Health Maintenance Examination Research Articles

Gender Differences in Routine Health Maintenance Examinations Before and During the COVID-19 Pandemic

PurposeAdolescent and young adult (AYA) males historically have lower healthcare utilization than their female peers. MethodsElectronic health record data from an Adolescent/Young Adult Medicine outpatient practice were reviewed to assess gender differences in routine health maintenance examinations before and during the COVID-19 pandemic. ResultsRoutine health maintenance examinations decreased for both males and females during the pandemic. However, a two-proportion z-test demonstrated that established male patients were statistically less likely (p < .01) to have a routine health maintenance examination from December 2020 to December 2021 than their female counterparts. DiscussionAYA males are at a higher risk for persistent disengagement in healthcare and exacerbates future gender gaps in healthcare utilization. Primary care providers need to focus efforts on re-engaging all young people in preventive care, with specific efforts tailored to AYA males.

Adolescents With Inflammatory Bowel Disease Have Decreased Rates of Health Maintenance Visits.

Inflammatory bowel disease (IBD) commonly presents during adolescence and may affect health care utilization. This study aimed to assess rates of health maintenance examinations (HMEs) in adolescents with IBD with their primary care physicians (PCPs). This is a single center, case-control study of adolescents with IBD who received their IBD care and primary care within the same healthcare system. Adolescents diagnosed with IBD between 13 and 17 years of age were matched 1:1 by age, gender, race/ethnicity, and insurance status to healthy controls. Patient demographics, IBD characteristics, and health outcomes were extracted from the medical record. HME rate was defined as having one HME with a PCP during a 12-month period. This study included 150 IBD-control matched pairs. HME rates were similar at baseline between cases and controls (83% vs 85%, P = 0.53) but approached significance in year 1 post-diagnosis (77% vs 85%, P = 0.056). In year 2 post-diagnosis, IBD patients had less frequent HME (62% vs 74%, P = 0.0486). Disease severity did not affect HME rates. IBD patients from under-represented minority groups had lower rates than matched controls (46.2% vs 91.7%, P = 0.03). Meningococcal and human papilloma vaccination rates were lower in cases versus controls (79% vs 94%, P = 0.0005 and 60% vs 84%, P < 0.0001). Adolescents with IBD have less frequent HME and lower rates of certain vaccinations than their peers. Those from underrepresented minority groups are at particular risk. Given the important issues addressed at HMEs, gastroenterologists should recommend that adolescents with IBD have ongoing PCP engagement to optimize health outcomes.

Do Japan's Health Care Personnel Meet the Personal Health Goals of the "National Health Promotion Program"?

To improve health among the population and reduce the societal burden of care and health-related costs in a rapidly aging environment, the Japanese government launched the "National Health Promotion Program in the 21st Century" (HJ21), which contains goals concerning areas such as lifestyle behavior and the use of preventive medicine. While health care personnel are responsible for guiding others' health choices, they may not maintain healthy lifestyles themselves. Whether these individuals are meeting the HJ21 goals has not yet been examined. This study aims to determine whether certified specialists in health management are meeting such goals, and to compare their performance with the national average. This is a cross-sectional survey study. Study participants, sourced from all prefectures in Japan, were specialists certified in health management. We measured data concerning demographic information, lifestyle (physical activity, nutrition, diet, sleep, rest, smoking, and alcohol use), and the use of preventive medicine. The study participants exhibited many characteristics of high health literacy. They had an overall healthy lifestyle and met most of the HJ21 goals of healthy lifestyle, and a high proportion underwent health maintenance examinations and cancer screenings. These practices and behaviors maybe associated with high health literacy and social engagement activities.

