Showing papers in "Journal of the American Board of Family Medicine in 2009"

Overtreating Chronic Back Pain: Time to Back Off?

Abstract: Chronic back pain is among the most common patient complaints. Its prevalence and impact have spawned a rapidly expanding range of tests and treatments. Some of these have become widely used for indications that are not well validated, leading to uncertainty about efficacy and safety, increasing complication rates, and marketing abuses. Recent studies document a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates. The limited studies available suggest that these increases have not been accompanied by population-level improvements in patient outcomes or disability rates. We suggest a need for a better understanding of the basic science of pain mechanisms, more rigorous and independent trials of many treatments, a stronger regulatory stance toward approval and post-marketing surveillance of new drugs and devices for chronic pain, and a chronic disease model for managing chronic back pain.

Vitamin D: An Evidence-Based Review

Abstract: Vitamin D is a fat-soluble vitamin that plays an important role in bone metabolism and seems to have some anti-inflammatory and immune-modulating properties In addition, recent epidemiologic studies have observed relationships between low vitamin D levels and multiple disease states Low vitamin D levels are associated with increased overall and cardiovascular mortality, cancer incidence and mortality, and autoimmune diseases such as multiple sclerosis Although it is well known that the combination of vitamin D and calcium is necessary to maintain bone density as people age, vitamin D may also be an independent risk factor for falls among the elderly New recommendations from the American Academy of Pediatrics [corrected] address the need for supplementation in breastfed newborns and many questions are raised regarding the role of maternal supplementation during lactation Unfortunately, little evidence guides clinicians on when to screen for vitamin D deficiency or effective treatment options

Effectiveness of Cinnamon for Lowering Hemoglobin A1C in Patients with Type 2 Diabetes: A Randomized, Controlled Trial

Abstract: Purpose: Multiple trials in the past have shown conflicting results of whether cinnamon lowers glucose or hemoglobin A1C (HbA1C). The purpose of this study was to determine whether cinnamon lowers HbA1C in patients with type 2 diabetes. I performed a randomized, controlled trial to evaluate whether daily cinnamon plus usual care versus usual care alone lowers HbA1c. Methods: I randomized 109 type 2 diabetics (HbA1C >7.0) from 3 primary care clinics caring for pediatric, adult, and geriatric patients at a United States military base. Participants were randomly allocated to either usual care with management changes by their primary care physician or usual care with management changes plus cinnamon capsules, 1g daily for 90 days. HbA1c was drawn at baseline and 90 days and compared with intention-to-treat analysis. This study was approved by an institutional review board. Results: Cinnamon lowered HbA1C 0.83% (95% CI, 0.46–1.20) compared with usual care alone lowering HbA1C 0.37% (95% CI, 0.15–0.59). Conclusions: Taking cinnamon could be useful for lowering serum HbA1C in type 2 diabetics with HbA1C >7.0 in addition to usual care.

The Prevalence of Vitamin B12 Deficiency in Patients with Type 2 Diabetes: A Cross-Sectional Study

Abstract: Purpose: The purpose of this study is to define the prevalence of vitamin B 12 deficiency in a type 2 diabetic population within a primary care practice. Metformin use and advanced age are associated with vitamin B 12 deficiency and often present in type 2 diabetic patients, yet the prevalence of vitamin B 12 deficiency in the diabetic population is unknown. Methods: We conducted a cross-sectional study of 203 outpatient type 2 diabetic patients at a large military primary care clinic. Patients completed a survey and had B 12 levels measured. Patients with borderline B 12 levels also had methylmalonic acid and homocysteine levels drawn. Serum B 12 levels 243 nmol/L or homocysteine >11.9 nmol/L defined B 12 deficiency. Descriptive statistics described frequency and means. 2 and student’s t tests were used to analyze associations between categorical and continuous variables, respectively. Multivariate logistical regression identified covariates independently associated with B 12 deficiency. Results: Twenty-two percent (n 44) of diabetic patients had metabolically confirmed B 12 deficiency. Patients on metformin had lower serum B 12 levels (425.99 pg/mL vs 527.49 pg/mL; P .012) and were at increased risk for B 12 deficiency (P .04), as defined by a serum B 12 level <350 pg/mL. Prevalence of B 12 deficiency was significantly lower for patients using a multivitamin (odds ratio, 0.31; 95% CI, 0.15‐0.63). Conclusions: Our results found a 22% prevalence of metabolically confirmed B 12 deficiency in the primary care type 2 diabetic population. Although further research needs to be performed to determine the clinical implications of our findings, B 12 deficiency should be considered in type 2 diabetic patients, especially those taking metformin. Furthermore, a daily multivitamin may protect against B 12 deficiency. (J Am Board Fam Med 2009;22:528‐534.)

