The rational clinical examination. Does this patient have clubbing?

CONTEXT: The association between digital clubbing and a host of diseases has been recognized since the time of Hippocrates. Although the features of advanced clubbing are familiar to most clinicians, the presence of early clubbing is often a source of debate. OBJECTIVE: To perform a systematic review of the literature for information on the precision and accuracy of clinical examination for clubbing. DATA SOURCES: The MEDLINE database from January 1966 to April 1999 was searched for English-language articles related to clubbing. Bibliographies of all retrieved articles and of standard textbooks of physical diagnosis were also searched. STUDY SELECTION: Studies selected for data extraction were those in which quantitative or qualitative assessment for clubbing was described in a series of patients. Sixteen studies met these criteria and were included in the final analysis. DATA EXTRACTION: Data were extracted by both authors, who independently reviewed and appraised the quality of each article. Data extracted included quantitative indices for distinguishing clubbed from normal digits, precision of clinical examination for clubbing, and accuracy of clubbing as a marker of selected diseases. DATA SYNTHESIS: The profile angle, hyponychial angle, and phalangeal depth ratio can be used as quantitative indices to assist in identifying clubbing. In individuals without clubbing, values for these indices do not exceed 176 degrees, 192 degrees, and 1.0, respectively. When clinicians make a global assessment of clubbing at the bedside, interobserver agreement is variable, with kappa values ranging between 0.39 and 0.90. Because of the lack of an objective diagnostic criterion standard, accuracy of physical examination for clubbing is difficult to determine. The accuracy of clubbing as a marker of specific underlying disease has been determined for lung cancer (likelihood ratio, 3.9 with phalangeal depth ratio in excess of 1.0) and for inflammatory bowel disease (likelihood ratio, 2.8 and 3.7 for active Crohn disease and ulcerative colitis, respectively, if clubbing is present). CONCLUSIONS: We recommend use of the profile angle and phalangeal depth ratio as quantitative indices in identifying clubbing. Clinical judgment must be exercised in determining the extent of further evaluation for underlying disease when these values exceed 180 degrees and 1.0, respectively.     

Balancing roles and blurring boundaries: Community health workers’ experiences of navigating the crossroads between personal and professional life in rural South Africa

As demand for health services grows, task-shifting to lay health workers has become an attractive solution to address shortages in human resources. Community health workers (CHWs), particularly in low-resource settings, play critical roles in promoting equitable healthcare among underserved populations. However, CHWs often shoulder additional burdens as members of the same communities in which they work. We examined the experiences of a group of CHWs called Mentor Mothers (MMs) working in a maternal and child health programme, navigating the crossroads between personal and professional life in the rural Eastern Cape, South Africa. Semi-structured qualitative interviews (n = 10) were conducted by an experienced isiXhosa research assistant, asking MMs questions about their experiences working in their own communities, and documenting benefits and challenges. Interviews were transcribed and translated into English and thematically coded. Emergent themes include balancing roles (positive, affirming aspects of the role) and blurring boundaries (challenges navigating between professional and personal obligations). While many MMs described empowering clients to seek care and drawing strength from being seen as a respected health worker, others spoke about difficulties in adequately addressing clients’ needs, and additional burdens they adopted in their personal lives related to the role. We discuss the implications of these findings, on an immediate level (equipping CHWs with self-care and boundary-setting skills), and an intermediate level (introducing opportunities for structured debriefings and emphasising supportive supervision). We also argue that, at a conceptual level, CHW programmes should provide avenues for professionalisation and invest more up-front in their workforce selection, training and support.     

