The postcholecystectomy syndrome in morbid obesity.

Choledocholithiasis has been found in about 5% to 20% of the approximately 20 million Americans with cholelithiasis who have undergone cholecystectomy. We report a case of a 64-year-old woman who developed gallstones after undergoing a cholecystectomy >40 years earlier. The potential of retained gallstones, incomplete gallbladder removal, or regeneration of gallstones in the gallbladder remnant or cystic duct remnant after a long time following cholecystectomy is discussed.

Importance of imaging in knee pain.

A 72-year-old woman with a prior history of stage IIIa lung adenocarcinoma was seen with complaints of knee pain, swelling, and difficulty sleeping at night for 1 month. Although mimicking osteoarthritis, patellofemoral syndrome, and iliotibial band syndrome, radiographs showed a lytic lesion suspicious for metastatic disease. The right tibial lesion was excised, saphenous neurolysis was performed, and radiation treatment and four cycles of chemotherapy were administered. This case shows the importance of early imaging in patients with knee pain of prolonged duration seen in the primary care setting.

Steroid-induced psychosis.

Steroid-induced psychosis is a well-documented phenomenon. It usually occurs with oral systemic steroid treatment and is more common at higher doses, although there are case reports of occurrence with local steroid injections. We report a case of a 35-year-old man with no previous history of psychosis who was seen for follow-up after a brief psychotic episode following an injection of 5 mg of dexamethasone into his scrotum the previous day. The injection was given to treat chronic pain from a combat injury.

Diagnosis of Waldenström macroglobulinemia.

Waldenström macroglobulinemia is a rare disorder affecting about 1400 people annually in the United States. This case report reviews from a primary care provider's perspective the initial presentation of a patient who complained of fatigue and dizziness that ultimately led to hospital admission with a diagnosis of Waldenström macroglobulinemia. The referral to hematology/oncology prompting the bone marrow biopsy that led to the diagnosis highlights the important role of the primary care provider in the initial workup, coordination among specialists, and overall management of patients with rare disorders.

Acute kidney injury and undiagnosed immunoglobulin A nephropathy after dabigatran therapy.

Dabigatran, a new oral anticoagulant, is a direct thrombin inhibitor used as an alternative to warfarin to reduce the risk of stroke and systemic embolism with nonvalvular atrial fibrillation. We report a case of a man who resumed dabigatran after 6 weeks of prior therapy and began experiencing hematuria with worsening kidney function. Renal biopsy with immunofluorescence and electron microscopy showed mesangial deposits consistent with immunoglobulin A nephropathy. With discontinuation of dabigatran and addition of methylprednisolone, the gross hematuria cleared and urine output improved.

Nontypical Salmonella meningitis in an infant.

A previously healthy 3-month-old girl was admitted to the hospital after 1 day of fever, decreased oral intake, irritability, lethargy, and decreased activity. Examination disclosed a bulging anterior fontanelle, tachycardia (heart rate of 160 beats/minute), and urate crystals in her diaper. Lumbar puncture revealed meningitis. She was treated with broad-spectrum antibiotics and fluids. A urine culture was negative, but blood and cerebrospinal fluid cultures came back positive for Salmonella species, nontyphoid. During her hospitalization, she developed seizures but quickly improved with treatment and made a complete recovery with no sequela. Additional inquiry disclosed that the baby spent several days a week at her grandparents' house, where they raised chickens and ate fresh chicken eggs, which are well-known carriers for Salmonella.

Fear of Outdoor Falling Among Community-Dwelling Middle-Aged and Older Adults: The Role of Neighborhood Environments.

Background and Objectives: Fear of falling is a substantial barrier to walking and has been associated with increased fall risks. This study examines neighborhood environmental risk factors related to fear of outdoor falling in middle-aged and older adults. Research Design and Methods: A total of 394 participants aged 50 years or older living independently in the community were recruited between 2013 and 2014 from an integrated health care network serving Central Texas. Fear of outdoor falling and perceived neighborhood environmental variables were assessed using self-reported questionnaires. Logistic regression identified perceived neighborhood environmental variables associated with fear of outdoor falling. Results: Sixty-nine (17.9%) of 385 participants reported having a fear of outdoor falling. Compared to those who did not report a fear of outdoor falling, those who reported having a fear of outdoor falling were more likely to be adults aged 65 years or older (odds ratio [OR] = 2.974, 95% confidence interval [CI] = 1.247-7.094), be female (OR = 4.423, 95% CI = 1.830-10.689), have difficulty with walking for a quarter of a mile (OR = 2.761, 95% CI = 1.124-6.782), and have had a fall in the past year (OR = 4.720, 95% CI = 1.472-15.137). Among the neighborhood environmental characteristics examined, low traffic speed on streets (OR = 0.420, 95% CI = 0.188-0.935), drainage ditches (OR = 2.383, 95% CI = 1.136-5.000), and broken sidewalks (OR = 3.800, 95% CI = 1.742-8.288) were associated with the odds of having a fear of outdoor falling. Discussion and Implications: In addition to the individual factors, findings from this study suggest the importance of addressing the environmental risk factors in identifying and reducing fear of outdoor falling among middle-aged and older adults.

