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Because many skin lesions and disorders can appear similar, primary care clinicians often struggle to diagnose them definitively without histopathologic information obtained from a biopsy. This review article explains how to decide whether a lesion should be biopsied and what type of biopsy technique to use and then outlines the stepwise approach to each of the most common skin biopsy techniques: shave, saucerization, punch, fusiform, and subcutaneous nodule biopsies. Finally, potential pitfalls and complications are discussed so the clinician can avoid those and can provide a cosmetically acceptable result from these common outpatient procedures.

Estimates suggest 30% of health care expenditures are wasteful. This has led to increased educational interventions in graduate medical education (GME) training aimed to prepare residents for high value, cost-conscious practice. International health electives (IHE) are widely available in GME training and may be provide trainees a unique perspective on principles related to high value, cost-conscious care (HVCCC).The purpose of this study was to explore how trainee reflections on IHE experiences offer insight into HVCCC.The authors conducted an applied thematic analysis of narrative reflective reports of GME trainees' IHE experiences to characterize their perceptions of HVCCC.The Mayo International Health Program (MIHP) supports residents and fellows from all specialties across all Mayo Clinic sites. We included 546 MIHP participants from 2001 to 2020.The authors collected post-elective narrative reports from all MIHP participants. Reflections were coded and themes were organized into model for transformative learning during IHEs, focusing on HVCCC.GME trainees across 24 different medical specialties participated in IHEs in 73 different countries. Three components of transformative learning were identified: disorienting dilemma, critical reflection, and commitment to behavior change. Within the component of critical reflection, three topics related to HVCCC were identified: cost transparency, resource stewardship, and reduced fear of litigation. Transformation was demonstrated through reflection on future behavioral change, including cost-aware practice, stepwise approach to health care, and greater reliance on clinical skills.IHEs provide rich experiences for transformative learning and reflection on HVCCC. These experiences may help shape trainees' ideology of and commitment to HVCCC practices.

Background: Vitamin D deficiency may increase the risk of severe COVID-19 disease. Objectives: To determine if 25-hydroxyvitamin D [25(OH)D] levels in patients hospitalized for COVID-19 were associated with the clinical outcomes of days on oxygen, duration of hospitalization, ICU admission, need for assisted ventilation, or mortality. Methods: We conducted a retrospective study of 92 patients admitted to the hospital with SARS-CoV-2 infection between April 16, 2020 and October 17, 2020. Multivariable regression was performed to assess the independent relationship of 25(OH)D values on outcomes, adjusting for significant covariates and the hospitalization day the level was tested. Results: About 15 patients (16.3%) had 25(OH)D levels Conclusion: Vitamin D status was not related to any of the primary outcomes reflecting severity of COVID-19 in hospitalized patients. However, our sample size may have lacked sufficient power to demonstrate a small effect of vitamin D status on these outcomes.

Purpose International health electives (IHEs) provide numerous educational benefits; potential harms are less well understood. One potential harm is trainee distress associated with increased patient death during IHEs. The purpose of this study was to explore residents' and fellows' IHE experiences with patient death. Method The authors used applied thematic analysis to explore residents' and fellows' IHE experiences with patient death. The Mayo International Health Program supports IHEs from all specialties across three Mayo Clinic sites. Data were collected and analyzed in two steps. First the authors collected, coded, and analyzed narrative reflections from 43 postrotation reports gathered in 2001-2017 and identified themes relating to experiences with patient death. Second, in 2016-2017 the authors conducted semistructured interviews with six previous participants to refine thematic analysis. Results Participants described impacts of experiencing increased patient death and identified themes in two domains: difficult experiences with patient death and potential interventions to help residents process their experiences. They identified four themes illustrating why these experiences were difficult: lack of preparation for increased exposure to death, lack of closure, consequences of limited resources, and differences in cultural beliefs regarding death. While pretrip preparation for dealing with death was viewed as important, trainees identified support during and debriefing after IHEs as additional important interventions. Conclusions Given the popularity of IHEs, residency programs should consider the effect on trainees of increased exposure to patient death. Study findings can inform IHE preparation, support, and debriefing to minimize distress associated with witnessing patient deaths on IHEs.

