Search

Background: Comorbidities are expected to impact the pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF). However, comorbidity profiles are usually reduced to a few comorbid disorders. Systems medicine approaches can model phenome-wide comorbidity profiles to improve our understanding of HFpEF and infer associated genetic profiles., Methods: We retrospectively explored 569 comorbidities in 29,047 HF patients, including 8062 HFpEF and 6585 HF with reduced ejection fraction (HFrEF) patients from a German university hospital. We assessed differences in comorbidity profiles between HF subtypes via multiple correspondence analysis. Then, we used machine learning classifiers to identify distinctive comorbidity profiles of HFpEF and HFrEF patients. Moreover, we built a comorbidity network (HFnet) to identify the main disease clusters that summarized the phenome-wide comorbidity. Lastly, we predicted novel gene candidates for HFpEF by linking the HFnet to a multilayer gene network, integrating multiple databases. To corroborate HFpEF candidate genes, we collected transcriptomic data in a murine HFpEF model. We compared predicted genes with the murine disease signature as well as with the literature., Results: We found a high degree of variance between the comorbidity profiles of HFpEF and HFrEF, while each was more similar to HFmrEF. The comorbidities present in HFpEF patients were more diverse than those in HFrEF and included neoplastic, osteologic and rheumatoid disorders. Disease communities in the HFnet captured important comorbidity concepts of HF patients which could be assigned to HF subtypes, age groups, and sex. Based on the HFpEF comorbidity profile, we predicted and recovered gene candidates, including genes involved in fibrosis (COL3A1, LOX, SMAD9, PTHL), hypertrophy (GATA5, MYH7), oxidative stress (NOS1, GSST1, XDH), and endoplasmic reticulum stress (ATF6). Finally, predicted genes were significantly overrepresented in the murine transcriptomic disease signature providing additional plausibility for their relevance., Conclusions: We applied systems medicine concepts to analyze comorbidity profiles in a HF patient cohort. We were able to identify disease clusters that helped to characterize HF patients. We derived a distinct comorbidity profile for HFpEF, which was leveraged to suggest novel candidate genes via network propagation. The identification of distinctive comorbidity profiles and candidate genes from routine clinical data provides insights that may be leveraged to improve diagnosis and identify treatment targets for HFpEF patients., (© 2023. The Author(s).)

Objectives: To identify and characterise medical consultations to psychiatric inpatients., Method: Retrospective cross-sectional descriptive study of 451 psychiatric inpatients' electronic medical records between 1 January and 30 June 2021 with descriptive statistics., Results: Thirty one percent ( n = 131) of inpatients required medical consultation, with 382 total consultations including ward call. Half (57.9%) were telephone advice. Main consulting specialties were general medicine (25%), anaesthetics (12%), neurology (9.9%), cardiology (6.5%) and endocrinology (6.2%). Almost all (99.0%) consultations resulted in documented management plans., Conclusions: This is the first Australian descriptive study quantifying and characterising psychiatric inpatient consultation requests. Physical and psychiatric healthcare integration requires ongoing efforts, including improved referral pathways.

This study was designed to increase our understanding about characteristics and the impact of sensory symptoms (SS) and signs of hyperarousal (HA) in individuals with fragile X syndrome (FXS) from childhood through early adulthood and by gender. Data derived from the Fragile X Online Registry With Accessible Research Database (FORWARD), a natural history study of FXS, were analyzed using descriptive statistics and multivariate linear and logistic regression models to examine SS and signs of HA, their impact on behavioral regulation and limitations on the subject/family. The sample (N = 933) consisted of 720 males and 213 females. More males were affected with SS (87% vs. 68%) and signs of HA (92% vs. 79%). Subjects who were endorsed as having a strong sensory response had more comorbidities, including behavioral problems. The predominant SS was difficulty with eye gaze that increased with age in both genders. As individuals age, there was less use of non-medication therapies, such as occupational therapy (OT)/physical therapy (PT), but there was more use of psychopharmacological medications and investigational drugs for behaviors. Multiple regression models suggested that endorsing SS and signs of HA was associated with statistically significantly increased ABC-C-I subscale scores and limited participation in everyday activities. This study improves our understanding of SS and signs of HA as well as their impact in FXS. It supports the need for more research regarding these clinical symptoms, especially to understand how they contribute to well-known behavioral concerns.

