A 'stages of change' approach to helping patients change behavior.

Helping patients change behavior is an important role for family physicians. Change interventions are especially useful in addressing lifestyle modification for disease prevention, long-term disease management and addictions. The concepts of "patient noncompliance" and motivation often focus on patient failure. Understanding patient readiness to make change, appreciating barriers to change and helping patients anticipate relapse can improve patient satisfaction and lower physician frustration during the change process. In this article, we review the Transtheoretical Model of Change, also known as the Stages of Change model, and discuss its application to the family practice setting. The Readiness to Change Ruler and the Agenda-Setting Chart are two simple tools that can be used in the office to promote discussion.

Senile dementia of the Binswanger's type.

Senile dementia of the Binswanger's type is a term used to describe a dementia syndrome characterized by onset in the sixth or seventh decade of life, subcortical neurologic deficits, psychiatric disorders and evidence of hypertension or systemic vascular disease. The status of senile dementia of the Binswanger's type as a distinct entity is a matter of some controversy. The array of neuroimaging abnormalities and clinical findings attributed to this condition overlap with a number of other neuropathologies. Leukoaraiosis, or attenuation of subcortical white matter, seen on computed tomographic scans or magnetic resonance imaging of the brain, is a hallmark of senile dementia of the Binswanger's type. The clinical findings associated with Binswanger's disease are varied but typically include a progressive dementia, depression and "subcortical" dysfunction such as gait abnormalities, rigidity and neurogenic bladder. Treatment is largely supportive and includes a discussion about advanced directives, social support and antidepressant therapy. Control of hypertension and aspirin prophylaxis may help prevent further progression of white matter disease.

Comorbid disease in geriatric patients: dementia and depression.

As the population ages, Alzheimer's disease and depression are becoming increasingly common concerns for primary care physicians. While the comorbidity of Alzheimer's disease and depression presents a complex diagnostic and management challenge, treatment can improve the patient's quality of life. Changes in functional status, complaints of pain and fluctuations in mental status may signify the onset of depression in a patient with dementia. Because of differences in treatment, it is important to separate depression from other disruptions in behavior. Unfortunately, screening tools for depression and cognitive function are of limited usefulness in patients with Alzheimer's disease. Improvement with antidepressant therapy is often diagnostic. The caregiver plays a large role in assisting with the diagnosis and assessing the effectiveness of therapy.

The role of the family physician in the day care setting.

Injuries and infectious respiratory, gastrointestinal and dermatologic diseases are common in day care settings. Most day care injuries are contusions, abrasions and cuts involving the head and extremities. Impact-absorbing surfaces under playground equipment, safely-proofing of all play areas, increased staff supervision, and staff and parental education might reduce injuries by as much as 75 percent. Respiratory illnesses are the most common day care infections. Chemoprophylaxis with rifampin is required for all close contacts of children infected with Haemophilus influenzae type B and Neisseria meningitidis. Diarrheal illness may be caused by viral pathogens, bacterial agents such as Shigella, Campylobacter or Salmonella, or parasitic infections caused by Giardia lamblia and Cryptosporidium. Strict hand-washing procedures, especially before food preparation and after toileting, may reduce diarrheal illness by 50 percent. Head lice (Pediculosis capitis) and scabies are common dermatologic infections spread by direct contact and through clothing, bedding and hair brushes. Screening and treating affected children with permethrin preparations and thoroughly washing bedding and clothing are necessary to stop outbreaks. Use of universal precautions for the handling of stool is essential to prevent the spread of both ordinary diarrheal illnesses and serious infections such as hepatitis A and B, human immunodeficiency virus and cytomegalovirus.

Myxedema coma in the elderly.

BACKGROUND: Myxedema coma in the elderly, although uncommon, is frequently overlooked and has a high mortality rate. Signs and symptoms are many and are often insidious. Nearly every organ system is involved. Prompt recognition and treatment are mandatory for a successful outcome. METHODS: A case study is presented. Using the key words "myxedema" with the word "aged," MEDLINE files were searched from 1989 to present. Articles dating before 1989 were accessed from the reference lists of the more recent articles. RESULTS AND CONCLUSIONS: This review describes the signs and symptoms of myxedema coma in the elderly. Epidemiology and histopathology of the disorder are discussed. Prompt recognition and emergency medical treatment are essential for a successful outcome. Prevention requires screening of elderly patients at risk for hypothyroidism and assuring thyroid hormone replacement therapy.

