Non-specialist Physician Research Articles

Recent Improvements in Attainment of the Hemoglobin A1c Target of ≤7.0% Among Adults with Type 1 Diabetes in Ontario: A Retrospective Cohort Study.

Aims: We evaluated attainment of the hemoglobin A1c (HbA1c) target of ≤7.0%, its temporal trends, and associated factors among adults with type 1 diabetes in Ontario, Canada, using administrative data. Methods: We conducted a retrospective cohort study, including Ontarians with type 1 diabetes ≥18 years old with ≥1 HbA1c test between April 1, 2012 (fiscal year 2013), and March 31, 2023. Generalized estimating equations were used to determine probabilities of meeting the HbA1c target, as well as associations between fiscal year and individual-, physician-, and system-level factors on odds of meeting the target. Results: Among 28,827 adults with type 1 diabetes [14,385 (49.9%) female, 17,998 (62.4%) pump users], with median age at index of 25 years [interquartile range (IQR) 18-37] and median diabetes duration of 12 years [6-18], there were 474,714 HbA1c tests [median 2/individual/year (IQR: 1-3)]. The model-estimated probability of meeting the HbA1c target of ≤7.0% was 22.1% (95% confidence interval, CI: 21.6 to 22.5) in 2013, remained stable until 2020, and increased to 34.7% (95% CI: 34.3 to 35.2) in 2023. The age- and sex-adjusted odds ratio for meeting the target in 2023 versus 2013 was 1.87 (95% CI: 1.79 to 1.96). Young adults (18-25 years), diabetic ketoacidosis, greater comorbidity, and receiving diabetes care from a nonspecialist physician were associated with reduced odds of meeting the HbA1c target. Conclusions: One-third of adults with type 1 diabetes in Ontario met the recommended HbA1c target of ≤7.0% in 2023, with improvement noted since 2021, which may be due to advanced technologies or effects of the COVID-19 pandemic.

The economic burden associated with unmet surgical needs in Liberia: a retrospective macroeconomic analysis based on a nationwide enumeration of surgical procedures

ObjectivesThe economic consequences of untreated surgical disease are potentially large. The aim of this study was to estimate the economic burden associated with unmet surgical needs in Liberia.DesignA nationwide enumeration...

Point of care ultrasonography in the evaluation of myocardial dysfunction due to sepsis.

Background: Septic shock is commonly diagnosed in critically ill patients and is an important cause of mortality. Techniques used to assess fluid responsiveness and hemodynamic profile with physical examination and central venous pressure have been shown to be insufficient. Thus, the importance of other methods, such as bedside ultrasound (POCUS), is evident. The aim of this study was to analyze patients with septic shock who developed left ventricular dysfunction by POCUS. Methods: Prospective study involving 14 patients diagnosed with septic shock, over 18 years old, without previous cardiac pathologies. Clinical, laboratory and imaging data were collected. POCUS was applied by a cardiology resident; the results were compared with those found by an echocardiographer. Results: Variables were compared between patients with normal and depressed ventricular function (VF). Mean arterial pressure was significantly lower in patients with depressed VF (p = 0.01). Vasopressor drug dose and Pro-BNP value were significantly higher in patients with depressed VF (p = 0.01). Regarding the POCUS inter-rater comparison, the variables of left ventricular global systolic function, vena cava index and presence of B line were significantly concordant (p= 0.02; 0.003; 0.002). Conclusions: Patients with depressed VF had a greater severity of shock, suggesting refractoriness, with cardiac dysfunction as a possible aggravating factor, which was visualized only by POCUS and corroborated by higher Pro-BNP values. A short POCUS training is enough for the non-specialist physician to be able to use this resource in the management of these patients.

Epilepsy in Niger: An overview of the current situation.

