Swaddling and Infant Sleeping Practices.

Swaddling promotes quiet sleep and may be a useful strategy to encourage infant safe sleep practices. We explored the effect of a swaddling education intervention on infant sleep practices in an urban minority community. We compared a cohort of postpartum mothers who were given education about swaddling to a historical group. Breastfeeding and pacifier use were similar in both groups. Compared to the historical group (n = 121), mothers in the swaddling group (n = 40) were more likely to swaddle infants to sleep (52.5 vs. 23.1 %, p = .001) and less likely to bedshare (15.4 vs. 33.1 %, p = .042). No significant effect was reported on infant supine sleep (81.6 vs. 69.4 %, p = .212). A postpartum swaddling education intervention had a limited impact on infant safe sleeping practices in an urban minority community. A recent metaanalysis demonstrated an increased risk of sudden infant death in infants swaddled for sleep and recommended the need to avoid the prone and side sleep position, especially for swaddled infants, and to set an age and developmentally appropriate limit for the use of swaddling. Ongoing studies are needed to monitor the safety and effectiveness of swaddling as a tool to promote safe sleeping in infants.

Osteopathic Manipulative Treatment for Older Patients: A National Survey of Osteopathic Physicians.

CONTEXT: The mission of the American Academy of Osteopathy (AAO) emphasizes "the integration of osteopathic principles, practices and manipulative treatment in patient care." Osteopathic manipulative treatment (OMT) can be used to address serious conditions affecting older persons (≥65 years). However, the percentage of osteopathic physicians who use OMT in older patients, the differences in conditions for which OMT is used, and the OMT techniques used in older patients compared with younger patients are unknown. OBJECTIVE: To determine the use of OMT by osteopathic physicians in older patients compared with younger patients. METHODS: Members of the AAO were invited, via 3 e-mail messages sent over the course of a 4-month period, to participate in an anonymous online survey. The survey asked physicians to report the percentage of patients by age group (<65 years, 65-79 years, and ≥80 years) to whom they provided OMT, the types of musculoskeletal and system-based conditions for which OMT was used, and the specific OMT techniques used. RESULTS: A total of 197 of 629 AAO members (31.3%) responded to the survey. Respondents indicated that OMT was used at approximately the same rate in all patients in the 3 age groups. Osteopathic manipulative treatment was frequently used to manage a variety of musculoskeletal conditions, with the exception of osteoporosis, in all patients in the 3 age groups. The system-based conditions most often managed with OMT were respiratory and neurologic conditions. Various OMT techniques were used to treat patients in the 3 age groups; however, high-velocity, low-amplitude (HVLA) was usually avoided in patients aged 65 years or older. CONCLUSION: Osteopathic physicians who used OMT in their practice administered OMT for a variety of musculoskeletal and system-based conditions in patients of all ages. Various OMT techniques were used by these physicians for patients of all ages, with the exception of HVLA, which was mainly used in patients younger than 65 years.

Antibiotic-associated diarrhea and the older dental patient: how do dentists respond?

BACKGROUND: Gastrointestinal complications from antibiotic use, including Clostridium difficile infection (CDI), can have significant morbidity, especially among older patients. This descriptive study surveyed dentists to find out how they would respond to a patient with signs indicating potential CDI. METHODS: A survey on prescribing medications for older patients was mailed to 1,000 dentists in New Jersey. Questions were asked regarding antibiotic selection, probiotic use, and approach to a patient scenario of diarrhea after antibiotic use. RESULTS: Respondents chose amoxicillin most frequently as an antibiotic, and clindamycin if penicillin allergy. When informed their patients had diarrhea, 64.5% advised them to stop the antibiotic. If the patient continued to have diarrhea on follow-up, 75.5% contacted the patient's physician. Most (61.6%) do not prescribe probiotics prophylactically. CONCLUSIONS: Most dentists respond appropriately to antibiotic-associated diarrhea in advising to stop the antibiotic, and seeking physician involvement if no improvement, but there are still many who make recommendations that could delay appropriate care. Dentists may wish to learn more about benefits of probiotics.

Reliability and benefits of medical student peers in rating complex clinical skills.

