Management of Obesity: Office-Based Strategies.

Obesity in the United States is increasing, with the most recent national data indicating a prevalence of 41.9%. Obesity is generally considered a body mass index (BMI) of 30 kg per m2 or greater; however, increased waist circumference (female: 35 inches or greater; male: 40 inches or greater) may be a more accurate indicator of obesity, particularly in older adults. For patients who are overweight or obese, the history should include whether patients are taking medications that can increase weight and identifying comorbid conditions contributing to or resulting from obesity. Clinicians should also ask about previous weight-management strategies and whether they were effective. Initial laboratory testing includes a complete blood count, metabolic profile, lipids, thyroid-stimulating hormone and A1C levels, and additional testing as needed. The Obesity Medicine Association recommends that weight management incorporate five pillars: behavioral counseling, nutrition, physical activity, pharmacotherapy, and, when appropriate, bariatric procedures. Pharmacotherapy with anti-obesity medications such as glucagon-like peptide-1 receptor agonists, sympathomimetics, and others should be considered for any patient with a BMI of 30 kg per m2 or greater and for any patients who are overweight (i.e., BMI of 27 kg per m2 or greater) with metabolic comorbidities. Referral for bariatric surgery should be considered for patients who meet the criteria. Successful management requires individualized support systems with periodic follow-ups through each phase of treatment.

Chronic Rhinosinusitis.

Chronic rhinosinusitis (CRS) is an inflammatory disease of the nose and paranasal sinuses, with a prevalence of approximately 1% to 7%. It is defined by the presence of at least two cardinal symptoms (nasal blockage, obstruction, or congestion; anterior or posterior nasal drainage; facial pain or pressure; and hyposmia) for at least three consecutive months, with objective findings on imaging or nasal endoscopy. CRS can result in significant patient costs and lower quality of life due to severe fatigue, depression, and sometimes reduced cognitive function. The condition is categorized as primary or secondary and with or without nasal polyps. Treatment is directed at reducing symptoms, improving mucus clearance, reducing inflammation, enhancing ciliary function, and removing bacteria and biofilms from the nasal mucosa. First-line treatment comprises nasal saline irrigation and intranasal corticosteroids. Acute exacerbation of CRS is common and is defined as a transient worsening of symptoms. The role of oral antibiotics and oral corticosteroids for acute exacerbations is unclear. Optimal maintenance therapy can help alleviate exacerbations. Patients with refractory CRS that is not responsive to first-line treatment and patients with alarm symptoms should be referred to an otolaryngologist for further evaluation and consideration of surgical management. Identifying patients who have CRS with nasal polyps or comorbid conditions such as atopic dermatitis, asthma, or eosinophilic esophagitis is especially important to ensure they are referred to a specialist for consideration of biologic therapy.

Characterizing the Impact of Clinical Exposure to Patients with Opioid Use Disorder on Medical Students' Perceptions of Stigma and Patient Care.

PHENOMENON: Opioid use disorder (OUD) is a growing public health crisis. Many residents and physicians do not feel comfortable working with patients with OUD. Social stigma promotes negative attitudes toward these patients and is a roadblock to delivering equitable and effective care. This study sought to (1) characterize medical students' experiences with patients with OUD, (2) understand the features that make a patient encounter memorable, (3) explore factors that influence future practice, and (4) describe the influence on stigma toward patients with OUD. Approach: A study was conducted using qualitative descriptive theory and purposive sampling of fourth-year medical students (M4s) enrolled at Wake Forest School of Medicine (WFSOM). Data collection consisted of a free-text question as a part of a larger survey to M4s in the Class of 2019 and 2020, followed by semi-structured interviews. The goal of the survey was to gain a broad understanding of student encounters with patients with OUD. The goal of the interviews was to gain a deeper understanding of the impact of these encounters on future practice and stigma. Thematic analysis was used to analyze all data. Findings: One-hundred-seventy out of 237 students (RR = 71.7%) completed the free text question describing a memorable encounter with a patient with OUD. Twelve students then completed interviews. Patient encounters occurred in three primary settings: Emergency department, inpatient clerkship, or Intensive Outpatient Program (IOP) meetings during psychiatry clerkship. Clinical encounters were memorable when there was: (1) conflict with patients or teams, (2) complicated care, (3) inadequate care, and (4) relevance to the student's future career. Memorable encounters influenced future practice by changing students' approaches to: (1) future treatment, (2) future communication, or (3) allowing students to practice professionalism. Regarding opioid stigma, students reported that these encounters made them: (1) more aware of stereotypes in medicine, (2) stereotypes in their personal lives, and (3) generated actions that students want to take in the future. Insights: A single, influential clinical encounter has the potential to substantially influence medical students' approach to patients with OUD, including both clinical management and attitudes toward care. Affecting encounters increased knowledge of OUD and fostered empathy and perspective-taking. Not all encounters had a defining impact on students' stigma toward OUD. Medical schools need to create opportunities that will have lasting impact by encouraging students to fully engage with patients with OUD.Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2022.2038175 .