A major public health concern in the world, particularly in sub-Saharan African countries, epilepsy is poorly studied in Niger, and its prevalence in the general population is unknown. Only two hospital-based studies have been published in Niger, reporting an estimated mean hospital prevalence of epilepsy of 24.2% (95% CI: 23.2-25.2), mainly affecting patients younger than 18 years (54.6%, 95% CI: 52.2-57.0), and males (59.8%, 95% CI: 57.4-62.2). To date in Niger, people living with epilepsy (PWE) are usually cared for by non-physician healthcare workers (mainly nurse technicians in mental health), general medical doctors (non-specialist physician), and non-neurologist physicians. In routine practice, these health workers make the diagnosis of epilepsy essentially based on the clinic, i.e., the repetition of epileptic seizures over time (mainly generalized tonic-clonic seizures) because most of them practiced in health centers or district hospitals or regional hospital centers in which electroencephalogram and neuroradiological explorations are of limited access or unavailable as well as a referral neurologist. Only 10 neurologists are currently practicing in Niger for a total population estimated at 21466800 inhabitants by the World Health Organization in 2018. In 41.8% (95% CI: 39.4-43.2) of the cases, the etiology was unknown with neuroradiological explorations and laboratory tests not performed in most cases. Genetic etiologies are the most frequent etiologies (40.8; 95% CI: 38.4-43.2), followed by Structural etiologies (11.7; 95% CI: 10.1-13.3) particularly hypoxic-ischemic brain injury, and infectious etiologies (6.8%; 95% CI: 5.6-8.0), especially cerebral malaria. PWEs are the target of social stigma and discrimination due to erroneous cultural and religious beliefs about epilepsy of the people from Niger. The present review is an update on the different aspects of epilepsy in Niger.

Mapping of referral patterns for undescended testes – Risk factors for referral of children with normal testes

Accurate referral of boys with suspected undescended testes (UDT) is of importance to preserve fertility and reduce risk of future testicular cancer. While late referral is well studied, there is less knowledge about incorrect referrals, hence, referral of boys with normal testes. To evaluate the proportion of UDT referrals that did not lead to surgery or follow-up, and to assess risk factors for referral of boys with normal testes. All UDT referrals to a tertiary center of pediatric surgery during 2019-2020 were retrospectively assessed. Only children with suspected UDT in the referral (not suspected retractile testicles) were included. Primary outcome was normal testes at examination by a pediatric urologist. Independent variables were age, season, region of residence, referring care unit, referrer's educational level, referrer's findings, and ultrasound result. Risk factors for not needing surgery/follow-up were assessed with logistic regression and presented as adjusted odds ratios with a 95% confidence interval (aOR, [95% CI]). A total of 378 out of 740 included boys (51.1%) had normal testes. Patients >4 years (aOR 0,53, 95% CI [0,30-0,94]), referrals from pediatric clinics (aOR 0.27, 95% CI [0.14-0.51]) or surgery clinics (aOR 0.06, 95% CI [0.01-0.38]) had lower risk of normal testes. Boys referred during spring (aOR 1.80, 95% CI [1.06-3.05]), by a non-specialist physician (aOR 1.58, 95% CI [1.01-2.48]) or referrer's description of bilateral UDT (aOR 2.34, 95% CI [1.58-3.45]), or retractile testes (aOR 6.99, 95% CI [3.61-13.55]) had higher risk of not needing surgery/follow-up. None of the referred boys that had normal testes had been re-admitted at the end of this study (October 2022). Over 50% of boys referred for UDT had normal testes. This is higher or equal to previous reports. Efforts to reduce this rate should in our setting probably be directed towards well-child centers and training in examination of testicles. The main limitation of this study is the retrospective design and the rather short follow-up time, which however should have very modest effect on the main findings. Over 50% of boys referred for UDT have normal testes. A national survey regarding the management and examination of boys testicles has been launched and directed at well-child centers to further evaluate the findings of the current study.

P299 What happens if the rheumatologist is no longer the gatekeeper to temporal artery ultrasound in giant cell arteritis?

