The Shoeshine Stand and the Renaissance of Primary Care.

Over the past century, family physicians have moved from small independently owned practices, many of them solo, to being employed by large hospital systems, corporate entities, or health systems. Today, almost three-quarters of all physicians are employed and the highest percentage of employed physicians are family physicians.This essay contrasts the elements of independent practice with employed practice as part of what has been lost in the past half century, but what might be regained if physicians demanded more autonomy and control over their practices.

General Practitioners in US Medical Practice Compared With Family Physicians.

PURPOSE: General practitioners (GPs) are part of the US physician workforce, but little is known about who they are, what they do, and how they differ from family physicians (FPs). We describe self-identified GPs and compare them with board-certified FPs. METHODS: Analysis of data on 102,604 Doctor of Medicine and Doctor of Osteopathy physicians in direct patient care in the United States in 2016, who identify themselves as GPs or FPs. The study used linking databases (American Medical Association Masterfile, American Board of Family Medicine [ABFM], Area Health Resource File, Medicare Public Use File) to examine personal, professional, and practice characteristics. RESULTS: Of the physicians identified, 6,661 self-designated as GPs and 95,943 self-designated as FPs. Of the self-designated GPs, 116 had been ABFM certified and were excluded from the study. Of the remaining 102,488 physicians, those who self-designated as GPs but were never ABFM certified constituted the GP group (n = 6,545, 6%). Self-designated FPs that were ABFM certified made up the FP group (n = 79,449, 78%). The remaining self-designated FPs not ABFM certified constituted the uncertified group (n = 16,494, 16%). GPs differed from FPs in every characteristic examined. Compared with FPs, GPs are more likely to be older, male, Doctors of Osteopathy, graduates of non-US medical schools, and have no family medicine residency training. GPs practice location is similar to FPs, but GPs are less likely to participate in Medicare or to work in hospitals. CONCLUSIONS: GPs in the United States are a varied group that differ from FPs. Researchers, educators, and policy makers should not lump GPs together with FPs in data collection, analysis, and reporting.

Bronchoscopic features, associations, and outcomes of organizing pneumonia following allogeneic hematopoietic stem cell transplantation.

Organizing pneumonia (OP) is a poorly understood complication of hematopoietic stem cell transplant (HSCT). We identified 15 patients diagnosed with OP following HSCT and described their clinical course. CT chest findings were remarkable for multifocal infiltrates that were predominantly consolidating or ground glass opacities. Bronchoalveolar lavage (BAL) was performed on 14 patients with five having lymphocytosis (> 25% lymphocytes), three with eosinophilia (> 5% eosinophils), three with neutrophilia (> 30% neutrophils), and three with normal cell counts. Flow cytometry was analyzed on BAL fluid in 13 patients with 11 having a CD4/CD8 of < 0.9. Initial treatment with 0.3-1.0 mg/kg prednisone resulted in improvement in symptoms, in radiographic findings, and in pulmonary function testing for the majority of patients. Six patients had recurrence of OP after completing treatment. Eleven patients had evidence of extra-pulmonary graft-versus-host disease prior to diagnosis of OP, and seven patients were diagnosed with an upper respiratory tract infection (URI) within 8 weeks of OP diagnosis. Most patients respond well to prednisone with significant improvement in pulmonary function, but risk of recurrence is high after cessation of steroid treatment. Risk factors for the development of OP may include prior URI.

Loneliness in Primary Care Patients: A Prevalence Study.

PURPOSE: Loneliness has important health consequences. Little is known, however, about loneliness in primary care patient populations. This study describes the prevalence of loneliness in patients presenting for primary care and associations with self-reported demographic factors, health care utilization, and health-related quality of life. METHODS: We conducted cross-sectional surveys of adults presenting for routine care to outpatient primary care practices in 2 diverse practice-based research networks. The 3-item University of California, Los Angeles Loneliness Scale was utilized to determine loneliness. RESULTS: The prevalence of loneliness was 20% (246/1,235). Loneliness prevalence was inversely associated with age (P <.01) and less likely in those who were married (P <.01) or employed (P <.01). Loneliness was more common in those with lower health status (P <.01), including when adjusting for employment and relationship status (odds ratio [OR] = 1.05; 95% CI, 1.03-1.07). Primary care visits (OR = 1.07; 95% CI, 1.03-1.10), urgent care/emergency department visits (OR = 1.24; 95% CI, 1.12-1.38), and hospitalizations (OR = 1.15; 95% CI, 1.01-1.31) were associated with loneliness status. There was no significant difference in rates of loneliness between sexes (P = .08), racial categories (P = .57), or rural and urban respondents (P = .42). CONCLUSIONS: Our findings demonstrate that loneliness is common in primary care patients and is associated with adverse health consequences including poorer health status and greater health care utilization. Further work is needed to understand the value of screening for and using interventions to treat loneliness in primary care.

Geographic Characteristics of Loneliness in Primary Care.

