Knowledge and attitudes of family physicians coming to COPD continuing medical education

Barbara P Yawn, Peter C WollanOlmsted Medical Center, Research Department, Rochester, MN, USAPurpose: COPD remains under-recognized and under-treated. Much of early COPD care is given by primary care physicians but only when COPD is recognized. This survey explores the attitudes, beliefs, and knowledge related to COPD recognition, diagnosis, and treatment from family physicians and nurse practitioners (NPs) and physician assistants (PAs) working in primary care.Methods: We completed a survey of family physicians, and NPs/PAs attending one of three CME programs on five common chronic conditions including COPD.Results: Return rate was 62% (n = 284) including 178 physicians and 100 NPs/PAs. Fewer than half of the respondents reported knowledge of or use of COPD guidelines. The barriers to recognition and diagnosis of COPD they reported included the multiple morbidities of most COPD patients, failure of patients to report COPD symptoms, as well as lack of knowledge and inadequate training in COPD diagnosis and management. Three quarters (74%) of respondents reported use of spirometry to diagnose COPD but only 32% said they included reversibility assessment. COPD was incorrectly assessed as a disease primarily of men (78% of respondents) that appeared after age 60 (61%). Few respondents reported that they believed COPD treatment was useful or very useful for improving symptoms (15%) or decreasing exacerbations (3%) or that pulmonary rehabilitation was helpful (3%), but 13% reported they thought COPD treatment could extend longevity.Conclusions: Primary care physicians and NPs/PAs working in primary care continue to report lack of awareness and use of COPD guidelines, as well as correct information related to COPD epidemiology or potential benefits of available treatments including pulmonary rehabilitation. It is unlikely that diagnosis and management of COPD will improve in primary care until these knowledge gaps and discrepancies with published efficacy of therapy issues are addressed.Keywords: COPD treatment, diagnosis, management, patients, family physician

Do published guidelines for evaluation of Irritable Bowel Syndrome reflect practice?

BACKGROUND: The only US guidelines listed in the National Guideline Warehouse for the diagnosis of Irritable Bowel Syndrome (IBS) are the expert opinion guidelines published by The American Gastroenterology Association. Although the listed target audience of these guidelines includes family physicians and general internists, the care recommended in the guidelines has not been compared to actual primary care practice. This study was designed to compare expert opinion guidelines with the actual primary care provided and to assess outcomes in the 3 years following the IBS diagnosis. METHODS: This is a retrospective medical record review study using a random sample of incident IBS cases from all Olmsted County, Minnesota providers diagnosed between January 1, 1993 and December 31, 1995. Data was collected on all care and testing provided to the subjects as well as 3-year outcomes related to the IBS diagnosis. RESULTS: Of the 149 IBS patients, 99 were women and the mean age was 47.6 years. No patient had all of the diagnostic tests recommended in the guidelines. 42% had the basic blood tests of CBC and a chemistry panel. Sedimentation rate (2%) and serum thyroxine level (3%) were uncommon. Colon imaging studies were done in 41% including 74% of those over the age of 50. In the 3 years following the diagnosis, only one person had a change in diagnosis and no diagnoses of gastro-intestinal malignancies were made in the cohort. CONCLUSIONS: Primary care practice based diagnostic evaluations for IBS differ significantly from the specialty expert opinion-based guidelines. Implementation of the specialty guidelines in primary care practice would increase utilization with apparent limited improvement in diagnostic outcomes

Entanglement in a Solid State Spin Ensemble

Entanglement is the quintessential quantum phenomenon and a necessary ingredient in most emerging quantum technologies, including quantum repeaters, quantum information processing (QIP) and the strongest forms of quantum cryptography. Spin ensembles, such as those in liquid state nuclear magnetic resonance, have been powerful in the development of quantum control methods, however, these demonstrations contained no entanglement and ultimately constitute classical simulations of quantum algorithms. Here we report the on-demand generation of entanglement between an ensemble of electron and nuclear spins in isotopically engineered phosphorus-doped silicon. We combined high field/low temperature electron spin resonance (3.4 T, 2.9 K) with hyperpolarisation of the 31P nuclear spin to obtain an initial state of sufficient purity to create a non-classical, inseparable state. The state was verified using density matrix tomography based on geometric phase gates, and had a fidelity of 98% compared with the ideal state at this field and temperature. The entanglement operation was performed simultaneously, with high fidelity, to 10^10 spin pairs, and represents an essential requirement of a silicon-based quantum information processor.Comment: 4 pages, 3 figures plus supporting information of 4 pages, 1 figure v2: Updated reference

