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1.
Eboni G. Price-Haywood Katherine G. Roth Kit Shelby Lisa A. Cooper 《Journal of general internal medicine》2010,25(2):126-129
BACKGROUND
Low health literacy (HL) is an important risk factor for cancer health disparities.OBJECTIVE
Describe a continuing medical education (CME) program to teach primary care physicians (PCP) cancer risk communication and shared decision-making (SDM) with low HL patients and baseline skills assessment.DESIGN
Cluster randomized controlled trial in five primary care clinics in New Orleans, LA.PARTICIPANTS
Eighteen PCPs and 73 low HL patients overdue for cancer screening.INTERVENTION
Primary care physicians completed unannounced standardized patient (SP) encounters at baseline. Intervention physicians received SP verbal feedback; academic detailing to review cancer screening guidelines, red flags for identifying low HL, and strategies for effective counseling; and web-based tutorial of SP comments and checklist items hyperlinked to reference articles/websites.MAIN MEASURES
Baseline PCP self-rated proficiency, SP ratings of physician general cancer risk communication and SDM skills, patient perceived involvement in care.RESULTS
Baseline assessments show physicians rated their proficiency in discussing cancer risks and eliciting patient preference for treatment/decision-making as “very good”. SPs rated physician exploration of perceived cancer susceptibility, screening barriers/motivators, checking understanding, explaining screening options and associated risks/benefits, and eliciting preferences for screening as “satisfactory”. Clinic patients rated their doctor’s facilitation of involvement in care and information exchange as “good”. However, they rated their participation in decision-making as “poor”.DISCUSSION
The baseline skills assessment suggests a need for physician training in cancer risk communication and shared decision making for patients with low HL. We are determining the effectiveness of teaching methods, required resources and long-term feasibility for a CME program.2.
Scott K. Aberegg Andrew M. Hersh Matthew H. Samore 《Journal of general internal medicine》2018,33(1):88-96
Background
Noninferiority trials are increasingly common, though they have less standardized designs and their interpretation is less familiar to clinicians than superiority trials.Objective
To empirically evaluate a cohort of noninferiority trials to determine 1) their interpretation as recommended by CONSORT, 2) choice of alpha threshold and its sidedness, and 3) differences between methods of analysis such as intention-to-treat and per-protocol.Design
We searched MEDLINE for parallel-group randomized controlled noninferiority trials published in the five highest-impact general medical journals between 2011 and 2016.Main Measures
Data abstracted included trial design parameters, results, and interpretation of results based on CONSORT recommendations.Key Results
One hundred sixty-three trials and 182 noninferiority comparisons were included in our analysis. Based on CONSORT-recommended interpretation, 79% of experimental therapies met criteria for noninferiority, 13% met criteria for superiority, 20% were declared inconclusive, and 2% met criteria for inferiority. However, for 12% of trials, the experimental therapy was statistically significantly worse than the active control, but CONSORT recommended an interpretation of inconclusive or noninferior. A two-sided alpha equivalent of greater than 0.05 was used in 34% of the trials, and in five of these trials, the use of a standard two-sided alpha of 0.05 led to changes in the interpretation of results that disfavored the experimental therapy. In four of the five comparisons where different methods of analysis (e.g., intention-to-treat and per-protocol) yielded different results, the intention-to-treat analysis was the more conservative. In 11% of trials, a secondary advantage of the new therapy was neither reported nor could it be inferred by reviewers.Conclusions
In this cohort, the design and interpretation of noninferiority trials led to significant and systematic bias in favor of the experimental therapy. Clinicians should exercise caution when interpreting these trials. Future trials may be more reliable if design parameters are standardized.3.
