Metabolic control in patients with type 2 diabetes mellitus in a public hospital in Peru: a cross-sectional study in a low-middle income country

Objective The objective of this study was to assess patients’ achievement of ADA (American Diabetes Association) guideline recommendations for glycosylated hemoglobin, lipid profile, and blood pressure in a type 2 diabetes mellitus (T2DM) outpatient clinic in a low-middle income country (LMIC) setting. Methods This is a descriptive cross-sectional study with 123 ambulatory T2DM patients who are being treated at a public hospital in Lima, Peru. Data was gathered via standardized interviews, clinical surveys, and anthropomorphic measurements for each patient. Blood samples were drawn in fasting state for measures of glucose, glycosylated hemoglobin (HbA1c), and lipid profile. Laboratory parameters and blood pressure were evaluated according to ADA recommendations. Results Of the 123 patients, 81 were women and the mean age was 61.8 years. Glycemic control was abnormal in 82 (68.33%) participants, and 45 (37.50%) were unable to control their blood pressure. Lipid profile was abnormal in 73 (60.83%) participants. Only nine (7.50%) participants fulfilled ADA recommendations for glycemic, blood pressure, and lipid control. Conclusions Amongst individuals with type 2 diabetes, there was poor attainment of the ADA recommendations (HbA1c, blood pressure and LDL-cholesterol) for ambulatory T2DM patients. Interventions are urgently needed in order to prevent long-term diabetic complications

Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.

OBJECTIVE: To compare the effectiveness of shared decision making with usual care in choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome. DESIGN: Multicenter pragmatic parallel randomized controlled trial. SETTING: Six emergency departments in the United States. PARTICIPANTS: 898 adults (aged \u3e17 years) with a primary complaint of chest pain who were being considered for admission to an observation unit for cardiac testing (451 were allocated to the decision aid and 447 to usual care), and 361 emergency clinicians (emergency physicians, nurse practitioners, and physician assistants) caring for patients with chest pain. INTERVENTIONS: Patients were randomly assigned (1:1) by an electronic, web based system to shared decision making facilitated by a decision aid or to usual care. The primary outcome, selected by patient and caregiver advisers, was patient knowledge of their risk for acute coronary syndrome and options for care; secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, and the 30 day rate of major adverse cardiac events. RESULTS: Compared with the usual care arm, patients in the decision aid arm had greater knowledge of their risk for acute coronary syndrome and options for care (questions correct: decision aid, 4.2 v usual care, 3.6; mean difference 0.66, 95% confidence interval 0.46 to 0.86), were more involved in the decision (observing patient involvement scores: decision aid, 18.3 v usual care, 7.9; 10.3, 9.1 to 11.5), and less frequently decided with their clinician to be admitted for cardiac testing (decision aid, 37% v usual care, 52%; absolute difference 15%; P CONCLUSIONS: Use of a decision aid in patients at low risk for acute coronary syndrome increased patient knowledge about their risk, increased engagement, and safely decreased the rate of admission to an observation unit for cardiac testing.Trial registration ClinicalTrials.gov NCT01969240

Humor During Clinical Practice: Analysis of Recorded Clinical Encounters

Objective: Little is known about humor’s use in clinical encounters, despite its many potential benefits. We aimed to describe humor during clinical encounters. Design: We analyzed 112 recorded clinical encounters. Two reviewers working independently identified instances of humor, as well as information surrounding the logistics of its use. Results: Of the 112 encounters, 66 (59%) contained 131 instances of humor. Humor was similarly frequent in primary care (36/61, 59%) and in specialty care (30/51, 59%), was more common in gender-concordant interactions (43/63, 68%), and was most common during counseling (81/112, 62%). Patients and clinicians introduced humor similarly (63 vs 66 instances). Typically, humor was about the patient’s medical condition (40/131, 31%). Discussion and Conclusion: Humor is used commonly during counseling to discuss the patient’s medical condition and to relate to general life events bringing warmth to the medical encounter. The timing and topic of humor and its use by all parties suggests humor plays a role in the social connection between patients and physicians and allows easier discussion of difficult topics. Further research is necessary to establish its impact on clinicians, patients, and outcomes. (J Am Board Fam Med 2018;31: 270–278.) Keywords: Humor, Patient-Centered Care, Primary Health Care, Physician-Patient Relations, Patient-Physician Communicatio

Patient capacity and constraints in the experience of chronic disease: a qualitative systematic review and thematic synthesis.