Delay of diagnosis and empiric treatment of angiotensin-converting enzyme inhibitor-induced cough in office practice.

OBJECTIVE: To evaluate the length of time taken to diagnose cough due to the use of an angiotensin-converting enzyme (ACE) inhibitor and the frequency of interim diagnoses and treatments given in an office practice. DESIGN: Retrospective case study. SETTING: Two academic group family practice offices. PATIENTS: Seventeen solicited cases of patients with suspected or known ACE inhibitor-induced cough over a 2-year period. MAIN OUTCOME MEASURES: Documentation in the patient chart of the nature and complaint of the cough; the time between initiation of therapy with the drug and complaint of the cough; the time between initiation of therapy with the drug and assessment of ACE inhibitor-induced cough or discontinuation of drug treatment; other diagnoses given to explain the cough; and other treatments given. RESULTS: There was an average of 14.5 weeks between the initiation of ACE inhibitor therapy and the first documentation of the complaint of cough, and an average of 24.0 weeks between the initiation of ACE inhibitor therapy and documentation of the cough side effect. Physicians made several interim diagnoses prior to recognizing cough as a side effect of ACE inhibitor therapy. Physicians prescribed 30 medications and took two chest radiographs on seven patients experiencing ACE inhibitor-induced cough prior to recognition of this side effect. CONCLUSIONS: The investigation found a significant delay in making the final diagnosis of ACE inhibitor-induced cough. Frequently, physicians gave other diagnoses, ordered unnecessary diagnostic tests, and ordered treatments other than the discontinuation of ACE inhibitor therapy. Earlier identification would be more cost-effective.

Informational yield of comprehensive Geriatric Home Assessment.

OBJECTIVE: The purpose of this study was to compare the relative informational yield of Geriatric Home Assessments with medical charts of patients seen in family practice settings. METHODS: The information from comprehensive Geriatric Home Assessments of 28 well-established patients, conducted by small groups of medical students in a family practice clerkship, was compared with information available in the medical charts of these patients for the previous three years. RESULTS: For no problem studied was identification in the medical chart as high as from the Geriatric Home Assessment. Problems with family/social support, inadequate dental care, and immunization deficiencies were frequently noted in the Geriatric Home Assessment but only rarely in the medical chart. Concordance between Geriatric Home Assessment and medical charts was greatest for depression/anxiety, sensory loss, smoking, dizziness, and sleep problems. CONCLUSIONS: While evaluation of the utilization of information was beyond the scope of the current study, the results suggest the potential usefulness of complementing office care with home assessments in establishing a data base for the medical management of elderly patients in primary care settings.

Caring for nursing home patients: strategies to avoid conflict.

The need for primary care physicians to care for nursing home patients will continue to increase as America's population ages. Although some conflicts persist, nursing home practice can be gratifying for the physician if certain patient care strategies are followed. Measures that can help make the practice more efficient and rewarding include careful planning, setting limits on the practice, establishing patient goals early, developing a strong rapport with nursing home staff and patients' families, and gaining an understanding of local and federal regulations. Primary care physicians can also play a significant role in improving the quality of life for patients in this setting.

Breast disorders in nursing mothers.

Family physicians should be familiar with the details of breast feeding and with the breast disorders that may occur during lactation. Such disorders range from relatively minor problems, such as sore nipples, milk stasis and mastitis, to more serious conditions, such as abscesses and neoplasms. Inflammatory changes are easily treated with frequent breast emptying; infectious processes require antibiotics. Surgical intervention may be needed for some conditions. Pregnancy or lactation should not delay or alter the diagnosis and treatment of suspected breast carcinoma.

Comparison of the blastogenic response of peripheral blood lymphocytes from canine parvovirus-positive and -negative outbred dogs.

Lymphocyte blast transformation assays (LBT) were performed on canine parvovirus (CPV) -positive and -negative mongrel dogs randomly selected from a humane facility. Concanavalin A as well as Phytohemagglutinin P stimulation was depressed (p less than 0.001) in the group of animals shedding CPV compared to CPV-negative dogs.