Purpose
This study was designed to analyze the characteristics and the quality of reporting of randomized, controlled trials published during the last ten years on fecal incontinence.Methods
An electronic search for all randomized, controlled trials on fecal incontinence was undertaken by using the MEDLINE database via PubMed. The data collected were divided into general data, characteristics of reporting, methodology quality assessment using the Jadad scale and a validated methodology quality score (MINCIR score), evaluation of the items published in the CONSORT statement, and the journal impact factor. Reports were divided into two groups: published articles from 1996 to 2000 (Group 1), and from 2001 to 2005 (Group 2).Results
Forty-two trials fulfilled the inclusion criteria of the study (Group 1, n?=?15; and Group 2, n?=?27). There were no significant differences in general characteristics of randomized, controlled trials between the two groups. In Group 2, there were a statistically significant higher number of studies that reported a flow chart (P?0.001), written informed consent (P?=?0.008), sample size calculation (P?=?0.023), and withdrawals and dropouts (P?0.001). We found a statistically significant higher score in Jadad scale (P?=?0.046) and MINCIR score (P?=?0.016) in the published studies in Group 2. Also we found higher journal impact factor of journals that published these randomized, controlled trials during the most recent years (P?=?0.04).Conclusions
There is a lack of high-quality reported randomized, controlled trials on fecal incontinence during the last ten years. Reports of randomized, controlled trials involving patients with fecal incontinence published after 2001 were better reported than in the previous five years.4.
Background
The middle colic artery (MCA) is of crucial importance in abdominal surgery, for laparoscopic or open right and transverse colectomies. Against this background, a high number of reports concerning anatomical variations of the MCA have been published intended to contribute to the improvement of operative techniques for the treatment of colon cancer. Despite this extensive literature, briefly reviewed in the present paper, a course of the MCA posterior to the superior mesenteric vein, called a retromesenteric trajectory, has been related to only once, to the best of our knowledge.Methods
A total series of 507 patients included in two prospective trials concerning laparoscopic or open right colectomy for cancer between 2011 and 2017 are reported. The investigation included preoperative or postoperative multidetector-computed tomography angiography.Results
We found four (0.79%) cases of retromesenteric MCA. They all underwent meticulous image analysis with mesenteric vessels’ road mapping, detailed morphometry, and surgical validation which revealed that, apart from their course, those cases did not differ significantly from the rest of the series.Conclusion
This paper therefore documents the worth-knowing behavior causing considerable confusion for the operating surgeon unaware of the abnormality and shows its concrete impact on patient-tailored surgical practice, in particular for laparoscopic D3 colectomy (including the “uncinated process first” approach).5.
Aim
Up to 80% of patients after low anterior resection, experience (low) anterior resection syndrome (ARS/LARS). However, there is no standard treatment option currently available. This systemic review aims to summarize treatment possibilities for LARS after surgical treatment of rectal cancer in the medical literature.Methods
Embase, PubMed, and the Cochrane Library were searched using the terms anterior resection syndrome, low anterior resection, colorectal/rectal/rectum, surgery/operation, pelvic floor rehabilitation, biofeedback, transanal irrigation, sacral nerve stimulation, and tibial nerve stimulation. All English language articles presenting original patient data regarding treatment and outcome of LARS were included. We focused on the effects of different treatment modalities for LARS. The Jadad score was used to assess the methodological quality of trials. The quality scale ranges from 0 to 5 points, with a score ≤?2 indicating a low quality report, and a score of ≥?3 indicating a high quality report.Results
Twenty-one of 160 studies met the inclusion criteria, of which 8 were reporting sacral nerve stimulation, 6 were designed to determine pelvic floor rehabilitation, 3 studies evaluated the effect of transanal irrigation, 2—percutaneous tibial nerve stimulation, and the rest of the studies assessed probiotics and 5-HT3 receptor antagonists for LARS in patients who had undergone rectal resection. All except one study were poor quality reports according to the Jadad score.Conclusions
LARS treatment still carries difficulties because of a lack of well-conducted, randomized multicenter trials. Well-performed randomized controlled trials are needed.6.