Methods: A systematic analysis was performed of the medical specialization academic programs of 20 different countries to establish which medical specialties take into account mental health issues in the specialty curricular design and which mental health content these programs address. The criteria that were explored in the educational programs include: 1) name of the medical specialties that take into account mental health content in curriculum design, 2) name of the mental health issues addressed by these programs. After independent review and data extraction, paired investigators compared the findings and reached consensus on all discrepancies before the final presentation of the data. Descriptive statistics evaluated the frequency of the data presented., Results: Internal medicine, family medicine, neurology, pediatrics and geriatrics were the specialties that included mental health topics in their programs. In four countries: Bangladesh, Serbia, the Netherlands and France, 50%of all graduate specialty training programs include mental health content. In ten countries: Germany, Sweden, the United Kingdom, Mexico, Belgium, India, Russia, Canada, Israel and Spain, between 20% and 49% of all graduate specialty training programs include mental health content. In six countries - Brazil, Chile, Colombia, Croatia, Kenya, and the United States-less than 20% of all graduate specialty training programs include mental health content., Discussion: The proposal that we have made in this article should be taken into account by decision-makers, in order to complement the different postgraduate training programs with mental health issues that are frequently present with other physical symptoms. It is not our intention that the different specialists know how to treat psychiatric comorbidities, but rather pay attention to their existence and implications in the diagnosis, evolution and prognosis of many other diseases. The current fragmentation of medicine into ever finer specialties makes the management of comorbidity ever more difficult: a reorientation of post- graduate training might improve the situation.

Background: Hip fractures typically occur in frail elderly patients. Preoperative specialty consults, in addition to hospitalist comanagement, are often requested for preoperative risk assessment., Objective: Determine if preoperative specialty consults meaningfully influence management and outcomes in hip fracture patients, while being comanaged by hospitalists DESIGN: Retrospective cohort study SETTING: Tertiary care hospital in Connecticut PATIENTS: 491 patients aged 50 years and older who underwent surgery for an isolated fragility hip fracture, defined as one occurring from a fall of a height of standing or less., Intervention: Presence or absence of a preoperative specialty consult MEASUREMENTS: Time to surgery (TTS), length of hospital stay (LOS), and postoperative complications RESULTS: 177 patients had a preoperative specialty consult. Patients with consults were older and had more comorbidities. Most consult recommendations were minor (72.8%); there was a major recommendation only for eight patients (4.5%). Multivariate analysis demonstrates that consults are more likely to be associated with a TTS beyond 24 hours (Odds Ratio [OR] 4.28 [2.79-6.56]) and 48 hours (OR 2.59 [1.52-4.43]), an extended LOS (OR 2.67 [1.78-4.03]), and a higher 30-day readmission rate (OR 2.11 [1.09-4.08]). A similar 30-day mortality rate was noted in both consult and no-consult groups., Conclusions: The majority of preoperative specialty consults did not meaningfully influence management and may have potentially increased morbidity by delaying surgery. Our data suggest that unless a hip fracture patient is unstable and likely to require active management by a consultant, such consults offer limited benefit when weighed against the negative impact of surgical delay.

Objective: This study aims to compare the management practices of a headache specialist with non-headache specialists in the treatment of children with migraine. The use of appropriate rescue medications and prophylactic agents, application of neuroimaging, and short-term outcomes are compared in children treated by the two groups of physicians., Methods: A retrospective cohort study was conducted by utilizing the electronic medical records of children 3-18 years of age with migraine, who were evaluated at a tertiary care children's hospital from 2016 to 2018., Results: Of the 849 patients who met the study criteria, 469 children were classified as having chronic migraine or high-frequency episodic migraine and were followed-up on at least 1 occasion by the neurologists. Imaging was obtained in 66.5% of all children with migraine. The headache specialist used 5-HT agonists ("triptans") for migraine management in 56.7% (76/135) of cases compared to non-headache specialists who prescribed them in 28.7% (96/334) of cases (P < .001). Of the children with chronic migraine, the headache specialist evaluated 135 patients while the non-headache specialists treated 334 children. Non-headache specialists prescribed prophylaxis in the form of natural supplements more frequently (63.8% of cases) compared to the headache specialist (38.5% of children) (P < .001). Moreover, prophylaxis with prescription drugs was utilized more often by headache specialist (66.7%) than non-headache specialists (37.4%) (P < .001)., Conclusions: Imaging appears to be commonly recommended by both headache specialists and non-headache specialists in children with migraine. The headache specialist was more likely to use triptans as rescue medications for pediatric migraine. Outcomes in the short-term were not statistically different whether children were being managed by the headache specialist or the non-headache specialists., (© 2019 American Headache Society.)

