Telemedicine for contraceptive counseling: Patient experiences during the early phase of the COVID-19 pandemic in New York City.

OBJECTIVE: During theCOVID-19 pandemic, many clinicians increased provision of telemedicine services. This study describes patient experiences with telemedicine for contraceptive counseling during the COVID-19 pandemic in New York City. STUDY DESIGN: This is a mixed-methods study which includes a web-based or phone survey and in-depth phone interviews with patients who had telemedicine visits for contraception. RESULTS: A total of 169 patients had eligible telemedicine visits between April 1 and June 30, 2020. Of these, 86 (51%) responded to the survey, and 23 (14%) participated in the interviews. We found that 86% of survey respondents were very satisfied with the telemedicine visit, and 63% said it completely met their needs. A majority (73%) strongly agreed that these visits should be maintained after the COVID-19 pandemic, and half (51%) would be very likely to choose them over in-person visits. In-depth interviews highlighted the convenience of telemedicine, especially for those with work or parenting responsibilities. Although some patients had in-person visits after telehealth, many appreciated the counseling they received remotely, and found the subsequent in-person visits more efficient. Patients identified visits that do not require physical exams as ideal visits for telehealth, and some hoped that all or most of their future visits would be telehealth visits. Many patients (43%) expressed a preference for phone over video visits. CONCLUSIONS: Patients reported an overall positive experience with telemedicine visits for contraceptive counseling during the COVID-19 pandemic. They appreciated the convenience of telemedicine visits and valued the virtual counseling experience. IMPLICATIONS: Health care providers who initiated or expanded telemedicine services for contraceptive counseling during the COVID-19 pandemic should consider continuing to offer them after the pandemic. At the policy level, these findings favor expanding access to telemedicine and providing reimbursement for virtual visits, including telephone visits.

Sport activity in patients with cardiac implantable electronic devices: evidence and perspectives.

Demographic characteristics of patients with cardiac implantable electronic devices have significantly changed during the last few years, according to the ageing of the population and the consequent increase in the number of elderly individuals with indication for pacemaker implant and, on the other hand, to the increased number of young individuals implanted with an implantable cardioverter defibrillator for the primary prevention of sudden death. More and more often, both elderly and young patients ask the physician to deal with the device in their daily activities, which often include sport practice. This latter is advisable because of its recognized benefits on cardiovascular prevention, although there are many limitations for patients with a cardiac implantable electronic device. Hence, the need to balance the patient's request with the appropriate precautions emerging from existing evidence. The current article aims to provide an overview of the most recent data on this topic, derived from registries and observational studies. Over the years an attempt to standardize recommendations has been made, but robust evidence is still lacking. Substantial differences exist between countries based on their sports regulations. Official recommendations of European and American Scientific Societies are resumed. The future perspective is to obtain data to allow these patients a safer practice of sport activity also through technological advances in terms of device materials and programming improvement and the possibility of remote monitoring.

Differences between pharmacists' perception of counseling and practice in the era of prescription drug misuse

OBJECTIVE: This study was conducted to assess pharmacists' practices when counseling patients on their prescription medications, and their preferences for training. METHODS: Five focus group discussions of community pharmacists (n=45, with seven to eleven participants in each group) were conducted in a major metropolitan city in the southern United States. Participants were recruited via email using a list of community pharmacists provided by the Texas State Board of Pharmacy. All focus group discussions were structured using a moderator guide consisting of both discrete and open-ended questions. Qualitative analysis software was used to analyze the data with a thematic analysis approach. RESULTS: The participants in this study had a high self-efficacy regarding their ability to counsel on both new and opioid prescriptions. Many pharmacists experienced the same barriers to counseling and agreed on the components o counseling. However, the themes that emerged showed that the participants exhibited only a partial understanding of the components of counseling. The themes that emerged in the thematic analysis were perceived confidence and discordant counseling practices, inadequate infrastructure, lack of comprehensive counseling, inconsistent use of the Prescription Drug Monitoring Program (PDMP), and pharmacists' desired training/assistance. CONCLUSIONS: Community pharmacists are in a unique position to help combat the opioid crisis; however, there has been very little research on the pharmacist-patient interaction in this context. With policy changes, such as the PDMP mandate, going into effect across the country, it is important to capitalize on the potential community pharmacists have in ameliorating the opioid crisis in the United States

No disponible

[The future of laboratory medicine, the future laboratory physician]. / Framtidens laboratorieläkare bör bidra mer med råd och tolkningar - Klokt utnyttjande av ett växande utbud av analyser krävs för att fortsatt kunna ge värdeskapande svar till allt fler.