Anneliese Butler Anne Canamucio David Macpherson Jennifer Skoko Gala True 《Journal of general internal medicine》2014,29(2):579-588
BACKGROUND
Many organizations rely on quality improvement collaboratives (QICs) to facilitate Patient-Centered Medical Home (PCMH) implementation, and there is a trend toward conducting QIC activities virtually to reduce costs and expand their reach. However, the evidence base for QICs is limited; questions remain about how QICs operate, why they succeed or fail, and how they are experienced by participants.OBJECTIVE
We surveyed participants in an innovative Virtual Collaborative (VC) designed to support PCMH implementation within one Veterans Integrated Service Network, to understand why and for whom the VC was more/less effective and identify opportunities for improvement.DESIGN
This anonymous online survey was designed to assess participants’ views on the VC’s usefulness, impact, and acceptability, and to explore variations by role, practice setting, prior training, and overall engagement in VC activities.PARTICIPANTS
Respondents were 353 primary care staff, including providers, nurses, and support staff.MEASURES/APPROACH
The survey comprised 32 structured and three free-response items. Structured items assessed participation in and perceived usefulness of VC activities; perceived acceptability of the training format; overall perceived impact; and basic demographics. Responses were dichotomized and compared using Chi-square tests. Free-response items inviting constructive criticism of the VC were coded and summarized to identify themes and illustrative quotes.RESULTS
The VC most benefited respondents with prior PCMH training and those who fully participated in VC activities. Respondents especially valued the opportunity to share experiences with other teams. Non-providers and those new to PCMH felt learning content did not meet their needs. Reported barriers to full participation included staffing constraints, insufficient and/or unprotected time, and inadequate leadership support.CONCLUSIONS
Our study offers practical lessons for others considering a virtual collaborative model for PCMH spread. Findings contribute to the evidence base for QICs overall and virtual QICs in particular, highlighting the value of seeking input from “the trenches.”7.
Operative Verfahren bei hohen kryptoglandulären Analfisteln: Systematische Übersicht und Metaanalyse
K. W. A. Göttgens R. R. Smeets L. P. S. Stassen G. Beets S. O. Breukink 《coloproctology》2016,38(2):93-105
Purpose
Perianal fistulas, and specifically high perianal fistulas, remain a challenge for surgical treatment. Many techniques have been and are still being developed to improve the outcome after surgery. A systematic review and meta-analysis was performed for surgical treatment of high cryptoglandular perianal fistulas.Methods
Medline (Pubmed, Ovid), Embase and The Cochrane Library databases were searched for relevant randomized controlled trials on surgical treatments for high cryptoglandular perianal fistulas. Two independent reviewers selected articles for inclusion based on title, abstract and outcomes described. The main outcome measurement was the recurrence/healing rate. Secondary outcomes were continence status, quality of life and complications.Results
The number of randomized trials available was low. Fourteen studies could be included in the review. A meta-analysis could only be performed for the mucosal advancement flap versus the fistula plug, and did not show a result in favour of either technique in recurrence or complication rate. The mucosal advancement flap was the most investigated technique but did not show any advantage over any other technique. Other techniques identified in randomized studies were seton treatment, medicated seton treatment, fibrin glue, autologous stem cells, island flap anoplasty, rectal wall advancement flap, ligation of the intersphincteric fistula tract, sphincter reconstruction, sphincter-preserving seton and techniques combined with antibiotics. None of these techniques seemed superior to each other.Conclusions
The best surgical treatment for high cryptoglandular perianal fistulas could not be identified. More randomized controlled trials are needed to find the best treatment. The mucosal advancement flap is the most investigated technique available.8.