Objective Effective health care for older people with complex health needs requires a diverse range of healthcare professionals working together. The Building Partnerships Framework of the New South Wales Agency for Clinical Innovation seeks to promote collaboration and integration among service providers. The aim of the present study was to inform implementation and evaluation of the Framework. Methods Data from the 45 and Up Study was linked with deaths and service data from hospitalisations and the Medicare Benefits Schedule (MBS). Participants with a hospitalisation for conditions representing 'geriatric syndrome' were allocated to a complex needs group; the remainder were allocated to a comparison group. Hospital admissions and MBS services use were modelled using log-linear Poisson regression. Results Multivariate analysis showed that the rate of hospitalisation in the 2 years following index admission for the complex needs group was 18% (95% confidence interval (CI) 1.12-1.24) greater than the comparison group and specialist physician attendance was 13% (95% CI 1.06 - 1.21) greater. The rate of general practitioner (GP) attendances was 2% (95% CI 0.97-1.07) greater in the complex needs group, but this was not statistically significant. Discussion The greater rates of hospitalisation and specialist service use, the absence of a similar finding for GP services and the prominence of the role of primary care in service integration literature, policy and strategy underscore the importance of careful planning, consultation and inclusiveness in the development and implementation of integrated care policy. What is known about the topic? Older people with complex health needs are significant consumers of primary and secondary health services and benefit from well-planned and coordinated care. What does this paper add? The findings presented here indicate that although hospitals and specialist physicians provide a significantly greater volume of services to people with complex health needs, GPs do not. Within the limitations of the present study, these findings can contribute to integrated care policy and strategy development and implementation. What are the implications for practitioners? Given the prominence of primary care in service integration literature, policy and strategy and the findings of the present study with regard to the relative level of GP involvement in the management of people with complex needs, careful policy implementation will be required to ensure GPs are able to contribute significantly to coordinated cooperation between health services.

Importance: Clinical experience suggests that there are substantial differences in patient complexity across medical specialties, but empirical data are lacking., Objective: To compare the complexity of patients seen by different types of physician in a universal health care system., Design, Setting, and Participants: Population-based retrospective cohort study of 2 597 127 residents of the Canadian province of Alberta aged 18 years and older with at least 1 physician visit between April 1, 2014 and March 31, 2015. Data were analyzed in September 2018., Exposures: Type of physician seeing each patient (family physician, general internist, or 11 types of medical subspecialist) assessed as non-mutually exclusive categories., Main Outcomes and Measures: Nine markers of patient complexity (number of comorbidities, presence of mental illness, number of types of physicians involved in each patient's care, number of physicians involved in each patient's care, number of prescribed medications, number of emergency department visits, rate of death, rate of hospitalization, rate of placement in a long-term care facility)., Results: Among the 2 597 127 participants, the median (interquartile range) age was 46 (32-59) years and 54.1% were female. Over 1 year of follow-up, 21 792 patients (0.8%) died, the median (range) number of days spent in the hospital was 0 (0-365), 8.1% of patients had at least 1 hospitalization, and the median (interquartile range) number of prescribed medications was 3 (1-7). When the complexity markers were considered individually, patients seen by nephrologists had the highest mean number of comorbidities (4.2; 95% CI, 4.2-4.3 vs [lowest] 1.1; 95% CI, 1.0-1.1), highest mean number of prescribed medications (14.2; 95% CI, 14.2-14.3 vs [lowest] 4.9; 95% CI, 4.9-4.9), highest rate of death (6.6%; 95% CI, 6.3%-6.9% vs [lowest] 0.1%; 95% CI, <0.1%-0.2%), and highest rate of placement in a long-term care facility (2.0%; 95% CI, 1.8%-2.2% vs [lowest] <0.1%; 95% CI, <0.1%-0.1%). Patients seen by infectious disease specialists had the highest complexity as assessed by the other 5 markers: rate of a mental health condition (29%; 95% CI, 28%-29% vs [lowest] 14%; 95% CI, 14%-14%), mean number of physician types (5.5; 95% CI, 5.5-5.6 vs [lowest] 2.1; 95% CI, 2.1-2.1), mean number of physicians (13.0; 95% CI, 12.9-13.1 vs [lowest] 3.8; 95% CI, 3.8-3.8), mean days in hospital (15.0; 95% CI, 14.9-15.0 vs [lowest] 0.4; 95% CI, 0.4-0.4), and mean emergency department visits (2.6; 95% CI, 2.6-2.6 vs [lowest] 0.5; 95% CI, 0.5-0.5). When types of physician were ranked according to patient complexity across all 9 markers, the order from most to least complex was nephrologist, infectious disease specialist, neurologist, respirologist, hematologist, rheumatologist, gastroenterologist, cardiologist, general internist, endocrinologist, allergist/immunologist, dermatologist, and family physician., Conclusion and Relevance: Substantial differences were found in 9 different markers of patient complexity across different types of physician, including medical subspecialists, general internists, and family physicians. These findings have implications for medical education and health policy.