Building a Pan-Canadian Primary Care Sentinel Surveillance Network: Initial Development and Moving Forward

Abstract: The development of a pan-Canadian network of primary care research networks for studying issues in primary care has been the vision of Canadian primary care researchers for many years. With the opportunity for funding from the Public Health Agency of Canada and the support of the College of Family Physicians of Canada, we have planned and developed a project to assess the feasibility of a network of networks of family medicine practices that exclusively use electronic medical records. The Canadian Primary Care Sentinel Surveillance Network will collect longitudinal data from practices across Canada to assess the primary care epidemiology and management of 5 chronic diseases: hypertension, diabetes, depression, chronic obstructive lung disease, and osteoarthritis. This article reports on the 7-month first phase of the feasibility project of 7 regional networks in Canada to develop a business plan, including governance, mission, and vision; develop memorandum of agreements with the regional networks and their respective universities; develop and obtain approval of research ethics board applications; develop methods for data extraction, a Canadian Primary Care Sentinel Surveillance Network database, and initial assessment of the types of data that can be extracted; and recruitment of 10 practices at each network that use electronic medical records. The project will continue in phase 2 of the feasibility testing until April 2010.

How Reliable is Pain as the Fifth Vital Sign

Abstract: Background: Although many health care organizations require routine pain screening (eg, “5th vital sign”) with the 0 to 10 numeric rating scale (NRS), its accuracy has been questioned; here we evaluated its accuracy and potential causes for error. Methods: We randomly surveyed veterans and reviewed their charts after outpatient encounters at 2 hospitals and 6 affiliated community sites. Using correlation and receiver operating characteristic analysis, we compared the routinely measured “5th vital sign” (nurse-recorded NRS) with a research-administered NRS (research-recorded NRS) and the Brief Pain Inventory (BPI). Results: During 528 encounters, nurse-recorded NRS and research-recorded NRS correlated moderately (r = 0.627), as did nurse-recorded NRS and BPI severity scales (r = 0.613 for pain during the last 24 hours and r = 0.588 for pain during the past week). Correlation with BPI interference was lower (r = 0.409). However, the research-recorded NRS correlated substantially with the BPI severity during the past 24 hours (r = 0.870) and BPI severity during the last week (r = 0.840). Receiver operating characteristic analysis showed similar results. Of the 98% of cases where a numeric score was recorded, 51% of patients reported their pain was rated qualitatively, rather than with a 0 to 10 scale, a practice associated with pain underestimation (χ2 = 64.04, P Conclusion: Though moderately accurate, the outpatient “5th vital sign” is less accurate than under ideal circumstances. Personalizing assessment is a common clinical practice but may affect the performance of research tools such as the NRS adopted for routine use.

An Assessment of Attitudes, Behaviors, and Outcomes of Patients with Type 2 Diabetes

Abstract: Objectives: Patient self-care behaviors, including taking medication, following a meal plan, exercising regularly, and testing blood glucose, influence diabetes control. The purpose of this research was to identify (1) which barriers to diabetes management are associated with problem behaviors and (2) which patient behaviors and barriers are associated with diabetes control. Methods: This was a cross-sectional study of linked medical record and self-reported information from patients with type 2 diabetes. A randomly selected sample of 800 clinic patients was mailed an investigator-developed survey. The study sample consisted of 253 (55%) individuals who had measured glycosylated hemoglobin (HbA1c) within 3 months of the survey date. Results: The barriers to each diabetes self-care behavior differed. Cost was the most common barrier to the 4 self-care behaviors. In a multivariable regression model, the belief that type 2 diabetes is a serious problem and depression were strongly associated with higher HbA1c levels. Lower HbA1c levels were significantly associated with being married and greater self-reported adherence-satisfaction with taking medication and testing blood glucose. Conclusion: This study expanded earlier research by focusing on 4 specific self-care behaviors, their barriers, and their association with HbA1c. Barriers that were significantly associated with HbA1c were specific to the behavior and varied across behaviors.

