Clinical problem-solving. More than meets the eye.
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Acute Kidney Injury↗
Biomedical subjects
Bimal H Ashar
Publications and source records attributed to Bimal H Ashar.
High prevalence and correlates of low bone mineral density in young adults with sickle cell disease.
Sickle cell disease (SCD) is a prevalent genetic disorder in which sickle hemoglobin leads to tissue hypoxia and adverse effects on bone. Published studies suggest that children with SCD often have undiagnosed osteopenia or osteoporosis. Minimal data exist on the prevalence of low bone mineral density (BMD) in adults. Our objective was to describe the prevalence of osteopenia and osteoporosis in adults with SCD and to identify patient or disease characteristics associated with low BMD. We conducted a cross-sectional study of adults with SCD. Through questionnaires, we collected data about disease course and osteoporosis risk factors. Patients underwent dual X-ray absorptiometry (DXA) measurement of BMD at the hip, spine, and forearm and sampling of blood and urine for markers of bone turnover, sickle cell disease severity, and secondary causes of osteoporosis. Our main outcome measure was prevalence of osteopenia and osteoporosis as defined by WHO criteria. Of 32 adults with SCD (14 men and 18 women) with a mean age of 34 years, 72% (95% confidence interval 53-86%) had low BMD at one or more anatomic sites. Thirteen patients were classified as osteoporotic and 10 as osteopenic. The prevalence of low BMD was greatest in the lumbar spine (66% of patients). Significant correlates of decreased BMD included low BMI (P < 0.01), male sex (P = 0.02), and low serum zinc concentrations (P < 0.01). The prevalence of osteopenia and osteoporosis in young adults with SCD is extremely high. Further research is needed to address fracture risk and therapeutic interventions.
Absorptiometry, Photon↗
Extent and determinants of physician participation in expert witness testimony.
OBJECTIVES: In the recent past, law firms have had difficulties in finding physicians to review malpractice cases and serve as expert witnesses. Over the last few years, however, many clinicians have had a decline in their income, causing some physicians to seek alternative sources of revenue such as the review of legal cases. The purpose of this study was to qualify and quantify the extent of physician participation in legal activities. METHODS: We conducted a survey of 1,000 Maryland internal medicine physicians. The survey consisted of 24 items designed to collect information on demographics, practice patterns, income variables, and participation in legal review. RESULTS: Twenty-four percent of our respondents reported engaging in expert witness testimony/review to supplement their incomes. Engagement was significantly associated with internal medicine sub-specialty practice, academic practice, a self-perception that personal income was higher than the income of colleagues, and being in practice for 11 to 20 years. Economic factors were not found to be associated with engaging in these activities. CONCLUSIONS: Physician participation in legal review and expert witness activities is significant and appears not to be determined by economic factors. Both the positive effects of such participation on the legal system and the potential ethical concerns require further study.
Ethics, Medical↗
Bisphosphonate-associated scleritis: a case report and review.
An 86-year-old female was treated for osteoporosis with alendronate, an aminobisphosphonate. Six weeks after alendronate therapy began, scleritis developed in the patient's right eye. The alendronate was discontinued, and, with the administration of prednisone, the symptoms of scleritis fully resolved. Rechallenge resulted in recurrence of the symptoms. Bisphosphonates are commonly used in the management of osteoporosis and are generally safe agents. Rarely, they have been linked with ocular inflammation. This case report reviews the literature on the ocular effects of bisphosphonates and discusses a possible mechanism for the association.
Aged↗
Disparities in osteoporosis screening between at-risk African-American and white women.
BACKGROUND: Despite a lower prevalence of osteoporosis in African-American women, they remain at risk and experience a greater mortality than white women after sustaining a hip fracture. Lack of recognition of risk factors may occur in African-American women, raising the possibility that disparities in screening practices may exist. OBJECTIVE: To determine whether there is a difference in physician screening for osteoporosis in postmenopausal, at-risk African-American and white women. METHODS: We conducted a retrospective chart review at an urban academic hospital and a suburban community hospital. Subjects included 205 African-American and white women, age > or = 65 years and weight < or = 127 pounds, who were seen in Internal Medicine clinics. The main outcome was dual-energy x-ray absorptiometry (DXA) scan referral. We investigated physician and patient factors associated with referral. Secondary outcomes included evidence of discussion of osteoporosis and prescription of medications to prevent osteoporosis. RESULTS: Significantly fewer African-American than white women were referred for a DXA scan (OR 0.39%, 95% confidence interval (CI): 0.22 to 0.68). Physicians were also less likely to mention consideration of osteoporosis in medical records (0.27, 0.15 to 0.48) and to recommend calcium and vitamin D supplementation for this population (0.21, 0.11 to 0.37). If referred, African-American women had comparable DXA completion rates when compared with white women. No physician characteristics were significantly associated with DXA referral patterns. CONCLUSIONS: Our study found a significant disparity in the recommendation for osteoporosis screening for African-American versus white women of similar risk, as well as evidence of disparate osteoporosis prevention and treatment, confirming results of other studies. Future educational and research initiatives should target this inequality.
Absorptiometry, Photon↗
Current evidence for the use of emerging radiologic technologies for disease screening.