A Multi-Level, Mobile-Enabled Intervention to Promote Physical Activity in Older Adults in the Primary Care Setting (iCanFit 2.0): Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: Most older adults do not adhere to the US Centers for Disease Control physical activity guidelines; their physical inactivity contributes to overweight and multiple chronic conditions. An urgent need exists for effective physical activity-promotion programs for the large number of older adults in the United States. OBJECTIVE: This study presents the development of the intervention and trial protocol of iCanFit 2.0, a multi-level, mobile-enabled, physical activity-promotion program developed for overweight older adults in primary care settings. METHODS: The iCanFit 2.0 program was developed based on our prior mHealth intervention programs, qualitative interviews with older patients in a primary care clinic, and iterative discussions with key stakeholders. We will test the efficacy of iCanFit 2.0 through a cluster randomized controlled trial in six pairs of primary care clinics. RESULTS: The proposed protocol received a high score in a National Institutes of Health review, but was not funded due to limited funding sources. We are seeking other funding sources to conduct the project. CONCLUSIONS: The iCanFit 2.0 program is one of the first multi-level, mobile-enabled, physical activity-promotion programs for older adults in a primary care setting. The development process has actively involved older patients and other key stakeholders. The patients, primary care providers, health coaches, and family and friends were engaged in the program using a low-cost, off-the-shelf mobile tool. Such low-cost, multi-level programs can potentially address the high prevalence of physical inactivity in older adults.

Determinants of Walking among Middle-Aged and Older Overweight and Obese Adults: Sociodemographic, Health, and Built Environmental Factors.

BACKGROUND: This study examined the association between selected sociodemographic, health, and built environmental factors and walking behaviors of middle-aged and older overweight/obese adults. METHODS: Subjective data were obtained from surveys administered to community-dwelling overweight/obese adults aged ≥50 years residing in four Texas cities from October 2013 to June 2014, along with objective data on neighborhood walkability (Walk Score™). Multivariate logistic regression identified factors predicting the odds of walking the recommended ≥150 minutes per week for any purpose. RESULTS: Of 253 participants, the majority were non-Hispanic white (81.8%), married (74.5%), and male (53.4%) and reported an annual income of ≥$50,000 (65.5%). Approximately, half were employed (49.6%) or had at least a college degree (51.6%). Walking the recommended ≥150 minutes per week for any purpose (n = 57, 22.5%) was significantly associated with having at least a college degree (OR = 5.55, 95% CI = 1.79-17.25), having no difficulty walking a quarter of a mile (OR = 5.18, 95% CI = 1.30-20.83), and being unemployed (OR = 3.25, 95% CI = 1.18-8.93) as well as perceived presence of sidewalks/protected walkways (OR = 3.56, 95% CI = 1.10-11.50) and perceived absence of distracted drivers in the neighborhood (OR = 4.08, 95% CI = 1.47-11.36). CONCLUSION: Addressing neighborhood conditions related to distracted drivers and pedestrian infrastructure may promote walking among middle-aged and older overweight/obese individuals.

Correlates of Receiving a Recommendation for More Physical Activity From a Primary Care Provider.

INTRODUCTION: Primary care providers (PCPs) are strategically positioned to communicate with their overweight/obese patients about positive behavioral changes to improve health and functioning. Demographic and behavioral correlates of receiving a recommendation for more physical activity (PA) from a PCP by overweight/obese patients were assessed. METHODS: Community-dwelling adults aged ≥50 years from four Texas cities who were seen by a family physician in a primary care clinic were surveyed from October 2013 to June 2014. Multivariate logistic regression predicted the likelihood of receiving a PA recommendation from a PCP, controlling for sociodemographic factors, health conditions, and walking behaviors. The analysis was conducted in 2016. RESULTS: Of the total 388 participants (survey response rate, 6.8%), 30.1% were obese, 55.4% were female, and most were non-Hispanic white (82.9%), married (75.6%), or reported an annual household income of ≥$50,000 (66.8%). Receipt of a PA recommendation from a PCP (n=151, 38.9%) was significantly correlated with reporting poor to fair health (OR=7.33, 95% CI=2.6, 20.32), obesity (OR=2.95, 95% CI=1.69, 5.14), having only a little or some difficulty walking for a quarter of a mile (OR=2.94, 95% CI=1.41, 5.88), not walking the recommended ≥150 minutes for any purpose (OR=2.60, 95% CI=1.25, 5.38), and being employed (OR=2.11, 95% CI=1.13. 3.94). CONCLUSIONS: PCPs seem to be targeting obese, inactive individuals with poor to fair health, populations traditionally not encouraged to be more physically active. These findings are consistent with the current trend in medical care to recommend positive lifestyle changes to a broader range of the population.

Social and environmental predictors of walking among older adults.