Trigger finger is a common condition usually curable by a safe, simple corticosteroid injection. Trigger finger results from a stenotic A1 pulley that has lost its gliding surface producing friction and nodular change in the tendon. This results in pain and tenderness to palpation of the A1 pulley, progressing to catching and then locking. Splinting for 6 to 9 weeks produces gradual improvement in most patients as does a quick steroid injection with the latter resulting in resolution of pain in days and resolution of catching or locking in a few weeks. Percutaneous or open release should be reserved for injection failures particularly those at high risk for continued injection failure including diabetics and those with multiple trigger fingers. We present a step-by-step method for injection with illustrations to encourage primary care providers to offer this easily performed procedure to their patients.

Residency programs offer international health electives (IHEs), providing multiple educational benefits. This study aimed to identify how IHEs fulfill the Accreditation Council for Graduate Medical Education (ACGME) core competencies.We conducted a thematic analysis of post-rotation reflective reports from residents who participated in IHEs through the Mayo International Health Program. We coded reports using a codebook created from the ACGME competencies. Using a constant comparative method, we identified significant themes within each competency.Residents from 40 specialties participated in 377 IHEs in 56 countries from 2001 to 2014. Multiple themes were identified within each of the six ACGME core competencies: Patient Care and Procedural Skills (4), Medical Knowledge (5), Practice-Based Learning and Improvement (3), Interpersonal and Communication Skills (5), Professionalism (4), and Systems-Based Practice and Improvement (3). Themes included improving physical exam and procedural skills, providing care in resource-limited setting, gaining knowledge of tropical and non-tropical diseases, identifying socioeconomic determinants of health, engaging in the education of others, and increasing communication across cultures and multidisciplinary teams.Through IHEs, residents advanced their knowledge, skills, and attitudes in each of the six ACGME competencies. These data can be used for development of IHE competencies and milestones for resident assessment.

Graduate medical education is an excellent means of building the capacity of health care systems in low and middle Income Countries (LMIC) and a growing way for physicians in the U.S to get involved in integral mission – the proclamation and demonstration of the Gospel. This white paper purposes to provide a “best practices” recommendations on family and internal medicine (“medical”) residency program development in majority world settings. An expert panel of residency educators convened in November 2015 at the Global Missions Health Conference (GMHC) in Louisville, Kentucky and through an iterative process identified themes that were then further defined and clarified by medical residency faculty unable to be present. Participants largely agreed that integration and cooperation with the country’s Ministry of Health (MOH) is essential for sustainable residency development. Recognition of family medicine as a specialty will enable graduates to succeed in the country’s physician job market and health systems leadership. Recognition by the national church of the unique needs of their mission hospitals’ educational programs to control their revenue in order to fund their programs’ growth and development exemplifies the common wisdom to provide authority and resources where responsibility for good outcomes is expected. Co-training of general surgeons and medical residents who can provide essential surgical call coverage may lead to on-going synergies. Teaching by medical and surgical subspecialists is essential in medical residencies to provide the depth of instruction residents need to develop as excellent clinicians. Dependable scheduling of their specialty instruction allows residency program directors to assure inclusion of their content in the residency curriculum. In summary, participants agreed that teaching in medical residency programs in LMIC present excellent opportunities for national and expat Christian physician educators interested in integral mission.