Abstract Background/Aims Prior to 2019, temporal artery ultrasound (TAUS) was introduced under close supervision of rheumatology consultants to support the diagnosis of giant cell arteritis (GCA). Evaluation of these early scans highlighted how the majority of patients presented via the acute medical unit (AMU). In 2019 a GCA fast-track pathway (GCA-FTP) was introduced at our centre in collaboration with AMU colleagues. The aim was to promote early utilisation of TAUS by expanding access of this test to physicians working across acute care prior to specialist rheumatology input, in contrast to many other units. This evaluation sought to establish if the new GCA-FTP led to improved presentation to scan times, as well as assessing the impact on availability of TAUS. Methods A retrospective analysis of data was carried out on all patients referred with suspected GCA for TAUS during a 4-month period in 2020. Results were compared with those from the 2019 evaluation and benchmarked against BSR GCA guidelines. An ultrasound was considered positive if a definite halo sign, or irregular thickening consistent with arteritis, was reported. Clinical records were reviewed to identify the final diagnosis made following the rheumatology consult. The rheumatologist’s intention to treat for GCA was considered the ‘gold standard’. Results We identified 58 patients (39 female, 19 male) with a mean age of 68 years (range 40-90). A positive TAUS was reported in 7/58 cases, with 4/58 reported as inconclusive and 47/58 as negative. A positive ultrasound in our cohort carried a sensitivity of 64% and specificity of 100%. A total of 50 patients were referred to a rheumatologist, of which 17/50 (34%) were reviewed on the same day. 8 patients were given an alternative diagnosis without rheumatology input and were deemed to have low clinical probability of GCA. The average number of scans per week was 2.2, compared to 0.4 pre pathway. The scans were requested by rheumatologists (21/58, 36%), acute physicians (15/58, 26%), ophthalmologists (13/58, 22%), emergency department physicians (1/58, 2%), other (5/58, 9%) and unknown source (3/58, 5%). Median time from initial review to scan request was <1 working day compared to 2 days pre-pathway. Median time from scan request to performance was 1 working day (previously 2 days). All scans were performed within 4 days of the request. Conclusion Despite reservations that enabling the non-specialist physician to access TAUS might overwhelm TAUS capacity, we have shown the opposite. Despite the higher volume of requests, the scans were requested earlier in the patient journey and performed more quickly. Diagnostic specificity remained high, despite more than 50% of the TAUS studies being requested by non-rheumatologists. We have shown that acute care physicians were able to successfully initiate diagnostic work-up in a collaborative GCA pathway. Disclosure A. Redfern: None. R. Benson: None. C. Cotton: None. C. Amoasii: None. D. Mewar: None.

Color Dependence Analysis in a CNN-Based Computer-Aided Diagnosis System for Middle and External Ear Diseases

Artificial intelligence-assisted otologic diagnosis has been of growing interest in the scientific community, where middle and external ear disorders are the most frequent diseases in daily ENT practice. There are some efforts focused on reducing medical errors and enhancing physician capabilities using conventional artificial vision systems. However, approaches with multispectral analysis have not yet been addressed. Tissues of the tympanic membrane possess optical properties that define their characteristics in specific light spectra. This work explores color wavelengths dependence in a model that classifies four middle and external ear conditions: normal, chronic otitis media, otitis media with effusion, and earwax plug. The model is constructed under a computer-aided diagnosis system that uses a convolutional neural network architecture. We trained several models using different single-channel images by taking each color wavelength separately. The results showed that a single green channel model achieves the best overall performance in terms of accuracy (92%), sensitivity (85%), specificity (95%), precision (86%), and F1-score (85%). Our findings can be a suitable alternative for artificial intelligence diagnosis systems compared to the 50% of overall misdiagnosis of a non-specialist physician.

Industry payments to Australian medical oncologists and clinical haematologists: a cross-sectional analysis of publicly available disclosures.

Payments to medical oncologists and clinical haematologists can negatively affect prescribing practice, but the extent of payments to these specialists is unknown in Australia. To analyse the extent of payments from the pharmaceutical industry to Australian cancer physicians as reported during the first collated period of the Disclosure Australia website. We performed a retrospective, cross-sectional analysis of payments made from November 2018 to April 2019, using a file downloaded from the Disclosure Australia website. We checked the names of listed medical practitioners against Medical Board of Australia records to assign specialties. The number of medical oncologists, clinical haematologists, other specialist physicians and non-specialist physician medical practitioners was calculated, along with the payments to each of these groups. A total of A$7 332 407 was paid to 2775 medical practitioners. Of these, 236 were medical oncologists, 189 were haematologists and 1145 were other specialist physicians. This represents 31.7% of Australian medical oncologists and 30.9% of Australian haematologists, compared with 11.7% of all other specialist physicians and 1.1% of all other non-specialist physician medical practitioners. Medical oncologists received significantly higher payments (median A$2131.26) than other specialist physicians (median A$1376.00, 2-tailed P = 0.004) and other medical practitioners (median A$709.00, 2-tailed P < 0.001), while haematologists received significantly higher payments (median A$1519.95) than other medical practitioners (2-tailed P < 0.001), but similar payments to other specialist physicians (2-tailed P = 0.08). Australian cancer physicians receive payments at a higher proportional frequency and in greater dollar amounts than other specialist physicians and other medical practitioners in general.

