Adult Physicians Research Articles

Atlantoaxial subluxation as an early manifestation in an adolescent with undifferentiated spondyloarthritis: a case report and review of the literature

IntroductionAtlantoaxial instability has been described as a manifestation of ankylosing spondylitis (juvenile and adult onset), reactive arthritis, juvenile idiopathic arthritis, and rheumatoid arthritis; however, it has rarely been reported as an early manifestation of these disorders. We present this case report to increase awareness of the condition in the hope that earlier recognition of this disease may prevent further serious injury.Case presentationWe report the case of a 17-year-old Hispanic adolescent woman who was initially diagnosed with undifferentiated spondyloarthritis due to peripheral arthritis, enthesitis, a positive human leukocyte antigen B27 result, and inflammatory spinal pain lasting two months. Our patient experienced persistent and worsening occipitocervical pain and signs of myelopathy three months after diagnosis; consequently, we found atlantoaxial instability along with cervical spine bone erosion and pannus formation. She was treated surgically with a C1-2 posterior instrumented fusion and at six weeks post-operatively was started on tumor necrosis factor α blockade. Her occipitocervical symptoms subsided following surgery and initiation of immunomodulation.ConclusionsOur report serves to emphasize to pediatric and adult general practitioners, pediatricians, internists, family physicians, pediatric and adult rheumatologists and spine surgeons that atlantoaxial subluxation may be an early manifestation of spondyloarthritis, and that the condition is treatable by surgical intervention and immunomodulation.

Analysis of Prescribing Patterns for Mixed Dyslipidemia Among Adult Primary Care Physicians and Cardiologists in a Multispecialty Group

Analysis of Prescribing Patterns for Mixed Dyslipidemia Among Adult Primary Care Physicians and Cardiologists in a Multispecialty Group

Improving the transition between paediatric and adult healthcare: a systematic review

IntroductionThe transition between paediatric and adult care for young people with chronic illness or disability is often poorly managed, with adverse consequences for health. Although many agree that adolescent services...

Primary care physician perspectives on providing adult vaccines

Recently, several new vaccines have been recommended for adults. Little is known regarding the immunization purchase and stocking practices of adult primary care physicians. To determine the proportion of family practice and internal medicine physicians who routinely stock specific adult vaccines and their rationale for those decisions, we conducted a cross-sectional survey in 2009 of a national random sample of 993 family physicians (FPs) and 997 general internists (IMs) in the US. Of the 1109 respondents, 886 reported that they provide primary care to adults aged 19–64 years and 96% of these physicians stock at least one vaccine recommended for adults. Of those, 2% plan to stop and 12% plan to increase vaccine purchases; the rest plan to maintain status quo. Of the respondents, 27% (31% FPs vs 20% IMs) stocked all adult vaccines. We conclude that many primary care physicians who provide care to adults do not stock all recommended immunizations. Efforts to improve adult immunization rates must address this fundamental issue.

Estimation de la douleur induite par les soins de réanimation par les différentes catégories de soignants

ObjectivesTo assess the procedures considered as the most painful by health personnel of two adult critical care units. MethodsIndividual written survey with a questionnaire about 46 potentially painful procedures. Each individual has to estimate the pain intensity as well as the frequency of performance for each painful procedures. ResultsOne hundred questionnaires were provided (15 physicians, 71 nurses and 14 auxiliaries). The rate of answer was 53 % and 2110 scores were recorded and analyzed. The insertion of a pleural drain was associated with the higher pain score (7.5 [6.5–9]). Discrepancies were observed between the professional categories in ranking painful procedures. However, the mobilization of a severe trauma patient, the removal of an otorhinolaryngological or a pleural drain were classified in the 10 most painful procedures by physicians, nurses as well as auxiliaries. Whatever the procedure was, the median global scores estimated by the auxiliaries (n=385; 6 [4–7]) were higher than those corresponding to the nurses (n=1267; 5 [3–7]) (p<0.01). Nurses attributed a higher score than the physicians for 39 of 46 procedures. No relation was found between the estimated pain intensity and the estimated frequency of the procedures. ConclusionAs in paediatrics, adult intensivist physicians underestimate pain during procedure comparing with nurses and auxiliaries. Consequently, health care professionals should elaborate protocols to accurately assess, prevent, or treat painful procedures in intensive care units.