Internal and external factors influence the future of laboratory medicine. In the coming years point of care testing and faster and cheaper methods of genome sequencing are predicted to become more important. Changes in laboratory organization and demography with an aging population will likewise impact the coming years. An increased information flow between laboratories and clinicians, where symptoms, findings and vital signs are combined with laboratory results and their change over time, has the potential of generating refined reports. Sharing of equipment between laboratory specialities as well as working in conjunction with clinicians in influencing patterns of testing through guidelines and algorithms may also aid in saving precious resources.

Adequately Addressing Pediatric Obesity: Challenges Faced by Primary Care Providers.

OBJECTIVE: To assess the challenges primary care providers encounter when providing counseling for pediatric patients identified as obese. METHODS: A survey assessed the current challenges and barriers to the screening and treatment of pediatric obesity for providers in northwest Arkansas who provide care to families. The survey consisted of 15 Likert scale questions and 4 open-ended questions. RESULTS: Time, resources, comfort, and cultural issues were reported by providers as the biggest barriers in screening and the treatment of pediatric obesity. All providers reported lack of time as a barrier to providing the care needed for obese children. Cultural barriers of both the provider and client were identified as factors, which negatively affect the care and treatment of obese children. CONCLUSIONS: Primary care providers continue to experience challenges when addressing pediatric obesity. In this study, a lack of adequate time to address obesity was identified as the most significant current barrier and may likely be tied to physician resources. Although reimbursement for obesity is increasing, the level of reimbursement does not support the time or the resources needed to treat patients. Many providers reported their patients' cultural view of obesity influenced how they counsel their patients. Increasing providers' knowledge concerning differences in how weight is viewed or valued may assist them in the assessment and care of obese pediatric patients. The challenges identified in previous research continue to limit providers when addressing obesity. Although progress has been made regarding knowledge of guidelines, continuing effort is needed to tackle the remaining challenges. This will allow for earlier identification and intervention, resulting in improved outcomes in pediatric obesity.

Healthcare experiences of patients with age-related macular degeneration: have things improved? Cross-sectional survey responses of Macular Society members in 2013 compared with 1999.

OBJECTIVE: To investigate healthcare experiences of patients with age-related macular degeneration (AMD) and determine whether a previous survey and Royal College of Ophthalmologists (RCOphth) management guidelines brought improvements. DESIGN: Cross-sectional survey of Macular Society members in 2013 compared with previous 1999 survey. SETTING: UK Postal Questionnaires. PARTICIPANTS: 1169 respondents in 2013 (1187 in 1999). INTERVENTION: Publication of 1999 survey results (2002), and RCOphth AMD guidelines (2009). MAIN OUTCOME MEASURES: Respondents answered questions about experiences at diagnosis. Five questions were replicated from the 1999 survey for direct comparison in the 2013 survey which included additional questions based on 2009 RCOphth recommendations for information and support provision for patients with AMD. RESULTS: Most 2013 survey respondents were given the name of their macular condition (91%), felt the healthcare professional was interested in them (71%) and were satisfied overall with the diagnostic consultation (76%). These outcomes show significant improvement since 1999. Within the 2013 sample, multivariable analyses showed gradual trends of improvement over time in: provision of written information, Macular Society information and receiving appropriate help, support and advice at diagnosis. Only overall satisfaction with the diagnostic consultation (but not the other nine areas of information and support provision studied) significantly improved in the time after publication of the RCOphth 2009 guidelines. There were no significant improvements associated with the publication of the 1999 survey results. Low information and support provision remained, for example, 44% of respondents diagnosed after the RCOphth 2009 guidelines reported not receiving information on what to do if vision deteriorated. Lack of such information at diagnosis was significantly associated with registration as sight impaired (p<0.01). Reports of general practitioner (GP) knowledge of AMD remained low: 39% reported their GP was 'not at all well informed'. The 2013 respondents reported lower levels of help and support from GPs than 1999 respondents (p<0.001). CONCLUSIONS: Patients diagnosed with AMD after 1999 (vs before 1999) reported better experiences at diagnostic consultation. However, information and support provision at diagnosis, and satisfaction with GPs remained low.

Pediatric obesity pharmacotherapy: current state of the field, review of the literature and clinical trial considerations.

