We previously (2009) surveyed children attending our general...

How to optimally manage unhappy, anxious, and difficult patients

Patient satisfaction has been and is of growing importance in healthcare. Recent healthcare initiatives aim to provide physicians with performance feedback reports based partially on patient completed surveys; thus, patient satisfaction will be an even more important determinant of high quality care. In the field of dermatology, patient satisfaction is particularly relevant and at times difficult to achieve, since many patients are plagued with chronic skin diseases often requiring intensive topical regimens or undesirable systemic immunosuppressants. The discussion of patient satisfaction is usually restricted to encounters with the general clinic population leaving encounters with difficult patients largely underreported; therefore, we provide examples of more common difficult patient encounters a dermatologist may face with specific recommendations on how to best optimize patient satisfaction.

Open-angle Glaucoma in Filipino and White Americans

To compare the frequency of open-angle glaucoma (OAG) subtypes between Filipino and white Americans in a general ophthalmology clinic population. In this retrospective cross-sectional epidemiologic study with prospective sampling, medical charts of 1113 patients aged 40 years or older (513 Filipinos, 600 whites) seen in 2008 were randomly sampled from 2 private comprehensive ophthalmology clinics. Glaucoma was diagnosed based on optic nerve appearance, visual field defects, and other ocular findings using the International Society of Geographical and Epidemiological Ophthalmology (ISGEO) scheme. The normal-tension subtype of OAG [normal-tension glaucoma (NTG)] was defined by intraocular pressure ≤21 mm Hg as determined by review of medical records. NTG comprised a greater proportion of all glaucomatous disease in Filipino subjects [Filipino (F) vs. white (W): 46.7% vs. 26.8%; P=0.02]. Filipinos were more commonly diagnosed with OAG and NTG than whites (F vs. W: OAG, 11.9% vs. 8.2%; NTG, 6.8% vs. 2.5%; P=0.04, 0.001, respectively). There was no significant difference in central corneal thickness between Filipino and white subjects with NTG (P=0.66). Both OAG and NTG may be more common in Filipino Americans than in white Americans with the propensity for NTG being particularly high in the former relative to the latter group.

Factors associated with non-attendance in a general practice super clinic population in regional Australia: a retrospective cohort study

Factors associated with non-attendance in a general practice super clinic population in regional Australia: a retrospective cohort study

Autism traits in the RASopathies

BackgroundMutations in Ras/mitogen-activated protein kinase (Ras/MAPK) pathway genes lead to a class of disorders known as RASopathies, including neurofibromatosis type 1 (NF1), Noonan syndrome (NS), Costello syndrome (CS), and cardio-facio-cutaneous...

Doctors and Lawyers Collaborating to HeLP Children—: Outcomes from a Successful Partnership between Professions

Clear associations exist between socioeconomic risks and health, and these risks are often amenable to legal interventions. This is a case study of an implementation of a medical-legal partnership (MLP) in three pediatric primary care centers that serve a predominantly high-risk population. Referral circumstances and outcomes over the first three years are described. During the three-year study period, 1,808 MLP referrals were made for 1,614 patients by all levels of provider. Those referred were more likely to have asthma (p<.0001) and developmental delay/behavioral disorder (p<.0001) than the general clinic population. Housing (37%) and income/health benefit (33%) problems were the most common reasons for referral. Referrals led to 1,742 (89%) positive legal outcomes affecting nearly 6,000 cohabitating children and adults and translating into nearly $200,000 in recovered back benefits. Successful MLP implementation enabled pediatric providers to address social determinants of health potentially improving health and reducing disparities.

ICD-9 tobacco use codes are effective identifiers of smoking status

To evaluate the validity of, characterize the usage of, and propose potential research applications for International Classification of Diseases, Ninth Revision (ICD-9) tobacco codes in clinical populations. Using data on cancer cases and cancer-free controls from Vanderbilt's biorepository, BioVU, we evaluated the utility of ICD-9 tobacco use codes to identify ever-smokers in general and high smoking prevalence (lung cancer) clinic populations. We assessed potential biases in documentation, and performed temporal analysis relating transitions between smoking codes to smoking cessation attempts. We also examined the suitability of these codes for use in genetic association analyses. ICD-9 tobacco use codes can identify smokers in a general clinic population (specificity of 1, sensitivity of 0.32), and there is little evidence of documentation bias. Frequency of code transitions between 'current' and 'former' tobacco use was significantly correlated with initial success at smoking cessation (p<0.0001). Finally, code-based smoking status assignment is a comparable covariate to text-based smoking status for genetic association studies. Our results support the use of ICD-9 tobacco use codes for identifying smokers in a clinical population. Furthermore, with some limitations, these codes are suitable for adjustment of smoking status in genetic studies utilizing electronic health records. Researchers should not be deterred by the unavailability of full-text records to determine smoking status if they have ICD-9 code histories.