BACKGROUND: Life and healthcare demand work from patients, more so from patients living with multimorbidity. Patients must respond by mobilizing available abilities and resources, their so-called capacity. We sought to summarize accounts of challenges that reduce patient capacity to access or use healthcare or to enact self-care while carrying out their lives. METHODS: We conducted a systematic review and synthesis of the qualitative literature published since 2000 identifying from MEDLINE, EMBASE, Psychinfo, and CINAHL and retrieving selected abstracts for full text assessment for inclusion. After assessing their methodological rigor, we coded their results using a thematic synthesis approach. RESULTS: The 110 reports selected, when synthesized, showed that patient capacity is an accomplishment of interaction with (1) the process of rewriting their biographies and making meaningful lives in the face of chronic condition(s); (2) the mobilization of resources; (3) healthcare and self-care tasks, particularly, the cognitive, emotional, and experiential results of accomplishing these tasks despite competing priorities; (4) their social networks; and (5) their environment, particularly when they encountered kindness or empathy about their condition and a feasible treatment plan. CONCLUSION: Patient capacity is a complex and dynamic construct that exceeds "resources" alone. Additional work needs to translate this emerging theory into useful practice for which we propose a clinical mnemonic (BREWS) and the ICAN Discussion Aid

What Is Shared Decision Making? (and What It Is Not)

Both the practice of medicine and the expectations of patients regarding their care are changing. A point of confluence is in the need for medicine to be more patient centered, and in the need for patients to be more involved in their care.(1,2) This confluence is particularly pertinent when more than one reasonable approach is available to manage the patient's situation, and when those approaches differ in ways that matter to patients.(3) In shared decision-making (SDM), clinicians and patients work together to understand the patient's situation and to determine how best to address it. Emergency medicine is not exempt from these trends. In this paper we seek to define SDM and its role in contemporary healthcare. Our goal is to set the stage for the active exploration of SDM in the care of patients in the emergency department. This article is protected by copyright. All rights reserve

Vasculitis secundaria a infección por Fasciola hepática Secondary vasculitis to infection by Fasciola hepatica

Se presenta el caso de un paciente varón de 38 años, procedente de una zona endémica para fascioliasis hepática en el Perú. Fue hospitalizado por presentar un cuadro de cuatro semanas de evolución; con fiebre, mialgias intensas, lesiones eritematosas y dolorosas en las regiones de extensión de las extremidades. La electromiografía y la velocidad de conducción nerviosa mostraron una miopatía inflamatoria global. La biopsia de piel evidenció una vasculitis de tipo poliarteritis nodosa. En el proceso de evaluación previa a la terapia inmunosupresora, se hallaron huevos de Fasciola hepática en el examen coproparasitológico. El diagnóstico de fascioliasis se confirmó con fas2-ELISA: 0,46 (VN <0,20). El cuadro clínico remitió luego del tratamiento con ticlabendazol. Se mantuvo contacto con el paciente durante un año y no se evidenció recurrencia de la enfermedad, manteniéndose asintomático<br>There is a case of a 38 year-old male patient coming from an area where hepatic fascioliasis is endemic in Peru. He was hospitalized because he showed 4 weeks of symptoms like fever, intense myalgias, erythematous and painful injuries on limb extensions. The electromyography and nerve conduction velocity showed a global inflammatory myopathy. A skin biopsy showed polyarteritis nodosa-type vasculitis. During the evaluation process prior to the immunosuppressive therapy, hepatic Fasciola eggs were found in the parasitological examination of stools. The fascioliasis diagnosis was confirmed by fas2-ELISA: 0.46 (VN <0.20). Clinical symptoms started to subside after treatment with ticlabendazol. Contact with the patient was maintained for a year and there was no evidence of disease recurrence, and he was asymptomati

Clinical Features and Outcomes Associated with Angioedema in the Emergency Department

