Validity of self-reported colorectal cancer test use in different racial/ethnic groups.

OBJECTIVE: Prevalence of colorectal cancer (CRC) screening is ascertained by self-reported screening, yet little is known about the accuracy of this method across different racial/ethnic groups, particularly Hispanics. The purpose of this study was to compare the accuracy of CRC self-report measures across three racial/ethnic groups. METHODS: During 2004 and 2005, 271 white, African-American and Hispanic participants were recruited from a primary care clinic in Southeast Texas, and their CRC testing history based on self-report and medical record (the 'gold standard') were compared. RESULTS: Over-reporting was prevalent. Overall, up-to-date CRC test use was 57.6% by self-report and 43.9% by medical record. Racial/ethnic group differences were most pronounced for Hispanics in whom sensitivity was significantly lower for any up-to-date testing, fecal occult blood testing, flexible sigmoidoscopy and double contrast barium enema. There were no statistically significant differences across groups for over-reporting, specificity or concordance. CONCLUSIONS: Self-report prevalence data are overestimating CRC test use in all groups; current measures are less sensitive in Hispanics.

Informed decision making changes test preferences for colorectal cancer screening in a diverse population.

PURPOSE: We wanted to better understand patient preferences and decision making about options for colorectal cancer screening. Consistency in patient preferences could improve patient-clinician communication about tests by simplifying and focusing discussions. METHODS: In a cross-sectional sample of primary care patients, cognitive ranking tasks were used to estimate patient preferences for fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and double-contrast barium enema before and after consideration of 13 test attributes, such as accuracy and scientific evidence. Patients also ranked the 13 test attributes and attribute descriptions in terms of importance. Friedman's nonparametric test was used to measure overall discrimination among items, and the average Pearson correlation coefficient (r) among participants was used to measure the degree of consistency in choices. RESULTS: Participants (n = 168) averaged 62.1 years of age, and 64.3% were of minority racial ethnicity. For test-specific attributes, preferences were for high test accuracy (r = 0.63, P < .001), amount of colon examined (r = 0.64, P < .001), strong scientific evidence for efficacy (r = 0.59, P < .001), minimum discomfort (r = 0.50, P < .001), and low risk of complications (r = 0.38, P < .001). When all 13 attributes were considered together, agreement dropped (r = 0.13, P < .001), but attributes considered most important for decision making were test accuracy, scientific evidence for efficacy, amount of colon examined, and need for sedation. Test preferences showed moderate agreement (r = 0.20, P < .001), and choices were fairly consistent before and after exposure to test-specific attributes (kappa = 0.17, P = .007). Initially the modal choice was fecal occult blood testing (59%); however, after exposure to test specific attributes, the modal choice was colonoscopy (54%). CONCLUSION: Participants were clear about the attributes that they prefer, but no single test has those attributes. Preferences were varied across participants and were not predictable; clinicians should discuss the full range of recommended tests for colorectal cancer with all patients.

Factors associated with racial/ethnic differences in colorectal cancer screening.

INTRODUCTION: Racial/ethnic differences in colorectal cancer (CRC) screening rates are thought to account, in part, for the racial/ethnic differences in CRC disease burden. The purpose of this study was to examine which factors mediate racial/ethnic differences in CRC screening. METHODS: Five hundred sixty participants attending a primary care clinic, aged 50 to 80 years, and of African-American, Hispanic, or non-Hispanic white race/ethnicity were interviewed. The goal was to assess the contribution of sociodemographic characteristics, knowledge, beliefs about CRC, and the health care experience with their primary care doctor to racial/ethnic differences in CRC screening. The outcome variable was self-reported screening. All analyses were weighted; bivariate testing and multivariate logistic regression was conducted. RESULTS: The response rate was 55.7%, with no sociodemographic differences noted between respondents and non-respondents. Respondents were African-American (n = 194), Hispanic (n = 162), and non-Hispanic white (n = 204); 64.5% were aged 50 to 64 years; 63.1% were women; 96.9% were insured; and over half reported a total annual income of less than $25,000. Overall 62.5% were current with CRC screening: 67.5% of non-Hispanic whites, 54.3% of African-Americans, and 48.6% of Hispanics (P < .001). A doctor's recommendation (odds ratio, 3.86); awareness of screening (odds ratio, 3.32); older age (odds ratio, 2.88); greater education (odds ratio, 2.02); and perceived susceptibility (odds ratio, 1.74) contributed to racial/ethnic differences in CRC screening. CONCLUSIONS: Interventions to address CRC screening disparities among racial/ethnic groups should focus on the health care setting and patient education about CRC screening; differences in attitudes and beliefs seem to be less important.