Acceptance of treatment for latent tuberculosis infection: prospective cohort study in the United States and Canada

An estimated 300 000 individuals are treated for latent tuberculosis infection (LTBI) in the United States and Canada annually. Little is known about the proportion or characteristics of those who decline treatment. To define the proportion of individuals in various groups who accept LTBI treatment and to identify factors associated with non-acceptance of treatment. Persons offered LTBI treatment at 30 clinics in 12 Tuberculosis Epidemiologic Studies Consortium sites were prospectively enrolled. Multivariate regression models were constructed based on manual stepwise assessment of potential predictors. Of 1692 participants enrolled from March 2007 to September 2008, 1515 (89.5%) accepted treatment and 177 (10.5%) declined. Predictors of acceptance included believing one could personally spread TB germs, having greater TB knowledge, finding clinic schedules convenient and having low acculturation. Predictors of non-acceptance included being a health care worker, being previously recommended for treatment and believing that taking medicines would be problematic. This is the first prospective multisite study to examine predictors of LTBI treatment acceptance in general clinic populations. Greater efforts should be made to increase acceptance among health care workers, those previously recommended for treatment and those who expect problems with LTBI medicines. Ensuring convenient clinic schedules and TB education to increase knowledge could be important for ensuring acceptance.

Evaluation of Ara h2 IgE thresholds in the diagnosis of peanut allergy in a clinical population

Evaluation of Ara h2 IgE thresholds in the diagnosis of peanut allergy in a clinical population

Identifying and Treating a Substandard Housing Cluster Using a Medical-Legal Partnership

There is a documented connection between the home environment and health. Medical-legal partnerships (MLPs) can address social and environmental determinants of health. Our objective was to describe a cluster of substandard housing identified and treated by an MLP based in a pediatric primary care setting. Potential cases of poor-quality housing were identified during outpatient primary care. A case was defined as any rented housing unit with a reported unaddressed housing risk within a defined building portfolio (owned by a single developer) in which ≥ 1 child lived. An on-site MLP offered affected families legal services including ordinance enforcement and connection to resources. They also initiated portfolio-wide advocacy. Legal advocates reported case outcomes. Medical history and household demographics were collected from the medical record and compared with clinic-wide data by using Fisher's exact test or χ(2) statistics. After identification of a single case, an additional 15 cases were identified. Pest infestation was the most common initial risk identified. Of 14 units with outcome data, repairs were completed in 10 (71%). Of the 19 building complexes with the same owner, 11 received significant systemic repairs. Of the 45 children living within the 16 identified case units, 36% had asthma, 33% had developmental delay or behavioral disorder, and 9% had an elevated lead level. Affected children were more likely to have one of these diagnoses than the general clinic population (all P < .01). An MLP identified and improved home environmental conditions for children living in a cluster of substandard housing.

Aflibercept in clinical practice: Evaluation of the first 50 patients treated with antiVEGF trap for age‐related macular degeneration

AbstractPurpose To evaluate the short‐term outcomes after intravitreal aflibercept (Eylea; Regeneron Pharmaceuticals, Inc.) injection in a general clinic population treated for neovascular age‐related macular degeneration (AMD).Methods This is aretrospective chart review of consecutive patients who received intravitreal aflibercept injection for AMD. The main outcome measures were mean visual acuity (VA), central macular thickness, presence of subretinal fluid, cystic changes and pigment epithelial detachment on optical coherence tomography (OCT).Results Sixty‐three eyes of 52 patients (mean age 81.2, range 59‐98years) were evaluated. Mean baseline visual acuity was 0.79 LogMar (STDEV 0.43)at baseline and 0.66 at follow‐up(STDEV 0.48) (P = 0.43). Mean follow‐up was 1 to 4 month (average 1.7). Mean baseline central macular thickness was 352 microns and improved to 257 microns at 3 months (P &lt; 0.001) in patients who had at least 3 months of follow up. 39 patients (75%) were treated with monthly injections, the remaining patients were treated based on a “treat and extend” protocol. Treatment was well tolerated with no adverse events reported.Conclusion Short‐term results of aflibercept therapy showed encouraging results with improvement in OCT parameters. Patients who underwent antiVEGF treatment with other medications prior the use of aflibercept may stabilize but not further improve after short‐term treatment with aflibercept. Further studies are needed to assess the effect of aflibercept in patients who are not treatment naïve.

