The role of between-session homework in cognitive-behavioral therapy for comorbid obsessive-compulsive disorder and autism: A case vignette

OBJECTIVE

Cognitive-behavioral therapy (CBT), which includes a decided emphasis on exposure and response/ritual prevention (ERP) and between-session practice of treatment principles, has consistently demonstrated efficacy for the treatment of obsessive-compulsive disorder (OCD) and is a gold standard, recommended first-line treatment. CBT with ERP has been successfully adapted to fit the needs of autistic individuals with OCD. The present article provides a brief overview of CBT for OCD and outlines special considerations and adaptations needed when working with patients with OCD and comorbid autism, with an emphasis on the importance of between-session homework.

METHOD

A case vignette is presented.

RESULTS

This case study illustrates the role of homework in the exposure-based treatment of an adult autistic individual with comorbid OCD.

CONCLUSION

Implications of this case vignette are discussed, and recommendations are offered for clinicians working with autistic individuals with OCD, especially in regard to bolstering completion of between-session ERP homework.

Understanding the role of the primary care physician in the management of patients with Crohn's perianal fistulas

OBJECTIVES

To understand the role of primary care physicians (PCPs) in the recognition, diagnosis, and management of Crohn's perianal fistulas (CPF) and their referral patterns and treatment expectations.

METHODS

This survey-based study was conducted between September 2020 and October 2020. US-based PCPs managing at least one patient with Crohn's disease per week were included. Participants were presented with two case vignettes relevant to primary care practice; Case Vignette 1 comprised three parts and focused on initial CPF presentation and progression to partial response; Case Vignette 2 focused on recurrent CPF. Survey questions elicited the physician's clinical approach to each case. Data were presented as descriptive statistics.

RESULTS

Overall, 151 PCPs (median 23 years in practice) who saw about three patients per month with new/existing CPF responded. For Case Vignette 1, upon identification of a fistulous tract, 89% of respondents would refer the patient, mostly to a colorectal surgeon or gastroenterologist. Most PCPs (69%) would begin the patient on medication; 46% would conduct a diagnostic/imaging study. Treatment expectations after referral varied: 55% of respondents believed surgeons would place a seton or use one prior to surgery; 23% expected medical management only; 23% were unsure. Case Vignette 2 revealed that 98% of PCPs preferred to be involved in patient care after referral; however, only 49% were. Of these, 76% considered reinforcing patient treatment adherence as their primary role. While 80% of PCPs were at least moderately satisfied with communication and care coordination with multidisciplinary teams, 52% considered lack of access to specialists as at least a moderate barrier to multidisciplinary team management.

CONCLUSION

PCPs want more involvement in multidisciplinary management of patients with CPF. Continuing education providing PCPs with up-to-date information on diagnostic modalities, treatment options, early diagnosis, the role of PCPs within a multidisciplinary team, and effective initial CPF care is required.

Deprescribing in a multimorbid older adult: A case vignette study among community pharmacists and primary care physicians

Collaborative deprescribing can include pharmacists' medication review with identification and suggestion of potential deprescribing targets to physicians. Case vignettes can be a valuable method for researching variations in clinical decision making, especially in settings unaccustomed to newer clinical approaches such as deprescribing. This study aimed to explore if pharmacists can identify deprescribing targets and if physicians would accept pharmacist's deprescribing rationales. A cross-sectional study was performed using an online case vignette based on a real-life elderly patient. Pharmacists were asked to indicate which medicines they would recommend deprescribing, alongside a rationale. Physicians were asked to state their acceptance of the proposed pharmacist's deprescribing suggestion. Pharmacists gave 1275 deprescribing rationales, and most were given for deprescribing opioids, NSAID and diuretics. Physicians would accept rationales to deprescribe a median of 10 medicines, while pharmacist would recommend deprescribing a median of six medicines. Most difference lays in deprescribing of preventative medicines. Healthcare providers share agreement on deprescribing targets, but pharmacists show hesitancies in making recommendations that could hamper potential collaboration. Action is needed to improve pharmacists' skills in recognizing deprescribing targets and confidence in making suggestions, which could lead to opening of possibilities for joint patient care.

