Aaron J. Bonham

Patients' question-asking behavior during primary care visits: a report from the AAFP National Research Network.

PURPOSE The Ask Me 3 (AM3) health communication program encourages patients to ask specific questions during office visits with the intention of improving understanding of their health conditions and adherence to treatment recommendations. This study evaluated whether implementing AM3 improves patients’ question-asking behavior and increases adherence to prescription medications and lifestyle recommendations. METHODS This randomized trial involved 20 practices from the American Academy of Family Physicians National Research Network that were assigned to an AM3 intervention group or a control group. Forty-one physicians in the practices were each asked to enroll at least 20 patients. The patients’ visits were audio recorded, and recordings were reviewed to determine whether patients asked questions and which questions they asked. Patients were interviewed 1 to 3 weeks after the visit to assess their recall of physicians’ recommendations, rates of prescription filling and taking, and attempts at complying with lifestyle recommendations. RESULTS The study enrolled 834 eligible patients in 20 practices. There were no significant difference between the AM3 and control patients in the rate of asking questions, but this rate was high (92%) in both groups. There also were no differences in rates of either filling or taking prescriptions, although rates of these outcomes were fairly high, too. Control patients were more likely to recall that their physician recommended a lifestyle change, however (68% vs 59%, P=.04). CONCLUSIONS In a patient population in which asking questions already occurs at a high rate and levels of adherence are fairly high, we found no evidence that the AM3 intervention results in patients asking specific questions or more questions in general, or in better adherence to prescription medications or lifestyle recommendations.

Gains in power for exhaustive analyses of haplotypes using variable-sized sliding window strategy: a comparison of association-mapping strategies

Linkage disequilibrium (LD)-based association mapping is often performed by analyzing either individual SNPs or block-based multi-SNP haplotypes. Sliding windows of several fixed sizes (in terms of SNP numbers) were also applied to a few simulated or real data sets. In comparison, exhaustively testing based on variable-sized sliding windows (VSW) of all possible sizes of SNPs over a genomic region has the best chance to capture the optimum markers (single SNPs or haplotypes) that are most significantly associated with the traits under study. However, the cost is the increased number of multiple tests and computation. Here, a strategy of VSW of all possible sizes is proposed and its power is examined, in comparison with those using only haplotype blocks (BLK) or single SNP loci (SGL) tests. Critical values for statistical significance testing that account for multiple testing are simulated. We demonstrated that, over a wide range of parameters simulated, VSW increased power for the detection of disease variants by ∼1–15% over the BLK and SGL approaches. The improved performance was more significant in regions with high recombination rates. In an empirical data set, VSW obtained the most significant signal and identified the LRP5 gene as strongly associated with osteoporosis. With the use of computational techniques such as parallel algorithms and clustering computing, it is feasible to apply VSW to large genomic regions or those regions preliminarily identified by traditional SGL/BLK methods.

Anaphylaxis Knowledge Among Paramedics: Results of a National Survey

Abstract Background. Very little is known about prehospital providers’ knowledge regarding anaphylaxis care. Objectives. The purpose of this study was to evaluate how well nationally registered paramedics in the United States recognize classic and atypical presentations of anaphylaxis. We also assessed knowledge regarding treatment with epinephrine, including dosing, route of administration, and perceived contraindications to epinephrine use. Methods. This was a blinded, cross-sectional online survey of a random sample of paramedics registered by the National Registry of Emergency Medical Technicians that was distributed via e-mail. The survey contained two main sections: demographic data/self-assessment of confidence with anaphylaxis care and a cognitive assessment. Results. A total of 3,537 paramedics completed the survey, for a 36.6% response rate. Among the respondents, 98.9% correctly recognized a case of classic anaphylaxis, whereas only 2.9% correctly identified the atypical presentation. Regarding treatment, 46.2% identified epinephrine as the initial drug of choice; 38.9% chose the intramuscular (IM) route of administration, and 60.5% identified the deltoid as the preferred location (11.6% thigh). Of the respondents, 98.0% were confident they could recognize anaphylaxis; 97.1% were confident they could manage anaphylaxis; 39.5% carry epinephrine autoinjectors (EAIs) on response vehicles; 95.4% were confident they could use an EAI; and 36.2% stated that there were contraindications to epinephrine administration in anaphylactic shock. Conclusions. Whereas a large percentage of the paramedics recognized classic anaphylaxis, a very small percentage recognized atypical anaphylaxis. Less than half chose epinephrine as the initial drug of choice, and most respondents were unable to identify the correct route/location of administration. This survey identifies a number of areas for improved education.