Despite the increasing number of medications recently approved to treat obesity among adults, few agents have been formally evaluated in children or adolescents for this indication. Moreover, there is a paucity of guidance in the literature addressing best practices with regard to pediatric obesity pharmacotherapy clinical trial design, and only general recommendations have been offered by regulatory agencies on this topic. The purposes of this article are to (1) offer a background of the current state of the field of pediatric obesity medicine, (2) provide a brief review of the literature summarizing pediatric obesity pharmacotherapy clinical trials, and (3) highlight and discuss some of the unique aspects that should be considered when designing and conducting high-quality clinical trials evaluating the safety and efficacy of obesity medications in children and adolescents. Suggestions are offered in the areas of target population and eligibility criteria, clinical trial end-point selection, trial duration, implementation of lifestyle modification therapy and recruitment and retention of participants. Efforts should be made to design and conduct trials appropriately to ensure that high-quality evidence is generated on the safety and efficacy of various medications used to treat pediatric obesity.

Antenatal care provider's advice is the key determinant of influenza vaccination uptake in pregnant women.

BACKGROUND: Although influenza vaccination is an important component of antenatal care and is recommended and funded by the Australian government, vaccination uptake has been low. AIMS: This study compared seasonal influenza vaccination uptake among pregnant Western Australian (WA) women and identified factors associated with vaccination uptake. MATERIALS AND METHODS: Adult women who were pregnant during the 2012 and 2013 influenza vaccination seasons were selected at random and invited to complete a computer-assisted telephone interview survey about whether they received influenza vaccination during pregnancy. Data analyses were weighted to the age distribution of women of reproductive age in WA. Multivariate logistic regression was used to identify factors associated with vaccination uptake. RESULTS: Between 2012 and 2013, the proportion of WA women whose antenatal care provider recommended influenza vaccination increased from 37.6 to 62.1% and vaccination uptake increased from 23.0 to 36.5%. The antenatal care provider's advice to have influenza vaccine was the single most important factor associated with vaccination (OR 11.1, 95% CI 7.9-15.5). Most women (63.7%) were vaccinated in general practice, 18.8% in a public hospital antenatal clinic and 11.0% at their workplace. Wanting to protect their infant from infection (91.2%) and having the vaccine recommended by their GP (60.0%) or obstetrician (51.0%) were commonly reported reasons for vaccination; worrying about side effects was a common reason for nonvaccination. CONCLUSIONS: To optimise maternal and infant health outcomes, Australian antenatal care providers and services need to incorporate both the recommendation and delivery of influenza vaccination into routine antenatal care.

Physician burnout: coaching a way out.

Twenty-five to sixty percent of physicians report burnout across all specialties. Changes in the healthcare environment have created marked and growing external pressures. In addition, physicians are predisposed to burnout due to internal traits such as compulsiveness, guilt, and self-denial, and a medical culture that emphasizes perfectionism, denial of personal vulnerability, and delayed gratification. Professional coaching, long utilized in the business world, provides a results-oriented and stigma-free method to address burnout, primarily by increasing one's internal locus of control. Coaching enhances self-awareness, drawing on individual strengths, questioning self-defeating thoughts and beliefs, examining new perspectives, and aligning personal values with professional duties. Coaching utilizes established techniques to increase one's sense of accomplishment, purpose, and engagement, all critical in ameliorating burnout. Coaching presumes that the client already possesses strengths and skills to handle life's challenges, but is not accessing them maximally. Although an evidence base is not yet established, the theoretical basis of coaching's efficacy derives from the fields of positive psychology, mindfulness, and self-determination theory. Using a case example, this article demonstrates the potential of professional coaching to address physician burnout.

Physical activity promotion in the health care system.

Physical activity (PA) and exercise training (ET) have great potential in the prevention, management, and rehabilitation of a variety of diseases, but this potential has not been fully realized in clinical practice. The health care system (HCS) could do much more to support patients in increasing their PA and ET. However, counseling on ET is not used widely by the HCS owing partly to attitudes but mainly to practical obstacles. Extensive searches of MEDLINE, the Cochrane Library, the Database of Abstracts of Reviews of Effects, and ScienceDirect for literature published between January 1, 2000, and January 31, 2013, provided data to assess the critical characteristics of ET counseling. The evidence reveals that especially brief ET counseling is an efficient, effective, and cost-effective means to increase PA and ET and to bring considerable clinical benefits to various patient groups. Furthermore, it can be practiced as part of the routine work of the HCS. However, there is a need and feasible means to increase the use and improve the quality of ET counseling. To include PA and ET promotion as important means of comprehensive health care and disease management, a fundamental change is needed. Because exercise is medicine, it should be seen and dealt with in the same ways as pharmaceuticals and other medical interventions regarding the basic and continuing education and training of health care personnel and processes to assess its needs and to prescribe and deliver it, to reimburse the services related to it, and to fund research on its efficacy, effectiveness, feasibility, and interactions and comparability with other preventive, therapeutic, and rehabilitative modalities. This change requires credible, strong, and skillful advocacy inside the medical community and the HCS.

