Co-creating opportunities to incorporate cessation for electronic nicotine delivery systems in family medicine - a qualitative program evaluation.

BACKGROUND: The number of Americans who use tobacco has decreased in the twenty-first century, but electronic nicotine delivery systems (ENDS) have increased the complexity of treating tobacco dependence. The experiences of 18 family medicine practices were explored and opportunities to improve ENDS cessation were co-created in this study. METHODS: Eighteen family medicine practices were enrolled into an implementation project to incorporate ENDS cessation into their practice. The participants' experiences were explored throughout the project using an iterative qualitative approach. The research team provided technical assistance. Semi-structured group interviews and focus groups were held with participants at the beginning, middle, and end of the project to explore participants' experiences. The collective knowledge and experiences of participants, expert consultants and the research team were fused together to co-create opportunities to improve ENDS cessation. RESULTS: Nine opportunities to improve ENDS cessation were identified in three larger categories. The first category was leading change. This included: creating a vision for change to establish buy-in from key stakeholders and educate health care professionals to improve their confidence to address ENDS. The second category was creating processes. This included: establishing criteria for screening and quality improvement for ENDS cessation; being specific when asking about ENDS; creating electronic health record systems to support incorporating ENDS cessation; using chart audits if electronic health records cannot support incorporating ENDS into tobacco cessation; and assigning roles and responsibilities to members of the clinical care team. The third category was assisting patients who use ENDS. This included: educating patients and their parents/caregivers about ENDS and their potential harms, avoiding dual use, and developing a plan to quit. CONCLUSIONS: This study highlights challenges and opportunities for incorporating ENDS cessation into family medicine. The opportunities outlined here provide a practical approach which is rooted in the experiences of family physicians and their clinical care teams working to improve how they address ENDS and based on peer reviewed literature and expert input. Improving how ENDS are addressed in family medicine will require more than clinical expertise. It will also require leadership skills and the ability to create process improvements. TRIAL REGISTRATION: Not applicable.

Patient characteristics associated with favorable perceptions of patient-provider communication in early-stage lung cancer treatment.

Perceived quality of lung cancer communication is strongly associated with receiving potentially curative surgery for early-stage disease. The patient characteristics associated with poor quality communication in the setting of new lung cancer diagnosis are not known, although race may be a contributing factor. Using data from a prospective study of decision making in early-stage non-small cell lung cancer patients in five academic and community medical centers (N = 386), the authors used logistic regression techniques to identify patient-level characteristics correlated with scoring in the lowest quartile of a communication scale and a single-item communication variable describing shared communication. Income, lung cancer diagnostic status, and trust score were significantly associated with the overall communication scale. Lung cancer diagnostic status and trust score were also associated with patient perceptions of the single shared communication item, in addition to participation in a religious organization. Improving patient perceptions of communication with their provider is an important next step in ensuring that eligible patients receive optimal care for this deadly disease. This analysis identifies several modifiable factors that could improve patient perceptions of patient-provider communication. The fact that patient perception of communication is a predictor of the decision to undergo surgery independent of race highlights the need for broad communication interventions to ensure that as many eligible patients as possible are receiving surgery.

Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer.

CONTEXT: Lung cancer is the leading cause of cancer death in the United States. Surgical resection for stage I or II non-small cell cancer remains the only reliable treatment for cure. Patients who do not undergo surgery have a median survival of less than 1 year. Despite the survival disadvantage, many patients with early-stage disease do not receive surgical care and rates are even lower for black patients. OBJECTIVES: To identify potentially modifiable factors regarding surgery in patients newly diagnosed with early-stage lung cancer and to explore why blacks undergo surgery less often than whites. DESIGN, SETTING, AND PATIENTS: Prospective cohort study with patients identified by pulmonary, oncology, thoracic surgery, and generalist practices in 5 communities through study referral or computerized tomography review protocol. A total of 437 patients with biopsy-proven or probable early-stage lung cancer were enrolled between December 2005 and December 2008. Before establishment of treatment plans, patients were administered a survey including questions about trust, patient-physician communication, attitudes toward cancer, and functional status. Information about comorbid illnesses was obtained through chart audits. MAIN OUTCOME MEASURE: Lung cancer surgery within 4 months of diagnosis. RESULTS: A total of 386 patients met full eligibility criteria for lung resection surgery. The median age was 66 years (range, 26-90 years) and 29% of patients were black. The surgical rate was 66% for white patients (n = 179/273) compared with 55% for black patients (n = 62/113; P = .05). Negative perceptions of patient-physician communication manifested by a 5-point decrement on a 25-point communication scale (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.32-0.74) and negative perception of 1-year prognosis postsurgery (OR, 0.27; 95% CI, 0.14-0.50; absolute risk, 34%) were associated with decisions against surgery. Surgical rates for blacks were particularly low when they had 2 or more comorbid illnesses (13% vs 62% for <2 comorbidities; OR, 0.04 [95% CI, 0.01-0.25]; absolute risk, 49%) and when blacks lacked a regular source of care (42% with no regular care vs 57% with regular care; OR, 0.20 [95% CI, 0.10-0.43]; absolute risk, 15%). CONCLUSIONS: A decision not to undergo surgery by patients with newly diagnosed lung cancer was independently associated with perceptions of communication and prognosis, older age, multiple comorbidities, and black race. Interventions to optimize surgery should consider these factors.

