Building Climate Change into Medical Education: A Society of General Internal Medicine Position Statement.

Building expertise in climate and planetary health among healthcare professionals cannot come with greater urgency as the threats from climate change become increasingly apparent. Current and future healthcare professionals-particularly internists-will increasingly need to understand the interconnectedness of natural systems and human health to better serve their patients longitudinally. Despite this, few national medical societies and accreditation bodies espouse frameworks for climate change and planetary health-related education at the undergraduate (UME), graduate (GME), and continuing (CME) medical education level. As a community of medical educators with an enduring interest in climate change and planetary health, the Society of General Internal Medicine (SGIM) recognizes the need to explicitly define structured educational opportunities and core competencies in both UME and GME as well as pathways for faculty development. In this position statement, we build from the related SGIM Climate and Health position statement, and review and synthesize existing position statements made by US-based medical societies and accreditation bodies that focus on climate change and planetary health-related medical education, identify gaps using Bloom's Hierarchy, and provide recommendations on behalf of SGIM regarding the development of climate and planetary health curricula development. Identified gaps include (1) limited systematic approach to climate and planetary health medical education at all levels; (2) minimal emphasis on learner-driven approaches; (3) limited focus on physician and learner well-being; and (4) limited role for health equity and climate justice. Recommendations include a call to relevant accreditation bodies to explicitly include climate change and planetary health as a competency, extend the structural competency framework to climate change and planetary health to build climate justice, proactively include learners in curricular development and teaching, and ensure resources and support to design and implement climate and planetary health-focused education that includes well-being and resiliency.

Hypothyroidism in Adult Women: The Utility of Targeted vs Universal Thyroid Screening.

Hypothyroidism is a common disease that is more prevalent in female populations. The purpose of this paper is to discuss the evidence, risks, and benefits of screening asymptomatic women for hypothyroidism. There is lack of evidence to support clinical management of asymptomatic individuals with an elevated TSH and normal serum thyroxine levels. Patients with subclinical hypothyroidism, especially the elderly, are at risk of overtreatment. Given these considerations, the majority of US and UK professional organizations do not support universal screening. Many do offer caveats for special groups, including pregnant people, who may need screening if there are clinical symptoms or family history of autoimmune disease. In conclusion, targeted screening may be best recommended based on risk factors, symptoms, and clinical suspicion, rather than at a universal level.

Primary hypothyroidism and chronotypes in adult women.

OBJECTIVE: Abnormal thyroid function may disrupt sleep architecture. We aimed to determine the frequency of various chronotypes in women with hypothyroidism. We performed a single-center retrospective study at an ambulatory clinic from January 2013-December 2015. Participants were women with hypothyroidism. Chronotype was determined from the Munich ChronoType Questionnaire. The χ2 test was used to compare differences in clinical characteristics and sleep patterns in early and intermediate/late chronotypes. The t test was used to compare differences between means. RESULTS: We evaluated 99 patients (mean [SD], 56 [7] years): calculated chronotype revealed: 56% early, 38% intermediate and 6% late. Analysis with the χ2 test showed significant differences between early and intermediate/late calculated chronotypes for sleep latency (P = 0.01), light exposure (P = 0.009), and no alcohol intake (P = 0.001). t test showed the following differences in mean (SD) between chronotypes: sleep duration, 7.30 (1.39) hours (early chronotype) and 7.04 (2.06) hours (intermediate/late); body mass index (BMI), 29.4 (7.3) (early) and 31.1 (6.8) (intermediate/late); and TSH level, 2.89 (3.69) mIU/L (early) and 1.69 (1.41) mIU/L (intermediate/late). Early chronotypes were frequent in women with hypothyroidism. Light exposure and BMI may influence chronotypes in patients with hypothyroidism; findings are consistent with healthier behaviors in patients who tend toward morningness.

Perception of Breast Density Information Among Women in Miami, FL: a Qualitative Study.