The successful implementation of an integrated care pathway (ICP) for any given condition is a challenge. Even more challenging is successful ICP implementation for individuals who have multiple co-morbidities. This is further compounded when there are dual mental health and physical disabilities that require integrated working across multiple disciplines, specialties, institutions and organisations. Anti-NMDA-Receptor encephalitis (aNMDARe) is a relatively new diagnostic entity with patients typically presenting with significant psychiatric symptoms followed by progressive neurological deterioration. In this case series, we describe 3 cases of females with aNMDARe who were referred for complex specialist rehabilitation (CSR) to The National Rehabilitation Hospital. CSR is the total active care of patients with a disabling condition, and their families, by a multi-professional team who have undergone recognised specialist training in rehabilitation, led /supported by a consultant trained and accredited in rehabilitation medicine (RM). These services provide for patients with highly complex rehabilitation needs that are beyond the scope of local services. In these cases, referral to CSR resulted in the construction of a bespoke integrated care pathway (ICP) that transcended the barriers between primary, secondary and tertiary care and across the boundaries of physical and mental health. A care pathway is a complex intervention for the mutual decision-making and organisation of care processes Rehabilitation services acted as the coordinator of services in these cases to ensure implementation of the care plan and to ensure successful transitions of care and supported local specialist and general teams in the management of these complex cases.

Insomnia is a common feature of both medical and psychiatric disorders. Whether as a symptom of an illness or as a comorbid disorder, insomnia worsens patient outcomes related to quality of life, functioning, workplace productivity, and health care expenditures. This CME webcast covers how to screen for insomnia in patients with both medical and mental illnesses and how to develop a comprehensive treatment plan. The authors also review evidence-based therapies for insomnia, including psychological/behavioral interventions and medications., (© Copyright 2016 Physicians Postgraduate Press, Inc.)