BACKGROUND: Peers have been shown to be reliable raters in an objective structured clinical exam (OSCE). While the literature supports the use of senior level students in rating basic clinical skills, little is known about the reliability of peers of the same level of training in assessing complex clinical skills. AIM: To investigate the reliability of student peers of the same level of training in rating complex clinical skills in a geriatric OSCE. METHODS: Peer (n = 115) ratings were compared to faculty ratings using correlation and generalizability analysis. Paired Wilcoxon Signed-Rank test was used to establish peer learning benefits. RESULTS: Reliability of the OSCE was moderately strong (G-coefficient = 0.70) with strong correlations between peer and faculty ratings for the overall OSCE (r = 0.78, p = 0.001) and for each case (r = 0.70-0.85, p = 0.001). Generalizability analysis indicated that raters contributed minimally to score variance. Peers reported gaining learning benefits from the rating process. CONCLUSION: Peer raters of the same level of training can provide accurate ratings of complex clinical tasks and can serve as an important resource in assessing student performance in an OSCE. The peer review process can also serve an important role in enhancing student learning.

Developing osteopathic competencies in geriatrics for medical students.

CONTEXT: Minimum core competencies for allopathic medical students in the specialty area of geriatrics have been developed, comprising 26 competencies divided into 8 topical domains. These competencies are appropriate for osteopathic medical students, but they do not include competencies relating to osteopathic principles and practice (OPP) in geriatrics. There remains a need within the osteopathic profession to develop specialty-specific competencies specific to OPP. OBJECTIVE: To develop more specific and comprehensive minimum competencies in OPP for osteopathic medical students in the field of geriatric medicine. METHODS: The Delphi technique (a structured communication technique that uses a panel of experts to reach consensus) was adapted to generate new core competencies relating to OPP. Osteopathic geriatricians and members of the Educational Council on Osteopathic Principles (ECOP) of the American Association of Colleges of Osteopathic Medicine participated in a breakout session and 2 rounds of surveys. Proposed competencies with 80% of the participants ranking it as "very important and should be added as a competency" were retained. Participants were also asked if they agreed that competencies in OPP should include specific types of osteopathic manipulative treatment techniques for the elderly. RESULTS: Responses were received from 26 osteopathic physician experts: 17 ECOP members and 9 geriatricians. Fourteen proposed competencies were developed: 7 related to the existing topic domains, and 7 were placed into a new domain of osteopathic manipulative medicine (OMM). Six proposed competencies were retained, all of which were in the new OMM domain. These competencies related to using OMM for gait and balance assessment, knowing adverse events and contraindications of OMM, using OMM for pain relief and end-of-life care, using OMM in the hospital and nursing home setting, adapting OMM to fit an elderly individual, and using OMM to address limited range of motion and ability to perform activities of daily living. Thirteen of 22 participants (59%) agreed that OPP competencies should include specific osteopathic manipulative treatment techniques. CONCLUSIONS: The Delphi consensus building process was used to create 6 new minimum competencies in OMM for osteopathic medical students for the specialty area of geriatrics. Using data from this consensus, medical schools, residencies, and fellowships can create standards and expectations for osteopathic physicians regarding the best care of geriatric patients.

Statins decrease the occurrence of venous thromboembolism in patients with cancer.

BACKGROUND: Recent data suggest a reduction in the occurrence of venous thromboembolism in select groups of patients who use statins. The objective of this study is to evaluate the impact of statin use on the occurrence of venous thromboembolism in patients with solid organ tumor. METHODS: We conducted a retrospective, case-control study reviewing 740 consecutive patients with a diagnosis of solid organ tumor who were admitted to the Albert Einstein Medical Center, Philadelphia, Penn, between October 2004 and September 2007. Patients treated with anticoagulation therapy before their first admission were excluded. The occurrence of venous thromboembolism, risk factors for venous thromboembolism, and statin use were recorded. Patients who never used statins or had used them for less than 2 months were relegated to the control group. RESULTS: The mean age of the study population was 65 years, and 52% of the patients were women and 76% were African American. The occurrence of venous thromboembolism was 18% (N=132), and 26% (N=194) were receiving statins. Among patients receiving statins, 8% (N=16) developed a venous thromboembolism compared with 21% (N=116) in the control group (odds ratio 0.33; 95% confidence interval, 0.19-0.57). A logistic regression analysis including risk factors for venous thromboembolism (metastatic disease, use of chemotherapy, immobilization, smoking, and aspirin use) along with statin use yielded the same results. CONCLUSION: This study suggests that the use of statins is associated with a significant reduction in the occurrence of venous thromboembolism. This pleiotropic effect warrants further investigation.