Loneliness is associated with poor health outcomes, and there is growing attention on loneliness as a social determinant of health. Our study sought to determine the associations between community factors and loneliness. The Three-Item Loneliness Scale and zip codes of residence were collected in primary care practices in Colorado and Virginia. Living in zip codes with higher unemployment, poor access to health care, lower income, higher proportions of blacks, and poor transportation was associated with higher mean loneliness scores. Future studies that examine interventions addressing loneliness may be more effective if they consider social context and community characteristics.

Professional Loneliness and the Loss of the Doctors' Dining Room.

Historically, family physicians moved among all the venues of medical care- office, hospital, community-and were a part of a connected professional community. That connected community was sustained in great part through informal gatherings of clinicians in hospitals, clinics, and professional organizations. The current fragmentation of medicine into narrowly defined, boundaried workspaces and job descriptions, as well as the increasing size of practices has negatively affected the professional culture in which physicians work. These structural changes have led to an increasing sense of professional loneliness that not only threatens the quality of clinical care by replacing personal discussions about patients but also poses risks to physician personal and professional wellbeing.

Human herpesvirus-6 encephalitis following chemotherapy induction for acute myelogenous leukemia.

We report a case of human herpesvirus-6 (HHV-6) encephalitis in a neutropenic patient who had undergone chemotherapy induction for acute myelogenous leukemia while on broad-spectrum antimicrobial therapy. The patient displayed symptoms of confusion, amnesia, and lethargy. Diagnosis was made via polymerase chain reaction analysis of cerebrospinal fluid. Electroencephalogram and magnetic resonance imaging of the brain were unremarkable. Following diagnosis, the patient was successfully treated with ganciclovir. HHV-6 encephalitis should be considered in immunocompromised patients who become encephalopathic.

Wisconsin Firearm Mortality, 2000-2014.

BACKGROUND: Despite low firearm mortality rates in Wisconsin, overall firearm fatalities continue to rise in recent years. In 2013, the statewide age-adjusted death rate due to firearms was 9.6 per 100,000 persons, the highest mark since the new millennium. This raises not only public safety concerns, but also raises questions regarding ongoing gun violence. OBJECTIVES: To describe the population and geographic characteristics of firearm mortality rates on population and geographic characteristics in Wisconsin. METHODS: Mortality data for firearm deaths caused by suicides, homicides and other death intent were obtained from the Wisconsin Interactive Statistics on Health (WISH) query system from 2000 through 2014. The probability of firearm fatality was analyzed through log-linear Poisson regression models to assess the variations of firearm mortality risks in relation to a person's sex, age, race/ethnicity, and region. RESULTS: Firearm violence is responsible for 14% of injury-related deaths in Wisconsin. Seventy-two percent of firearm-related deaths were attributed to suicides; the majority of decedents were white men aged 45 years or older. The proportion of homicides by gun to all homicides increased from 63% in 2000 to 72% in 2014. Disproportionally high firearm homicides were found among black men aged 18 to 34 years in southeastern Wisconsin, accounting for 38% of the entire gun-related murder deaths. CONCLUSION: Our study shows that the association of the demographic and geographic characteristics with mortality rates differs among suicides, homicides and the other intent. Understanding characteristics associated with firearm related-deaths is the first step toward addressing them.

The role of diacylglycerol kinase ζ and phosphatidic acid in the mechanical activation of mammalian target of rapamycin (mTOR) signaling and skeletal muscle hypertrophy.

The activation of mTOR signaling is essential for mechanically induced changes in skeletal muscle mass, and previous studies have suggested that mechanical stimuli activate mTOR (mammalian target of rapamycin) signaling through a phospholipase D (PLD)-dependent increase in the concentration of phosphatidic acid (PA). Consistent with this conclusion, we obtained evidence which further suggests that mechanical stimuli utilize PA as a direct upstream activator of mTOR signaling. Unexpectedly though, we found that the activation of PLD is not necessary for the mechanically induced increases in PA or mTOR signaling. Motivated by this observation, we performed experiments that were aimed at identifying the enzyme(s) that promotes the increase in PA. These experiments revealed that mechanical stimulation increases the concentration of diacylglycerol (DAG) and the activity of DAG kinases (DGKs) in membranous structures. Furthermore, using knock-out mice, we determined that the ζ isoform of DGK (DGKζ) is necessary for the mechanically induced increase in PA. We also determined that DGKζ significantly contributes to the mechanical activation of mTOR signaling, and this is likely driven by an enhanced binding of PA to mTOR. Last, we found that the overexpression of DGKζ is sufficient to induce muscle fiber hypertrophy through an mTOR-dependent mechanism, and this event requires DGKζ kinase activity (i.e. the synthesis of PA). Combined, these results indicate that DGKζ, but not PLD, plays an important role in mechanically induced increases in PA and mTOR signaling. Furthermore, this study suggests that DGKζ could be a fundamental component of the mechanism(s) through which mechanical stimuli regulate skeletal muscle mass.

Storylines of family medicine XI: professional identity formation-nurturing one's own story.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'XI: professional identity formation-nurturing one's own story', authors address the following themes: 'The social construction of professional identity', 'On becoming a family physician', 'What's on the test?-professionalism for family physicians', 'The ugly doc-ling', 'Teachers-the essence of who we are', 'Family medicine research-it starts in the clinic', 'Socially accountability in medical education', 'Personal philosophy and how to find it' and 'Teaching and learning with Storylines of Family Medicine'. May these essays encourage readers to find their own creative spark in medicine.