BDUMP: A Rare Case of Vision Loss in a Lung Transplant Recipient

Introduction Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a potentially devastating rare paraneoplastic syndrome often associated with severe vision loss occurring in patients with underlying carcinoma. In approximately 50% of cases this may be the first sign of an underlying primary malignancy. First described in 1966 there are currently less then 100 cases described in the literature. Treatment of this condition includes treatment of the primary malignancy and plasmapheresis. We describe what we believe to be the first case reported in a lung transplant recipient. Case Report A 72 year old woman status post bilateral lung transplant for COPD was referred to ophthalmology due to increased vision loss for four months, one month prior to presentation she had undergone a left YAG capsulotomy. Maintenance immunosuppression included tacrolimus, mycophenolate mofetil, and prednisone. Fundus exam was remarkable for bilateral retinal pigment epithelium mottling and leopard spot fundus. Exam on the left showed edema. BDUMP was diagnosed, she was admitted to the hospital for plasmapheresis and an extensive evaluation for underlying malignancy. Remarkable laboratory studies showed a new acute kidney injury in the setting of chronic kidney disease with nephrotic range proteinuria. All tumor markers, ANA, ANCA, SPEP, and PLA2R were negative. CT of the head, chest, abdomen, and pelvis were unrevealing, PET scan showed a hypermetabolic breast nodule which was biopsied. The biopsy was consistent with ductal carcinoma in situ, and her mycophenolate was stopped. She completed 14 sessions of plasmapheresis and had improvement in her vision. Summary BDUMP, a rare condition which left untreated can lead to rapid vision loss, is associated with carcinomas of the cervix, uterus, ovary, lung, kidney, pancreas, breast, gastrointestinal tract, and Hodgkin lymphoma. While the exact pathogenesis for BDUMP has not yet been described it has been shown that these patients have a factor in the IgG fraction of serum that selectively causes melanocyte proliferation and thus plasmapheresis is an effective treatment. Patients that are immune suppressed are at an elevated risk for cancer, therefore it's highly important to keep up with health maintenance examinations in this population. Visual changes after transplant are also common, and a complete ophthalmologic examination should be completed with new onset of symptoms.

Understanding type 2 diabetes mellitus screening practices among primary care physicians: a qualitative chart-stimulated recall study

BackgroundEarly diagnosis and treatment of prediabetes and type 2 diabetes mellitus (T2DM) can prevent future health problems, yet many individuals with these conditions are undiagnosed. This could be due, in part, to primary care physicians’ (PCP) screening practices, about which little is known. The objectives of this study were to identify factors that influence PCPs’ decisions to screen patients for T2DM and to characterize their interpretation and communication of screening test results to patients.MethodsWe conducted semi-structured chart-stimulated recall interviews with 20 University of Michigan Health System (UMHS) primary care physicians. PCPs were asked about their recent decisions to screen or not screen 134 purposively sampled non-diabetic patients who met American Diabetes Association criteria for screening for T2DM. Interviews were audio-recorded, transcribed, and analyzed using qualitative directed content analysis. Data on patient demographic characteristics and comorbidities were abstracted from the electronic health record.ResultsThe most common reasons PCPs gave for not screening 63 patients for T2DM were knowledge of a previously normal screening test (49%) and a visit for reasons other than a health maintenance examination (48%). The most common reasons PCPs gave for screening 71 patients for T2DM were knowledge of a previously abnormal screening test (49%), and patients’ weight (42%) and age (38%). PCPs correctly interpreted 89% of screening test results and communicated 95% of test results to patients. Among 24 patients found to have prediabetes, PCPs usually (58%) recommended weight loss and increased physical activity but never recommended participation in a Diabetes Prevention Program or use of metformin.ConclusionsPrevious screening test results, visit types, and patients’ weight and age influenced PCPs’ decisions to screen for T2DM. When patients were screened, test results were generally correctly interpreted and consistently communicated. Recommendations to patients with prediabetes could better reflect evidence-based strategies to prevent T2DM.

Assessment of postgraduate skin lesion education among Iowa family physicians.

