Do Internists,Pediatricians, and Psychiatrists Feel Competent in Obesity Care?

BACKGROUND  Physicians must effectively evaluate and treat obesity. To design a needs-driven curriculum intended to improve patient outcomes, physicians were surveyed about their self-perceived knowledge and skills. OBJECTIVE  The objective of this study was to determine the expressed needs of residents and faculty regarding obesity care training across three specialties. DESIGN  The study used a survey given to faculty and residents in General Internal Medicine, Pediatrics, and Psychiatry. METHODS  Survey questions were generated from comprehensive nutrition curriculum and clinical recommendations, administered online, and then organized around a validated behavioral health framework—the 5As (assess, advise, agree, assist, arrange). Analyses were conducted to evaluate differences in perceived knowledge and skills between specialties and across training levels. RESULTS  From an overall response rate of 65% (65 residents and 250 faculty members), nearly 20% reported inadequate competency in every item with 48% of respondents reporting an inability to adequately counsel patients about common treatment options. Internists reported the lowest competency in arranging referrals and follow-up. Psychiatrists reported the lowest competency in assessment skills. CONCLUSIONS  This survey demonstrated a critical need for training in specific areas of obesity care. The proposed curriculum targets these areas taking into consideration observed differences across specialties.     

Primary Care Consultations About Medically Unexplained Symptoms: How Do Patients Indicate What They Want?

Background  Patients with medically unexplained physical symptoms (MUS) are often thought to deny psychological needs when they consult general practitioners (GPs) and to request somatic intervention instead. We tested predictions from the contrasting theory that they are transparent in communicating their psychological and other needs. Objective  To test predictions that what patients tell GPs when they consult about MUS is related transparently to their desire for (1) emotional support, (2) symptom explanation and (3) somatic intervention. Design  Prospective naturalistic study. Before consultation, patients indicated what they wanted from it using a self-report questionnaire measuring patients’ desire for: emotional support, explanation and reassurance, and physical investigation and treatment. Their speech during consultation was audio-recorded, transcribed and coded utterance-by-utterance. Multilevel regression analysis tested relationships between what patients sought and what they said. Participants  Patients (N = 326) consulting 33 GPs about symptoms that the GPs designated as MUS. Results  Patients who wanted emotional support spoke more about psychosocial problems, including psychosocial causes of symptoms and their need for psychosocial help. Patients who wanted explanation and reassurance suggested more physical explanations, including diseases, but did not overtly request explanation. Patients’ wish for somatic intervention was associated only with their talk about details of such interventions and not with their requests for them. Conclusions  In general, patients with medically unexplained symptoms provide many cues to their desire for emotional support. They are more indirect or guarded in communicating their desire for explanation and somatic intervention.     

How we Provide Nutritional Treatment in Hospitalized Patients?

Background: In this study, we aimed to evaluate enteral nutrition (EN), parenteral nutrition (PN) and supplemental parenteral nutrition (SPN) in terms of achieving nutritional goals. Methods: Patients receiving either EN, PN, or SPN treatment followed up by the clinical nutrition team between January and December 2017 at the university research and training hospital were included in the study. Daily nutritional requirements were calculated according to the recommendations. Total energy intake during nutritional treatment (NT) and all metabolic, mechanical, technical complications of NT were recorded. Results: A total of 603 inpatients were included in the study. The nutritional goal was achieved in the majority of the SPN group patients (87.5%) statistically significant relation was found between the achievement of the target (or not) and PN access route (peripheral or central) (P < .001). However, none of the complications found statistically related to achieving the target, including gastrointestinal complications of EN (P = .46), metabolic complications of EN (P = .07), mechanical complications of EN (P = .79), metabolic complications of PN (P = .89), gastrointestinal complications in SPN group (P = .45), and metabolic complications in SPN group (P = .68).Conclusion: Nutritional goals could be achieved with SPN without increasing complications in the majority of patients. Commencement of SPN should be considered for positive outcomes in patients who failed to achieve desired nutritional outcomes.     

Advance Directives for Euthanasia in Dementia: How Do They Affect Resident Care in Dutch Nursing Homes? Experiences of Physicians and Relatives

OBJECTIVES: To gain insight into how advance directives for euthanasia affect resident care in Dutch nursing homes. DESIGN: Survey of elderly care physicians and additional qualitative interviews with a selection of elderly care physicians and relatives of people with dementia who had an advance directive for euthanasia. SETTING: Dutch nursing home practice. PARTICIPANTS: Four hundred thirty‐four elderly care physicians completed the general part of the questionnaire; 110 physicians provided case histories. Interviews were conducted with 11 physicians and eight relatives. MEASUREMENTS: The questionnaire contained general questions about the incidence of advance directives for euthanasia in people with dementia. A second part involved questions about the most recent case of a person with dementia and an advance directive for euthanasia who had died. The interviews with elderly care physicians and relatives focused on further exploration of the decision‐making process regarding adherence to the advance directive for euthanasia. RESULTS: Despite law‐based possibilities, advance directives for euthanasia of people with dementia were rarely adhered to, although they seem to have a supportive role in setting limitations on life‐sustaining treatments. Elderly care physicians and relatives were found to be reluctant to adhere to advance directives for euthanasia. Not being able to engage in meaningful communication played a crucial role in this reluctance. CONCLUSION: Advance directives for euthanasia are never adhered to in the Netherlands in the case of people with advanced dementia, and their role in advance care planning and end‐of‐life care of people with advanced dementia is limited. Communication with the patient is essential for elderly care physicians to consider adherence to an advance directive for euthanasia of a person with dementia.     

