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1.
C.?C.?Moor M.?J.?G.?van?Manen P.?M.?van?Hagen J.?R.?Miedema L.?M.?van den?Toorn Y.?Gür-Demirel A.?P.?C.?Berendse J.?A.?M.?van?Laar M.?S.?Wijsenbeek
Objectives
Sarcoidosis is a chronic, multisystem disease with often a major impact on quality of life. Information on unmet needs of patients and their partners is lacking. We assessed needs and perceptions of sarcoidosis patients and their partners.Methods
During patient information meetings in 2015 and 2017 in the Erasmus University Medical Center, we interviewed patients and partners using interactive voting boxes. Patients responded anonymously to 17 questions. Answers were projected directly on the screen in the room.Results
210 patients and 132 partners participated. Sarcoidosis has a subjective significant impact on lives of both patients and partners. The vast majority of patients and partners feel regularly misunderstood because of the general unawareness of sarcoidosis. Many patients and partners experience anxiety. Three-quarters of patients would like to see more attention and support for their psychological problems. Additionally, more supportive care for partners of sarcoidosis patients is warranted. Interactive interviewing was considered educational (91%) and pleasant (84%).Discussion
This study improves awareness of needs and perceptions of patients with sarcoidosis and their partners. Sarcoidosis leads to anxiety and psychological distress and impairs well-being of patients and their partners. Attention for psychological support, better disease education, and more supportive care for partners is warranted.2.
Sebastian Uijtdehaage Karen E. Hauer Margaret Stuber Shobita Rajagopalan Vay L. Go LuAnn Wilkerson 《Journal of general internal medicine》2009,24(2):491
BACKGROUND
Cancer survivorship care is not adequately addressed in current medical school curricula.OBJECTIVES
To develop, implement, and evaluate a modular cancer survivorship curriculum that is portable to other educational settings and is designed to provide medical students with a foundation of knowledge, attitudes, and skills related to care for cancer survivors.PROGRAM DESCRIPTION
An expert consensus panel developed a set of learning objectives related to cancer survivorship to guide the development of educational modules, such as computer-based self-instructional modules, problem-based learning cases, videos, and clinical exercises. Course and clerkship chairs were directly involved in the development and implementation of the modules.EVALUATION
A cohort study with a historical control group demonstrated that fourth-year medical students increased their knowledge in survivorship issues and their self-reported level of comfort in care activities compared to similar students who did not receive the survivorship curriculum.CONCLUSIONS
Our framework resulted in a cancer survivorship curriculum that was implemented in a modular manner across the medical curriculum that improved learning and that is potentially portable to other educational settings.3.
Elliott J. Goytia David W. Lounsbury Mary S. McCabe Elisa Weiss Meghan Newcomer Deena J. Nelson Debra Brennessel Bruce D. Rapkin M. Margaret Kemeny 《Journal of general internal medicine》2009,24(2):451
INTRODUCTION
Many cancer centers and community hospitals are developing novel models of survivorship care. However, few are specifically focused on services for socio-economically disadvantaged cancer survivors.AIMS
To describe a new model of survivorship care serving culturally diverse, urban adult cancer patients and to present findings from a feasibility evaluation.SETTING
Adult cancer patients treated at a public city hospital cancer center.PROGRAM DESCRIPTION
The clinic provides comprehensive medical and psychosocial services for patients within a public hospital cancer center where they receive their oncology care.PROGRAM EVALUATION
Longitudinal data collected over a 3-year period were used to describe patient demographics, patient needs, and services delivered. Since inception, 410 cancer patients have been served. Demand for services has grown steadily. Hypertension was the most frequent comorbid condition treated. Pain, depression, cardiovascular disease, hyperlipidemia, and bowel dysfunction were the most common post-treatment problems experienced by the patients. Financial counseling was an important patient resource.DISCUSSION
This new clinical service has been well-integrated into its public urban hospital setting and constitutes an innovative model of health-care delivery for socio-economically challenged, culturally diverse adult cancer survivors.4.
5.
Purpose of Review
The purposes of this review are to identify population characteristics of important risk factors for the development and progression of diabetic kidney disease (DKD) in the United States and to discuss barriers and opportunities to improve awareness, management, and outcomes in patients with DKD.Recent Findings
The major risk factors for the development and progression of DKD include hyperglycemia, hypertension, and albuminuria. DKD disproportionately affects minorities and individuals with low educational and socioeconomic status. Barriers to effective management of DKD include the following: (a) limited patient and healthcare provider awareness of DKD, (b) lack of timely referrals of patients to a nephrologist, (c) low patient healthcare literacy, and (d) insufficient access to healthcare and health insurance.Summary
Increased patient and physician awareness of DKD has been shown to enhance patient outcomes. Multifactorial and multidisciplinary interventions targeting multiple risk factors and patient/physician education may provide better outcomes in patients with DKD.6.