Effectiveness of Vitamin B12 in Treating Recurrent Aphthous Stomatitis: A Randomized, Double-Blind, Placebo-Controlled Trial

Abstract: Background: The frequency of recurrent aphthous stomatitis (RAS), the most common oral mucosa lesions seen in primary care, is up to 25% in the general population. However, there has been no optimal therapeutic approach. Our objective was to confirm our previous clinical observation of the beneficial treatment of RAS with vitamin B12. Methods: A randomized, double-blind, placebo-controlled trial was done using primary care patients. A sublingual a dose of 1000 mcg of vitamin B12 was used in patients in the intervention group for 6 months. Results: In total, 58 patients suffering from RAS participated in the study: 31 were included in the intervention group and 27 were included in control group. All parameters of RAS among patients in the intervention group were recorded and compared with the control group. The duration of outbreaks, the number of ulcers, and the level of pain were reduced significantly (P Conclusion: Vitamin B12 treatment, which is simple, inexpensive, and low-risk, seems to be effective for patients suffering from RAS, regardless of the serum vitamin B12 level.

Concordance of Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9) to Assess Increased Risk of Depression among Postpartum Women

Abstract: Objectives: To compare the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9) as screening tools for postpartum depression. Methods: This study population included the first 500 women to enroll and return their packets during an ongoing study of postpartum depression. Results: The primary outcome of this study was to find rates of concordance and discordance in the EPDS and PHQ-9 categories of “normal” and “increased risk for major depressive disorder.” Overall, 97% of eligible women enrolled and 70% returned the packets that included the EPDS and PHQ-9. Four hundred eighty-one of the first 500 packets had complete data, with elevated EPDS or PHQ-9 scores in 138 and 132 women, respectively. Concordance of the EPDS and PHQ-9 were present in 399 women (83%): 326 (67.8%) had “normal” score on both, and 73 (15.2%) had elevated scores for both. Discordant scores in 82 women included 17 with elevated PHQ-9 scores but normal EPDS scores and 65 with elevated EPDS scores and PHQ-9 scores 30 and low education level were predictive of discordant scores, using EPDS and PHQ-9 scores of ≥10 as elevated (odds ratio, 1.9 and P = .02; and odds ratio, 2.3 and P = .01, respectively). PHQ-9 scores of 5 to 9 have been referred to as consistent with “mild depressive symptoms” and appropriate for “watchful waiting” and repeat PHQ-9 at follow-up. Using this follow-up approach would require re-evaluation of 120 (25%) of the women screened. Conclusions: Postpartum depression screening is feasible in primary care practices, and for most women the EPDS and PHQ-9 scores were concordant. Further work is required to identify reasons for the 17% discordant scores as well as to provide definitive recommendations for PHQ-9 scores of 5 to 9.

Secondary Hyperparathyroidism: Pathophysiology and Treatment

Abstract: Secondary hyperparathyroidism is a frequently encountered problem in the management of patients with chronic kidney disease (CKD). Its pathophysiology is mainly due to hyperphosphatemia and vitamin D deficiency and resistance. This condition has a high impact on the mortality and morbidity of dialysis patients. Early diagnosis of secondary hyperparathyroidism is crucial in the management of patients with CKD. The treatment remains a challenge for patients and their clinicians. It should include a combination of dietary phosphorus restriction, phosphate binders, vitamin D analogues, and calcimimetics.