Analysis of the Health Status of the Homeless Clients Utilizing a Free Clinic

The purpose of this study is to evaluate the health status of the homeless population who utilize a free clinic. The study specifically aims to compare the prevalence of asthma, diabetes, tuberculosis, mental health disorders, sexually transmitted diseases, sinus problems, and hepatitis among the homeless population. Investigators collected data from paper medical records during patient visits from 2004 to 2009. Diagnosed health conditions among the homeless population were compared to the general clinic users using logistic regression. There were several similarities between the general clinic and homeless population, however, the homeless population had statistically significant (p < 0.05) outcomes for diagnosed cases of tuberculosis, hepatitis, anxiety, and bipolar disorders. Prevalence of diabetes, sinus problems, asthma, diabetes, and depression were similar among both populations. The odds ratios among hepatitis, tuberculosis, STDs, bipolar disorder and anxiety disorder indicated the homeless had a significantly greater risk of developing hepatitis, tuberculosis, and bipolar disorder. This study adds to the literature by illustrating the characteristics of the homeless population who utilize the free health clinic and their medical conditions. Previous studies have shown the free clinic clients have a lower level of health than the general population. This study finds that the homeless clients of a free clinic have an even worse level of health than the general clinic clients. This research can contribute to the improvement of the healthcare delivery system in providing access to needed health care services for the homeless population.

Interventions for preventing excessive weight gain during pregnancy.

Excessive weight gain during pregnancy is associated with multiple maternal and neonatal complications. However, interventions to prevent excessive weight gain during pregnancy have not been adequately evaluated. To evaluate the effectiveness of interventions for preventing excessive weight gain during pregnancy and associated pregnancy complications. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 October 2011) and MEDLINE (1966 to 20 October 2011). All randomised controlled trials and quasi-randomised trials of interventions for preventing excessive weight gain during pregnancy. We assessed for inclusion all potential studies we identified as a result of the search strategy. At least two review authors independently assessed trial quality and extracted data. We resolved discrepancies through discussion. We have presented results using risk ratio (RR) for categorical data and mean difference for continuous data. We analysed data using a fixed-effect model. We included 28 studies involving 3976 women; 27 of these studies with 3964 women contributed data to the analyses. Interventions focused on a broad range of interventions. However, for most outcomes we could not combine data in a meta-analysis, and where we did pool data, no more than two or three studies could be combined for a particular intervention and outcome. Overall, results from this review were mainly not statistically significant, and where there did appear to be differences between intervention and control groups, results were not consistent. For women in general clinic populations one (behavioural counselling versus standard care) of three interventions examined was associated with a reduction in the rate of excessive weight gain (RR 0.72, 95% confidence interval 0.54 to 0.95); for women in high-risk groups no intervention appeared to reduce excess weight gain. There were inconsistent results for mean weight gain (reported in all but one of the included studies). We found a statistically significant effect on mean weight gain for five interventions in the general population and for two interventions in high-risk groups.Most studies did not show statistically significant effects on maternal complications, and none reported significant effects on adverse neonatal outcomes. There is not enough evidence to recommend any intervention for preventing excessive weight gain during pregnancy, due to the significant methodological limitations of included studies and the small observed effect sizes. More high-quality randomised controlled trials with adequate sample sizes are required to evaluate the effectiveness of potential interventions.

14:15 PERSISTENCE OF THE EXTENDED PSYCHOSIS PHENOTYPE IN YOUNG PEOPLE: LINK BETWEEN VULNERABILITY AND CLINICAL NEED

Psychosis is one of the most severe psychiatric conditions, in terms of both individual and societal burden. The pathway from the earliest and mildest expressions of psychosis to clinical disorder is highly variable and heterogeneous. A better understanding of the psychosis phenotype and its development into clinical states is important, since this offers opportunities for early intervention of psychotic disorders, with the ultimate goal to delay, attenuate or even prevent transition to clinical disorder. Psychosis is currently conceptualized as an extended, or continuous, phenotype, ranging from normal functioning at one end, through eccentricity and subclinical psychotic experiences, to florid psychotic disorder at the other end. The manifestation of this (liability to) psychotic psychopathology is represented by a continuous distribution of psychotic symptom severity/intensity in the general population. The studies in this thesis showed that many adolescents reported incidental subclinical psychotic experiences, underlining the high level of psychosis proneness in this developmental life phase. This psychosis proneness decreased with age, demonstrated by the lower levels of psychotic experiences reported by the young adult female sample compared to the adolescent samples. A model with five subdimensions, labeled Hallucinations, Delusions, Paranoia, Grandiosity and Paranormal beliefs, was shown to describe these experiences well in two large adolescent samples from the general population and was furthermore replicated in young adulthood, suggesting life-long stability of this underlying structure. Only some of these subdimensions (i.e. Hallucinations, Delusions and Paranoia) may tap into the extended psychosis phenotype in their continuity with mental illness. Psychosis proneness was shown to be very dynamic, particularly during adolescence. Many (biological, psychological and sociological) factors play a role in its development, such as trauma, cannabis use, depression, coping and genetic liability for psychosis; thus, it demonstrates that the development of psychosis over time takes place in a developmental and psychopathological context. Subclinical psychotic experiences are thought to be predictive for later clinical psychosis, as is, more strongly, Ultra High Risk (UHR) status. In other words, it is assumed that there is a dose-response function of risk between psychotic experiences/symptoms and later psychotic disorder. There is, however, a gap in the conceptualization of the psychosis continuum between subclinical psychosis at the level of the general population and UHR status for psychosis: there is no clear phenotype on the hypothesized psychosis continuum connecting individuals from the general population and individuals who are seeking help for their psychotic experiences. Studying the persistence of subclinical psychotic experiences over time may form the bridge between general population samples and UHR samples in the study of (the development of) psychosis, because this paradigm offers the possibility to study the extended psychosis phenotype at the level of the general population while focusing on a more specific phenotype that may be indicative for later psychotic development. Studying this phenotype of persisting subclinical psychotic experiences that can be seen as intermediate between general population and clinical population may thus be a fruitful paradigm for identifying individuals at increased risk for the development of psychosis.

