Faculty Bibliography

A Morel-Lavallee lesion is a relatively rare condition involving a closed, degloving injury to the pelvis, resulting in a blood-filled cystic cavity created by separation of the subcutaneous tissue from the underlying fascia. This injury typically occurs following high-speed trauma. We describe a case that occurred in a professional American football player who was treated with percutaneous decompression and evacuation of the hematoma. The player returned to playing football at the professional level 22 days after the injury without residual deformity or disability

The problem with media headlines on pharma is that they are rarely subtle or nuanced, instead they smear and cripple some of the best medications. The latest pronouncement involves some of the best anticonvulsant drugs, which have now raised alarms because they have significantly increased suicide risk. Patients have been led to believe by the media that either a drug will kill them or it will save them. The media is a powerful force for doctors to have to contend with

BACKGROUND: It is uncertain whether training improves physicians' obesity counseling. OBJECTIVE: To assess the impact of an obesity counseling curriculum for residents. DESIGN: A non-randomized, wait-list/control design. PARTICIPANTS: Twenty-three primary care internal medicine residents; 12 were assigned to the curriculum group, and 11 were assigned to the no-curriculum group. Over a 7-month period (1-8 months post-intervention) 163 of the residents' obese patients were interviewed after their medical visits. INTERVENTION: A 5-hour, multi-modal obesity counseling curriculum based on the 5As (Assess, Advise, Agree, Assist, Arrange) using didactics, role-playing, and standardized patients. MAIN MEASURES: Patient-report of physicians' use of the 5As was assessed using a structured interview survey. Main outcomes were whether obese patients were counseled about diet, exercise, or weight loss (rate of counseling) and the quality of counseling provided (percentage of 5As skills performed during the visit). Univariate statistics (t-tests) were used to compare the rate and quality of counseling in the two resident groups. Logistic and linear regression was used to isolate the impact of the curriculum after controlling for patient, physician, and visit characteristics. KEY RESULTS: A large percentage of patients seen by both groups of residents received counseling about their weight, diet, and/or exercise (over 70%), but the quality of counseling was low in both the curriculum and no curriculum groups (mean 36.6% vs. 31.2% of 19 possible 5As counseling strategies, p = 0.21). This difference was not significant. However, after controlling for patient, physician and visit characteristics, residents in the curriculum group appeared to provide significantly higher quality counseling than those in the control group (std beta = 0.18; R(2) change = 2.9%, P < 0.05). CONCLUSIONS: Residents who received an obesity counseling curriculum were not more likely to counsel obese patients than residents who did not. Training, however, is associated with higher quality of counseling when patient, physician, and visit characteristics are taken into account

Language barriers may contribute to the under-detection of depression in Latinos and Asians. A total of 782 English, Spanish, and Chinese-speaking primary care patients were enrolled in a randomized controlled trial. Language discordant patients were randomized to Remote Simultaneous Medical Interpreting (RSMI) or usual and customary (U&C) interpreting. The Beck Depression Inventory-Fast Screen (BDI-FS) was administered. Patients were tracked for 1 year. A total of 462 patients completed the BDI-FS. Thirty-three percent had a positive (>/=4) screen. Twenty-seven percent of BDI-FS positive patients were diagnosed with depression. Among BDI-FS positive patients, Chinese-speakers were less likely to be diagnosed compared with English speakers (31% vs. 10%, P < 0.05). There was a trend towards greater diagnosis with RSMI (27% detection with RSMI vs. 20% U&C, P = 0.41). The diagnosis of depression among BDI-FS positive patients in our population was low, particularly among Chinese-speakers. RSMI could be an important part of a multi-faceted approach to improving the detection of depression

Over 22 million US residents are limited English proficient. Hospitals often call upon untrained persons to interpret. There is a dearth of information on errors in medical interpreting and their impact upon cancer education. We conducted an experimental study of standardized medical interpreting training on interpreting errors in the cancer encounter, by comparing trained and untrained interpreters, using identical content. Nine interpreted cancer encounters with identical scripts were recorded and transcribed. Using an 'Error Analysis Tool,' a bilingual linguist and two bilingual medical providers scored the transcripts for interpreting errors made, including their potential clinical severity. Trained interpreters were 70% less likely to have clinical errors than untrained ones. The likelihood of medical error increased with the length of the concept and decreased with the precision of vocabulary. It is important to train medical interpreters and to ensure their availability in cancer education encounters to minimize the risk for errors