The use of electronic health records in the exam room and patient satisfaction: a systematic review

Abstract: Background: Physicians may hesitate to implement electronic health record (EHR) systems because they fear a decrease in patient satisfaction We conducted a systematic review to determine whether physician EHR use in the patient room affects patient satisfaction Methods: We searched the literature using MEDLINE (Ovid), EMBASE, CINAHL, Cochrane Library, PsycINFO, Proceedings First, and ProQuest Digital Dissertations Our inclusion criteria were a description of physician EHR use in the examination room, EHR use in an outpatient setting, setting in the United States, publication year no earlier than 2000, and measurement of patient satisfaction We included both qualitative and quantitative research We included 7 articles in the final analysis: 3 crosssectional, and 4 pre-design and post-design Results: Several studies had methodological concerns Six studies found that physician EHR use had either a positive or neutral effect on patient satisfaction One study found a negative effect on the physicians’ perception of patient satisfaction The reported statistical results from these studies were not homogenous enough for meta-analysis Conclusion: Studies examining physician EHR use have found mostly neutral or positive effects on patient satisfaction, but primary care researchers need to conduct further research for a more definitive answer (J Am Board Fam Med 2009;22:553‐562) Electronic health record (EHR) systems are becoming a major component of the twenty-first century health care delivery system, and their adoption by physicians is rising 1 Many practitioners hope that electronic medical records will provide more efficient care and reduce medical errors 2 Computer

Fertility Awareness-Based Methods: Another Option for Family Planning

Abstract: Modern fertility awareness-based methods (FABMs) of family planning have been offered as alternative methods of family planning. Billings Ovulation Method, the Creighton Model, and the Symptothermal Method are the more widely used FABMs and can be more narrowly defined as natural family planning. The first 2 methods are based on the examination of cervical secretions to assess fertility. The Symptothermal Method combines characteristics of cervical secretions, basal body temperature, and historical cycle data to determine fertility. FABMs also include the more recently developed Standard Days Method and TwoDays Method. All are distinct from the more traditional rhythm and basal body temperature methods alone. Although these older methods are not highly effective, modern FABMs have typical-use unintended pregnancy rates of 1% to 3% in both industrialized and nonindustrialized nations. Studies suggest that in the United States physician knowledge of FABMs is frequently incomplete. We review the available evidence about the effectiveness for preventing unintended pregnancy, prognostic social demographics of users of the methods, and social outcomes related to FABMs, all of which suggest that family physicians can offer modern FABMs as effective means of family planning. We also provide suggestions about useful educational and instructional resources for family physicians and their patients.

Sleep-Disordered Breathing During Pregnancy

Abstract: Pregnancy is associated with many physiologic and hormonal changes along with changes in sleep architecture, placing pregnant women at risk for the development of sleep-disordered breathing or worsening of preexisting sleep apnea. Snoring, the most common symptom of sleep-disordered breathing, is markedly increased during pregnancy. The exact prevalence of obstructive sleep apnea in pregnant women is unknown. Because the apneic episodes are commonly associated with oxyhemoglobin desaturations, the combination of obstructive sleep apnea and pregnancy can be potentially harmful to the fetus given the low oxygen reserves during pregnancy. Obstructive sleep apnea has been associated with an increased risk of hypertension among the general population, and this raises the possibility of its association with gestational hypertension and preeclampsia. In this clinical review, we discuss the physiologic changes of pregnancy that predispose pregnant women to the development of obstructive sleep apnea and the effects of sleep-disordered breathing on pregnancy outcomes. We also review the recommendations regarding evaluation for sleep apnea and treatment options during pregnancy and postpartum.

Variables associated with human papillomavirus (HPV) vaccine acceptance by men.

Abstract: Results: Positive correlates of HPV vaccine acceptance included higher education (P < .0001); hispanic ethnicity (P .0003); wearing a seat belt most of the time (P .02); regular tobacco use (P <.001); not being sexually active (P .0008); history of more than 10 female sexual partners (P .0004); not having oral sex (P .045); extreme worry about vaccine side effects (P < .0001); extreme concern about vaccine safety (P < .0001); the importance of getting vaccines (P < .0001); familiarity with HPV (P < .0001); and extreme importance of receiving the HPV vaccine (P < .0001). Conclusions: Men with greater general education, high-risk behaviors, and knowledge about HPV are more likely to want the HPV vaccine. Focused educational efforts should facilitate even wider acceptance of the HPV vaccine by men. (J Am Board Fam Med 2009;22:34–42.)