Development and internal validation of the male osteoporosis risk estimation score.

PURPOSE: We wanted to develop and validate a clinical prediction rule to identify men at risk for osteoporosis and subsequent hip fracture who might benefit from dual-energy x-ray absorptiometry (DXA). METHODS: We used risk factor data from the National Health and Nutrition Examination Survey III to develop a best fitting multivariable logistic regression model in men aged 50 years and older randomized to either the development (n = 1,497) or validation (n = 1,498) cohorts. The best fitting model was transformed into a simplified scoring algorithm, the Male Osteoporosis Risk Estimation Score (MORES). We validated the MORES, comparing sensitivity, specificity, and area under the receiver operating characteristics (ROC) curve in the 2 cohorts and assessed clinical utility with an analysis of the number needed-to-screen (NNS) to prevent 1 additional hip fracture. RESULTS: The MORES included 3 variables-age, weight, and history of chronic obstructive pulmonary disease-and showed excellent predictive validity in the validation cohort. A score of 6 or greater yielded an overall sensitivity of 0.93 (95% CI, 0.85-0.97), a specificity of 0.59 (95% CI, 0.56-0.62), and an area under the ROC curve of 0.832 (95% CI, 0.807-0.858). The overall NNS to prevent 1 additional hip fracture was 279 in a cohort of men representative of the US population. CONCLUSIONS: Osteoporosis is a major predictor of hip fractures. Experts believe bisphosphonate treatment in men should yield results similar to that in women and reduce hip fracture rates associated with osteoporosis. In men aged 60 years and older, the MORES is a simple approach to identify men at risk for osteoporosis and refer them for confirmatory DXA scans.

Prevalence of colorectal cancer testing and screening in a multiethnic primary care population.

Colorectal cancer (CRC) screening is strongly supported by evidence and widely recommended, but remains underutilized. This study reports the prevalence of CRC diagnostic testing and CRC screening in three racial/ethnic groups attending the same primary care clinic. A cross-sectional survey was conducted to elicit past history of CRC testing, including test type, indication and timing. A comparable number of African American, Hispanic and non-Hispanic white patients aged 50-80 were recruited. 560 surveys were completed: mean age was 63.4 years, 64% reported minority race/ethnicity, and 96.8% had insurance. Overall, 62.5% [95% CI: 58.5%, 66.5%] of patients were current with any type of CRC test, when diagnostic and screening procedures were included. However, 48.6% [95% CI: 44.5%, 52.7%] of the sample was current with CRC screening, when only procedures performed for screening in asymptomatic patients were included. Patients least likely to be current with testing were those of minority race/ethnicity (48.2% of Hispanics, 56.7% of African Americans and 67.5% of non Hispanic whites, p < 0.05), younger age, (57.6% of those aged 50-64, and 71.4% of those aged 65-80, p < 0.005), and those with private insurance alone (56.0% private, 67.7% public and 68.1% mixed, p < 0.05). Our findings indicate that racial/ethnic and age related disparities in CRC screening exist even in a patient population that has the same source of health care and no differences in insurance status. These results underline the need for providers to emphasize CRC screening in their practices to minority patients and those younger than 65 years of age.

Physician and patient influences on the rate of colorectal cancer screening in a primary care clinic.

BACKGROUND: Colorectal cancer (CRC) screening rates remain low, despite widespread recommendations. The study purpose was to ascertain whether lack of CRC screening is attributable to physicians' failure to address CRC screening or to patients' failure to comply with physician recommendation. This relationship was also examined over time. METHODS: Retrospective chart review of 400 preventive health visits. RESULTS: Physicians appropriately addressed screening 16.5% of the time during 1998-1999 and 51% of the time during 2002-2003 (P

Osteoporosis risk assessment and ethnicity: validation and comparison of 2 clinical risk stratification instruments.

