Use of Ultrasound by Internists to Improve Diagnostic Small Joint Aspiration.

BACKGROUND: Primary care internists are often the first to see patients with an initial episode of crystalline arthritis. Timely aspiration of the affected joint for definitive diagnosis and treatment in the office is desirable but can be difficult, especially if the joint is small, surrounded by soft tissue swelling distorting landmarks, and is very painful to move or palpate. METHODS: We compared the likelihood of successful aspiration of the great toe metatarsophalangeal joint by primary care internists for the diagnosis of potential crystalline arthritis by either landmark identification of the joint space or by employing ultrasound to identify the joint space. RESULTS: Aspiration was performed by one of 2 primary care internists using landmarks and palpation to identify the joint space in 27 patients with suspected crystalline arthritis affecting the first metatarsophalangeal joint. A sample adequate for diagnosis by polarized light microscopic crystal analysis was obtained in 14 of the 27 aspirations (52%) when landmarks alone were used to locate the joint space. In an additional 27 patients with suspected crystalline arthritis affecting the first metatarsophalangeal joint, ultrasound was used to identify the joint space and resulted in a significant increase in the success of obtaining an adequate diagnostic sample, which was obtained in 25 of the 27 aspirations (93%). CONCLUSIONS: The primary care internist can easily provide quality and timely small joint diagnostic aspiration when ultrasound is used to identify the location of the joint space.

Primary Care Management of Skin Abscesses Guided by Ultrasound.

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.

Changes in body composition in women following treatment of overt and subclinical hyperthyroidism.

OBJECTIVE: To determine changes in weight, body composition, and bone density after treatment of overt hyperthyroidism (OH) and subclinical hyperthyroidism (SCH) in women. METHODS: Women with OH and SCH referred to the Mayo Clinic Thyroid Clinic were recruited. Hyperthyroid patients and euthyroid control women were matched for age (within decade) and body mass index. Patients with OH and SCH were treated to normalize thyroid function test results and were restudied after 6 months of normal thyroid function. Baseline and posttreatment studies included measurement of height, weight, bone density, lean mass, fat mass, and thigh muscle cross-sectional area. All participants had normal thyroid function test results for at least 6 months before completion of the posttreatment studies. RESULTS: Twenty-four patients with OH, 21 patients with SCH, and 36 control patients were studied. In the OH group, fat-free mass increased from a mean of 36.8 kg (95% confidence interval [CI], 34.8-38.8) to 40.4 kg (95% CI, 38.5-42.3); in the SCH group, fat-free mass increased from a mean of 40.3 kg (95% CI, 38.1-42.5) to 42.2 kg (95% CI, 39.7-44.7). In both groups, fat mass increased to approximately the same extent, and both groups experienced significant weight gain with no change in percent body fat. Thigh muscle cross-sectional area increased in both groups -- from 100.6 cm(2) (95% CI, 92.7-108.5) to 113.3 cm(2) (95% CI, 105.5-121.1) in the OH group and from 106.1 cm(2) (95% CI, 96.7-115.5) to 112.2 cm(2) (95% CI, 102.0-122.4) in the SCH group. Bone density increased in patients with OH (P<.01) and in patients with SCH (P<.05). CONCLUSIONS: Treatment of OH and SCH leads to increases in muscle area and bone density. Weight gain reflects increases in both fat and fat-free mass. While these results provide some support for actively treating SCH in women, further prospective studies are needed to determine whether the changes documented translate into real patient benefit.

Dehydroepiandrosterone replacement therapy in hypoadrenal women: protein anabolism and skeletal muscle function.

OBJECTIVE: To determine whether dehydroepiandrosterone (DHEA) replacement therapy in hypoadrenal women improves performance, muscle protein accretion, and mitochondrial functions. PARTICIPANTS AND METHODS: Thirty-three hypoadrenal women were enrolled in the study from May 1, 2002, through May 31, 2003. Twenty-eight completed a 12-week, prospective, randomized, placebo-controlled, crossover study with either daily placebo or 50 mg of DHEA with a 2-week washout period and then crossed over to the other treatment. Body composition, physical performance, whole-body and muscle protein metabolism, and mitochondrial functions were determined. RESULTS: Administration of DHEA significantly increased plasma levels of DHEA sulfate, testosterone, and androstenedione but did not change body composition, muscle strength, peak aerobic capacity, and whole-body protein turnover or synthesis rates of mitochondrial, sarcoplasmic, or mixed muscle proteins. Muscle mitochondrial oxidative enzymes and messenger RNA (mRNA) levels of genes encoding mitochondrial proteins and nuclear transcription factors did not change after DHEA administration. However, mRNA levels of muscle myosin heavy chain 1 (P=.004), which determines muscle fiber type, and those of insulinlike growth factor binding proteins 4 and 5 significantly decreased (P=.02 and P=.03, respectively). CONCLUSION: Three months of DHEA administration increased DHEA sulfate and androgen levels but had no effect on physical performance, body composition, protein metabolism, or muscle mitochondrial biogenesis in hypoadrenal women. However, lowering of mRNA levels of binding proteins of insulinlike growth factor 1 and myosin heavy chain 1 suggests potential effects of longterm treatment with DHEA on muscle fiber type.