David Weismantel

Practice-Based Referrals to a Tobacco Cessation Quit Line: Assessing the Impact of Comparative Feedback vs General Reminders

PURPOSE We undertook a study to assess the impact of comparative feedback vs general reminders on practice-based referrals to a tobacco cessation quit line and estimated costs for projected quit responses. METHODS We conducted a group-randomized clinical trial comparing the impact of 6 quarterly (18 months) feedback reports (intervention) with that of general reminders (control) on practice-based clinician referrals to a quit-line service. Feedback reports were based on an Achievable Benchmark of Care approach using baseline practice, clinician, and patient survey responses, and referrals per quarter. Comparable quit responses and costs were estimated. RESULTS Three hundred eight clinicians participated (171 family medicine, 88 internal medicine, 49 obstetrics-gynecology) from 87 primary care practices in Michigan. After 18 months, there were more referrals from the intervention than from the control practices (484 vs 220; P <.001). Practice facsimile (fax) referrals (84%, n = 595) exceeded telephone referrals (16%, n = 109), but telephone referrals resulted in greater likelihood of enrollment (77% telephone vs 44% fax, P <.001). The estimated number of smokers who quit based on the level of services utilized by referred smokers was 66 in the feedback and 36 in the gentle reminder practices. CONCLUSION Providing comparative feedback on clinician referrals to a quit-line service had a modest impact with limited increased costs.

Clinician perceptions of factors influencing referrals to a smoking cessation program

BackgroundReferral of patients to smoking cessation telephone counseling (i.e., quitline) is an underutilized resource by primary care physicians. Previously, we conducted a randomized trial to determine the effectiveness of benchmarked feedback on clinician referrals to a quitline. Subsequently, we sought to understand the successful practices used by the high-referring clinicians, and the perceptions of the barriers of referring patients to a quitline among both high and non-referring clinicians in the trial.MethodsWe conducted a qualitative sub-study with subjects from the randomized trial, comparing high- and non-referring clinicians. Structured interviews were conducted and two investigators employed a thematic analysis of the transcribed data. Themes and included categories were organized into a thematic framework to represent the main response sets.ResultsAs compared to non-referring clinicians, high-referring clinicians more often reported use of the quitline as a primary source of referral, an appreciation of the quitline as an additional resource, reduced barriers to use of the quitline referral process, and a greater personal motivation related to tobacco cessation. Time and competing demands were critical barriers to initiating smoking cessation treatment with patients for all clinicians. Clinicians reported that having one referral source, a referral coordinator, and reimbursement for tobacco counseling (as a billable code) would aid referral.ConclusionFurther research is needed to test the effectiveness of new approaches in improving the connection of patients with smoking cessation resources.Trial Registration NumberClinicaltrials.gov NCT00529256

Megestrol Acetate Improves Weight Gain in Pediatric Patients With Chronic Kidney Disease

OBJECTIVE Megestrol acetate (MA) has been used to treat weight loss in pediatric patients with malignancies, cystic fibrosis and HIV/AIDS. We herein report our experience with MA in pediatric patients with chronic kidney disease (CKD). DESIGN We conducted a retrospective cohort study. Charts were evaluated for clinical, treatment, and laboratory data at six time points: approximately 6 months prior to initiation of MA, at initiation and cessation of MA, and at 2-, 4-, and 8-month follow-up. Anthropometric measurements were corrected for age and sex by conversion to z scores. SETTING Division of Pediatric Nephrology, Helen DeVos Childrens Hospital, Grand Rapids, MI. PATIENTS Pediatric patients (n = 25) with CKD and poor weight gain. INTERVENTION Patients were administered MA at initial and tapered doses of 14.4 ± 8.1 mg/kg/d and 10.1 ± 6.5 mg/kg/d, respectively, for 5.4 ± 6.3 months. RESULTS The study population (n = 25) was 60% male, 16% African American, 72% white, and 12% Hispanic with a mean ± SD age of 8.9 ± 5.4 years. Prior to MA therapy, patients demonstrated a decrease in BMI and poor weight gain. The treatment phase was associated with significant increases in BMI (P < .0001) and weight (P < .0001), which were well sustained at 8-month follow-up (P < 0.01 and P < 0.001, respectively). Patients demonstrated continued increases in height. A single patient exhibited physical adverse side effects (cushingoid features) associated with MA; otherwise, MA was well tolerated. CONCLUSIONS MA appears to effectively improve weight gain in pediatric CKD patients with minimal adverse side effects and may therefore serve as a safe, short-term, nutritional strategy.