The US Food and Drug Administration has proposed requiring that all women undergoing mammography receive written information about their breast density. Past research suggests many women may misperceive the meaning of breast density. Additionally, women with dense breasts may not understand the risks and benefits of pursuing additional imaging studies. The goal of this study was to explore women's beliefs about breast density and their preferences for how this information is conveyed. Women with increased breast density detected on mammography at a university-based breast imaging center in South Florida were recruited for a series of focus groups. Twenty-five women participated, ranging in age from 42 to 65 years. Nine women (36%) self-identified as Hispanic/Latina, eight (32%) as Black, four (16%) as White, three (12%) as Asian, and one as "other." Four focus groups were conducted in English and one in Spanish by professional moderators using a semi-structured format. A constant comparative method was used to identify common themes using a general inductive approach. Areas explored included understanding of the term breast density; personal reaction to being informed of dense breasts; questions about breast density; understanding of supplemental screening; and preferences for how to convey breast density information. Subthemes identified included a misperception that breast density is palpable; a feeling of fear on learning of increased breast density results; a concern about what causes increased breast density and whether it can be reversed; a desire to proceed with supplemental ultrasound imaging; and a preference for simple messages explaining the concept of breast density in multiple formats including video. Participants voiced the incorrect belief that caffeine intake could increase breast density and stated that they wanted to know specific details about their personal results. There is a need for better tools to communicate breast density in a way that allays anxiety while enabling women to make fully informed decisions about their breast health. Clinicians and cancer educators should be aware of misperceptions women may have about breast density. Policymakers should keep in mind potential public confusion about this complex topic when crafting density notification rules.

Seizure Disorder Exacerbated by Hepatic Encephalopathy: A Case Report.

BACKGROUND: Hepatic encephalopathy is a serious complication of cirrhosis that presents with a variety of neuropsychiatric abnormalities, including disorientation, asterixis, and coma. Seizures are an uncommon and potentially dangerous complication of hepatic encephalopathy. We present a unique case of a 42-year-old female with a history of well-controlled seizure disorder suddenly become refractory to anticonvulsant therapy following the development of hepatic encephalopathy secondary to liver decompensation. CASE PRESENTATION: A 42-year-old female presented to our hospital following a seizure accompanied by loss of consciousness, urinary incontinence, and the prolonged postictal state. She reports her seizures were initially well-controlled with Levetiracetam 500 mg twice a day but recently began experiencing seizures every other day despite up-titration of Levetiracetam to 1500 mg twice a day over a few weeks. On arrival, her serum ammonia level was 116 µmol/L. CT brain was negative while CT liver was consistent with cirrhotic morphology. An electroencephalogram revealed irregular, diffuse, delta/theta slowing consistent with mild to moderate encephalopathy. The patient was started on lactulose 40mg and Rifaximin 550 mg twice a day. Her symptoms of disorientation and lethargy resolved over 3 days. CONCLUSION: Though uncommon, hepatic encephalopathy should be considered in patients presenting with convulsions, especially if there is a known history of liver disease. Until the underlying liver issues are addressed, patients may not respond to traditional anti-convulsant therapy for their seizures.

A Brochure to Improve Understanding of Incomplete Mammogram Results Among Black Women at a Public Hospital in Miami, Florida.

OBJECTIVES: Black women are at increased risk of being called back for additional studies after a screening mammogram. With focus group input, we developed a brochure to improve awareness of the frequency of abnormal results. This study explored the brochure's acceptability and effect on understanding risk and breast cancer fears among black mammography patients at an urban safety-net breast imaging center in Miami, Florida. METHODS: A randomized controlled trial of the brochure (plus the standard result notification letter) versus usual care (standard notification letter alone). Black English-speaking women with an incomplete mammography result were randomized to the intervention or control group. Consenting participants completed a telephone questionnaire. Outcomes included awareness of result, anxiety level, and brochure acceptability. The χ2 or Fisher exact test was used and a univariate logistic regression was performed for intervention and control odds ratios. RESULTS: A total of 106 women were randomly selected to receive the brochure plus the letter or the letter alone. One chose to opt out; a minimum of three attempts were made to reach each of the remaining 105 women by telephone. Verbal communication was established with 59 of the randomized women, and 51 of those women agreed to participate in a survey to evaluate the brochure. There was no significant difference between the surveyed groups in knowledge of the result and follow-up plan. Surveyed intervention subjects were more likely to agree that "it is very common for women to have to follow up after a mammogram" (odds ratio [OR] 25.91, P = 0.029) and less likely to agree with the statement "getting a follow-up mammogram is scary" (OR 0.24, P = 0.021). Most intervention subjects said the pamphlet helped them understand their result "a lot" (79%, 19) and viewed it as "extremely" or "mostly" clear (96%, 23). Intervention subjects also voiced greater awareness of a telephone number they could call for more information about cancer (OR 11.38, P = 0.029). CONCLUSIONS: A culturally tailored brochure explaining the frequency of abnormal mammograms was well received by women at a large safety-net health system. Pilot testing suggests that it may improve patient perception of risk and awareness of informational resources. This strategy should be considered to enhance result communication.

Glycaemic indices and haemoglobin A1c as predictors for non-healing ulcers.

