Do Physicians Underrecognize Obesity?

Objectives: A physician's advice is among the strongest predictors of efforts toward weight management made by obese patients, yet only a minority receives such advice. One contributor could be the physician's failure to recognize true obesity. The objectives of this study were to assess physicians' ability to recognize obesity and to identify factors associated with recognition and documentation of obesity. Methods: Internal medicine residents and attending physicians at three academic urban primary care clinics and their adult patients participated in a study using recognition and documentation of patient obesity as the main measures. Results: A total of 52 physicians completed weight assessments for 400 patients. The mean patient age was 51 years, 56% were women, 77% were Hispanic, and 67% had one or more obesity-related comorbidity. There were 192 (48%) patients, of whom 66% were correctly identified by physicians as being obese, 86% of those with a body mass index (BMI) Q35, but only 49% of those with a BMI of 30 to 34.9 (P G 0.0001). Fewer obese Hispanic patients were identified than were non-Hispanic patients (62% vs 76%; P = 0.03). No physician characteristics were significantly associated with recognition of obesity. Physicians documented obesity as a problem for 51% of patients. Attending physicians documented obesity more frequently than did residents (64% vs 43%, odds ratio 2.5, 95% confidence interval 1.3Y4.6) and normal-weight physicians documented obesity more frequently than overweight physicians (58% vs 41%, odds ratio 2.0, 95% confidence interval 1.0Y4.0). Documentation was more common for patients with a BMI Q35 and for non-Hispanics. Documentation was not more common for patients with obesity-related comorbidities. Conclusions: Physicians have difficulty recognizing obesity unless patients' BMI is Q35. Training physicians to recognize true obesity may increase rates of documentation, a first step toward treatment

Impact of the 2008 U.S. Preventative services task force recommendation on frequency of prostate-specific antigen screening in older men

OBJECTIVES: To evaluate the effect of the 2008 U.S. Preventative Services Task Force recommendation against prostate-specific antigen (PSA) screening in men aged 75 and older on frequency of PSA screening in elderly men. DESIGN: Retrospective, cross-sectional analysis. SETTING: Fifteen community primary care practices in western Massachusetts. PARTICIPANTS: Men aged 65 and older with one or more annual physicals between January 1, 2006, and December 31, 2010. MEASUREMENTS: PSA testing was determined from the electronic health record. Mixed-effects logistic regression was used to model the rate of PSA testing over time for two age groups: 65 to 74, and 75 and older. RESULTS: Of the 7,833 men in this study, 60% were younger than 75. PSA screening rates were consistently lower in men aged 75 and older. Annual rates, adjusted for number of clinic visits, ranged from 12% to 28% in men aged 75 and older, and 37% to 49% in men aged 65 to 74. In the 2 years before the guideline was released, there was already a slow decline in screening rate in men aged 75 and older, whereas the screening rate in men aged 65 to 74 was rising. Compared to 2008, there was a 36% relative reduction in screening rate in 2009 and a 51% relative reduction in 2010 for men aged 75 and older, and a 12% relative reduction in screening rate in 2009 and a 24% relative reduction in 2010 for men aged 65 to 74. CONCLUSION: The 2008 recommendation appeared to reduce PSA screening rates in older men in 2009 and 2010; there was a substantial reduction in men aged 75 and older and a more modest reduction in men aged 65 to 74

A Predictive Model Facilitates Early Recognition of Spinal Epidural Abscess in Adults

Introduction: Spinal epidural abscess (SEA), a highly morbid and potentially lethal deep tissue infection of the central nervous system has more than tripled in incidence over the past decade. Early recognition at the point of initial clinical presentation may prevent irreversible neurologic injury or other serious, adverse outcomes. To facilitate early recognition of SEA, we developed a predictive scoring model.Methods: Using data from a 10-year, retrospective, case-control study of adults presenting for care at a tertiary-care, regional, academic medical center, we used the Integrated Discrimination Improvement Index (IDI) to identify candidate discriminators and created a multivariable logistic regression model, refined based on p-value significance. We selected a cutpoint that optimized sensitivity and specificity.  Results: The final multivariable logistic regression model based on five characteristics –patient age, fever and/or rigor, antimicrobial use within 30 days, back/neck pain, and injection drug use – shows excellent discrimination (AUC 0.88 [95% confidence interval 0.84, 0.92]). We used the model’s β coefficients to develop a scoring system in which a cutpoint of six correctly identifies cases 89% of the time. Bootstrapped validation measures suggest this model will perform well across samples drawn from this population. Conclusion: Our predictive scoring model appears to reliably discriminate patients who require emergent spinal imaging upon clinical presentation to rule out SEA and should be used in conjunction with clinical judgment

A Predictive Model Facilitates Early Recognition of Spinal Epidural Abscess in Adults

Introduction: Spinal epidural abscess (SEA), a highly morbid and potentially lethal deep tissue infection of the central nervous system has more than tripled in incidence over the past decade. Early recognition at the point of initial clinical presentation may prevent irreversible neurologic injury or other serious, adverse outcomes. To facilitate early recognition of SEA, we developed a predictive scoring model. Methods: Using data from a 10-year, retrospective, case-control study of adults presenting for care at a tertiary-care, regional, academic medical center, we used the Integrated Discrimination Improvement Index (IDI) to identify candidate discriminators and created a multivariable logistic regression model, refined based on p-value significance. We selected a cutpoint that optimized sensitivity and specificity. Results: The final multivariable logistic regression model based on five characteristics -patient age, fever and/or rigor, antimicrobial use within 30 days, back/neck pain, and injection drug use - shows excellent discrimination (AUC 0.88 [95% confidence interval {0.84, 0.92}]). We used the model\u27s β coefficients to develop a scoring system in which a cutpoint of six correctly identifies cases 89% of the time. Bootstrapped validation measures suggest this model will perform well across samples drawn from this population. Conclusion: Our predictive scoring model appears to reliably discriminate patients who require emergent spinal imaging upon clinical presentation to rule out SEA and should be used in conjunction with clinical judgment