Eccentric contractions increase the phosphorylation of tuberous sclerosis complex-2 (TSC2) and alter the targeting of TSC2 and the mechanistic target of rapamycin to the lysosome.

The goal of this study was to determine whether the mechanical activation of mechanistic target of rapamycin (mTOR) signalling is associated with changes in phosphorylation of tuberous sclerosis complex-2 (TSC2) and targeting of mTOR and TSC2 to the lysosome. As a source of mechanical stimulation, mouse skeletal muscles were subjected to eccentric contractions (ECs). The results demonstrated that ECs induced hyper-phosphorylation of TSC2 and at least part of this increase occurred on residue(s) that fall within RxRxxS/T consensus motif(s). Furthermore, in control muscles, we found that both mTOR and TSC2 are highly enriched at the lysosome. Intriguingly, ECs enhanced the lysosomal association of mTOR and almost completely abolished the lysosomal association of TSC2. Based on these results, we developed a new model that could potentially explain how mechanical stimuli activate mTOR signalling. Furthermore, this is the first study to reveal that the activation of mTOR is associated with the translocation of TSC2 away from the lysosome. Since a large number of signalling pathways rely on TSC2 to control mTOR signalling, our results have potentially revealed a fundamental mechanism via which not only mechanical, but also various other types of stimuli, control mTOR signalling.

GIFTS: Geriatric Intensive Functional Therapy Sessions - For the older trauma patient.

BACKGROUND: Considering resources for comprehensive geriatric (GERI) care, it would be beneficial for geriatric trauma (GTP) and medical patients to be co-managed in one program focusing on ancillary therapeutics (AT): physical (PT), occupational (OT), speech (SLP), respiratory (RT) and sleep wake hygiene (SWH). This pilot describes outcomes of GTP in a hospital-wide program focused on GERI-specific AT. METHODS: GTP and GERI patients were screened by program coordinator (PC) for enrollment at one Level II trauma center from Aug 2021-Dec 2022. Enrolled patients (EP) were admitted to trauma or medicine floors and received repetitive AT with attention to SWH throughout hospitalization and compared to similar non-enrolled patients (NEP). Excluded patients had any of the following: indication of geriatric syndrome with FRAIL 5, no frailty with FRAIL 0, comfort focused plans, or arrived from skilled care. Retrospective chart review of demographics and outcomes was completed for both EP and NEP. RESULTS: 224 EP (28 trauma (TR)) were compared to 574 NEP (148 TR). EP showed shorter LOS (mean 3.8 vs 6.1, p = 0.0001), less delirium (3.1% vs 9.6%, p = 0.00222), less time to ambulate (13 h vs 39 h, p = 0.0005), and higher likelihood to discharge home (56% vs 27%, p < 0.0001) as compared to NEP. Median FRAIL was 3 for both groups. Medical enrolled (M-EP) ambulated the soonest at 11 average hours, compared to 23 hours for TR-EP, compared to 39 hours for NEP. Zero delirium events among TR-EP; 25% among TR-NEP, p = 0.00288. CONCLUSION: Despite a small trauma cohort, results support feasibility to include GTP in hospital-wide programs with GERI specific AT. Mobility and cognitive strategies may improve opportunities to avoid delirium, decrease LOS and influence more frequent disposition to home. TYPE OF STUDY: Original observational retrospective review. LEVEL OF EVIDENCE: Level IV- Therapeutic / Care Management.

Novel insights into the regulation of skeletal muscle protein synthesis as revealed by a new nonradioactive in vivo technique.

In this study, the principles of surface sensing of translation (SUnSET) were used to develop a nonradioactive method for ex vivo and in vivo measurements of protein synthesis (PS). Compared with controls, we first demonstrate excellent agreement between SUnSET and a [(3)H]phenylalanine method when detecting synergist ablation-induced increases in skeletal muscle PS ex vivo. We then show that SUnSET can detect the same synergist ablation-induced increase in PS when used in vivo (IV-SUnSET). In addition, IV-SUnSET detected food deprivation-induced decreases in PS in the heart, kidney, and skeletal muscles, with similar changes being visualized with an immunohistochemical version of IV-SUnSET (IV-IHC-SUnSET). By combining IV-IHC-SUnSET with in vivo transfection, we demonstrate that constitutively active PKB induces a robust increase in skeletal muscle PS. Furthermore, transfection with Ras homolog enriched in brain (Rheb) revealed that a PKB-independent activation of mammalian target of rapamycin is also sufficient to induce an increase in skeletal muscle PS. Finally, IV-IHC-SUnSET exposed the existence of fiber type-dependent differences in skeletal muscle PS, with PS in type 2B and 2X fibers being significantly lower than that in type 2A fibers within the same muscle. Thus, our nonradioactive method allowed us to accurately visualize and quantify PS under various ex vivo and in vivo conditions and revealed novel insights into the regulation of PS in skeletal muscle.