Identifying and assessing interests and concerns of priority populations for work-site programs to promote physical activity.

The work site has been identified as an ideal context for promoting physical activity. Assessing employee interest, identifying who could most benefit, and understanding impact of work-related barriers on potential participation is key. We conducted focus groups and surveyed the employee population of a large urban hospital. Using the "stages of change" construct, employees were categorized based on their motivation to exercise into exerciser, intender, and nonintender groups. Intenders were significantly more interested in most physical activity programs at work than were exercisers (p < .05). Intenders also found environmental and personal barriers to be more significant deterrents to participation than did exercisers (p < .01). Half of nonintenders reported interest in physical activity programs. Interest in physical activity programs at work is strong for employees who are not currently exercising. Both structural changes to promote safe environments and time allotments through work-related policies may encourage participation, especially for the priority populations of nonexercising employees.

Reduced risk of bone metastasis for patients with breast cancer who use COX-2 inhibitors.

PURPOSE: We hypothesize that the use of cyclooxygenase (COX)-2 inhibitors in early disease phases could protect against the development of bony metastases. PATIENTS AND METHODS: The medical charts of patients with stage II-III breast cancer diagnosed between 1999 and 2005 were reviewed. Patients were subdivided according to the use of COX-2 inhibitors after the diagnosis and for > or = 6 months. Bivariate analyses were undertaken, and statistically significant variables were included in a multivariate logistic regression model. RESULTS: Eleven percent of patients (74 of 644) who did not use COX-2 inhibitors developed bone metastases compared with 2% (1 of 48) of those who did use COX-2 inhibitors (Fisher exact test, P = .05). Significant predictors for bone metastases in a multivariate logistic regression model included: > or = 3 positive nodes (odds ratio [OR], 3.26 [95% CI, 1.79-5.93]; P < .001), stage IIB-IIIC disease (OR, 3.89 [95% CI: 1.74-8.69]; P = .001) and use of COX-2 inhibitors (OR, 0.12 [95% CI, 0.02-0.88]; P = .037). Adjusting for TNM stage, of the 327 patients with stages IIB-IIIC disease, 22% (63 of 293) had bone metastases in the non-COX-2 group versus 3% (1 of 34) in the COX-2 inhibitors consumers (Fisher exact test, P = .006). In this high-risk group of patients, the calculated OR associated with COX-2 inhibitors was 0.10 (95% CI, 0.01-0.78). CONCLUSION: The use of COX-2 inhibitors could reduce the risk of bone metastases in stage II-III breast cancer.

Practice patterns of osteopathic physicians providing end-of-life care: a survey-based study.

CONTEXT: In 1996, the American Medical Association drafted and organized the Education for Physicians on End-of-Life Care (EPEC) curriculum. Leadership in the osteopathic medical profession has similarly recognized the goals of EPEC-resulting in the development of Osteopathic-EPEC, which incorporates the core tenets of osteopathic medicine. OBJECTIVE: To assess the impact of EPEC training and the integration of osteopathic principles and practice in end-of-life care provided by osteopathic physicians (DOs). METHODS: Osteopathic physicians who participated in the 2002 and 2003 AOA (American Osteopathic Association) End-of-Life Care-National Osteopathic Workshops were surveyed (N=100) on the use of advance directives and on their application of the tenets of osteopathic medicine, including the use of osteopathic manipulative techniques, for terminally ill patients. RESULTS: More than 90% of responding DOs (n=66) ranked each of the four core tenets of osteopathic medicine as important. Among completed responses, 58 DOs (89%) said they believed the tenets and philosophy of osteopathic medicine better prepared them to provide end-of-life care. Forty-eight DOs (79%) agreed that the use of osteopathic diagnostic and treatment skills augmented their ability to provide quality care for terminally ill patients. CONCLUSION: Osteopathic physicians indicated that the tenets of osteopathic medicine improve their effectiveness in providing quality end-of-life care to patients. However, fewer than half of surveyed DOs who used osteopathic manipulative techniques to relieve pain and manage the physical symptoms associated with the dying process reported that the techniques are often or always effective.

Patterns and predictors of early hospital readmission in patients with congestive heart failure.

