Showing papers in "Journal of The American Board of Family Practice in 2005"
TL;DR: The reported results of these studies indicate beneficial changes overall in several IRS-related indices of CVD risk, including glucose tolerance and insulin sensitivity, lipid profiles, anthropometric characteristics, blood pressure, oxidative stress, coagulation profiles, sympathetic activation, and cardiovagal function.
Abstract: Objective: To conduct a systematic review of published literature regarding the effects of yoga, a promising mind-body therapy, on specific anthropometric and physiologic indices of cardiovascular disease (CVD) risk and on related clinical endpoints. Methods: We performed a literature search using 4 computerized English and Indian scientific databases. The search was restricted to original studies (1970 to 2004) evaluating the effects of yoga on CVD or indices of CVD risk associated with the insulin resistance syndrome (IRS). Randomized controlled trials (RCTs), nonrandomized controlled trials, uncontrolled (pre and post) clinical trials, and cross-sectional (observational) studies were included if they met specific criteria. Data were extracted regarding study design, setting, population size and characteristics, intervention type and duration, comparison group or condition, outcome assessment, data analysis and presentation, follow-up, and key results, and the quality of each study was evaluated according to specific predetermined criteria. Results: We identified 70 eligible studies, including 1 observational study, 26 uncontrolled clinical trials, 21 nonrandomized controlled clinical trials, and 22 RCTs. Together, the reported results of these studies indicate beneficial changes overall in several IRS-related indices of CVD risk, including glucose tolerance and insulin sensitivity, lipid profiles, anthropometric characteristics, blood pressure, oxidative stress, coagulation profiles, sympathetic activation, and cardiovagal function, as well as improvement in several clinical endpoints. Conclusions: Collectively, these studies suggest that yoga may reduce many IRS-related risk factors for CVD, may improve clinical outcomes, and may aid in the management of CVD and other IRS-related conditions. However, the methodologic and other limitations characterizing most of these studies preclude drawing firm conclusions. Additional high quality RCTs are needed to confirm and further elucidate the effects of standardized yoga programs on specific indices of CVD risk and related clinical endpoints.
370 citations
TL;DR: To help reduce the number of depressed Hispanic patients who pass through primary care undetected or inadequately treated, family physicians should make a concerted effort to increase their awareness of the presentation of major depression in this population and actively promote adherence to effective treatments.
Abstract: US Hispanics, currently the largest minority group in the country, face disparities in the recognition and treatment of major depression. This article provides an evidence-based review of the prevalence, presentation, and management of major depression in primary care in this heterogeneous ethnic group. Under-recognition of depression in adult Hispanic Americans may be related to language differences, health literacy barriers, somatic presentations, and use of cultural idioms of distress. Hispanic patients are often agreeable to treatment but as a group may tend to prefer psychotherapy or combined counseling and medication to pharmacotherapy alone. Recent studies have found both psychological and pharmacologic treatment options are efficacious in this minority group. Treatment adherence should be actively monitored to help ensure its effectiveness. To help reduce the number of depressed Hispanic patients who pass through primary care undetected or inadequately treated, family physicians should make a concerted effort to increase their awareness of the presentation of major depression in this population and actively promote adherence to effective treatments.
235 citations
TL;DR: Bipolar disorder frequently occurs in patients being treated with antidepressants in primary care settings, and screening for bipolar disorder in such patients may improve recognition, identification, and appropriate treatment.
Abstract: 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.
180 citations
TL;DR: E-mail communication was found to be a more convenient form of communication and has the potential to improve the doctor-patient relationship as a result of better communication.
Abstract: Background: The doctor-patient relationship has been eroded by many factors. Would e-mail enhance communication and address some of the barriers inherent to our medical practices? Methods: Of our study population, 4 physicians offered e-mail communication to participating patients and 4 did not. Both patients and physicians completed questionnaires regarding satisfaction, perceived quality, convenience, and promptness of the communication. Results: Patient satisfaction significantly increased in the e-mail group compared with the control group in the areas of convenience (P Conclusion: E-mail communication was found to be a more convenient form of communication. Satisfaction by both patients and physicians improved in the e-mail group. The volume of messages and the time spent answering messages for the e-mail group physicians was not increased. E-mail has the potential to improve the doctor-patient relationship as a result of better communication.
177 citations
TL;DR: The ATLFF was not a useful tool to identify which tongue-tied infants are at risk for breast-feeding problems, and affected infants are significantly more likely to be exclusively bottle-fed by 1 week of age.