Peer review of non-specialist occupational physician reports.

Peer review of non-specialist occupational physician reports Christopher W Ide Christopher W Ide e-mail: christopher_ide@yahoo.co.uk https://orcid.org/0000-0001-9574-5387 Search for other works by this author on: Oxford Academic PubMed Google Scholar Occupational Medicine, Volume 71, Issue 2, March 2021, Page 109, https://doi.org/10.1093/occmed/kqab008 Published: 09 April 2021

Absceso de Brodie, una patología de difícil diagnóstico

Las infecciones osteoarticulares agudas pediátricas constituyen patologías poco frecuentes, siendo de suma importancia realizar un diagnóstico precoz y tratamiento adecuado para evitar las complicaciones agudas o a largo plazo. El absceso de Brodie (AB) es una forma de osteomielitis subaguda de baja incidencia y de difícil diagnóstico, por lo que es imprescindible la sospecha clínica.Objetivo: Presentar un caso de AB y describir las características etiológicas y clínicas de esta patología.Caso Clínico: Paciente 14 años, evaluado por dolor de muslo derecho de un mes de evolución, afebril y sin antecedente de trauma. Al examen físico no presentaba aumento de volumen, el rango de movimiento (ROM) de cadera derecha era doloroso y la sensibilidad estaba aumentada a la palpación superficial de banda iliotibial (BIT) derecha. Estudio radiológico sin alteraciones. Por persistir síntomas se solicitó ecografía de muslo que mostró irregularidad ósea cortical. Resonancia Magnética (RM) evidenció lesión en diáfisis de fémur derecho de probable origen tumoral o infeccioso. Parámetros inflamatorios sin alteraciones. Se realizó toma de biopsia y cultivos, aislando Staphylococcus aureus multisensible. Se procedió a aseo quirúrgico y terapia antibiótica endovenosa, evolucionando favorablemente.Conclusiones: La presentación clínica y laboratorio en AB pueden ser inespecíficas. El clínico no especialista debe tener un alto índice de sospecha de esta patología como posible diagnóstico diferencial en pacientes que persisten con dolor y presentan una alteración radiológica, incluso ante la ausencia de otros síntomas y parámetros inflamatorios normales. Es importante realizar una biopsia ósea para el diagnóstico diferencial de patologías tumorales.

Peer review audit of non-specialist occupational physician reports.

With declining specialist occupational physician (OP) numbers, there is increasing recognition of the importance of non-specialist physicians in occupational health (OH) service delivery, yet to date, this physician group remains understudied and their competency requirements poorly understood. To evaluate the quality of a sample of non-specialist OH reports and compare these with specialist reports. A retrospective peer review audit of a convenience sample of 200 consecutive non-specialist and specialist OH reports from an Irish OH service using an assessment form based on the modified Sheffield Assessment Instrument for Letters SAIL(OH)1. Of the 200 peer reviewed OH reports, 159 (80%) were from non-specialists. For all questions, 87% and above of non-specialist reports were 'satisfactory' or 'above expected'. On the overall assessment, out of 10, the mean non-specialist report score was 6.8 (standard deviation (SD) 3-10) and the specialist score was 7.3 (SD 3-10). Comparatively, non-specialist reports highlighted legal/ethical issues marginally more and adhered slightly better to contractual/ethical/legal boundaries, while specialist reports fared better in addressing manager's questions, in their structure and clarity and in covering all significant aspects of the case, particularly if the case was complex. Our findings demonstrate a high standard of OH report quality in this sample of non-specialist OPs that is consistent across all key OH report components. Potential development areas are also identified that can inform education/training tailored to this physician group and assist in competency standard-setting.

Medical software applications for in-hospital insulin therapy: A systematic review.