The expectations and realities of nutrigenomic testing in australia: A qualitative study

BackgroundConsumer genomic testing for nutrition and wellness, (nutritional genomics), is becoming increasingly popular. Concurrently, health‐care practitioners (HPs) working in private practice (including doctors interested in integrative medicine, private genetic counsellors, pharmacists, dieticians, naturopaths and nutritionists) are involved as test facilitators or interpreters.ObjectiveTo explore Australian consumers’ and HPs’ experiences with nutrigenomic testing.MethodSemi‐structured in‐depth interviews were conducted using predominantly purposive sampling. The two data sets were analysed individually, then combined, using a constant comparative, thematic approach.ResultsOverall, 45 interviews were conducted with consumers (n = 18) and HPs (n = 27). Many of the consumer interviewees experienced chronic ill‐health. Nutrigenomic testing was perceived as empowering and a source of hope for answers. While most made changes to their diet/supplements post‐test, self‐reported health improvements were small. A positive relationship with their HP appeared to minimize disappointment. HPs’ adoption and views of nutrigenomic testing varied. Those enthusiastic about testing saw the possibilities it could offer. However, many felt nutrigenomic testing was not the only ‘tool’ to utilize when offering health care.DiscussionThis research highlights the important role HPs play in consumers’ experiences of nutrigenomics. The varied practice suggests relevant HPs require upskilling in this area to at least support their patients/clients, even if nutrigenomic testing is not part of their practice.Patient or public contributionAdvisory group included patient/public group representatives who informed study design; focus group participants gave feedback on the survey from which consumer interviewees were sourced. This informed the HP data set design. Interviewees from HP data set assisted with snowball sampling.     

Stereoselectivity for interactions of agonists and antagonists at mouse, rat and human beta3-adrenoceptors

This study examines the stereoselectivity profile of recombinant mouse, rat and human beta(3)-adrenoceptors expressed in Chinese Hamster Ovary (CHO-K1) cells using radioligand binding, in comparison with endogenously expressed beta(3)-adrenoceptors mediating relaxation responses in mouse ileum. The enantiomeric ratios for several beta-adrenoceptor agonists and antagonists at the cloned mouse, rat and human beta(3)-adrenoceptor were less than those reported at the cloned beta(1)-/beta(2)-adrenoceptor but higher than those reported in previous studies. The degree of stereoselectivity was relatively low for the agonists isoprenaline and noradrenaline but higher for antagonists and, in particular, tertatolol and propranolol. In mouse ileum, stereoselectivity of propranolol and tertatolol was observed under beta(1)-/beta(2)-adrenoceptor blockade. The (-)-enantiomers of propranolol and tertatolol were more effective at antagonism of (-)-isoprenaline-mediated relaxation of mouse ileum than their (+)-enantiomers. The recombinant mouse, rat and human beta(3)-adrenoceptors display stereoselective interactions for agonists and antagonists similar to the stereoselective profile of beta(3)-adrenoceptors in mouse ileum. The degree of stereoselectivity varied between species and the human beta(3)-adrenoceptor displayed higher affinities and enantiomeric ratios than the mouse or rat beta(3)-adrenoceptors.     

Free mycophenolic acid should be monitored in renal transplant recipients with hypoalbuminemia

The current approach for therapeutic drug monitoring in renal transplant recipients receiving mycophenolate mofetil (MMF) is measurement of total mycophenolic acid (MPA) concentration. Because MPA is highly bound, during hypoalbuminemia the total concentration no longer reflects the free (pharmacologically active) concentration. The authors investigated what degree of hypoalbuminemia causes a significant change in protein binding and thus percentage free MPA. Forty-two renal transplant recipients were recruited for the study. Free and total concentrations of MPA (predose, and 1, 3, and 6 hours post-MMF dose samples) and plasma albumin concentrations were determined on day 5 posttransplantation. Six-hour area under the concentration-time curve (AUC(0-6)) values were calculated for free and total MPA, and percentage free MPA was determined for each patient. The authors found a significant relationship between low albumin concentrations and increased percentage free MPA (Spearman correlation = -0.54, P < 0.0001). Receiver operating characteristic (ROC) curve analysis was performed on the albumin versus percentage free MPA data. The cutoff value of albumin determined from the ROC analysis that differentiated normal from elevated percentage free MPA (defined as > or = 3%) in this patient population was 31 g/L. At this cutoff value albumin was found to be a good predictor of altered free MPA percentage, with a sensitivity and specificity of 0.75 and 0.80, respectively, and an area under the ROC curve of 0.79. To rationalize MMF dosing regimens in hypoalbuminemic patients (plasma albumin < or = 31 g/L), clinicians should consider monitoring the free MPA concentration.