Abstract: Objective: The purposes of this study were: (1) to determine whether breast-fed infants with tongue-tie have decreased rates of breast-feeding at 1 week and 1 month of age, (2) to determine the prevalence of tongue-tie, and (3) to test the usefulness of the Assessment Tool for Lingual Frenulum Function (ATLFF) in assessing the severity of tongue-tie in breast-feeding newborns. Methods: A case-control design was used. All infants in the Regions Hospital newborn nursery were examined for tongue-tie. Tongue-tied babies were examined using the ATLFF. Two breast-feeding babies with normal tongues were identified and matched for each case. Mothers were interviewed when the babies were 1 week and 1 month old. Results: The prevalence of tongue-tie was 4.2%. Forty-nine tongue-tied and 98 control infants were enrolled. Tongue-tied babies were 3 times as likely as control babies to be bottle fed only at 1 week [risk ratio (RR), 3.11; 95% confidence interval (CI), 1.21, 8.03) By 1 month, tongue-tied babies were as likely as controls to be bottle fed only. (RR, 1.00; 95% CI, 0.55, 1.82) Twelve of the tongue-tied infants had ATLFF scores of “Perfect,” none had scores of “Acceptable,” and 6 had scores of “Function Impaired.” The remaining 31 infants had scores that fell into none of these categories. Conclusions: Tongue-tie is a relatively common condition in newborns. Affected infants are significantly more likely to be exclusively bottle-fed by 1 week of age. The ATLFF was not a useful tool to identify which tongue-tied infants are at risk for breast-feeding problems.
143 citations
TL;DR: Recommendations about adequate calcium intake in standard dietary counseling about weight management should be included, as Epidemiologic data suggest that people with high calcium intake have a lower prevalence of overweight, obesity, and insulin resistance syndrome.
Abstract: Obesity is increasing in the United States in epidemic proportions. Epidemiologic data suggest that people with high calcium intake have a lower prevalence of overweight, obesity, and insulin resistance syndrome. Studies in transgenic mice have demonstrated that calcium influences adipocyte metabolism. High calcium intake depresses levels of parathyroid hormone and 1,25-hydroxy vitamin D. These decreased hormone levels cause decreases in intracellular calcium, thereby inhibiting lipogenesis and stimulating lipolysis. High dietary calcium intakes also increases excretion of fecal fat and may increase core body temperature. Calcium from dairy products seems to have more of an impact than calcium from dietary supplements. Primary care providers should include recommendations about adequate calcium intake in standard dietary counseling about weight management.
124 citations
TL;DR: It is argued that improving the disappointing results of translation efforts will require a detailed understanding of how adoption takes place, and strategies that can capitalize on the cognitive processes by which declarative knowledge is proceduralized are suggested.
Abstract: Translation of new knowledge into practice proceeds through 3 stages, from awareness through acceptance to adoption. Translational research focuses almost exclusively on the first 2 stages. We argue that improving the disappointing results of translation efforts will require a detailed understanding of how adoption takes place. We summarize research in cognitive science that illustrates how accepted "declarative" knowledge (acquired through lectures, reading, and discussion) differs (even down to its locus in the brain) from adopted "procedural" knowledge that is acted on in clinical practice. We suggest strategies that can capitalize on the cognitive processes by which declarative knowledge is proceduralized, as a means of making translation more effective, including (1) structured case-level feedback, automated or from human consultants, during the declarative stage; (2) practice in context early in the procedural stage; and (3) deliberative practice when procedural knowledge has been formed but is still being refined.
121 citations
TL;DR: Despite of hearing loss level, persons who are deaf or hard of hearing (D&HH) have altered health care utilization patterns and significant changes in employment patterns are observed.
Abstract: Approximately 9% to 10% of Americans have hearing loss,[1][1] making it the second most common disability in the United States.[2][2] Regardless of hearing loss level, persons who are deaf or hard of hearing (D&HH) have altered health care utilization patterns[3][3][,4][4] and significant
119 citations
TL;DR: Clinical treatment ought to especially target poor sleepers presenting with significant insomnia-related impairment, medical morbidity, or both and future research should further clarify the role of medical and psychiatric comorbidities.
