General Medicine Physicians Research Articles

Approach to the Geriatric Patient

As of 2012, over one in eight Americans is over the age of 65, and this number is rising, particularly in the 85+ age group. This segment of the population has a rate of hospitalization three times higher than that for persons of all ages. General internists and family medicine physicians provide a large portion of care for this age group and should therefore be comfortable using a comprehensive approach to geriatric assessment. This review describes general considerations regarding geriatric care, including the process of taking a functional history and clinical implications of geriatric care. The geriatric assessment process is discussed in terms of physical, cognitive, social, and medical domains. The benefits of geriatric assessment in primary care, specialty care, and hospitalized patients are described. Tables outline activities of daily living, sensory changes with aging, major causes of visual impairment in the geriatric population, major neurocognitive disorder diagnostic criteria, medications to avoid or use with caution based on Beers criteria and Screening Tool of Older individuals’ Potentially inappropriate Prescriptions criteria, U.S. Preventive Services Task Force–recommended services relevant to older adults, and vaccinations in older adults. Figures illustrate the key vulnerabilities of older adults; outcomes linked to functional dependence; common disorders associated with cognitive concerns; domains of cognition and examples of impairment in theDiagnostic and Statistical Manual of Mental Disorders, fifth edition; the social and medical domains of geriatric assessment; barriers to medication adherence in older patients; and resources for medication appropriateness in older adults. This review contains 8 highly rendered figures, 8 tables, 110 references, and 5 MCQs.

Approach to the Geriatric Patient

As of 2012, over one in eight Americans is over the age of 65, and this number is rising, particularly in the 85+ age group. This segment of the population has a rate of hospitalization three times higher than that for persons of all ages. General internists and family medicine physicians provide a large portion of care for this age group and should therefore be comfortable using a comprehensive approach to geriatric assessment. This review describes general considerations regarding geriatric care, including the process of taking a functional history and clinical implications of geriatric care. The geriatric assessment process is discussed in terms of physical, cognitive, social, and medical domains. The benefits of geriatric assessment in primary care, specialty care, and hospitalized patients are described. Tables outline activities of daily living, sensory changes with aging, major causes of visual impairment in the geriatric population, major neurocognitive disorder diagnostic criteria, medications to avoid or use with caution based on Beers criteria and Screening Tool of Older individuals’ Potentially inappropriate Prescriptions criteria, U.S. Preventive Services Task Force–recommended services relevant to older adults, and vaccinations in older adults. Figures illustrate the key vulnerabilities of older adults; outcomes linked to functional dependence; common disorders associated with cognitive concerns; domains of cognition and examples of impairment in theDiagnostic and Statistical Manual of Mental Disorders, fifth edition; the social and medical domains of geriatric assessment; barriers to medication adherence in older patients; and resources for medication appropriateness in older adults. This review contains 8 highly rendered figures, 8 tables, 110 references, and 5 MCQs.

Balancing the Rights to Protection and Participation: A Call for Expanded Access to Ethically Conducted Correctional Health Research.

Incarcerated individuals, over 95% of whom are eventually released, experience high burdens of chronic disease and behavioral health and social risk factors. Understanding the health needs of this population is critical to ensuring that general medicine physicians in prisons and in the community are adequately prepared to meet those needs. However, people in prison are significantly underrepresented in health research. In response to historical exploitation of prisoners in medical experimentation, federal guidelines appropriately require additional oversight for, and limit the scope of, research in prisons. Yet, according to a 2006 Institute of Medicine report, these requirements have produced inconsistent local regulations that often limit opportunities for incarcerated individuals to participate in research, and can slow the development of innovative medical interventions to improve their health. In this article, we describe the historical context surrounding regulations on research involving individuals in prison, the harms that can arise from excessive limitations to research in such settings, and the benefits of greater access to ethically conducted research in prison. We conclude with recommended actions that can be taken by general medicine researchers, correctional leaders, and policymakers to achieve consistent access to health research for incarcerated populations.

Job Stress Factors Affect Workplace Resignation and Burnout among Japanese Rural Physicians.