Background
Living through cancer often involves developing new identities which may strongly influence well-being and relationships with care providers, yet little is currently known about these post-cancer identities.Objectives
To examine (1) the extent to which four post-cancer identities (patient, person who has had cancer, victim, and survivor) are adopted, (2) relations between each identity and involvement in cancer-related activities and mental and physical well-being, and (3) correlates of these identities.Design
Cross-sectional questionnaire-based study.Participants
168 young to middle-aged adults who had previously experienced cancer.Measurements
Cancer identifications, background variables, psychological functioning, cancer risk appraisals and coping, cancer-related activities, and mental and physical well-being.Results
At least somewhat, 83% endorsed survivor identity, 81% identity of “person who has had cancer”, 58% “patient”, and 18% “victim”. Identities were minimally correlated with one another and differentially associated with involvement in cancer-related activities. Survivor and person who has had cancer identities correlated with involvement in most cancer-related activities such as wearing cancer-related items and talking about prevention (ps?<? 0.5). Survivor identity correlated with better psychological well-being and post-traumatic growth, victim identity with poorer well-being (ps?<? 0.5); neither identifying as a patient nor a person with cancer was related to well-being. Through regression analyses, identities were shown to be explained by unique combination of background, functioning, appraisal and coping variables.Conclusions
Survivor identity appears most common and most associated with active involvement and better psychological well-being, but other identifications are also common and simultaneously held. Adoption of specific cancer identities is likely to impact interactions with health care providers, including those in general internal medicine, and health behavior changes.9.
Kristina Maria Würth Stella Reiter-Theil Wolf Langewitz Sylvie Schuster 《Journal of general internal medicine》2018,33(11):1885-1891
Background
While the need to address language barriers to provide quality care for all is generally accepted, little is known about the complexities of decision-making around patients’ limited language proficiency in everyday clinical encounters.Objective
To understand how linguistic complexities shape cross-cultural encounters by incorporating the perspective of both, patients and physicians.Design
A qualitative hospital study with semi-structured interviews and participant-observation in a Swiss University Hospital. Thirty-two encounters were observed and 94 interviews conducted.Participants
Sixteen patients of Turkish and 16 of Albanian origin and all actors (administration, nurses, physicians, if required, interpreters) involved in the patients’ entire process.Main Approach
Interviews were audio-recorded and transcribed verbatim. A thematic content analysis was conducted using MAXQDA. For reporting, the COREQ guidelines were used.Key Results
Three themes were relevant to patients and physicians alike: Assessment of the language situation, the use of interpreters, and dealing with conversational limits. Physicians tend to assess patients’ language proficiency by their body language, individual demeanor, or adequacy of responses to questions. Physicians use professional interpreters for “high-stakes” conversations, and “get by” through “low-stakes” topics by resorting to bilingual family members, for example. Patients are driven by factors like fearing costs or the wish to manage on their own. High acceptance of conversational limits by patients and physicians alike stands in stark contrast to the availability of interpreters.Conclusions
The decision for or against interpreter use in the “real world” of clinical care is complex and shaped by small, frequently inconspicuous decisions with potential for suboptimal health care. Physicians occupy a key position in the decision-making to initiate the process of medical interpreting. The development and testing of a conceptual framework close to practice is crucial for guiding physicians’ assessment of patients’ language proficiency and their decision-making on the use of interpreting services.10.
Background and Aims
Fecal microbial transplantation (FMT) is an established successful treatment modality for recurrent Clostridium difficile infection (CDI). The safety profile and potential therapeutic advantages of FMT for diseases associated with dysbiosis and immune dysfunction have led to many publications, mainly case series, and while many studies and reviews have been published on the use of FMT for inflammatory bowel disease (IBD), its potential use for other disease conditions has not been thoroughly reviewed. The aim of this review was to investigate the evidence surrounding the use of FMT in conditions other than IBD and CDI.Methods
A PubMed search was performed using the terms “Fecal microbiota transplantation” OR “FMT” OR “Bacteriotherapy.”Results
A total of 26 articles describing the use of FMT in a variety of both intra-and extraintestinal disease conditions including gastrointestinal, hematologic, neurologic, metabolic, infectious, and autoimmune disorders have been included in this review and have demonstrated some positive results. The studies included were case reports, case series, controlled trials, and cohort studies.Conclusions
The findings of these studies demonstrate that FMT, particularly in conditions associated with gastrointestinal dysbiosis, shows promise to provide another effective tool in the therapeutic armament of the practicing physician. FMT was found to be possibly effective in various diseases, mostly associated with enteric dysbiosis or with immune dysfunction. Randomized clinical studies on large populations should be performed to explore the effectiveness of this therapy, and basic research studies should be designed to gain understanding of the mechanisms through which impact these disorders.11.