BackgroundIn-hospital hyperglycemia (HH) is frequent and related to higher morbidity and mortality. Despite the benefits of HH treatment, glycemic control is often poor and neglected. The use of health applications to support diagnosis and therapy is now incorporated into medical practice. Medical applications for inpatient glycemic management have potential to standardize this handling by the nonspecialist physician. However, related studies are scarce. We aim to evaluate the efficacy in inpatient glycemic control parameters of medical software applications in non-critical care settings.MethodsThis systematic review on in-hospital insulin applications was performed according to PRISMA guidelines. Data were extracted in triplicate and methodological quality was verified. Specific outcomes of interest were glycemic control efficacy, hypoglycemia risk, length of in-hospital stay, integration with the electronic medical record and healthcare staff acceptance.ResultsAmong the 573 articles initially identified and subsequent revision of the references of each one, seven studies involving six applications were eligible for the review. A better glycemic control was reported with the use of most in-hospital insulin applications in the studies evaluated, but there was no mention of the time to reach the glycemic goal. The risk of hypoglycemia was low. Different reasons influenced the varied acceptance of the use of applications among health professionals.ConclusionThe six applications of inpatient insulin therapy in a non-critical care environment proved to be useful and safe compared to the usual management. Medical apps are tools that can help improve the quality of patient care.

Four Child Health Histories for Philadelphia, 1846–52

This is an examination of a particular form of physician-cum-family child health documentary history. The document is used for two purposes. First, to confirm the macro-level assessments on the objective reasons for the decline in middle-class infant mortality in Philadelphia (circa 1820–60) and to reveal the interaction of those factors/initiatives within one concrete family. Second, to explore the subjective conceptual understanding of infant health and development for a nonspecialist physician and a middle-class family in the mid-nineteenth century. The study has relevance for the very early beginning of what became the infant-health movement in America’s eastern urban centers (Meckel, Save the Babies). As a unique document, it offers guidance on how the topic of “infant health” could be conceived, enhanced, and recorded.

Expanding Treatment Access for Chronic Hepatitis C with Task-shifting in the Era of Direct-acting Antivirals.

In the United States, the fight to eradicate hepatitis C virus (HCV) infection has been ongoing for many years, but the results have been less than ideal. Historically, patients with chronic hepatitis C (CHC) were treated with interferon-based regimens, which were associated with frequent adverse effects, suboptimal response rates, and long durations of treatment – of up to 48 weeks. Expertise from specialist-physicians, such as hepatologists and gastroenterologists, was needed to closely follow patients on these medications so as to monitor laboratory values and manage adverse effects. However, the emergence of direct-acting antiviral (DAA) agents against HCV infection have heralded outstanding progress in terms of safety, tolerability, lack of adverse effects, efficacy, and truncated duration of therapy – 12 weeks or less – thereby making the need for close monitoring by specialist-physicians obsolete. With the recent approval of DAA agents by the Food and Drug Administration, the treatment model for CHC no longer relies on the limited number of specialist-physicians, which represented a major barrier to treatment access in the past, especially in underserved areas of the United States. We propose and share our experiences in adapting a task-shifting treatment model, one that utilizes a relatively larger pool of non-specialist healthcare providers, such as nursing staff (medical assistants, vocational licensed nurses, registered nurses, etc.) and advanced practice providers (nurse practitioners and physician assistants), to perform a variety of important clinical functions in an effort to make DAA-based antiviral therapy widely available against HCV infection. Most recently, task-shifting was implemented by the United States and World Health Organization in the fight against the human immunodeficiency virus and showed encouraging results. Based on our experiences in implementing this model at our outreach clinics, the majority of HCV-infected patients treated with DAA agents can be easily monitored by non-specialist healthcare providers and physician extenders. Task-shifting can effectively address one of the major rate-limiting factors in expanding treatment access for HCV infection.

HYT-hypertension in Turkey: a cross-sectional survey on blood pressure control with calcium channel blockers alone or combined with other antihypertensive drugs.