The hyperkalemic Brugada sign.

BACKGROUND: A few case reports have indicated that hyperkalemia can induce a Brugada pattern in the electrocardiogram. The specific clinical and electrocardiographic features of the hyperkalemic Brugada sign, however, have not been previously described. METHODS: A case series was collected from hospitalized hyperkalemic patients with a type I Brugada pattern in the electrocardiogram, and a literature review was performed. Electrocardiograms were examined for rhythm and morphology, and clinical characteristics were analyzed. RESULTS: Nine new cases with the hyperkalemic Brugada sign were identified with an additional 15 cases found in the literature. Of the 9 cases, 8 were male patients, and all were critically ill; 5 of the 9 died within 48 hours. The mean (+/-SD) serum potassium level was 7.8 +/- 0.5 mEq/L. The mean QRS width was 144 +/- 31 milliseconds, and all had abnormal QRS axis. In 6 cases, there was a wide complex rhythm without visible P waves. The clinical and electrocardiographic characteristics of 15 cases found in the literature were remarkably similar to those in our series. CONCLUSIONS: The hyperkalemic Brugada pattern differs in substantial ways from the electrocardiogram of patients with the genetic Brugada syndrome. Many patients have wide complex rhythms without visible P waves, marked QRS widening, and an abnormal QRS axis. Most patients are male, and many are critically ill. Prompt recognition of this clinical and electrocardiographic entity may expedite the initiation of appropriate treatment for hyperkalemia.

Vanilloid-mediated heterosynaptic facilitation of inhibitory synaptic input to neurons of the rat dorsal motor nucleus of the vagus.

Vanilloid type-1 receptors (VR1) are abundant in the dorsal vagal complex, where their function is mostly unknown. We examined the role of VR1 in regulating synaptic inputs to neurons of the dorsal motor nucleus of the vagus (DMV). Using patch-clamp recordings from DMV neurons in brainstem slices, capsaicin was found to increase action potential-independent inhibitory input onto DMV neurons. This rapid effect was mimicked by application of the endogenous cannabinoid, anandamide and blocked by VR1 antagonists. The VR1-mediated facilitation of synaptic inhibition was reduced by ionotropic and metabotropic glutamate receptor antagonists, suggesting an indirect, heterosynaptic enhancement of GABA release caused by a VR1-mediated increase in glutamate release from presynaptic terminals of excitatory neurons. Application of L-glutamate also increased GABA release. The paired-pulse ratio was increased for IPSCs evoked after electrical stimulation of the nucleus tractus solitarius, but the effect was slower than for the enhancement of spontaneous and miniature IPSCs. Capsaicin also increased the frequency of glutamatergic postsynaptic currents in a VR1-mediated manner. Results of these studies suggest that VR1-containing glutamatergic terminals contact DMV neurons. Activation of VR1 potently enhances glutamate release onto GABAergic terminals, facilitating GABA release. Endogenous cannabinoids can thereby rapidly enhance inhibitory input to DMV neurons via VR1-mediated presynaptic mechanisms.

A new algorithm for the initial evaluation and management of supraventricular tachycardia.

Interpretations by physicians and those generated by electrocardiograph computer softwares have poor ability to recognize different types of supraventricular tachycardia (SVT). Therefore, we developed and tested a new SVT algorithm based on easily identifiable morphological characteristics and a simple dichotomous yes/no format regarding initial electrocardiographic manifestation and response pattern. The algorithm was then tested by medical house staff during the initial evaluation of 50 adult ED and cardiac intensive care unit patients suspected of having SVT. For a wide representation of SVTs, the new algorithm gave an overall diagnostic accuracy rate of 90%. Adenosine use was limited to 54% of the cases. No patient developed hemodynamic instability after algorithm-dictated interventions were carried out. Electrocardiograph computer-generated diagnoses correctly identified the specific type of SVT in 38% of the cases. This study shows the effectiveness of the proposed new algorithm in the rapid bedside evaluation and management of SVTs and confirms that computer-generated diagnoses are unreliable.

Primary care physician preferences regarding spiritual behavior in medical practice.

