Gastrointestinal Physiological Changes and Their Relationship to Weight Loss Following the POSE Procedure.

BACKGROUND: Primary Obesity Surgery Endolumenal (POSE) is a novel bariatric endoscopic procedure that has been shown to reduce weight safely through 12 months. The study investigated potential mechanisms of weight loss following POSE. METHODS: Patients with class I-II obesity received transmural plications in the gastric fundus and distal gastric body. Patients were evaluated at baseline and at 2- and 6-month follow-up with gastric-emptying (GE) scintigraphy, a validated test of intake capacity (kcal) and plasma glucose homeostasis hormones/gastrointestinal peptides. Weight was recorded through 15 months. Mean data and 95% CIs are reported. Regression modeling assessed variables that influenced total weight loss (%TWL) and excess weight loss (%EWL). RESULTS: POSE was performed on 18 patients (14 F/4 M); mean age 39 years (34-44), body mass index (BMI, kg/m(2)) 36 (95% CI, 35; 37). At 15 months (n = 15), mean TWL was 19.1 ± 6.6% (15.5; 22.8) and EWL was 63.7 ± 25.1% (49.8; 77.6). At 2 and 6 months (n = 18), intake capacity decreased significantly from 901 (685; 1117) to 473 (345; 600) and 574 kcal (418; 730), respectively (p < 0.001). At 2 months, GE was delayed but returned to baseline levels at 6 months (n = 18). Glucose/insulin ratio improved (p < 0.05). Postprandial decrease in ghrelin was enhanced (p = 0.03) as well as postprandial increase in PYY (p = 0.001). The best model for EWL prediction 15 months after POSE (R (2): 66%, p = 0.006) included pre-POSE BMI, post-POSE GE, and postprandial PYY increase. CONCLUSIONS: The POSE procedure was followed by significant sustained weight loss and improved glucose homeostasis and satiation peptide responses. Weight loss following POSE may be mediated through changes in gastrointestinal neuro-endocrine physiology.

Development and testing of an HIV-risk screening instrument for use in health care settings.

OBJECTIVE: To develop and test a brief, reliable, and valid HIV-risk screening instrument for use in primary health care settings. DESIGN: A two-phase study: (1) developing a self-administered HIV-risk screening instrument, and (2) testing it with a primary care population, including testing the effect of confidentiality on disclosure of HIV-risk behaviors. SETTING: Phase 1: 3 types of sites (a blood donor center, a methadone clinic, and 2 STD clinics) representing low and high HIV-seroprevalence rates. Phase 2: 4 primary care sites. PARTICIPANTS: Phase 1: 293 consecutively recruited participants. Phase 2: 459 randomly recruited primary care patients. MAIN OUTCOME MEASURE: Phase 1: comparison of the responses of participants from low and high HIV-seroprevalence sites. Phase 2: primary care patients' rates of disclosure of HIV-risk behaviors and ratings of acceptability. RESULTS: Phase 1: through examining item-confirmation rates, item-total correlations, and comparison of responses from low and high HIV-seroprevalence sites, we developed a final 10-item HIV-risk Screening Instrument (HSI) with an internal consistency coefficient of .73. Phase 2: 76% of primary care patients disclosed at least 1 risky behavior and 52% disclosed 2 or more risky behaviors. Patients were willing to disclose HIV-risk behaviors even knowing that their physician would see this information. Ninety-five percent of our patient participants were comfortable with the questions on the HSI, 78% felt it was important that their doctor know their answers, and 52% wished to discuss their answers with their physician. CONCLUSION: Our brief, self-administered HSI is a reliable and valid measure. The HSI can be used in health care settings to identify individuals at risk for HIV and to initiate HIV testing, early care, and risk-reduction counseling, necessary goals for effective HIV prevention efforts.

Decision support software to help primary care physicians triage skin cancer: a pilot study.