Although improved during the past few years, high blood pressure control still remains an unmet goal of antihypertensive drug treatment. Among different antihypertensive agents, calcium channel blockers (CCBs), either as monotherapy or in combination with other drugs are recommended by several guidelines for initiation and maintenance of antihypertensive treatment. The HYT-HYperTension survey, carried out in Turkey was aimed to assess (a) blood pressure control in hypertensive patients under treatment with dihydropyridine CCBs, either as monotherapy or in combination with other drugs and (b) the prevalence of blood pressure control in subgroups of patients with cardiovascular risk factors (previous cardiovascular disease, diabetes, renal disease, isolated systolic hypertension, visceral obesity, overweight, current smoking habit). More than 7000 hypertensive patients (60.0 % men, mean age 61.2 ± 11.5 years), routinely visited by either a specialist or a non-specialist physician in the Primary Care Units of 26 cities across Turkey, were enrolled in the survey. Only patients treated with dihydropyridine-type CCBs, as mono- or combination therapy were included in the study, whereas individuals treated with non-dihydropyridine-type CCBs or with other drug classes (as monotherapy or combination therapy), were excluded. Demographic data (age, gender, height, weight, waist circumference, current smoker habit), clinical data and drug treatments were collected at each visit. Blood pressure was measured with a semiautomatic device (Omron-M6) with the patient in sitting position and after at least 5 min of rest. Measurements were repeated three times, at intervals of 5 min each other. In the overall survey population blood pressure control (blood pressure <140/90 mmHg) was achieved in 31.7 % of patients and the average systolic and diastolic blood pressure was 145.3/88.2 mmHg. Prevalence of patients treated with dihydropyridine-type CCBs, either as monotherapy or combined with other drugs, was superimposable (51.6 vs 48.4 %, P = NS). Dihydropyridine-type CCBs were more frequently combined with drugs acting on the renin-angiotensin-aldosterone system (86.4 %), particularly with ACE-inhibitors (34.1 %) and angiotensin II receptor antagonists (52.3 %), while in 13.6 % of patients CCBs were combined with diuretics and/or beta-blockers. Diabetes mellitus was detected in 22.7 % of patients, obesity in 41.5 % and history of cardiovascular disease in 23.0 % (coronary artery disease in 19.2 % and stroke in 3.8 %). Blood pressure control was more difficult to be achieved in complicated hypertension, particularly when cigarette smoking, obesity, overweight, visceral obesity and renal disease were associated with hypertension. Taken together these findings provide evidence that dihydropyridine-type CCBs, particularly when combined with ACE-inhibitors or angiotensin II receptors blockers, allow to achieve a blood pressure control better than the one reported in the same geographic area by other treatment strategies based on different combinations of diuretics, beta-blockers, ACE-inhibitors, angiotensin II receptors blockers and calcium channel blockers.

The Doctor in Claims for Work Injuries and Ill Health – Legal Pitfalls

Occupational health work is currently undertaken by the specialist and the non-specialist physician alike. The work scope can vary from medical assessments of individual workers to health risk assessment at the workplace. The scope of the latter will include evaluation of exposures, hazards, risks and its management to control these risks. Much of the case law governing legal disputes over industrial safety and health have involved the employers. Over the years, the actions brought forth by workers have resulted in a formidable volume of case law based on statutes and on the common law of negligence in tort. Disputes over the assessment of workers' health or workplace health risks to the extent that it is a failure to discharge a reasonable standard of care, may result in the doctor being a defendant. Measures to prevent these legal pitfalls include communication with employers about the causative link of the illness suffered to workplace factors and the clarity of contractual obligations undertaken with regard to workplace health risk assessment.

The assessment of suicidal inclination by the nonspecialist physician

The assessment of suicidal inclination by the nonspecialist physician

Association Between Physician Specialty and Volumes of Treated Patients and Mortality Among Patients Hospitalized for Newly Diagnosed Heart Failure

Purpose To assess the effects of hospital care by a specialist or nonspecialist physician, and by volume of treated patients, on mortality among hospitalized patients with newly diagnosed heart failure. Methods Data describing heart failure patients in Alberta, Canada, from April 1, 1994, to March 31, 2000, were extracted from hospital abstracts and analyzed using hierarchical regression, with adjustment for patient demographic characteristics, comorbid conditions, physician volume, physician specialty, and hospital volume. Results There were 16,162 hospital discharges for heart failure. Nonspecialist physicians were predominantly in the two lowest-volume quartiles (93%) and specialists were predominantly in the two highest-volume quartiles (68%). Considering the effects of volume alone and after adjustment for comorbidity, for each 10 additional hospital patients treated by a physician, the odds ratio for in-hospital mortality was 0.97 (95% confidence interval [CI]: 0.95 to 0.98), and the odds ratio for 1-year mortality was 0.99 (95% CI: 0.98 to 0.999). In analyses that considered both volume and specialty, the odds of in-hospital mortality decreased by 4% for each 10 additional in-hospital patients treated by a physician (odds ratio [OR] = 0.96; 95% CI: 0.95 to 0.98). In these same analyses, the odds ratio for in-hospital mortality was 1.32 (95% CI: 1.13 to1.53) for general practitioners with specialist consultation and 1.32 (95% CI: 1.08 to 1.61) for specialists compared with general practitioners without specialist consultations. At 1 year, mortality was not associated significantly with the volume of in-hospital patients treated, or with the specialty of the treating physician. Conclusion Treatment by high-volume physicians during hospitalization for newly diagnosed heart failure was associated with a decrease in mortality, but these benefits did not persist at 1 year. The increased mortality noted in patients treated by specialists may be due to residual confounding or unmeasured comorbidity.

