Keeping caries at bay in breastfeeding babies

As an infant grows, human milk may become the substrate for cariogenic bacteria. Here's what to watch for and how to counsel parents.

Shared decision-making about cardiovascular disease medication in older people: a qualitative study of patient experiences in general practice

OBJECTIVES

To explore older people's perspectives and experiences with shared decision-making (SDM) about medication for cardiovascular disease (CVD) prevention.

DESIGN, SETTING AND PARTICIPANTS

Semi-structured interviews with 30 general practice patients aged 75 years and older in New South Wales, Australia, who had elevated CVD risk factors (blood pressure, cholesterol) or had received CVD-related lifestyle advice. Data were analysed by multiple researchers using Framework analysis.

RESULTS

Twenty eight participants out of 30 were on CVD prevention medication, half with established CVD. We outlined patient experiences using the four steps of the SDM process, identifying key barriers and challenges: Step 1. Choice awareness: taking medication for CVD prevention was generally not recognised as a decision requiring patient input; Step 2. Discuss benefits/harms options: CVD prevention poorly understood with emphasis on benefits; Step 3. Explore preferences: goals, values and preferences (eg, length of life vs quality of life, reducing disease burden vs risk reduction) varied widely but generally not discussed with the general practitioner; Step 4. Making the decision: overall preference for directive approach, but some patients wanted more active involvement. Themes were similar across primary and secondary CVD prevention, different levels of self-reported health and people on and off medication.

CONCLUSIONS

Results demonstrate how older participants vary widely in their health goals and preferences for treatment outcomes, suggesting that CVD prevention decisions are preference sensitive. Combined with the fact that the vast majority of participants were taking medications, and few understood the aims and potential benefits and harms of CVD prevention, it seems that older patients are not always making an informed decision. Our findings highlight potentially modifiable barriers to greater participation of older people in SDM about CVD prevention medication and prevention in general.

CFHA Don Bloch Award acceptance speech, 2018

Provides John S. Rolland's acceptance speech for the 2018 CFHA Don Bloch Award. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Third-Order Thinking in Family Therapy: Addressing Social Justice Across Family Therapy Practice

We contend that the field of family therapy is undergoing a notable shift from second- to third-order thinking. We offer theoretical support and examples to demonstrate how third-order thinking provides a framework for integrating heightened sociocultural attunement into family therapy practice. We discuss the importance of third-order thinking relative to being prepared to invite families into third-order change. Finally, we offer a case example to show specific guidelines for third-order practice.

Anorexia nervosa requiring admission in adolescents

Question I recently saw in my office a patient whom I had initially diagnosed with anorexia nervosa 6 months earlier and she was continuing to lose weight. Her physical examination findings in the office revealed a blood pressure of 85/55 mm Hg and a heart rate of 55 beats/min at rest. Should patients such as this one be sent to the hospital for inpatient monitoring and treatment?Answer There is a lack of clear evidence-based guidelines for hospital admission of adolescents with anorexia nervosa, resulting in a high degree of variation in practices among physicians. Clinical judgment based on expert opinion seems to be the main driver of the decision to admit for inpatient care. Acceptable indications for a patient's admission include the following: weight is less than 75% of ideal body weight, temperature is lower than 35.5°C (95.9°F), heart rate is less than 45 beats/min, systolic blood pressure level is lower than 80 mm Hg, orthostatic change in pulse is higher than 20 beats/min, or orthostatic change in blood pressure is greater than 10 mm Hg. Consultation with an adolescent medicine specialist is highly recommended for adolescents with these vital signs.

[Usefulness and reliabitlity of musculoskeletal point of care ultrasound in family practice (2): Muscle injuries, osteoarthritis, rheumatological diseases and eco-guided procedures]

This article is a continuation of the review initiated in the previous issue about the usefulness of musculoskeletal point of care ultrasound in Primary Care, completing the scenarios of muscle injuries, osteoarthritis, rheumatological diseases and eco-guided procedures.

Neuropsychological Evaluations in Adults

Neuropsychologists provide detailed assessments of cognitive and emotional functioning that often cannot be obtained through other diagnostic means. They use standardized assessment tools and integrate the findings with other data to determine whether cognitive decline has occurred, to differentiate neurologic from psychiatric conditions, to identify neurocognitive etiologies, and to determine the relationship between neurologic factors and difficulties in daily functioning. Family physicians should consider referring patients when there are questions about diagnostic decision making or planning of individualized management strategies for patients with mild cognitive impairment, dementia, traumatic brain injury, and other clinical conditions that affect cognitive functioning. Neuropsychological testing can differentiate Alzheimer dementia from nondementia with nearly 90% accuracy. The addition of neuropsychological testing to injury severity variables (e.g., posttraumatic amnesia) increases predicted accuracy in functional outcomes. A neuropsychological evaluation can be helpful in addressing concerns about functional capacities (e.g., ability to drive or live independently) and in determining a patient's capacity to make decisions about health care or finances. Most patients who underwent neuropsychological evaluation and their significant others reported that they found the evaluation helpful in understanding and coping with cognitive problems.