Background Primary care providers often manage skin abscesses in the outpatient setting. Estimating the size and depth of an abscess, and distinguishing abscess from cellulitis by clinical examination can be challenging due to surrounding firm tissue induration. Definitive treatment of abscess requires incision and drainage, and the approach chosen may be altered by abscess size, depth, and surrounding neurovascular structures. Methods For 31 consecutive patients seen in the primary care outpatient clinic, we prospectively compared the estimated size of skin abscesses by clinical examination with that determined by ultrasound. Prior to incision and drainage, a limited point-of-care ultrasound examination was performed and the abscess dimensions were measured, the depth was determined, and adjacent vascular structures were noted. Based on ultrasound findings, physicians reported whether the decision to perform the procedure or the techniques used to perform the procedure were altered by the scan. Results The clinical examination was inaccurate for size estimation by >0.5 cm in 16 of 31 patients (52%). Ultrasound examination changed the physician decision of whether or not incision and drainage should be performed in 7 patients (23%) and altered the technique/approach in an additional 10 patients (32%); thus, management was changed in 55% of cases. Physician confidence in performing the procedure was improved in 16 cases (52%). Conclusion Outpatient procedural management of skin abscesses by primary care physicians was altered in more than half the cases by performing point-of-care ultrasound prior to incision and drainage.

International health electives (IHEs) are widely available during residency and provide unique experiences for trainees. Theoretical models of professional identity formation and transformative learning may provide insight into residents' experiences during IHEs. The purpose of this study was to explore transformative learning and professional identity formation during resident IHEs and characterize the relationship between transformative learning and professional identity formation.The authors used a constructivist grounded theory approach, with the sensitizing concepts of transformative learning and professional identity formation to analyze narrative reflective reports of residents' IHEs. The Mayo International Health Program supports residents from all specialties across three Mayo Clinic sites. In 2015, the authors collected narrative reflective reports from 377 IHE participants dating from 2001 to 2014. Reflections were coded and themes were organized into a model for transformative learning during IHEs, focusing on professional identity.Five components of transformative learning were identified during IHEs: a disorienting experience; an emotional response; critical reflection; perspective change; and a commitment to future action. Within the component of critical reflection, three domains relating to professional identity were identified: making a difference; the doctor-patient relationship; and medicine in its "purest form." Transformation was demonstrated through perspective change and a commitment to future action, including continued service, education, and development.IHEs provide rich experiences for transformative learning and professional identity formation. Understanding the components of transformative learning may provide insight into the interaction between learner, experiences, and the influence of mentors in the process of professional identity formation.

Rationale, aims and objectives Achieving control over elevated lipid parameters, particularly low-density lipoprotein (LDL)-cholesterol, is an acknowledged quality indicator in primary care. The Centers for Disease Control and Prevention (CDC)'s model for investigation of outbreaks (person–place–time) can be applied to the analysis of quality indicators. Methods A sample of 322 family medicine patients for whom lipid levels were ordered was extracted. LDL > 100 mg/dL was cross-tabulated by personal characteristics [age group, gender, body mass index (BMI), diagnoses], month (time) and ordering department (place). Results Age (except one age category), gender, time and location were not related to LDL > 100 mg/dL after adjustment for covariates. All levels of BMI above normal elevated the risk of LDL > 100 mg/dL [BMI 25–29.9: odds ratio (OR) = 3.41, confidence interval (CI) = 1.61–7.23, P = 0.0014; BMI 30–34.9: OR = 2.93, CI = 1.28–6.70, P = 0.0109; BMI ≥ 35: OR = 2.75, CI = 1.19–6.37, P = 0.0181]. Patients with coronary artery disease (CAD) and diabetes mellitus (DM) were at reduced risk for LDL > 100 mg/dL (CAD: OR = 0.47, CI = 0.24–0.91, P = 0.0254; DM: OR = 0.28, CI = 0.14–0.55, P = 0.0002). Conclusion An outbreak investigation model is useful for analysing variations in this quality indicator. Patients with higher BMI and those not diagnosed with CAD or DM type I/II may be considered for intensified lipid lowering using quality improvement efforts. These might include counselling for lifestyle changes or medication therapy depending upon their calculated cardiac risk.