Goal-directed therapy for RA in routine practice is associated with improved function in patients with disease duration up to 15 years

Goal-directed therapy for RA in routine practice is associated with improved function in patients with disease duration up to 15 years

Keratinizing Squamous Dysplasia Pap Test

This study characterized women with Pap tests showing keratinizing squamous dysplasia (KSD) and helped develop management strategies in these patients. This is a retrospective chart review of women presenting to Palmetto Health Women's Center with KSD on a Pap test from 1999 to 2009. Data analysis was performed with standard statistical computer programming; null hypothesis was rejected for p values .05 or less. A total of 65 Pap tests with KSD were identified. We found that women with KSD were statistically older (35 vs 26.8 y) and were more likely African American and less likely Hispanic than the general clinic population at Palmetto Health Women's Center. There were no statistical differences in body mass index or history of teen pregnancy. Interestingly, 41% of the women with KSD were immunosuppressed (e.g., human immunodeficiency virus infection, end-stage renal disease, long-term steroid use). All women with KSD were referred for colposcopy; 24% of patients failed to follow-up. Pathology distribution on cervical biopsies were similar to what is found after high-grade squamous intraepithelial lesion findings in Pap tests, with 58% cervical intraepithelial neoplasia (CIN) 2/3 or cancer, 32% CIN 1, and 10% negative biopsies. Of the women who had CIN 1 on cervical biopsy, 80% had persistent dysplasia or abnormal Pap test. Also, 60% had CIN 1 and 20% progressed to CIN 2/3 or carcinoma in situ. Our data suggest that women with KSD on Pap test should be managed aggressively with immediate colposcopy and cervical biopsies and not with expectant management.

Severe and anxious depression: Combining definitions of clinical sub-types to identify patients differentially responsive to selective serotonin reuptake inhibitors

Patients with severe major depressive disorder are more likely than those with mild/moderate depression to experience the relative benefits of antidepressant therapy versus placebo. Several studies have, unexpectedly, failed to show a similar antidepressant–placebo discrepancy between patients with versus without anxious depression, although patients with anxious depression are more likely to meet criteria for severe depression than those without. The aim of this study was to confirm the absence of treatment moderating effects for anxious depression in a general clinical trial population, and to examine for the presence of treatment moderating effects in severe depression. Patient-level outcome data from all randomized, double-blind, placebo-controlled trials involving the use of the selective serotonin reuptake inhibitor escitalopram for adults with major depressive disorder sponsored by H. Lundbeck A/S or Forest Laboratories were pooled. Studies focusing on patients with a specific axis-I or -III co-morbidity were excluded. Data from five trials were pooled. Anxious depression was not found to serve as a treatment moderator for selective serotonin reuptake inhibitor therapy versus placebo. However, when patients with severe depression were analyzed separately, anxious depression significantly influenced the relative degree of symptom reduction with selective serotonin reuptake inhibitors versus placebo (p=0.0094). In fact, the numbers needed to treat for remission for these two sub-types were the largest and smallest reported to date from analyses of large datasets of antidepressants (22 for severe anxious versus 4 for severe non-anxious depression). Subdividing patients with severe major depressive disorder into those with versus without anxious depression results in the characterization of sub-types that are particularly “responsive” (severe non-anxious) and “unresponsive” (severe anxious) to selective serotonin reuptake inhibitor therapy (relative to placebo). These findings are preliminary, of yet undetermined clinical relevance, and warrant replication and further exploration.