Alcoholic Hepatitis: Diagnosis and Management.

Alcoholic hepatitis is a clinical syndrome characterized by acute-onset jaundice and liver enzyme abnormalities in the setting of long-term heavy alcohol use. High rates of concomitant infections, systemic inflammation, and multiorgan failure lead to significant morbidity and mortality. Diagnosis of alcoholic hepatitis is primarily clinical, based on a consensus definition from the National Institute on Alcohol Abuse and Alcoholism. Initial workup should include chest radiography and cultures of peritoneal fluid, blood, and urine. Close monitoring for inflammation and organ failure is crucial throughout hospitalization. Laboratory-based prognostic scores, including Maddrey Discriminant Function and the Model for End-Stage Liver Disease, help determine disease severity and treatment options. Treatment for moderate disease primarily consists of supportive care, including alcohol cessation and nutritional support. Corticosteroids are recommended for severe alcoholic hepatitis. Responsiveness to corticosteroid therapy should be evaluated using the Lille score on day 7 of treatment. Hospital physicians should involve a multidisciplinary team, including substance abuse specialists, gastroenterologists or hepatologists, nephrologists, dietitians, and intensivists, as appropriate. Long-term follow-up should focus on abstinence from alcohol, management of underlying cirrhosis, and evaluation for liver transplantation if indicated. Pharmacologic treatment of alcohol use disorder can aid patients in maintaining abstinence from alcohol. The presence of underlying cirrhosis and continued alcohol use negatively impact long-term prognosis.

Opioid stewardship training during the transition to residency to prepare medical students to recognize and treat opioid use disorder.

Background: With a drastic shortage of addiction medicine specialists-and an ever-growing number of patients with opioid use disorder (OUD)-there is a dire need for more clinicians to feel confident in prevention and management of OUD and obtain a DEA-X waiver to prescribe medications to treat OUD. Here we determine if it is feasible to certify 4th year medical students with DEA-X waiver training as a component of the PROUD (Prevent and Reduce Opioid Use Disorder) curriculum, and if PROUD enhanced preparedness for medical students to manage OUD as interns. Methods: We implemented a sequential mixed-methods IRB approved study to assess feasibility (completing all required components of DEA-X waiver training) and impact of PROUD (measured by knowledge growth, enhancement for residency, and utilization of training during internship). Students completed 11 hours of required OUD training. Quantitative data included pre-/post- knowledge and curriculum satisfaction assessments as well as long-term impact with follow up survey as interns. Qualitative data was collected by survey and semi-structured focus groups. Results: All 120 graduating medical students completed the required components of the curriculum. Knowledge improved on the Provider Clinical Support Services (12.9-17.3, p < 0.0001) and Brief Opioid Overdose Knowledge assessments (10.15-10.81, p < 0.0001). Course satisfaction was high: 90% recommended online modules; 85% recommended training overall. Six qualitative themes emerged: (1) curriculum content was practical, (2) online modules allowed flexibility, (3) in-person seminars ensured authenticity, (4) timing at the transition to residency was optimal, (5) curriculum enhanced awareness and confidence, and (6) training was applicable to future careers. At 3 months, 60% reported using their training during internship; 64% felt more prepared to treat OUD than peers. Conclusions: PROUD trained 4th year medical students in opioid stewardship. As interns, students felt ready to serve as change agents to prevent, diagnose, and treat OUD.