The US Preventative Services Task Force (USPSTF) recommends consideration for screening for osteoporosis in women under age 65 who have an estimated 10-year major osteoporotic fracture risk of 9.3 % or higher. We found that this threshold for osteoporosis screening in women ages 50–64 years old has a low sensitivity to detect osteoporosis. The US Preventative Services Task Force (USPSTF) recommends consideration of dual-energy X-ray absorptiometry (DXA) in women under ages 50–64 with a major osteoporotic fracture (MOF) risk of 9.3 % or higher, as estimated by the fracture risk assessment tool (FRAX) tool. We assessed the performance of the 9.3 % MOF risk threshold for detecting osteoporosis and evaluated whether DXA indication appeared appropriate, based on USPSTF criteria and other risk factors, at our institution. We performed a retrospective record review of women ages 50–64.5 years old to determine clinical factors and FRAX scores of women undergoing a DXA at our institution over a 6-month period after the USPSTF recommendations were released and evaluated the sensitivity and specificity of the 9.3 % MOF threshold to detect densitometric osteoporosis. Additionally, using the USPSTF criteria and several additional risk factors, we evaluated the extent of potentially inappropriate DXA use in women ages 50 to 64 years in a large primary care practice in an academic medical center. The analysis included 465 DXA tests. The overall sensitivity and specificity of a FRAX-calculated MOF risk ≥9.3 % was 37 and 74 %, respectively, for the detection of osteoporosis. The receiver operator characteristic curve (ROC) demonstrated an area under the curve of 0.58. Lowering the FRAX risk threshold to 5.5 % would increase the sensitivity of detecting osteoporosis in our population from 37 to 80 % while reducing the specificity from 74 to 27 %. Out of 465 DXAs, 371 (79.8 %) were classified as appropriately ordered per our pre-specified criteria. Of the 120 women with osteoporosis at the hip and/or spine based on T-score values of −2.5 or less, 14 DXAs (11.7 %) were classified as potentially inappropriate based on a FRAX-predicted MOF risk less than 9.3 % and lack of additional pre-specified risk factors. We found that the USPSTF-recommended MOF risk threshold of 9.3 % for osteoporosis screening in women ages 50–64 years old has a low sensitivity to detect osteoporosis.

Background: Mental illness has been increasingly recognised as a source of morbidity in low- and middle-income countries and significant treatment gaps exist worldwide. Studies have demonstrated the effectiveness of task sharing through community-based treatment models for addressing international mental health issues.Aim: This paper aims to evaluate the perceptions of a wide range of mental health stakeholders in a Ugandan community regarding the benefits and barriers to developing a community-based mental health programme.Setting: Bwindi Community Hospital (BCH) in south-west Uganda provides services through a team of community health workers to people in the Kanungu District.Methods: Thematic analysis of 13 semi-structured interviews and 6 focus group discussions involving 54 community members and 13 mental health stakeholders within the BCH catchment area.Results: Stakeholders perceived benefits to a community-based compared to a hospital-based programme, including improved patient care, lower costs to patients and improved community understanding of mental illness. They also cited barriers including cost, insufficient workforce and a lack of community readiness.Conclusions: Stakeholders express interest in developing community-based mental health programmes, as they feel that it will address mental health needs in the community and improve community awareness of mental illness. However, they also report that cost is a significant barrier to programme development that will have to be addressed prior to being able to successfully establish such programming. Additionally, many community members expressed unique sociocultural beliefs regarding the nature of mental illness and those suffering from a psychiatric disease.