Adults with left-to-right cardiac shunts and with shunts treated in childhood

Pediatric cardiac care has advanced over the past decade and many children born with heart defects have been operated and managed resulting in improvement of outcome and life expectancy. This review focuses on patients born with left-to-right shunts that survive into adulthood and we believe it is important for the adult primary care physician to realize that more and more patients with congenital heart defects will enter into their practice over the next several decades as improvements in childhood cardiac care continue to be made. Although the field of adult congenital heart disease continues to grow and advance, the number of cardiologists specifically trained in this area are not yet adequate to deal with the growing amount of patients with these conditions. This requires a concerted effort from cardiologists of both adult and pediatric specialties, but perhaps more importantly from the multitude of primary care physicians that will most probably be the only physicians many of these patients will ever see. Many adult patients born with left-to-right heart lesions underwent treatment and repair early in childhood and might not have felt it necessary to continue follow-up with a cardiologist. Many other patients with these defects might have survived to adulthood without diagnosis and could present to the primary care provider with new symptoms that finally developed. Primary care physicians will most certainly be at the frontlines of caring for these congenital heart defects.

Adult Outcome of Extremely Preterm Infants

Survival rates for extremely preterm (<28 weeks' gestational age) infants have increased and are approaching 3 in 4 with the advent of modern perinatal and neonatal intensive care. In contrast with some children with chronic diseases such as cystic fibrosis, most survivors of extreme prematurity have no ongoing health issues. However, as a group, they do have higher rates of adverse health outcomes, and more of them will present to pediatricians over time and, ultimately, to adult physicians as they grow older. Pediatricians can aid the transition to adult health care by being aware of the nutritional, cardiovascular, respiratory, motor, cognitive, psychiatric, and functional outcomes into adulthood of survivors of extreme prematurity.

End-of-life needs as perceived by terminally ill older adult patients, family and staff

Purpose of the study A comparison of inpatient end-of-life needs as perceived by terminally ill older adult patients, family, physicians and nurses, is lacking. This study aimed to compare the importance attributed to different end-of-life needs by terminally ill older adult patients in long-term care facilities, their families and care providers (physicians and nurses). Method This descriptive, cross-sectional study recruited a convenience sample of 451 subjects, including 73 terminally ill older adult patients, 58 family members, 71 physicians and 249 nurses, from two Israeli geriatric centers. Results This study found a high congruence between the staff and terminally ill older adults and their families regarding most needs identified as important to dying people. The five needs identified as most important by all subjects were: not suffering pain, having no difficulty breathing, maintaining dignity, having someone who listens, and receiving adequate nursing care. The results of this survey suggest that for terminally ill older adult patients and their families, physical care is crucial. In contrast, nurses attribute higher significance to spiritual needs, but this finding may be affected by the fact that the rate of religiosity among nurses was much higher than among all other research groups. Conclusions Identifying terminally ill older adults’ end-of-life needs may enable nurses and physicians to modify and improve end-of-life care. This could result in a substantial decrease in suffering amongst nursing home terminally ill older adult patients and their families.

Transition: a rheumatology perspective

This article reviews the evidence regarding the process of transition which young people experience when moving from paediatric to adult care. Rheumatology has championed this process and this article prioritizes the perspective of adult physicians.

Physician preferences and knowledge gaps regarding the care of childhood cancer survivors: A survey of ASCO oncologists.

