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1.
James E. Aikens Ranak Trivedi David C. Aron John D. Piette 《Journal of general internal medicine》2015,30(3):319-326
Objective
The purpose of this study was to investigate the potential benefits for medication adherence of integrating a patient-selected support person into an automated diabetes telemonitoring and self-management program, and to determine whether these benefits vary by patients’ baseline level of psychological distress.Study Design
The study was a quasi-experimental patient preference trial.Methods
The study included patients with type 2 diabetes who participated in three to six months of weekly automated telemonitoring via interactive voice response (IVR) calls, with the option of designating a supportive relative or friend to receive automated updates on the patient’s health and self-management, along with guidance regarding potential patient assistance. We measured long-term medication adherence using the four-point Morisky Medication Adherence Scale (MMAS-4, possible range 0–4), weekly adherence with an IVR item, and psychological distress at baseline with the Mental Composite Summary (MCS) of the SF-12.Results
Of 98 initially nonadherent patients, 42 % opted to involve a support person. Participants with a support person demonstrated significantly greater improvement in long-term adherence than those who participated alone (linear regression slopes: −1.17 vs. −0.57, respectively, p =0.001). Among distressed patients in particular, the odds of weekly nonadherence tended to decrease 25 % per week for those with a support person (p =0.030), yet remained high for those who participated alone (p =0.820).Conclusions
Despite their multiple challenges in illness self-management, patients with diabetes who are both nonadherent and psychologically distressed may benefit by the incorporation of a support person when they receive assistance via automated telemonitoring.KEY WORDS: diabetes, telehealth, primary care, care management 相似文献2.
3.
Julie Silverman James Krieger Meghan Kiefer Paul Hebert June Robinson Karin Nelson 《Journal of general internal medicine》2015,30(10):1476-1480
BACKGROUND
Food insecurity— lack of dependable access to adequate food—may play a role in poor diabetes control.OBJECTIVE
We aimed to determine the relationship between food security status and depression, diabetes distress, medication adherence and glycemic control.DESIGN
Secondary analysis of baseline data from Peer Support for Achieving Independence in Diabetes, a randomized controlled trial that enrolled patients from November 2011 to October 2013.PARTICIPANTS
Participants had poorly controlled type 2 diabetes (A1c ≥ 8.0 % on eligibility screen), household income < 250 % of the federal poverty level, were 30–70 years old, and were recruited from a large public hospital, a VA medical center and a community-health center in King County, Washington.MAIN MEASURES
We measured food insecurity determined by the Department of Agriculture’s 6-Item Food Security Module. Depression, diabetes distress and medication adherence measured by PHQ-8, Diabetes Distress Scale and Morisky Medication Adherence Scale, respectively. Diet was assessed through Summary of Diabetes Self-Care Activities and Starting the Conversation tool. Incidence of hypoglycemic episodes was by patient report. Glycemic control was assessed with glycosylated hemoglobin (A1c) values from fingerstick blood sample.KEY RESULTS
The prevalence of food insecurity was 47.4 %. Chi-square tests revealed participants with food insecurity were more likely to be depressed (40.7 % vs. 15.4 %, p < 0.001), report diabetes distress (55.2 % vs. 33.8 %, p < 0.001) and have low medication adherence (52.9 % vs. 37.2 %, p = 0.02). Based on linear regression modeling, those with food insecurity had significantly higher mean A1c levels (β = 0.51; p = 0.02) after adjusting for sex, age, race/ethnicity, language, education, marital status, BMI, insulin use, depression, diabetes distress and low medication adherence.CONCLUSIONS
Almost half of participants had food insecurity. Food insecurity was associated with depression, diabetes distress, low medication adherence and worse glycemic control. Even with adjustment, people with food insecurity had higher mean A1c levels than their food-secure counterparts, suggesting there may be other mediating factors, such as diet, that explain the relationship between food security status and diabetes control.KEY WORDS: food insecurity, diabetes, glycemic control 相似文献4.
