Determining primary care physician information needs to inform ambulatory visit note display.

BACKGROUND: With the increase in the adoption of electronic health records (EHR) across the US, primary care physicians are experiencing information overload. The purpose of this pilot study was to determine the information needs of primary care physicians (PCPs) as they review clinic visit notes to inform EHR display. METHOD: Data collection was conducted with 15 primary care physicians during semi-structured interviews, including a third party observer to control bias. Physicians reviewed major sections of an artificial but typical acute and chronic care visit note to identify the note sections that were relevant to their information needs. Statistical methods used were McNemar-Mosteller's and Cochran Q. RESULTS: Physicians identified History of Present Illness (HPI), Assessment, and Plan (A&P) as the most important sections of a visit note. In contrast, they largely judged the Review of Systems (ROS) to be superfluous. There was also a statistical difference in physicians' highlighting among all seven major note sections in acute (p = 0.00) and chronic (p = 0.00) care visit notes. CONCLUSION: A&P and HPI sections were most frequently identified as important which suggests that physicians may have to identify a few key sections out of a long, unnecessarily verbose visit note. ROS is viewed by doctors as mostly "not needed," but can have relevant information. The ROS can contain information needed for patient care when other sections of the Visit note, such as the HPI, lack the relevant information. Future studies should include producing a display that provides only relevant information to increase physician efficiency at the point of care. Also, research on moving A&P to the top of visit notes instead of having A&P at the bottom of the page is needed, since those are usually the first sections physicians refer to and reviewing from top to bottom may cause cognitive load.

Impact of the population at risk of diabetes on projections of diabetes burden in the United States: an epidemic on the way.

AIMS/HYPOTHESIS: The aim of this study was to make projections of the future diabetes burden for the adult US population based in part on the prevalence of individuals at high risk of developing diabetes. MATERIALS AND METHODS: Models were created from data in the nationally representative National Health and Nutrition Examination Survey (NHANES) II mortality survey (1976-1992), the NHANES III (1988-1994) and the NHANES 1999-2002. Population models for adults (>20 years of age) from NHANES III data were fitted to known diabetes prevalence in the NHANES 1999-2002 before making future projections. We used a multivariable diabetes risk score to estimate the likelihood of diabetes incidence in 10 years. Estimates of future diabetes (diagnosed and undiagnosed) prevalence in 2011, 2021, and 2031 were made under several assumptions. RESULTS: Based on the multivariable diabetes risk score, the number of adults at high risk of diabetes was 38.4 million in 1991 and 49.9 million in 2001. The total diabetes burden is anticipated to be 11.5% (25.4 million) in 2011, 13.5% (32.6 million) in 2021, and 14.5% (37.7 million) in 2031. Among individuals aged 30 to 39 years old who are not currently targeted for screening according to age, the prevalence of diabetes is expected to rise from 3.7% in 2001 to 5.2% in 2031. By 2031, 20.2% of adult Hispanic individuals are expected to have diabetes. CONCLUSIONS/INTERPRETATION: The prevalence of diabetes is projected to rise to substantially greater levels than previously estimated. Diabetes prevalence within the Hispanic community is projected to be potentially overwhelming.

Are ethnic differences in insulin sensitivity explained by variation in carbohydrate intake?

AIMS/HYPOTHESIS: Minority populations are disproportionately affected by diabetes. This health disparity may be due to less healthy diets and/or heritable factors in minority populations. These factors must be assessed concurrently to better appreciate their contribution to insulin sensitivity. METHODS: We analysed overweight, healthy adults using the National Health and Nutrition Examination Survey 1999-2000. Means for dietary intake variables and insulin sensitivity were calculated by ethnicity. Linear regressions were performed to evaluate the association between ethnicity, dietary variables, dietary glycaemic index and insulin sensitivity. Fasting insulin was used to characterise insulin sensitivity. RESULTS: Non-Hispanic whites have higher energy and fat intake, while Hispanics have higher carbohydrate intake and African-Americans have lower fibre intake. In unadjusted analyses both Hispanics and African-Americans have lower insulin sensitivity, but only Hispanics are more likely to have lower insulin sensitivity after controlling for dietary variables and BMI. CONCLUSIONS/INTERPRETATION: Ethnic differences in insulin sensitivity remain after controlling for dietary differences and other factors, suggesting that inherent metabolic differences exist. Further studies are needed to define inherent metabolic factors, as well as other non-dietary factors that affect insulin sensitivity.