The Association of Vitamin D Deficiency and Insufficiency with Diabetic Nephropathy: Implications for Health Disparities

Abstract: Objective: To evaluate the association between vitamin D deficiency and insufficiency with diabetic nephropathy across racial/ethnic groups. Methods: Cross-sectional analysis of the 2001 to 2006 National Health and Nutrition Examination Survey. A nationally representative sample of 1216 adults (≥20 years old) with diagnosed diabetes provides population estimates for >12.6 million individuals. Nephropathy was defined as urinary albumin-to-creatinine ratio ≥30 mg/g in a random spot urine sample. Serum 25-hydroxycalciferol vitamin D levels were characterized as Results: Overall, 30.7% of adults with diabetes have nephropathy, 48.9% have vitamin D deficiency and 36.6% have vitamin D insufficiency. Minorities are more likely to have nephropathy (non-Hispanic whites, 27.8%; non-Hispanic blacks, 36.2%; Hispanics 38.5%; P = .02) and vitamin D deficiency (non-Hispanic whites, 39.5%; non-Hispanic blacks, 80.4%; Hispanic, 59.0%; P Conclusions: There is a high prevalence of vitamin D deficiency and insufficiency in individuals with diabetes; minorities have the highest prevalences. Thus, evaluating vitamin D levels in people with diabetes may be warranted. There is an independent association between vitamin D deficiency and vitamin D insufficiency with the presence of nephropathy, even after adjustment for race/ethnicity and other variables. Further studies of this relationship may lead to new interventions that decrease health disparities in the progression of diabetic nephropathy.

Health care for patients with serious mental illness: family medicine's role.

Abstract: Numerous studies document disproportionate physical morbidity and premature death among people with serious mental illness. Although suicide remains an important cause of mortality for this population, cardiovascular disease is the leading cause of death. Cardiovascular death among those with serious mental illness is 2 to 3 times that of the general population. This vulnerability is commonly attributed to underlying mental illness and behavior. Some excess disease and deaths result from poor access to and use of quality health care. Negative cardiometabolic effects of newer psychotropic medications augment these trends by increasing rates of obesity, diabetes, and hyperlipidemia among those treated. Researchers have developed innovative care models aimed at minimizing the disparate health outcomes of patients with serious mental illness. Most strive to enhance access to primary care, but publications on this topic appear almost exclusively in the psychiatric literature. A focus on primary care for the prevention of excess cardiometabolic morbidity and mortality in this population is appropriate, but depends on primary care physicians' understanding of the problem, involvement in the solutions, and collaboration with psychiatrists. We review health outcomes of the seriously mentally ill and models designed to improve these outcomes. We propose specific strategies for Family Medicine clinicians and researchers to address this problem.

Barriers, Enablers, and Incentives for Research Participation: A Report from the Ambulatory Care Research Network (ACRN)

Abstract: Background: Supported by a supplement to our Clinical and Translational Science Award, we studied the feasibility of implementing clinical research in Northern Manhattan community practices that primarily serve Hispanic patients. Methods: We applied a mixed-methods approach (surveys, focus groups, interviews) based on the PRECEDE-PROCEED model to determine the level of interest in clinical research among community clinicians (both practice-based research network [PBRN] members and non-PBRN members), the perceived barriers that hamper participation in clinical research, and the perceived facilitators for conducting research in such practices. Results: Survey and qualitative data indicated strong interest in clinical research among current and potential PBRN members if it was relevant to improving quality of care in their practice or community. They also identified important perceived barriers (lack of time, inadequate training in research methods, lack of collaborators and support staff, institutional review board hurdles, and community distrust of research) and the necessary requirements for overcoming barriers to conducting research in busy clinical settings, which included collaborators, mentors, research support staff, and a trusting patient-clinician relationship. Conclusion: It is feasible to conduct clinical research studies in urban community medical practices if the topics are relevant to the community and appropriate enabling structures and processes are put into place.

