Linda M. Lucas

Polypharmacy: the cure becomes the disease

Polypharmacy occurs when a medical regimen includes at least one unnecessary medication. Factors that contribute to this problem include: patient characteristics of increasing age, multiple medical problems, therapy expectations, and decisions to self-treat; physician factors such as excessive prescribing; and system problems of multiple providers and lack of a coordinating provider. Complications include increased adverse drug reactions and noncompliance, which can lead to increased hospitalization and associated costs. Polypharmacy can be avoided by patient education and sharing the decisions for making the treatment goals and plan. The medication regimen can be simplified by eliminating pharmacologic duplication, decreasing dosing frequency, and regular review of the drug regimen. The goal should be to prescribe the least complex drug regimen for the patient as possible, while considering the medical problems and symptoms and the cost of therapy.SummaryPolypharmacy occurs when a medical regimen includes at least one unnecessary medication. Factors that contribute to this problem include: patient characteristics of increasing age, multiple medical problems, therapy expectations, and decisions to self-treat; physician factors such as excessive prescribing; and system problems of multiple providers and lack of a coordinating provider. Complications include increased adverse drug reactions and noncompliance, which can lead to increased hospitalization and associated costs. Polypharmacy can be avoided by patient education and sharing the decisions for making the treatment goals and plan. The medication regimen can be simplified by eliminating pharmacologic duplication, decreasing dosing frequency, and regular review of the drug regimen. The goal should be to prescribe the least complex drug regimen for the patient as possible, while considering the medical problems and symptoms and the cost of therapy.

Collaborative Care Intervention for Stable Ischemic Heart Disease

BACKGROUND Accumulating evidence suggests that collaborative models of care enhance communication among primary care providers, improving quality of care and outcomes for patients with chronic conditions. We sought to determine whether a multifaceted intervention that used a collaborative care model and was directed through primary care providers would improve symptoms of angina, self-perceived health, and concordance with practice guidelines for managing chronic stable angina. METHODS We conducted a prospective trial, cluster randomized by provider, involving patients with symptomatic ischemic heart disease recruited from primary care clinics at 4 academically affiliated Department of Veterans Affairs health care systems. Primary end points were changes over 12 months in symptoms on the Seattle Angina Questionnaire, self-perceived health, and concordance with practice guidelines. RESULTS In total, 183 primary care providers and 703 patients participated in the study. Providers accepted and implemented 91.6% of 701 recommendations made by collaborative care teams. Almost half were related to medications, including adjustments to β-blockers, long-acting nitrates, and statins. The intervention did not significantly improve symptoms of angina or self-perceived health, although end points favored collaborative care for 10 of 13 prespecified measures. While concordance with practice guidelines improved 4.5% more among patients receiving collaborative care than among those receiving usual care (P < .01), this was mainly because of increased use of diagnostic testing rather than increased use of recommended medications. CONCLUSION A collaborative care intervention was well accepted by primary care providers and modestly improved receipt of guideline-concordant care but not symptoms or self-perceived health in patients with stable angina.

Gynecomastia. A worrisome problem for the patient.

Gynecomastia is common in obese or elderly men. Drug-induced breast enlargement is also frequent, whereas other causes of gynecomastia are relatively uncommon. Standardized measurement of breast tissue should be routinely performed in male patients. Diagnostic evaluation should be individualized on the basis of clinical suspicion. Therapy most often involves treating an underlying condition or discontinuing use of an offending drug.

Aiming to improve care of older adults: an innovative faculty development workshop.

Introduction/ AimsInternists care for older adults and teach geriatrics to trainees, but they often feel ill-prepared for these tasks. The aims of our 1-day Continuing Medical Education workshop were to improve the knowledge and self-perceived competence of general internists in their care of older adults and to increase their geriatrics teaching for learners.SettingTwo internal medicine training programs encompassing University, Veterans Affairs, and a community-based hospital in Portland, OR, USA.Program DescriptionCourse faculty identified gaps in assessment of cognition, function, and decisional capacity; managing care transitions; and treatment of behavioral symptoms. To address these gaps, our workshop provided geriatric content discussions followed by small group role plays to apply newly learned content. Forty teaching faculty participated.Program EvaluationParticipants completed 13-item multiple-choice pre- and post-workshop geriatric knowledge tests, pre- and post-workshop surveys of self-perceived competence to care for older adults, and completed an open-ended ‘commitment to change’ prompt after the intervention. Knowledge scores improved following the intervention (61% to 72%, p < .0001), as did self-perceived competence (11 of 14 items significant). Seventy-one percent of participants reported success in meeting their commitment to change goals.DiscussionA 1-day intervention improved teaching faculty knowledge and self-perceived competence to care for older patients and led to self-perceived changes in teaching behaviors.

A housestaff ambulatory block model—description and evaluation

Background: Recommendations are to increase ambulatory training in postgraduate medical education. Description: We collected pre‐and postrotation measures of satisfaction in 1, 500 patients. We also collected postrotation ratings from 60 residents concerning (a) changes in knowledge and skill and (b) evaluation of selected components and overall experience. Evaluation: Most patients gave high ratings to their physicians pre‐and postrotation. Housestaff reported increased self‐rated knowledge and skills for Rheumatology and Behavioral Medicine (p < .001) and for Womens Health (p < .05). Trainees valued hands‐on patient care and focused clinical content. Modules with observational format, limited staff involvement, or fewer patients received lower ratings. Conclusions: We found significant increases in self‐rated knowledge and skills, and that trainees preferred an interactive, hands‐on, focused‐learning format. Research is needed to determine the effect of ambulatory experiences on actual patient care or ...

Sjögren's syndrome: More than dry eyes and dry mouth

Sjögrens syndrome is a complex disease state with multisystem manifestations. Two forms of the disease, primary and secondary, are recognized; the secondary form is more easily diagnosed because of its association with an already established rheumatic or autoimmune disease. Treatment consists of measures to prevent damage from ocular and oral dryness (sicca complex) and to minimize systemic manifestations.Sjogren’s syndrome (SS) is a systemic autoimmune disease characterized by exocrine gland dysfunction and destruction, mainly localized at the level of salivary and lacrimal glands, leading to dryness of the mouth and eyes, as the most frequent symptoms of the disease. From a pathological point of view, SS is an exocrinopathy (i.e. an autoimmune epitheliitis of the exocrine glands) characterized by dense lymphocytic infiltrates of glandular tissue and B-cell hyperreactivity.