Shortage of healthcare workers is a global problem. It is important to clarify factors, including job stress, that influence workplace resignation and factors that cause burnout among rural physicians. The study was designed as a cross-sectional questionnaire survey. We sent questionnaires to town or village hospitals and clinics (n = 1,898) in Hokkaido, Tohoku, Shikoku, and Kyushu and Okinawa. The number of participants was 509. Of these 7.7% were female and 21.6% were < 50 years. Internal or general medicine physicians were asked about personal and job factors, job stress based on the demand-control-support model, intention to resign from current position, and burnout evaluated using the Maslach Burnout Inventory-General Survey. Overall, 10.4% of the participants intended to resign, and 21.8% was defined as burnout positive. In the multivariate logistic regression analysis, dissatisfaction with income (OR, 3.63; 95% CI, 1.63-8.10), having one's hometown in another town or village in the same prefecture (OR, 3.53; 95% CI, 1.18-10.62) were significantly related to intention to resign, while high job control (OR, 0.72; 95% CI, 0.58-0.88) had a significantly protective effect. In the multivariate analysis, high job demand (OR, 1.48; 95% CI, 1.28-1.72) was significantly related to burnout, and high job control (OR, 0.66; 95% CI, 0.55-0.78) and high support from co-workers (OR 0.88, 95% CI, 0.78-1.00) had a significantly protective effect. Improving job stress factors, especially job control, and taking into consideration physicians' hometown and income may be important factors to prevent resignation from a current position and burnout among Japanese rural physicians.

Irritable bowel syndrome – dissection of a disease. A 13-steps polemic

The last 35 years (since about 1985) have produced a vast amount of scientific publications with respect to the irritable bowel syndrome (IBS), but no real progress: The etiology and pathogenesis of IBS is still incompletely understood, and diagnosis and therapy is left to the individual understanding of the treating physicians in general medicine, gastroenterology and psychosomatic/psychiatry. In this gloss, three prominent representatives of neurogastroenterology in Germany assess their own contributions and those of their colleagues and lament the huge gapbetween ambitions and reality in clinical and basic science in IBS.

Missed Diagnosis of Cardiovascular Disease in Outpatient General Medicine: Insights from Malpractice Claims Data

Diagnostic errors are an underrecognized source of patient harm, and cardiovascular disease can be challenging to diagnose in the ambulatory setting. Although malpractice data can inform diagnostic error reduction efforts, no studies have examined outpatient cardiovascular malpractice cases in depth. A study was conducted to examine the characteristics of outpatient cardiovascular malpractice cases brought against general medicine practitioners. Some 3,407 closed malpractice claims were analyzed in outpatient general medicine from CRICO Strategies' Comparative Benchmarking System database-the largest detailed database of paid and unpaid malpractice in the world-and multivariate models were created to determine the factors that predicted case outcomes. Among the 153 patients in cardiovascular malpractice cases for whom patient comorbidities were coded, the majority (63%) had at least one traditional cardiac risk factor, such as diabetes, tobacco use, or previous cardiovascular disease. Cardiovascular malpractice cases were more likely to involve an allegation of error in diagnosis (75% vs. 47%, p <0.0001), have high clinical severity (86% vs. 49%, p <0.0001) and result in death (75% vs. 27%, p <0.0001), as compared to noncardiovascular cases. Initial diagnoses of nonspecific chest pain and mimics of cardiovascular pain (for example, esophageal disease) were common and independently increased the likelihood of a claim resulting in a payment (p <0.01). Cardiovascular malpractice cases against outpatient general medicine physicians mostly occur in patients with conventional risk factors for coronary artery disease and are often diagnosed with common mimics of cardiovascular pain. These findings suggest that these patients may be high-yield targets for preventing diagnostic errors in the ambulatory setting.