Practice-based Research is Community Engagement

Abstract: Community engagement has become a major contributor to medical research during the past 10 years and is an essential component of the current National Institutes of Health (NIH) Roadmap and the Clinical and Translational Science Awards program.[1][1][,2][2] But, what is a community? And what

Virtual Reality Skills Training for Health Care Professionals in Alcohol Screening and Brief Intervention

Abstract: Background: Educating physicians and other health care professionals about the identification and treatment of patients who drink more than recommended limits is an ongoing challenge. Methods: An educational randomized controlled trial was conducted to test the ability of a stand-alone training simulation to improve the clinical skills of health care professionals in alcohol screening and intervention. The “virtual reality simulation” combined video, voice recognition, and nonbranching logic to create an interactive environment that allowed trainees to encounter complex social cues and realistic interpersonal exchanges. The simulation included 707 questions and statements and 1207 simulated patient responses. Results: A sample of 102 health care professionals (10 physicians; 30 physician assistants or nurse practitioners; 36 medical students; 26 pharmacy, physican assistant, or nurse practitioner students) were randomly assigned to a no training group (n = 51) or a computer-based virtual reality intervention (n = 51). Professionals in both groups had similar pretest standardized patient alcohol screening skill scores: 53.2 (experimental) vs 54.4 (controls), 52.2 vs 53.7 alcohol brief intervention skills, and 42.9 vs 43.5 alcohol referral skills. After repeated practice with the simulation there were significant increases in the scores of the experimental group at 6 months after randomization compared with the control group for the screening (67.7 vs 58.1; P P Conclusions: The technology tested in this trial is the first virtual reality simulation to demonstrate an increase in the alcohol screening and brief intervention skills of health care professionals.

Documentation and Management of Overweight and Obesity in Primary Care

Abstract: tained via a telephone interview and abstraction of patients’ medical records. BMI (kg/m 2 ) was calculated from measured height and weight. Management of overweight/obesity included advice to lose weight, physical activity recommendations, dietary recommendations, and referral for nutrition counseling. Results: Documentation of weight status was more common with increasing BMI (13% of overweight patients, 39% of mildly obese patients, and 77% of moderately/severely obese patients). Documentation of overweight/obesity was associated with increased behavioral treatment; the biggest increase was seen for advice to lose weight (odds ratios were 7.2 for overweight patients, 3.3 for patients with mild obesity, and 4.0 for patients with moderate/severe obesity). Although weight-related comorbidities were associated with increased overweight/obesity management at all BMIs, the biggest increase in odds was for patients with moderate/severe obesity. Conclusions: Documentation of weight management was more common among patients with documented overweight/obesity and with weight-related comorbidities. These insights may help in designing new interventions in primary care settings for overweight and obese patients. (J Am Board Fam Med 2009;22:544–552.)

Perceived complexity of care, perceived autonomy, and career satisfaction among primary care physicians.

Abstract: Background: The purpose of this study was to examine relationships of both perceived autonomy and perceived complexity of care with career satisfaction. Methods: This secondary analysis used 3 consecutive surveys of family physicians, internists, and pediatricians from the Community Tracking Survey. Two-way analysis of variance assessed interaction effects of perceived complexity of care and perceived autonomy on satisfaction. Logistic regression analysis identified physician characteristics, practice characteristics, practice improvement strategies, perceived complexity, and perceived autonomy that accounted for variance in career satisfaction among physicians. Results: Although 24% to 27% of physicians felt perceived complexity of care expected was greater than it should be, 83% to 86% felt free to make clinical decisions. Approximately 80% of physicians were satisfied with their careers. Differences in probability of career satisfaction were highly significant (P Conclusion: Higher perceived autonomy and lower perceived patient complexity as higher than desirable were associated with high career satisfaction among primary care physicians.

Lemierre syndrome following oropharyngeal infection: a case series.

Abstract: Lemierre syndrome is a potentially fatal complication of oropharyngeal infections that is characterized by jugular vein thrombosis and septic emboli. Fusobacterium spp. are the causative organisms. Patients typically present with high fevers, neck pain, and pulmonary symptoms. Prompt clinical diagnosis and treatment with appropriate antibiotics are critical. Anticoagulation for this syndrome is controversial. We present 3 cases within a 12-month period of young, family practice patients seen with oropharyngeal infections who developed Lemierre syndrome. The incidence of Lemierre syndrome may be increasing and primary care physicians should be aware of this rare though serious condition.