Peter P. Reese Judd B. Kessler Jalpa A. Doshi Joelle Friedman Adam S. Mussell Caroline Carney Jingsan Zhu Wenli Wang Andrea Troxel Peinie Young Victor Lawnicki Swapnil Rajpathak Kevin Volpp 《Journal of general internal medicine》2016,31(4):402-410
Background
Medication nonadherence is an important obstacle to cardiovascular disease management.Objective
To improve adherence through real-time feedback based on theories of how social forces influence behavior.Design
Two randomized controlled pilot trials called PROMOTE and SUPPORT. Participants stored statin medication in wireless-enabled pill bottles that transmitted adherence data to researchers.Participants
Adults with diabetes and a history of low statin adherence based on pharmacy refills (i.e., Medication Possession Ratio [MPR] <80 % in the pre-randomization screening period).Intervention
In PROMOTE, each participant was randomized to 1) weekly messages in which that participant’s statin adherence was compared to that of other participants (comparison), 2) weekly summaries of that participant’s statin adherence (summary), or 3) control. In SUPPORT, each participant identified another person (the Medication Adherence Partner [MAP]) to receive reports about that participant’s adherence, and was randomized to 1) daily reports to MAP, 2) weekly reports to MAP, 3) reports to MAP only if dose was missed, or 4) control.Main Outcomes Measure
Adherence measured by pill bottle.Key Results
Among 45,000 health plan members contacted by mail, <1 % joined the trial. Participants had low baseline MPRs (median?=?60 %, IQR 41–72 %) but high pill-bottle adherence (90 % in PROMOTE, 92 % in SUPPORT) during the trial. In PROMOTE (n?=?201) and SUPPORT (n?=?200), no intervention demonstrated significantly better adherence vs. control. In a subgroup of PROMOTE participants with the lowest pre-study MPR, pill-bottle-measured adherence in the comparison arm (89 %) was higher than the control (86 %) and summary (76 %) arms, but differences were non-significant (p?=?0.10).Conclusions
Interventions based on social forces did not improve medication adherence vs. control over a 3-month period. Given the low percentage of invited individuals who enrolled, the studies may have attracted participants who required little encouragement to improve adherence other than study participation.12.
Hong-Yu Zhang Chun-Lin Zhao Jing Xie Yan-Wei Ye Jun-Feng Sun Zhao-Hui Ding Hua-Nan Xu Li Ding 《International journal of colorectal disease》2016,31(5):951-960
Background
Currently, many surgeons place a prophylactic drain in the abdominal or pelvic cavity after colorectal anastomosis as a conventional treatment. However, some trials have demonstrated that this procedure may not be beneficial to the patients.Objective
To determine whether prophylactic placement of a drain in colorectal anastomosis can reduce postoperative complications.Methods
We systematically searched all the electronic databases for randomized controlled trials (RCTs) that compared routine use of drainage to non-drainage regimes after colorectal anastomosis, using the terms “colorectal” or “colon/colonic” or “rectum/rectal” and “anastomo*” and “drain or drainage.” Reference lists of relevant articles, conference proceedings, and ongoing trial databases were also screened. Primary outcome measures were clinical and radiological anastomotic leakage. Secondary outcome measures included mortality, wound infection, re-operation, and respiratory complications. We assessed the eligible studies for risk of bias using the Cochrane Risk of Bias Tool. Two authors independently extracted data.Results
Eleven RCTs were included (1803 patients in total, 939 patients in the drain group and 864 patients in the no drain group). Meta-analysis showed that there was no statistically significant differences between the drain group and the no drain group in (1) overall anastomotic leakage (relative risk (RR)?=?1.14, 95 % confidence interval (CI) 0.80–1.62, P?=?0.47), (2) clinical anastomotic leakage (RR?=?1.39, 95 % CI 0.80–2.39, P?=?0.24), (3) radiologic anastomotic leakage (RR?=?0.92, 95 % CI 0.56–1.51, P?=?0.74), (4) mortality (RR?=?0.94, 95 % CI 0.57–1.55, P?=?0.81), (5) wound infection (RR?=?1.19, 95 % CI 0.84–1.69, P?=?0.34), (6) re-operation (RR?=?1.18, 95 % CI 0.75–1.85, P?=?0.47), and (7) respiratory complications (RR?=?0.82, 95 % CI 0.55–1.23, P?=?0.34).Conclusions
Routine use of prophylactic drainage in colorectal anastomosis does not benefit in decreasing postoperative complications.13.