Tensile Strength of a Surgeon's or a Square Knot

OBJECTIVE To test the integrity of surgeons knots and flat square knots using 4 different suture materials. STUDY DESIGN Chromic catgut, polyglactin 910, silk, and polydioxanone sutures were tied in the 2 types of knot configurations. For all sutures, a 0-gauge United States Pharmacopeia suture was used. Knots were tied by a single investigator (J.B.). The suture was soaked in 0.9% sodium chloride for 60 s and subsequently transferred to a tensiometer where the tails were cut to 3-mm length. We compared the knots, measuring knot strength with a tensiometer until the sutures broke or untied. RESULTS A total of 119 throws were tied. We found no difference in mean tension at failure between a surgeons knot (79.7 N) and a flat square knot (82.9 N). Using a chi(2) test, we did not find a statistically significant difference in the likelihood of knots coming untied between surgeons knots (29%) and flat square knots (38%). CONCLUSIONS Under laboratory conditions, surgeons knots and flat square knots did not differ in tension at failure or in likelihood of untying.

Suture End Length as a Function of Knot Integrity

OBJECTIVE To evaluate tension at the failure of 3 commonly used sutures when suture ends were cut to 3 lengths. STUDY DESIGN Knots were tied using U.S. Pharmacopeia Size 0-0 polyglactin 910, silk, or polydioxanone sutures. The knots were tied randomly on a jig by the same surgeon. End lengths were then cut to random lengths of 0, 3, and 10 mm. We compared the individual knot strength when subjected to tensile forces via tensiometer with the point of knot failure, which was defined as untying and/or breaking of the knot. RESULTS Three types of suture were divided into 3 groups based on end lengths for a total of 178 knots. A logistic regression analysis showed the odds of knots coming untied were highest for polyglactin 910 (odds ratio [OR] = 33.7; 95% confidence interval [CI] = 4.1-277.1). End length also had a significant effect on knots untying, with the 0-mm knots being more likely to come untied (OR, 21.2; 95% CI, 2.9-153.0). Post hoc tests for a 3 x 3 analysis of variance found that silk knots failed at significantly lower tension than polydioxanone (p < 0.001) and polyglactin 910 (p < 0.001) knots. CONCLUSIONS The knots with an end length of 0 mm were significantly more likely to come untied than either 3- or 10-mm knots. Among all the materials, polyglactin 910 was the most prone to untying; however, it resulted in untying at a mean tension greater than the breaking point of silk.

A Predictive Equation to Guide Vitamin D Replacement Dose in Patients

Background: Vitamin D is essential for bone health and probably the health of most nonskeletal tissues. Vitamin D deficiency is widespread, and recommended doses are usually inadequate to maintain healthy levels. We conducted a retrospective observational study to determine whether the recommended doses of vitamin D are adequate to correct deficiency and maintain normal levels in a population seeking health care. We also sought to develop a predictive equation for replacement doses of vitamin D. Methods: We reviewed the response to vitamin D supplementation in 1327 patients and 3885 episodes of vitamin D replacement and attempted to discern factors affecting the response to vitamin D replacement by conducting multiple regression analyses. Results: For the whole population, average daily dose resulting in any increase in serum 25-hydroxyvitamin D level was 4707 IU/day; corresponding values for ambulatory and nursing home patients were 4229 and 6103 IU/day, respectively. Significant factors affecting the change in serum concentrations of 25-hydroxyvitamin D, in addition to the dose administered, are (1) starting serum concentration of 25-hydroxyvitamin D, (2) body mass index (BMI), (3) age, and (f) serum albumin concentration. The following equation predicts the dose of vitamin D needed (in international units per day) to affect a given change in serum concentrations of 25-hydroxyvitamin D: Dose = [(8.52 − Desired change in serum 25-hydroxyvitamin D level) + (0.074 × Age) – (0.20 × BMI) + (1.74 × Albumin concentration) – (0.62 × Starting serum 25-hydroxyvitamin D concentration)]/(−0.002). Analysis of the dose responses among 3 racial groups—white, black, and others—did not reveal clinically meaningful differences between the races. The main limitation of the study is its retrospective observational nature; however, that is also its strength in that we assessed the circumstances seen in usual health care setting. Conclusions: The recommended daily allowance for vitamin D is grossly inadequate for correcting low serum concentrations of 25-hydroxyvitamin D in many adult patients. About 5000 IU vitamin D3/day is usually needed to correct deficiency, and the maintenance dose should be ≥2000 IU/day. The required dose may be calculated from the predictive equations specific for ambulatory and nursing home patients.