Objectives: Building on an existing theoretical shared primary care/specialist care framework to (1) develop a unique typology of care for people living with human immunodeficiency virus (HIV) in Ontario, (2) assess sensitivity of the typology by varying typology definitions, and (3) describe characteristics of typology categories., Study Design and Setting: Retrospective population-based observational study from April 1, 2009, to March 31, 2012. A total of 13,480 eligible patients with HIV and receiving publicly funded health care in Ontario. We derived a typology of care by linking patients to usual family physicians and to HIV specialists with five possible patterns of care. Patient and physician characteristics and outpatient visits for HIV-related and non-HIV-related care were used to assess the robustness and characteristics of the typology., Results: Five possible patterns of care were described as low engagement (8.6%), exclusively primary care (52.7%), family physician-dominated comanagement (10.0%), specialist-dominated comanagement (30.5%), and exclusively specialist care (5.2%). Sensitivity analyses demonstrated robustness of typology assignments. Visit patterns varied in ways that conform to typology assignments., Conclusion: We anticipate this typology can be used to assess the impact of care patterns on the quality of primary care for people living with HIV., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To describe the developmental-behavioral pediatricians (DBPs), patients, and clinical practices used in the diagnostic assessments of attention-deficit/hyperactivity disorder (ADHD) within all 12 academic medical centers comprising Developmental-Behavioral Pediatrics Research Network (DBPNet)., Methods: Between December 2011 and June 2012, all DBPs who evaluated children with ADHD or autism spectrum disorders were asked to complete a diagnostic encounter survey form for up to 10 consecutive new cases that resulted in the diagnosis of ADHD or autism spectrum disorder. Fifty-two clinicians returned one or more forms for children diagnosed with ADHD (n = 211)., Results: DBPs were generally experienced full-time academics. Children were 76.3% male, 62.3% white, 24.5% African American, and 20.7% Hispanic. Mean child age was 8.0 + 3.1 years. DBPs reviewed parent ratings of behavior in 84.4% and teacher ratings in 69.2% of cases. They reviewed or completed at least one developmental assessment in 79.2% of cases: intelligence (60.2%), academic (57.8%), fine motor or visual motor (39.3%), speech/language (34.6%), or adaptive skills (28.9%). They made the diagnosis of coexisting conditions in 82.7% of cases, including learning disabilities (31.8%), speech/language disorders (31.8%), anxiety (14.2%), externalizing disorders (10.9%), and sleep disorders (9.5%). Among 146 children not medicated before the visit, stimulant medications were initiated in 15 children (10.2%)., Conclusions: Within DBPNet, DBPs were highly likely to complete comprehensive assessments of ADHD that went beyond the requirements of primary care practice guidelines. They typically identified coexisting developmental and learning conditions. They did not typically prescribe medication at the end of diagnostic encounters., (Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Electronic health records (EHR) represent a rich and relatively untapped resource for characterizing the true nature of clinical practice and for quantifying the degree of inter-relatedness of medical entities such as drugs, diseases, procedures and devices. We provide a unique set of co-occurrence matrices, quantifying the pairwise mentions of 3 million terms mapped onto 1 million clinical concepts, calculated from the raw text of 20 million clinical notes spanning 19 years of data. Co-frequencies were computed by means of a parallelized annotation, hashing, and counting pipeline that was applied over clinical notes from Stanford Hospitals and Clinics. The co-occurrence matrix quantifies the relatedness among medical concepts which can serve as the basis for many statistical tests, and can be used to directly compute Bayesian conditional probabilities, association rules, as well as a range of test statistics such as relative risks and odds ratios. This dataset can be leveraged to quantitatively assess comorbidity, drug-drug, and drug-disease patterns for a range of clinical, epidemiological, and financial applications.

Background: Physicians are frequently studied as a population that experiences extremely high stress, burnout, and prolonged working hours that might harm one's health. However, they have sound medical knowledge and have easy access to medical resources. We studied the incidence of cancer among Taiwanese physicians using a nationwide cohort study design., Methods: Data were obtained from the National Health Insurance (NHI) system in Taiwan. The physician cohort contained 22,309 physicians, and each physician was randomly frequency-matched according to age and sex with 4 people from the general population., Results: The overall incidence ratio of cancer was 27% lower in the physician cohort than in the nonphysician comparison cohort (33.9 vs. 46.5 people per 10,000 person-years, crude hazard ratio (HR)=0.73, 95% CI=0.70, 0.76). The adjusted HR was 0.78 (95% CI=0.72, 0.84). Female physicians experienced a higher incidence rate ratio of overall cancer, compared to male physicians (crude HR=1.17, 95% CI=1.03, 1.33 vs. crude HR=0.70, 95% CI=0.67, 0.74, respectively). Physicians were at a significantly higher risk of thyroid cancer (HR 1.75, 95% CI=1.14, 2.68), prostate cancer (HR=1.54, 95% CI=1.21, 1.97), breast cancer (HR=1.45, 95% CI=1.00, 2.09), and non-cervical gynecological cancer (HR=4.03, 95% CI=1.77, 9.17), compared with the general population., Conclusions: Physicians are at lower overall risk of cancer than the general population, apart from cancer of the thyroid, prostate, breast, and non-cervical gynecological cancer.

This case report describes a patient with multiple morbidity resulting from complicated type 2 diabetes, psoriatic arthritis and abdominal surgery. It highlights the importance of specialist palliative care services in meeting his complex holistic care needs. We acknowledge the growing number of patients living with multiple morbidity and the challenges this group can present. There is then a debate around when to involve specialist palliative care services in the management of multiple morbidity given that there is often an uncertain disease trajectory.