Having a regular physician and attempted weight loss after screening for hypertension or hypercholesterolemia.

OBJECTIVE: To examine the relationship between having a regular physician, results of screening tests for cardiovascular risk (hypertension, hypercholesterolemia) and efforts to lose weight among obese adults. DESIGN: Analysis of a population-based telephone survey (2002 Behavioral Risk Factor Surveillance System). SETTING: Four states (Iowa, South Carolina, South Dakota, Virginia) in the US. PARTICIPANTS: Adults (> or =18 y old) who were obese (body mass index > or =30 kg/m(2)) (unweighted n=1735). MAIN OUTCOME MEASURES: Currently attempting to lose weight; changes in diet or exercise as strategies to lose weight. RESULTS: Obese individuals with a personal physician were more likely to report attempts to lose weight in the face of screening normal for hypertension or hypercholesterolemia than those without a personal physician (75.6 vs 60.5% for hypercholesterolemia, P=0.03; 74.6 vs 57.7% for hypertension, P=0.01). In adjusted models, obese individuals screening normal for hypertension but having a personal physician were significantly more likely to attempt to lose weight than individuals without a personal physician (OR 1.71, 95% CI 1.12-2.60). CONCLUSIONS: Having a regular physician is associated with a higher likelihood of attempted weight loss among obese individuals who believe that they do not have hypertension or hypercholesterolemia, than their counterparts with no regular physician. This suggests a previously unrecognized benefit of having a personal physician.

Potential effect of patient-assisted teledermatology on outpatient referral rates.

We carried out a pilot study on the feasibility and accuracy of store-and-forward teledermatology based on patient-provided images and history as a triage tool for outpatient consultation. Patients referred by their general practitioner provided a history and images via the Internet. The information was reviewed by one of 12 teledermatologists and the patient then visited a different dermatologist in person within two days. Three independent dermatologists compared the remote and in-person diagnoses in random order to determine diagnostic agreement. Broader agreement was also measured, by comparing the main disease groups into which the two diagnoses fell. The teledermatologists indicated whether an in-person consultation or further investigations were necessary. There were 105 eligible patients, aged four months to 72 years, who were willing to participate. For the 96 cases included in the analysis, complete diagnostic agreement was found in 41% (n=39), partial diagnostic agreement in 10% (n=10) and no agreement in 49% (n=47). There was disease group agreement in 66% of cases (n=63). Nearly a quarter (23%) of participating patients could have safely been managed without an in-person visit to a dermatologist.

Concept of twin spotting.

This article describes the formation of apparent twin spots presumed to be caused by a specific form of somatic recombination. Twin spots consist of two genetically different clones of neighboring cells in a background of normal cells. The phenomenon is well known in plants and animals and is used as a marker to evaluate the recombinogenic activity of chemicals. The equivalent of the twin spot phenomenon in humans has only been described recently. We now give a review on a number of paired skin disorders possibly caused by the mechanism of twin spotting. They include vascular twin nevi, phacomatosis pigmentovascularis, phacomatosis pigmentokeratotica, Proteus syndrome, and cutis tricolor. Clinicians will probably spot other nevoid skin lesions occurring in close proximity to each other, which might be explained by the twin spot phenomenon.

Vulvar paraneoplastic amyloidosis with the appearance of a vulvar carcinoma.

Nodular cutaneous amyloidosis of the vulva is a rare phenomenon. We describe a patient with localized nodular lesions on the vulva that mimicked kissing ulcers such as are seen with vulvar carcinoma. These lesions were a result of multiple myeloma with subsequent primary systemic amyloidosis. The patient died of cardiac and renal decompensation 2 months after diagnosis.

Becker nevus syndrome.

The new term Becker nevus syndrome is proposed for a phenotype characterized by the presence of a particular type of organoid epithelial nevus showing hyperpigmentation, increased hairiness and hamartomatous augmentation of smooth muscle fibers, and other developmental defects such as ipsilateral hypoplasia of breast and skeletal anomalies including scoliosis, spina bifida occulta, or ipsilateral hypoplasia of a limb. The present review includes 23 cases that can be categorized under this designation. The Becker nevus syndrome usually occurs sporadically. The associated anomalies tend to show a definite regional correspondence, suggesting a common origin from an early postzygotic mutation.

[D-penicillamine in treatment of scleroderma "en coup de sabre"]. / D-Penizillamin in der Behandlung von Sklerodermie "en coup de sabre".

