Applying a multidimensional approach to understanding clinical conversations: A deprescribing case study in primary care

OBJECTIVE

To describe and evaluate the contribution of multiple coding approaches applied to a clinical conversation on deprescribing in primary care (PC).

METHODS

Seven distinct coding approaches were applied to one audiotaped consultation. Only exchanges related to deprescribing a benzodiazepine (BZD) were coded for: content, interaction, arguments, connectors, transitions, orientation towards deprescribing and concordance with a deprescribing algorithm. A discursive map presents the unfolding of the exchanges.

RESULTS

The deprescribing conversation was broken down into 31 utterances divided into three segments: opening (n = 6), development (n = 16) and closing (n = 9). The family physician dominated the last two segments and most of her utterances were favorable to BZD deprescribing while the patient's utterances were generally unfavorable in the first two segments. The number of distinct codes assigned to utterances varied according to the coding approach. The map illustrates how each utterance can be viewed through different lenses revealing the dynamics and complexity of the deprescribing conversation.

CONCLUSION

This multidimensional methodological approach with its proposed way of presenting results, either quantitatively or qualitatively, and its map offer a comprehensive evaluation of the deprescribing process in this PC setting.

PRACTICE IMPLICATIONS

This novel multidimensional coding approach has potential to be applied to a range of other topics in clinical communications.

Exome sequencing study of partial agenesis of the corpus callosum in men with developmental delay, epilepsy, and microcephaly

Background

This study reports the genetic features of four Caucasian males from the Saguenay‒Lac‐St‐Jean region affected by partial agenesis of the corpus callosum (ACC) with hypotonia, epilepsy, developmental delay, microcephaly, hypoplasia, and autistic behavior.

Methods

We performed whole exome sequencing (WES) to identify new genes involved in this pathological phenotype. The regions of interest were subsequently sequenced for family members.

Results

Single‐nucleotide variations (SNVs) and insertions or deletions were detected in genes potentially implicated in brain defects observed in these patients. One patient did not have mutations in genes related to ACC, but carried a de novo pathogenic mutation in Mucolipin‐1 (MCOLN1) and was diagnosed with mucolipidosis type IV. Among the other probands, missense SNVs were observed in DCLK2 (Doublecortin Like Kinase 2), HERC2 (HECT And RLD Domain Containing E3 Ubiquitin Protein Ligase 2), and KCNH3 (Potassium channel, voltage‐gated, subfamily H, member 3). One patient also carried a non‐frameshift insertion in CACNA1A (Cav2.1(P/Q‐type) calcium channels).

Conclusion

Although no common genetic defect was observed in this study, we provide evidence for new avenues of investigation for ACC, such as molecular pathways involving HERC2, CACNA1A, KCNH3, and more importantly DCLK2. We also allowed to diagnose an individual with mucolipidosis type IV.

Increased subcutaneous adipose tissue expression of genes involved in glycerolipid-fatty acid cycling in obese insulin-resistant versus -sensitive individuals

CONTEXT

A subpopulation of obese individuals remains insulin sensitive (ISO). They represent a unique human model to investigate factors underlying insulin resistance (IR) without the confounding effect of major differences in weight/adiposity. Altered fatty-acid (FA) metabolism in sc adipose tissue (SAT) contributes to obesity-associated IR.

OBJECTIVE

To test the hypothesis that ISO and body mass index-matched insulin-resistant obese (IRO) patients demonstrate differential SAT expression profiles of genes involved in glycerolipid-FA metabolism and that weight loss-induced improvement of IR ameliorates these changes.

DESIGN AND SETTING

A cross-sectional and longitudinal study.

PATIENTS AND INTERVENTION

Thirty-eight nondiabetic obese women were stratified into ISO (n = 25) or IRO (n = 13) groups based on hyperinsulinemic-euglycemic clamp results. Subjects were studied before and after a 6-month hypocaloric diet intervention.

MAIN OUTCOME MEASURES

mRNA (quantitative RT-PCR) and protein (mass spectrometry and immunoblots) levels were measured in SAT biopsies.