Association between physician specialty and volumes of treated patients and mortality among patients hospitalized for newly diagnosed heart failure

To assess the effects of hospital care by a specialist or nonspecialist physician, and by volume of treated patients, on mortality among hospitalized patients with newly diagnosed heart failure. Data describing heart failure patients in Alberta, Canada, from April 1, 1994, to March 31, 2000, were extracted from hospital abstracts and analyzed using hierarchical regression, with adjustment for patient demographic characteristics, comorbid conditions, physician volume, physician specialty, and hospital volume. There were 16,162 hospital discharges for heart failure. Nonspecialist physicians were predominantly in the two lowest-volume quartiles (93%) and specialists were predominantly in the two highest-volume quartiles (68%). Considering the effects of volume alone and after adjustment for comorbidity, for each 10 additional hospital patients treated by a physician, the odds ratio for in-hospital mortality was 0.97 (95% confidence interval [CI]: 0.95 to 0.98), and the odds ratio for 1-year mortality was 0.99 (95% CI: 0.98 to 0.999). In analyses that considered both volume and specialty, the odds of in-hospital mortality decreased by 4% for each 10 additional in-hospital patients treated by a physician (odds ratio [OR] = 0.96; 95% CI: 0.95 to 0.98). In these same analyses, the odds ratio for in-hospital mortality was 1.32 (95% CI: 1.13 to 1.53) for general practitioners with specialist consultation and 1.32 (95% CI: 1.08 to 1.61) for specialists compared with general practitioners without specialist consultations. At 1 year, mortality was not associated significantly with the volume of in-hospital patients treated, or with the specialty of the treating physician. Treatment by high-volume physicians during hospitalization for newly diagnosed heart failure was associated with a decrease in mortality, but these benefits did not persist at 1 year. The increased mortality noted in patients treated by specialists may be due to residual confounding or unmeasured comorbidity.

Core document on erectile dysfunction: key aspects in the care of a patient with erectile dysfunction

The aim of this Core Document of the Spanish Consensus on Erectile dysfunction (ED) is to offer guidance to the nonspecialist physician in the management of patients with ED. ED is one of the most frequent chronic health problems in men older than 40 y of age and may also act as a sentinel symptom for other important underlying diseases. Its etiology can be classified into organic, psychogenic, or mixed. In most cases, the underlying cause of ED is usually a chronic health problem (such as diabetes, hypertension, atherosclerosis, and so on) or an adverse drug effect. The initial step in the management is to assess erectile function in patients with risk factors for ED. Once ED has been established, a detailed sexual, medical, and social history, including a review of medications used, is the most important aspect of a patient's assessment. Generally, examination should be limited to the cardiovascular, neurological, and urogenital systems. Fasting glucose and blood lipid profile should be performed in every man with ED, and free testosterone levels in men older than 50 y or if hypogonadism is suspected; other diagnostic tests are optional and should be requested on an individualized basis. In many cases, the most likely cause of ED can be identified based on the above information. Therapeutic intervention should be patient-oriented and based on the expectations and wishes of the patient and his partner, who should be included in discussions whenever possible. Basic interventions common to any type of ED include sexual counseling, lifestyle modifications, treatment of associated medical conditions, and switching to alternative drugs with lower risk of ED. In certain cases, an etiologic treatment may be performed (sex therapy, revascularization surgery, and hormonal therapy). Most patients with ED will benefit from symptomatic treatments; first-line therapy may be prescribed by physicians who are not specialists in ED, and includes oral agents such as inhibitors of phosphodiesterase type 5, currently considered the drugs of choice for initial treatment of ED. Intracavernous drugs are the second-line therapy, and surgical treatments, such as implantation of penile prostheses, are reserved for urologists/andrologists who specialize in ED. Referral may be appropriate where indicated by age, clinical findings, or the patient's request.