Kong MC Nahata MC Lacombe VA Seiber EE Balkrishnan R 《Journal of general internal medicine》2012,27(9):1159-1164
Background
Racial disparities exist in many aspects of HIV/AIDS. Comorbid depression adds to the complexity of disease management. However, prior research does not clearly show an association between race and antiretroviral therapy (ART) adherence, or depression and adherence. It is also not known whether the co-existence of depression modifies any racial differences that may exist.Objective
To examine racial differences in ART adherence and whether the presence of comorbid depression moderates these differences among Medicaid-enrolled HIV-infected patients.Design
Retrospective cohort study.Setting
Multi-state Medicaid database (Thomson Reuters MarketScan®).Participants
Data for 7,034 HIV-infected patients with at least two months of antiretroviral drug claims between 2003 and 2007 were assessed.Main Measures
Antiretroviral therapy adherence (90 % days covered) were measured for a 12-month period. The main independent variables of interest were race and depression. Other covariates included patient variables, clinical variables (comorbidity and disease severity), and therapy-related variables.Key Results
In this study sample, over 66 % of patients were of black race, and almost 50 % experienced depression during the study period. A significantly higher portion of non-black patients were able to achieve optimal adherence (≥90 %) compared to black patients (38.6 % vs. 28.7 %, p < 0.001). In fact, black patients had nearly 30 % decreased odds of being optimally adherent to antiretroviral drugs compared to non-black patients (OR = 0.70, 95 % CI: 0.63–0.78), and was unchanged regard less of whether the patient had depression. Antidepressant treatment nearly doubled the odds of optimal ART adherence among patients with depression (OR = 1.92, 95 % CI: 1.12–3.29).Conclusions
Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. Under-diagnosis and under-treatment of depression may hinder ART adherence among HIV-infected patients of all races.KEY WORDS: HIV, adherence, depression, race, Medicaid 相似文献5.
Anastasia Sofianou MS Melissa Martynenko MPA MPH Michael S. Wolf PhD MPH Juan P. Wisnivesky MD DrPH Katherine Krauskopf MD MPH Elizabeth A. H. Wilson PhD Mita Sanghavi Goel MD MPH Howard Leventhal PhD Ethan A. Halm MD MPH Alex D. Federman MD MPH 《Journal of general internal medicine》2013,28(1):67-73
BACKGROUND
Empirical research and health policies on asthma have focused on children and young adults, even though asthma morbidity and mortality are higher among older asthmatics.OBJECTIVE
To explore the relationship of asthma-related beliefs and self-reported controller medication adherence in older asthmatics.DESIGN
An observational study of asthma beliefs and self-management among older adults.PARTICIPANTS
Asthmatics ages ≥60 years (N = 324, mean age 67.4 ± 6.8, 28 % white, 32 % black, 30 % Hispanic) were recruited from primary care practices in New York City and Chicago.MAIN MEASURES
Self-reported controller medication adherence was assessed using the Medication Adherence Report Scale. Based on the Common Sense Model of Self-Regulation, patients were asked if they believe they only have asthma with symptoms, their physician can cure their asthma, and if their asthma will persist. Beliefs on the benefit, necessity and concerns of treatment use were also assessed. Multivariate logistic regression was used to examine the association of beliefs with self-reported medication adherence.KEY RESULTS
The majority (57.0 %) of patients reported poor adherence. Poor self-reported adherence was more common among those with erroneous beliefs about asthma illness and treatments, including the “no symptoms, no asthma” belief (58.7 % vs. 31.7 %, respectively, p < 0.001), “will not always have asthma” belief (34.8 % vs. 12.5 %, p < 0.001), and the “MD can cure asthma” belief (21.7 % vs. 9.6 %, p = 0.01). Adjusting for illness beliefs, treatment beliefs and demographics, patients with a “no symptoms, no asthma” belief had lower odds of having good self-reported adherence (odds ratio [OR] 0.45, 95 % confidence interval [CI] 0.23-0.86), as did those with negative beliefs about the benefits (OR 0.73, 95 % CI 0.57-0.94) and necessity (OR 0.89, 95 % CI 0.83-0.96) of treatment.CONCLUSIONS
Illness and treatment beliefs have a strong influence on self-reported medication adherence in older asthmatics. Interventions to improve medication adherence in older asthmatics by modifying illness and treatment beliefs warrant study.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2160-z) contains supplementary material, which is available to authorized users.KEY WORDS: asthma, disease management, medication adherence, aging, health beliefs. 相似文献6.