9560 Background: Outside of the pediatric oncology specialty, little is known about physicians' attitudes and knowledge regarding the health care needs and long term follow-up care (LTFU) of childhood cancer survivors (CCS). We sought to obtain adult cancer physicians' self-reported attitudes and knowledge regarding this population. Methods: Following a pre-notification letter, surveys including a $5 gift card were mailed to 1,249 U.S. medical oncologists from the ASCO membership directory in November 2009. A second mailing to non-responders is planned. Results: In response to the first mailing, 346 surveys have been returned (28% response rate). Respondents' median age is 53 years (range: 33-79); 80% men; 30% practice in an academic medical center; 16% in a cancer center; 51% in private practice. Respondents practiced a median of 20 years (range: 1-41) and see a median of 60 patients/week (range: 0-700). When describing comfort levels in caring for CCS (1 = very uncomfortable; 7 = very comfortable), respondents were most comfortable with survivors > 30 years (mean ± SD 6.2 ±1.3), less comfortable with those >18 years and < 30 years (mean 5.7 ± 1.4), and least comfortable with CCS ≤ 18 years (mean 3.6 ± 2.0). In response to a vignette of a 26 year old female treated with mantle radiation at 16 years, based on available guidelines, 45% of respondents did not appropriately recommend yearly breast cancer surveillance; 84% did not appropriately recommend cardiac surveillance; and 55% did not appropriately recommend yearly thyroid screening. Only 4% of respondents answered all three questions in accordance with available guidelines, and those respondents were more likely to be familiar with the guidelines (p<0.05) and have received training in LTFU of CCS (p=0.02). Conclusions: Medical oncologists express a range of preferences with regard to LTFU of childhood cancer survivors. Many appear unfamiliar with LTFU surveillance guidelines. No significant financial relationships to disclose.

C-A2-02: Virtual Consult Use in an Electronic Medical Record: Descriptive Statistics at Mid-Point of Study

Ted E Palen, PhD, MD, MSPH, David W Price, MD, Kristin Wallace, MPH and Susan M Shetterly, MS Ted E Palen, PhD, MD, MSPH, Institute Kaiser Permanente Colorado; David W Price, MD, Kaiser Permanente Colorado; Kristin Wallace, MPH, Kaiser Permanente Colorado; Susan M Shetterly, MS, Kaiser Permanente Colorado

Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: Introduction

With advances in pediatric cardiology and cardiac surgery, the population of adults with congenital heart disease (CHD) has increased. In the current era, there are more adults with CHD than children. This population has many unique issues and needs. Since the 2001 Canadian Cardiovascular Society consensus conference report on the management of adults with CHD, there have been significant advances in the field of adult CHD. Therefore, new clinical guidelines have been written by Canadian adult CHD physicians in collaboration with an international panel of experts in the field. The present introductory section is a summary of the epidemiology and scope of adult CHD in Canada, the structure of the Canadian health care system and adult congenital cardiac health services in Canada. The recommendations for antibiotic prophylaxis and genetic evaluation in this population are included. The complete document consists of four manuscripts, which are published online in the present issue of The Canadian Journal of Cardiology, including sections on genetics, outcomes, diagnostic workups, surgical and interventional options, treatment of arrhythmias, assessment of pregnancy and contraception risks, and follow-up recommendations. The complete document and references can also be found at www.ccs.ca or www.cachnet.org.

Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: Shunt lesions

With advances in pediatric cardiology and cardiac surgery, the population of adults with congenital heart disease (CHD) has increased. In the current era, there are more adults with CHD than children. This population has many unique issues and needs. Since the 2001 Canadian Cardiovascular Society Consensus Conference report on the management of adults with congenital heart disease, there have been significant advances in the field of adult CHD. Therefore, new clinical guidelines have been written by Canadian adult CHD physicians in collaboration with an international panel of experts in the field. Part I of the guidelines includes recommendations for the care of patients with atrial septal defects, ventricular septal defects, atrioventricular septal defects and patent ductus arteriosus. Topics addressed include genetics, clinical outcomes, recommended diagnostic workup, surgical and interventional options, treatment of arrhythmias, assessment of pregnancy risk, and follow-up requirements. The complete document consists of four manuscripts, which are published online in the present issue of The Canadian Journal of Cardiology. The complete document and references can also be found at www.ccs.ca or www.cachnet.org.

Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: Complex congenital cardiac lesions