Rationale, aims and objectives This study was undertaken to assess the frequency of lipid screening in comparison with the United States Preventive Services Task Force guideline in a sample of family medicine patients. In addition, we sought to determine the association between testing frequency and achievement of lipid targets. Methods A random sample was extracted from 271 patients from among all patients cared for in our Department of Family Medicine for whom lipid screening was ordered from March to September 2012 and who had ≥2 well-defined cardiovascular risk factors. Lipid testing frequency was classified in three ways: semi-annual or less often (0–12 tests over 6 years), annual or less often (0–6 tests), or biennial (0–3 tests). Results Multiple logistic regression analysis revealed that the predictors of lipid screening more often than semi-annually were age ≥60 years [odds ratio (OR) = 3.7] and diabetes mellitus (DM) (OR = 30.6). Predictors of screening more often than annually were DM (OR = 4.3), hypertension (OR = 2.1), family history of premature coronary artery disease (OR = 5.6) and statin treatment (OR = 3.5). Lipid goal attainment was not associated with testing frequency except with regard to low-density lipoprotein levels (P = 0.043, P

The objective of this study was to compare the performance of the US Preventive Services Task Force (USPSTF) recommended WHO Fracture Risk Assessment Tool (FRAX) threshold score of 9.3% (calculated without femoral neck bone density) with the Simple Calculated Osteoporosis Risk Estimate (SCORE), Osteoporosis Self-Assessment Tool (OST), and the Osteoporosis Risk Assessment Instrument (ORAI) to identify osteoporosis in younger women.We conducted a retrospective review of women ages 50 to 64 years who underwent dual-energy radiographic absorptiometry (DXA) at our institution over a 6-month period. Scores for the FRAX, ORAI, OST, and SCORE tools were calculated using various thresholds: FRAX ≥9.3%, SCORE ≥6, OST2, and ORAI ≥9. Sensitivity, specificity, and area under the receiver-operating characteristic curve for detection of densitometric osteoporosis by DXA for each tool were compared.A total of 290 women were identified. Of these, 284 (97.9%) were white, and the mean ± standard deviation age was 56.6 ± 3.4 years. Fifty (17.2%) had osteoporosis of the lumbar spine and/or femoral neck on DXA. Sensitivity, specificity, and area under the receiver-operating characteristic curve for identifying densitometric osteoporosis at the femoral neck and/or spine were 36%, 73%, and 0.55 for FRAX; 74%, 42%, and 0.58 for SCORE; 56%, 69%, and 0.63 for the OST; and 52%, 67%, and 0.60 for the ORAI, respectively.DXA screening based on the USPSTF-recommended FRAX threshold score of 9.3% has a low sensitivity to identify densitometric osteoporosis in women ages 50 to 64. Lowering the threshold score would increase sensitivity but would also increase the number of women sent for screening DXA. Use of the validated SCORE tool would improve sensitivity to identify osteoporosis in this age group.

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

Context: Integral to the location of health resources is the distance decay of utilization observed in a population. In rural Peru, a nongovernmental organization planning to increase the availability of health services needed this information. Purpose: To determine variables associated with utilization of a central medical clinic and determine whether, because of the mountainous topography, travel time (TT) would be a better predictor of utilization than distance. Methods: A door-to-door survey of all available households (81% of total), using a Spanish translation of questions excerpted from the Behavioral Risk Factor Surveillance System Survey, was conducted in the summer of 2008 to determine variables associated with self-reported history of clinic utilization. Results: Utilization was inversely related to TT and distance. Of those living within 5 minutes of the clinic, 61% had been to the clinic whereas only 25% of those living 30 or more minutes away had sought care. Female gender and fever predicted increased odds of clinic utilization. Having a disability reduced one's odds (OR 0.55) of visiting the clinic, after adjusting for gender, TT, and fever. The inverse correlation of utilization with travel distance and TT was not significantly different, thus failing to demonstrate that TT is a better predictor of utilization than distance. Conclusion: In health service planning, care for common conditions should be available within 5 minutes’ TT or a few kilometers’ distance from each person's home in order to improve health care access and reduce health care disparities worsened by disability.