Laura Panattoni Ashley Stone Sukyung Chung Ming Tai-Seale 《Journal of general internal medicine》2015,30(3):327-333
BACKGROUND
The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient’s experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes.OBJECTIVE
We aimed to examine the relationships between a physicians’ clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician.DESIGN
We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010.PARTICIPANTS
The study included family medicine (n = 104) and internal medicine (n = 101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n = 12,688).MAIN MEASURES
Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0–100 % scale, were measured. Access to care was measured as days to the third next-available appointment.KEY RESULTS
Physician FTE was directly associated with better continuity of care received (0.172 % per FTE, p < 0.001), better continuity of care provided (0.108 % per FTE, p < 0.001), and better access to care (−0.033 days per FTE, p < 0.01), but worse patient satisfaction scores (−0.080 % per FTE, p = 0.03). The continuity of care provided was a significant mediator (0.016 % per FTE, p < 0.01) of the relationship between FTE and patient satisfaction; but overall, reduced clinical work hours were associated with better patient satisfaction (−0.053 % per FTE, p = 0.03).CONCLUSIONS
These results suggest that PCPs who choose to work fewer clinical hours may have worse continuity and access, but they may provide a better patient experience. Physician workforce planning should consider these care attributes when considering the role of part-time PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-014-3104-6) contains supplementary material, which is available to authorized users.KEY WORDS: part-time work, continuity of care, access to care, patient satisfaction 相似文献7.
Michael D. Stein Debra S. Herman Genie L. Bailey John Straus Bradley J. Anderson Lisa A. Uebelacker Risa B. Weisberg 《Journal of general internal medicine》2015,30(7):935-941
BACKGROUND
Pain and depression are each prevalent among opioid dependent patients receiving maintenance buprenorphine, but their interaction has not been studied in primary care patients.OBJECTIVE
We set out to examine the relationship between chronic pain, depression, and ongoing substance use, among persons maintained on buprenorphine in primary care settings.DESIGN
Between September 2012 and December 2013, we interviewed buprenorphine patients at three practice sites.PARTICIPANTS
Opioid dependent persons at two private internal medicine offices and a federally qualified health center participated in the study.MAIN MEASURES
Pain was measured in terms of chronicity, with chronic pain being defined as pain lasting at least 6 months; and in terms of severity, as measured by self-reported pain in the past week, measured on a 0–100 scale. We defined mild chronic pain as pain severity between 0 and 39 and lasting at least 6 months, and moderate/severe chronic pain as severity ≥ 40 and lasting at least 6 months. To assess depression, we used the Center for Epidemiologic Studies Depression (CESD) ten-item symptom scale and the two-item Patient Health Questionnaire (PHQ-2).KEY RESULTS
Among 328 participants, 169 reported no chronic pain, 56 reported mild chronic pain, and 103 reported moderate/severe chronic pain. Participants with moderate/severe chronic pain commonly used non-opioid pain medications (56.3 %) and antidepressants (44.7 %), yet also used marijuana, alcohol, or cocaine (40.8 %) to help relieve pain. Mean CESD scores were 7.1 (±6.8), 8.3 (±6.0), and 13.6 (±7.6) in the no chronic, mild, and moderate/severe pain groups, respectively. Controlling for covariates, higher CESD scores were associated with a higher likelihood of moderate/severe chronic pain relative to both no chronic pain (OR = 1.09, p < 0.001) and mild chronic pain (OR = 1.06, p = 0.04).CONCLUSION
Many buprenorphine patients are receiving over-the-counter or prescribed pain medications, as well as antidepressants, and yet continue to have significant and disabling pain and depressive symptoms. There is a clear need to address the pain–depression nexus in novel ways.KEY WORDS: buprenorphine, chronic pain, depression 相似文献8.
