A survey of physician knowledge and practices related to chemosensory disorders

Findings from a questionnaire survey document the need to increasethe awareness of physicians regarding current understandingof chemosensory disorders and their clinical management.     

Infant feeding information,attitudes and practices: a longitudinal survey in central Nepal

Background

Infant feeding is governed by environmental as well as cultural factors. Breastfeeding knowledge and attitudes are known to be associated with breastfeeding duration. This study investigated breastfeeding information, attitudes and supplementary feeding in the central hills district of Nepal.

Methods

A community-based prospective cohort study of 701 pregnant women was conducted. Information on breastfeeding attitudes, feeding practices and supplementary feeding was sought from the cohort at 4 weeks, 12 weeks and 22 weeks postpartum through repeated interviews using validated questionnaires.

Results

Average duration of intended breastfeeding was 28 months (SD 7.9) and average target time to introduce solid foods was 6.1 months (SD 1.2). About 80% of women reported their husband, mother/mother-in-law preferred breastfeeding. Eleven percent of the cohort said that breastfeeding was not enjoyable. At 12 weeks and 22 weeks after birth, about a quarter (24.8%) and half (52.8%) of the infants were introduced cow/buffalo milk, respectively, while only 6.3% and 13.4% of them were given infant formula. Overall, any breastfeeding rate remained high at over 98% throughout the follow up period.

Conclusions

Breastfeeding attitudes were encouraging in this population. Breastfeeding was almost universal. Use of infant formula was quite low, whereas cow or buffalo milk appeared to be popular supplementary foods.

     

Impact of patient care appraisal on physician behaviour in the office setting

The effect of patient care appraisal on physicians'' management of patients'' problems was assessed. Sixteen family physicians were involved. The eight in the experimental group helped in the selection of two of the five disease conditions to be audited and in the generation of optimal criteria of care for two of the conditions. Participation in the generation of optimal criteria was followed by a significant improvement in the physicians'' behaviour, but involvement in the selection of the conditions to be audited caused no change. The patient care appraisal did not lead to significant improvement of physicians'' management of the conditions. In a second analysis, in which only essential criteria of care were considered, the physicians who participated in the patient care appraisal significantly improved their management of patients'' problems. However, participation in the selection of the conditions and in the generation of the criteria of care had no effect on their performance. Patient care appraisal is an effective tool in continuing medical education and leads to improvement in the quality of care, provided the process focuses on essential criteria of care.     

Newborn infants with severe defects: a survey of paediatric attitudes and practices in the United Kingdom

This article reports the first results of a survey, by mail questionnaire, of the attitudes and practices of paediatricians with respect to the nontreatment of newborn infants with severe defects. Questionnaires were sent to 500 paediatricians in senior positions throughout the United Kingdom. 263 questionnaires, (52.6%) were completed and returned. The survey was an attempt to identify areas of consensus amongst paediatric specialists, and to discover some of the factors which influence their practice. A preliminary analysis of the data has revealed variations in attitudes and practices in some areas, and a broad consensus in others. The following report is not an endorsement of any particular point of view.     

When a physician and a clinical ethicist collaborate for better patient care

Bioethics is a relatively new addition to bedside medical care in Arab world which is characterized by a special culture that often makes blind adaptation of western ethics codes and principles; a challenge that has to be faced. To date, the American University of Beirut Medical Center is the only hospital that offers bedside ethics consultations in the Arab Region aiming towards better patient‐centered care. This article tackles the role of the bedside clinical ethics consultant as an active member of the medical team and the impact of such consultations on decision‐making and patient‐centered care. Using the case of a child with multiple medical problems and a futile medical condition, we describe how the collaboration of the medical team and the clinical ethics consultant took a comprehensive approach to accompany and lead the parents and the medical team in their decision‐making process and how the consultations allowed several salient issues to be addressed. This approach proved to be effective in the Arab cultural setting and indeed did lead to better patientcentered care.     

A survey of current mammal rehabilitation and release practices

Mammal rehabilitation is carried out in hundreds of centres worldwide, requiring a large investment of time, personnel and funds. Although there are numerous published studies focusing on post-release outcomes, few have discussed the methods employed in rehabilitation. As an important first step toward addressing this, data were collected directly from rehabilitation centres about their aims, methods employed and assessment of outcomes. A survey of mammal rehabilitation centres was conducted with data collected in the form of responses to multiple-choice questions and written responses. Our results indicated a number of challenges, including: problems surrounding social group formation, lack of predator avoidance training, limited or no pre-release medical screening, release of animals exhibiting stereotypic behaviours, frequently short-term (<6 months) post-release monitoring, with only a third of centres assessing the success of releases. Although many factors may influence the success of rehabilitation, improvements to monitoring and assessment are needed before the effects of any changes to protocols could be determined. Extended post-release monitoring and thorough assessment should be a part of any future mammal rehabilitation projects. With a view to improving the rehabilitation phase, we have developed a decision tree to assist the assessment of mammals at each stage of the rehabilitation process. This could be easily adapted to create detailed species-specific models in the future.     

Placebo medication use in patient care: a survey of medical interns

The use of placebo medication, long recognized by clinicians, often has serious practical implications, such as patient deception. Past evidence has suggested that resident physicians tend to misuse placebo medication. Interns from two consecutive years of a residency program were surveyed anonymously to assess their knowledge and use of placebos. Of the 74 interns surveyed, 44 (59%) were familiar with placebo use in patient care. Fifty percent of these interns familiar with placebo use had learned about placebos from another physician. All interns who had learned about placebos during their internships had learned from another physician, whereas interns who had gained their knowledge of placebos as medical students were as likely to have learned from the medical literature as they were to have learned from a physician (P = 0.027). Interns aware of placebo use were more likely to consider placebo administration for suspected, factitious pain (P = 0.022). The present study uncovered no relationship between interns' estimations of placebo efficacy and the utility they attributed to placebos in assessing a complaint of pain. This suggests that conceptual inconsistencies underlie their use of placebos. Interns often learn of placebos as medical students and are influenced by physician-mentors. Placebo use in patient care is an area of attention for medical educators.     