Background:Family medicine physicians play a pivotal role in the prevention and early detection of skin cancer. Our objective was to evaluate how family physicians believe their postgraduate training in skin cancer screening and prevention has prepared them for independent practice and to assess the need for enhanced skin lesion teaching in a family medicine residency setting.Methods:A descriptive, cross-sectional survey investigating provider demographics, confidence in providing dermatological care, residency training, current medical practice, and skin cancer prevention beliefs was mailed to all family medicine physicians in the state of Iowa as listed in the Iowa Academy of Family Physicians annual directory in 2006 (N = 1069).Results:A total of 575 family medicine physicians completed the survey for an overall response rate of 53.8%. Overall, family medicine physicians reported feeling confident in their ability to diagnose skin lesions (83.2%), differentiate between benign and malignant lesions (85.3%), and perform a biopsy of a lesion (94.3%). Only 65% of surveyed physicians felt that their residency program adequately trained them in diagnosing skin lesions and 65.7% of physicians agree that they could have benefited from additional training on skin lesions during residency training. Nearly 90% of clinicians surveyed believe that skin cancer screenings are the standard of care; however, only 51.8% perform skin cancer screening examinations during adult health maintenance visits more than 75% of the time. The primary reason listed by respondents who said they do not routinely perform skin cancer screenings was inadequate time (68.2%).Conclusion:Family medicine physicians in the state of Iowa are confident in evaluating skin lesions. However, they reported a need for additional enhanced, targeted skin lesion education in family medicine residency training programs. Physicians believe that skin cancer screening examination is the standard of care, but find that inadequate time increasingly hinders skin cancer screening during routine health maintenance examinations.

Lack of health maintenance examinations and risk in myeloma patients.

Health maintenance (HM) practices are essential to prevent illness, promote well‐being, and maximize health. Patients with multiple myeloma (MM) are at increased risk for cardiovascular disease and cancers, yet, research on HM practices and preventative care of MM survivors has limited report. The study comprised a descriptive, correlational, and cross‐sectional online survey design. Survey of patients with MM was carried out through the International Myeloma Foundation (IMF) and the Association of Cancer Online Resources (ACOR) e‐mail list services. The members of the IMF and ACOR e‐mail list services were surveyed, of which 237 patients responded. The modified Medical Expenditure Preventive Survey–Preventive Care questionnaire was used; it included items that ask patients regarding their healthcare practices that relate to dental care, cancer prevention, addiction, lifestyles, sensory screening, immunizations, cardiovascular, endocrine, psychosocial, and bone health. Descriptive statistics, Pearson's chi‐square, and Spearman's rho correlation coefficient were obtained. In this study, men had statistically significant inferior global health maintenance scores than women (P = 0.002). Being employed (P = 0.054) and married or partnered (P = 0.017) were significantly correlated with better health maintenance patterns among male respondents. In contrast, no statistically significant correlations between sociodemographic factors and health maintenance patterns were found in women. Patients with MM, particularly men, require continued education and close monitoring of health maintenance practices. These findings are consistent with publications looking at gender disparities in healthcare utilization in the United States. Studies show that men, in general, are less likely to seek preventative healthcare screenings. Healthcare providers must incorporate health maintenance promotion during clinic visits.

A Systematic Review of the Bimanual Examination as a Test for Ovarian Cancer

Context An annual bimanual pelvic examination remains widely recommended for healthy women, but its inclusion may discourage attendance. Our goal was to determine the accuracy of the pelvic examination as a screening test for ovarian cancer and to distinguish benign from malignant lesions. Evidence acquisition PubMed was searched to identify studies evaluating the accuracy of the bimanual pelvic examination for ovarian cancer diagnosis. Data regarding study design, study quality, and test accuracy were abstracted. Heterogeneity was evaluated and meta-analysis performed where appropriate, including bivariate receiver operating characteristic curves. Evidence synthesis Eight studies in screening populations ( n =36,599) and seven studies in symptomatic patients ( n =782) were identified. Search was completed in November 2013; included studies were published between 1988 and 2009. Screening studies were homogeneous; the summary estimates of sensitivity and specificity of the pelvic examination as a screening test for ovarian cancer were 0.44 and 0.98 (positive likelihood ratio, 24.7; negative likelihood ratio, 0.57). For distinguishing benign versus malignant lesions, there was considerable heterogeneity, with a range of sensitivity from 0.43 to 0.93 and specificity from 0.53 to 0.91. Conclusions The bimanual pelvic examination lacks accuracy as a screening test for ovarian cancer and as a way to distinguish benign from malignant lesions. In a typical screening population, the positive predictive value of an abnormal pelvic examination is only 1% (95% CI=0.67%, 3.0%). Its inclusion in a health maintenance examination cannot be justified on the basis of using it to screen for ovarian cancer.