Early Diagnosis and Treatment of Discoid Lupus Erythematosus

Abstract: Discoid lupus erythematosus is a chronic dermatological disease that can lead to scarring, hair loss, and hyperpigmentation changes in skin if it is not treated early and promptly. It has a prolonged course and can have a considerable effect on quality of life. Early recognition and treatment improves the prognosis. The diagnosis is usually made by clinical examination. In some cases histopathology may be required to confirm the diagnosis. The histology is that of an inflammatory interface dermatosis. There is insufficient evidence for which treatment is most effective. Because lesions are induced or exacerbated by ultraviolet exposure, photoprotective measures are important. Potent topical steroids and antimalarials are the mainstay of treatment. Some cases of discoid lupus erythematosus can be refractory to standard therapy; in these cases retinoids, thalidomide, and topical tacrolimus offer alternatives, as do immunosuppressives like azathioprine, cyclosporine, mycophenolate mofetil, and methotrexate.

Hear today, gone tomorrow: an assessment of portable entertainment player use and hearing acuity in a community sample.

Abstract: Background : Noise-induced hearing loss (NIHL) is a common but preventable disability. The purpose of this study was to assess the understanding of NIHL in a community sample in the context of exposure to portable music players, including MP3 players, and personal hearing acuity as tested with the Welch Allyn Audioscope 3. Methods : A cross-sectional convenience sample of 94 adults (18 to 65 years old) at a university recreation center completed an analysis of personal use of portable digital music players (MP3 players), concerns about hearing loss, and a 3-dB-level hearing test at 4 levels of speech frequency in a low ambient noise setting. Results : The majority of participants (85%) were concerned about hearing loss, willing to protect their hearing with lower volume (77%), had little measurable hearing loss but were exposed to longer and louder periods of noise than other national samples, and mistakenly felt that NIHL is a medically reversible condition. Many (40%) also wanted their family medicine physician to be more concerned about their hearing. Conclusions : Family medicine physicians are in a key position to provide basic information on the preventability and negative consequences of NIHL, as well as to identify and refer patients with identified hearing loss.

Brief Intervention for Anxiety in Primary Care Patients

Abstract: To address the difficulty of assessing and managing multiple anxiety disorders in the primary care setting, this article provides a simple, easy-to-learn, unified approach to the diagnosis, care management, and pharmacotherapy of the 4 most common anxiety disorders found in primary care: panic, generalized anxiety disorders, social anxiety disorders, and posttraumatic stress disorder. This evidence-based approach was developed for an ongoing National Institute of Mental Health-funded study designed to improve the delivery of evidence-based medication and psychotherapy treatment to primary care patients with these anxiety disorders. We present a simple, validated method to screen for the 4 major disorders that emphasizes identifying other medical or psychiatric comorbidities that can complicate treatment; an approach for initial education of the patient and discussion about treatment, including provision of some simple cognitive behavioral therapy skills, based on motivational interviewing/brief intervention approaches previously used for substance use disorders; a validated method for monitoring treatment outcome; and an algorithmic approach for the selection of initial medication treatment, the selection of alternative or adjunctive treatments when the initial approach has not produced optimal results, and indications for mental health referral.