Sunil Kripalani MD MSc Brian Schmotzer MS Terry A. Jacobson MD 《Journal of general internal medicine》2012,27(12):1609-1617
Background
Up to 50 % of patients do not take medications as prescribed. Interventions to improve adherence are needed, with an understanding of which patients benefit most.Objective
To test the effect of two low-literacy interventions on medication adherence.Design
Randomized controlled trial, 2 × 2 factorial design.Participants
Adults with coronary heart disease in an inner-city primary care clinic.Interventions
For 1 year, patients received usual care, refill reminder postcards, illustrated daily medication schedules, or both interventions.Main Measures
The primary outcome was cardiovascular medication refill adherence, assessed by the cumulative medication gap (CMG). Patients with CMG < 0.20 were considered adherent. We assessed the effect of the interventions overall and, post-hoc, in subgroups of interest.Key Results
Most of the 435 participants were elderly (mean age = 63.7 years), African-American (91 %), and read below the 9th-grade level (78 %). Among the 420 subjects (97 %) for whom CMG could be calculated, 138 (32.9 %) had CMG < 0.20 during follow-up and were considered adherent. Overall, adherence did not differ significantly across treatments: 31.2 % in usual care, 28.3 % with mailed refill reminders, 34.2 % with illustrated medication schedules, and 36.9 % with both interventions. In post-hoc analyses, illustrated medication schedules led to significantly greater odds of adherence among patients who at baseline had more than eight medications (OR = 2.2; 95 % CI, 1.21 to 4.04) or low self-efficacy for managing medications (OR = 2.15; 95 % CI, 1.11 to 4.16); a trend was present among patients who reported non-adherence at baseline (OR = 1.89; 95 % CI, 0.99 to 3.60).Conclusions
The interventions did not improve adherence overall. Illustrated medication schedules may improve adherence among patients with low self-efficacy, polypharmacy, or baseline non-adherence, though this requires confirmation.KEY WORDS: coronary heart disease, medical adherence, medication management 相似文献9.
Areej El-Jawahri Susan L. Mitchell Michael K. Paasche-Orlow Jennifer S. Temel Vicki A. Jackson Renee R. Rutledge Mihir Parikh Aretha D. Davis Muriel R. Gillick Michael J. Barry Lenny Lopez Elizabeth S. Walker-Corkery Yuchiao Chang Kathleen Finn Christopher Coley Angelo E. Volandes 《Journal of general internal medicine》2015,30(8):1071-1080
BACKGROUND
Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided.OBJECTIVES
We aimed to examine the impact of a video decision tool for CPR and intubation on patients’ choices, knowledge, medical orders, and discussions with providers.DESIGN
This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston.PARTICIPANTS
One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51 % were women.INTERVENTION
Three-minute video describing CPR and intubation plus verbal communication of participants’ preferences to their physicians (intervention) (N = 75) or control arm (usual care) (N = 75).MAIN MEASURES
The primary outcome was participants’ preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants’ knowledge of CPR/ intubation (five-item test, range 0–5, higher scores indicate greater knowledge).RESULTS
Intervention participants (vs. controls) were more likely not to want CPR (64 % vs. 32 %, p <0.0001) and intubation (72 % vs. 43 %, p < 0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57 % vs. 19 %, p < 0.0001) and intubation (64 % vs.19 %, p < 0.0001) by hospital discharge, documented discussions about their preferences (81 % vs. 43 %, p < 0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p < 0.0001).CONCLUSIONS
Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers.Trial registration: Clinicaltrials.gov Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients. NCT01325519相似文献10.
