Factors Influencing Primary Care Physicians' Referral for Bariatric Surgery.

BACKGROUND AND OBJECTIVES: Bariatric surgery has been shown to be an effective weight loss treatment for the morbidly obese, but some primary care physicians remain hesitant about postoperative treatment and management of patients who have undergone the surgery and recommend it to their obese patients infrequently. The purpose of this study was to evaluate perceptions of primary care physicians of the role of bariatric surgery in the management of obese patients and to identify possible barriers to treatment. METHODS: A survey of PCPs within our institution was conducted to determine attitudes, knowledge, and practices regarding the treatment of morbidly obese patients,with a specific focus on identifying factors that influence referral patterns for bariatric surgery. RESULTS: Among 161 eligible PCPs, 57 (35.4%) responded. Most respondents (59%) reported that at least 1 in 4 of their patients had a BMI 35 kg/m2. Although 39% thought that diet and exercise were an effective means of sustained weight loss, only 12% were satisfied with prescribing nonsurgical interventions. Sixty-three percent agreed that bariatric surgery is generally effective in the long term. All respondents were aware of the commonly established benefits, including improvement of diabetes, hypertension, and hyperlipidemia. In addition, 65% were familiar with the indications for bariatric surgery, and 70% felt comfortable discussing it with patients as a treatment option. Fewer than half of the respondents felt confident in providing postoperative management. Cost was a perceived limitation, with 53%reporting that most of their patients could not afford bariatric surgery. CONCLUSIONS: The general attitude of PCPs toward bariatric surgery is supportive. Physicians are largely aware of the indications and benefits; however, far fewer are comfortable in management of patients after surgery. A lack of supplemental information and concerns regarding the cost of surgery can impede treatment and referrals.

Epidemiologic associations of carpal tunnel syndrome and sleep position: Is there a case for causation?

INTRODUCTION: Carpal tunnel syndrome (CTS) is thought to be due to compression of the median nerve in the carpal tunnel. It is known that carpal tunnel pressures are elevated in wrist postures of flexion and extension and in those patients with CTS. Classic symptoms of CTS include night waking with pain, tingling, and numbness. These classic symptoms stimulated our interest in the relationship of sleep to the development of CTS. METHOD: We reviewed the literature surrounding the epidemiology of CTS and the literature regarding sleep disturbances. Through careful distillation of these studies and a process of reasoning, we have developed a hypothesis for a causal mechanism of CTS. RESULTS: Epidemiologically, it has been shown that CTS is associated with age, gender, increased body mass index (BMI), diabetes, pregnancy, and is more common in some populations. The same associations noted above for CTS are strongly associated with sleep disturbances. Sleep disturbances due to age, gender, BMI, pregnancy, and population variations are all associated with sleeping in the lateral position supporting the hypothesis that a common causative mechanism of CTS is sleeping in a lateral position. DISCUSSION: We believe that the epidemiologic associations with CTS act through a common causative mechanism, increased sleeping in the lateral position which puts the wrist at increased risk of flexion or extension, compressing the median nerve in the carpal tunnel. This hypothesis is simple and explains the connection between a previously unconnected group of epidemiologic associations. This realization has real clinical significance in that it focuses our attention on the early disorder when it is completely reversible. It clarifies previously confused clinical circumstances, creates research questions that can be tested, and it invites us to change our clinical perspective in this most common form of nerve compression.