Simone P. Rauh Femke Rutters Amber A. W. A. van der Heijden Thomas Luimes Marjan Alssema Martijn W. Heymans Dianna J. Magliano Jonathan E. Shaw Joline W. Beulens Jacqueline M. Dekker 《Journal of general internal medicine》2018,33(2):182-188
Background
Chronic cardiometabolic diseases, including cardiovascular disease (CVD), type 2 diabetes (T2D) and chronic kidney disease (CKD), share many modifiable risk factors and can be prevented using combined prevention programs. Valid risk prediction tools are needed to accurately identify individuals at risk.Objective
We aimed to validate a previously developed non-invasive risk prediction tool for predicting the combined 7-year-risk for chronic cardiometabolic diseases.Design
The previously developed tool is stratified for sex and contains the predictors age, BMI, waist circumference, use of antihypertensives, smoking, family history of myocardial infarction/stroke, and family history of diabetes. This tool was externally validated, evaluating model performance using area under the receiver operating characteristic curve (AUC)—assessing discrimination—and Hosmer–Lemeshow goodness-of-fit (HL) statistics—assessing calibration. The intercept was recalibrated to improve calibration performance.Participants
The risk prediction tool was validated in 3544 participants from the Australian Diabetes, Obesity and Lifestyle Study (AusDiab).Key Results
Discrimination was acceptable, with an AUC of 0.78 (95% CI 0.75–0.81) in men and 0.78 (95% CI 0.74–0.81) in women. Calibration was poor (HL statistic: p?<?0.001), but improved considerably after intercept recalibration. Examination of individual outcomes showed that in men, AUC was highest for CKD (0.85 [95% CI 0.78–0.91]) and lowest for T2D (0.69 [95% CI 0.65–0.74]). In women, AUC was highest for CVD (0.88 [95% CI 0.83–0.94)]) and lowest for T2D (0.71 [95% CI 0.66–0.75]).Conclusions
Validation of our previously developed tool showed robust discriminative performance across populations. Model recalibration is recommended to account for different disease rates. Our risk prediction tool can be useful in large-scale prevention programs for identifying those in need of further risk profiling because of their increased risk for chronic cardiometabolic diseases.7.
8.
BACKGROUND
Educating medical students about health disparities may be one step in diminishing the disparities in health among different populations. According to adult learning theory, learners’ opinions are vital to the development of future curricula.DESIGN
Qualitative research using focus group methodology.OBJECTIVES
Our objectives were to explore the content that learners value in a health disparities curriculum and how they would want such a curriculum to be taught.PARTICIPANTS
Study participants were first year medical students with an interest in health disparities (n?=?17).APPROACH
Semi-structured interviews consisting of 12 predetermined questions, with follow-up and clarifying questions arising from the discussion. Using grounded theory, codes were initially developed by the team of investigators, applied, and validated through an iterative process.MAIN RESULTS
The students perceived negative attitudes towards health disparities education as a potential barrier towards the development of a health disparities curriculum and proposed possible solutions. These solutions centered around the learning environment and skill building to combat health disparities.CONCLUSIONS
While many of the students’ opinions were corroborated in the literature, the most striking differences were their opinions on how to develop good attitudes among the student body. Given the impact of the provider on health disparities, how to develop such attitudes is an important area for further research.9.
Hector M. González William A. Vega Michael A. Rodríguez Wassim Tarraf William M. Sribney 《Journal of general internal medicine》2009,24(3):528
Objective
To provide national prevalence estimates of usual source of healthcare (USHC), and examine the relationship between USHC and diabetes awareness and knowledge among Latinos using a modified Andersen model of healthcare access.Participants
Three thousand eight hundred and ninety-nine Latino (18-years or older) participants of the Pew Hispanic Center/Robert Wood Johnson Foundation Hispanic/Latino Health survey from the 48 contiguous United States.Design
Cross-sectional, stratified, random sample telephone interviews.Methods
Self-reported healthcare service use was examined in regression models that included a past-year USHC as the main predictor of diabetes awareness and knowledge. Anderson model predisposing and enabling factors were included in additional statistical models.Results
Significant differences in USHC between Latino groups were found with Mexican Americans having the lowest rates (59.7%). USHC was associated with significantly higher diabetes awareness and knowledge (OR=1.24; 95%CI=1.05-1.46) after accounting for important healthcare access factors. Men were significantly (OR=0.64; 95%CI=0.52-0.75) less informed about diabetes than women.Conclusion
We found important and previously unreported differences between Latinos with a current USHC provider, where the predominant group, Mexican Americans, are the least likely to have access to a USHC. USHC was associated with Latinos being better informed about diabetes; however, socioeconomic barriers limit the availability of this potentially valuable tool for reducing the risks and burden of diabetes, which is a major public health problem facing Latinos.10.
