The Right Ingredients: Essential If You Want to Bake the Cake Right!

Docēre, the Latin root for doctor, means to teach. At the heart of what we do as physicians is teaching; we teach our patients, their families, and our future physicians. Why do we devote so much time to education? No matter how well we diagnose and treat, if patients and families do not understand their treatment, it may be unsuccessful. No matter how knowledgeable and skillful we are, if we do not nurture the next generation, key knowledge, skills, and values will disappear

A study of the use of a small computer as a communication interface for a large on-line system

Increasing use of digital computers in communication environments has emphasized the need for an efficient method of interfacing communication lines to the central computer. Hard-wired multiplexors, acting as slaves to the central computer, must look to it for instruction for polling, error checking and other tasks. This has slowed the central computer from its main task of referencing data and constructing replies

Program ACTIVE II: Design and Methods for a Multi-Center Community-Based Depression Treatment for Rural and Urban Adults with Type 2 Diabetes

OBJECTIVE: Depression affects one in four adults with type 2 diabetes (T2DM) and is associated with worsened diabetes complications, increased health care costs and early mortality. Rural and low-income urban areas, including the Appalachian region, represent an epicenter of the T2DM epidemic. Program ACTIVE II is a comparative effectiveness treatment trial designed to test whether a combination of cognitive behavioral therapy (CBT) and community-based exercise (EXER) will offer greater improvements in diabetes and depression outcomes compared to individual treatment approaches and usual care (UC). The secondary aims are to assess changes in cardiovascular risk factors across groups and to conduct a cost-effectiveness analysis of predicted incidence of cardiovascular complications across groups. METHODS: The study is a 2-by-2 factorial randomized controlled trial consisting of 4 treatment groups: CBT alone, EXER alone, combination of CBT and EXER, and UC. Adults with T2DM for > 1 year and who meet DSM-IVTR criteria for Major Depressive Disorder (MDD) are eligible to participate at two rural Appalachian sites (southeastern Ohio and West Virginia) and one urban site (Indianapolis). This type II behavioral translation study uses a community-engaged research (CEnR) approach by incorporating community fitness centers and mental health practices as interventionists. CONCLUSIONS: This is the first study to evaluate the comparative effectiveness of combined CBT and exercise in the treatment of depression using community-based intervention delivery. This approach may serve as a national model for expanding depression treatment for patients with T2DM

Depression Among Adults With Diabetes: Prevalence, Impact, and Treatment Options

Patients with type 1 or type 2 diabetes are two times more likely to experience depression than their peers without diabetes. Comorbid depression results in deleterious effects on glycemic control, worsened diabetes complications, functional disability, and premature mortality. Once identified, depression can be effectively treated with antidepressant medications, psychotherapy, or a combination of both. Patients and providers should monitor depressive symptoms to identify their recurrence and work collaboratively to address barriers to care that exist in both urban and rural areas

Depression Among Type 2 Diabetes Rural Appalachian Clinic Attendees

The prevalence and impact of type 2 diabetes in Appalachia is understudied despite the presence of high-risk socioeconomic conditions (e.g., low levels of education and income). Appalachian counties experience greater burdens of poverty, income inequality, unemployment (1), and diabetes compared with non-Appalachian counties (2–5). Rates of comorbid depression have not been documented in this region. Patients with type 2 diabetes are two times more likely to experience depressive symptoms than their peers without diabetes (6). Depression prevalence in studies using self-report depression inventories was found to be 32.9%, with lower rates (28.5%) observed in studies using diagnostic interview schedules (6,7). Depressive symptoms are associated with worsened blood glucose levels (8), diabetes complications (9), increased functional disability (10), worsened adherence to diabetes regimen (11), higher ambulatory care costs (12), and increased mortality (13). The current study was conducted to identify rates of self-reported depression and to identify the socioeconomic and medical correlates of depression among type 2 diabetic patients attending family medicine and endocrinology appointments from rural Appalachian counties of southeastern Ohio and West Virginia. It was hypothesized that poverty would increase the risk of comorbid depression in this region

Prophylactic antibiotic regimens in tumor surgery (PARITY) survey

BACKGROUND: Deep infection following endoprosthetic limb reconstruction for sarcoma of the long bones is a devastating complication occurring in 15% of sarcoma patients. Optimizing infection protocols and conducting definitive surgical trials are critical to improving outcomes. In this study, the PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) investigators aimed to examine surgeon preferences in antibiotic prophylaxis and perceptions about current evidence, as well as to ascertain interest in resolving uncertainty in the evidence with clinical trials. METHODS: We used a cross-sectional survey to examine current practice in the prescription of prophylactic antibiotics in Musculoskeletal Tumor Surgery. The survey was approved by our institution’s Ethics Board and emailed to all Active Members of the Musculoskeletal Tumor Society (MSTS) and Canadian Orthopaedic Oncology Society (CANOOS). Survey answers were collected using an anonymous online survey tool. RESULTS: Of the 96 surgeons who received the questionnaire, 72 responded (75% response rate (% CI: 65.5, 82.5%)). While almost all respondents agreed antibiotic regimens were important in reducing the risk of infection, respondents varied considerably in their choices of antibiotic regimens and dosages. Although 73% (95% CI: 61, 82%) of respondents prescribe a first generation cephalosporin, 25% favor additional coverage with an aminoglycoside and/or Vancomycin. Of those who prescribe a cephalosporin, 33% prescribe a dosage of one gram for all patients and the reminder prescribe up to 2 grams based on body weight. One in three surgeons (95% CI: 25, 48%) believes antibiotics could be discontinued after 24 hours but 40% (95% CI: 30, 53%) continue antibiotics until the suction drain is removed. Given the ongoing uncertainty in evidence to guide best practices, 90% (95% CI: 81, 95%) of respondents agreed that they would change their practice if a large randomized controlled trial showed clear benefit of an antibiotic drug regimen different from what they are currently using. Further support for a clinical trial was observed by an overwhelming surgeon interest (87%; 95% CI: 77, 93%) in participating in a multi-center randomized controlled study. CONCLUSION: The current lack of guidelines for the prescription of prophylactic antibiotics in Musculoskeletal Tumor Surgery has left Orthopaedic Oncologists with varying opinions and practices. The lack of current evidence and strong surgeon support for participating in a definitive study provides strong rationale for clinical trials

Two Cases of Hypertensive Encephalopathy Involving the Brainstem

Hypertensive encephalopathy is a medical emergency whose clinical manifestations are usually associated with bilateral parieto-occipital lesions. Predominant brainstem edema without accompanying occipital lesions is rare in hypertensive encephalopathy and usually occurs in patients with secondary hypertension. We describe the clinical and radiological features of two patients with reversible hypertensive brainstem encephalopathy. Both patients had chronic renal failure, but the extensive neuroimaging abnormalities revealed few clinical features of brainstem involvement. The clinical findings and neuroimaging abnormalities resolved once the hypertension was treated