BACKGROUND
Recent changes in health care delivery may reduce continuity with the patient’s primary care provider (PCP). Little is known about the association between continuity and quality of communication during ongoing efforts to redesign primary care in the Veterans Administration (VA).OBJECTIVE
To evaluate the association between longitudinal continuity of care (COC) with the same PCP and ratings of patient–provider communication during the Patient Aligned Care Team (PACT) initiative.DESIGN
Cross-sectional survey.PARTICIPANTS
Four thousand three hundred ninety-three VA outpatients who were assigned to a PCP, had at least three primary care visits to physicians or physician extenders during Fiscal Years 2009 and 2010 (combined), and who completed the Survey of Healthcare Experiences of Patients (SHEP) following a primary care visit in Fiscal Year (FY)2011.MAIN MEASURES
Usual Provider of Continuity (UPC), Modified Modified Continuity Index (MMCI), and duration of PCP care were calculated for each primary care patient. UPC and MMCI values were categorized as follows: 1.0 (perfect), 0.75–0.99 (high), 0.50–0.74 (intermediate), and < 0.50 (low). Quality of communication was measured using the four-item Consumer Assessment of Healthcare Providers and Systems-Health Plan program (CAHPS-HP) communication subscale and a two-item measure of shared decision-making (SDM). Excellent care was defined using an “all-or-none” scoring strategy (i.e., when all items within a scale were rated “always”).KEY RESULTS
UPC and MMCI continuity remained high (0.81) during the early phase of PACT implementation. In multivariable models, low MMCI continuity was associated with decreased odds of excellent communication (OR?=?0.74, 95 % CI?=?0.58–0.95) and SDM (OR?=?0.70, 95 % CI?=?0.49, 0.99). Abbreviated duration of PCP care (< 1 year) was also associated with decreased odds of excellent communication (OR?=?0.35, 95 % CI?=?0.18, 0.71).CONCLUSIONS
Reduced PCP continuity may significantly decrease the quality of patient–provider communication in VA primary care. By improving longitudinal continuity with the assigned PCP, while redesigning team-based roles, the PACT initiative has the potential to improve patient–provider communication.14.
Background
Full laparoscopic left colectomy with transrectal specimen extraction is proposed as an improvement of the minimally invasive surgical technique. This paper reviews in detail the current status of left-sided colectomy and upper rectum resection with transrectal specimen extraction.Methods
A systematic review was performed of all types of publications on colorectal resection with natural orifice specimen extraction (NOSE). We only included studies reporting on left colectomy, sigmoidectomy, and high anterior resection with transrectal specimen extraction (TRSE), excluding transanal (TASE), transvaginal, or transcolonic specimen extraction. Surgical techniques, patient characteristics, and outcomes were reviewed in detail.Results
Thirty-five papers reported on TRSE (2 randomized clinical trials, 7 case-matched series, 19 case series, 5 case reports, and 2 articles on surgical technique). We found a wide variety of innovative anastomotic and specimen extraction techniques. After excluding duplicates and papers reporting mixed TRSE and TASE results, outcomes in patients undergoing TRSE from 23 publications showed a conversion rate to conventional laparoscopy of 3.7% (21/559), overall morbidity 9.5% (53/559) [major in 2.9% (16/559), intra-abdominal infection in 2.1% (12/559)]. No mortality was reported. Postoperative anal incontinence was rarely reported. Several studies showed a decrease in postoperative pain and some in length of hospital stay.Conclusions
Colectomy with TRSE is feasible and seems safe in selected patients. Reported outcomes seem in general similar to conventional laparoscopic colectomy with a possible benefit in postoperative pain and length of hospital stay. Obvious selection bias and lack of high quality trials do not allow firm conclusions to be drawn.15.