Effectiveness and cost-effectiveness of antidepressants in primary care: a multiple treatment comparison meta-analysis and cost-effectiveness model

Objective

To determine effectiveness and cost-effectiveness over a one-year time horizon of pharmacological first line treatment in primary care for patients with moderate to severe depression.

Design

A multiple treatment comparison meta-analysis was employed to determine the relative efficacy in terms of remission of 10 antidepressants (citalopram, duloxetine escitalopram, fluoxetine, fluvoxamine mirtazapine, paroxetine, reboxetine, sertraline and venlafaxine). The estimated remission rates were then applied in a decision-analytic model in order to estimate costs and quality of life with different treatments at one year.

Data Sources

Meta-analyses of remission rates from randomised controlled trials, and cost and quality-of-life data from published sources.

Results

The most favourable pharmacological treatment in terms of remission was escitalopram with an 8- to 12-week probability of remission of 0.47. Despite a high acquisition cost, this clinical effectiveness translated into escitalopram being both more effective and having a lower total cost than all other comparators from a societal perspective. From a healthcare perspective, the cost per QALY of escitalopram was €3732 compared with venlafaxine.

Conclusion

Of the investigated antidepressants, escitalopram has the highest probability of remission and is the most effective and cost-effective pharmacological treatment in a primary care setting, when evaluated over a one year time-horizon. Small differences in remission rates may be important when assessing costs and cost-effectiveness of antidepressants.     

Early detection and treatment of hyperlipidemia: physician practices in Canada.

We surveyed primary care physicians in Canada to determine their current practices regarding the detection and treatment of hyperlipidemia in asymptomatic adults 20 years of age or more and to determine the role of selected patient characteristics (age, sex and the presence of coronary heart disease [CHD] risk factors) in their management decisions. The self-administered questionnaire was completed by 428 of 804 family physicians and general practitioners. The proportion of physicians who reported having tested at least 50% of their adult patients varied from 29% to 85% and was related to the number of CHD risk factors present and the patient''s age. The proportion of respondents who reported starting dietary or drug therapy among patients with a cholesterol level of 6.2 mmol/L or less increased as the number of CHD risk factors increased and was not related to patient age or sex. According to the factors examined our results suggest that primary care physicians in Canada select patients for screening and treatment mainly on the basis of CHD risk factors present and that their approach is more conservative than that recommended by the Canadian and US consensus conferences.     

The friendship model of physician/patient relationship and patient autonomy

A model of the physician patient relationship based on friendship is evaluated in terms of how it serves the interests of patients. The author maintains that this model violates the autonomy of patients who do not want to be friends with their physicians and also diminishes the autonomy of those who seek friendship with their physicians because such a desire is based on "psychological oppression," that is, the "internalization of intimations of inferiority." Ilingworth concludes that an autonomy enhancing model would be one that is open-ended, that accommodates individual patient preferences, and that embraces patient participation.     

A survey of state insurance commissioners concerning genetic testing and life insurance.

Rapid advances in genetic testing have stimulated growing concern about the potential for misuse of genetic data by insurance companies, employers, and other third parties. Thus far, reports of genetically based discrimination in life insurance have been anecdotal. Reasoning that state insurance commissioners were likely to be aware of (1) the extent of current use of and interest in genetic tests by life insurers and (2) consumer complaints about insurance being denied because of genetic condition or because of genetic test results, we conducted a survey of that group. We received responses from 42 of the 51 jurisdictions. Our results suggest (1) that those who regulate the life insurance industry do not yet perceive genetic testing to pose a significant problem in how insurers rate applicants, (2) that life insurers have much legal latitude to require genetic tests, and (3) that so far few consumers have formally complained to commissioners about the use of genetic data by life insurers.     

The impact of primary care resident physician training on patient weight loss at 12 months

Objective:

It is unclear whether training physicians to counsel obese patients leads to weight loss. This study assessed whether a 5‐h multimodal longitudinal obesity curriculum for residents on the basis of the 5As (assess, advise, agree, assist, and arrange) was associated with weight loss in their obese patients.

Design and Methods:

Twenty‐three primary care internal medicine residents were assigned by rotation schedule to intervention (curriculum) or control groups. We then conducted follow‐up chart reviews to determine weight change at up to 12 months following the index visit. 158 obese patients (76 in the intervention group and 82 in the control group) completed exit interviews; 22 patients who presented for acute care at the index visit were excluded. Chart reviews were conducted on the 46 patients in the intervention group and 41 patients in the control group who were seen again within 12 months of the index visit and had follow‐up weight measurements.

Results:

The main outcome of interest was mean change in weight at 12 months compared between the intervention and control groups. Patients of residents in the intervention group had a mean weight loss of ?1.53 kg (s.d. = 3.72) although the patients of those in the control group had a mean weight gain of 0.30 kg (s.d. = 3.60), P = 0.03. Six (15.8%) patients in the intervention group and 2 (5.4%) patients in the control group lost >5% body weight (P = 0.14).

Conclusions:

Although the magnitude of weight loss was small, this study shows that training physicians to counsel patients can produce measurable patient outcomes.