Manganites at Quarter Filling: Role of Jahn-Teller Interactions

We have analyzed different correlation functions in a realistic spin-orbital model for half-doped manganites. Using a finite-temperature diagonalization technique the CE phase was found in the charge-ordered phase in the case of small antiferromagnetic interactions between $t_{2g}$ electrons. It is shown that a key ingredient responsible for stabilization of the CE-type spin and orbital-ordered state is the cooperative Jahn-Teller (JT) interaction between next-nearest Mn$^{+3}$ neighbors mediated by the breathing mode distortion of Mn$^{+4}$ octahedra and displacements of Mn$^{+4}$ ions. The topological phase factor in the Mn-Mn hopping leading to gap formation in one-dimensional models for the CE phase as well as the nearest neighbor JT coupling are not able to produce the zigzag chains typical for the CE phase in our model.Comment: 16 pages with 16 figures, contains a more detailed parameter estimate based on the structural data by Radaelli et al. (accepted for publication in Phys. Rev. B

The gender specific frequency of risk factor and CHD diagnoses prior to incident MI: A community study

BACKGROUND: CHD is a chronic disease often present years prior to incident AMI. Earlier recognition of CHD may be associated with higher levels of recognition and treatment of CHD risk factors that may delay incident AMI. To assess timing of CHD and CHD risk factor diagnoses prior to incident AMI. METHODS: This is a 10-year population based medical record review study that included all medical care providers in Olmsted County, Minnesota for all women and a sample of men residing in Olmsted County, MN with confirmed incident AMI between 1995 and 2000. RESULTS: All medical care for the 10 years prior to incident AMI was reviewed for 150 women and 148 men (38% sample) in Olmsted County, MN. On average, women were older than men at the time of incident AMI (74.7 versus 65.9 years, p < 0.0001). 30.4% of the men and 52.0% of the women received diagnoses of CHD prior to incident AMI (p = 0.0002). Unrecognized and untreated CHD risk factors were present in both men (45% of men 5 years prior to AMI) and women (22% of women 5 years prior to first AMI), more common in men and those without a diagnosis of CHD prior to incident AMI (p < 0.0001). CONCLUSION: A CHD diagnosis prior to incident AMI is associated with higher rates of recognition and treatment of CHD risk factors suggesting that diagnosing CHD prior to AMI enhances opportunities to lower the risk of future CHD events

A Portable random number generator for parallel computers

Simulations on parallel computors require distinct streams of pseudo-random deviates for each processor. A combination generator is proposed which achieves distinct streams through a congruential component, and long period through a Fibonacci component. The algorithm has been coded in Fortran 77, and is suitable for fairly long simulations on machines of up to a thousand processors. © 1992, Taylor & Francis Group, LLC. All rights reserved

Skeletal, cardiac, and smooth muscle failure in Duchenne muscular dystrophy

The goals of this study were to describe the clinical course of skeletal, cardiac, and gastrointestinal muscle manifestations and trends in age at diagnosis and survival of Duchenne muscular dystrophy (DMD) patients. A retrospective cohort of 33 male patients with DMD, born between 1953 and 1983 and followed at the Mayo Clinic during their second decade of life, was studied. The mean age at DMD diagnosis was 4.6 years. Skeletal muscle weakness present in all patients at diagnosis progressed to wheelchair dependency in 32 patients (97%) by the age of 13 years (median age 10 years). Cardiac muscle failure developed in 5 patients (15%) (median age 21.5 years). Smooth muscle manifestations related to the digestive and urinary tracts occurred in 7 (21%) and 2 (6%) patients (median age 15 years), respectively. The gastrointestinal dilatations were primary in 2 patients or secondary to surgery or acute respiratory illness in 5 patients. By the end of the study period, 17 deaths had occurred (median age 17 years). Over time, there was a decrease in the time to DMD diagnosis (P = .05) but no significant change in survival (P = .44). Cardiac and smooth muscle manifestations occur late in the course of DMD. Clinical gastrointestinal symptoms related to smooth muscle function most often were secondary to surgery or a respiratory illness. In recent years, the diagnosis of DMD has been made at a younger age, but survival has not changed

Test-Retest Reproducibility of Heart Rate Recovery After Treadmill Exercise

BACKGROUND Slowed heart rate recovery (HRR) of less than 12 beats per minute in the first minute after an exercise stress test has been suggested as a useful addition to the criteria currently used to assess exercise stress test results. Although HRR has been tested in large populations, the short-term test-retest stability (reproducibility) of abnormal HRR for an individual has not been assessed. METHODS The study was a retrospective comparison of medical record information using a community-practice–based sample of 90 patients undergoing 2 exercise stress tests separated by 18 weeks or less. Concordance of abnormal HRR results on the first and second stress tests were assessed for individual patients using definitions of abnormal HRR from the medical literature. RESULTS Individual patient’s HRR was markedly variable from the first to second stress test. In this sample, no definition of abnormal HRR provided more than 55% concordance between results from the first and second stress tests. CONCLUSION These preliminary data suggest that HRR appears to have limited short-term test-retest stability or reproducibility and therefore might not be a reliable addition to current results of exercise stress tests