With advances in pediatric cardiology and cardiac surgery, the population of adults with congenital heart disease (CHD) has increased. In the current era, there are more adults with CHD than children. This population has many unique issues and needs. They have distinctive forms of heart failure and their cardiac disease can be associated with pulmonary hypertension, thromboemboli, complex arrhythmias and sudden death. Medical aspects that need to be considered relate to the long-term and multisystemic effects of single ventricle physiology, cyanosis, systemic right ventricles, complex intracardiac baffles and failing subpulmonary right ventricles. Since the 2001 Canadian Cardiovascular Society Consensus Conference report on the management of adults with CHD, there have been significant advances in the field of adult CHD. Therefore, new clinical guidelines have been written by Canadian adult CHD physicians in collaboration with an international panel of experts in the field. Part III of the guidelines includes recommendations for the care of patients with complete transposition of the great arteries, congenitally corrected transposition of the great arteries, Fontan operations and single ventricles, Eisenmenger's syndrome, and cyanotic heart disease. Topics addressed include genetics, clinical outcomes, recommended diagnostic workup, surgical and interventional options, treatment of arrhythmias, assessment of pregnancy risk and follow-up requirements. The complete document consists of four manuscripts, which are published online in the present issue of The Canadian Journal of Cardiology. The complete document and references can also be found at www.ccs.ca or www.cachnet.org.

Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: Executive summary

With advances in pediatric cardiology and cardiac surgery, the population of adults with congenital heart disease (CHD) has increased. In the current era, there are more adults with CHD than children. This population has many unique issues and needs. They have distinctive forms of heart failure, and their cardiac disease can be associated with pulmonary hypertension, thromboemboli, complex arrhythmias and sudden death.Medical aspects that need to be considered relate to the long-term and multisystemic effects of single-ventricle physiology, cyanosis, systemic right ventricles, complex intracardiac baffles and failing subpulmonary right ventricles. Since the 2001 Canadian Cardiovascular Society Consensus Conference report on the management of adults with CHD, there have been significant advances in the understanding of the late outcomes, genetics, medical therapy and interventional approaches in the field of adult CHD. Therefore, new clinical guidelines have been written by Canadian adult CHD physicians in collaboration with an international panel of experts in the field. The present executive summary is a brief overview of the new guidelines and includes the recommendations for interventions. The complete document consists of four manuscripts that are published online in the present issue of The Canadian Journal of Cardiology, including sections on genetics, clinical outcomes, recommended diagnostic workup, surgical and interventional options, treatment of arrhythmias, assessment of pregnancy and contraception risks, and follow-up requirements. The complete document and references can also be found at www.ccs.ca or www.cachnet.org.

C-A2-01: Virtual Consults in an Electronic Medical Record: Physician Use, Satisfaction, and Learnings

Background/Aims: Shared Electronic Medical Record (EMR) systems could increase communication between primary and specialty care. Electronic (virtual) EMR consults (VC) could streamline patient care. We describe physician use of VCs within Kaiser Permanente’s HealthConnect EMR, compared with traditional requests for consults (TC). Methods: Prospective, observational, case control study comparing VCs with TCs from Kaiser Colorado adult primary care physicians to several specialty departments. Every 2 weeks from June to November 2008, VCs were randomly selected and matched with TCs by requesting physician specialty, reason for referral, referral department, patient gender and age. Referring physicians were asked to complete an online survey on reason for consult, answers received, if answers met immediate patient care needs, likelihood of using (or actual use of) the information in subsequent patient care, the impact of the consult process on physician work flow, and their overall satisfaction with the consult. Results: Eighty-two of 205 unique physicians responded on 62 VCs and 49 TCs; overall return rate was 26.4% (30.0% of 207 VCs and 22.9% of 214 TCs). Etiology, screening and evaluation questions were similarly common reasons for both types of consults; requests to initiate treatment or assume care were more common in TCs. Seventy-four percent of physicians requesting VCs and 39% of those requesting TCs received information from the consultant by the time of survey completion; 91% of these physicians used at least some information from the referral in caring for the index patient. Fifteen percent had already used the information in the care of subsequent patients; 41% thought they would likely use the information in the future; 29% thought they would not likely use the information in the future. Sixty percent of physicians who received information were satisfied with the information from the referral, 24% were dissatisfied, with no difference between VCs and TCs. Conclusions: Referring physicians received information more quickly from VCs than TCs. Consult reasons, use of information received in the index and subsequent patients, and overall satisfaction with information were similar between VCs and TCs. Additional analysis will explore longer term educational outcomes, patient satisfaction, and economic differences between VCs and TCs.

