Do physicians underrecognize obesity?

OBJECTIVES: A physician's advice is among the strongest predictors of efforts toward weight management made by obese patients, yet only a minority receives such advice. One contributor could be the physician's failure to recognize true obesity. The objectives of this study were to assess physicians' ability to recognize obesity and to identify factors associated with recognition and documentation of obesity. METHODS: Internal medicine residents and attending physicians at three academic urban primary care clinics and their adult patients participated in a study using recognition and documentation of patient obesity as the main measures. RESULTS: A total of 52 physicians completed weight assessments for 400 patients. The mean patient age was 51 years, 56% were women, 77% were Hispanic, and 67% had one or more obesity-related comorbidity. There were 192 (48%) patients, of whom 66% were correctly identified by physicians as being obese, 86% of those with a body mass index (BMI) ≥ 35, but only 49% of those with a BMI of 30 to 34.9 (P < 0.0001). Fewer obese Hispanic patients were identified than were non-Hispanic patients (62% vs 76%; P = 0.03). No physician characteristics were significantly associated with recognition of obesity. Physicians documented obesity as a problem for 51% of patients. Attending physicians documented obesity more frequently than did residents (64% vs 43%, odds ratio 2.5, 95% confidence interval 1.3-4.6) and normal-weight physicians documented obesity more frequently than overweight physicians (58% vs 41%, odds ratio 2.0, 95% confidence interval 1.0-4.0). Documentation was more common for patients with a BMI ≥ 35 and for non-Hispanics. Documentation was not more common for patients with obesity-related comorbidities. CONCLUSIONS: Physicians have difficulty recognizing obesity unless patients' BMI is ≥ 35. Training physicians to recognize true obesity may increase rates of documentation, a first step toward treatment.

Trends and significance of VRE colonization in the ICU: a meta-analysis of published studies.

BACKGROUND: The burden and significance of vancomycin-resistant enterococci (VRE) colonization in the ICU is not clearly understood. METHODS: We searched PubMed and EMBASE up to May 2013 for studies reporting the prevalence of VRE upon admission to the ICU and performed a meta-analysis to assess rates and trends of VRE colonization. We calculated the prevalence of VRE on admission and the acquisition (colonization and/or infection) rates to estimate time trends and the impact of colonization on ensuing VRE infections. FINDINGS: Across 37 studies (62,959 patients at risk), the estimated prevalence of VRE on admission to the ICU was 8.8% (7.1-10.6). Estimates were more consistent when cultures were obtained within 24 hours from admission. The VRE acquisition rate was 8.8% (95% CI 6.9-11.0) across 26 evaluable studies (35,364 patients at risk). Across US studies, VRE acquisition rate was 10.2% (95% CI 7.7-13.0) and demonstrated significant decline in annual trends. We used the US estimate of colonization on admission [12.3% (10.5-14.3)] to evaluate the impact of VRE colonization on admission in overall VRE prevalence. We demonstrated that VRE colonization on admission is a major determinant of the overall VRE burden in the ICU. Importantly, among colonized patients (including admitted and/or acquired cases) the VRE infection rates vary widely from 0-45% (with the risk of VRE bacteremia being reported from 0-16%) and <2% among those without a proven colonization. CONCLUSION: In summary, up to 10.6% of patients admitted in the ICU are colonized with VRE on admission and a similar percentage will acquire VRE during their ICU stay. Importantly, colonization on admission is a major determinant of VRE dynamics in the ICU and the risk of VRE-related infections is close related to colonization.

Frostbite in a Sherpa.

Frostbite is frequently seen in high altitude climbers. Many Sherpas, members of an ethnic community living high in the Himalayas in Nepal, help the climbers as a guide or an assistant. They often seem to undertake few precautionary measures thus suffer more from frostbite. A young Sherpa, who had reached the top of Mt Kanchenjunga in March 2009, suffered from deep frostbite in his fingers. Fortunately, he recovered well with generous treatment. Though there is no evidence whether Sherpas are more or less prone to frostbite, simple techniques for adequate prevention of hypoxia, hypothermia and dehydration will benefit any climber to the high altitudes.

Another typhoid patient from Japan.

Typhoid treatment was empirically started in a Japanese patient with undifferentiated fever in Nepal since Japanese tourists, unlike most Americans and Europeans to South Asia, are unable to obtain typhoid vaccination in Japan even for travel to this area of high endemicity. Subsequently, his blood culture grew out Salmonella typhi.