An evaluation of knot integrity when tied robotically and conventionally

OBJECTIVE The purpose of this study was to evaluate the knot integrity of 3 commonly used sutures in sacrocolpopexy that were tied conventionally (by hand) and robotically. STUDY DESIGN Knots were tied with polyglactin 910, polypropylene, and polyester, with 5-6 knots tied, depending on the suture used. We compared the knots that were subjected to tensile force until the suture broke or untied. RESULTS The mean force that was required for the suture to untie was 47.7 +/- 18.8 (SD) Newtons and was seen only among the robotically tied polyglactin 910 knots. Robotically tied polyglactin 910 knots were significantly weaker than all other robotic and conventional knots that were tested (P < .05). The tying modality and material interaction was significant (P < .001), which suggests that the effect of suture material varied, depending on the tying modality. CONCLUSION Knot failure rates for conventional or robotically tied suture varied based on the suture material that was used.

Inducing sustainable improvement in depression care in primary care practices.

BACKGROUND Improving primary care depression care is costly and challenging to sustain. The feasibility and potential success ofa modified improvement collaborative model to create sustained improvements in depression care was assessed. METHODS Sixteen practices from the American Academy of Family Physicians National Research Network and the American College of Physicians Practice-based Research Network completed a nine-month program. Two practice champions (PCs) from each practice attended three two-day learning sessions, where practice change strategies and key depression care elements were discussed. The nine-item Patient Health Questionnaire (PHQ-9) was used for screening, diagnosis, surveillance, tracking and care management, and self-management support. Pre- and postintervention depression care survey data were gathered from all practice clinicians, and qualitative data were collected via interviews with PCs and field notes from learning sessions. RESULTS On the basis of PC reports at nine months, 16 practices had implemented the PHQ-9 for depression case-finding and 13 for monitoring severity; 5 practices had implemented tracking and care management and 1, self-management support. At the 15-month follow-up, nearly all changes had been sustained, and additional practices had implemented tracking/care management and self-management support. Significant pre-post improvements were reported on several subscales of the clinician survey, demonstrating substantial diffusion from the PC to other clinicians in the practice. DISCUSSION The program led to measurable improvements in implementation of office procedures and systems known to improve depression care. The improvements were both sustained beyond the end of the program and substantially diffused to the other clinicians in the practice.

Nonengagement in HIV Care A Descriptive and Qualitative Study in Hospitalized Patients and Community-Based Analysis

Nonengagement in HIV care is a major clinical and public health challenge. To identify the risk factors and reasons, we performed (1) a retrospective study of patients admitted to the hospital with advanced HIV disease, (2) a prospective qualitative study, and (3) a population-based area-wide telephone interview. In the retrospective study, clinic care engagement was associated with age (43.9 ± 9.1 years vs 37.9 ± 7.2 years, P = .005) and improved from 23% to 44% (P = .03) after hospitalization. Survival was higher (93% vs 73%, P = .03) among those who engaged in care. Twelve inpatients were interviewed in the qualitative study. Themes identified for nonengagement were social stigma, indifference, or lack of understanding of care needs/denial and life care issues. In the population-based study, 145 patients were interviewed. In all, 49 denied the need for HIV care and 28 denied their HIV status. Stigma, denial, and indifference or lack of understanding of need are significant barriers to care engagement.

Representativeness of PBRN Physician Practice Patterns and Related Beliefs: The Case of the AAFP National Research Network

PURPOSE We wanted to compare survey responses from members of a national practice-based research network (PBRN) with those of a larger sample of family physicians to assess the generalizability of findings from the PBRN to the larger physician population. METHODS The American Academy of Family Physicians National Research Network (AAFP NRN) conducted 3 separate national surveys among random samples of AAFP active members and physician members of the AAFP NRN. The surveys assessed self-reported clinical behaviors and beliefs related to hepatitis C, hyperlipidemia, and pharyngitis. Bivariate comparisons were conducted to detect statistical differences between the AAFP and AAFP NRN respondents on both demographic and clinically relevant survey items. Multivariate analyses of outcomes were found to be statistically significant at the bivariate level. RESULTS Response rates to the surveys ranged from 53% to 59% for AAFP members and 60% to 72% for AAFP NRN members. The most consistent differences (P <.05) in demographic comparisons were for percentage of time spent in patient care, practice location, practice type, and census region. Bivariate comparisons found the groups differed on 8 (12%) of 66 clinically relevant survey items, with the Bonferroni correction for multiple comparisons reducing these items to 4 (6%). These comparisons were followed by multivariate analyses of outcomes that were found statistically significant at bivariate level. CONCLUSIONS The AAFP NRN and AAFP membership differed on several demographic characteristics, but network members were overall more representative than not of the AAFP active membership in their self-reported clinical behaviors and related beliefs.