What Do Physicians Recommend To Their Overweight and Obese Patients

Abstract: Background: It is recognized that physicians play an important role in responding to the nation9s obesity epidemic. Little is known, however, about what physicians say to their obese patients to help them lose weight. Objective: This cross-sectional survey examined weight loss recommendations of family physicians and internists. Surveys were mailed to 188 physicians and 54% (n = 101) responded. The survey assessed physicians’ weight loss recommendations, the basis for recommendations, and their expected weight loss outcomes for a hypothetical patient. Physicians rated the extent to which they recommended various weight control strategies to their obese patients. They also rated the extent to which clinical experience, personal experience, and the medical literature were important in formulating their recommendations. Results: The most common strategies recommended were increasing physical activity, reducing consumption of fast foods, reducing portion sizes, and reducing soda consumption. Physicians were less likely to recommended regular self-weighing, recording food intake, and decreasing television viewing. Meal replacements and weight loss medications were rarely advised. Physicians reported that they based their weight loss recommendations more on clinical experience than on the medical literature or personal experience; these latter 2 were rated as equally important. Physicians reported that, from their perspective, the equivalent of a 21.5% weight loss would be an “acceptable” outcome for a hypothetical obese patient; a 10.6% weight loss “disappointing.” Conclusions: Physicians, like patients, need to be educated about the benefits of modest weight loss and the weight loss strategies empirically proven to be most effective, including self-monitoring. Further research is needed to understand the barriers to recommending and implementing these effective strategies.

Diffusion of breast cancer risk assessment in primary care.

Abstract: Background: Physicians who provide primary care to women have the opportunity to identify patients at high risk for breast cancer who are candidates for risk reduction strategies. Our objective was to determine the prevalence and determinants of the adoption of breast cancer risk assessment by primary care physicians. Methods: A cross-sectional survey of a nationally representative random sample of 351 internists, family practitioners, and obstetricians-gynecologists. We used a questionnaire that assessed knowledge, attitudes, discussion of breast cancer risk, use of software to calculate breast cancer risk, and ordering of BRCA1/2 testing. Results: Eighty-eight percent of physicians reported discussing breast cancer risk at least once during the previous 12 months; 48% had ordered or referred a patient for BRCA1/2 testing; and 18% had used a software program to calculate breast cancer risk. Physicians who had used BRCA1/2 testing or discussed breast cancer risk factors were more likely to be obstetrician-gynecologists and not in a solo practice; the use of risk software was also more common among obstetrician-gynecologists but was also associated with having a family member with breast cancer and a greater knowledge about breast cancer risk. Having patients ask for risk information was associated with the discussion of risk factors but not with the other risk assessment strategies. Conclusions: Diffusion of breast cancer risk assessment is occurring in primary care practices, with a greater adoption of BRCA1/2 testing than of the use of risk assessment software. Adoption of these strategies seems to be related to the salience of breast cancer personally (for the physician) and within the practice, as well as the size of the practice, rather than attitudes about the risk assessment methods. (J Am Board Fam Med 2009;22:272–9.)

Stepped care treatment of postpartum depression: impact on treatment, health, and work outcomes.

Abstract: Purpose: The purpose of this study was to pilot a stepped collaborative care intervention for women with postpartum depression and evaluate health differences between self-diagnosed depressed and nondepressed women. Methods: Five hundred six mothers of infants from 7 clinics completed surveys at 0 to 1, 2, 4, 6, and 9 months postpartum and a Structured Clinical Interview for DSM-IV (SCID). SCID-positive depressed women were randomized to stepped collaborative care or usual care. Nine-month treatment, health, and work outcomes were evaluated for stepped care women (n = 19) versus control depressed women (n = 20), and self-diagnosed depressed women (n = 122) versus nondepressed women (n = 344). Results: Forty-five women had SCID-positive depression whereas 122 had self-diagnosed depression. For SCID-positive depressed women, the stepped care intervention increased mothers’ awareness of their depression diagnosis (100% vs 61%; P = .008) and their receipt of treatment (94% vs 56%; P = .019). Self-diagnosed depressed women (vs nondepressed women) had more depressive symptoms and acute care visits, worse general and mental health, and greater impact of health problems on regular activities. Conclusions: The stepped care intervention improved women9s knowledge of their postpartum depression diagnosis and their receipt of treatment. However, our formal diagnostic procedures missed many women whose depressed mood interfered with their health and function.

Kummel disease: a not-so-rare complication of osteoporotic vertebral compression fractures.

Abstract: Kummel disease is the eponym for avascular necrosis of the vertebral body after a vertebral compression fracture. As our population ages, the prevalence of osteoporosis, its most common fragility fracture (vertebral compression fracture), and Kummel disease will increase. The purpose of this article is to report a prototypical case with complete radiographic and histologic workup and to provide facts regarding Kummel disease that are salient to the primary care provider.