Canadian Cardiovascular Society 2009 Consensus Conference on the management of adults with congenital heart disease: Outflow tract obstruction, coarctation of the aorta, tetralogy of Fallot, Ebstein anomaly and Marfan's syndrome

With advances in pediatric cardiology and cardiac surgery, the population of adults with congenital heart disease (CHD) has increased. In the current era, there are more adults with CHD than children. This population has many unique issues and needs. Since the 2001 Canadian Cardiovascular Society Consensus Conference report on the management of adults with CHD, there have been significant advances in the field of adult CHD. Therefore, new clinical guidelines have been written by Canadian adult CHD physicians in collaboration with an international panel of experts in the field. Part II of the guidelines includes recommendations for the care of patients with left ventricular outflow tract obstruction and bicuspid aortic valve disease, coarctation of the aorta, right ventricular outflow tract obstruction, tetralogy of Fallot, Ebstein anomaly and Marfan's syndrome. Topics addressed include genetics, clinical outcomes, recommended diagnostic workup, surgical and interventional options, treatment of arrhythmias, assessment of pregnancy risk and follow-up requirements. The complete document consists of four manuscripts that are published online in the present issue of The Canadian Journal of Cardiology. The complete document and references can also be found at www.ccs.ca or www.cachnet.org.

Assessing Primary Care Physician`s Beliefs and Attitudes of Asthma Exacerbation Treatment and Follow-Up~!2009-11-18~!2010-01-20~!2010-02-22~!

Objective:The objective of this survey was to assess adult primary care physicians’ and pediatricians’ perceptions of asthma exacerbation management, including beliefs concerning the discharge of patients from the emergency department (ED) following asthma exacerbations.Methods:This was a cross-sectional survey of primary care physicians (PCPs) treating adult or pediatric patients. Surveys were mailed to physicians and included questions on how PCPs define an exacerbation, how they are notified and how they followed-up with their patients who experienced exacerbations.Results:A total of 189 physicians were targeted in this survey, with 124 (65%) returning a completed survey. The majority of physicians agreed that an exacerbation included worsening asthma requiring a course of oral corticosteroids (83%). However, ≥70% of physicians agreed that an exacerbation could also include events which did not require OCS. Overall, 71% of PCPs believed that the majority of their patients’ asthma exacerbations were treated in the doctor’s office with only 6% believing the majority were treated in the ED. Over 90% of PCPs surveyed said they scheduled a follow-up with their patients “all or most of the time” when notified of an ED visit for an asthma exacerbation. Of the adult PCPs surveyed, 20% said they were never notified when one of their patients received treatment in the hospital because of an asthma exacerbation, whereas only 10% of pediatricians said they were never notified. The majority of PCPs surveyed (79%) indicated that if a controller medication was warranted, the ED staff should initiate treatment at time of discharge.Conclusions:This study showed that healthcare providers may not share a common definition of an asthma exacerbation. In addition, most physicians believe that the majority of exacerbations are treated in their office or at home. Further, most agreed that if a controller medication was warranted, the ED or urgent care staff should initiate treatment.

Preparing for Growth: Current Capacity and Challenges in Hematopoietic Stem Cell Transplantation Programs

During the past decade, the demand for hematopoietic stem cell transplantation has grown dramatically, and there are expectations that this will continue or even accelerate over the next decade. This prompts a variety of questions about the ability of the health care system to accommodate the increased demands on transplantation centers; for example, what is the current patient capacity of transplantation programs, and how much elasticity do they have to accept a larger volume of patients? An informal survey of a sample of medical directors of transplantation programs found that existing facilities might be able to increase their patient volume by about 7%. Expanding much beyond that limit will require an infusion of resources to enlarge current programs and/or establish new programs.

Caring for adults with cystic fibrosis

Adults with cystic fibrosis (CF) will soon outnumber children, thus CF is a disease that adult and pediatric physicians must understand. Adults with CF face a very difficult challenge: to have a career and/or a family while still finding the time to keep up the often demanding treatment regimen required to maintain their health in the face of a complicated multisystem disease, such as CF. It is our duty as physicians to help them meet this challenge by providing effective and compassionate care. More and more effective treatments for CF are gradually becoming available that will markedly enhance the quality of life and improve survival for patients with CF. Intelligently integrating these new therapies with existing therapies to minimize treatment burden while maximizing the benefit of these therapies to maintain lung function and prolong life is perhaps the greatest challenge we face as CF caregivers. It is a wonderful challenge to face for CF patients and their caregivers.