Shira Maguen Erin Madden Beth Cohen Daniel Bertenthal Thomas Neylan Lisa Talbot Carl Grunfeld Karen Seal 《Journal of general internal medicine》2013,28(2):563-570
BACKGROUND
Obesity is a growing public health concern and is becoming an epidemic among veterans in the post-deployment period.OBJECTIVE
To explore the relationship between body mass index (BMI) and posttraumatic stress disorder (PTSD) in a large cohort of Iraq and Afghanistan veterans, and to evaluate trajectories of change in BMI over 3 years.DESIGN
Retrospective, longitudinal cohort analysis of veterans’ health recordsPARTICIPANTS
A total of 496,722 veterans (59,790 female and 436,932 male veterans) whose height and weight were recorded at the Department of Veterans Affairs (VA) healthcare system at least once after the end of their last deployment and whose first post-deployment outpatient encounter at the VA was at least 1 year prior to the end of the study period (December 31, 2011).MAIN MEASURES
BMI, mental health diagnoses.KEY RESULTS
Seventy-five percent of Iraq and Afghanistan veterans were either overweight or obese at baseline. Four trajectories were observed: “stable overweight” represented the largest class; followed by “stable obese;” “overweight/obese gaining;” and “obese losing.” During the 3-year ascertainment period, those with PTSD and depression in particular were at the greatest risk of being either obese without weight loss or overweight or obese and continuing to gain weight. Adjustment for demographics and antipsychotic medication attenuated the relationship between BMI and certain mental health diagnoses. Although BMI trajectories were similar in men and women, some gender differences were observed. For example, the risk of being in the persistently obese class in men was highest for those with PTSD, whereas for women, the risk was highest among those with depression.CONCLUSIONS
The growing number of overweight or obese returning veterans is a concerning problem for clinicians who work with these patients. Successful intervention to reduce the prevalence of obesity will require integrated efforts from primary care and mental health to treat underlying mental health causes and assist with engagement in weight loss programs.16.
I. L. Silva M. Iskandarani A. Hotouras J. Murphy C. Bhan B. Adada S. D. Wexner 《Techniques in coloproctology》2017,21(11):847-852
Background
Colorectal cancer (CRC) rarely metastasizes to the brain. The incidence of cerebral metastases (CM) is estimated between 1 and 3%. Given the improved survival from advanced CRC as a result of surgical and oncological advances, it is anticipated that the incidence of patients with CM from CRC will rise over the next few years. The aim of this article was to systematically review the treatment options and outcome of patients with CM from CRC.Methods
PubMed and Medline databases were examined using the search words or MESH headings “colorectal” “cancer/carcinoma/adenocarcinoma”, “cerebral”/”brain” and “metastases/metastasis”.Results
CM from CRC are diagnosed on average 28.3 months after the primary tumour. The median survival time following diagnosis is 5.3 months. Surgery (with or without associated radiotherapy), stereotactic radiosurgery, whole brain radiotherapy and best supportive care result in median survival of 10.3, 6.4, 4.4 and 1.8 months, respectively. On average, the 1-year overall survival rate for patients with CM from CRC regardless of the treatment modality is estimated to be around 24%.Conclusions
The prognosis of patients with CM from CRC is dismal. Surgery may increase survival, but the additional benefit of perioperative radiotherapy cannot be ascertained due to paucity of data. Further studies are required to identify the role of the different oncological and surgical therapies and identify those patients likely to benefit most. Identification of patients who are at higher risk of developing brain metastases may be another important area for future research.17.