Abstract: Objective: To clarify the patient characteristics associated with seeking medical help for insomnia Methods: A consecutive sample (n = 700) of adults attending a nonurgent primary care appointment was screened for sleep problems A follow-up mailed survey then assessed insomnia symptoms, daytime impairment, beliefs about sleep, medication use, sleepiness and fatigue, and medical help-seeking Results: Fifty-two percent of patients with probable insomnia reported discussing this with a physician Multivariate logistic regression analyses indicated that discussing one’s probable insomnia with a physician was independently associated with having a greater number of medical conditions (OR, 219 [95% CI, 113 to 422]), being more highly educated (167 [95% CI, 111 to 251]), sleeping less per night (OR, 071 [95% CI, 052 to 096]), and greater perceived daytime impairment due to insomnia (OR, 207 [95% CI, 106 to 403]) Conclusions: Primary care patients often seek medical help when they experience insomnia Clinical treatment ought to especially target poor sleepers presenting with significant insomnia-related impairment, medical morbidity, or both Future research should further clarify the role of medical and psychiatric comorbidities and determine whether resolution of insomnia and its consequences improves the outcomes of common medical conditions
102 citations
TL;DR: Most people spent considerable time engaged in self-care, but many skipped individual tasks, offering clinicians opportunities for collaborative decision making.
Abstract: Introduction: Little is reported about how much time patients spend on self-management, a cornerstone of diabetes care. Methods: We studied a cross-section of 1482 diabetic patients enrolled in 3 northeastern United States managed care plans. Patients were surveyed about how much time they spent on foot care, exercise, and food shopping/preparation (7/00 to 9/01). Logistic regressions modeled which types of patients were likely to spend time, and linear regressions modeled characteristics associated with spending more/less time. Results: Patients (57.9% ≥55 years; 51.6% women; 36.2% African American; 31.1% on insulin) spent 58 (mean) minutes/day on self-care (interquartile range 19, 84). Many patients skipped individual self-care elements: 37.9% reported no foot care, 37.7% no exercise, and 54.4% no time on food shopping/preparation. One fourth of patients with severe foot neuropathy symptoms spent no time on foot care. Never self-testers were less likely than others to engage in foot care (odds ratio (OR) 0.4 (95% CI 0.3, 0.6), exercise (OR 0.4 (95% CI 0.3, 0.6)), and food shopping/preparation (OR 0.7 (95% CI 0.5, 1.0)), and were likely to spend 30 minutes less total self-care time than frequent self-testers (P Discussion: Most people spent considerable time engaged in self-care, but many skipped individual tasks, offering clinicians opportunities for collaborative decision making.
102 citations
TL;DR: Adherence to antidepressant medications and to mental health referrals should be examined separately and an initial assessment for nonadherence risk factors may identify persons for targeted adherence promoting interventions.
Abstract: Background: Patient nonadherence is common for the standard mental health treatments in primary care: antidepressants and referrals to specialty mental health treatment. This is one of few studies to prospectively identify predictors of nonadherence. Methods: We observed 95 veterans attending an internal medicine clinic prescribed antidepressant medication or referred to mental health treatment. We collected information on sociodemographic factors, health beliefs, preferences about treatment, past experiences, and treatment knowledge. Results: At 1 month, medication adherence was greater when patients experienced previous pharmacy trouble and traveled for less than 30 minutes to reach the clinic. Appointment attendance improved when patients were ready for treatment, perceived benefits, and saw their physician as collaborative. At 6 months, medication adherence was greater when patients reported a preference for medicine treatment, traveled for less than 30 minutes, and perceived greater benefits. Fewer negative effects from previous mental health treatment improved adherence to appointments. In multivariate analyses examining adherence to all treatments, greater readiness for treatment predicted 1-month adherence, whereas being unmarried and seeing the physician as more collaborative improved 6-month adherence. Conclusions: Adherence to antidepressant medications and to mental health referrals should be examined separately. A brief initial assessment for nonadherence risk factors may identify persons for targeted adherence promoting interventions.
TL;DR: Most respondents reported recommending the appropriate vaccinations during preventive health visits; however, older adolescents were least likely to be targeted for immunization assessment and administration of all recommended vaccines.