Erin?E.?Krebs Misti?Paudel Brent?C.?Taylor Douglas?C.?Bauer Howard?A.?Fink Nancy?E.?Lane Kristine?E.?Ensrud for the Osteoporotic Fractures in Men Study Research Group 《Journal of general internal medicine》2016,31(5):463-469
Background
Although older adults are disproportionately affected by painful musculoskeletal conditions and receive more opioid analgesics than persons in other age groups, insufficient evidence is available regarding opioid harms in this age group.Objective
To examine longitudinal relationships between opioid use and falls, clinical fractures, and changes in physical performance. We hypothesized that opioid use would be associated with greater risks of falling and incident clinical fractures and greater declines in physical performance.Design
We analyzed data from the Osteoporotic Fractures in Men Study (MrOS), a large prospective longitudinal cohort study. Participants completed baseline visits from 2000 to 2002 and were followed for 9.1 (SD 4.0) years.Participants
MrOS enrolled 5994 community-dwelling men ≥ 65 years of age. The present study included 2902 participants with back, hip, or knee pain most or all of the time at baseline.Main Measures
The exposure of interest was opioid use, defined at each visit as participant-reported daily or near-daily use of any opioid-containing analgesic. Among patients, 309 (13.4 %) reported opioid use at one or more visits. Participants were queried every 4 months about falls and fractures. Physical performance scores were derived from tests of grip strength, chair stands, gait speed, and dynamic balance.Key Results
In the main analysis, the adjusted risk of falling did not differ significantly between opioid use and non-use groups (RR 1.10, 95 % CI 0.99, 1.24). Similarly, adjusted rates of incident clinical fracture did not differ between groups (HR 1.13, 95 % CI 0.94, 1.36). Physical performance was worse at baseline for the opioid use group, but annualized change in physical performance scores did not differ between groups (?0.022, 95 % CI ?0.138, 0.093).Conclusions
Additional research is needed to determine whether opioid use is a marker of risk or a cause of falls, fractures, and progressive impairment among older adults with persistent pain.11.
Giovanni B. Gaeta Massimo Puoti Nicola Coppola Teresa Santantonio Raffaele Bruno Antonio Chirianni Massimo Galli 《Infection》2018,46(2):183-188
Aim
This paper is aimed at providing practical recommendations for the management of acute hepatitis C (AHC).Methods
This is an expert position paper based on the literature revision. Final recommendations were graded by level of evidence and strength of the recommendations.Results
Treatment of AHC with direct-acting antivirals (DAA) is safe and effective; it overcomes the limitations of INF-based treatments.Conclusions
Early treatment with DAA should be offered when available.12.
Zachary A. Marcum Christopher W. Forsberg Kathryn P. Moore Ian H. de Boer Nicholas L. Smith James S. Floyd 《Journal of general internal medicine》2018,33(2):155-165
Background
For patients with type 2 diabetes and chronic kidney disease (CKD), high-quality evidence about the relative benefits and harms of oral glucose-lowering drugs is limited.Objective
To evaluate whether mortality risk differs after the initiation of monotherapy with either metformin or a sulfonylurea in Veterans with type 2 diabetes and CKD.Design
Observational, national cohort study in the Veterans Health Administration (VHA).Participants
Veterans who received care from the VHA for at least 1 year prior to initiating monotherapy treatment for type 2 diabetes with either metformin or a sulfonylurea between 2004 and 2009.Main Measures
Metformin and sulfonylurea use was assessed from VHA electronic pharmacy records. The CKD-EPI equation was used to estimate glomerular filtration rate (eGFR). The outcome of death from January 1, 2004, through December 31, 2009, was assessed from VHA Vital Status files.Key Results
Among 175,296 new users of metformin or a sulfonylurea monotherapy, 5121 deaths were observed. In primary analyses adjusted for all measured potential confounding factors, metformin monotherapy was associated with a lower mortality hazard ratio (HR) compared with sulfonylurea monotherapy across all ranges of eGFR evaluated (HR ranging from 0.59 to 0.80). A secondary analysis of mortality risk differences favored metformin across all eGFR ranges; the greatest risk difference was observed in the eGFR category 30–44 mL/min/1.73m2 (12.1 fewer deaths/1000 person-years, 95% CI 5.2–19.0).Conclusions
Initiation of metformin versus a sulfonylurea among individuals with type 2 diabetes and CKD was associated with a substantial reduction in mortality, in terms of both relative and absolute risk reduction. The largest absolute risk reduction was observed among individuals with moderately–severely reduced eGFR (30–44 mL/min/1.73m2).13.