Introduction: Angioedema represents self-limited, localized swelling of submucosal or subcutaneous tissues. While the underlying etiology may be undeterminable in the emergent setting, nonhistaminergic and histaminergic angioedema respond differently to therapeutic interventions, with implications for empiric treatment. Clinical features and outcome differences among nonhistaminergic vs histaminergic angioedema patients in the emergency department (ED) are poorly characterized. We aim to describe the clinical characteristics and outcomes among ED patients with angioedema by suspected etiology.Methods: This was a 10-year retrospective study of adult ED patients with angioedema, using data abstracted from the electronic health record. We evaluated univariable associations of select clinical features with etiology and used them to develop a multivariable logistic regression model for nonhistaminergic vs histaminergic angioedema.Results: Among 450 adult angioedema patients, the mean +/- standard deviation age was 57 +/- 18 years, and 264 (59%) were female. Among patients, 30% had suspected nonhistaminergic angioedema, 30% had suspected histaminergic angioedema, and 40% were of unknown etiology. As compared to histaminergic angioedema, nonhistaminergic angioedema was associated with angiotensin-converting enzyme inhibitors (ACEI) or use of angiotensin II receptor blockers (ARB) (odds ratio [OR] [60.9]; 95% confidence interval [CI], 23.16-160.14) and time of onset one hour or more prior to ED arrival (OR [5.91]; 95% CI,1.87-18.70) and was inversely associated with urticaria (OR [0.05]; 95% CI, 0.02-0.15), dyspnea (OR [0.23]; 95% CI, 0.08-0.67), and periorbital or lip edema (OR [0.25]; 95% CI, 0.08-0.79 and OR [0.32]; 95% CI, 0.13-0.79, respectively).Conclusion: As compared to histaminergic angioedema, patients with nonhistaminergic angioedema were more likely to present one hour or more after symptom onset and take ACEI or ARB medications, and were less likely to have urticaria, dyspnea, or periorbital or lip angioedema. Identification of characteristics associated with the etiology of angioedema may assist providers in more rapidly initiating targeted therapies

Clinical Features and Outcomes Associated with Angioedema in the Emergency Department

Introduction: Angioedema represents self-limited, localized swelling of submucosal or subcutaneous tissues. While the underlying etiology may be undeterminable in the emergent setting, nonhistaminergic and histaminergic angioedema respond differently to therapeutic interventions, with implications for empiric treatment. Clinical features and outcome differences among nonhistaminergic vs histaminergic angioedema patients in the emergency department (ED) are poorly characterized. We aim to describe the clinical characteristics and outcomes among ED patients with angioedema by suspected etiology.Methods: This was a 10-year retrospective study of adult ED patients with angioedema, using data abstracted from the electronic health record. We evaluated univariable associations of select clinical features with etiology and used them to develop a multivariable logistic regression model for nonhistaminergic vs histaminergic angioedema.Results: Among 450 adult angioedema patients, the mean +/- standard deviation age was 57 +/- 18 years, and 264 (59%) were female. Among patients, 30% had suspected nonhistaminergic angioedema, 30% had suspected histaminergic angioedema, and 40% were of unknown etiology. As compared to histaminergic angioedema, nonhistaminergic angioedema was associated with angiotensin-converting enzyme inhibitors (ACEI) or use of angiotensin II receptor blockers (ARB) (odds ratio [OR] [60.9]; 95% confidence interval [CI], 23.16-160.14) and time of onset one hour or more prior to ED arrival (OR [5.91]; 95% CI,1.87-18.70) and was inversely associated with urticaria (OR [0.05]; 95% CI, 0.02-0.15), dyspnea (OR [0.23]; 95% CI, 0.08-0.67), and periorbital or lip edema (OR [0.25]; 95% CI, 0.08-0.79 and OR [0.32]; 95% CI, 0.13-0.79, respectively).Conclusion: As compared to histaminergic angioedema, patients with nonhistaminergic angioedema were more likely to present one hour or more after symptom onset and take ACEI or ARB medications, and were less likely to have urticaria, dyspnea, or periorbital or lip angioedema. Identification of characteristics associated with the etiology of angioedema may assist providers in more rapidly initiating targeted therapies

Additional file 1: of Patient capacity and constraints in the experience of chronic disease: a qualitative systematic review and thematic synthesis

Appendix: Complete Search Strategy for Data. Full Search Strategy used to complete the review. (DOCX 23 kb