[Psycho-oncology]. / Psychoonkologie.

Psycho-oncology addresses the psychosocial care of patients with cancer. Systematic research on the interactions between biological, psychological and social factors before, during and after cancer has only been carried out for a few decades. All cancer patients, their relatives and the treating medical team should receive low-threshold offers for psychosocial support. The demand for interdisciplinary counselling and therapy detected by clinical diagnosis and by systematic screening, is not satisfactorily covered and is continuously increasing. In collaboration between the involved professional groups, education and professional qualifications for psycho-oncologists are still being developed.

Communication and adherence in the Caribbean: teaching skills for concordant management of care

Effective treatment of contemporary chronic and communicable illnesses can require increasingly complex degrees of adherence. This means that new approaches should be developed to manage the age old problem of adherence or, as it is often called, compliance with medical protocols. Promotion of care-giver and patient concordance as a partnership to address these contemporary concerns must include the development of the requisite communication skills. Within the Caribbean culture, lack of adherence may be exacerbated by a number of issues, including patients' literacy levels, religious and cultural beliefs, perceptions of health care providers, and even attitudes to generic medications. The differences that exist among individual patients/clients, and among the health care providers require the identification and management of the psychosocial factors and communication skills influencing adherence in the Caribbean context. Unfortunately, the exploration of these issues and the teaching of communication skills have not been a standard part of traditional educational programmes for health care providers in the Caribbean. In the introduction to Medical Practice curriculum and as part of the personal and professional development theme, medical students at the University of the West Indies (UWI), Mona, Faculty of Medical Sciences, are asked to examine their experiences of adherence to medical treatment in order to identify common issues as well as those unique to certain patient populations. The issues commonly identified as affecting compliance with medical protocols include the personality of the provider, misunderstanding of instructions, the impact of side effects, and the cost of the medication. Students are then taught four key communication skills geared to increase their competencies in communicating with their patients. These are organizational skills, rapport building skills, data gathering skills, and patient education and management skills. The factors affecting adherence to therapy are examined, such as the patient's condition, treatment prescribed, the clinician, the patient and socioeconomic conditions. The importance of the relationship (including the level of trust and confidence shared) and the quantity and quality of the communication between the patient and the provider are stressed. This chapter makes recommendations on how to improve communication competencies and techniques for effective adherence management. It addresses, in particular, opportunities within the curriculum for supervised communication skills training especially with clinical settings.

College counselors' perceptions and practices regarding anticipatory guidance on firearms.

OBJECTIVES: This study assessed college counselors' anticipatory guidance on firearms for student clients. PARTICIPANTS: The membership of the Association for University and College Counseling Center Directors was used to identify a national random sample of counseling centers (n = 361). One counselor from each center was selected to survey. METHODS: In the winter of 2008, a 3-wave mailing procedure was used to maximize the response rate. Completed surveys served as consent (as approved by the University Human Subjects Committee). RESULTS: A total of 213 counselors (59%) responded. They were unlikely to provide anticipatory guidance (6%), chart/keep records on client ownership/access to firearms (17%), or to counsel the majority of clients from various diagnostic categories on firearms. CONCLUSIONS: University personnel are likely to refer students with suspected mental health problems to university counseling centers. The findings indicate that few counseling centers will address firearm issues with students.

Lifestyle modification advice for lowering or controlling high blood pressure: who's getting it?

Lifestyle modifications (LSMs) are important in hypertension management. Using data from a population-based sample of hypertensive adults (N=28,457), the authors examined variations in reports of receipt of LSM advice by patient characteristics. Most adults (90.3%) with known hypertension reported receiving some type of advice. Exercise advice was reported most frequently (74.6%), followed by advice to reduce salt intake (69.3%), change eating habits (61.9%), and reduce alcohol intake (43.5%). Compared with adults aged 60 years or older, persons aged 18 to 39 years were more likely to report receipt of advice (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.11-1.81). Overweight persons (OR, 1.64; 95% CI, 1.40-1.93) and obese persons (OR, 2.75; 95% CI, 2.28-3.31) were more likely to report receipt of advice. Persons receiving antihypertensive medication were also more likely to report receiving advice (OR, 2.35; 95% CI, 1.98-2.81). This study demonstrates that older persons, persons not taking antihypertensive medication, and individuals who are not overweight or obese are less likely to report receiving LSM advice.