14.
Temple A. Ratcliffe Meghan A. Crabtree Raymond F. Palmer Jacqueline A. Pugh Holly J. Lanham Luci K. Leykum 《Journal of general internal medicine》2018,33(4):449-454
Background
Attending rounds remain the primary venue for formal teaching and learning at academic medical centers. Little is known about the effect of increasing clinical demands on teaching during attending rounds.Objective
To explore the relationships among teaching time, teaching topics, clinical workload, and patient complexity variables.Design
Observational study of medicine teaching teams from September 2008 through August 2014. Teams at two large teaching hospitals associated with a single medical school were observed for periods of 2 to 4 weeks.Participants
Twelve medicine teaching teams consisting of one attending, one second- or third-year resident, two to three interns, and two to three medical students.Main Measures
The study examined relationships between patient complexity (comorbidities, complications) and clinical workload variables (census, turnover) with educational measures. Teams were clustered based on clinical workload and patient complexity. Educational measures of interest were time spent teaching and number of teaching topics. Data were analyzed both at the daily observation level and across a given patient’s admission.Key Results
We observed 12 teams, 1994 discussions (approximately 373 h of rounds) of 563 patients over 244 observation days. Teams clustered into three groups: low patient complexity/high clinical workload, average patient complexity/low clinical workload, and high patient complexity/high clinical workload. Modest associations for team, patient complexity, and clinical workload variables were noted with total time spent teaching (9.1% of the variance in time spent teaching during a patient’s admission; F[8,549]?=?6.90, p <?0.001) and number of teaching topics (16% of the variance in the total number of teaching topics during a patient’s admission; F[8,548]?=?14.18, p <?0.001).Conclusions
Clinical workload and patient complexity characteristics among teams were only modestly associated with total teaching time and teaching topics.15.
Richard L. StreetJr Lin Liu Neil J. Farber Yunan Chen Alan Calvitti Nadir Weibel Mark T. Gabuzda Kristin Bell Barbara Gray Steven Rick Shazia Ashfaq Zia Agha 《Journal of general internal medicine》2018,33(4):423-428
Background
Evidence is mixed regarding how physicians' use of the electronic health record (EHR) affects communication in medical encounters.Objective
To investigate whether the different ways physicians interact with the computer (mouse clicks, key strokes, and gaze) vary in their effects on patient participation in the consultation, physicians’ efforts to facilitate patient involvement, and silence.Design
Cross-sectional, observational study of video and event recordings of primary care and specialty consultations.Participants
Thirty-two physicians and 217 patients.Main Measures
Predictor variables included measures of physician interaction with the EHR (mouse clicks, key strokes, gaze). Outcome measures included active patient participation (asking questions, stating preferences, expressing concerns), physician facilitation of patient involvement (partnership-building and supportive talk), and silence.Key Results
Patients were less active participants in consultations in which physicians engaged in more keyboard activity (b?=??0.002, SE?=?0.001, p?=?0.02). More physician gaze at the computer was associated with more silence in the encounter (b?=?0.21, SE?=?0.09, p?=?0.02). Physicians’ facilitative communication, which predicted more active patient participation (b?=?0.65, SE?=?0.14, p?<?0.001), was not related to EHR activity measures.Conclusions
Patients may be more reluctant to actively participate in medical encounters when physicians are more physically engaged with the computer (e.g., keyboard activity) than when their behavior is less demonstrative (e.g., gazing at EHR). Using easy to deploy communication tactics (e.g., asking about a patient’s thoughts and concerns, social conversation) while working on the computer can help physicians engage patients as well as maintain conversational flow.16.
17.