The feasibility of using extended-release injectable naltrexone (XR-NTX) to treat alcohol dependence in routine primary care settings is unknown. An open-label, observational cohort study evaluated 3-month treatment retention, patient satisfaction, and alcohol use among alcohol-dependent patients in two urban public hospital medical clinics. Adults seeking treatment were offered monthly medical management (MM) and three XR-NTX injections (380 mg, intramuscular). Physician-delivered MM emphasized alcohol abstinence, medication effects, and accessing mutual help and counseling resources. Seventy-two alcohol-dependent patients were enrolled; 90% (65 of 72) of eligible subjects received the first XR-NTX injection; 75% (49 of 65) initiating treatment received the second XR-NTX injection; 62% (40 of 65), the third. Among the 56% (n = 40) receiving three injections, median drinks per day decreased from 4.1 (95% confidence interval = 2.9-6) at baseline to 0.5 (0-1.7) during Month 3. Extended-release naltrexone delivered in a primary care MM model appears a feasible and acceptable treatment for alcohol dependence

BACKGROUND: Hypertension is the major risk factor for cardiovascular (CV) disease such as myocardial infarction (MI) and stroke. This risk is well known to extend into the perioperative period. Although most perioperative hypertension can be managed with the patient's outpatient regimen, there are situations in which oral medications cannot be administered and parenteral medications become necessary. They include postoperative nil per os status, severe pancreatitis, and mechanical ventilation. This article reviews the management of perioperative hypertensive urgency with parenteral medications. METHODS: A PubMed search was conducted by cross-referencing the terms 'perioperative hypertension,' 'hypertensive urgency,' 'hypertensive emergency,' 'parenteral anti-hypertensive,' and 'medication.' The search was limited to English-language articles published between 1970 and 2008. Subsequent PubMed searches were performed to clarify data from the initial search. RESULTS: As patients with hypertensive urgency are not at great risk for target-organ damage (TOD), continuous infusions that require intensive care unit (ICU) monitoring and intraarterial catheters seem to be unnecessary and a possible misuse of resources. CONCLUSIONS: When oral therapy cannot be administered, patients with hypertensive urgency can have their blood pressure (BP) reduced with hydralazine, enalaprilat, metoprolol, or labetalol. Due to the scarcity of comparative trials looking at clinically significant outcomes, the medication should be chosen based on comorbidity, efficacy, toxicity, and cost

OBJECTIVE: Communication skills are crucial for high-risk behavior screening and counseling. Practicing physicians have limited opportunities to improve these skills. This paper assesses the impact of a continuing medical education (CME) program for Student Health Center clinicians that targeted communication skills, screening practices and patient satisfaction. METHODS: Program evaluation included pre- and post-objective structured clinical examinations (OSCE's), chart review, and provider and patient satisfaction surveys. Data were analyzed using paired t-tests and ranked sum tests. RESULTS: OSCE scores (n=15) revealed significant improvements in communication skills overall (p=0.004) and within specific domains (data gathering: p=0.003; rapport building: p=0.01; patient education: p=0.02), but no change in case-specific knowledge (p=0.1). Participants (n=14) reported high satisfaction with program methods (mean=4.6/5) and content (mean=4.7/5), 70% planning to alter their clinical practice. Chart audits (pre=96, post=103) showed increased screening for smoking (RR 1.65, p=0.03), depressed mood (RR 1.40, p=0.04), anhedonia (RR 1.47, p=0.01), sexual activity (RR 1.73, p=0.002) and drinking (RR 1.77, p=0.04). Sampling of satisfaction among participants' patients (pre n=689, post n=383) detected no increase in already high baseline satisfaction. CONCLUSION: This curriculum improved clinicians' relevant skills and screening behavior. PRACTICE IMPLICATIONS: Skills-oriented CME can improve clinicians' communication skills and screening and counseling practices

The purpose of this study was to validate the use of Leigh's (1990) alcohol sex expectancies scale among HIV-infected individuals presenting for treatment as a way to facilitate research on sexual risk reduction among individuals in that population. The participants were 944 men who presented for treatment at infectious disease or general medicine clinics across 8 different VA Medical Center sites. A total of 534 of these men were HIV-positive and 410 were HIV-negative. The total sample was randomly divided in half within each HIV group to form exploratory (Sample 1) and confirmatory (Sample 2) subsamples. A principal components factor analysis with oblique rotation of the original 13-item Leigh scale within each HIV group in Sample 1 revealed a 2-factor (7 and 4 items, respectively) solution that was consistent across both HIV groups. These factors were named 'More Open to Sexual Pleasure' (Factor 1) and 'Reduced Inhibitions about Sex (Factor 2).' A confirmatory factor analysis of the 11-item, 2-factor solution on the full Sample 2 showed a modest fit to the data, excellent internal consistency reliability of both factors, a high correlation between the factors, and strong evidence for construct validity. These results were interpreted as supporting the use of the 11-item, 2-factor version of Leigh's scale in studies of clinical samples of HIV-positive adults, and directions for research on further scale refinement are discussed