OBJECTIVE: To determine whether decision support software can help primary care physicians proficiently triage lesions suggestive of basal cell and squamous cell carcinoma. DESIGN/MEASURES: Physicians selected triage options for 15 digitized images of skin lesions, with and without use of the decision support software. PARTICIPANTS/SETTINGS: Twenty primary care physicians practicing in a health maintenance organization or a city health clinic. INTERVENTION: Decision support software designed to help physicians arrive at a triage recommendation consisted of a clinical information form, a decision tree, and support features (teaching points, example images, and diagrams). RESULTS: Without using the decision support software, physicians chose the wrong triage decision 36.7% of the time; using the decision support software, they chose the wrong response only 13.3% of the time. Not using the decision support software, they failed to correctly perform a biopsy on or refer patients with cancerous lesions 22.1% of the time; using the software, they failed to correctly perform a biopsy on or refer patients with cancerous lesions only 3.6% of the time. Physicians scored an average of 3 points (of a possible 15 points) higher when they used the software (signed rank, 101.0; P<.001). They scored an average of 1 point higher on the 7 cancerous lesions when they used the software (signed rank, 65.5; P<.001). CONCLUSIONS: Use of decision support software could improve primary care physicians' triage decisions for lesions suggestive of nonmelanoma skin cancer, and potentially reduce morbidity and health care costs. We are designing a larger study to evaluate the accuracy and utility of the software with patients seen in clinical practice.

Primary care physicians as gatekeepers in managed care. Primary care physicians' and dermatologists' skills at secondary prevention of skin cancer.

BACKGROUND AND DESIGN: This study determines (1) the readiness of primary care physicians (PCPs) to triage optimally lesions suspicious for skin cancer, (2) the difference in their abilities from those of dermatologists, and (3) whether accurate diagnosis after viewing slide images transfers to accurate diagnosis after viewing lesions on patients. Seventy-one primary care residents and 15 dermatologists and resident dermatologists diagnosed and selected a treatment/diagnostic plan for skin lesions suspicious for cancer. The lesions were shown on slides, computer images, and patients. Participants' performance was compared with biopsy results of all lesions. RESULTS: Dermatologists' scores were almost double those of primary care residents, and primary care residents' performance was positively associated with previous experience in dermatology. Primary care residents failed 50% of the time to diagnose correctly nonmelanoma skin cancer and malignant melanomas, and 33% of the time they failed to recommend biopsies for cancerous lesions. Primary care residents failed to diagnose malignant melanomas 40% of the time; dermatologists failed to do so 26% of the time. Both groups performed better using slide images compared with patients. CONCLUSIONS: Primary care residents may not be ready to assume a gatekeeper role for lesions suspicious for skin cancer. Because of the seriousness of missed diagnoses, especially of malignant melanomas, we need to improve the triage skills of PCPs. Future studies should evaluate whether primary care training allows sufficient time for PCPs to learn the necessary skills. Until we can show that PCPs are prepared to triage optimally, managed care plans should reduce the threshold for referrals to dermatologists of potential skin cancers.

Physicians' transmission prevention assessment and counseling practices with their HIV positive patients.

Physicians can help prevent transmission of HIV by assessing HIV positive patients for risky sexual and needle-sharing behaviors, and by providing risk reduction counseling. From 1995 to 1997, we gathered data on the HIV transmission prevention assessment and counseling practices of 44 San Francisco Bay area physicians in face-to-face, semistructured interviews. A refined coding scheme and constant comparative analytic method were used. Although physicians varied in their responses to coded items, two styles of engagement, at the extremes, emerged from the data: "consultant" and "collaborator." Consultants conducted transmission prevention assessment and counseling during initial visits or upon medical cues (e.g., presence of sexually transmitted diseases) and viewed themselves primarily as information sources, whereas collaborators regularly conducted transmission prevention counseling and viewed themselves as actively helping patients reduce transmission risk. Physicians who fell between the two styles generally did not conduct regular counseling themselves, but many used referrals to health educators. The findings suggest that consultant and collaborator styles may influence patients differently, and offer insight into the role that physicians can play in transmission prevention with HIV positive patients.

Toward a definition of HIV expertise: a survey of experienced HIV physicians.