Promotion Preparation Tips for Academic Family Medicine Educators.

BACKGROUND AND OBJECTIVES: Promotion has historically valued the scholarship of discovery over the scholarship of teaching. The clinician-educator promotion pathway is an attractive option for academic family physicians engaged in significant teaching. However, clinician-educators are less often promoted than peers on other tracks. Family medicine educators face unique challenges in promotion due to clinical requirements and often less guidance on how to meet promotion criteria. Promotion recognizes achievements of faculty and is often tied to higher base salary. We aimed to identify promotion preparation tips for academic family medicine educators. METHODS: We surveyed members of the Society of Teachers of Family Medicine (STFM) Medical Student Education Collaborative electronically on promotion preparation lessons learned in (1) curriculum vitae preparation, (2) personal statement preparation, (3) selecting external reviewers, and (4) identifying measurable achievements. This qualitative study used grounded theory and constant comparison. RESULTS: Fourteen individuals from 13 medical institutions responded with tips for success in promotion preparation. The tips identified actionable steps for promotion preparation of academic family medicine educators. Several main themes emerged, including the importance of timely and thorough documentation, detailed planning, and being knowledgeable about institutional-specific criteria early. CONCLUSIONS: The tips provided in this study support family medicine educators in preparing for promotion and can be used as a tool for mentors, chairs and faculty development.

Transparency.

This poem focuses on a patient who was suffering but whose physicians were optimistic for recovery. The author-physician saw the degree of suffering and made the patient's DNR, ending the suffering. The author expresses the need for complete honesty. (PsycINFO Database Record

The effect of a creative art program on self-esteem, hope, perceived social support, and self-efficacy in individuals with multiple sclerosis: a pilot study.

BACKGROUND: Creative art has been found to be beneficial to some patients with chronic illness. Little is understood about how creative art can benefit individuals living with multiple sclerosis (MS). OBJECTIVES: The purpose of the pilot study was to determine if there was a difference in self-esteem, hope, perceived social support, and self-efficacy in individuals with MS after a 4-week creative art program. METHODS: A one-group, pretest/posttest design was used. The convenience sample of 14 individuals was recruited from MS Centers and the National MS Society. They ranged in age from 29 to 70 years (M = 51.3 years, SD = 12.5 years). Participants included 14 women. The creative art program included week 1-watercolor, week 2-collage making, week 3-beading, and week 4-knitting. Each of the four weekly sessions was facilitated by a registered nurse with expertise in MS and lasted 2 hours. Creative artists instructed participants and provided a hands-on experience for each of the creative projects. Participants were free to share thoughts, experiences, and words of support and encouragement during each session. The variables were measured before starting the creative art program and after the final session. The instruments included the Rosenberg Self-Esteem Scale, the Herth Hope Index, the Modified Social Support Survey, the MS Self-Efficacy Scale, and a sociodemographic questionnaire. The Statistical Package for the Social Sciences Version 16.0 was used to analyze the data. RESULTS: There was a significant increase in all variables after the creative art program as follows: self-esteem (t = -3.05, p = 009), hope (t = -3.96, p = .002), social support (t = -2.21, p = .046), self-efficacy to function with MS (t = -2.68, p = .019), and self-efficacy to control MS (t = 3.22, p = .007). The power analysis revealed a large effect size for hope (d = 1.06), self-esteem (d = 0.82), and self-efficacy (control; d = 0.86). A medium effect size was found for self-efficacy (function; d = 0.72) and social support (d = 0.59). CONCLUSIONS: The creative art program was found to be effective and had a positive influence on self-esteem, hope, social support, and self-efficacy to function and control MS. Creative art has the potential to enhance the lives of those living with MS and should be investigated with a larger sample of participants.