Is It Painful to Manage Chronic Pain? A Cross-Sectional Study of Physicians In-Training in a University Program.

BACKGROUND: Prescribing opioids for chronic non-cancer pain (CNCP) is a challenge due to associated risks from abuse, addiction and adverse effects. We surveyed resident physicians on their knowledge, attitude and practices in opioid prescription practices in the ambulatory setting and conducted an educational module to address their knowledge gaps. METHODS: A phase 1 survey assessed knowledge, attitudes and practices of residents in the out-patient management of CNCP with opioids. Demographics, numbers of patients seen, those with concerns for risky behaviors, adverse effects and the reasons for concern were also recorded. In Phase 2, an educational module in the form of didactics and case based discussions addressed the perceived deficiencies noted from results of phase 1 survey. Pre and post module surveys assessed the effectiveness of the educational module. RESULTS: In the phase 1 study (45/49, 92% response rate, M:F = 30:15) 33.3% (15/45) were in Post-Graduate Year (PGY) 1, 35.6% (16/45) PGY2s and 31.1% (14/45) PGY3s; 80% (36/45) saw more than one patient with CNCP in the previous 3 months; 62.2% (28/45) had at least one patient with concerns for misuse and addiction; 77.8% (35/45) and 86.7% (39/45) reported a lack of training and consistent documentation respectively, and 82.2% (37/45) were uncomfortable to refill for other provider's patients. All (100%, 45/45) consulted the clinical pharmacist; 86.7% (39/45) believed that either focused education would be beneficial. In the phase 2 study (44/49, 89.7% response rate, M: F = 29: 15), the pre- and post-module responses showed that > 90% of the residents perceived improvement in knowledge and confidence in management of CNCP with opioids after the educational module. CONCLUSIONS: Internal medicine residents perceived deficits in their ability to manage CNCP. Following a focused educational training, residents' knowledge and confidence in prescription of opioids improved, demonstrating the need to include management of CNCP with opioids into their curriculum.

MedlinePlus-based health information prescriptions: a comparison of email vs paper delivery.

BACKGROUND: The internet can provide evidence-based patient education to overcome time constraints of busy ambulatory practices. Health information prescriptions (HIPs) can be effectively integrated into clinic workflow, but compliance to visit health information sites such as MedlinePlus is limited. OBJECTIVE: Compare the efficacy of paper (pHIP) and email (eHIP) links to deliver HIPs; evaluate patient satisfaction with the HIP process and MedlinePlus information; assess reasons for noncompliance to HIPs. METHOD: Of 948 patients approached at two internal medicine clinics affiliated with an academic medical centre, 592 gave informed consent after meeting the inclusion criteria. In this randomised controlled trial, subjects were randomised to receive pHIP or eHIP for accessing an intermediate website that provided up to five MedlinePlus links for physician-selected HIP conditions. Patients accessing the intermediate website were surveyed by email to assess satisfaction with the health information. Survey non-responders were contacted by telephone to determine the reasons for no response. RESULTS: One hundred and eighty-one patients accessed the website, with significantly more 'filling' eHIP than pHIP (38% vs 23%; P < 0.001). Most (82%) survey respondents found the website information useful, with 77% favouring email for future HIPs delivery. Lack of time, forgot, lost instructions or changed mind were reasons given for not accessing the websites. CONCLUSIONS: Delivery of MedlinePlus-based HIPs in clinic is more effective using email prescriptions than paper. Satisfaction with the HIP information was high, but overall response was low and deserves further investigation to improve compliance and related outcomes.

Bariatric surgery: 1-year weight loss outcomes in patients with bipolar and other psychiatric disorders.

BACKGROUND: Bariatric surgery is the most effective obesity treatment in terms of weight loss and resolution of comorbidities. Roux-en-Y bypass surgery achieves weight loss of 60% to 70% excess body weight in most morbidly obese individuals. Patients with psychological disorders are reported to have less optimal results and those with bipolar, possibly worse. METHODS: A retrospective survey of Roux-en-Y bypass bariatric surgery patient clinical records to assess weight loss outcomes for morbidly obese patients, including those with bipolar disorders, other psychiatric conditions, and those without psychiatric diagnoses, was conducted. RESULTS: For all three study subgroups, the baseline mean weight exceeded 300 lbs, and mean BMI was 50. At 6 months, mean values for weight, percent weight loss, BMI, and percent change in BMI for all three groups were not significantly different. At 1 year, overall mean weight was less than 200 lbs, percent weight loss exceeded 35%, and mean BMI was 32. These outcomes were remarkably similar and not significantly different for those with bipolar disorder, other psychological conditions, and those without. The percent reaching follow-up at 12 months also did not differ between the three psychiatric status subgroups. CONCLUSION: In patients who undergo Roux-en-Y gastric bypass surgery, those with bipolar disorder have successful weight loss outcomes at 12 months that are not significantly different than those who have other psychiatric diagnoses and those with no psychiatric disorder. Despite practices that suggest the contrary, well-managed morbidly obese bipolar patients should be considered as suitable candidates for bariatric surgery using established criteria for risk assessment.