A Predictive Model Facilitates Early Recognition of Spinal Epidural Abscess in Adults

Introduction: Spinal epidural abscess (SEA), a highly morbid and potentially lethal deep tissue infection of the central nervous system has more than tripled in incidence over the past decade. Early recognition at the point of initial clinical presentation may prevent irreversible neurologic injury or other serious, adverse outcomes. To facilitate early recognition of SEA, we developed a predictive scoring model. Methods: Using data from a 10-year, retrospective, case-control study of adults presenting for care at a tertiary-care, regional, academic medical center, we used the Integrated Discrimination Improvement Index (IDI) to identify candidate discriminators and created a multivariable logistic regression model, refined based on p-value significance. We selected a cutpoint that optimized sensitivity and specificity. Results: The final multivariable logistic regression model based on five characteristics –patient age, fever and/or rigor, antimicrobial use within 30 days, back/neck pain, and injection drug use – shows excellent discrimination (AUC 0.88 [95% confidence interval {0.84, 0.92}]). We used the model’s β coefficients to develop a scoring system in which a cutpoint of six correctly identifies cases 89% of the time. Bootstrapped validation measures suggest this model will perform well across samples drawn from this population. Conclusion: Our predictive scoring model appears to reliably discriminate patients who require emergent spinal imaging upon clinical presentation to rule out SEA and should be used in conjunction with clinical judgment

Implementing a resident research program to overcome barriers to resident research

Internal medicine residents are required to participate in scholarly activity, but conducting originalresearch during residency is challenging. Following a poor Match at Baystate Medical Center, the authors implemented a resident research program to overcome known barriers to resident research. The multifaceted program addressed the following barriers: lack of interest, lack of time, insufficient technical support, and paucity of mentors. The program consisted of evidence-based medicine training to stimulate residents\u27 interest in research and structural changes to support their conduct of research, including protected time for research during ambulatory blocks, a research assistant to help with tasks such as institutional review board applications and data entry, a research nurse to help with data collection, easily accessible biostatistical support, and a resident research director to provide mentorship. Following implementation in the fall of 2005, there was a steady rise in the number of resident presentations at national meetings, then in the number of resident publications. From 2001 to 2006, the department saw 3 resident publications. From 2006 to 2012, that number increased to 39 (P\u3c .001). The department also saw more original research (29 publications) andresident first authors (12 publications) after program implementation. The percentage of residents accepted into fellowships rose from 33% before program implementation to 49% after (P = .04). This comprehensive resident research program, which focused on evidence-based medicine and was tailored to overcome specific barriers, led to a significant increase in the number of resident Medline publications and improved the reputation of the residency program

Procedural sedation for MRI in children with ADHD

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood, affecting 5-8% of children. It has been observed that these children have poor sedation experiences; however, to date there is minimal research on procedural sedation in this population. AIM: To examine whether children with ADHD required larger doses of propofol for magnetic resonance imaging (MRI) sedation. METHODS: The hospital\u27s administrative billing database was used to identify all billing codes for MRI brain scans (with and without contrast) in children aged between 5 and 12 years over the preceding 5.5 years. The hospital\u27s electronic medical record database provided baseline demographics. The sedation record was reviewed for propofol dose, psychostimulant use, and prescribed dose. All children received a standard weight-based dose of midazolam prior to receiving the necessary amount of propofol. Primary outcome was the dose of propofol administered (mg·kg(-1) ) to achieve adequate sedation. RESULTS: A total of 258 procedures met the inclusion criteria. The sample was 52% male, 74% White, 7.8% Black, 7.8% Hispanic, 4.3% Asian, and 6.2% other. ADHD was documented for 49 procedures with a prevalence of 18.5%. Patients with ADHD were older, more likely to be male, Hispanic, or to report race as \u27Refused/Unknown\u27. Indications for MRI for patients with ADHD varied significantly, with \u27Behavioral\u27 and \u27Neurocutaneous\u27 being significantly overrepresented in the ADHD group. The average sedative dose for all patients was 2.8 mg·kg(-1) (95% CI 2.62-2.94). Sedative dose was similar among children with and without ADHD diagnosis. CONCLUSIONS: Our study illustrates that children with ADHD do not have higher sedative requirements to achieve a successful brain MRI

The impact of a palliative care team on residents\u27 experiences and comfort levels with pediatric palliative care

Abstract Background: 8,600 children are eligible for palliative care services each day in the US, yet many pediatric residents and pediatricians do not feel comfortable providing palliative/end of life care. Objective: To evaluate the impact of a palliative care team (PCT) on pediatric and internal medicine/pediatric (IM/Peds) residents knowledge, comfort level and experience providing pediatric palliative care (PPC). Design: Electronic 32-item questionnaire. Subjects: Pediatric and IM/Peds residents at ACGME accredited programs during the 2011-2012 academic year. Measurements: Residents\u27 PPC training, knowledge, comfort levels and experiences. Results: Nearly two-thirds of 294 respondents (63.6%; 95% CI: 58.2, 69.1) selected a description of PPC that describes palliative care as starting at the time of diagnosis regardless of treatment goals. Participants who reported the presence of a PCT at their institution selected this accurate description of PPC more often than those who did not report the presence of a PCT (72.3% vs. 53.3%;