RESULTS

Despite having age, body mass index, and fat mass similar to ISO individuals, IRO patients had lower insulin sensitivity and glucose tolerance (P < .05). Baseline SAT mRNA and protein levels of genes involved in both the synthesis and lipolysis of glycerolipid-FAs were higher in IRO individuals (P < .05), even when groups were matched for visceral adipose tissue content. The dietary intervention resulted in approximately 6% weight loss in both the IRO and ISO groups (P < .05) but only ameliorated insulin sensitivity in IRO individuals (P < .05). Likewise, the intervention reduced the expression of most glycerolipid-FA metabolism genes (P < .05), with expression levels in IRO individuals being restored to ISO levels.

CONCLUSIONS

Increased SAT expression of genes involved in both the synthesis and hydrolysis of glycerolipid-FAs is closely associated with IR in obese women. The results suggest that enhanced glycerolipid-FA cycling in SAT contributes to obesity-associated IR.

Association between Abdominal Fat (DXA) and Its Subcomponents (CT Scan) before and after Weight Loss in Obese Postmenopausal Women: A MONET Study

Introduction. Subcutaneous fat (ScF) and visceral fat (VF) measurements using CT scan are expensive and may imply significant radiation doses. Cross-sectional studies using CT scan showed that ScF and VF are significantly correlated with abdominal fat measured by DXA (AF-DXA). The association has not been studied after a weight loss. Objective. To determine (1) the associations between AF-DXA and ScF and VF before and after weight loss and (2) the associations between their changes. Methods. 137 overweight/obese postmenopausal women were divided in two groups (1-caloric restriction or 2-caloric restriction + resistance training). AF was assessed using DXA and CT scan. Results. Correlations between AF-DXA and ScF (before: r = 0.87, after; r = 0.87; P < .01) and, AF-DXA and VF (before: r = 0.61, after; r = 0.69; P < .01) are not different before and after the weight loss. Correlations between delta AF-DXA and delta ScF (r = 0.72; P < .01) or delta VF (r = 0.51; P < .01) were found. Conclusion. The use of AF-DXA as a surrogate for VF after weight loss is questionable, but may be interesting for ScF.

Relationship between the metabolic syndrome and physical activity energy expenditure: a MONET study

The purpose of this cross-sectional study was to examine the association between the metabolic syndrome (MetS) and physical activity energy expenditure (PAEE) in overweight and obese sedentary postmenopausal women. The study population consisted of 137 overweight and obese sedentary postmenopausal women (age, 57.7 ± 4.8 years; BMI, 32.4 ± 4.6 kg·m–2). Subjects had the MetS if 3 out of the following 5 criteria were met: visceral fat > 130 cm2, high-density lipoprotein (HDL) cholesterol < 1.29 mmol·L–1, fasting triglycerides ≥ 1.7 mmol·L–1, blood pressure ≥ 130/85 mmHg, and fasting glucose ≥5.6 mmol·L–1. We measured (i) body composition (by dual-energy X-ray absorptiometry); (ii) visceral fat (by computed tomography); (iii) insulin sensitivity (using the hyperinsulinemic-euglycemic clamp); (iv) plasma lipids, fasting glucose, and insulin, as well as 2 h glucose during an oral glucose tolerance test; (v) resting blood pressure; (vi) peak oxygen consumption (VO2 peak); (vii) PAEE (using doubly labeled water); and (viii) lower-body muscle strength (using weight-training equipment). Forty-two women (30.7%) had the MetS in our cohort. Individuals without the MetS had significantly higher levels of PAEE (962 ± 296 vs. 837 ± 271 kcal·d–1; p < 0.05), VO2 peak (18.2 ± 3.0 vs. 16.7 ± 3.2 mL·min–1·kg–1; p < 0.05), and insulin sensitivity, as well as significantly lower levels of 2 h glucose and central lean body mass. No differences in total energy expenditure, resting metabolic rate, and muscle strength between groups were observed. Logistic regression analysis showed that 2 h glucose (odds ratio (OR): 1.50 (95% CI 1.17–1.92)), central lean body mass (OR: 1.17 (95% CI 1.05–1.31)), and PAEE (OR: 0.998 (95% CI 0.997–1.000)), but not VO2 peak and (or) muscle strength, were independent predictors of the MetS. Lower levels of PAEE and higher levels of 2 h glucose, as well as central lean body mass, are independent determinants of the MetS in our cohort of overweight and obese postmenopausal women.