A ten year old boy with linear erythema above the right eyebrow and a groove in the underlying skull bone is described. Histological examination of a biopsy revealed a spotty, periadnexal, perivascular, lymphocytic infiltrate. The papillary dermis was almost absent and the collagen fibres were slightly thickened. Based on the clinical appearance and the histology a diagnosis of linear scleroderma (en coup de sabre) was made. As the signs and symptoms were progressive, treatment with D-penicillamine was started. Subsequently the erythema disappeared. The shallow groove in the skull bone remained palpable. After thirteen months, treatment was stopped. The patient is currently free of signs and symptoms after a follow-up period of three and a half years. We feel that the strong clinical improvement is due to treatment with D-penicillamine rather than to the natural course of the disease.

Vascular malformations: a review of 10 years' management in a university hospital.

In order to gain insight into the management of patients with vascular malformations (VM) in the University Hospital Nijmegen in the past 10 years, 151 cases managed by different specialists were reviewed. To avoid the usual confusion in terminology, all recorded diagnoses were reclassified according to the biological classification of Mulliken. The sex distribution was equal; 79% of the malformations were diagnosed at birth or in the 1st year of life. The median time between presentation and consultation was 3 years. Sixty-two lymphatic, 26 venous, 24 capillary, 1 arterial, and 38 combined malformations (8 arteriovenous, 30 others) were found. The head and neck region was most frequently involved, followed by the lower and upper limbs and trunk. The pediatric surgeon was the most frequently consulted specialist. Confusing, mutually incompatible terminology and a wide variety of different diagnostic techniques and treatments had been used by the different specialists. To improve the management of patients with vascular malformations, the use of a uniform classification, an increase in basic investigations, and the development and evaluation of protocols for diagnosis and treatment by multidisciplinary teams are necessary.

[Erythema ab igne]. / Erythema ab igne.

A 47-year-old woman suffering from chronic abdominal pain developed erythema ab igne (reticular hyperpigmentation of the skin caused by exposure to heat). Histological examination revealed premalignant changes in two specimens of affected skin. The incidence of erythema ab igne is declining since fewer people use open fires for heating. Nowadays it is found mostly in patients suffering from chronic pain using hot water bottles, infrared lamps or heating pads. The disease is an important clinical indication for underlying chronic diseases. The affected skin runs a higher risk of development of actinic keratoses. Bowen's disease and squamous cell carcinomas. Dysplastic features of keratinocytes can be found histologically in lesions which are clinically not under suspicion.

Juvenile xanthogranuloma and acute leukemia: a case report.

Juvenile xanthogranuloma (JXG) is a rare benign disease of the skin. It is seen in combination with juvenile chronic myelo-monocytic leukemia (JCML) and/or neurofibromatosis type 1 (NF1). The association with acute lymphoblastic leukemia is hardly mentioned in the literature. A case report of this rare combination is described and a review of the literature is given.

Cellulitis as first clinical presentation of disseminated cryptococcosis in renal transplant recipients.

Two renal transplant recipients with cellulitis due to Cryptococcus neoformans are described. The patients were treated empirically for a presumed bacterial erysipelas, but without response. Examination of skin biopsies revealed C. neoformans as the causative organism. In both patients the cellulitis was the presenting clinical manifestation of disseminated cryptococcosis. Therapy with antifungal agents was successful. Disseminated cryptococcal disease occurs mainly in immunocompromised patients. When left untreated, it nearly always has a fatal course. Early diagnosis and appropriate therapy are therefore essential.

MIDAS syndrome (microphthalmia, dermal aplasia, and sclerocornea): an X-linked phenotype distinct from Goltz syndrome.

Bilateral microphthalmia with blepharophimosis, linear lesions of dermal aplasia involving the face, and microcephaly were present in a newborn girl who died at age 9 months from cardiomyopathy resulting in ventricular fibrillation. Autopsy showed an atrial septum defect, persistent gross trabeculation of the left ventricle, and an arteria lusoria. This case represents a further example of a new entity for which we propose the term MIDAS syndrome. The acronym stands for microphthalmia, dermal aplasia, and sclerocornea. Our patient is the second with this syndrome to have a major congenital heart defect. Cytogenetic studies reported in previous cases indicate that the underlying gene defect can be assigned to Xp22.3. This new X-linked male-lethal trait should be distinguished from focal dermal hypoplasia that will be found to map elsewhere on the X-chromosome.