Alcohol use disorder: How best to screen and intervene

The USPSTF recommends the AUDIT, the AUDIT-C, or the single-question NIAAA screen. The CAGE screening tool has low sensitivity at lower levels of alcohol intake.

Unfinished Business: The Role of Research in Family Medicine

Although the generation of new knowledge through research is a hallmark of medical specialties, research was a low priority in family practice when it was established in 1969. Today, when a base of knowledge is crucial to the ability to lead health care change, the early relationship between family practice and research continues to influence the specialty. An examination of archival and secondary materials finds that the priority placed on research during family practice's early years was shaped by internal and external factors, including, (1) family physicians' desire to differentiate themselves from the prevailing specialty environment; (2) lack of a clear identity in family practice; (3) the non-laboratory nature of family medicine research; (4) reliance on information from other specialties; and, (5) a focus on establishing an academic presence. The low level of attention given to research during the early years of family practice has had lasting implications, as the specialty seeks to transform practice while continuing to struggle to achieve academic acceptance. A strong culture of generalist knowledge is crucial in assuring family medicine's future and strengthening its ability to improve the health of individuals, families, and communities.

Dermoscopy in family medicine: A primer

Dermoscopy allows you to see deeper into the skin than with the naked eye. Here's how you can make use of it to spot malignant conditions sooner.

Factors associated with residents' contract behavior with family doctors in community health service centers: A longitudinal survey from China

BACKGROUND

China adopted family doctor (FD) to help achieve "Healthy China 2030" through providing continuous, comprehensive, and life-cycle contract services. However, there is a disparity between actual and targeted FD use, as residents continue to visit specialists in large hospitals. The government implemented initiatives to improve residents' willingness to sign up with and visit their FDs. Factors that influence contract behavior are therefore significant for frontier policy research.

METHODS

Two survey waves were conducted in Shanghai (2013 and 2016). The first wave included 2754 people and the second 1995 people. Exploratory factor analysis was used to synthesize "satisfaction" as a predictor of contract behavior. Pearson's chi-square, pooled and logistic regression models were used to estimate associations between influencing factors and contract behavior, and clarify variations in factors across the two waves.

RESULTS

Four factors were extracted from 15 satisfaction items: "Treatment Environment," "Medical Technology," "Service Specification" and "Service Attitude". Consistent with descriptive analysis, longitudinal analysis showed sociodemographic characteristics (age, education, marital status, and hukou) were significant predictors of contract behavior. The odds ratio of non-communicable diseases (NCD) patients for contract behavior was 2.218 times that of residents without NCD. Contract behavior was positively correlated with awareness of FD services (OR = 21.674, 95%CI = 15.043-31.229), satisfaction with Service Attitude (OR = 1.210, 95%CI = 1.009-1.451), and visit compliance (OR = 1.959, 95%CI = 1.564-2.452). Over time, the odds ratios of the married, Shanghai hukou, NCD, and awareness of FD services declined from 0.456, 1.795, 2.492, 28.690 to 0.443, 1.678, 1.910 and 14.031 respectively, while those of age, and visit compliance increased from 1.027, 1.521 to 1.041 and 2.305 respectively. In 2016, an education-contract gradient had formed (the higher the education level, the higher probability of signing with a FD), whereas high school education had the highest odds ratio (OR = 1.163,95%CI = 0.740-1.827) in 2013. Service Attitude was the only significant satisfaction-related predictor (OR = 1.358, 95%CI = 1.001-1.842) in 2016, compared with "Treatment Environment" (OR = 1.224, 95%CI = 1.001-1.496) and "Service Specification" in 2013(OR = 1.270, 95%CI = 1.040-1.552).

CONCLUSIONS

Except for the socio-demographic variables, NCD, awareness of FD services, satisfaction and visit compliance were significant predictors of contract behavior with FDs. The effect of visit compliance had increased over time while NCD and awareness of FD services were losing impact over time. Significant satisfaction factors had also changed from "Treatment Environment" and "Service Specification" to "Service Attitude".

Adult foot fractures: A guide

This review can help you refine your approach to the diagnosis and management of adult foot fractures, while offering guidance on when to pursue advanced imaging.

Otolaryngology for the Internist: Hearing Loss

Hearing loss is the third most common chronic condition but can be secondary to a range of conditions encountered in primary care. This article reviews the presentation, evaluation, differential diagnosis, and associated treatments for both acute and chronic causes of hearing loss. As the most common cause of hearing loss, this article provides an overview of age-related hearing loss, its consequences, and pragmatic treatment approaches, including over-the-counter hearing technology.