The Looming Geriatrician Shortage: Ramifications and Solutions.

Objective: Geriatricians are skilled in the recognition of asymptomatic and atypical presentations that occur in the elderly and provide comprehensive medication management including recognizing adverse drug events, reducing polypharmacy, and de-prescribing. However, despite the increasing average age of the U.S. population, with the number of individuals above 65 years old predicted to increase 55% by 2030, the geriatric workforce capacity in the United States has actually decreased from 10,270 in 2000 to 8,502 in 2010. Method: We describe physiologic changes in older adults, historical trends in geriatric training, and propose solutions for this looming crisis. Results: Many factors are responsible for the shortage of skilled geriatric providers. Discussion: We discuss the historical context of the lack of geriatricians including changes to the training system, describe the impact of expert geriatric care on patient care and health system outcomes, and propose methods to improve recruitment and retention for geriatric medicine.

Pancreatic Cancer Heralded by Worsening Glycemic Control: A Report of Two Cases.

Pancreatic ductal adenocarcinoma is the third leading cause of cancer-related death in the United States. Since it is usually diagnosed at an advanced stage, its prognosis remains poor. The initial presentation varies according to the tumor location. The most common presenting signs are weight loss, jaundice, and pain. Several epidemiological, clinical, and experimental studies over the past 2 decades have shown that long-standing diabetes is a modest risk factor for pancreatic cancer. However, new-onset diabetes has also been observed to be an early manifestation of pancreatic cancer. We report 2 cases where worsening glycemic control led to the diagnosis of pancreatic cancer.

Team-based care to improve control of hypertension in an inner city practice.

The purpose of this case study was to identify which intervention or interventions, if any, resulted in improved hypertension control in an intercity public practice. Data includes interventions, graphed chronologically and the results in the form of percentage of patients with controlled hypertension. Challenges to success included understaffing of the practice and significantly limited access to appointments. Also, the variety of patients' languages and cultures presented a challenge. We reached our target of 60% of patients meeting criteria for control of hypertension. Although we instituted several interventions and all cumulatively contributed to the outcome, the two likely to be most effective were the establishment of hypertension-only appointments with either primary providers or with nurses. Both of these interventions resulted in an increased number of available appointments and improved access to timely follow up.

Impact of a focused nutrition educational intervention coupled with improved access to fresh produce on purchasing behavior and consumption of fruits and vegetables in overweight patients with diabetes mellitus.

PURPOSE: The purpose of this study was to test the impact of distributing coupons redeemable at farmers markets plus an educational intervention on fruit and vegetable (F&V) purchase and consumption in overweight patients with type 2 diabetes (T2DM). METHODS: Seventy-eight participants with T2DM being followed at Jacobi Medical Center, a large public hospital in the Bronx, New York, were randomized to receive the standard of care or a 1-hour session focused on benefits of F&V consumption and $6 in coupons. Questionnaires assessed demographics, F&V intake, and farmers market purchasing at baseline and 12 weeks. Clinical parameters were obtained through chart review at baseline and at 12 weeks. RESULTS: Participants were predominantly Latino, females, and low income. At 12 weeks, there was a statistically significant increase in the number of participants in the intervention arm who reported purchasing from a farmers market. In addition, there was a minimal increase in fresh fruit intake in the intervention arm at 12 weeks. CONCLUSION: Focused education combined with a small economic incentive resulted in an increase in purchasing behavior and fresh fruit intake per day. A more intense behavioral intervention combined with increased access may result in a significant impact on obesity and diabetes, particularly among low-income and racially diverse communities.