A systematic review of the bimanual examination as a test for ovarian cancer.

An annual bimanual pelvic examination remains widely recommended for healthy women, but its inclusion may discourage attendance. Our goal was to determine the accuracy of the pelvic examination as a screening test for ovarian cancer and to distinguish benign from malignant lesions. PubMed was searched to identify studies evaluating the accuracy of the bimanual pelvic examination for ovarian cancer diagnosis. Data regarding study design, study quality, and test accuracy were abstracted. Heterogeneity was evaluated and meta-analysis performed where appropriate, including bivariate receiver operating characteristic curves. Eight studies in screening populations (n=36,599) and seven studies in symptomatic patients (n=782) were identified. Search was completed in November 2013; included studies were published between 1988 and 2009. Screening studies were homogeneous; the summary estimates of sensitivity and specificity of the pelvic examination as a screening test for ovarian cancer were 0.44 and 0.98 (positive likelihood ratio, 24.7; negative likelihood ratio, 0.57). For distinguishing benign versus malignant lesions, there was considerable heterogeneity, with a range of sensitivity from 0.43 to 0.93 and specificity from 0.53 to 0.91. The bimanual pelvic examination lacks accuracy as a screening test for ovarian cancer and as a way to distinguish benign from malignant lesions. In a typical screening population, the positive predictive value of an abnormal pelvic examination is only 1% (95% CI=0.67%, 3.0%). Its inclusion in a health maintenance examination cannot be justified on the basis of using it to screen for ovarian cancer.

Depression Screening in a Primary Care Practice in Oregon

Depression is a serious and common mental illness in primary care. Regardless of the improvements in depression management, depression in many patients is still unrecognized. Routine screening for depression among adults in primary care is recommended by the U.S Preventive Service Task Force, as long as healthcare organizations are equipped with staff-assisted depression support systems. The purpose of this dissemination pilot project was to evaluate the routine use of the PHQ-9, a depression screening tool, among adult patients presenting for annual health maintenance examinations. Additionally, increasing follow-up visits among patients with positive depression screens was also investigated. The three-week practice quality improvement project was successful in implementing a routine depression screening policy. Among patients scheduled for their annual health maintenance examination, 94% were screened for depression. All patients who self-identified as at risk for depression were screened with the PHQ-9. Among patients with positive screens, the majority were invited for follow-up care during the study. As a result of the pilot, this clinic now exclusively uses the PHQ-9 depression screening tool. Furthermore, they modified their annual health maintenance examination policy to include routine screening for depression.

Preventive Care Quality Outcomes in an Inflammatory Bowel Disease Population

Purpose: Vaccination rates and health maintenance examinations in patients with inflammatory bowel disease (IBD) have been reported to be low. To address this, the American Gastroenterological Association (AGA) and Crohn's and Colitis Foundation of America (CCFA) have developed practice guidelines for IBD patients to improve preventive care. Recently, the Center for Medicare and Medicaid Services has adopted these guidelines as quality outcomes for pay-for-performance. The purpose of this study was to evaluate provider adherence to AGA and CCFA endorsed quality measures for patients with IBD at a University based gastroenterology practice. Methods: We performed a single center study to evaluate the delivery of preventive care to IBD patients. Eight quality measures were assessed by chart review. Eligible subjects were patients with established IBD (i.e. ulcerative colitis [UC] or Crohn's disease [CD]) who received their primary care and gastrointestinal (GI) specialty care at the University of Wisconsin Hospital and Clinics. Patients were identified using a database listing patients in the GI clinic by diagnosis. All primary care and gastroenterology notes within the past two years were reviewed for vaccinations and other predefined preventive care measures. Results: 101 consecutive IBD patients were included in the study. All patients received their GI specialty care by 1 of 5 healthcare providers (4 physicians, 1 CNP). Thirty-seven patients were initiated with a tumor necrosis factoralpha (TNF-α) inhibitor during the study period and 30 were treated with a corticosteroid for 3 months or greater during a 12-month period. IBD disease location was documented in 97% of patients and the use of corticosteroid sparing therapy was documented in 91%. Tuberculosis screening and hepatitis B screening prior to initiation of a TNF-α inhibitor were documented in 43% and 16% of patients, respectively. Fifty-four (53%) of patients received yearly influenza vaccinations and 43 (43%) were vaccinated for Pneumonia. Corticosteroid bone loss assessment was performed in 27% of eligible patients. All 4 patients self-identified as smokers were counseled about smoking cessation. Conclusion: Our results suggest that many patients with IBD are not undergoing standard preventive care, which puts them at increased risk for preventable infections and other complications. Vaccination rates for influenza and pneumonia were low at around 50%. Hepatitis B and tuberculosis screening prior to initiation of TNF-α inhibitor therapy were also very low, occurring in less than 50% of eligible patients. Development of standardized protocols and automated reminders aimed at preventive care delivery are needed to improve the quality of care patients with IBD receive.Table: Quality outcomes per provider