BACKGROUND: Knowledge of physician attitudes and preferences regarding religion and spirituality in the medical encounter is limited by the nonspecific questions asked in previous studies and by the omission of specialties other than family practice. This study was designed to determine the willingness of internists and family physicians to be involved with varying degrees of spiritual behaviors in varied clinical settings. METHODS: The study was a multicenter, cross-sectional, nonrandomized design recruiting physicians from 6 teaching hospitals with sites in North Carolina, Vermont, and Florida. A self-administered survey was used to explore physicians' willingness to address religion and spirituality in the medical encounter. Data were gathered on the physicians' religiosity and spirituality and sociodemographic characteristics. RESULTS: Four hundred seventy-six physicians responded, for a response rate of 62.0%. While 84.5% of physicians thought they should be aware of patients' spirituality, most would not ask about spiritual issues unless a patient were dying. Fewer than one third of physicians would pray with patients even if they were dying. This number increased to 77.1% if a patient requested physician prayer. Family practitioners were more likely to take a spiritual history than general internists. CONCLUSIONS: Most primary care physicians surveyed would not initiate any involvement with patients' spirituality in the medical encounter except for the clinical setting of dying. If a patient requests involvement, however, most physicians express a willingness to comply, even if the request involves prayer.

Brugada syndrome and "Brugada sign": clinical spectrum with a guide for the clinician.

BACKGROUND: Patients with the manifest Brugada syndrome have an inordinate risk of sudden death and are candidates for implantation of a defibrillator. The Brugada type electrocardiogram (ECG) abnormality (the "Brugada sign"), however, is known to be associated with a wide range of conditions, many of which may not pose such a threat. Clinicians need guidance in choosing a rational approach for the evaluation and treatment of patients with a finding of the Brugada sign. METHODS: A systematic literature search was performed to identify publications on the Brugada syndrome and the Brugada-type ECG abnormality, with special emphasis on analyzing outcomes data. In addition, the ECG database of our institution was reviewed for tracings consistent with the Brugada sign, and, when possible, clinical correlations were made. RESULTS: Patients with the Brugada sign and a family history of sudden death or a personal history of syncope are at a high risk of sudden death and therefore should be strongly considered for implantation of a defibrillator. In patients who are hospitalized and critically ill, the Brugada sign is frequently the result of severe hyperkalemia, drug toxicity, or right ventricular injury. In most individuals with no symptoms and without a family history of sudden death, the Brugada sign is likely a normal variant. CONCLUSIONS: Most patients with the Brugada sign can be risk-stratified with simple clinical tools. Specific testing for the Brugada syndrome should be reserved for questionable cases and for the research setting. A provisional diagnostic-therapeutic algorithm is offered as a means of assisting the clinician in the evaluation and treatment of patients with the Brugada sign.

Patient preference for physician discussion and practice of spirituality.

OBJECTIVE: To determine patient preferences for addressing religion and spirituality in the medical encounter. DESIGN: Multicenter survey verbally administered by trained research assistants. Survey items included questions on demographics, health status, health care utilization, functional status, spiritual well-being, and patient preference for religious/spiritual involvement in their own medical encounters and in hypothetical medical situations. SETTING: Primary care clinics of 6 academic medical centers in 3 states (NC, Fla, Vt). PATIENTS/PARTICIPANTS: Patients 18 years of age and older who were systematically selected from the waiting rooms of their primary care physicians. MEASUREMENTS AND MAIN RESULTS: Four hundred fifty-six patients participated in the study. One third of patients wanted to be asked about their religious beliefs during a routine office visit. Two thirds felt that physicians should be aware of their religious or spiritual beliefs. Patient agreement with physician spiritual interaction increased strongly with the severity of the illness setting, with 19% patient agreement with physician prayer in a routine office visit, 29% agreement in a hospitalized setting, and 50% agreement in a near-death scenario (P <.001). Patient interest in religious or spiritual interaction decreased when the intensity of the interaction moved from a simple discussion of spiritual issues (33% agree) to physician silent prayer (28% agree) to physician prayer with a patient (19% agree; P <.001). Ten percent of patients were willing to give up time spent on medical issues in an office visit setting to discuss religious/spiritual issues with their physician. After controlling for age, gender, marital status, education, spirituality score, and health care utilization, African-American subjects were more likely to accept this time trade-off (odds ratio, 4.9; confidence interval, 2.1 to 11.7). CONCLUSION: Physicians should be aware that a substantial minority of patients desire spiritual interaction in routine office visits. When asked about specific prayer behaviors across a range of clinical scenarios, patient desire for spiritual interaction increased with increasing severity of illness setting and decreased when referring to more-intense spiritual interactions. For most patients, the routine office visit may not be the optimal setting for a physician-patient spiritual dialog.