Les affections neuro-ophtalmologiques : étude du parcours de soins du patient

Neuro-ophthalmologic conditions require specialized multidisciplinary management, both medical and surgical, for patients affected by visual loss due to nervous system disease. The primary goal of this study is to define the specificity of neuro-ophthalmology within the realm of visual health. The secondary goal is to review clinical care pathways by studying the organization of management, in terms of accessibility to care and personalization of the care pathway. A field study was carried out from February to June 2015, within the ophthalmology service of the Pitié-Salpêtrière University Medical Center in Paris. A 30-minute interview with the patient before or after his or her neuro-ophthalmology consultation was performed, so as to describe the clinical care pathway. The medical records of interviewed patients were also analyzed. Seventeen care pathways (10women and 7men) were reviewed. The mean age at appearance of visual involvement was 44.5years (±8.4years). If we exclude 3patients over 66years and retired, 35.71% were active, 35.71% were disabled, and 28.57% were on sick leave. Ten patients (58.82%) met the criteria for admission to long-term care. The first step had been carried out by local private practitioners. The first physician seen was the general medicine physician (59%), then the private ophthalmologist on an emergency basis (17%). On average, patients went through 8steps during their care pathway (from 6to 10steps) and 14medical departments were involved. The study showed collaboration with the other services of the University Hospital Department of Vision and Disabilities (notably with the Fondation Rothschild, the Quinze-Vingts National Ophthalmology Hospital and the Fondation Sainte-Marie). In addition to rehabilitation services, health care professionals participating in the outpatient care of the patients included an orthoptist (11.7%), a psychologist (11.7%), and an optician specializing in low vision for visual aids. And finally, patient support groups, AFM-Téléthon (myasthenia) and the ARIBa Association (visual disability) were solicited by 2patients for their involvement. A disturbance in activities of daily living leading to disabilities with psychological repercussions was noted by a number of patients. The most frequent complaints involve mobility (29.41%) and reading (23.52%). In total, 77% of patients state that their well-being has been affected and they are disturbed by the progression of their disease. The review of the clinical care pathway of patients affected by neuro-ophthalmological conditions shows that these pathologies are, on the one hand, often poorly understood, and on the other hand complex, leading to an often significant number of steps for the patient. This also emphasizes the necessity of a care network, specialized and structured to improve the efficiency of this management. Finally, these results demonstrate the existence of a very frequent disability, which may affect all aspects of the patients' lives, highlighting the importance of rehabilitation services and individuals participating in the follow-up of these patients beyond their acute care.

Neuro-ophthalmological conditions: Study of the clinical care pathway

Neuro-ophthalmologic conditions require specialized multidisciplinary management, both medical and surgical, for patients affected by visual loss due to nervous system disease. The primary goal of this study is to define the specificity of neuro-ophthalmology within the realm of visual health. The secondary goal is to review clinical care pathways by studying the organization of management, in terms of accessibility to care and personalization of the care pathway. A field study was carried out from February to June 2015, within the ophthalmology service of the Pitié-Salpêtrière University Medical Center in Paris. A 30-minute interview with the patient before or after his or her neuro-ophthalmology consultation was performed, to describe the clinical care pathway. The medical records of interviewed patients were also analyzed. Seventeen care pathways (10 women and 7 men) were reviewed. The mean age at appearance of visual involvement was 44.5 years (±8.4 years). If we exclude 3 patients over 66 years and retired, 35.71% were active, 35.71% were disabled, and 28.57% were on sick leave. Ten patients (58.82%) met the criteria for admission to long-term care. The first step had been carried out by local private practitioners. The first physician seen was the general medicine physician (59%), then the private ophthalmologist on an emergency basis (17%). On average, patients went through 8 steps during their care pathway (from 6 to 10 steps) and 14 medical departments were involved. The study showed collaboration with the other services of the University Hospital Department of Vision and Disabilities (notably with the Fondation Rothschild, the Quinze-Vingts National Ophthalmology Hospital, and the Fondation Sainte-Marie). In addition to rehabilitation services, health care professionals participating in the outpatient care of the patients included an orthoptist (11.7%), a psychologist (11.7%), and an optician specializing in low vision for visual aids. Finally, patient support groups, AFM-Téléthon (myasthenia) and the ARIBa association (visual disability) were solicited by 2 patients for their involvement. A disturbance in activities of daily living leading to disabilities with psychological repercussions was noted by a number of patients. The most frequent complaints involve mobility (29.41%) and reading (23.52%). In total, 77% of patients state that their well-being has been affected, and they are disturbed by the progression of their disease. The review of the clinical care pathway of patients affected by neuro-ophthalmological conditions shows that these pathologies are, on the one hand, often poorly understood, and on the other hand complex, leading to an often significant number of steps for the patient. This also emphasizes the necessity of a care network, specialized and structured to improve the efficiency of this management. Finally, these results demonstrate the existence of a very frequent disability, which may affect all aspects of the patients' lives, highlighting the importance of rehabilitation services and individuals participating in the follow-up of these patients beyond their acute care.