Assessment of the Association Between Colchicine Therapy and Serious Adverse Events

As data that prompted a 2009 labeling change detailing contraindications, precautions, and dosing recommendations for the first branded colchicine product were limited to case reports of myotoxicity and blood dyscrasias ascribed to the drug, we sought to quantify the association of colchicine therapy with serious adverse outcomes in a cohort of insured patients. Case-control study. Kaiser Permanente Colorado electronic data warehouses and electronic medical records. Cases were patients with a creatine kinase (CK) level of at least 2000 U/L or who developed a clinically significant non-cancer-related blood dyscrasia (thrombocytopenia, neutropenia, leukopenia, aplastic anemia, or pancytopenia) between January 1, 2006, and June 30, 2009 (954 cases). Each case was matched to up to 10 controls by age, sex, and index date (date of the increased CK level or blood dyscrasia-supporting laboratory value). Controls were patients without elevated CK levels or blood dyscrasias who had a routine health maintenance examination during the same time period (index date was the date of their health maintenance examination [9007 controls]). The primary study outcome was colchicine exposure, defined as a colchicine prescription purchase in the 100days before the index date. The likelihood of colchicine exposure was examined with conditional logistic regression. Cases experienced a higher rate of previous colchicine exposure compared with controls (0.6% vs 0.2%, odds ratio 3.9, 95% confidence interval 1.4-10.7). In addition, cases had higher hospitalization rates (14.9% vs 5.0%, p<0.001), higher mean chronic disease scores (2.5 vs 0.0, p<0.001), and were more likely to have been exposed to drugs that may increase the risk of adverse events due to an interaction with a CYP3A4 inhibitor drug (6.9% vs 2.3%, p<0.001). Patients with confirmed elevations in CK level and/or blood dyscrasias had a higher rate of previous colchicine exposure, although low overall, and greater hospitalization rates and exposure to drugs that may increase the risk of adverse events compared with controls. These findings support the 2009 United States Food and Drug Administration labeling for the first branded colchicine product, cautioning use in patients with liver impairment or renal dysfunction and/or those receiving concurrent drugs that may increase risk of adverse events.

‘How do you know what Aunt Martha looks like?’ A video elicitation study exploring tacit clues in doctor–patient interactions