Heritage J Robinson JD Elliott MN Beckett M Wilkes M 《Journal of general internal medicine》2007,22(10):1429-1433
Context
In primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed.Objective
To test an intervention to reduce patients’ unmet concerns.Design
Cross-sectional comparison of 2 experimental questions, with videotaping of office visits and pre and postvisit surveys.Setting
Twenty outpatient offices of community-based physicians equally divided between Los Angeles County and a midsized town in Pennsylvania.Participants
A volunteer sample of 20 family physicians (participation rate?=?80%) and 224 patients approached consecutively within physicians (participation rate?=?73%; approximately 11 participating for each enrolled physician) seeking care for an acute condition.Intervention
After seeing 4 nonintervention patients, physicians were randomly assigned to solicit additional concerns by asking 1 of the following 2 questions after patients presented their chief concern: “Is there anything else you want to address in the visit today?” (ANY condition) and “Is there something else you want to address in the visit today?” (SOME condition).Main Outcome Measures
Patients’ unmet concerns: concerns listed on previsit surveys but not addressed during visits, visit time, unanticipated concerns: concerns that were addressed during the visit but not listed on previsit surveys.Results
Relative to nonintervention cases, the implemented SOME intervention eliminated 78% of unmet concerns (odds ratio (OR)?=?.154, p?=?.001). The ANY intervention could not be significantly distinguished from the control condition (p?=?.122). Neither intervention affected visit length, or patients’; expression of unanticipated concerns not listed in previsit surveys.Conclusions
Patients’ unmet concerns can be dramatically reduced by a simple inquiry framed in the SOME form. Both the learning and implementation of the intervention require very little time.18.
Syed Yaseen Naqvi Anas Jawaid Ilan Goldenberg Valentina Kutyifa 《Current heart failure reports》2018,15(5):315-321
Purpose of Review
Cardiac resynchronization therapy (CRT) is an effective treatment option for therapy-refractory mild to severe heart failure (HF) patients with reduced ejection fraction and left ventricular (LV) conduction delay. Multiple clinical trials have shown that CRT improves cardiac function and overall quality of life, as well as reduces HF hospitalizations, health care costs, and mortality.Recent Findings
Despite its effectiveness, the “non-response” rate to CRT is around 30%, remaining a major challenge that faces electrophysiologists and researchers. It has been recently suggested that the etiology of CRT non-response is multifactorial, and it requires a multifaceted approach to address it.Summary
In this focused review, we will summarize the definitions of CRT non-response, identify key factors for CRT non-response, and offer a simplified framework to address CRT non-response with the main goal of improving CRT outcomes.19.
Jennifer N. Miller Paula Schulz Bunny Pozehl Douglas Fiedler Alissa Fial Ann M. Berger 《Sleep & breathing》2018,22(3):569-577
Purpose
Home sleep apnea testing (HSAT) has increased due to improvements in technology, accessibility, and changes in third party reimbursement requirements. Research studies using HSAT have not consistently reported procedures and methodological challenges. This paper had two objectives: (1) summarize the literature on use of HSAT in research of adults and (2) identify methodological strategies to use in research and practice to standardize HSAT procedures and information.Methods
Search strategy included studies of participants undergoing sleep testing for OSA using HSAT. MEDLINE via PubMed, CINAHL, and Embase with the following search terms: “polysomnography,” “home,” “level III,” “obstructive sleep apnea,” and “out of center testing.”Results
Research articles that met inclusion criteria (n?=?34) inconsistently reported methods and methodological challenges in terms of: (a) participant sampling; (b) instrumentation issues; (c) clinical variables; (d) data processing; and (e) patient acceptability. Ten methodological strategies were identified for adoption when using HSAT in research and practice.Conclusions
Future studies need to address the methodological challenges summarized in this paper as well as identify and report consistent HSAT procedures and information.20.
Joseph S. Redman Yamini Natarajan Jason K. Hou Jingqi Wang Muzammil Hanif Hua Feng Jennifer R. Kramer Roxanne Desiderio Hua Xu Hashem B. El-Serag Fasiha Kanwal 《Digestive diseases and sciences》2017,62(10):2713-2718