BACKGROUND
Depression is common among individuals with osteoarthritis and leads to increased healthcare burden. The objective of this study was to examine excess total healthcare expenditures associated with depression among individuals with osteoarthritis in the US.DESIGN
Adults with self-reported osteoarthritis (n = 1881) were identified using data from the 2010 Medical Expenditure Panel Survey (MEPS). Among those with osteoarthritis, chi-square tests and ordinary least square regressions (OLS) were used to examine differences in healthcare expenditures between those with and without depression. Post-regression linear decomposition technique was used to estimate the relative contribution of different constructs of the Anderson’s behavioral model, i.e., predisposing, enabling, need, personal healthcare practices, and external environment factors, to the excess expenditures associated with depression among individuals with osteoarthritis. All analysis accounted for the complex survey design of MEPS.KEY RESULTS
Depression coexisted among 20.6 % of adults with osteoarthritis. The average total healthcare expenditures were $13,684 among adults with depression compared to $9284 among those without depression. Multivariable OLS regression revealed that adults with depression had 38.8 % higher healthcare expenditures (p < 0.001) compared to those without depression. Post-regression linear decomposition analysis indicated that 50 % of differences in expenditures among adults with and without depression can be explained by differences in need factors.CONCLUSIONS
Among individuals with coexisting osteoarthritis and depression, excess healthcare expenditures associated with depression were mainly due to comorbid anxiety, chronic conditions and poor health status. These expenditures may potentially be reduced by providing timely intervention for need factors or by providing care under a collaborative care model.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-015-3393-4) contains supplementary material, which is available to authorized users.KEY WORDS: depression, osteoarthritis, expenditures, decomposition, Anderson model 相似文献11.
12.
Karen L. Margolis Stephen E. Asche Anna R. Bergdall Steven P. Dehmer Michael V. Maciosek Rachel A. Nyboer Patrick J. O’Connor Pamala A. Pawloski JoAnn M. Sperl-Hillen Nicole K. Trower Ann D. Tucker Beverly B. Green 《Journal of general internal medicine》2015,30(11):1665-1672
Background
It is important to understand which components of successful multifaceted interventions are responsible for study outcomes, since some components may be more important contributors to the intervention effect than others.Objective
We conducted a mediation analysis to determine which of seven factors had the greatest effect on change in systolic blood pressure (BP) after 6 months in a trial to improve hypertension control.Design
The study was a preplanned secondary analysis of a cluster-randomized clinical trial. Eight clinics in an integrated health system were randomized to provide usual care to their patients (n = 222), and eight were randomized to provide a telemonitoring intervention (n = 228).Participants
Four hundred three of 450 trial participants completing the 6-month follow-up visit were included.Interventions
Intervention group participants received home BP telemonitors and transmitted measurements to pharmacists, who adjusted medications and provided advice to improve adherence to medications and lifestyle modification via telephone visits.Main measures
Path analytic models estimated indirect effects of the seven potential mediators of intervention effect (defined as the difference between the intervention and usual care groups in change in systolic BP from baseline to 6 months). The potential mediators were change in home BP monitor use, number of BP medication classes, adherence to BP medications, physical activity, salt intake, alcohol use, and weight.Key Results
The difference in change in systolic BP was 11.3 mmHg. The multivariable mediation model explained 47 % (5.3 mmHg) of the intervention effect. Nearly all of this was mediated by two factors: an increase in medication treatment intensity (24 %) and increased home BP monitor use (19 %). The other five factors were not significant mediators, although medication adherence and salt intake improved more in the intervention group than in the usual care group.Conclusions
Most of the explained intervention effect was attributable to the combination of self-monitoring and medication intensification. High adherence at baseline and the relatively low intensity of resources directed toward lifestyle change may explain why these factors did not contribute to the improvement in BP.KEY WORDS: Blood pressure, Hypertension, Randomized trial, Mediation, Telemonitoring, Case management 相似文献13.
14.