OBJECTIVE: Non-healing lower extremity ulcers (NHLU) are a common podiatric complication of diabetes, with poor glycaemic control as a risk factor for development. Glycaemic indices, such as haemoglobin A1c (HbA1c) and fasting plasma glucose (FPG), are used to diagnose and to monitor diabetes. Using a population-based, nationally representative sample, we evaluate the relationship between glycaemic indices and NHLU (as defined by the patient) to propose glycaemic thresholds for clinical suspicion of patient NHLU status. METHOD: Using data from the 1999-2004 National Health and Nutrition Examination Surveys (NHANES), a total of 9769 adults (≥40 years old) with available self-reported diabetes and NHLU status were analysed. Glycaemic index markers, including FPG and HbA1c, were assessed via laboratory analysis from serum blood samples. Logistic regression models were fitted to determine optimal thresholds for FPG and HbA1c to predict NHLU status. RESULTS: Compared with those without NHLU, NHLU patients were older, male, had higher rates of diabetes, were more likely to take insulin, and had lower total cholesterol. Youden's Index for NHLU identified the optimal FPG threshold as 117.7mg/dl (sensitivity: 33.5%; specificity: 82.6%). The optimal HbA1c threshold was 5.9% (sensitivity: 43.2%; specificity: 77.3%). HbA1c (Odds ratio (OR) 2.44, 95% Confidence Interval (CI) 1.96-3.05; Area under curve (AUC) 0.62) was a stronger discriminator of NHLU compared to FPG (OR 2.19; 95%CI 1.57-3.05; AUC 0.60). CONCLUSION: This study identified glycaemic thresholds for suspicion of NHLU development that are lower than the glucose goal levels recommended as optimal by the American Diabetes Association. Health professionals should be aware of these glycaemic indices when screening patients with diabetes for NHLU. Future longitudinal and validation studies are necessary to better discern the ideal glycaemic index thresholds to identify NHLU.

Minority Veterans Are More Willing to Participate in Complex Studies Compared to Non-minorities.

BACKGROUND: Minorities are an underrepresented population in clinical trials. A potential explanation for this underrepresentation could be lack of willingness to participate. The aim of our study was to evaluate willingness to participate in different hypothetical clinical research scenarios and to evaluate the role that predictors (e.g. health literacy) could have on the willingness of minorities to participate in clinical research studies. METHODS: We conducted a mixed-methods study at the Miami VA Healthcare system and included primary care patients with hypertension. We measured willingness to participate as a survey of four clinical research scenarios that evaluated common study designs encountered in clinical research and that differed in degree of complexity. Our qualitative portion included comments about the scenarios. RESULTS: We included 123 patients with hypertension in our study. Of the entire sample, ninety-three patients were minorities. Seventy per cent of the minorities were willing to participate, compared to 60 per cent of the non-minorities. The odds ratio (OR) of willingness to participate in simple studies was 0.58; 95 per cent CI 0.18-1.88 p=0.37 and the OR of willingness to participate in complex studies was 5.8; 95 per cent CI 1.10-1.31 p=0.03. In complex studies, minorities with low health literacy cited obtaining benefits (47 per cent) as the most common reason to be willing to participate. Minorities who were not willing to participate, cited fear of unintended outcomes as the main reason. CONCLUSIONS: Minorities were more likely to be willing to participate in complex studies compared to non-minorities. Low health literacy and therapeutic misconception are important mediators when considering willingness to participate in clinical research.

Acceptability and Feasibility of Human Papilloma Virus Self-Sampling for Cervical Cancer Screening.

OBJECTIVES: Women in safety-net institutions are less likely to receive cervical cancer screening. Human papilloma virus (HPV) self-sampling is an alternative method of cervical cancer screening. We examine the acceptability and feasibility of HPV self-sampling among patients and clinic staff in two safety-net clinics in Miami. MATERIALS AND METHODS: Haitian and Latina women aged 30-65 years with no Pap smear in the past 3 years were recruited. Women were offered HPV self-sampling or traditional Pap smear screening. The acceptability of HPV self-sampling among patients and clinic staff was assessed. If traditional screening was preferred the medical record was reviewed. RESULTS: A total of 180 women were recruited (134 Latinas and 46 Haitian). HPV self-sampling was selected by 67% women. Among those selecting traditional screening, 22% were not screened 5 months postrecruitment. Over 80% of women agreed HPV self-sampling was faster, more private, easy to use, and would prefer to use again. Among clinic staff, 80% agreed they would be willing to incorporate HPV self-sampling into practice. CONCLUSIONS: HPV self-sampling was both acceptable and feasible to participants and clinic staff and may help overcome barriers to screening.