BACKGROUND: Regular physical activity (PA) is a major factor in maintaining health in aging populations. This study examines the influences of sociodemographic, health, and environmental characteristics on older adults' walking behaviors, and the role physicians can play in promoting physical activity. METHODS: Online and paper surveys (n = 272) were distributed to community-dwelling older (age ≥ 60) adults from a large integrated healthcare system in two counties in Central Texas. Descriptive statistics were utilized to characterize participant's walking behaviors and places. Multivariate logistic regression was employed to predict being: 1) a frequent walker (i.e., walking at least three times a week); and 2) meeting the Centers for Disease Control and Prevention (CDC) PA recommendation through walking (i.e., walking ≥150 min per week), while considering sociodemographic, health, and environmental factors. RESULTS: Individuals had a median age of 69 years, were of both genders (50.37 % female), and were primarily non-Hispanic White (84.87 %). While the majority (59.55 %) walked at least three times a week, only 27.86 % walked ≥150 min a week. Factors associated with a lower likelihood of being frequent walkers included experiencing poor mental health in the past month (OR = 0.345, 95 % CI = 0.185-0.645) and residing in areas with low or moderate (versus high) perceived neighborhood cohesion (OR = 0.471, 95 % CI = 0.228-0.974), while those in Census Tracts reflecting populations with a lower median age were more likely to report frequent walking behavior (OR = 1.799, 95 % CI = 1.034-3.131). Factors associated with a lower likelihood of meeting the CDC PA recommendation included being 60-69 years (versus 70 years or older) (OR = 0.538, 95 % CI = 0.290-0.997), experiencing poor mental health in the past month (OR = 0.432, 95 % CI = 0.198-0.944), and lacking social support for walking (OR = 0.383, 95 % CI = 0.154-0.957). CONCLUSION: Given the health benefits, PA promotion must be seen as a national responsibility. In particular, physicians have a major role to play in communicating the importance of PA to their older patients and making discussions about strategies for overcoming barriers to walking an integral part of their clinical encounter with these patients.

Neighborhood safety factors associated with older adults' health-related outcomes: A systematic literature review.

RATIONALE: Neighborhood safety is important for older adults' health and wellbeing, but there has not been a synthesis in the literature of what is currently known about this construct. OBJECTIVES: This systematic literature review, following the PRISMA guidelines, focuses on identifying neighborhood safety factors associated with health-related outcomes and behaviors of older adults in the U.S. METHODS: A search was conducted in 2014 via Academic Search Complete, CINAHL, Embase, MEDLINE, SportDis, and Transportation Databases. Based on our inclusion and exclusion criteria, we identified thirty-two articles for review. RESULTS: Sixteen studies examined health outcomes such as health status, mental health, physical function, morbidity/mortality, and obesity; the other sixteen studies focused on health behaviors, such as physical activity and walking. Four domains of neighborhood safety were identified: overall/general neighborhood safety; crime-related safety; traffic-related safety; and proxies for safety (e.g., vandalism, graffiti). Overall/general neighborhood safety appeared most relevant to mental health and physical function. Traffic-related safety was most pertinent to physical activity, while crime-related safety was more consistently associated with mental health and walking. While all safety variables were significantly associated with mental health, no significant associations were found for obesity. We also found that specific measures or constructs of safety were not applied consistently across the examined studies, making it difficult to compare the results. CONCLUSION: This review identified several important gaps in the existing studies dealing with neighborhood safety-health relationships among older adults. Further studies are needed that examine the different roles of multidimensional neighborhood safety in promoting the community health, not only in the U.S., but globally.

Using Walk Score™ and Neighborhood Perceptions to Assess Walking Among Middle-Aged and Older Adults.

We aimed to determine the relationship between neighborhood characteristics (walkability, cohesion/safety) and recommended activity levels among community-dwelling middle-aged and older adults. Subjective and objective data on 394 individuals aged ≥50 years were used to assess the likelihood of walking ≥150 min/week. Environmental factors associated with a greater likelihood of any walking ≥150 min/week included living in a neighborhood with high perception of cohesion/safety versus low, living in walkable areas versus car-dependent, and living in an area with a low-moderate median income versus the lowest. Middle-aged and older adults were more likely to walk ≥150 min/week in a walkable, perceived safe/cohesive neighborhood. Identifying neighborhood factors associated with promoting walking among this population can enable stakeholders (e.g., researchers, planners, and policy makers) to direct interventions focusing on the built environment.

Physician Recommendation of Diabetes Clinical Protocols.

The authors examined the responses of 63 primary care physicians to diabetes clinical protocols (DCPs) for the management of type II diabetes (T2DM). We measured physician demographics, current diabetes patient loads, and responses to DCPs (physician attitudes, physician familiarity, and physician recommendation of DCPs) using a 20-question electronic survey. Results of the survey indicate that primary care physicians may be unfamiliar with the benefits of diabetes clinical protocols for the self-management of T2DM. Given the importance of diabetes self-management education in controlling T2DM, those interested in implementing DCPs should address the beliefs and attitudes of primary care physicians.