Background: Specialized stroke unit care improves outcome in stroke patients. However, it is uncertain whether the units should be placed in a neurological or non-neurological (eg, internal medicine or geriatric) setting., Objectives: To assess whether stroke unit setting (neurological/non-neurological) is associated with quality of care and outcome among patients with stroke, and whether these associations depend on the severity of comorbidity., Methods: In a nationwide population-based follow-up study, we identified 45,521 patients admitted to stroke units in Denmark between 2003 and 2008. Outcomes were quality of care (whether patients received evidence-based processes of acute stroke care), mortality, length of stay, and readmission. Charlson comorbidity index was used to assess comorbidity, and comparisons were adjusted for patient and hospital characteristics., Results: Patients admitted to stroke units in neurological settings had higher odds for early antiplatelet therapy (odds ratio, 1.68; 95% confidence interval, 1.10-2.56) and early computed tomographic scan or magnetic resonance imaging (odds ratio, 1.77; 95% confidence interval, 1.29-2.45) compared with patients in non-neurological settings. No other differences were found when studying quality of care and patient outcomes. However, patients with moderate comorbidity admitted to stroke units in neurological settings had higher odds for 1-year mortality, but comparisons across strata of comorbidity were not statistical significant., Conclusions: Except for early antiplatelet therapy and early computed tomographic scan or magnetic resonance imaging, the medical setting was not associated with differences in processes of acute stroke care and patient outcome. No medical setting related differences were found according to comorbidity, although indications of a worse outcome in patients with moderate comorbidity in neurological settings warrant further investigation.

Geriatric otolaryngology is an emerging medical subspecialty developed in response to a pressing societal need. In this article, the author explains the rationale for this new subspecialty, reviews the landmark events that led to the creation of an organizational structure, celebrates the accomplishments that have been achieved thus far, and discusses the challenges that remain and the opportunities for future growth.

Coronary heart disease (CHD) patients are currently attended by many different medical specialities. CHD patients must achieve the highest grade of treatment implementation and risk factors control. The aims were to describe differences in medical treatment of CHD according to the medical specialities. For this purpose we conducted an observational, cross-sectional, and multicenter study of CHD patients attended by internal medicine (IM), outpatient clinic cardiologist (OCC), hospital cardiologist (HC), and general practitioners (PC). Burden of noncardiac diseases was evaluated by the Charlson index. Joint prescription of antiplatelets, statins, beta-blockade agents and blockade of the renin-angiotensin system by angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptors blockers (ARB) was considered optimal medical treatment (OMT). A total of 2987 patients, mean age 67.4 (11.5) years and 71.5% males, were analyzed. Patients visited by IM physicians had slightly higher mean age and higher prevalence of hypertension, diabetes, and noncardiac diseases (median Charlson index 3.0, 1.0-5.0, vs. 2.0, 1.0-4.0, of total sample). OMT was prescribed in 25.9% (95% CI 25.6-26.2) of the patients and was statistically more frequently carried out by HC (32.1%) and OCC (29.0%) compared to IM (22.0%) and PC practitioners (21.5%). Multivariate analysis showed an independent association between OMT prescription and HC (OR 1.42; 95% CI 1.08-1.87) or OCC (OR 1.31; 95% CI 1.04-1.67); this association remained after including the Charlson index. Noncardiac diseases are the main clinical differences in CHD patients visited by different medical specialist although it does not explain the higher prescription of OMT by cardiologist.

Objective: Almost no cross-sectional studies directly compared the rate and pattern of comorbidity of affective disorders in relation to personality traits of patients seen in primary care versus specialty mental health care., Method: Using data from the Netherlands Study of Depression and Anxiety, we compared 1086 primary care patients with 790 consecutive specialized mental health care patients. All participants had at least one lifetime Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition-based diagnosis of depression or anxiety. Personality was assessed with the NEO Five-Factor Inventory., Results: In both settings it was common to have at least one lifetime comorbid affective disorder. Compared to primary care patients, specialty care patients showed elevated scores for Neuroticism and lower scores for Extraversion and Conscientiousness. The odds of having another disorder given any one disorder was no longer significant after accounting for personality dimensions. Only Neuroticism proved to be positively associated with comorbidity per se., Conclusions: Prevalence of and comorbidity among anxiety and depressive disorders in primary care were very similar to those in specialty care. Neuroticism - but no other personality traits - may help to understand the comorbidity among anxiety and depressive disorders irrespective of recruitment setting.