Little is known about factors related to rehospitalizations that occur soon after discharge in patients with congestive heart failure (CHF). The aim of this study was to determine if there are specific characteristics common to CHF patients readmitted within 30 days. Study methods included retrospective chart review. Patients included all those hospitalized and readmitted to a large community teaching hospital for CHF exacerbation within 30 days between January 7, 2005 and June 30, 2006. A total of 58 patients were responsible for 79 readmissions. Half of all patients readmitted for CHF exacerbation were incorrectly labeled, raising doubt about reliance on administrative data alone to determine overall quality performance. Forty-five percent of all readmitted patients had underlying chronic renal insufficiency/failure (CRI/CRF) compared with 26% of CHF patients who were not readmitted within 30 days. Therefore, specifically targeting CHF patients with CRI/CRF could lead to major improvement of early readmission rates.

Computer-assisted instruction: a survey on the attitudes of osteopathic medical students.

OBJECTIVES: To investigate the views of osteopathic medical students on their preferred learning methods, their current use of computers as an educational tool, and their attitudes regarding the role of computers in medical education, based on their skill level. METHODS: A 27-item questionnaire was distributed to first-through fourth-year osteopathic medical students. Items asked students to assess their levels of computer skills and experience, their current use of computers as an educational tool, and their attitudes regarding the role of computers in medical education. RESULTS: Of the 246 students (80% of enrolled students) who responded to the questionnaire, a majority (129 [53%]) rated themselves as having intermediate computer skills, and the remaining students rated their skills as basic (69 [28%]) or advanced (46 [19%]). Most students (176 [72%]) felt that they learned best by both hearing and seeing or reading new material, that they learned more easily from a printed page than a computer screen, and that live lectures provided them with the best opportunity for learning. However, when compared with students who have basic and intermediate computer skills, students with advanced computer skills were more in favor of computer-assisted instruction and testing as well as a school requirement to own a computer and to use a laptop computer in class. CONCLUSIONS: Students' opinions of the importance of computer technology in medical education seem to be based mainly on their self-assessed technical competency levels. Understanding this dynamic may aid medical educators in the implementation of computer-assisted instruction.

Sexuality in older adults: behaviours and preferences.

BACKGROUND: while much has been written about adult sexuality, relatively little is available about the sexuality of older people. Available literature often does not discuss specific sexual behaviours and includes predominantly married, better-educated, mostly young old. OBJECTIVE: the purpose of this study was to assess a sample of lower-income older adults, about whom there is limited information, to describe a full range of sexual behaviours and to identify the degree to which they are satisfied with their sexual activities. METHODS: subjects were 179 people (60 and older) who were residents of subsidised independent-living facilities, recruited during a lecture or in public areas in the building. Thirteen of 179 were excluded due to age. Most were white (82%), living alone (83%) and female (63%). RESULTS: overall, the majority reported to have had physical and sexual experiences in the past year such as touching/holding hands (60.5%), embracing/hugging (61.7%) and kissing (57%) daily to at least once a month; mutual stroking, masturbation and intercourse were experienced 'not at all' by 82% or more. For all activities except masturbation, participants wanted to participate in sexual activities more often than they did. The most important barrier to sexual activity was lack of a partner. Self-reported health was related to sexual activities wanted, with age also related to some preferences. CONCLUSIONS: most of the elderly surveyed want to maintain a sexual relationship which includes touching and kissing, and they would like to have more sexual experiences than they have accessible. Further studies are needed.

Physicians' practices related to the use of terminal sedation: moral and ethical concerns.

OBJECTIVE: Although terminal sedation (TS) has generally been seen as legal and ethically acceptable, ethical and moral issues remain. Little is known about the use of TS in general clinical practice and about how TS is viewed by physicians, given moral and ethical concerns. The objectives of this study are (1) to describe attitudes of physicians regarding terminal sedation; (2) to explore demographic characteristics, such as age, gender, subspecialty, and number of years in practice, that might be related to the use of TS; and (3) to compare physicians who have and have not used TS on the degree to which they view TS as moral and consistent with their professional and personal ethics. METHODS: An anonymous survey of New Jersey physicians was conducted at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine. A 39-item questionnaire assessing general opinions about, experiences with, and religious, moral, ethical attitudes toward TS and other end-of-life treatments was utilized. RESULTS: A majority of physicians (73%) had used TS for a patient. Most (93%) said there were circumstances under which they would use TS. With regard to questions about whether TS would be "immoral," "would violate my religious beliefs," "would violate my professional ethics" and "is inconsistent with the physician's role of preserving life," approximately 55% of those who have used TS disagreed; for those who have not used TS, approximately 35% disagreed. SIGNIFICANCE OF RESULTS: Professional education and opportunities for discussion appear necessary to help reconcile the conflicts raised in the use of this end-of-life treatment strategy.