Approach to the Geriatric Patient

As of 2012, over one in eight Americans is over the age of 65, and this number is rising, particularly in the 85+ age group. This segment of the population has a rate of hospitalization three times higher than that for persons of all ages. General internists and family medicine physicians provide a large portion of care for this age group and should therefore be comfortable using a comprehensive approach to geriatric assessment. This review describes general considerations regarding geriatric care, including the process of taking a functional history and clinical implications of geriatric care. The geriatric assessment process is discussed in terms of physical, cognitive, social, and medical domains. The benefits of geriatric assessment in primary care, specialty care, and hospitalized patients are described. Tables outline activities of daily living, sensory changes with aging, major causes of visual impairment in the geriatric population, major neurocognitive disorder diagnostic criteria, medications to avoid or use with caution based on Beers criteria and Screening Tool of Older individuals’ Potentially inappropriate Prescriptions criteria, U.S. Preventive Services Task Force–recommended services relevant to older adults, and vaccinations in older adults. Figures illustrate the key vulnerabilities of older adults; outcomes linked to functional dependence; common disorders associated with cognitive concerns; domains of cognition and examples of impairment in theDiagnostic and Statistical Manual of Mental Disorders, fifth edition; the social and medical domains of geriatric assessment; barriers to medication adherence in older patients; and resources for medication appropriateness in older adults. This review contains 8 highly rendered figures, 8 tables, 110 references, and 5 MCQs.

Rostering general medicine physicians to balance workload across inpatient wards: a case study

During an expansion of the General Medicine (GM) department at Waitakere Hospital, a new roster was required for its teams. Patients being transferred to another hospital due to uneven patient...

Chronicity of Voice‐Related Health Care Utilization in the General Medicine Community

Objectives To examine voice-related health care utilization of patients in the general medical community without otolaryngology evaluation and explore factors associated with prolonged voice-related health care. Study Design Retrospective cohort analysis. Setting Large, national administrative US claims database. Subjects and Methods Patients with voice disorders per International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM) codes from January 1, 2010, to December 31, 2012, seen by a general medical physician, and who did not see an otolaryngologist in the subsequent year were included. Voice-related health care utilization, patient demographics, comorbid conditions, and index laryngeal diagnosis were collected. Logistic regression with variable selection was performed to evaluate the association between predictors and ≥30 days of voice-related health care use. Results In total, 46,205 unique voice-disordered patients met inclusion criteria. Of these patients, 8.5%, 10.0%, and 12.5% had voice-related health care use of ≥90, ≥60, and ≥30 days, respectively. Of the ≥30-day subset, 80.3% and 68.5%, respectively, had ≥60 and ≥90 days of voice-related health care utilization. The ≥30-day subset had more general medicine and nonotolaryngology specialty physician visits, more prescriptions and procedures, and 4 times the voice-related health care costs compared with those in the <30-day subset. Age, sex, employment status, initial voice disorder diagnosis, and comorbid conditions were related to ≥30 days of voice-related health care utilization. Conclusions Thirty days of nonotolaryngology-based care for a voice disorder may represent a threshold beyond which patients are more likely to experience prolonged voice-related health care utilization. Specific factors were associated with extended voice-related health care.

How Accurate Are First Visit Diagnoses Using Synchronous Video Visits with Physicians?

Telediagnosis (TD), which uses information and communications technology, has recently undergone rapid development. Since no studies have compared the diagnostic precision of TD to that of face-to-face diagnosis (FD), we examined and compared the diagnostic accuracy of these diagnostic approaches among general medicine outpatients. Data of 97 patients (45 men and 52 women with a mean age of 52 years) who underwent initial examinations at a regional hospital were analyzed. Two fully trained general medicine physicians were selected from a group of three physicians to perform FD and TD. Levels of agreement (as κ coefficients) were determined between TD and FD diagnoses as well as between final diagnoses and TD and FD diagnoses. The κ coefficients were 0.75 for TD and FD and 0.81 for both, the final diagnoses and the TD and FD diagnoses, revealing a sufficiently high level of diagnostic agreement. TD can provide the same level of diagnostic accuracy as FD among general medicine outpatients for adults. The help of medical assistants and the utilization of physical examination devices might enable medical staff to provide TD care similar in quality to FD. TD could be a useful diagnostic tool when medical work force is limited (e.g., in remote areas, during natural disasters, and in at-home care).