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

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

Background: Pain assessment and control have received increasing attention as a quality issue in medicine. However, pain has rarely been addressed as a cost-containment issue. Methods: We performed a single-center retrospective analysis of information abstracted from the medical records of 1445 adult patients who were treated in family medicine clinics and referred to specialists in Rochester, Minnesota, USA. Patients were categorized into frequent utilizers of physician visits and others, with those having more than eight medical visits in the previous 6 months being classified as frequent users. General pain was self-assessed using a 10-point scale. Multiple logistic regression analysis was used to test the relationship between pain and the frequency of visits, after adjustment for co-morbidities, body mass index (BMI), and demographic characteristics. Results: Findings revealed that patients with pain scores >=7 had higher odds of being frequent visitors after adjusting for co-morbidity, BMI, age, marital status, and gender (adjusted odds ratio [AOR] = 1.60; 95% CI 1.12, 2.28; p

BACKGROUND The obesity epidemic threatens to shorten life expectancy and reduce the quality of life for large segments of the population. The purpose of this study was to develop a decision rule for referral to a weight-loss program on the basis of the relationship between body mass index (BMI) and self-rated overall health. METHODS We employed a patient satisfaction survey of family medicine patients treated in Mayo Clinic in Rochester, Minnesota, linked with medical record information, to test the theory that, in primary care patients, BMI exhibits an inverse and independent relationship with overall self-rated health after adjusting for age, gender, marital status, and cigarette smoking. Interviews were linked to medical records for 679 adult patients. RESULTS Adjusting for age and other confounders using multiple logistic regression analysis revealed that overweight (BMI = 25-30 kg/m(2)) was not a risk factor for poor self-rated health and only BMI above 35 kg/m(2) was significantly related to poor overall health (adjusted odds ratio = 0.33, confidence interval = 0.17-0.64, P = .0012). CONCLUSIONS Quality improvement programs should monitor whether obesity is being addressed in clinical settings. A patient-centered decision rule for addressing obesity could involve referral of patients whose BMI is above 35 kg/m(2) to weight management programs, monitoring of patients whose BMI scores are between 30 and 35 kg/m(2), and encouragement of patients whose BMI is above 25 kg/m(2) to avoid weight gain.

CONTEXT AND OBJECTIVE: To evaluate predictors of changes in lipid parameters consisting of LDL-C (low-density lipoprotein cholesterol), TC (total cholesterol) and non-HDL-C (non-high density lipoprotein cholesterol) among primary care patients. DESIGN AND SETTING: Retrospective study conducted on family medicine patients. METHODS: Demographic features and other clinically relevant information were abstracted from medical records. The primary outcome was the difference in LDL-C level from initial testing to the index test. Secondary outcomes were the changes in TC and non-HDL-C levels between two measurements. RESULTS: Three hundred and eleven participants were included in the final secondary analysis. Multiple linear regression revealed that male patients (β = 4.97, P = 0.040), diabetes (β = 9.75, P = 0.003) and higher LDL-C levels at baseline (β = 0.35, P < 0.001) were positively associated with LDL variance, whereas longer time period (β = -0.15, P = 0.045) and familial hypercholesterolemia history (β = -7.56, P = 0.033) were negatively associated. Male patients (β = 8.45, P = 0.002), DM (β = 9.26, P = 0.011), higher TC levels at baseline (β = 0.35, P < 0.001) and taking statins (β = 7.31, P = 0.023) were positively associated with TC variance, whilst longer time period (β = -0.183, P = 0.031) and familial hypercholesterolemia (β = -10.70, P = 0.008) were negatively associated. CONCLUSION: In the present study, patients who were male, on statin treatment, diagnosed with diabetes and had higher baseline lipid values were more likely associated with better lipid outcomes at future testing. RESUMO CONTEXTO E OBJETIVO: Avaliar preditores de alterações nos parâmetros lipídicos que consistem em LDL-C (colesterol de lipoproteína de baixa densidade), TC (colesterol total) e não HDL-C (não colesterol de lipoproteína de alta densidade) entre os pacientes de cuidados primários. TIPO DE ESTUDO E LOCAL: Estudo retrospectivo realizado em pacientes de medicina familiar. MÉTODOS: Aspectos demográficos e outras informações clinicamente relevantes foram extraídos dos prontuários médicos. O desfecho primário foi a diferença de nível de LDL-C entre os exames iniciais e o exame índice. Os desfechos secundários foram as mudanças dos níveis de TC e não HDL-C entre as duas medidas. RESULTADOS: Trezentos e onze participantes foram incluídos na análise secundária final. Regressão linear múltipla revelou que os pacientes do sexo masculino (β = 4,97, P = 0,040), diabetes (DM) (β = 9,75, P = 0,003) e níveis de LDL mais elevados no início do estudo (β = 0,35, P < 0,001) foram associados positivamente com variância LDL, enquanto longo período de tempo (β = -0,15, P = 0,045) e história hipercolesterolemia familiar (β = -7,56, P = 0,033) foram associados negativamente. Pacientes do sexo masculino (β = 8,45, P = 0,002), com DM (β = 9,26, P = 0,011), níveis elevados de CT na linha de base (β = 0,35, P < 0,001) e tomar estatinas (β = 7,31, P = 0,023) associaram-se positivamente com a variância TC, enquanto longo período de tempo (β = -0,183, P = 0,031), hipercolesterolemia familiar (β = -10,70, P = 0,008) foram associados negativamente. CONCLUSÕES: No presente estudo, os pacientes que eram do sexo masculino, em tratamento com estatinas, com diagnóstico de DM e que tinham valores lipídicos basais mais elevados foram mais provavelmente associados a melhores resultados de lipídios em testes futuros.

Achieving control over elevated lipid parameters, particularly low-density lipoprotein (LDL)-cholesterol, is an acknowledged quality indicator in primary care. The Centers for Disease Control and Prevention (CDC)'s model for investigation of outbreaks (person-place-time) can be applied to the analysis of quality indicators.A sample of 322 family medicine patients for whom lipid levels were ordered was extracted. LDL 100 mg/dL was cross-tabulated by personal characteristics [age group, gender, body mass index (BMI), diagnoses], month (time) and ordering department (place).Age (except one age category), gender, time and location were not related to LDL 100 mg/dL after adjustment for covariates. All levels of BMI above normal elevated the risk of LDL 100 mg/dL [BMI 25-29.9: odds ratio (OR) = 3.41, confidence interval (CI) = 1.61-7.23, P = 0.0014; BMI 30-34.9: OR = 2.93, CI = 1.28-6.70, P = 0.0109; BMI ≥ 35: OR = 2.75, CI = 1.19-6.37, P = 0.0181]. Patients with coronary artery disease (CAD) and diabetes mellitus (DM) were at reduced risk for LDL 100 mg/dL (CAD: OR = 0.47, CI = 0.24-0.91, P = 0.0254; DM: OR = 0.28, CI = 0.14-0.55, P = 0.0002).An outbreak investigation model is useful for analysing variations in this quality indicator. Patients with higher BMI and those not diagnosed with CAD or DM type I/II may be considered for intensified lipid lowering using quality improvement efforts. These might include counselling for lifestyle changes or medication therapy depending upon their calculated cardiac risk.

In the United States, there is a growing number of medical students participating in international health electives. These experiences have the potential to be mutually beneficial to both the host country and the student. However, there is a significant risk of unethical and damaging practices during these trips including concerns for sending trainees without appropriate pre-travel preparation with inadequate accountability to local health care providers at a stage in their education which imposes an undue burden on the local health facilities. This article describes one first year medical student’s experience in navigating common challenges faced on international health electives and offers practical advice enlightened by the literature on how to overcome them. We emphasize the need for students to ensure adequate pretrip preparation, communicate their level of training clearly, practice cultural humility, ensure personal safety, and engage in projects needed by the host community.