Medical care for human immunodeficiency virus (HIV)-infected persons has grown increasingly complex, yet few studies have examined experienced HIV physicians' views about current HIV medical care. The objective of this study was to examine the relationship between physicians' HIV experience, self-perceived expertise, and confidence with providing 18 aspects of HIV medical care and between confidence in aspects of care and medical specialty. At geographically diverse, HIV continuing medical education programs conducted in the fall of 1999, 359 currently practicing HIV physicians completed a written survey measuring participants' demographic characteristics, experience, HIV expertise, and level of confidence providing essential aspects of HIV care. Participants currently managed a median of 50 HIV-infected patients with a career total of 300. Significant correlations were found between experience and expertise items and experience and 15 of 18 confidence items. Confidence levels varied from 11% to 85% highly confident across 18 aspects of HIV care. Physicians' confidence with providing aspects of HIV care varied by the three predominant specialty groups (infectious diseases, internal medicine, and family practice/general medicine). Physicians who have informally specialized in HIV care reported a range of self-perceived expertise and confidence, indicating the complexity of HIV medical care today. Our results suggest that even the most experienced HIV physicians in the United States continue to benefit from more experience and that each medical specialty examined in this study brings its own set of skills needed to provide optimal HIV care. This study constitutes a first step toward defining and formalizing HIV medical care.

Dentists' attitudes and behaviors regarding domestic violence. The need for an effective response.

BACKGROUND: The authors examined the attitudes and behaviors of a national sample of dentists regarding domestic violence and the barriers dentists face in intervening to help victims. METHODS: The authors surveyed a national random sample of 321 dentists by mail from November 1997 to March 1998 about their attitudes and clinical practice behaviors related to domestic violence. Survey items were developed based on the domestic violence and health care literature. The authors used the Total Design Method to maximize the response rate and analyzed data to determine differences between dentists who had received domestic violence education and those who had not. RESULTS: Eighty-seven percent of responding dentists never screened for domestic violence; 18 percent never screened even when patients had visible signs of trauma on their heads or necks. Overall, respondents intervened only minimally to help patients whom they had identified as victims. Respondents reported that the major barriers to screening were the presence of a partner or children (77 percent), lack of training (68 percent), concern about offending patients (66 percent) and their own embarrassment about bringing up the topic of abuse (51 percent). Respondents who had received domestic violence education were significantly more likely to screen for domestic violence and to intervene. CONCLUSIONS: Dentists face many barriers to identifying and helping patients who are abuse victims, yet these data suggest that education about domestic violence could help them overcome some of these barriers. CLINICAL IMPLICATIONS: We suggest that dentists follow the AVDR model when approaching abused patients in their practice: Ask about abuse, provide Validating messages, Document presenting signs and Refer victims to domestic violence specialists.

Interventions that help victims of domestic violence. A qualitative analysis of physicians' experiences.

BACKGROUND: The barriers physicians face when providing care to victims of domestic violence are well detailed in the literature, but few studies provide insight into how physicians overcome these barriers. Our goal was to describe the domestic violence interventions used by physicians who are committed to providing quality health care to battered women. METHODS: We conducted 6 focus groups with 45 San Francisco Bay Area physicians who had intervened with victims of domestic violence. The sessions were audiotaped and transcribed. We constructed, through constant comparison, a template of open codes to identify themes that emerged from the data. RESULTS: Our analysis revealed that physicians viewed validation (ie, providing messages to the patients that they are worth caring about) as the foundation of intervention. Other interventions included labeling the abuse as abuse; listening and being nonjudgmental; documenting, referring, and safety planning; using a team approach; and prioritizing domestic violence in the health care environment. Physicians described a range of rewards for intervening with victims, from seeing a patient change her entire life to subtle shifts in the way a woman thinks of her relationship and herself. CONCLUSIONS: Our study offers insight into how physicians can intervene to help victims of domestic violence. Recent interview and survey studies of battered women support the physician interventions described.

A computer-based assessment detects regimen misunderstandings and nonadherence for patients on HIV antiretroviral therapy.

Accurately assessing nonadherence is a necessary first step toward improving adherence to highly active antiretroviral therapy (HAART). Patient self report is the most practical method for assessing adherence in clinical settings, but may produce unreliable and invalid results unless optimally performed. A computer-assisted, self-administered interview (CASI) may improve the disclosure of medication nonadherence by providing a neutral and seemingly private interview. One hundred and ten patients completed a computer program which assessed their understanding of and adherence to HIV medications and produced a report for their providers. Eleven providers of these patients completed a questionnaire describing their patients' medication regimens and estimating adherence. Patients completed a written exit survey and providers completed an exit interview to assess the acceptability of our CASI-based assessment. More than half of patients (54%) made at least one error in reporting their medication regimen. Providers tended to overestimate their patients' adherence and correctly classified only 24% of nonadherent patients at the 80% adherence level. Computerized HIV medication adherence assessment is feasible and acceptable to patients and providers. Clinical tools that can accurately and efficiently detect important medication errors and nonadherence, and alert providers to these problems, will help ensure the health of HIV-seropositive patients.