Aggression and violence directed toward general medicine physicians

Objective: To explore the extent of aggression (verbal abuse) and violence (physical abuse) directed toward General Medicine physicians by their patients, to identify causes and consequences of such behaviour on physicians' professional work and to establish prevention measures. Method: All general medicine physicians who attended an educational seminar from 28 to 29 February 2015 in Belgrade were given the questionnaire and asked to complete it. Results: 411 general medicine physicians have completed the questionnaire. Both genders were included: 86.37% of them were women. Majority of the participants were in the age group of 51-60 years (45.25%), mean age was 49.27±9.32. Mean number of years in practice was 21.10±9.87. Most of them specialized in General Medicine (62.30%). 85.40% of physicians have encountered some kind of abuse during their work and there was no significant difference regarding physicians' gender or qualifications. In the preceding year 62.3% of participants have encountered aggression or violence in their workplace. Aggression was reported by 82.97% and violence by 8.83% of participants. There were no statistically significant differences in terms of physicians' gender (p=0.859), type of workplace (p=0.097), number of years in practice (p=0.640) and specialty (p=0.537). In 83.2% of cases acts of aggression or violence have been committed by patients and in 40.2% by members of their families. In 44.2% of these cases nobody tried to assist the physicians and even less so if they were male doctors (p=0.05). The most common causes were: patients' dissatisfaction (60.4%), long waiting time for examination (37.0%) and patient's alcohol or drug intoxication (35.0%). The most common consequence of this on physicians was decreased satisfaction with their job (53.6%). Prevention measures for this issue would be: decreasing of the number of consultations per day (56.0%), introduction of a new 'in line of duty' status for healthcare workers (55.60%), providing security personnel (49.3%) and stricter punishments for such offences (50.0%). Conclusion: Aggression and violence directed toward physicians are largely present, predominantly in the form of aggression. The most often offenders are patients, the cause is patients' dissatisfaction with their unfulfilled expectations and the most common consequence on physicians is decreased satisfaction with the job they are doing.

Diabetes drug development: time for a shift in paradigm

Gregory C Jones* speaks to Daphne Boulicault, Commissioning Editor: Gregory C Jones, MbChB, FRCPG, is a Consultant Physician in general (internal) medicine, diabetes and endocrinology at Western Infirmary and Gartnavel General Hospital, Glasgow, UK appointed in 2001. He is Honorary Associate Clinical Professor at the University of Glasgow. He graduated in medicine from the University of Dundee in 1991, and undertook general medical training in Coventry, England and specialist training in Edinburgh, Scotland. He was a Wellcome Clinical Research Fellow at Edinburgh University. His principal research interests are pharmacotherapy in Type 2 diabetes, service delivery and in-patient diabetes care. He has written several papers in this field. He has a wide experience as a leader in medical education. He was previously the Training Program Director for Diabetes and Endocrinology and is currently Associate Director of Medical Education, Academic Foundation Programme Director and Chair of Academic Foundation Medic...

Continuing Medical Education Learning Module for the Primary Care and Emergency Medicine Physicians: Musculoskeletal Assessment of the Knee and Shoulder Joints

Primary care physicians (PCPs) are often responsible for evaluating, treating and further referring musculoskeletal (MSK) disorders and injuries. The objective of this learning module is to provide PCP and Emergency Medicine physicians with an online training resource regarding the assessment and treatment of common and important knee and shoulder injuries. A web‐based survey was sent to general internal medicine, family medicine and emergency medicine physicians via email. A total of 66 responses were received. Results revealed that 32‐50% of the physicians felt ‘not at all confident’ or 'somewhat confident’ in evaluating, treating and referring a variety of knee and shoulder disorders and injuries. The physicians' responses revealed they were the least confident in evaluating meniscal tears, patellofemoral pain, adhesive capsulitis and shoulder impingement. Additionally there is an overall interest in a learning module addressing these conditions. This needs assessment will provide information to drive the development of an online training module to supplement providers' current level of training, and increase confidence in approaching MSK disorders and injuries.

European Early Career Psychiatrists' Views On E-learning: Preliminary Findings of a Focus Group Study

Introduction E-learning may be a cost-efficient alternative or addition to traditional continuous medical education (CME) face-to-face courses. Even though some data are available regarding views on e-learning of general medicine physicians, preferences of psychiatrists have not been systematically assessed as yet. Aims To assess early career psychiatrists' (ECPs) preferences on e-learning. Objectives To explore: 1) What do early career psychiatrists want to learn via e-learning? 2) How should e-learning be provided? Methods Online focus groups were conducted via skype. Participants were purposively sampled for professional qualification (trainees/newly-qualified psychiatrists) and recruited in 14 European countries. Qualitative analysis of the data is in progress. Preliminary findings are presented. Results Four focus groups with in total 20 early career psychiatrists from different countries were conducted. The number of participants to focus groups varied from four to seven. ECPs would use e-learning to learn about topics not normally thaught during standard psychiatric training, and to have contact with experts in the field. E-learning courses on general basic knowledge (psychotherapy theories, psycho-pharmacology) need to be related to clinical practice. ECPs suggested that e-learning courses should be interactive, user-friendly and accredited by national authorities. Cost of e-learning courses and lack of awareness of e-learning opportunities are significant barriers to access, particularly for trainees. Conclusions Access of ECPs to e-learning may be increased by offering information on courses and affordable fees. Content-wise, e-learning should provide specialist knowledge or training in generic skills closely related to practice. E-learning courses should be delivered by renowned international experts.