Introduction: COPD is one of the most important lung diseases. It is responsible for significant proportion of outpatients pulmonary clinics visits. Data on outpatients care of COPD patients in Poland are limited. This article presents design of the KOMPAS study and basic results relating to COPD patients., Material and Methods: The aim of this prospective study was to describe population of patients with COPD treated by specialists, and to characterize methods of care used in various COPD stages. Participating physicians used pocket PCs equipped with specially developed software to collect COPD patients' data., Results: Data on 2958 COPD patients were analyzed. 2/3 of patients were males. Mean patients age was 63 years and mean FEV(1) - 57% of predicted value. 86% of all subjects underwent spirometry during the first visit or the previous 6 months. Cough and exertional dyspnoea were the most frequently reported COPD symptoms (about 80% of patients). At the first visit 32% of subjects were current smokers and 51% were ex-smokers. 17% of all study patients have never smoked. Before inclusion 2/3 of patients were treated with bronchodilatator, and about 1/3 with inhaled steroid. After entering the study, over 90% received bronchodilatator and more than 2/3 received inhaled steroid. Differences in treatment between stages of COPD based on its severity were relatively small., Conclusions: Results of the KOMPAS study provide basic information about COPD outpatients care in Poland. These data, especially concerning physicians' compliance with current COPD guidelines, may be useful in planning undergraduate/postgraduate training for physicians and for those who are responsible for health resource allocation.

Making a prognosis is one of the primary functions of the medical profession. At the end of the nineteenth century prognostication took up approximately ten percent of medical textbooks, by 1970 this had fallen to nearly zero. Given medical technology's awesome ability to prolong the process and suffering of dying today's patients need to know their prognosis in order to make choices about their treatment options. Whilst precise predictions of the future are obviously not possible, relatively simple mathematical modelling techniques can make reasonable estimates of likely outcomes for individual patients. The life expectancy of a patient of any age with any illness can be estimated provided the disease-specific mortality of the illness is known. Decision analysis or logistic regression models can then be used to determine the risks and benefits of various treatment options. A patient's prognosis does not just depend on their age and primary diagnosis, but also on the severity of their illness, their functional capacity both prior to and during the illness and the number of co-morbidities also suffered from. Several predictive instruments have been developed to help simplify the prediction of the outcome of individual patients. There are conflicting reports on how these models compare with doctors' intuition--whatever their strengths and weaknesses it is unlikely that they worsen clinical judgement. Therefore, all doctors should become familiar with them and use them appropriately.

Drug users are disproportionately affected by hepatitis C virus (HCV), yet they face barriers to health care that place them at risk for levels of HCV-related care that are lower than those of nondrug users. Substance abuse treatment physicians may treat more HCV-infected persons than other generalist physicians, yet little is known about how such physicians facilitate HCV-related care. We conducted a nationwide survey of American Society of Addiction Medicine physicians (n = 320) to determine substance abuse physicians' HCV-related management practices and to describe factors associated with these practices. We found that substance abuse treatment physicians promote several elements of HCV-related care, including screening for HCV antibodies, recommending vaccinations against hepatitis A and B, and referring patients to subspecialists for HCV treatment. Substance abuse physicians who also provide primary medical or HIV-related care were most likely to facilitate HCV-related care. A significant minority of physicians were either providing HCV antiviral treatment or willing to provide HCV antiviral treatment.

Background: The global rise in morbid obesity and associated comorbid diseases concerns a wide range of specialists. Although bariatric surgery has been proven to be an effective, enduring treatment available for morbid obesity, the rates of referral for surgery are not consistent with the number of individuals affected., Methods: A survey of 478 experienced physicians from 6 specialty areas was conducted to ascertain the attitudes and practices regarding the treatment of morbidly obese patients., Results: Approximately 21% (12% family practitioners and 34% internists) of patients seen by respondents were morbidly obese. Bariatric surgery was perceived as, by far, the most effective morbid obesity treatment available (judged to be effective for 49% of patients). Medical treatments were perceived as effective for <20% of patients (15% drugs and 23% exercise). Despite the respondents' perception that most surgery recipients achieve good to excellent long-term results, only 15.4% of patients were referred for consultation with a surgeon (8.0% for cardiologists and 26.1% for bariatricians). Most physicians were not knowledgeable regarding the National Institutes of Health morbid obesity management guidelines. Few could identify a local bariatric surgeon. The volume of referrals across all 6 specialty groups was low, at an average of 6 patients annually (3 patients for cardiologists and 19 patients for bariatricians)., Conclusions: The results of our study have demonstrated that primary care physicians and subspecialists see a high proportion of morbidly obese patients; however, many are unfamiliar with morbid obesity management and surgical referral guidelines. Even though the perception of surgical effectiveness was quite high, the referrals for surgery were relatively low.