Theory suggests that tacit clues inform clinical judgements, but the prevalence and role of tacit clues during clinical interactions is unknown. This study explored whether doctors and patients identify information likely to be tacit clues or judgements based on tacit clues during health maintenance examinations. Qualitative analysis of video elicitation interview transcripts involving 18 community-based primary care doctors and 36 patients. Outcomes were description and analysis of tacit clues and judgements based on tacit clues mentioned by participants. A total of 57 references to tacit clues and 53 references to judgements based on tacit clues were identified from patient and doctor transcripts. Non-verbal behaviours comprised the most common category of tacit clues (53% of doctor comments; 42% of patient comments). Patients mostly discussed judgements based on tacit clues that related to the doctor-patient relationship. Doctors discussed actively using non-verbal behaviours to provide patients with tacit clues about the doctor-patient relationship. They also mentioned tacit clues that informed medical judgements and decision making. Gestalt judgements based on tacit clues were common (33% of doctor comments). Several participants identified instances in which they had difficulty articulating their rationale for specific judgements. Doctors varied widely in how frequently they mentioned tacit clues. During video elicitation interviews, patients and doctors identified tacit clues and judgements based on these clues as playing a role during health maintenance examinations. Future research should further elucidate the role of tacit clues in medical judgements and doctor-patient relationships.

Child safety seats: 2010 educational update

Parental education about the use of age-appropriate child restraints is an essential aspect of all routine well-child examinations. Despite this guidance, automobile accidents remain the leading cause of death in children 8 years of age and younger. The evolution of the car seat began in the 19th century and its design continues to change to incorporate further safety advancements. Each of the 50 states has laws regarding child restraints; however, most do not correspond with those set forth by the American Academy of Pediatrics and the Insurance Institute for Highway Safety. As a child advances from a rear-facing car seat to a booster seat, it is crucial to know the height, weight, and age milestones necessary to make such changes. Parents or guardians need to understand that every car seat has a manufacturing date and that most expire within 5 years of that date. Lack of physical strength by caretakers may contribute to improper installation of child restraints. Many valuable resources exist for both physicians and parents/guardians regarding child restraint safety, reliability, and recalls. Family physicians play a pivotal role in educating parents about up-to-date car restraint recommendations during routine health maintenance examinations for pediatric patients.

Clinical Decision Support Technology to Increase Advance Care Planning in the Primary Care Setting

Physicians are often unable to guide patients through the advance care planning (ACP) process due to cost and time constraints. We conducted a retrospective analysis in the primary care setting targeting older adults without an advance medical directive (AMD). An ACP educational packet was sent to intervention patients before their health maintenance examination (HME). Additionally, their physicians had access to a computerized clinical decision support system on AMD completion at the time of the HME. Control participants' physicians had access to the computerized decision support system and traditional resources only. All participants who received the packet were sent a follow-up survey. In all, 21.6% of intervention participants completed an AMD, compared with 4.1% of control participants. Combining clinical decision support systems and standardized processes enhances the ACP process.

Health Care Utilization by Adolescents on Medicaid: Implications for Delivering Vaccines

To examine the degree to which current health care utilization patterns of Medicaid-enrolled adolescents living in Michigan would allow opportunities for adolescent immunizations to be provided. Outpatient claims data from 2001-2005 were analyzed for 11- to 18-year-old Medicaid-enrolled adolescents living in Michigan. Visits were classified as either health-maintenance examinations (HMEs) or problem focused by using diagnostic and procedural codes. Data were divided into 4 overlapping 2-year time periods, and the age-specific proportion of adolescents who attended these 2 visit types was calculated for each. chi(2) tests were used to evaluate associations of visit patterns with gender. Of the 718847 adolescents included in the study, <50% had >or=1 HME visit within any 2-year time period, and substantially fewer (<15%) had annual HMEs. In contrast, at least 75% of the adolescents had >or=1 problem-focused visit in any given 2-year period, and approximately half had participated in at least 2 problem-focused visits. Problem-focused, but not HME, visit utilization was significantly associated with gender, with girls increasing, but boys decreasing, visit utilization as they aged. Similar to privately insured adolescents, most Medicaid-enrolled adolescents do not have annual preventive-care visits, which calls into question the feasibility of providing immunizations primarily at annual HMEs. Participation in problem-focused encounters was generally high in our study. However, even problem-focused visit utilization was low among older adolescent boys. This suggests that in addition to strengthening immunization within the medical home, alternative venues for reaching certain subpopulations of adolescents should also be developed.