Sean M. Phelan Diana J. Burgess Rebecca Puhl Liselotte N. Dyrbye John F. Dovidio Mark Yeazel Jennifer L. Ridgeway David Nelson Sylvia Perry Julia M. Przedworski Sara E. Burke Rachel R. Hardeman Michelle van Ryn 《Journal of general internal medicine》2015,30(9):1251-1258
BACKGROUND
The stigma of obesity is a common and overt social bias. Negative attitudes and derogatory humor about overweight/obese individuals are commonplace among health care providers and medical students. As such, medical school may be particularly threatening for students who are overweight or obese.OBJECTIVE
The purpose of our study was to assess the frequency that obese/overweight students report being stigmatized, the degree to which stigma is internalized, and the impact of these factors on their well-being.DESIGN
We performed cross-sectional analysis of data from the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES) survey.PARTICIPANTS
A total of 4,687 first-year medical students (1,146 overweight/obese) from a stratified random sample of 49 medical schools participated in the study.MAIN MEASURES
Implicit and explicit self-stigma were measured with the Implicit Association Test and Anti-Fat Attitudes Questionnaire. Overall health, anxiety, depression, fatigue, self-esteem, sense of mastery, social support, loneliness, and use of alcohol/drugs to cope with stress were measured using previously validated scales.KEY RESULTS
Among obese and overweight students, perceived stigma was associated with each measured component of well-being, including anxiety (beta coefficient [b] = 0.18; standard error [SE] = 0.03; p < 0.001) and depression (b = 0.20; SE = 0.03; p < 0.001). Among the subscales of the explicit self-stigma measure, dislike of obese people was associated with several factors, including depression (b = 0.07; SE = 0.01; p < 0.001), a lower sense of mastery (b = −0.10; SE = 0.02; p < 0.001), and greater likelihood of using drugs or alcohol to cope with stress (b = 0.05; SE = 0.01; p < 0.001). Fear of becoming fat was associated with each measured component of well-being, including lower body esteem (b = −0.25; SE = 0.01; p < 0.001) and less social support (b = −0.06; SE = 0.01; p < 0.001). Implicit self-stigma was not consistently associated with well-being factors. Compared to normal-weight/underweight peers, overweight/obese medical students had worse overall health (b = −0.33; SE = 0.03; p < 0.001) and body esteem (b = −0.70; SE = 0.02; p < 0.001), and overweight/obese female students reported less social support (b = −0.12; SE = 0.03; p < 0.001) and more loneliness (b = 0.22; SE = 0.04; p < 0.001).CONCLUSIONS
Perceived and internalized weight stigma may contribute to worse well-being among overweight/obese medical students.KEY WORDS: Medical students, Stigmatization, Psychological stress, Obesity, Body weightTo succeed academically and professionally, medical students must withstand the stress of medical school, including learning new and complex material, meeting faculty expectations, interacting with patients, making new friends and colleagues, and assimilating the culture of medicine.1–3 Ability to cope with stress is important to health and professional development, as medical student stress is linked to burnout, substance use, mental health problems, suicidal thoughts, and poor academic performance.1,4–6 Stress also disproportionately affects female medical students, who may then be more vulnerable to these outcomes.5,7–9Self-esteem, physical and emotional health, fatigue, sense of mastery, and social support all affect vulnerability to stress.10,11 Members of stigmatized groups, including overweight/obese individuals, may face additional stress.12–17 Experiences of weight-related stigma can have negative effects on self-esteem, health, and well-being.12–14,17–23 Overweight/obese individuals may also be self-stigmatized, i.e., exhibit negative, self-deprecating attitudes about themselves, which may worsen their overall well-being.24–26These additional stressors may challenge students’ ability to cope in the competitive medical school environment. Although little is known about the experience of these medical students, several studies have documented strong anti-fat attitudes among health care providers and trainees,27–31 and suggest that overweight/obese individuals are a common target of derogatory humor among medical students.32,33The present study aimed to assess whether stigma or self-stigma is associated with factors that affect vulnerability to stress among overweight and obese medical students. We hypothesized that 1) these medical students, and female students in particular, have worse self-reported outcomes than normal-weight/underweight medical students on factors affecting vulnerability to stress; and that 2) among overweight/obese students, experiencing more stigma/self-stigma is associated with worse outcomes. 相似文献15.