Clinical and technological advances in medicine have resulted in more patients requiring multidisciplinary care and coordination of services. This is particularly challenging in pediatrics, given the dependency of children. Coordination of care is a key ingredient of quality care; when suboptimal, clinical outcomes and satisfaction can suffer. In this article we view coordination of care through the lens of complexity science in an effort to find new solutions to this healthcare challenge.

Objectives: The aims of this study were to compare rates of intimate partner violence (IPV) across different medical specialties and health care sites in one metropolitan area, describe demographic characteristics of women with abusive partners, characterize health care provider assessment of IPV, and describe patient characteristics associated with health care assessment for partner violence., Methods: Women (N = 2,465) completed written surveys about partner violence and health care screening for violence in the waiting rooms of five types of health care settings (obstetrician/gynecologist office, emergency department, primary care office, pediatrics, and addiction recovery) across eight different hospitals in the greater Boston area., Results: The overall survey response rate was 62%. The 12-month prevalence rate of IPV was 14%, with 37% disclosing lifetime prevalence. The highest rates of recent IPV were disclosed in the hospital-based addiction recovery unit (36%) and in emergency departments (17%). Adjusted demographic risk characteristics for IPV included age (younger than 24 years), low income, and unemployment. Health care providers were more likely to discuss IPV with low-income women than with middle- or high-income women but were no more likely to assess violence within the youngest age group. Among women who disclosed abuse to their health care provider, 50% reported receiving direct interventions or services as a result., Conclusions: Using the same instrument and protocol, different rates of IPV and detection of IPV were found across medical departments, with the highest rates in emergency departments and an addiction recovery program. It is especially important for assessment of IPV to include young women who present to medical departments.

Objective: Variability in the management of patients hospitalized with community-acquired pneumonia (CAP) is attributable to many factors. The objective of this study was to determine whether such variability is influenced by the medical specialty area where the patient is treated., Patients and Methods: The treatment and outcomes for a random sample of patients with CAP admitted to 4 hospitals over 2 periods (1 year starting March 1, 1998, and 1.5 years starting March 1, 2000) were compared by medical specialty department. Multiple linear and logistic regression models were used to analyze differences., Results: Differences were found between departments in the coverage of atypical pathogens (P<.001). The adjusted mean length of stay in hospital varied between 6.8 and 9.1 days (P<.01), and the duration of intravenous treatment varied between 4.6 and 7.3 days (P<.05). Adjusted models showed that mortality in hospital and at 30 days was significantly higher for patients treated in internal medicine departments (odds ratios, 2.1 and 2, respectively) than for those treated in pulmonology departments., Conclusions: Interdepartmental differences were observed in how patients hospitalized with CAP were treated and in the outcomes achieved. This variation is probably influenced by the differences that were found in the use of antibiotics.

Purpose: The impact of comorbidity on use of primary care and specialty services is poorly understood. The purpose of this study was to determine the relationship between morbidity burden, comorbid conditions, and use of primary care and specialist services, Methods: The study population was a 5% random sample of Medicare beneficiaries, taken from 1999 Medicare files. We analyzed the number of ambulatory face-to-face patient visits to primary care physicians and specialists for each diagnosis, with each one first considered as the "main" one and then as a comorbid diagnosis to another. Each patient was categorized by extent of total morbidity burden using the Johns Hopkins Adjusted Clinical Group case-mix system., Results: Higher morbidity burden was associated with more visits to specialists, but not to primary care physicians. Patients with most diagnoses had more visits, both to primary care and specialist physicians for comorbid diagnoses than for the main diagnosis itself. Although patients, especially those with high morbidity burdens, generally made more visits to specialists than to primary care physicians, this finding was not always the case. For patients with 66 diagnoses, primary care visits for those diagnoses exceeded specialist visits in all morbidity burden groups; for patients with 87 diagnoses, specialty visits exceeded primary care visits in all morbidity burden groups., Conclusion: In the elderly, a high morbidity burden leads to higher use of specialist physicians, but not primary care physicians, even for patients with common diagnoses not generally considered to require specialist care. This finding calls for a better understanding of the relative roles of generalists and specialists in the US health services system.

During one year from November 2002 to October 2003, 810 patients with epilepsy were examined in Shiga Medical Center for Children, and 186 patients (23%) were over 18 years old. Among them, 162 adult patients (male; 52%, female; 48%) were regularly examined at the outpatient-clinic. