Showing papers in "Southern Medical Journal in 2012"

Preexposure prophylaxis for HIV infection: healthcare providers' knowledge, perception, and willingness to adopt future implementation in the southern US.

Abstract: BACKGROUND Understanding providers' perspective on preexposure prophylaxis (PrEP) would facilitate planning for future implementation. METHODS A survey of care providers from sexually transmitted disease and family planning clinics in South Carolina and Mississippi was conducted to assess their knowledge, perception, and willingness to adopt PrEP. Multivariable logistic and general linear regression with inverse propensity score treatment weights were used for analyses. RESULTS Survey response rate was 360/480 (75%). Median age was 46.9 years and a majority were women (279 [78%]), non-Hispanic white (277 [78%]), nonphysicians (254 [71%]), and public health care providers (223 [62%]). Knowledge about PrEP was higher among physicians compared with nonphysicians (P = 0.001); nonpublic health care providers compared with public health care providers (P = 0.023), and non-Hispanic whites compared with non-Hispanic blacks (P = 0.034). The majority of the providers were concerned about the safety, efficacy, and cost of PrEP. Providers' perceptions about PrEP were significantly associated with their sociodemographic and occupational characteristics. The willingness to prescribe PrEP was more likely with higher PrEP knowledge scores (adjusted odds ratio [aOR] 14.94; 95% confidence interval [CI] 3.21-69.61), older age (aOR 1.14; 95% CI 1.01-1.29), and in those who agreed that "PrEP would empower women" (aOR 2.90; 95% CI 1.28-6.61); and was less likely for "other" race/ethnicity versus white (aOR 0.23; 95% CI 0.07-0.76) and in those who agreed that "PrEP, if not effective, could lead to higher HIV transmission" (aOR 0.45; 95% CI 0.27-0.75). CONCLUSIONS To improve the acceptance of PrEP among providers, there is a need to develop tailored education/training programs to alleviate their concerns about the safety and efficacy of PrEP.

Pharmacotherapy considerations in elderly adults.

Abstract: Life expectancy for Americans has increased dramatically since 1900, as have the available pharmacotherapeutic options. Un- fortunately, pharmacotherapy mishaps occur commonly in the older adult population. This problem greatly affects the morbidity and mortality of elderly patients and greatly increases healthcare costs. To improve patient care among elderly adults, healthcare practitioners must consider several issues when developing a pharmacotherapy plan. A thorough understanding of pharmacokinetics, pharmacodynamics, adverse drug reactions, drug interactions, and several other factors is necessary for practitioners to develop a safe and effective drug therapy plan for older adults. This review provides a general but comprehensive review of the issues pertaining to pharmacotherapy in elderly people and offers several suggestions for improving their pharmaceutical care.

Proton pump inhibitors: the good, the bad, and the unwanted.

Abstract: Proton pump inhibitors (PPIs) are one of the most commonly prescribed classes of medications in the United States. By inhibiting gastric H/K adenosine triphosphatase via covalent binding to the cysteine residues of the proton pump, they provide the most potent acid suppression available. Long-term PPI use accounts for the majority of total PPI use. Absolute indications include peptic ulcer disease, chronic nonsteroidal anti-inflammatory drugs use, treatment of Helicobacter pylori, and erosive esophagitis. Although PPIs are generally considered safe, numerous adverse effects, particularly associated with long-term use have been reported. Many patients receiving chronic PPI therapy do not have clear indications for their use, prompting consideration for reduction or discontinuation of their use. This article reviews the indications for PPI use, the adverse effects/risks involved with their use, and conditions in which their use is controversial.

Using music interventions in perioperative care

Abstract: Anxiety and pain are common responses to surgery, and both can negatively affect patient outcomes. Music interventions have been suggested as a nonpharmacological intervention to alleviate pain and anxiety during surgical treatment. Although the data are somewhat mixed, the research suggests that music-based interventions are effective in reducing anxiety, pain perception, and sedative intake. The majority of studies have focused on interventions during the postoperative period and address pain reduction, with preoperative use of music targeting anxiety reduction the second most commonly cited objective. Most of the studies found in the literature involve passive music listening via headphones. The data suggest that researcher-selected music is most effective in reducing anxiety, primarily because it incorporates evidence-based parameters such as consistent tempo and dynamics, stable rhythms, and smooth melodic lines. Finally, the literature suggests that music therapists can serve as experts to help medical personnel identify effective implementation strategies.

Parkinson disease: research update and clinical management.

Abstract: More than 1 million people in the United States have Parkinson disease (PD), more than are diagnosed as having multiple sclerosis, amyotrophic lateral sclerosis, muscular dystrophy, and myasthenia gravis combined. PD affects approximately 1 in 100 Americans older than 60 years. It burdens patients, their care partners, and the overall healthcare system. This article reviews the epidemiology, clinical features, putative environmental risk and protective factors, neuropathological aspects, heterogeneity, medical management, and recent studies regarding genetics and PD. The article suggests that based on new research, the prevalence of PD varies in different regions of the United States. Some progress has been made in identifying the risk and protective factors of PD, and a newly emphasized area of study in PD is genetics. Patient care recommendations, based on American Academy of Neurology practice guidelines, are outlined to show the state of contemporary medical management of PD and related disorders.

Abnormal urine color.

Abstract: A change in urine color can be distressing for patients and physicians alike. Many of the causes of abnormal urine color are benign effects of medications and foods; however, a change in urine color may be a sign of an underlying pathological condition. The good news is that in many cases the diagnosis can be determined from a thorough history and urinalysis. This article presents many of the conditions physicians may encounter and will help them form a narrow differential diagnosis and treatment plan.

Secondary Hyperparathyroidism: Benign Bystander or Culpable Contributor to Adverse Health Outcomes?

Abstract: Elevation in serum parathyroid hormone (PTH) often accompanies vitamin D deficiency and renal impairment. PTH elevation in renal failure is viewed as an unfavorable development. Evidence is increasing that PTH elevation may be associated with increased morbidity and mortality. In many instances these PTH effects appear to be independent of vitamin D status. PTH mediates its effects through the ubiquitous type 1 PTH/PTH-related peptide receptor, which is notably present in the cardiovascular system. Increased PTH may promote cardiovascular disease through diminished cardiac contractility, enhanced coronary risk, and cardiac valvular and vascular calcification. High PTH levels appear to be linked to the metabolic syndrome and are aligned with hyperlipidemia, decreased insulin sensitivity, and, perhaps, decreased insulin secretion. Increased PTH also is associated with neuroendocrine activation, increased sympathetic activity, and endothelial stress. The relation between PTH and vitamin D is complex and may show significant threshold variations, especially when calcium intake, age, and race are considered. Moreover, evidence is increasing that fragments of PTH may not only be hormonally active but also may have opposing effects to PTH. Despite these caveats, PTH values provide useful clinical diagnostic and prognostic information in monitoring many chronic ailments such as heart and renal failure and multiple sclerosis.

Pneumonectomy for non-small cell lung cancer: outcomes analysis.

Abstract: Objective The purpose of this study was to investigate the morbidity and mortality of 100 consecutive patients with pneumonectomy for non-small cell lung cancer at the University of Kentucky. Methods We retrospectively reviewed the medical records of 100 consecutive pneumonectomy patients, 1998-2009. Results The median age of patients was 59 years, with a range of 27 to 79 years. Sixty-eight patients (68%) were men. Fifty-four patients (54%) received left pneumonectomy. Major postoperative complication rate was 39%, with atrial fibrillation being the most common complication, occurring in 26 patients. The overall postoperative mortality rate was 11% (11/100 patients). The mortality rate among right pneumonectomy patients was 17.4% (8/46 patients) compared with 5.6% (3/54 patients) for left pneumonectomy. The postoperative mortality rate among patients receiving neoadjuvant therapy was 14.3% (4/28 patients). In addition, among patients who received neoadjuvant therapy, the mortality rate for right and left pneumonectomy was 21.4% (3/14 patients) and 7.1% (1/14 patients), respectively. The mortality rate among patients older than 70 years at the time of pneumonectomy was 18.2% (2/11 patients). Conclusions With a postoperative mortality rate of 11% and a major postoperative complication rate of 39%, pneumonectomy for non-small cell lung cancer is associated with high morbidity and mortality. The factors associated with the increased mortality rate include right pneumonectomy, patient age older than 70 years at the time of procedure, and neoadjuvant therapy before pneumonectomy.

Intimate partner violence education for medical students: toward a comprehensive curriculum revision.

Abstract: OBJECTIVES: Previous studies examined the prevalence and efficacy of intimate partner violence (IPV) education in medical school. We documented IPV content exposure shortage in medical school curriculum at a southern university health science center and measured personal IPV experience among medical students. METHODS: Responses were gathered from a 67-item survey adapted from the Physician Readiness to Manage Intimate Partner Violence Survey. Our survey measured IPV knowledge and attitudes, along with sufficiency of IPV education that students received before and during medical school. Three summary scales were created to examine students' perceived preparedness to deal with IPV survivors and their perceived and actual knowledge about IPV. RESULTS: Across summary scales, differences were higher but not significant between medical students who received IPV education either before or during medical school and those with no IPV education. Of all of the medical students surveyed, 28.7% (n = 33) had experienced some type of domestic violence including IPV. Gaps in knowledge also were identified. CONCLUSIONS: Student IPV experience (whether directly by way of personal exposure to IPV or indirectly through family members or acquaintances who were victims of IPV) can be applicable in classrooms, clinics, and students' careers, but it may not necessarily increase perceived or actual IPV knowledge; however, our results show that any IPV education that students receive can be effective in increasing confidence and perceived preparedness to address IPV with patients. Comprehensive approaches to teaching IPV should be integrated fully into medical school curricula. Language: en

Misclassification of pulmonary hypertension in adults with sickle hemoglobinopathies using Doppler echocardiography.

Abstract: Objective To compare the diagnostic utility of Doppler echocardiography-derived tricuspid regurgitant jet velocity (TRV) ≥ 2.5 m/s to right heart catheterization (RHC) in defining pulmonary hypertension (PH) in adult patients with sickle cell disease (SCD). Methods This is a retrospective chart review of adults with SCD who had a TRV ≥ 2.5 m/s and RHC. A TRV ≥ 2.5 m/s is suggestive of PH. Pulmonary arterial hypertension (PAH) was defined as a mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg and pulmonary capillary wedge pressure ≤ 15 mm Hg. Pulmonary venous hypertension was defined as an mPAP ≥ 25 mm Hg and pulmonary capillary wedge pressure >15 mm Hg. Results Twenty-five patients with SCD met the inclusion criteria. Nine of the 25 (36%) patients had an mPAP ≥ 25 mm Hg. Of these 9, 3 (33%) had PAH and 6 (66%) had pulmonary venous hypertension. Patients with PH did not have a higher TRV (3.1 ± 0.68 vs 2.70 ± 0.16 m/s; P = 0.12), but they did have higher cardiac outputs (10.4 ± 2.7 vs 7.81 ± 1.85 L/min; P = 0.012. The specificity of TRV equal to 2.51 m/s in diagnosing PH was 18.8%. At a TRV of 2.88 m/s, the specificity increased to 81%. Conclusions In adults with SCD, a TRV of 2.5 m/s lacks specificity for use as a screening tool in the diagnosis of PH. Using a TRV of ≥ 2.88 m/s allows the TRV to be used as a screening tool and reduces the false-positive rate and need for unnecessary RHC.

Carisoprodol: update on abuse potential and legal status.

Abstract: Carisoprodol is a centrally acting skeletal muscle relaxant of which meprobamate, a controlled substance, is the primary active metabolite. The abuse of carisoprodol has increased dramatically in the last several years. A withdrawal syndrome occurs in some patients who abruptly cease carisoprodol intake. The symptoms of this syndrome are similar to those seen with meprobamate withdrawal, suggesting that they may result from withdrawal from meprobamate accumulated with intake of excessive carisoprodol; however, carisoprodol is capable of modulating GABAA function, which may contribute to its abuse potential.There has been considerable debate about whether carisoprodol should be considered a controlled substance. Carisoprodol was removed from the market in Norway on May 1, 2008, but may still be used by specially approved patients. Carisoprodol was classified as a controlled substance in several US states, and effective January 11, 2012, became a schedule IV controlled substance at the US federal level. This article updates the literature on abuse potential and examines recent developments regarding the legal status of carisoprodol.

Resident preferences for a curriculum in healthcare transitions for young adults.

Abstract: OBJECTIVES Numerous national groups recognize that healthcare providers should be trained to care for patients with special healthcare needs who are transitioning from pediatric to adult health care, yet there is little emphasis on this training in most residency programs. The survey discussed here assessed resident preferences for a curriculum that addresses healthcare transitions for young adults. METHODS Trainees in primary care residency programs at three institutions in South Carolina were surveyed. Residents were asked about their preferences for timing and modality of transition education and desire to see patients older/younger than dictated by training. Residents also ranked topics of transition by level of need/interest. Comparison of responses was analyzed via t tests and the Fisher exact test. RESULTS Respondents (n = 84) represented three institutions and eight training programs. Eighty percent of residents prefer that a curriculum be continuous throughout training and include clinical experiences (79%), case discussions (60%), and lectures/didactics (56%). Pediatric residents were more likely than were internal medicine residents to value seeing patients older/younger than their program dictates (84% vs 42%; P < 0.01). Internal medicine residents were more likely than pediatric residents to rank as high need/interest "medical knowledge of pediatric disease persisting into adulthood" (77% vs 47%; P= 0.05) and "caring for adult-aged patients reliant on caregivers" (53% vs 9%; P < 0.01). CONCLUSIONS Residents prefer a healthcare transition curriculum that is continuous throughout residency and uses combined modalities for topic presentation. Residents training in different disciplines have varied levels of need/interest for transition-related topics and this should direct the development of healthcare transition curricula.

Prospective evaluation of surgical outcomes of robot-assisted sacrocolpopexy and sacrocervicopexy for the management of apical pelvic support defects.

Abstract: OBJECTIVE To evaluate outcomes of robot-assisted sacrocolpopexy (RSCP) and sacrocervicopexy (RCSP). METHODS We conducted a prospective study of women undergoing RSCP or RCSP between June 2008 and January 2010. RESULTS A total of 85 cases (48 RSCP and 37 supracervical hysterectomy with concomitant RCSP) were performed: 33% (28/85) for stage II, 54% (46/85) for stage III, and 13% (11/85) for stage IV pelvic organ prolapse (POP). Six weeks postoperatively, 96% (80/83) had stage 0, 2.4% (2/83) had stage I, and 1.2% (1/83) had stage II POP (P < 0.001). Six months postoperatively, 77% (24/31) had stage 0, 6.5% (2/31) had stage I, and 16% (5/31) had stage II POP (P < 0.001). Mean surgical time, estimated blood loss, and length of hospital stay was 194 ± 54 minutes, 49 ± 48 cm, and 1.6 ± 0.72 days, respectively. There were 2 cases of mesh erosion (2.3%), both in the RSCP group. CONCLUSIONS RSCP and RCSP are effective, efficient, and safe procedures.

Evaluation of health literacy among Spanish-speaking primary care patients along the US--Mexico border.

Abstract: OBJECTIVES Health literacy (HL) is a measure of the communication skills that are needed by an individual to effectively navigate the healthcare system. Hispanic adults have lower average levels of HL than any other racial/ethnic group; however, the prevalence of adequate HL among Hispanics along the US-Mexico border is unknown. METHODS We performed a cross-sectional survey of 200 adult primary care patients who attended four low-income community clinics along the US-Mexico border. Patients were included in the study if they were self-described Hispanics whose first language was Spanish or bilingual patients who reported that they were primarily Spanish speakers. Adequate HL was defined as having a score of ≥38 on the Short Assessment of Health Literacy for Spanish Adults-50. RESULTS Three patients (1.5%) had inadequate HL. Because of the high proportion of patients having adequate HL, we found no statistical differences between patients with adequate HL versus inadequate HL by age, sex, educational attainment, health coverage, or self-reported health status; however, all three patients with inadequate HL were found to be 60 years old or older and had less than a high school education. CONCLUSIONS The results of HL assessment varied according to the tool and setting used in measuring Spanish-speaking Hispanics. In certain clinical scenarios, current tools may underestimate the actual prevalence of adequate HL. Further development and assessment of HL tools appropriate for Spanish-speaking Hispanics is needed as a first step in developing interventions to limit disparities in health care among all Americans.

Androgen abuse and increased cardiac risk.

Abstract: The objectives of this article were to review the anabolic androgen steroids, specifically the direct and indirect effects on the cardiovascular system of the individuals who use them, and to summarize the evidence regarding the effects of androgens on the cardiovascular system. A search of the English-language scientific literature from 1976 to March 2012 was performed primarily by searching the MEDLINE and Embase databases and Google. Anabolic androgenic steroids are associated with direct effects such as cardiac muscle hypertrophy and myocardial fibrosis and indirect effects, including dyslipidemia, hypertension, arrhythmia, and myocardial infarction. It is likely that chronic exposure to these agents can result in significant alterations in the cardiovascular system, and their safety has not been fully established.

Current Concepts and Management Strategies in Chronic Kidney Disease-Mineral and Bone Disorder

Abstract: The term renal osteodystrophy describes the pathological changes in bone structure in chronic kidney disease (CKD); however, this term fails to describe adequately the adverse changes in mineral and hormonal metabolism in CKD that have grave consequences for patient survival. CKD-mineral and bone disorder (CKD-MBD) is a broader, newly defined term that should be used instead of renal osteodystrophy to define the mineral, bone, hormonal, and calcific cardiovascular abnormalities that are seen in CKD. The new paradigm in the management of renal bone disease is to "think beyond the bones" and strive to improve cardiovascular outcomes and survival. This means treating other aspects of the disease process that go beyond merely controlling parathyroid hormone levels. Primary physicians need to take a proactive approach to the management of CKD-MBD because the disorder begins early in the course of CKD, well before a patient is referred to a nephrologist. This review outlines the evidence behind the understanding of CKD-MBD, its implications for overall mortality, and the latest recommendations for management of CKD-MBD in patients with predialysis CKD.

Relation between prefracture characteristics and perioperative complications in the elderly adult patient with hip fracture.

Abstract: BACKGROUND The exact relation among patient prefracture characteristics such as age, American Society of Anesthesiologists (ASA) class, fracture type, and prefracture mobility status with perioperative complications in elderly adult patients with hip fracture is still unclear. The aim of the study was to assess the relations among patient prefracture characteristics and perioperative complications. METHODS Patients 65 years old and older admitted to our institution between January 2006 and May 2010 with the diagnosis of a low-energy hip fracture were retrospectively reviewed. A total of 389 patients met the inclusion criteria and were analyzed in this investigation. Patient prefracture characteristics, comorbidities, and surgical and hospital courses were reviewed. RESULTS Using logistic regression analysis, ASA class was found to be the only significant predictor of a patient having at least one or more perioperative complications (odds ratio [OR] 2.007). In addition to ASA class, prefracture mobility status was a significant predictor of delirium (OR 1.39) and pneumonia (OR 1.77), advanced age was a significant predictor of congestive heart failure (OR 1.73), and fracture type was a significant predictor of pneumonia (OR 1.6). None of the examined prefracture characteristics was found to be a significant predictor of pulmonary embolus, deep venous thrombosis, surgical wounds, transfusions, urinary tract infection, or death. CONCLUSIONS At our institution, certain patient prefracture characteristics, particularly high ASA class, are related to certain perioperative complications. Recognition of patients who possess these risk factors can be used to alert the caregiving team about a potentially complicated hospital course.

Variation in fruit juice consumption among infants and toddlers: associations with WIC participation.

Abstract: OBJECTIVES Juice is a common component of a child's diet. Excessive juice consumption may lead to adverse nutritional and dental outcomes. The objective of the study was to evaluate consumption patterns and parental perception regarding juice in a sample of children from families participating or not participating in Women, Infants, and Children (WIC) services. METHODS Parents of children aged 12 months to 5 years completed a survey consisting of questions about beverage intake and related opinions. Practices were selected to provide a mix of families who do and do not use WIC services. Comparisons were made by WIC use and by quantity of juice consumption. RESULTS Of 173 surveys, 51% of participants had received benefits from the WIC program. Overall, children who drank larger quantities of fruit juice drank less milk. One-third of all of the parents who responded to the survey reported that they believed that juice was at least as healthy as fresh fruit, with WIC parents reporting this belief more often (56% vs 9%; P < 0.01) than non-WIC parents. Two-thirds of all of the parents surveyed (66%) introduced juice before their child reached age 12 months, and this was more likely in WIC families (78% vs 54%; P < 0.05). Overall, 81% would prefer to receive fresh fruit as part of the WIC package. CONCLUSIONS Higher juice consumption is associated with decreased milk consumption. Many parents expressed a belief that juice was at least as healthful as fresh fruit. Being a WIC recipient was associated with an earlier introduction of juice into a child's diet and a greater perception that juice was healthful.

Using the antinuclear antibody test to diagnose rheumatic diseases: when does a positive test warrant further investigation?

Abstract: The anti-nuclear antibody (ANA) test is ordered commonly as a screening test for rheumatic diseases. Although ANA positivity is highly sensitive for certain rheumatic diseases, the presence of ANA is nonspecific and can be associated with numerous nonrheumatic factors, including environmental exposures, malignancies, drugs, and infections. This article describes a practical approach for physicians when evaluating patients using a positive ANA test. In the absence of connective tissue disease symptoms, the ANA test has minimal clinical significance in diagnosing rheumatic diseases. Understanding how to use ANA test results appropriately may reduce unnecessary referrals and costly workups.

Elderly adults and skin disorders: common problems for nondermatologists.

Abstract: Diseases of elderly adults are becoming increasingly important as life expectancy gradually rises worldwide. To promote healthy aging, it is important to understand the skin changes associated with aging. This review focuses on the special considerations for some of the more common dermatological disorders in elderly adults and examines presentation, contributing factors, and association with systemic diseases.

Calcium abnormalities in hospitalized patients.

Abstract: Depending upon the method of measurement, hypocalcemia occurs in 15% to 88% and hypercalcemia occurs in 15% of hospitalized patients. Ionized calcium should be measured in place of total serum calcium to avoid errors related to hypoalbuminemia, which is seen commonly in acutely ill patients. Symptomatic hypocalcemia requires prompt intravenous calcium administration. Symptomatic hypercalcemia (most often caused by hyperparathyroidism or malignancy) warrants aggressive intravenous hydration to correct volume depletion and, usually, additional therapy with diuretics, bisphosphonates, calcitonin, or corticosteroids. Identification and treatment of the underlying cause of the calcium derangement must be addressed after the acute electrolyte abnormality is stabilized.

Carbohydrate challenge tests: do you need to measure methane?

Abstract: Objective Breath tests that measure hydrogen (H2) have been judged reliable for the detection of lactose maldigestion (LM) and fructose malabsorption (FM). Recently, methane (CH4) testing has been advocated and measurement of CH4 in addition to H2 has been shown to increase the diagnostic accuracy for LM. Purpose This study was designed to consider the additional yield from CH4 measurement in patients tested for LM and FM. Methods Patients reported for testing after an overnight fast, not smoking and with their prior evening meal carbohydrate restricted. After challenge with 50 g lactose or 25 g fructose in water, end-alveolar breath samples collected over a 4-hour duration were analyzed for H2 and CH4. Diagnostic positivity was compared using a cutoff level of 20 ppm increase above fasting baseline for H2 alone, which is consistent with consensus guidelines, versus H2 plus twice CH4, which recognizes that CH4 consumes twice the hydrogen. Results There were 406 LM performed in 93 men and 313 women. Of those tested, 124 (30%) had a positive test for H2 and 139 (34%) had a positive test for H2 + CH4 ×2. There were 178 FM tests performed in 31 men and 147 women. Of those tested, 17 (9%) had a positive test for H2 and 42 (23%) had a positive test for H2 + CH4 ×2. Conclusion If H2 alone was measured without additional CH4 analysis, 4% of patients with LM and 14% patients with FM would not have been identified.

Pediatricians', obstetricians', gynecologists', and family medicine physicians' experiences with and attitudes about breast-feeding.

Abstract: OBJECTIVES Investigate physicians' breast-feeding experiences and attitudes using a survey based on two behavioral theories: theory of reasoned action (TRA) and the health belief model (HBM). METHODS There were 73 participants included in the investigation. These participants were resident and faculty physicians from pediatrics, obstetrics/gynecology, and family medicine at a university campus, located on the US-Mexico border. The sample was reduced to 53 and 56 records for the attitude and confidence variables, respectively. Physicians answered a survey about their breast-feeding experiences and attitudes to learn about intention and ability applying constructs from TRA and HBM. An attitude scale, confidence variable (from self-efficacy items), and a lactation training index were created for the analysis. RESULTS Analysis of the association between physicians' breastfeeding experiences and their attitudes revealed physicians are knowledgeable about breast-feeding and have positive attitudes towards breast-feeding. They did not seem to remember how long they breast-fed their children or whether they enjoyed breast-feeding, but they wanted to continue breast-feeding. Physicians cite work as a main reason for not continuing to breast-feed. CONCLUSIONS Physicians' attitudes toward breast-feeding are positive. They are expected to practice health-promotion behavior including breast-feeding; however, physicians' breast-feeding rates are low and although they are knowledgeable about breast-feeding their training lacks on didactic depth and hands-on experience. If physicians learn more about breast-feeding and breast-feed exclusively and successfully, the rates in the United States would increase naturally.

Osteoporosis in adults with intellectual disabilities.

Abstract: The medical care of adults with intellectual disabilities (ID) originates in primary care physicians' offices. With the move toward the deinstitutionalization of these individuals in the 1970s and 1980s and the increasing longevity of this population, more adults with disabilities are living in the community. Primary care providers need to be comfortable with treating the conditions of these individuals with special needs. Individuals with ID are at higher than average risk for many chronic conditions. One condition that is often overlooked or underdiagnosed is osteoporosis. Much research regarding osteoporosis has been conducted in postmenopausal women and other high-risk groups; however, gaps remain in our understanding of the evaluation and treatment of osteoporosis in adults with ID.

Diversity of patients' beliefs about the soul after death and their importance in end-of-life care.

Abstract: Background Because beliefs about the soul after death affect the dying experience, patients and survivors may want to discuss those beliefs with their healthcare provider; however, almost no medical research describes such beliefs, leaving healthcare professionals ill prepared to respond. This exploratory study begins the descriptive process. Methods Assuming that culture is key, we asked older adult Mexican American (MA), European American (EA), and African American (AA) inpatients their beliefs about whether the soul lives on after physical death; if so, where; and what the "afterlife" is like. Results Some beliefs varied little across the sample. For example, most participants said that the soul lives on after physical death, leaves the body immediately at death, and eventually reaches heaven. Many participants also said death ends physical suffering; however, other beliefs varied distinctly by ethnic group or sex. More AAs than MAs or EAs said that they believed that the soul after physical death exists in the world (57% vs 35% and 33%) or interacts with the living (43% vs 31% and 28%). Furthermore, in every ethnic group more women than men said they believed that the soul exists in the world (42% vs 29% for MAs, 45% vs 14% for EAs, and 71% vs 43% for AAs). Conclusions As death nears, patients or survivors may want to discuss beliefs about the soul after death with their healthcare provider. This preliminary study characterizes some of those beliefs. By suggesting questions to ask and responses to give, the study provides healthcare professionals a supportive, knowledgeable way to participate in such discussions.

Repeat pregnancy prevention self-efficacy in adolescents: associations with provider communication, provider type, and depression.

Abstract: OBJECTIVES Among adolescent mothers, pregnancy prevention self-efficacy developed during pregnancy may predict the use of contraception following delivery. Communication between patients and their primary care providers (PCPs) is important for adherence to physician recommendations and may be associated with pregnancy prevention self-efficacy. Depression, which is common among adolescent mothers, has been associated with poor self-efficacy. The associations among pregnancy prevention self-efficacy, provider communication, provider type (PCP vs others), and depression are unclear. The objectives of the study were to determine the association of positive provider communication with pregnancy prevention self-efficacy, whether provider type or depression is associated with positive provider communication, and whether the association between provider communication and pregnancy prevention self-efficacy varies by provider type and depression. METHODS Cross-sectional study of 164 third trimester Baltimore adolescents measuring pregnancy prevention self-efficacy, perceptions of the quality of provider communication (Ambulatory Care Experiences Survey), provider type, and depressive symptoms. RESULTS Of 164 pregnant teens, 79% reported pregnancy prevention self-efficacy, 72% had a specific PCP, and 17% scored positive for depression. Positive provider communication was associated with pregnancy prevention self-efficacy (odds ratio 1.25; P = 0.04). Adolescents with PCPs had significantly higher communication scores (β 0.90; P = 0.001). Depressed adolescents had significantly lower communication scores (β -0.74; P = 0.03). The association between positive provider communication and self-efficacy was significant only for adolescents who reported having a PCP (P = 0.04) and those who were not depressed (P = 0.05). CONCLUSIONS Having a PCP and favorable perceptions of provider communication are important for pregnancy prevention self-efficacy among adolescents. Depression negatively affects perceptions of provider communication, which may limit self-efficacy.

Prevalence and impact of initial misclassification of pediatric type 1 diabetes mellitus.

Abstract: Purpose To characterize rates of initial misclassification of type 1 diabetes mellitus as type 2/unspecified diabetes mellitus in a cohort of children/adolescents and to examine the impact of misclassification on the risk of diabetes-related complications. Methods An 11-year dataset (1996-2006) was analyzed. Inclusion criteria included age 17 years and younger, enrollees in South Carolina State Medicaid, and diagnosis of type 2/unspecified or type 1 diabetes mellitus for at least two visits, 15 days apart. Survival analysis was used to assess the association of "misclassification" with the incidence of diabetic ketoacidosis (DKA), and the cumulative incidence of neuropathy, nephropathy, and cardiovascular complications, after controlling for individual risk factors and comorbid conditions. Results A total of 1130 individuals meeting the inclusion criteria were studied for a median of 7 years. Of the 1130 individuals, 669 (59.2%) maintained a diagnosis of type 2/unspecified diabetes mellitus, 205 (18.1%) were consistently diagnosed as type 1 diabetes mellitus, and the remaining 256 individuals (22.7%) were misclassified. Insulin treatment was used in 100% of the type 1 diabetes mellitus group and 73% of the misclassified group. Compared with the type 2 diabetes mellitus group, being misclassified was associated with earlier development of DKA (adjusted hazard ratio [aHR] 5.08, 95% confidence interval [CI] 3.09-8.37), neuropathy (aHR 1.94, CI 1.31-2.88), and nephropathy (aHR 1.72, CI 1.19-2.50), whereas being consistently classified with type 1 diabetes mellitus was associated only with earlier development of DKA (aHR 4.96, CI 2.56-9.61). Conclusions Proper categorization of pediatric diabetes can be challenging, especially with comorbid obesity. Failure to ascertain type 1 diabetes mellitus in a timely manner in a pediatric population may increase the risk of substandard care and diabetes-related complications.

Occurrence of vitamin D deficiency in pediatric patients at high risk in West Virginia.

Abstract: Objectives Vitamin D deficiency is prevalent and is increasingly associated with the development of medical conditions both related and unrelated to bone metabolism. The purpose of this study was to examine vitamin D deficiency in patients of a pediatrics subspecialty practice. Methods The study consisted of a retrospective chart review of patients aged 2 to 18 years who were referred to the West Virginia University Physicians of Charleston pediatrics subspecialty group with a diagnosis of obesity, chronic kidney disease, diabetes, hypertension, or cystic fibrosis. All of the patients had 25-hydroxyvitamin D levels measured from 2007-2009. Seventy-six patients met inclusion criteria. Results A total of 23.7% of patients were vitamin D deficient (≤ 20 ng/mL). Children with vitamin D deficiency were older and had higher rates of obesity than those with nondeficient vitamin D levels. The comorbidities of cystic fibrosis, diabetes, hypertension, and chronic kidney disease did not associate with vitamin D deficiency. Conclusions Vitamin D deficiency is common in children in West Virginia and is associated with increasing age and obesity. Vitamin D screening and supplementation should be considered in all children with chronic illness, particularly those who are overweight.

Conventional and endobronchial ultrasound-guided transbronchial needle aspiration: complementary procedures.

Abstract: OBJECTIVE The diagnosis of mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are on the rise. Most reports have demonstrated high yields with EBUS-TBNA and superiority of this procedure over conventional TBNA (cTBNA), but the relative roles of these procedures remain undefined. We present a comprehensive comparison of EBUS-TBNA to cTBNA. METHODS We reviewed all of the bronchoscopies performed at our medical center from January 2009 through December 2010. We collected data on 82 EBUS-TBNAs and 209 cTBNAs performed. A cost analysis was subsequently performed. RESULTS EBUS-TBNA was performed more often in patients with known prior cancer and suspicion of recurrence or staging compared with cTBNA (42% vs 18%, P < 0.001). cTBNA was more likely to be performed in patients suspected of having malignancy and needing diagnostic specimens (70% vs 46%, P = 0.009). The overall yield in which a diagnostic specimen or lymphoid tissue was obtained was not different in each group: EBUS 84% vs cTBNA 86% (P = 0.75). The cancer yield was 57% in cTBNAs compared with 44% in EBUS-TBNAs (P < 0.0001), with EBUS-TBNA more often targeting smaller nodes (mean 15 ± 7 mm vs 21 ± 11 mm; P < 0.0001) and paratracheal sites (67% vs 49%, P = 0.003). Per-procedure cost using a Medicare scale was higher for EBUS than it was for cTBNA ($1195 vs $808; P < 0.001). CONCLUSIONS EBUS-TBNA and cTBNA are complementary bronchoscopic procedures, and the appropriate diagnostic modality can be selected in a cost-effective manner based upon the primary indication for TBNA, lymph node size, and lymph node location.

Nasogastric tube feedings and gastric residual volume: a regional survey.

Abstract: Objectives To maintain adequate nutrition for patients who are in need, enteral feeding via nasogastric tube (NGT) is necessary. Although the literature suggests the safety of continued NGT feeding at a gastric residual volume of Methods A questionnaire was designed to evaluate nursing practice patterns regarding the decision of withholding NGT feeding based on a certain residual volume, which was distributed to the nursing staff at all major hospitals in the Oklahoma City metropolitan area. Statistical analysis was done with the Fisher exact test. All of the statistical tests were carried out at α = 0.05. Results A total of 582 nurses completed the survey. Residual volumes (milliliters) resulting in the termination of NGT feeding occurred in 89% of nurses at volumes 400 mL. Three main reasons for nurses to withhold NGT feeding were risk of aspiration (90%), potential feeding intolerance (81%), and risk of regurgitation (67%). Other less common concerns were abdominal distension and abdominal discomfort. Conclusions The decision of withholding NGT feeding varied among the nursing staff that were surveyed. A consensus is necessary for the standardization of withholding NGT feeding in clinical practice among nursing staff.