John B. Schorling

Persistent Diarrhea Signals a Critical Period of Increased Diarrhea Burdens and Nutritional Shortfalls: A Prospective Cohort Study among Children in Northeastern Brazil

Persistent diarrhea (PD; duration >/=14 days) is a growing part of the global burden of diarrheal diseases. A 45-month prospective cohort study (with illness, nutritional, and microbiologic surveillance) was conducted in a shantytown in northeastern Brazil, to elucidate the epidemiology, nutritional impact, and causes of PD in early childhood (0-3 years of age). A nested case-control design was used to examine childrens diarrhea burden and nutritional status before and after a first PD illness. PD illnesses accounted for 8% of episodes and 34% of days of diarrhea. First PD illnesses were preceded by a doubling of acute diarrhea burdens, were followed by further 2.6-3.5-fold increased diarrhea burdens for 18 months, and were associated with acute weight shortfalls. Exclusively breast-fed children had 8-fold lower diarrhea rates than did weaned children. PD-associated etiologic agents included Cryptosporidium, Giardia, enteric adenoviruses, and enterotoxigenic Escherichia coli. PD signals growth shortfalls and increased diarrhea burdens; children with PD merit extended support, and the illness warrants further study to elucidate its prevention, treatment, and impact.

A Mindfulness Course Decreases Burnout and Improves Well-Being among Healthcare Providers

Objective: Healthcare providers are under increasing stress and work-related burnout has become common. Mindfulness-based interventions have a potential role in decreasing stress and burnout. The purpose of this study was to determine if a continuing education course based on mindfulness-based stress reduction could decrease burnout and improve mental well-being among healthcare providers, from different professions. Design: This was a pre-post observational study conducted in a university medical center. A total of 93 healthcare providers, including physicians from multiple specialties, nurses, psychologists, and social workers who practiced in both university and community settings, participated. The intervention was a continuing education course based on mindfulness-based stress reduction that met 2.5 hours a week for 8 weeks plus a 7-hour retreat. The classes included training in four types of formal mindfulness practices, including the body scan, mindful movement, walking meditation and sitting meditation, as well as discussion focusing on the application of mindfulness at work. The course was offered 11 times over 6 years. The main outcome measures were work-related burnout as measured by the Maslach Burnout Inventory and self-perceived mental and physical well-being as measured by the SF-12v2. Results: Maslach Burnout Inventory scores improved significantly from before to after the course for both physicians and other healthcare providers for the Emotional Exhaustion (p < 0.03), Depersonalization (p < 0.04), and Personal Accomplishment (p < 0.001) scales. Mental well-being measured by the SF12v2 also improved significantly (p < 0.001). There were no significant changes in the SF12v2 physical health scores. Conclusion: A continuing education course based on mindfulness-based stress reduction was associated with significant improvements in burnout scores and mental well-being for a broad range of healthcare providers.

Tobacco, alcohol and other drug use among college students.

Smoking, binge drinking, and illicit drug use remain common among college students. The purpose of this study was to characterize college students who smoke, and to determine the relationship between smoking behavior and alcohol and illicit drug use. Cigarette smoking, alcohol use and illicit drug use practices were surveyed at ten public colleges in Virginia. A total of 3,374 undergraduate respondents from eight schools (those with response rates > 20%) were analyzed. The one-year smoking prevalence was 23.5%. Smokers were significantly more likely to be white, female, and to have lower life satisfaction and grade point averages than nonsmokers. Students classified themselves as regular or occasional smokers. Smoking was significantly associated with binge drinking in the last two weeks and with marijuana, cocaine, and LSD use in the past year. Except for binge drinking, the associations were stronger for regular than for occasional smokers. Cigarette smoking, even occasional use, identifies a subgroup of college students who are at increased risk of binge drinking and illicit drug use. This information may be useful in developing targeted drug prevention programs.

BRIEF REPORT: A Pilot Study Evaluating Mindfulness‐Based Stress Reduction and Massage for the Management of Chronic Pain

BACKGROUND: Mindfulness-based stress reduction (MBSR) and massage may be useful adjunctive therapies for chronic musculoskeletal pain.OBJECTIVE: To evaluate the feasibility of studying MBSR and massage for the management of chronic pain and estimate their effects on pain and mood.DESIGN: Randomized trial comparing MBSR or massage with standard care.PARTICIPANTS: Thirty patients with chronic musculoskeletal pain.MEASUREMENTS: Pain was assessed with 0 to 10 numeric rating scales. Physical and mental health status was measured with the SF-12.RESULTS: The study completion rate was 76.7%. At week 8, the massage group had average difference scores for pain unpleasantness of 2.9 and mental health status of 13.6 compared with 0.13 (P<.05) and 3.9 (P<.04), respectively, for the standard care group. These differences were no longer significant at week 12. There were no significant differences in the pain outcomes for the MBSR group. At week 12, the mean change in mental health status for the MBSR group was 10.2 compared with — 1.7 in the standard care group (P<.04).CONCLUSIONS: It is feasible to study MBSR and massage in patients with chronic musculoskeletal pain. Mindfulness-based stress reduction may be more effective and longer-lasting for mood improvement while massage may be more effective for reducing pain.

Persistent diarrhea in Northeast Brazil: etiologies and interactions with malnutrition

With the improved control of acute diarrheal illness mortality with oral rehydration therapy, persistent diarrhea is now emerging as a major cause of childhood mortality in tropical developing areas like the impoverished populations in Brazils Northeast. “Graveyard surveillance” in the rural community of Guaiuba in northeastern Brazil revealed fully half of the 70% diarrhea mortality was due to persistent diarrheal illnesses. Furthermore, 11% of 14 or more diarrheal illnesses per child per year in an urban slum in Fortaleza persisted beyond 14 days, a definition that clearly identified the high risk children for heavy diarrhea burdens. Not only did heavy diarrhea burdens ablate the key “catch‐up” growth seen in severely malnourished children and in children following previous diarrheal illnesses, but malnutrition significantly predisposed children to a greater incidence and duration of diarrhea as well as a greater incidence of persistent diarrhea. Etiologic studies of 37 children presenting with persistent diarrhea to Hospital das Clinicas in Fortaleza revealed that Cryptosporidium (in 13%) and enteroadherent E. coli (36% with aggregative, 29% with diffuse and 13% with localized adherence to HEp‐2 cells) were the predominant potential pathogens found in the stool or upper small bowel. These findings suggest that persistent diarrhea is emerging as an important health problem in Brazils Northeast, that it identifies a high risk child for heavy diarrhea burdens, that important interactions occur with malnutrition and that Cryptosporidium and enteroadherent E. coli warrant further study as potential etiologies of this major cause of morbidity and mortality.

Potential role of adherence traits of Escherichia coli in persistent diarrhea in an urban Brazilian slum.

We examined stools from 40 children with persistent diarrhea (duration, 14 days or more), from 50 children with acute diarrhea and from 38 control children to determine infectious etiologies for persistent diarrhea in Goncalves Dias, an urban favela (slum) in Fortaleza, Ceara, Brazil. Children with persistent diarrhea and children with acute diarrhea had similar rates of isolation of routine viral, bacterial and parasitic enteric pathogens. Routine pathogens were identified in at least 20% of cultures done more than 14 days into the diarrheal illness. We examined Escherichia coli isolated from these stools for adherence potential. Enteroaggregative E. coli were isolated significantly more often from children with persistent diarrhea than from control children or children with acute diarrhea (P less than 0.05). E. coli with hemagglutination patterns suggestive of adherence pili were also isolated more often from children with persistent diarrhea than from children with acute diarrhea (38% vs. 18%; P less than 0.05). Enterotoxigenic E. coli were isolated in combination with rotavirus more often from children with persistent diarrhea than from children with acute diarrhea. E. coli which were hydrophobic or exhibited hemagglutination were also seen more often in association with Giardia in children with persistent diarrhea. These findings suggest that the etiology of persistent diarrhea in children is complex and that the aggregative E. coli are associated with prolonged diarrheal illness. Although routine diarrheal pathogens may be present for more than 14 days, combinations of pathogens, including E. coli with adherence potential, may also contribute to prolonged diarrheal disease.