Recent technologic advances in the field of radiology have resulted in the availability of several new tests with potential applications for disease screening. Presently, these tests are being marketed directly to patients as noninvasive means to provide peace of mind that they are disease free. Such assurance is appealing to many individuals, and some are willing to spend up to 1500 dollars to choose from a menu of available diagnostic options. Given that a physician's referral is unnecessary, many healthcare providers are unaware that such testing has taken place until their patients present to them with abnormal test results. In this review, we examine the evidence supporting the use of electron beam computed tomography for coronary artery disease screening, spiral computed tomography of the chest for lung cancer screening, computed tomographic colonography for colon cancer screening, and total-body computed tomography for general screening. Although some of these modalities show promise for the future, there is insufficient evidence to support the use of any of these testing methods for secondary prevention. The potential for harm associated with false-positive test results, false-negative test results, undue anxiety, and radiation exposure exists but requires further study to quantify actual risk.
Colonic Neoplasms↗
Prevalence and determinants of physician participation in conducting pharmaceutical-sponsored clinical trials and lectures.
BACKGROUND: The relationship between physicians and the pharmaceutical industry is controversial because of the potential for conflicts of interest. However, little empirical evidence exists on the extent of physician participation in activities sponsored by pharmaceutical companies. OBJECTIVES: To determine the prevalence of participation of internal medicine physicians in clinical trials and lectures sponsored by pharmaceutical companies and to describe factors that are associated with such participation. DESIGN, SETTING, AND PARTICIPANTS: We conducted a cross-sectional regional survey of 1,000 Maryland internal medicine physicians between February 2000 and January 2001 in order to measure the prevalence of physician participation in pharmaceutical-sponsored clinical trials and lectures. We also collected economic and demographic information to examine potential associations between physician characteristics and engagement in such activities. RESULTS: Of 835 eligible physicians 444 (53%) responded, of whom 37% reported engaging in pharmaceutical-sponsored clinical trials and/or lectures to supplement their incomes. In our multivariable analysis, subspecialists versus generalist physicians (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.14 to 2.99), physicians in private group-single specialty and academic practice versus physicians in solo practice (OR, 2.30; 95% CI, 1.19 to 4.44 and OR, 2.56; 95% CI, 1.17 to 5.61, respectively), and physicians with higher versus lower annual incomes (OR, 1.22; 95% CI, 1.04 to 1.44) had a greater odds of participation in these activities. Additionally, physicians dissatisfied with their income had a 140% greater odds of participation (OR, 2.36; 95% CI, 1.45 to 3.83) than those who were satisfied with their income. CONCLUSIONS: A substantial number of internists engage in pharmaceutical industry-sponsored clinical trials and/or lectures in an effort to supplement their incomes. Physician dissatisfaction with income appears to partially explain such participation.
Clinical Trials as Topic↗
Evaluation of an audience response system for the continuing education of health professionals.
INTRODUCTION: Continuing medical education (CME) for physicians and other health personnel is becoming increasingly important in light of recertification requirements. Interactive learning is more effective and may be useful in a continuing education setting. This study examines the use of an audience response system (ARS) as an interactive learning tool for health care providers. METHOD: We conducted a national randomized controlled trial to evaluate the utility of an ARS to enhance attention and learning. Speakers at 42 clinical round table (CRT) programs in five regions across the United States were randomized to "use" or "no use" of an ARS during their lectures. We surveyed participants to collect data regarding presentation and speaker quality, impressions of the ARS, and knowledge of the material presented. We collected information from speakers regarding ease of use and overall opinions of the ARS. RESULTS: A total of 283 surveys were completed (164 from participants using the ARS and 119 from participants not using the ARS). ARS participants rated the quality of the presentation, the quality of the speaker, and their level of attention more highly than non-ARS participants (p < .05). Knowledge scores (of material presented) were not significantly different between the two groups. Both participants and speakers felt that the ARS was easy to use and preferred to use the system in future CRTs. DISCUSSION: Participants in CRTs with the ARS rated presentation and speaker quality more favorably than those participants in CRTs without the tool. Participant knowledge scores, however, were not significantly different. ARSs may provide easy-to-use tools to enhance attention and enthusiasm in CME learners.
Adult↗
A critical evaluation of Internet marketing of products that contain ephedra.
OBJECTIVE: To evaluate information contained within Internet sites that advertise and market dietary supplements containing ephedra. MATERIAL AND METHODS: We conducted an Internet search to identify Web sites advertising weight-loss supplements that contained ephedra. Between July 7 and July 18, 2002, 4 search engines were used by entering the term herbal weight loss. Outcome measures included disclosure of potential adverse effects of or contraindications to ephedra-containing supplements, disclosure of ephedra alkaloid dosage, and presence of misleading or incorrect information. RESULTS: Thirty-two products and advertisements were identified and systematically evaluated for deviance from truth-in-advertising standards. Of the 32 Web sites analyzed, 13 (41%) failed to disclose potential adverse effects or contraindications to supplement use. Seventeen (53%) did not reveal the dosage of ephedra alkaloids that was recommended. More importantly, 11 sites (34%) contained incorrect or misleading statements, some of which could directly result in serious harm to consumers. CONCLUSION: If dietary supplements containing ephedra are to continue to be marketed freely, substantial reform in advertising regulation and enforcement is warranted.
Advertising↗