Severe paediatric systemic lupus erythematosus nephritis—a single centre experience

BACKGROUND Paediatric patients with systemic lupus erythematosus (SLE) often have severe presentations including lupus nephritis (LN). Few paediatric studies have evaluated the anticardiolipin antibody (aCL) and renal histology. The purpose of this study was to evaluate clinicopathologic features, including aCL, short-term clinical and renal histologic outcomes of paediatric patients with new-onset SLE nephritis. METHODS We conducted a single centre, retrospective inception cohort study. Charts were reviewed at presentation (initial renal biopsy), 6-month (follow-up biopsy) and 12-month follow-up. RESULTS The population consisted of 21 patients (median age, 14.5 years): 19/21 were female, 6/21 African American, 3/21 Asian, 9/21 Caucasian and 3/21 Hispanic. At presentation, 19/21 had elevated aCL, 15/21 hypertensive, 12/21 nephrotic and 7/21 required haemodialysis (HD)-2/7 HD patients had thrombotic microangiopathy, 1/7 crescentic glomerulonephritis. Two patients had thromboembolism: both had aCL, were taking oral contraceptives and required HD, one was nephrotic and the other had elevated lupus anticoagulant. Initial biopsies revealed 6/21 ISN/RPS class II nephritis, 3/21 class III, 7/21 class IV and 5/21 class V. Treatment consisted of methylprednisolone, corticosteroids, cyclophosphamide or mycophenolate mofetil. Follow-up biopsies revealed 12/13 to have improved histology. Indication for a follow-up biopsy was severe illness at presentation. At 12-month follow-up, no patients were nephrotic (P < 0.001) or required HD (P < 0.001), and 3/14 had elevated aCL (P < 0.001). CONCLUSION Elevated aCL, hypertension, nephrotic syndrome and need for HD were common presentations among our paediatric SLE nephritis population. Renal histology and aCL were helpful in the therapeutic management.

Self-Report Tool for Recognizing Mania (SToRM): A New Scale for Aiding in the Diagnosis of Bipolar Disorder

Objective: Bipolar disorder is a disabling disease that is difficult to diagnose. Primary care physicians share in the burden of diagnosing and caring for significant mental illness, including bipolar disorder, but they lack an adequate screening and diagnostic tool that can fit into use in a primary care practice. Modeling after the Patient Health Questionnaire-9, we created the Self-report Tool for Recognizing Mania (SToRM) to aid primary care physicians in the screening and diagnosis of bipolar disorder. Methods: A 13-question tool was created and distributed to returning patients over an 11-month time period at the psychiatric clinic of a university health center. Each completed questionnaire was scored as positive or negative and then compared to the preexisting psychiatric diagnosis for that respondent, as shown on the problem list of the respondents electronic medical record. Results: A total of 102 subjects completed and returned their questionnaires. Twenty-eight surveys were scored as positive for bipolar disorder while 25 subjects carried this diagnosis on their problem list, giving a sensitivity of 72% and a specificity of 87% (CI at 95%). When alternative scoring was used, sensitivity increased to 96% with only a slight decrease in specificity to 84%. Conclusions: In this pilot study, we find that the SToRM shows potential in the pursuit of a highly reliable, self-report tool which could help primary care providers screen and diagnose bipolar disorder. As such, the SToRM deserves further study.