HIV risk assessment: a video doctor seeks patient disclosure.

We assessed the influence of a "video doctor's" affective communication style (warm vs. neutral) and of a preamble to questions about sexual activity on patients' disclosure of risky sexual behavior and injectable drug use. To isolate the effects of the independent variables, we created an interactive multimedia program for HIV risk assessment using a video doctor portrayed by an actor. Participants were assigned to one of four conditions: no preamble and a neutral physician, no preamble and a warm physician, a preamble and a neutral physician, or a preamble and a warm physician. Almost 60% of a convenience sample of 393 subjects reported engaging in two or more risky behaviors. Disclosure of risky behaviors was not significantly affected by the preamble. A warm communication style elicited more disclosure than a neutral style, suggesting that physicians' communication style is important in determining how much sensitive information patients are willing to reveal.

Combination antiretroviral therapy: health care providers confront emerging dilemmas.

Recent editorials, conferences and clinical practice articles have discussed providers' concerns and practices regarding prescribing antiretroviral combination therapy for HIV. We aimed to deepen our understanding of these largely anecdotal reports and of the challenges facing experienced HIV clinicians today using qualitative methodology. Eight focus groups using a structured discussion guide were conducted. Data were analyzed by constant comparative analysis and open codes. Participants were a diverse group of 23 physicians, eight nurse practitioners and four physician assistants with significant experience providing care to HIV-seropositive patients in various San Francisco Bay Area health care settings. The following major themes emerged from the data: (1) providers expressed new optimism about helping HIV-seropositive patients live; (2) the main factors affecting providers' decisions about when to start combination therapy were the risks versus benefits of delaying therapy, and patients' health status, readiness to adhere and treatment preferences; (3) providers lacked resources to prepare patients to begin therapy and enhance adherence; (4) providers varied regarding assessment of adherence; and (5) providers were anxious about making decisions under conditions of uncertainty and were concerned about patient health outcomes. We concluded that experienced HIV clinicians were hopeful and excited about their increasing ability to help patients. This hope, however, was tempered by scepticism about the future and by their daily struggles to make treatment decisions under conditions of great uncertainty. Without access to adjunct supports or a multidisciplinary team, providers may not be able to optimally assess and enhance antiretroviral medication adherence.

How health care providers help battered women: the survivor's perspective.

This qualitative study aimed to describe, from the perspective of domestic violence survivors, what helped victims in health care encounters improve their situation and thus their health, and how disclosure to and identification by health care providers were related to these helpful experiences. Semi-structured, open-ended interviews were conducted with a purposeful sample of survivors in the San Francisco Bay Area. Data were analyzed using constant comparative techniques and interpretative processes. Twenty-five women were interviewed, the majority being white and middle-class, with some college education. Two overlapping phenomena related to helpful experiences emerged: (1) the complicated dance of disclosure by victims and identification by health care providers, and (2) the power of receiving validation (acknowledgment of abuse and confirmation of patient worth) from a health care provider. The women described a range of disclosure and identification behaviors from direct to indirect or tacit. They also described how-with or without direct identification or disclosure-validation provided "relief," "comfort," "planted a seed," and "started the wheels turning" toward changing the way they perceived their situations, and moving them toward safety. Our data suggest that if health care providers suspect domestic violence, they should not depend on direct disclosure, but rather assume that the patient is being battered, acknowledge that battering is wrong, and confirm the patient's worth. Participants described how successful validation may take on tacit forms that do not jeopardize patient safety. After validating the patient's situation and worth, we suggest health care providers document the abuse and plan with the patient for safety, while offering ongoing validation, support, and referrals.

When asked, patients tell: disclosure of sensitive health-risk behaviors.

OBJECTIVES: National health care organizations recommend routinely screening patients for behavioral health risks, the effectiveness of which depends on patients' willingness to disclose risky behaviors. This study aimed to determine if primary care patients' disclosures of potentially stigmatizing behaviors would be affected by (1) their expectation about whether or not their physician would see their disclosures and (2) the assessment method. METHODS: One thousand nine hundred fifty-two primary care patients completed a questionnaire assessing human immunodeficiency virus (HIV), alcohol, drug, domestic violence, tobacco, oral health, and seat belt risks; half were told their responses would be seen by the researcher and their physician and half were told that their responses would be seen by the researcher only. Patients were randomly assigned to one of five assessment methods: written, face-to-face, audio-based, computer-based, or video-based. RESULTS: Across all risk areas, patients did not disclose differently whether or not they believed their physician would see their disclosures. Technologically advanced assessment methods (audio, computer, and video) produced greater risk disclosure (4%-8% greater) than traditional methods in three of seven risk areas. CONCLUSIONS: These findings suggest patients are not less willing to disclose health risks to a research assistant knowing that this information would be shared with their physician and that a number of assessment methods can effectively elicit patient disclosure. Potentially small increases in risk disclosure must be weighed against other factors, such as cost and convenience, in determining which method(s) to use in different health care settings.

A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims.

BACKGROUND: Physicians have been called upon to identify victims of domestic violence, but few studies provide insight into how physicians can navigate around the barriers to identification. OBJECTIVE: To describe how physicians who are committed to helping battered patients identify victims of domestic violence in health care encounters. DESIGN: Six focus groups were conducted. SETTING: Focus group research facilities. PARTICIPANTS: 45 emergency department, obstetrician/ gynecologist, and primary care physicians in the San Francisco Bay Area who identify and intervene with victims of domestic violence. MEASUREMENTS: Through constant comparison, a template of open codes was constructed to identify themes that emerged from the data. Data were analyzed according to the conventions of qualitative research. RESULTS: The data revealed five major themes: 1) how physicians framed screening questions to reduce patient discomfort; 2) patient signs that "switched on a light bulb" for physicians to suspect abuse; 3) direct and indirect approaches to identification, with an emphasis on facilitating patient trust and disclosure over time; 4) the rarity of direct patient disclosure; and 5) how physicians redefined successful outcomes of universal screening. Physicians also described two new barriers to screening: mandatory reporting and "burnout" due to lack of direct disclosure. CONCLUSIONS: Identifying domestic abuse is difficult even for physicians committed to helping victims. Physician reports illustrate the need to frame questions and develop indirect approaches that foster patient trust. Given the many barriers to screening and the rarity of direct patient disclosure, it may be more productive to redefine the goals of universal screening so that compassionate asking in and of itself constitutes the first step in helping battered patients.

Improving primary care residents' proficiency in the diagnosis of skin cancer.

OBJECTIVE: To determine whether a brief, multicomponent intervention could improve the skin cancer diagnosis and evaluation planning performance of primary care residents to a level equivalent to that of dermatologists. PARTICIPANTS: Fifty-two primary care residents (26 in the control group and 26 in the intervention group) and 13 dermatologists completed a pretest and posttest. DESIGN: A randomized, controlled trial with pretest and posttest measurements of residents' ability to diagnose and make evaluation plans for lesions indicative of skin cancer. INTERVENTION: The intervention included face-to-face feedback sessions focusing on residents' performance deficiencies; an interactive seminar including slide presentations, case examples, and live demonstrations; and the Melanoma Prevention Kit including a booklet, magnifying tool, measuring tool, and skin color guide. MEASUREMENTS AND MAIN RESULTS: We compared the abilities of a control and an intervention group of primary care residents, and a group of dermatologists to diagnose and make evaluation plans for six categories of skin lesions including three types of skin cancer-malignant melanoma, squamous cell carcinoma, and basal cell carcinoma. At posttest, both the intervention and control group demonstrated improved performance, with the intervention group revealing significantly larger gains. The intervention group showed greater improvement than the control group across all six diagnostic categories (a gain of 13 percentage points vs 5, p < .05), and in evaluation planning for malignant melanoma (a gain of 46 percentage points vs 36, p < .05) and squamous cell carcinoma (a gain of 42 percentage points vs 21, p < .01). The intervention group performed as well as the dermatologists on five of the six skin cancer diagnosis and evaluation planning scores with the exception of the diagnosis of basal cell carcinoma. CONCLUSIONS: Primary care residents can diagnose and make evaluation plans for cancerous skin lesions, including malignant melanoma, at a level equivalent to that of dermatologists if they receive relevant, targeted education.