How do breast imaging centers communicate results to women with limited English proficiency and other barriers to care?

Research suggests that women with Limited English Proficiency (LEP) and ethnic minority women are at increased risk of being inadequately informed of their mammogram result. The purpose of this study is to explore breast imaging centers' communication practices and assess how these centers accommodate women with low literacy and LEP. A 35-question survey was distributed to a national association of more than 700 breast health centers. Descriptive analysis of the overall sample and Fisher's exact or Chi squared testing to distinguish differences between subgroups were performed. Respondents from 206 centers completed questionnaires. 29% of respondents stated that more than a quarter of their patients were black, 27% of respondents stated that more than a quarter of their patients were Hispanic/Latina, and 13% of respondents stated that more than a quarter of their patients had LEP. Overall, 18% of respondents reported they do not routinely telephone patients with results, 15% do not have multilingual staff or translators available to answer questions, and 69% send result letters in English only. Of note, 69% use patient navigators. Centers reported systemic strengths and barriers to clear communication of mammography results. Our findings are consistent with past investigations identifying a general need to improve the communication of breast imaging results and suggesting that result notification letters alone are inadequate in ensuring that every woman understands her personal results and follow-up plan.

Does a bite cause cancer? Misperceptions of breast cancer etiology among low-income urban women in Miami, Florida.

OBJECTIVES: To explore breast cancer beliefs among a cohort of low-income, urban, English-speaking women in Miami, Florida, who had undergone screening mammography. METHODS: Four focus groups of 34 women were conducted. Discussions were transcribed verbatim and transcripts were analyzed separately by two investigators using an immersion-and-crystallization approach. Common risk factors were identified by consensus. RESULTS: Participants were predominantly African American (82%) women of low income (77% with a household income <$20,000/year). Common risk factors included family history, environmental factors, trauma, and sexual activity. There also was a perception that breast cancer grows rapidly and causes detectable symptoms. CONCLUSIONS: Women voiced some accurate and numerous inaccurate beliefs regarding the causes of breast cancer, suggesting a lack of knowledge about the potential benefits and harms of screening mammography before undergoing examination. These findings highlight the importance of identifying women's underlying beliefs when initiating a discussion of breast cancer screening and prevention to ensure that messages are mutually understood.

Improving the informed consent process for research subjects with low literacy: a systematic review.

BACKGROUND: Inadequate health literacy may impair research subjects' ability to participate adequately in the informed consent (IC) process. Our aim is to evaluate the evidence supporting interventions, to improve comprehension of the IC process in low literacy subjects. METHODS: We performed a MEDLINE database search (1966 to November 2011) supplemented by manual searches of bibliographies of key relevant articles. We selected all studies in which a modification of the IC was tested to improve comprehension in low literacy populations. Study design, quality criteria, population, interventions and outcomes for each trial were extracted. The main outcome evaluated was comprehension, measured using a written test or verbal comprehension. RESULTS: Our search strategy yielded 281 studies, of which only six met our eligibility criteria. The six studies included 1620 research participants. The studies predominantly included populations that were older (median age 61, range 48-64), ethnic minority, and with literacy level of 8th grade or below. Only one study had a randomized design. The specific intervention differed in each study. Two of the studies included the teach-back method or teach to goal method and achieved the highest level of comprehension. Two studies changed the readability level of the IC and resulted in the lowest comprehension among study subjects. CONCLUSIONS: The evidence supporting interventions to improve the informed consent process in low literacy populations is extremely limited. Among the interventions evaluated, having a study team member spend more time talking one-on-one to study participants was the most effective strategy for improving informed consent understanding; however, this finding is based on the results of a single study.

Urban women's preferences for learning of their mammogram result: a qualitative study.

Research suggests that communication of mammogram results is flawed for many low-income ethnic minority women. This study conducted four focus groups with low-income inner-city minority women (n = 34). The goals of our project were: (1) to elucidate women's experiences learning of their result; (2) to elicit their preferences as to how this communication could be improved; and (3) to gather information to help inform the development of a new tool for communicating mammogram results. Salient themes included dissatisfaction with result communication; difficulty elucidating the meaning of a typical results notification letter; a preference for direct verbal communication of results and for print materials that included pictures, testimonials, and an action plan including a hotline to call with questions; and a strong interest in advance education about the likelihood of having to return for additional follow up. Video and other programs to inform patients before the test about what happens after may improve patient satisfaction and enhance women's understanding of their personal result and follow up plan.