This study was undertaken to assess the frequency of lipid screening in comparison with the United States Preventive Services Task Force guideline in a sample of family medicine patients. In addition, we sought to determine the association between testing frequency and achievement of lipid targets.A random sample was extracted from 271 patients from among all patients cared for in our Department of Family Medicine for whom lipid screening was ordered from March to September 2012 and who had ≥2 well-defined cardiovascular risk factors. Lipid testing frequency was classified in three ways: semi-annual or less often (0-12 tests over 6 years), annual or less often (0-6 tests), or biennial (0-3 tests).Multiple logistic regression analysis revealed that the predictors of lipid screening more often than semi-annually were age ≥60 years [odds ratio (OR) = 3.7] and diabetes mellitus (DM) (OR = 30.6). Predictors of screening more often than annually were DM (OR = 4.3), hypertension (OR = 2.1), family history of premature coronary artery disease (OR = 5.6) and statin treatment (OR = 3.5). Lipid goal attainment was not associated with testing frequency except with regard to low-density lipoprotein levels (P = 0.043, P 0.001, P = 0.005, by semi-annual, annual and biennial, respectively) and total cholesterol levels (P = 0.015, P = 0.025 by semi-annual and annual, respectively).Questionable high frequency of lipid testing was detected even when the more conservative approach of annual monitoring was assumed. Frequency of testing was not associated with goal attainment for most parameters. Physicians should request the lipid testing based on overall risk assessment and person variability in accordance with published guidelines.

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

Integral to the location of health resources is the distance decay of utilization observed in a population. In rural Peru, a nongovernmental organization planning to increase the availability of health services needed this information.To determine variables associated with utilization of a central medical clinic and determine whether, because of the mountainous topography, travel time (TT) would be a better predictor of utilization than distance.A door-to-door survey of all available households (81% of total), using a Spanish translation of questions excerpted from the Behavioral Risk Factor Surveillance System Survey, was conducted in the summer of 2008 to determine variables associated with self-reported history of clinic utilization.Utilization was inversely related to TT and distance. Of those living within 5 minutes of the clinic, 61% had been to the clinic whereas only 25% of those living 30 or more minutes away had sought care. Female gender and fever predicted increased odds of clinic utilization. Having a disability reduced one's odds (OR 0.55) of visiting the clinic, after adjusting for gender, TT, and fever. The inverse correlation of utilization with travel distance and TT was not significantly different, thus failing to demonstrate that TT is a better predictor of utilization than distance.In health service planning, care for common conditions should be available within 5 minutes' TT or a few kilometers' distance from each person's home in order to improve health care access and reduce health care disparities worsened by disability.

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

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

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

Background The design of new diagnostic tests would benefit from knowing patients' preferences for the collection of bodily fluids. These preferences, however, are unknown. The authors assessed patients' preferences for the collection of saliva, urine and blood as diagnostic fluids. Methods The authors handed out surveys adult outpatients who sought treatment at two medical care sites and one dental care site at a medical center regarding the comfort, convenience and ease of collection of saliva, urine and blood for diagnostic testing. Results A total of 413 surveys were completed. Subjects regarded the donation of saliva as more comfortable and convenient than that of blood or urine at the doctor's (physician's or dentist's) office, and they reported that saliva and urine are easiest to collect at home compared with blood. Male subjects and subjects who had ever donated saliva were more likely to perceive saliva donation in the doctor's office favorably. Subjects at all care sites regarded the donation of saliva as more comfortable and convenient than that of blood or urine; however, subjects at the dental care site perceived saliva donation more favorably than did subjects at the medical care sites. In addition, respondents said they were more willing to participate in research and medical testing if it required saliva donation rather than urine or blood collection. Conclusions In terms of convenience and comfort, saliva compared well with blood and urine as a diagnostic fluid for clinical and research testing. Patients who sought care at both medical and dental sites shared these perceptions. Clinical Implications Given strong patient preferences, saliva may be the fluid of choice for the development and implementation of patient-centered diagnostic tests in research and practice.

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