Oral health in the elderly with non-insulin-dependent diabetes mellitus.

Non-insulin-dependent diabetes mellitus (NIDDM) is a common endocrine disease affecting the elderly in particular. Long-term complications involve the vasculature; vision, renal, and neural function; and the periodontium. Knowledge about the oral health of the elderly and the effects of NIDDM is limited. The objective of this study was to compare the oral health of patients aged 60+ years, who have NIDDM, with patients who do not have NIDDM. To evaluate oral health, we recorded retention and condition of the teeth, periodontal health, and condition of the oral mucosa. We also assessed oral hygiene, smoking history, regularity of dental checkups, and medication use. The study group was selected from among patients who came to the ambulatory care clinic at University of Medicine and Dentistry, New Jersey, Center for Aging with a diagnosis of NIDDM. The control group, which did not have NIDDM, was selected from among the same patient group and was matched for age and gender. Patients with severe dementia, those having fewer than 10 teeth or those who were in need of antibiotic prophylaxis were excluded from the study. Patients underwent a short interview and a clinical evaluation. Our study involved 32 elderly adults with NIDDM and 40 elderly adults who did not have NIDDM. Both groups had similar oral hygiene levels and regularity of professional dental care. In addition, the plasma glucose levels among the study group were well controlled. This study did not show statistically significant differences in oral health parameters between participants with diabetes and those in a control group.

Osteoporosis prevention project: a model multidisciplinary educational intervention.

Osteoporosis is a systemic metabolic disease resulting in low bone mass, which increases the risk for fracture. Evidence suggests that lifestyle changes to prevent or delay development of osteoporosis should be implemented throughout the life span. The purpose of this study was to evaluate the effectiveness of a multidisciplinary primary osteoporosis prevention program for community-dwelling women aged 25 to 75 years to determine if osteoporosis prevention program participants (treatment group) increased their knowledge of osteoporosis, calcium intake, and exercise compared with a control group. Other outcomes included participants' willingness to adopt lifestyle changes and ability to view themselves as able to make behavioral changes. Subjects in the treatment group versus control subjects increased their knowledge of osteoporosis over time. At posttest, subjects in the treatment group were more likely to be planning to change calcium intake, and at follow-up, they were more likely to be changing their calcium intake. No other group differences were found between the two groups. These findings suggest that a multidisciplinary education program may have an impact on knowledge and behaviors that may help to delay the development of osteoporosis.

Attitudes of osteopathic physicians toward physician-assisted suicide.

The use of physician-assisted suicide (PAS) in the care of terminally ill patients is controversial. While there are published surveys assessing the attitudes and views of physicians in certain specialties, both nationally and in targeted geographic areas, no such data are available specifically pertaining to osteopathic physicians, who deliver 9% of the primary care in the United States. This article describes a study whose purpose was to identify the views and perspectives of osteopathic physicians on PAS through a national survey. Questionnaires were forwarded to all board-certified internists who are members of the American College of Osteopathic Internists and all surgeons and a random sample of family physicians who are members of the American Osteopathic Association. Physicians were surveyed with initial and follow-up mailings. The 49-item questionnaire was a modified version of the Physician Survey, Center for Ethics in Health Care: Oregon Health Sciences University. Of the 2910 questionnaires that were mailed, 1028 were returned in a usable form, for a 35% response rate. Respondents were predominantly (81%) male and from all parts of the country. Most (58%) would not be willing to prescribe a medication for a competent, terminally ill patient to use with the primary intention of ending his or her own life, and most (55%) would oppose the legalization of PAS. Thirty-three percent of osteopathic physicians admit to receiving requests by terminally ill patients for PAS. Most (53%) osteopathic physicians indicate that the osteopathic principle of holistic care has influenced their decision-making on this issue, and a significant minority (44%) responded that the osteopathic oath influenced their view on PAS. Religion and the degree of prayer frequency were important predictors of the decisions to support or oppose PAS. When compared to other physician surveys, this survey of osteopathic physicians demonstrates some similarities in response but also significant differences. These data suggest that osteopathic education and training may result in a perspective on PAS that reflects the distinctiveness of the osteopathic profession.