Marian Goicoechea Soledad García de Vinuesa Borja Quiroga Eduardo Verde Carmen Bernis Enrique Morales Gema Fernández-Juárez Patricia de Sequera Ursula Verdalles Ramón Delgado Alberto Torres David Arroyo Soraya Abad Alberto Ortiz José Luño 《Cardiovascular drugs and therapy / sponsored by the International Society of Cardiovascular Pharmacotherapy》2018,32(3):255-263
Background
Patients with chronic kidney disease (CKD) are at high risk for developing cardiovascular events. However, limited evidence is available regarding the use of aspirin in CKD patients to decrease cardiovascular risk and to slow renal disease progression.Study Design
Prospective, multicenter, open-label randomized controlled trial.Setting and Participants
One hundred eleven patients with estimated glomerular filtration rate (eGFR) 15–60 ml/min/1.73 m2 without previous cardiovascular events.Intervention
Aspirin treatment (100 mg/day) (n?=?50) or usual therapy (n?=?61). Mean follow-up time was 64.8?±?16.4 months.Outcomes
The primary endpoint was composed of cardiovascular death, acute coronary syndrome (nonfatal MI, coronary revascularization, or unstable angina pectoris), cerebrovascular disease, heart failure, or nonfatal peripheral arterial disease. Secondary endpoints were fatal and nonfatal coronary events, renal events (defined as doubling of serum creatinine, ≥?50% decrease in eGFR, or renal replacement therapy), and bleeding episodes.Results
During follow-up, 17 and 5 participants suffered from a primary endpoint in the control and aspirin groups, respectively. Aspirin did not significantly reduce primary composite endpoint (HR, 0.396 (0.146–1.076), p?=?0.069. Eight patients suffered from a fatal or nonfatal coronary event in the control group compared to no patients in the aspirin group. Aspirin significantly reduced the risk of coronary events (log-rank, 5.997; p?=?0.014). Seventeen patients in the control group reached the renal outcome in comparison with 3 patients in the aspirin group. Aspirin treatment decreased renal disease progression in a model adjusted for age, baseline kidney function, and diabetes mellitus (HR, 0.272; 95% CI, 0.077–0.955; p?=?0.043) but did not when adjusted for albuminuria. No differences were found in minor bleeding episodes between groups and no major bleeding was registered.Limitations
Small sample size and open-label trial.Conclusions
Long-term treatment with low-dose aspirin did not reduce the composite primary endpoint; however, there were reductions in secondary endpoints with fewer coronary events and renal outcomes. ClinicalTrials.gov Identifier: NCT01709994.18.
Gloria D. Coronado Jennifer S. Rivelli Morgan J. Fuoco William M. Vollmer Amanda F. Petrik Erin Keast Sara Barker Emily Topalanchik Ricardo Jimenez 《Journal of general internal medicine》2018,33(1):72-78
Background
The Community Preventive Services Task Force recommends multi-component interventions, including patient reminders, to improve uptake of colorectal cancer screening.Objective
We sought to compare the effectiveness of different forms of reminders for a direct-mail fecal immunochemical test (FIT) program.Design
Patient-randomized controlled trial.Participants
2772 adults aged 50–75, not up to date with colorectal cancer screening recommendations, with a clinic visit in the previous year at any of four participating health center clinics.Intervention
Participants were mailed an introductory letter and FIT. Those who did not complete their FIT within 3 weeks were randomized to receive (1) a reminder letter, (2) two automated phone calls, (3) two text messages, (4) a live phone call, (5) a reminder letter and a live phone call, (6) two automated phone calls and a live phone call, or (7) two text messages and a live phone call. Patients with a patient portal account were sent two email reminders, but were not randomized.Main Measures
FIT return rates for each group, 6 months following randomization.Key Results
A total of 255 (10%) participants returned their FIT within 3 weeks of the mailing. Among randomized participants (n = 2010), an additional 25.5% returned their FITs after reminders were delivered (estimated overall return rate = 32.7%). In intention-to-treat analysis, compared to the group allocated to receive a reminder letter, return rates were higher for the group assigned to receive the live phone call (OR = 1.51 [1.03–2.21]) and lower for the group assigned to receive text messages (OR = 0.66 [0.43–0.99]). Reminder effectiveness differed by language preference.Conclusions
Our data suggest that FIT reminders that included a live call were more effective than reminders that relied solely on written communication (a text message or letter).Trial Registration: ClinicalTrials.gov/ctc2/show/NCT01742065.19.
Cornelia Lass-Flörl Astrid Mayr Maria Aigner Michaela Lackner Dorothea Orth-Höller 《Infection》2018,46(5):701-704
Purpose
To determine the burden of antifungal resistance in fungi over the last 10 years.Methods
Performance of a semi-nationwide surveillance on antifungal resistance.Results
We observed a low frequency of azole resistance in Aspergillus fumigatus, a moderate increase of echinocandin resistance in yeasts, and a stable amphotericin B activity in yeasts and molds. Posaconazole resistance in Aspergillus terreus occurred in a few isolates.Conclusion
The burden of resistance in fungi seems to be low in Tyrol, Austria.20.
Joseph J. Gallo Seungyoung Hwang Jin Hui Joo Hillary R. Bogner Knashawn H. Morales Martha L. Bruce Charles F. ReynoldsIII 《Journal of general internal medicine》2016,31(4):380-386