V Kacinik M Lyon M Purnama R A Reimer R Gahler T J Green S Wood 《Nutrition & diabetes》2011,1(12):e22
Introduction:
Dietary factors that help control perceived hunger might improve adherence to calorie-reduced diets.Objectives:
The objective of the study was to investigate the effect of supplementing a three-day, low-calorie diet with PolyGlycopleX (PGX), a highly viscous fibre, on subjective ratings of appetite compared with a placebo.Methods:
In a double-blind crossover design with a 3-week washout, 45 women (aged 38±9 years, body mass index 29.9±2.8 kg m−2) were randomised to consume a 1000-kcal per day diet for 3 days, supplemented with 5 g of PGX or placebo at each of breakfast, lunch and dinner. Subjective appetite was assessed using 100 mm visual analogue scales that were completed daily before, between and after consumption of meals.Results:
Thirty-five women completed the study. Consumption of PGX compared with placebo led to significantly lower mean area under the curve for hunger on day 3 (440.4 versus 375.4; P=0.048), prospective consumption on day 3 (471.0 versus 401.8; P=0.017) and the overall 3-day average (468.6 versus 420.2; P=0.026). More specifically, on day 3 PGX significantly reduced total appetite, hunger, desire to eat and prospective consumption for 2.5 and 4.5 h after lunch and before dinner times, with hunger also being reduced 2.5 h after dinner (P<0.05).Conclusion:
The results show that adding 5 g of PGX to meals during consumption of a low-calorie diet reduces subjective ratings of prospective consumption and increases the feelings of satiety, especially during afternoon and evening. This highly viscous polysaccharide may be a useful adjunct to weight-loss interventions involving significant caloric reductions. 相似文献16.
Bin Wu Thomas J Buddensick Hamid Ferdosi Dusty Marie Narducci Amanda Sautter Lisa Setiawan Haroon Shaukat Mustafa Siddique Gisela N Sulkowski Farin Kamangar Gopal C Kowdley Steven C Cunningham 《HPB : the official journal of the International Hepato Pancreato Biliary Association》2014,16(9):801-806
Background
Gangrenous cholecystitis (GC) is often challenging to treat. The objectives of this study were to determine the accuracy of pre-operative diagnosis, to assess the rate of post-cholecystectomy complications and to assess models to predict GC.Methods
A retrospective single-institution review identified patients undergoing a cholecystectomy. Logistic regression models were used to examine the association of variables with GC and to build risk-assessment models.Results
Of 5812 patients undergoing a cholecystectomy, 2219 had acute, 4837 chronic and 351 GC. Surgeons diagnosed GC pre-operatively in only 9% of cases. Patients with GC had more complications, including bile-duct injury, increased estimated blood loss (EBL) and more frequent open cholecystectomies. In unadjusted analyses, variables significantly associated with GC included: age > 45 years, male gender, heart rate (HR) > 90, white blood cell count (WBC) > 13 000/mm3, gallbladder wall thickening (GBWT) ≥ 4 mm, pericholecystic fluid (PCCF) and American Society of Anesthesiology (ASA) > 2. In adjusted analyses, age, WBC, GBWT and HR, but not gender, PCCF or ASA remained statistically significant. A 5-point scoring system was created: 0 points gave a 2% probability of GC and 5 points a 63% probability.Conclusion
Using models can improve a diagnosis of GC pre-operatively. A prediction of GC pre-operatively may allow surgeons to be better prepared for a difficult operation. 相似文献17.