Case 2: A persistent fever

A 3.5-month-old Asian girl presented to the emergency department (ED) with a two-week history of intermittent fever. Fifteen days before arrival, the patient began to have fevers as high as 41.1°C axillary. Her primary care physician (PCP) saw her on day 3 of her illness. The mother reported fever and increased fussiness, which responded to antipyretic medication. The baby had no other symptoms or sick contacts, good oral intake, and normal urination and bowel movements. In the office, she had a 39.6°C rectal temperature. A physical examination and urinalysis were normal. She was diagnosed with a viral illness and asked to return in 24 h. The next day, the mother reported no fever overnight, the physical examination remained normal and the urine culture was negative. The PCP instructed the family to come back if the fever returned. The patient was seen on day 15 for a health maintenance examination. Through an interpreter, the PCP found out that the patient had persistent intermittent fevers at night with fussiness and decreased appetite, but no daytime symptoms. The PCP found a slightly fussy but consolable baby with a normal physical examination. The patient was sent to the ED for evaluation of fever without a source. In the ED, the patient’s temperature was 39°C. She was alert and smiling. Once again, the physical examination was normal. Influenza A and B antigen tests were negative, with a clear urinalysis. A complete blood count showed leukocytosis (35.5×109/L with 70.4% granulocytes and 20.1% lymphocytes by automatic differential) and thrombocytosis (1192×109/L). The erythrocyte sedimentation rate was 89 mm/h. Chest x-ray was normal. Cerebrospinal fluid (CSF) was sent for cell count and biochemistry analysis, and to culture for bacteria, fungus and tuberculosis. CSF studies showed pleocytosis (white blood cell count 0.453×109/L; red blood cell count 0.015×109/L) with a neutrophil predominance (77% neutrophils, 14% lymphocytes, 9% monocytes). CSF glucose was 1.28 mmol/L, protein was 2.15 g/L and Gram stain showed no organisms.

Assessment of Primary Care Services and Perceived Barriers to Care in Persons with Disabilities

To determine what percentage of persons with disabilities have a primary care provider, participate in routine screening and health maintenance examinations, and identify perceived physical or physician barriers to receiving care. A total of 344 surveys, consisting of 66 questions, were collected from adults with disabilities receiving care at an outpatient rehabilitation clinic. A total of 89.5% (95% CI 86.3%-92.8%) of participants reported having a primary care physician. Younger persons (P < 0.0001), men (P < 0.02), persons with brain injury (P < 0.05), or persons with amputations (P < 0.05) were less likely to have a primary care physician. Participant report of screening for alcohol, nonprescription drug use, and safety with relationships at home ranged from 26.6% to 37.5% compared with screening for depression, diet, exercise, and smoking (64.5%-70%). Completion rates of age- and gender-appropriate health maintenance examinations ranged from 42.4% to 90%. A total of 2.67% of participants reported problems with physical access at their physician's office, and 36.4% (95% CI 30.8%-42.1%) of participants reported having to teach their primary care physician about their disability. Most persons with disabilities have a primary care physician. In general, completion rates for routine screening and health maintenance examinations were high. Perceived deficits in primary care physicians' knowledge of disability issues seem more prevalent than physical barriers to care.

AJR Teaching File: Asymptomatic Man with Giant Negative T Waves on ECG

Received July 31, 2008; accepted without revision August 12, 2008. 1Department of Radiology, Division of Cardiothoracic Radiology, East Ann Arbor Health and Geriatrics Center, University of Michigan, 4260 Plymouth Rd., Rm. 1847 SPC 2713, Ann Arbor, MI 48109-2713. Address correspondence to A. Attili (aattili@umich.edu). 2Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI. AJR 2009;192:S57–S61 0361–803X/09/1923–S57 © American Roentgen Ray Society Case History A 40-year-old asymptomatic man presents for a routine health maintenance examination. The physical examination is normal; in particular, he is normotensive. ECG reveals diffuse deep T wave inversion. His family history is significant for unexplained sudden cardiac death in his father. MRI was performed to further evaluate an abnormality revealed on echocardiography.

Despite Published Recommendations, Adults’ Routine Health Care Often Lacks Attention to STD Prevention

Despite Published Recommendations, Adults’ Routine Health Care Often Lacks Attention to STD Prevention