Do Alcoholics Anonymous Groups Really Work? Factors of Adherence in a Brazilian Sample of Hospitalized Alcohol Dependents

This study was designed to determine factors affecting adherence to Alcoholics Anonymous (AA) groups. This cohort involved 300 alcoholics committed to three hospitals in Porto Alegre, Brazil. They were interviewed again in their homes after six months. The SCID-I and a questionnaire focusing on patient relationship with AA groups were used. The responses obtained through the questionnaire were independently evaluated by two researchers. AA adherence was below 20%. The main factors reported by patients as reasons for non-adherence to AA were relapse, lack of identification with the method, lack of need, and lack of credibility. The factors reported by patients as reasons for adherence were identification with the method and a way to avoid relapse. Although AA is considered an effective intervention for alcoholism, its adherence rate was excessively low. The identification of these nonadherence factors could help health professionals in referring certain alcoholic patients to therapeutic interventions other than AA.     

What Do Long-Term Care Staff Know About the Differences Between Depression and Dementia?

A cross-sectional study was conducted of 159 long-term care staff who completed a series of questionnaires on knowledge of dementia and knowledge of depression, a series of forced-choice questions on the differentiation between dementia and depression, and a demographics questionnaire. Relative to professional staff, paraprofessional staff had lower scores in depression knowledge and differentiation knowledge. All staff had accurate knowledge of dementia. Differences in knowledge between type of staff were based on job type rather than level of education. Educational interventions about dementia have been effective in the long-term care community; however, there is a need for increased on-the-job training regarding depression in older adults in order to improve the ability to differentiate depression from dementia, especially for paraprofessional staff.     

How Much Time Do Low-Income Patients and Primary Care Physicians Actually Spend Discussing Pain? A Direct Observation Study

BACKGROUND

We know little about how much time low-income patients and physicians spend discussing pain during primary care visits.

OBJECTIVE

To measure the frequency and duration of pain-related discussions at a primary care clinic serving mostly low-income black patients; to investigate variables associated with these discussions.

DESIGN

We measured the frequency and duration of pain-related discussions using video-recorded primary care visits; we used multiple regression to evaluate associations between discussions and patient self-report variables.

PARTICIPANTS

A total of 133 patients presenting to a primary care clinic for any reason; 17 family medicine residents.

MAIN MEASURES

Independent variables were pain severity, health status, physical function, chief complaint, and whether the patient and physician had met previously. Dependent variables were presence of pain-related discussions and percent of total visit time spent discussing pain.

KEY RESULTS

Sixty-nine percent of visits included pain-related discussions with a mean duration of 5.9?min (34% of total visit time). Increasing pain severity [OR 1.69, 95% CI (1.18, 2.41)] and pain-related chief complaints [OR 4.10, 95% CI (1.39, 12.12)] were positively associated with the probability of discussing pain. When patients discussed pain, they spent 4.5% more [95% CI (0.60, 8.37)] total visit time discussing pain for every one-point increase in pain severity. Better physical function was negatively associated with the probability of discussing pain [OR 0.65, 95% CI (0.48, 0.86)], but positively associated with the percent of total visit time spent discussing pain [3% increase; 95% CI (0.32, 5.75)] for every one-point increase in physical function). Patients and physicians who had met previously spent 11% less [95% CI (-21.65, -0.55)] total visit time discussing pain. Pain severity was positively associated with time spent discussing pain only when patients and physicians had not met previously.

CONCLUSIONS

Pain-related discussions comprise a substantial proportion of time during primary care visits. Future research should evaluate the relationship between time spent discussing pain and the quality of primary care pain management.     

How Do Patients Aged 85 and Older Fare with Abdominal Surgery?

OBJECTIVES: To review the outcomes of patients aged 85 and older after abdominal surgery in terms of mortality, morbidity, and change in residential status and to analyze factors predicting such outcomes.
DESIGN: Retrospective clinical cohort study.
SETTING: A tertiary regional hospital in Victoria, Australia.
PARTICIPANTS: One hundred seventy-nine patients aged 85 and older who had abdominal surgery between 1998 and 2008.
MEASUREMENTS: Mortality, complications (morbidity), and change in residential status.
RESULTS: The patient sample had a mean age of 88.6, a mortality rate of 17.3%, and a morbidity rate of 62.8%. Approximately two-thirds (64%) of all abdominal surgeries were emergency surgeries. Factors predicting mortality included American Society of Anesthesiologists (ASA) score and premorbid residential status. Risk factors predicting severity of complications were ASA score and emergency surgery. Significant factors contributing to change in residential status were ASA score and severity of complications. Age, sex, and number of comorbidities were not significant factors.
CONCLUSION: Patients aged 85 and older experienced mortality rates of 17.3% after abdominal surgery. ASA score and premorbid residential status appear to be more important than age in determining risk for abdominal surgery in older persons.     

Quality of Care in Patients with Gout: Why is Management Suboptimal and What Can Be Done About It?

Gout is a common inflammatory arthritis. We know a great deal about its etiopathogenesis and have relatively safe and effective therapies for it. Gout, however, remains a poorly managed disease with mistakes made in securing an accurate diagnosis and in using appropriate therapies for acute and chronic stages of the disease. Synovial fluid analysis with polarizing microscopy is the “gold standard” for confirming the diagnosis of gout but has been used in fewer than 10% of all patients diagnosed with gout. The newly adopted European clinical guidelines offer a practical alternative to synovial fluid analysis, but primary care physicians are not well-versed in their use. Other serious errors in the management of gout are related to the use of medications to treat acute and chronic gout. Frequently, the anti-inflammatory drugs used to treat acute symptoms and urate-lowering drugs used to prevent long-term destruction are improperly dosed, leading to dissatisfaction on the part of patients and physicians. Widespread education about evidence-based diagnostic and treatment guidelines is desperately needed.