S. Beth Bierer Elaine F. Dannefer John E. Tetzlaff 《Journal of general internal medicine》2015,30(9):1339-1343
BACKGROUND
Remediation in the era of competency-based assessment demands a model that empowers students to improve performance.AIM
To examine a remediation model where students, rather than faculty, develop remedial plans to improve performance.SETTING/PARTICIPANTS
Private medical school, 177 medical students.PROGRAM DESCRIPTION
A promotion committee uses student-generated portfolios and faculty referrals to identify struggling students, and has them develop formal remediation plans with personal reflections, improvement strategies, and performance evidence. Students submit reports to document progress until formally released from remediation by the promotion committee.PROGRAM EVALUATION
Participants included 177 students from six classes (2009–2014). Twenty-six were placed in remediation, with more referrals occurring during Years 1 or 2 (n = 20, 76 %). Unprofessional behavior represented the most common reason for referral in Years 3–5. Remedial students did not differ from classmates (n = 151) on baseline characteristics (Age, Gender, US citizenship, MCAT) or willingness to recommend their medical school to future students (p < 0.05). Two remedial students did not graduate and three did not pass USLME licensure exams on first attempt. Most remedial students (92 %) generated appropriate plans to address performance deficits.DISCUSSION
Students can successfully design remedial interventions. This learner-driven remediation model promotes greater autonomy and reinforces self-regulated learning.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-015-3343-1) contains supplementary material, which is available to authorized users. 相似文献18.
Acute sleep deprivation delays the glucagon-like peptide 1 peak response to breakfast
in healthy men
Objective:
Previous experiments have demonstrated that acute sleep loss impairs glucose homeostasis and increases food intake in humans. The incretin hormone glucagon-like peptide 1 (GLP-1) enhances postprandial insulin secretion and promotes satiety. Hypothesizing that the detrimental metabolic effects of sleep curtailment imply alterations in GLP-1 signaling, we investigated 24-h serum total GLP-1 concentrations during total sleep deprivation (TSD) and a normal sleep/wake cycle (comprising ∼8 h of sleep) in 12 healthy young men.Methods:
Sessions started at 1800 h, and subjects were provided with standardized meals. Assessments of serum GLP-1 took place in 1.5- to 3-h intervals, focusing on the response to breakfast intake (3.8 MJ).Results:
Across conditions, 24-h concentration profiles of GLP-1 were characterized by the expected postprandial increases (P<0.001). Although there were no differences in magnitude between conditions (P>0.11), the postprandial GLP-1 peak response to breakfast intake was delayed by ∼90 min following sleep loss in comparison with regular sleep (P<0.02).Conclusions:
Results indicate that acute TSD exerts a mild, but discernible effect on the postprandial dynamics of circulating GLP-1 concentrations in healthy men. 相似文献19.
Elissa V. Klinger Sara V. Carlini Irina Gonzalez Stella St. Hubert Jeffrey A. Linder Nancy A. Rigotti Emily Z. Kontos Elyse R. Park Lucas X. Marinacci Jennifer S. Haas 《Journal of general internal medicine》2015,30(6):719-723
BACKGROUND
Collection of data on race, ethnicity, and language preference is required as part of the “meaningful use” of electronic health records (EHRs). These data serve as a foundation for interventions to reduce health disparities.OBJECTIVE
Our aim was to compare the accuracy of EHR-recorded data on race, ethnicity, and language preference to that reported directly by patients.DESIGN/SUBJECTS/MAIN MEASURES
Data collected as part of a tobacco cessation intervention for minority and low-income smokers across a network of 13 primary care clinics (n = 569).KEY RESULTS
Patients were more likely to self-report Hispanic ethnicity (19.6 % vs. 16.6 %, p < 0.001) and African American race (27.0 % vs. 20.4 %, p < 0.001) than was reported in the EHR. Conversely, patients were less likely to complete the survey in Spanish than the language preference noted in the EHR suggested (5.1 % vs. 6.3 %, p < 0.001). Thirty percent of whites self-reported identification with at least one other racial or ethnic group, as did 37.0 % of Hispanics, and 41.0 % of African Americans. Over one-third of EHR-documented Spanish speakers elected to take the survey in English. One-fifth of individuals who took the survey in Spanish were recorded in the EHR as English-speaking.CONCLUSION
We demonstrate important inaccuracies and the need for better processes to document race/ ethnicity and language preference in EHRs.KEY WORDS: disparities, race, ethnicity, health information technology 相似文献20.
Wenli Ouyang Monica M. Cuddy David B. Swanson 《Journal of general internal medicine》2015,30(9):1307-1312