MedLink: A Mobile Intervention to Address Failure Points in the Treatment of Depression in General Medicine.

Major depression is common, and imposes a high burden in terms of cost, morbidity, and suffering. Most people with depression are treated in general medicine using antidepressant medication. Outcomes are poor due to failure points across the care system, including patient non-adherence, failure of physicians to optimize the treatment regimens, and lack of patient-physician communication. This study reports on the 4-week pilot deployment of MedLink, a mobile intervention aimed at systemically addressing each of these failure points. A mobile app provides the patient with information and collects data on symptoms and side-effects. A cellularly enabled pill bottle monitors medication adherence. Data from these are provided to the physician and patient to foster communication and medication adjustments. Usability evaluation was generally favorable. Medication adherence rates in this first deployment were high with no patients discontinuing, and 84% of doses taken. Depressive symptom severity was significantly reduced. This study supports the use of a comprehensive, systemic approach to mHealth solutions to enhance processes of care for depression by general medicine physicians.

Approach to the Geriatric Patient

As of 2012, over one in eight Americans is over the age of 65, and this number is rising, particularly in the 85+ age group. This segment of the population has a rate of hospitalization three times higher than that for persons of all ages. General internists and family medicine physicians provide a large portion of care for this age group and should therefore be comfortable using a comprehensive approach to geriatric assessment. This review describes general considerations regarding geriatric care, including the process of taking a functional history and clinical implications of geriatric care. The geriatric assessment process is discussed in terms of physical, cognitive, social, and medical domains. The benefits of geriatric assessment in primary care, specialty care, and hospitalized patients are described. Tables outline activities of daily living, sensory changes with aging, major causes of visual impairment in the geriatric population, major neurocognitive disorder diagnostic criteria, medications to avoid or use with caution based on Beers criteria and Screening Tool of Older individuals’ Potentially inappropriate Prescriptions criteria, U.S. Preventive Services Task Force–recommended services relevant to older adults, and vaccinations in older adults. Figures illustrate the key vulnerabilities of older adults; outcomes linked to functional dependence; common disorders associated with cognitive concerns; domains of cognition and examples of impairment in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition; the social and medical domains of geriatric assessment; barriers to medication adherence in older patients; and resources for medication appropriateness in older adults. This review contains 8 highly rendered figures, 8 tables, 110 references, and 5 MCQs.

Approach to the Geriatric Patient

As of 2012, over one in eight Americans is over the age of 65, and this number is rising, particularly in the 85+ age group. This segment of the population has a rate of hospitalization three times higher than that for persons of all ages. General internists and family medicine physicians provide a large portion of care for this age group and should therefore be comfortable using a comprehensive approach to geriatric assessment. This review describes general considerations regarding geriatric care, including the process of taking a functional history and clinical implications of geriatric care. The geriatric assessment process is discussed in terms of physical, cognitive, social, and medical domains. The benefits of geriatric assessment in primary care, specialty care, and hospitalized patients are described. Tables outline activities of daily living, sensory changes with aging, major causes of visual impairment in the geriatric population, major neurocognitive disorder diagnostic criteria, medications to avoid or use with caution based on Beers criteria and Screening Tool of Older individuals’ Potentially inappropriate Prescriptions criteria, U.S. Preventive Services Task Force–recommended services relevant to older adults, and vaccinations in older adults. Figures illustrate the key vulnerabilities of older adults; outcomes linked to functional dependence; common disorders associated with cognitive concerns; domains of cognition and examples of impairment in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition; the social and medical domains of geriatric assessment; barriers to medication adherence in older patients; and resources for medication appropriateness in older adults. This review contains 8 highly rendered figures, 8 tables, 110 references, and 5 MCQs.

Do clinicians know which of their patients have central venous catheters?: a multicenter observational study.

Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown. To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients. Multicenter, cross-sectional study. 3 academic medical centers in the United States. Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings. To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests. 990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n=209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P=0.003). Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded. Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted. None.