Exploring beliefs and practice of opioid prescribing for persistent non-cancer pain by general practitioners.

Persistent non-cancer pain is a common reason for consultation in primary care but treatment options, including non-opioid analgesics, are limited, and neither strong evidence nor established guidelines address when and how primary care doctors should prescribe opioid analgesics for persistent non-cancer pain. The aim of this study was to investigate associations between doctors' prescribing patterns for persistent non-cancer pain in primary care and their personal and practice characteristics and beliefs about appropriateness and risks of opioids. A pilot survey sampled beliefs concerning the need for and risks of opioid prescribing for persistent non-cancer pain among volunteers from primary care practices and postgraduate educational events, using a self-report questionnaire, and related these beliefs to their reported opioid prescribing. One quarter of the sample prescribed no opioids for persistent non-cancer pain. Prescribing opioids was predicted by moderate belief in the appropriateness of opioids within certain constraints, and to a lesser extent by younger age. While some beliefs distinguished prescribers from non-prescribers, predicting non-prescribing was poor. Both prescribers and non-prescribers expressed concern about the risks of opioids. In addition, most primary care doctors were dissatisfied with their training on pain; few had prescribing guidelines; and neither training nor guidelines influenced prescribing. In conclusion, whether or not GPs prescribe opioids for persistent non-cancer pain is mainly determined by their personal beliefs about appropriateness of opioids for this problem.

Factors associated with colon cancer screening: the role of patient factors and physician counseling.

BACKGROUND: The prevalence of colon cancer screening is nationally low. The relative contribution of patient factors and physician counseling patterns to the low prevalence of screening is unclear. METHODS: We used multivariable analysis to examine the prevalence of colon cancer screening nationally and the reasons for this low prevalence using data from the 2000 National Health Interview Survey, a nationally generalizable survey of US households. RESULTS: Among 11,427 respondents to the Cancer Control Supplement, 16% reported annual fecal occult blood testing (FOBT) and 29% reported having undergone a sigmoidoscopy in the last 5 years or a colonoscopy in the last 10 years. After adjusting for age, sex, body mass index (BMI), healthcare access, and region of the country, Hispanics were less likely to undergo FOBT [OR 0.7 (95% CI 0.6-0.9)] and sigmoidoscopy or colonoscopy [OR 0.8 (95% CI 0.7-0.9)] compared to Whites. Respondents with lower education levels were also less likely to undergo screening. These factors were not associated with being less adherent to physician recommendations for screening. Nevertheless, non-Whites and those less educated were less likely to receive counseling from their health provider about colon cancer screening. Among respondents who did not undergo FOBT, 64% were unaware they needed the test; only 2% cited pain and discomfort as a deterrent, but 94% were not counseled by their physician about the test. Among those who did not undergo sigmoidoscopy or colonoscopy, 72% were unaware that they needed the test and only 1% was deterred by pain and discomfort; 92% were not counseled by their physician. CONCLUSION: The low prevalence of screening for colorectal cancer appears to be due to lack of awareness and inadequate provider counseling rather than poor patient acceptance for screening. Systematic counseling about colorectal cancer screening will likely improve screening rates and reduce disparities by race/ethnicity and education.

Pre-departure counselling and an email contact service for patients with epilepsy faring abroad for long periods of time.

The fate and management of 50 patients with epilepsy is described whilst they undertook varied gap year experiences in various countries. Despite initial apprehension on my part almost all had no change in their epilepsy (or had actual improvement) and it turned out to be a positive experience for all. With the ready availability of email it is suggested that the home clinic keeps in touch with gap year students whilst they are away and provides them with basic information and an assessment before they go, information which they can then take with them.

Effects of systematic asymmetric discounting on physician-patient interactions: a theoretical framework to explain poor compliance with lifestyle counseling.

BACKGROUND: This study advances the use of a utility model to model physician-patient interactions from the perspectives of physicians and patients. PRESENTATION OF THE HYPOTHESIS: In cases involving acute care, patient counseling involves a relatively straightforward transfer of information from the physician to a patient. The patient has less information than the physician on the impact the condition and its treatment have on utility. In decisions involving lifestyle changes, the patient may have more information than the physician on his/her utility of consumption; moreover, differences in discounting future health may contribute significantly to differences between patients' preferences and physicians' recommendations. TESTING THE HYPOTHESIS: The expectation of differences in internal discount rate between patients and their physicians is discussed. IMPLICATIONS OF THE HYPOTHESIS: This utility model provides a conceptual basis for the finding that educational approaches alone may not effect changes in patient behavior and suggests other economic variables that could be targeted in the attempt to produce healthier behavior.