What are specialist and primary care clinicians' attitudes and practices regarding home blood pressure monitoring for hypertensive patients?

Practice guidelines recommend home blood pressure monitoring (HBPM) in the management of hypertension. We surveyed generalists and subspecialists regarding HBPM attitudes and practices in hypertensive patients. Both use HBPM for diagnostic and therapeutic purposes but question the evidence regarding HBPM efficacy. Standardized implementation and monitoring methods to improve HBPM practices are absent. Both generalists and specialists have concerns about HBPM instrument capabilities and perceive patient physical limitations and negative attitudes as additional barriers to effective blood pressure monitoring outside the office.

Retrievable inferior vena cava filters are not getting retrieved: where is the gap?

OBJECTIVE: The purpose of this study is to assess the retrieval rate and the predictors of successful retrieval of Retrievable Inferior Vena Cava (RIVC) filters. METHODS: We retrospectively reviewed the medical records of adult patients who had RIVC filter placements from 2004-2008. We excluded patients who died or were lost to follow-up and those who refused or had unsuccessful retrieval. We collected demographic and clinical data including indications for placement and follow-up. Successful retrieval was defined as objective evidence of retrieval by medical records. RESULTS: Over a 4 year period, we identified 351 patients who had RIVC filter placements. We excluded 99 patients (65 died, 24 decided to leave filter in place, 7 had unsuccessful retrieval and 3 lost follow-up). Majority of the filters were placed for surgical patients (161, 63.9%). Of 252 eligible patients for retrieval, only 47 filters were successfully retrieved yielding a retrieval rate of 18.7%. We identified three predictors for successful retrieval: Male gender, home discharge and follow up with procedural service. CONCLUSION: In this large cohort we found that the retrieval rate of retrievable IVCF is extremely low consistent with national statistics. Male patients, patients who were discharged home and patients who were followed by the procedural service had higher chance of successful retrieval. We recommend that procedural service placing the filter should ascertain adequate follow-up. We are not certain why more males had successful retrieval than females. Further studies are necessary to investigate this finding.

Novel bimodular DNA aptamers with guanosine quadruplexes inhibit phylogenetically diverse HIV-1 reverse transcriptases.

DNA aptamers RT5, RT6 and RT47 form a group of related sequences that inhibit HIV-1 reverse transcriptase (RT). The essential inhibitory structure is identified here as bimodular, with a 5' stem-loop module physically connected to a 3'-guanosine quadruplex module. The stem-loop tolerates considerable sequence plasticity. Connections between the guanosine triplets in the quadruplex could be simplified to a single nucleotide or a nonnucleic acid linker, such as hexaethylene glycol. All 12 quadruplex guanosines are required in an aptamer retaining most of the original loop sequence from RT6; only 11 are required for aptamer R1T (single T residue in intra-quadruplex loops). Circular dichroism (CD) spectroscopy gave ellipticity minima and maxima at 240 nm and 264 nm, indicating a parallel arrangement of the quadruplex strands. The simplified aptamers displayed increased overall stability. An aptamer carrying the original intra-quadruplex loops from RT6 inhibited RT in K(+) buffers but not in Na(+) buffers and displayed significant CD spectral broadening in Na(+) buffers, while R1T inhibited RT in both buffers and displayed less broadening in Na(+) buffers. The bimodular ssDNA aptamers inhibited RT from diverse primate lentiviruses with low nM IC(50) values. These data provide insight into the requirements for broad-spectrum RT inhibition by nucleic acid aptamers.

Discovery of novel epigenetic markers in non-Hodgkin's lymphoma.

Non-Hodgkin's lymphoma (NHL) is a group of malignancies with heterogeneous genetic and epigenetic alterations. Discovery of molecular markers that better define NHL should improve diagnosis, prognosis and understanding of the biology. We developed a CpG island DNA microarray for discovery of aberrant methylation targets in cancer, and now apply this method to examine NHL cell lines and primary tumors. This methylation profiling revealed differential patterns in six cell lines originating from different subtypes of NHL. We identified 30 hypermethylated genes in these cell lines and independently confirmed 10 of them. Methylation of 6 of these genes was then further examined in 75 primary NHL specimens composed of four subtypes representing different stages of maturation. Each gene (DLC-1, PCDHGB7, CYP27B1, EFNA5, CCND1 and RARbeta2) was frequently hypermethylated in these NHLs (87, 78, 61, 53, 40 and 38%, respectively), but not in benign follicular hyperplasia. Although some genes such as DLC-1 and PCDHGB7 were methylated in the vast majority of NHLs, others were differentially methylated in specific subtypes. The methylation of the candidate tumor suppressor gene DLC-1 was detected in a high proportion of primary tumor and plasma DNA samples by using quantitative methylation-specific PCR analysis. This promoter hypermethylation inversely correlated with DLC-1 gene expression in primary NHL samples. Thus, this CpG island microarray is a powerful discovery tool to identify novel methylated genes for further studies of their relevant molecular pathways in NHLs and identification of potential epigenetic biomarkers of disease.