Does Informed Consent Alter Elderly Patients' Preferences for Colorectal Cancer Screening?: Results of a Randomized Trial

OBJECTIVE: To assess the impact of informed consent on elderly patients’ colorectal cancer (CRC) screening preferences.DESIGN: Randomized, controlled trial.SETTING: Four general internal medicine practices.PATIENTS: We studied 399 elderly patients visiting their primary care provider for routine office visits.INTERVENTIONS: Patients were randomized to receive either a scripted control message briefly describing CRC screening methods or one of two informational interventions simulating an informed consent presentation about CRC screening. One intervention described CRC mortality risk reduction in relative terms; the other, in absolute terms.MEASUREMENTS AND MAIN RESULTS: The main outcome measure was intent to begin or continue fecal occult blood testing (FOBT), flexible sigmoidoscopy, or both. There was no difference in screening interest between the control group and the two information groups (p=.8). The majority (63%) of patients intended to begin or continue CRC screening. Informed patients were able to gauge more accurately the positive predictive value of screening (p=.0009). Control patients rated the efficacy of screening higher than did patients receiving relative risk reduction information, who rated it higher than did patients receiving absolute risk reduction information (p=.0002).CONCLUSIONS: Elderly patients appeared to understand CRC screening information and use it to gauge the efficacy of screening, but provision of information had no impact on their preferences for screening. In view of the large proportion who preferred not to be screened, we conclude that elderly patients should be involved in the screening decision. However, factors other than provision of information must determine their CRC screening preferences.

Patient safety in the ambulatory setting: A clinician-based approach

BACKGROUND: Voluntary reporting of near misses/adverse events is an important but underutilized source of information on errors in medicine. To date, there is very little information on errors in the ambulatory setting and physicians have not traditionally participated actively in their reporting or analysis.OBJECTIVES: To determine the feasibility and effectiveness of clinician-based near miss/adverse event voluntary reporting coupled with systems analysis and redesign as a model for continuous quality improvement in the ambulatory setting.DESIGN: We report the initial 1-year experience of voluntary reporting by clinicians in the ambulatory setting, coupled with root cause analysis and system redesign by a patient safety committee made up of clinicians from the practice.SETTING: Internal medicine practice site of a large teaching hospital with 25,000 visits per year.MEASUREMENTS AND MAIN RESULTS: There were 100 reports in the 1-year period, increased from 5 in the previous year. Faculty physicians reported 44% of the events versus 22% by residents, 31% by nurses, and 3% by managers. Eighty-three percent were near misses and 17% were adverse events. Errors involved medication (47%), lab or x-rays (22%), office administration (21%), and communication (10%) processes. Seventy-two interventions were recommended with 75% implemented during the study period.CONCLUSION: This model of clinician-based voluntary reporting, systems analysis, and redesign was effective in increasing error reporting, particularly among physicians, and in promoting system changes to improve care and prevent errors. This process can be a powerful tool for incorporating error reporting and analysis into the culture of medicine.

Clinical Implications of Body Image Among Rural African-American Women

OBJECTIVE: To increase understanding of body image among rural, African-American women through open-ended interviews.DESIGN: Individuals’ perceptions of body image were investigated using open-ended, in-depth interviews that were taperecorded, transcribed, and analyzed to identify common themes and to compare thematic data across three body mass index categories (obese, overweight, and normal).SETTING: University-affiliated rural community health center.PARTICIPANTS: Twenty-four African-American women, aged 21 to 47 years.MAIN RESULTS: Respondents reported the following common themes: dissatisfaction with current weight; fluctuating levels of dissatisfaction (including periods of satisfaction); family and social pressure to be self-accepting; and social and physical barriers to weight loss. The interviews revealed ambivalence and conflicts with regard to body image and weight. Among these women, there was strong cultural pressure to be self-accepting of their physical shape, to “be happy with what God gave you,” and to make the most of their appearance.CONCLUSIONS: The pressure to be self-accepting often conflicted with these obese women’s dissatisfaction with their own appearance and weight. Although the respondents believed they could lose weight “if [they] put [their] mind to it,” those women wanting to lose weight found that they lacked the necessary social support and resources to do so. The conflicts stemming from social pressures and their own ambivalence may result in additional barriers to the prevention of obesity, and an understanding of these issues can help health care providers better address the needs of their patients.

Evaluation and diagnosis of acute infectious diarrhea

The appropriate approach to the diagnosis and management of acute infectious diarrhea is determined by the frequency and setting of the illness, the recognizable causes or syndromes, the cost and yield of available diagnostic tests, and the treatability of the disease. Acute diarrhea affects everyone throughout the world from one to more than six times each year, depending on age, location, and living conditions. The range of identifiable viral, bacterial, and parasitic etiologies is great, and the cost of indiscriminate use of etiologic studies for diagnosis is prohibitive. Because of its insensitivity for many organisms and poor selection of cases for testing, routine stool culture has been one of the most costly and ineffective microbiologic tests; the cost per positive result has traditionally exceeded