BACKGROUND: Dual energy x-ray absorptiometry (DXA), coupled with early treatment, may reduce morbidity and mortality associated with osteoporosis. Clinical tools to enhance selection of women for DXA screening have not been developed or validated in an ethnically diverse population. OBJECTIVE: To compare the performance of the osteoporosis risk assessment instrument (ORAI) and the simple calculated osteoporosis risk estimation (SCORE) instrument across 3 racial/ethnic groups to identify women who would benefit from DXA scans. DESIGN: Blinded comparison of the instruments in a cross-sectional sample. PARTICIPANTS: Two-hundred twenty-six postmenopausal women were recruited from a university-based family medicine clinic. Women with a prior diagnosis of osteoporosis or those taking bone active medications were excluded. MEASUREMENTS: Participants completed a questionnaire that contained the ORAI and the SCORE questions; 203 completed a DXA scan. RESULTS: The sensitivity and specificity for the ORAI (0.68, [0.49 to 0.88, 95% CI]; 0.66, [0.59 to 0.73, 95% CI]) and the SCORE instrument (0.54, [0.34 to 0.75, 95% CI]; 0.72, [0.65 to 0.78, 95% CI]) differed significantly from previous reports. Overall, the accuracy of the ORAI (66.5%) and SCORE instrument (70.0%) were similar (McNemar's test P value = .37). The accuracy between instruments differed significantly in African-American women (McNemar's test, P value <.001). In African Americans, the SCORE instrument correctly identified more women without osteoporosis, but missed 70% of those with osteoporosis. CONCLUSIONS: The performance of the ORAI and SCORE instrument differed significantly from previous reports. Although both can reduce the use of DXA scans for screening for osteoporosis, lower sensitivities resulted in underrecognition of osteoporosis and may limit their clinical usefulness in an ethnically diverse population.

Screening for bipolar disorder in patients treated for depression in a family medicine clinic.

PURPOSE: The prevalence of bipolar disorder in patients being treated for depression with antidepressants in a family medicine clinic was investigated in this study. METHODS: Adult patients with depression who were treated with an antidepressant in a general outpatient family medicine clinic at the University of Texas were screened for bipolar disorder using the Mood Disorder Questionnaire (MDQ), a brief self-report inventory. A subsample of subjects received the Structured Clinical Interview based on the DSM-IV (SCID) to test the operating characteristics of the MDQ in this population. RESULTS: of the patients taking an antidepressant for depression, 21.3% screened positive for bipolar disorder on the MDQ. These patients were somewhat younger, more likely to be white, more likely to be living alone, much less likely to be married, and less likely to be employed than those who screen negative. Nearly two thirds of those screened positive had never received diagnosis of bipolar disorder. The sensitivity and specificity of the MDQ in this population, after adjusting for the sampling protocol, were 0.580 (0.454 to 0.706, 95% CI) and 0.930 (0.878 to 0.981, 95% CI) respectively. CONCLUSION: Bipolar disorder frequently occurs in patients being treated with antidepressants in primary care settings. Most are unrecognized and undiagnosed. Screening for bipolar disorder in such patients may improve recognition, identification, and appropriate treatment.

Rapid analysis of legume root nodule development using confocal microscopy.

• A rapid method for detailed analysis of nodule formation has been developed. • Inoculated root tissues were stained with SYTO 13, a cell-permeant fluorescent nucleic acid-binding dye, and visualized using confocal laser scanning microscopy (CLSM). Structures with high concentrations of DNA and RNA, such as plant cell nuclei and bacteria, labeled strongly. The autofluorescent properties of cell walls made it possible to use CLSM to visualize both plant and rhizobial structures and generate a three-dimensional reconstruction of the root and invading bacteria. • This method allowed clear observation of stages and structures important in nodule formation, such as rhizobial attachment to root hairs, hair deformation, infection thread ramification, nodule primordium development and nodule cell invasion. Bacteroid structures were easily assessed without the need for fixation that might alter cellular integrity. Plant nodulation mutants with phenotypic differences in thread growth, cellular invasion and plant defense response were also documented. • Multiple samples can be assessed using detailed microscopy without the need for extensive preparative work, labor-intensive analysis, or the generation of genetically modified samples.