Abstract: Background: Although early childhood vaccination rates have increased, many adolescents are not up to date on recommended vaccinations. We assessed attitudes and practices of family physicians and pediatricians regarding adolescent vaccination to identify provider-level barriers that may contribute to low immunization rates. Methods: A 94-item self-report questionnaire was mailed to 400 physicians contracted with a managed care organization. Physicians were queried about demographic characteristics, source of vaccine recommendations, adolescent immunization practices, barriers to immunizing adolescents, and use of reminder/recall systems. Results: Response rate was 59%. Most respondents reported routinely recommending vaccines for tetanus and diphtheria toxoids (98%), Hepatitis B (90%), and measles, mumps, and rubella (84%), whereas 60% routinely recommended varicella vaccine. Physicians reported that they were more likely to assess immunization status, administer indicated immunizations, and schedule return immunization visits to younger adolescents (11 to 13 years old) than to older adolescents (14 to 18 and 19 to 21 years old). Conclusion: Most respondents reported recommending the appropriate vaccinations during preventive health visits; however, older adolescents were least likely to be targeted for immunization assessment and administration of all recommended vaccines.
TL;DR: With the potential health benefits of fish, women of childbearing age should be encouraged to eat 1 to 2 low-mercury fish meals per week and higher doses may be used for its potent triglyceride-lowering effects and for patients with rheumatoid arthritis to reduce nonsteroidal anti-inflammatory use.
Abstract: Background: Fish oil (-3 fatty acids) has been studied for more than 30 years. However, recent concerns of mercury and environmental toxins have clouded fish oil’s potential clinical benefits. This article aims to review practical, evidence-based applications of fish oil for the primary care physician. Methods: PubMed search using key words ‘fish oil,’ ‘docosahexaenoic,’ and ‘eicosapentaenoic’ in title/abstract. Limited to human clinical trials. Articles were further scanned for relevant sources. Results: For secondary prevention of cardiovascular disease ,1go f fi sh oil hasshown to reduce overall and cardiovascular mortality, myocardial infarction, and sudden cardiac death. Higher doses may be used for its potent triglyceride-lowering effects and for patients with rheumatoid arthritis to reduce nonsteroidal anti-inflammatory use. -3 fatty acid supplementation of infant formula has shown benefit in infant neural growth and development. With the potential health benefits of fish, women of childbearing age should be encouraged to eat 1 to 2 low-mercury fish meals per week. Conclusions: Fish oil has numerous practical applications for the primary care physician. Understanding the diverse clinical research of -3 fatty acids and fish oil is important in determining its role in primary care practices. (J Am Board Fam Pract 2005;18:28‐36.)
TL;DR: The role of insulin therapy in patients with type 2 diabetes is discussed, emphasizing long-acting insulin agents designed to approximate physiologic basal insulin secretion and provide control over fasting plasma glucose.
Abstract: Patients with type 2 diabetes mellitus are usually treated initially with oral antidiabetic agents, but as the disease progresses, most patients eventually require insulin to maintain glucose control. Optimal insulin therapy should mimic the normal physiologic secretion of insulin and minimize the risk of hypoglycemia. This article discusses the role of insulin therapy in patients with type 2 diabetes, emphasizing long-acting insulin agents designed to approximate physiologic basal insulin secretion and provide control over fasting plasma glucose. Clinical trials of recently developed long-acting insulins are reviewed herein, with emphasis on studies that combined basal insulin with oral agents or with short-acting insulins in a basal-bolus approach. The normal physiologic pattern of insulin secretion by pancreatic beta cells consists of a sustained basal insulin level throughout the day, superimposed after meals by relatively large bursts of insulin that slowly decay over 2 to 3 hours (bolus insulin). Basal support with long-acting insulin is a key component of basal-bolus therapy for patients with diabetes who require insulin with or without the addition of oral agents. Newer long-acting agents such as insulin glargine provide a steadier and more reliable level of basal insulin coverage and may have significant advantages over traditional long-acting insulins as part of a basal-bolus treatment strategy.
TL;DR: Training in postpartum depression and female sex are the variables most strongly associated with frequent screening, and screening is not universal and use of screening tools designed for PPD is uncommon.
Abstract: Purpose: Despite the availability of screening tools for postpartum depression (PPD), there is a general consensus that the condition is underdiagnosed. This study was conducted to determine how frequently family physicians screen for PPD, what methods they use to screen, and what influences their screening frequency. Methods: A survey of members of the Washington Academy of Family Physicians was conducted. Three hundred sixty-two (60.9%) mailed surveys were returned. The 298 physicians who saw postpartum women and children younger than 1 year of age were included in the study. Results: Of the study population, 70.2% always or often screened for PPD at postpartum gynecologic examinations, and 46% always or often screened mothers at well-child visits. Of those who screened, 30.6% reported using a validated screening tool. Of those, only 18% used a tool specifically designed to screen for PPD. Logistic regression modeling showed that female sex [odds ratio (OR) 2.2], training in PPD during residency (OR 8.1), training in PPD through medical literature (OR 2.1), and agreement that postpartum depression is common enough to warrant screening (OR 1.9) were all significantly associated with more frequent screening at postpartum gynecologic visits. Agreement that screening takes too much effort was associated with less frequent screening (OR 0.8). Conclusions: Although family physicians believe that PPD is serious, identifiable, and treatable; screening is not universal and use of screening tools designed for PPD is uncommon. Training in postpartum depression and female sex are the variables most strongly associated with frequent screening. (J Am Board Fam Pract 2005;18:104‐12.)
TL;DR: Although there was no significant HRV response to stimuli, root mean square of successive differences were negatively correlated with fat mass, fat percentage, and waist-to-hip ratio at rest in obese persons, meaning obesity can change cardiac autonomic nervous response.
Abstract: Background Obese people have a higher prevalence of cardiovascular disease, but the mechanism of this result remains obscure. The purpose of this study was to prove heart rate variability (HRV) response at rest and during stimuli in these persons. Methods The subjects were 41 healthy persons (19 men, 22 women) ranging in age from 20 to 65 years. HRV was measured at rest and at given stresses with noise and standing. Results Higher levels of fat mass, percentage fat content, and waist/hip ratio were significantly associated with lower low frequency (LF) (r = -0.34, r = -0.43; P .05). Conclusion Although there was no significant HRV response to stimuli, root mean square of successive differences (which reflects parasympathetic acivity) and low frequency (which mainly reflects sympathetic activity) were negatively correlated with fat mass, fat percentage, and waist-to-hip ratio at rest in obese persons. These results mean obesity can change cardiac autonomic nervous response, meaning that the mechanism by which obesity increases cardiac mortality would be explained, at least partially.
TL;DR: The results of this pilot study highlight the need for further research on the use of pedometers as a motivational tool in the context of medical encounters with inactive patients.
Abstract: Because of their frequent encounters with sedentary patients, family physicians are poised to be on the forefront of the medical community's response to physical inactivity. The purpose of this pilot study was to examine whether the addition of a pedometer to brief physician counseling could help patients increase their ambulatory activity. Ninety four participants recruited from a family medicine clinic were randomly assigned to 2 groups. Both groups received a brief physician endorsement of regular physical activity, a handout on the benefits of an active lifestyle, and 3 follow-up phone calls from a health educator. In addition, the intervention group received a pedometer and was instructed to record their steps daily over the 9-week study period. Measurements were taken for self-reported walking, walking stage-of-change, walking self-efficacy, and pedometer steps (intervention group only). Among completers, mean daily step counts in the pedometer group rose from 6779 at baseline to 8855 at study end. Average individual improvement was 41% over the study period. Both groups significantly increased blocks walked per day, stair climbing versus using the elevator, days per week walking > or = 30 minutes, and walking for fun/leisure. The frequency of walking short trips improved significantly more in the pedometer group relative to the comparison group. The results of this pilot study highlight the need for further research on the use of pedometers as a motivational tool in the context of medical encounters with inactive patients.
TL;DR: Pharmacotherapy was found to be the most widely used treatment despite current evidence-based recommendations, and the negotiation process during the patient-provider encounter would shed light on patient and physician factors influencing treatment decisions.
Abstract: Background: Depression costs the United States $40 billion annually. Primary care physicians play a key role in the identification and treatment of depression. This study focused on the treatment options recommended by physicians and whether physicians were following the recommended treatment guidelines. Methods: We recorded treatment recommendations by examining charts for all patients with newly detected depression. The patients were from 44 family medicine practitioners and 23 general internal medicine practitioners in a Midwest university medical center setting. Results: For both medical specialties combined, pharmacotherapy was the most widely used intervention (recommended for 52% of patients), whereas psychotherapy alone was the least frequently used intervention (recommended for 4% of patients). Family medicine practitioners recommended combination treatment (pharmacotherapy and psychotherapy) more frequently than did general internal medicine practitioners ( P = .022), and female physicians recommended combination treatment more frequently than did male physicians ( P = .010). Conclusions: Pharmacotherapy was found to be the most widely used treatment despite current evidence-based recommendations. Barriers to effective treatment plan are discussed. The implications for mental health interventions, combination therapy, and cost offset are also discussed. Further research exploring the negotiation process during the patient-provider encounter would shed light on patient and physician factors influencing treatment decisions.
TL;DR: Continuing medical education for providers about depression, provision of counseling services and antidepressant medications at the primary care level, and efforts to destigmatize depression may result in increased rates of recognition and treatment of depression in this population of patients.
Abstract: Background: Depression is one of the most common causes of morbidity in developing countries. It is believed that there are many barriers to diagnosis and treatment in the primary care setting, but little research exists. Methods: Five focus groups were conducted with the goal of exploring themes related to barriers to the diagnosis and treatment of depression, with a purposeful nationwide sample of 50 primary health care providers working in the public health clinics of the Jordanian Ministry of Health (MOH). Participant comments were transcribed and analyzed by the authors, who agreed on common themes. Results: Lack of education about depression, lack of availability of appropriate therapies, competing clinical demands, social issues, and the lack of patient acceptance of the diagnosis were felt to be among the most important barriers to the identification, diagnosis, and treatment of patients with depression in this population. Conclusions: Continuing medical education for providers about depression, provision of counseling services and antidepressant medications at the primary care level, and efforts to destigmatize depression may result in increased rates of recognition and treatment of depression in this population. Systematizing traditional social support behaviors may be effective in reducing the numbers of patients referred for medical care.
TL;DR: A systematic review of the effect of GERD on health-related quality of life (HRQL) in the primary-care setting and in the community concluded that many aspects of HRQL are impaired in GERD patients.
Abstract: Gastroesophageal reflux disease (GERD) is a chronic disease that affects up to 20% of the population of Western countries and accounts for around 5% of a primary-care physician's workload. A better understanding of how GERD affects many aspects of patients' lives may aid the management of patients in primary care. We conducted a systematic review of the effect of GERD on health-related quality of life (HRQL) in the primary-care setting and in the community. Validated questionnaires have shown that GERD patients consulting in primary care experience substantial reductions in both physical and psychosocial aspects of HRQL, as well as work productivity. Impairments in HRQL are seen whether or not reflux esophagitis or Barrett's esophagus is present on endoscopy, and are comparable with or worse than those seen in patients with other chronic diseases such as heart disease, diabetes, and cancer. Surveys in primary care and in the community highlight disrupted sleep, reduced concentration at work, and interference with physical activities such as exercise, housework, and gardening. Psychosocial aspects of patient well-being are also impaired, including enjoyment of social gatherings, intimacy, sex, and many individuals with GERD remain worried about the underlying cause of their symptoms. In conclusion, many aspects of HRQL are impaired in GERD patients. The primary-care physician is uniquely placed to assess and address the impact of GERD on patients' lives.
TL;DR: In multivariate analyses, loss of sexual interest was associated with postmenopause status in white but not in African American women, and the prevalence of vasomotor symptoms in premenopausal women may be an under-recognized aspect of the natural history of the menopause transition.
Abstract: Background: The association between changes in menopausal status and menopause-related symptom reporting over the course of the menopause transition is not well understood, especially whether there are any racial differences in this association. Objective: To determine (1) the prevalence and the natural history of menopause symptoms among primary care patients approaching, or at menopause; (2) the relationship between self-reported symptoms and menopausal status; and (3) whether this relationship varies in African American and white women. Study Design: Cross-sectional self-report survey of 342 women aged 40 to 55 years (31.6% African American) were recruited from 8 family practice centers in 2000 and 2001. Results: Among 251 women without surgical menopause, 133 (53.0%) were premenopausal, 72 (28.7%) were peri-menopausal, and 46 (18.3%) were postmenopausal. The most commonly reported symptoms were joint/muscle pain and headache, which did not vary by menopausal status. As many as 28.6% of the women with regular menstruation reported hot flashes, and 18.8% had night sweats; although both symptoms were strongly associated with changes in menopausal status (P Conclusions: Symptoms are not uncommon among premenopausal women and become more prevalent as the transition through menopause occurs. The prevalence of vasomotor symptoms in premenopausal women may be an under-recognized aspect of the natural history of the menopause transition. African American and white women may present different symptoms through menopause transition.
TL;DR: It is found that community-oriented primary care (COPC) and complementary and alternative medicine (CAM) are well developed within the Cuban medical system.
Abstract: Family physicians in Cuba and the United States operate within very different health systems. Cuba's health system is notable for achieving developed country health outcomes despite a developing country economy. The authors of this study traveled to Cuba and reviewed the literature to investigate which practices of Cuban family physicians might be applicable for US family physicians wishing to learn from the Cuban experience. We found that community-oriented primary care (COPC) and complementary and alternative medicine (CAM) are well developed within the Cuban medical system. Because COPC and CAM are already recommended by US family medicine professional bodies, US family physicians may want to learn from the Cuban experience and perhaps incorporate elements into their individual practices.
TL;DR: Funding for clinical research has changed dramatically over the past 2 or 3 decades, and scientists who 10 years ago would have snubbed their academic noses now have to consider their options.
Abstract: Funding for clinical research has changed dramatically over the past 2 or 3 decades. Before 1970, few clinical studies were sponsored solely by the drug companies.[1][1] A 1982 article in the journal Science noted the transition: “Scientists who 10 years ago would have snubbed their academic noses
TL;DR: A pilot study to examine physician patient interaction when elderly patients are accompanied during a medical visit found no differences between the number of words spoken in accompanied versus unaccompanied visits, comparing patients alone with patients and companions combined.
Abstract: Objectives: To conduct a pilot study to examine physician patient interaction when elderly patients are accompanied during a medical visit. Methods: This was a study in which 30 patients were randomly assigned to be accompanied (13) or unaccompanied (17) during a regular medical visit to their physician. Visits were tape recorded, transcribed, and coded with the Measure of Patient-Centered Communication (MPCC) and with the Rochester Participatory Decision-Making Scale (RPAD). Results: We found no differences between the number of words spoken in accompanied versus unaccompanied visits, comparing patients alone with patients and companions combined. Physicians spoke longer without interruption in accompanied encounters (39.9 vs 78.6 words per speech turn). There were no differences in the level of MPCC or in the level of participatory decision making between the 2 types of visits. In accompanied visits, patients introduced most of the concerns and physicians discussed concerns with patients more than with companions. Conclusions: Previously reported differences in accompanied versus unaccompanied visits may reflect patients’ preferences for being accompanied, the role they wish their companion to play, and the patients’ health status. Being accompanied by a family member or friend does not result in less attention being paid to patients’ concerns.
TL;DR: The ankle-brachial index could become routine screening among patients with diabetes mellitus and/or who smoke and a lack of both demonstrated low rates for predicting asymptomatic PAD.
Abstract: Objective: To describe coexisting medical conditions and lifestyle factors associated with asymptomatic peripheral arterial disease (PAD) in a population of white, African American, and Hispanic patients. Study Design and Setting: White, African American, and Hispanic patients 50 years or older were recruited for this cross-sectional study from 4 primary care clinics in Houston, TX. Patients with an ankle-brachial index (ABI) Results: 403 patients were screened for PAD. Of these, 25 (6.2%) had asymptomatic PAD. Compared with patients without PAD, diabetes mellitus ([OR] 3.8; 95% CI 1.6, 9.0) and a history of smoking at least 1 pack of cigarettes per day ([OR] 2.5; 95% CI 1.1, 6.0) were significantly associated with asymptomatic PAD. An interaction effect existed between diabetes mellitus and smoking at least 1 pack of cigarettes per day. Diabetes mellitus combined with heavy smoking showed the highest predicted value positive (15%) and the highest specificity (92%). A lack of both demonstrated low rates for predicting asymptomatic PAD (predicted value positive, 1%). Conclusion: The ankle-brachial index could become routine screening among patients with diabetes mellitus and/or who smoke.
TL;DR: This unusual cause of extrinsic venous compression and intimal injury leading to thrombosis was treated uniquely with good outcome and highlights the need for randomized clinical trials to guide management and to assess the safety and efficacy of anticoagulants commonly used.
Abstract: We report this case of effort thrombosis of the upper extremity (Paget-Schroetter syndrome) caused by hypertrophied muscles. This unusual cause of extrinsic venous compression and intimal injury leading to thrombosis was treated uniquely with good outcome. Untreated symptomatic patients can sustain long-term disability from venous obstruction resulting in significant loss of occupational productivity and quality of life. For the same reason, early catheter directed thrombolysis followed by anticoagulation and surgical intervention are recommended in much of the recent literature. Thrombolysis is the most common form of treatment, followed by surgery, if needed, after careful diagnostic approach. A majority of the literature supports a multimodal approach, but there is no definite consensus on management. This highlights the need for randomized clinical trials to guide management as well as to assess the safety and efficacy of anticoagulants commonly used and to define the optimal duration of therapy after thrombolysis.
TL;DR: Until the kind of systematic follow-up and follow-through that the US Preventive Services Task Force said is a prerequisite for its recommendation to routinely screen for depression is established, none of these earlier actions will make much difference.
Abstract: Certainly we could improve our identification, diagnosis, and initial treatment approaches to the large numbers of depressed patients we see in primary care. However, until we have established the kind of systematic follow-up and follow-through that the US Preventive Services Task Force said is a prerequisite for its recommendation to routinely screen for depression, none of these earlier actions will make much difference. Recently, a number of controlled trials of innovative approaches to care management have demonstrated clearly how much patient outcomes are improved when systematic follow-up is in place. The problem is that there are few examples of such systems in real clinical practices. This article describes the main components of such a systematic approach.
TL;DR: A healthy tension between physician autonomy and recommended practice guidelines needs to be cultivated in primary care as well as in specialty clinical practice, and a mechanism designed to assure integrity and credibility of guidelines is required.
Abstract: In a medical milieu of extensive research, rapidly proliferating information, and a multitude of potential therapies, there has been an escalating trend toward the development and dissemination of clinical practice guidelines outlining investigative and management protocols for clinical problems. There are substantial benefits to providing educational directives and securing widespread adherence to specific clinical practice standards as a means to ensure a consistent acceptable standard-of-care. On the other hand, the increasing tendency to regard authoritative documents as dogma may hinder ongoing medical progress and facilitate the adoption of a "follow-the-recipe" approach to medical practice. A healthy tension between physician autonomy and recommended practice guidelines needs to be cultivated in primary care as well as in specialty clinical practice. In response to increasing concern surrounding issues of impartiality and commercial influence on the development of practice directives, a mechanism designed to assure integrity and credibility of guidelines is required.
TL;DR: The strongest evidence supports an intensive lifestyle intervention designed to induce modest weight loss and Metformin and troglitazone have appreciable evidence in specific populations, and orlistat and acarbose have slightly less evidence among obese patients, for preventing diabetes.
Abstract: Type 2 diabetes is a serious, costly, and increasingly common disease. Several conditions commonly seen in family medicine settings confer increased risk of developing diabetes. Among these conditions are impaired glucose tolerance, impaired fasting glucose, obesity, gestational diabetes, hypertension, hyperlipidemia, and menopause. We here present the results of a systematic review of the literature examining the evidence for different strategies aimed at preventing type 2 diabetes in patients with these conditions. The strongest evidence supports an intensive lifestyle intervention designed to induce modest weight loss. The greatest degree of prevention, based on lesser quality evidence, may be imparted by bariatric surgery. Metformin and troglitazone have appreciable evidence in specific populations, and orlistat and acarbose have slightly less evidence among obese patients, for preventing diabetes. Ramipril, captopril, losartan, pravastatin, and estrogens show some very preliminary promise for preventing diabetes in patients treated for hypertension, hyperlipidemia, and menopause, but each needs a more rigorous evaluation. Although more questions remain to be answered, family physicians now have tools available to help our patients lead lives free of diabetes.
TL;DR: This article focuses specifically on how to recognize the identifying features suggestive of a bipolar disorder in patients who present with depressive symptoms or who have previously been diagnosed with major depression or dysthymia.
Abstract: Accurate diagnosis of mood disorders is critical for treatment to be effective. Distinguishing between major depression and bipolar disorders, especially the depressed phase of a bipolar disorder, is essential, because they differ substantially in their genetics, clinical course, outcomes, prognosis, and treatment. In current practice, bipolar disorders, especially bipolar II disorder, are underdiagnosed. Misdiagnosing bipolar disorders deprives patients of timely and potentially lifesaving treatment, particularly considering the development of newer and possibly more effective medications for both depressive features and the maintenance treatment (prevention of recurrence/relapse). This article focuses specifically on how to recognize the identifying features suggestive of a bipolar disorder in patients who present with depressive symptoms or who have previously been diagnosed with major depression or dysthymia. This task is not especially time-consuming, and the interested primary care or family physician can easily perform this assessment. Tools to assist the physician in daily practice with the evaluation and recognition of bipolar disorders and bipolar depression are presented and discussed.