Performance of Large Language Models (ChatGPT, Bing Search, and Google Bard) in Solving Case Vignettes in Physiology

Background Large language models (LLMs) have emerged as powerful tools capable of processing and generating human-like text. These LLMs, such as ChatGPT (OpenAI Incorporated, Mission District, San Francisco, United States), Google Bard (Alphabet Inc., CA, US), and Microsoft Bing (Microsoft Corporation, WA, US), have been applied across various domains, demonstrating their potential to assist in solving complex tasks and improving information accessibility. However, their application in solving case vignettes in physiology has not been explored. This study aimed to assess the performance of three LLMs, namely, ChatGPT (3.5; free research version), Google Bard (Experiment), and Microsoft Bing (precise), in answering cases vignettes in Physiology. Methods This cross-sectional study was conducted in July 2023. A total of 77 case vignettes in physiology were prepared by two physiologists and were validated by two other content experts. These cases were presented to each LLM, and their responses were collected. Two physiologists independently rated the answers provided by the LLMs based on their accuracy. The ratings were measured on a scale from 0 to 4 according to the structure of the observed learning outcome (pre-structural = 0, uni-structural = 1, multi-structural = 2, relational = 3, extended-abstract). The scores among the LLMs were compared by Friedman's test and inter-observer agreement was checked by the intraclass correlation coefficient (ICC). Results The overall scores for ChatGPT, Bing, and Bard in the study, with a total of 77 cases, were found to be 3.19±0.3, 2.15±0.6, and 2.91±0.5, respectively, p<0.0001. Hence, ChatGPT 3.5 (free version) obtained the highest score, Bing (Precise) had the lowest score, and Bard (Experiment) fell in between the two in terms of performance. The average ICC values for ChatGPT, Bing, and Bard were 0.858 (95% CI: 0.777 to 0.91, p<0.0001), 0.975 (95% CI: 0.961 to 0.984, p<0.0001), and 0.964 (95% CI: 0.944 to 0.977, p<0.0001), respectively. Conclusion ChatGPT outperformed Bard and Bing in answering case vignettes in physiology. Hence, students and teachers may think about choosing LLMs for their educational purposes accordingly for case-based learning in physiology. Further exploration of their capabilities is needed for adopting those in medical education and support for clinical decision-making.

How Doctors' Beliefs Influence Gynecological Health Care for Women Who Have Sex with Other Women

Background: Women who occasionally or regularly have sex with other women (WSW) are rarely identified in primary care. Although we know about their specific health needs, health care professionals still find it difficult to ask questions about sexual orientation (SO) and behaviors, and sometimes, patients may find them difficult to answer. The presumption of heterosexuality still remains a widespread attitude in health care. This study took place in a primary care setting, and aimed to identify differences in gynecological health care and clinical practice for women, according to what their presumed SO and behaviors were. Methods: We conducted a cross-sectional observational, descriptive, and comparative study from October 2018 to February 2019. Three hundred thirty-eight general practitioners (GPs) from Rhône-Alpes area (France) received an anonymous questionnaire with clinical case vignettes. The main outcome was the percentage of GPs who perform a different gynecological follow-up for WSW and non-WSW. Results: In total, 165 questionnaires were analyzed. Ninety percent of respondents performed a different gynecological follow-up for WSW, compared with other women. They less often addressed topics such as contraception needs, use of barrier protections, and screening of sexually transmitted infections. Ninety-two percent of respondents were aware that they have WSW among their patients, but 2/3 of them never or rarely asked about SO. Conclusion: Most GPs know that they manage WSW but may misidentify these patients and their real care needs. Therefore, WSW receive a different and poorer follow-up than non-WSW. Clinical guidelines would be useful to improve and standardize quality and experience of health care for WSW.

Communication gaps between physicians and patients with postherpetic neuralgia: results from a national study on practice patterns

Background

The purpose of this study was to identify differences in perceptions of care regarding postherpetic neuralgia, including communication patterns between patients and physicians and levels of satisfaction with therapies and care.

Methods

A survey was developed for physicians (neurologists, internists, and family physicians) and patients with postherpetic neuralgia in order to determine their perspectives on its management.

Results

A total of 142 eligible patient respondents were included in the study, and responses were compared with those of 150 primary care physicians and 76 neurologist respondents. Few patients and physicians indicated satisfaction with the currently available treatments for postherpetic neuralgia. While nearly all physicians responded that they discuss the cause of postherpetic neuralgia with a patient, one in four patients indicated that their physician did not discuss the cause. Similarly, one in four patients were not aware of the duration of postherpetic neuralgia, the treatment side effects, or what to expect from treatment. Patients may be less likely to discuss treatment side effects and quality of life issues than physicians perceive.

Conclusion

Physicians and patients have similar perceptions regarding treatment options for postherpetic neuralgia; however, certain gaps in communication were evident, which may be attributable to physician knowledge and communication skills with patients. Strategies to improve issues of expected outcomes and side effects of treatment may be useful to physicians.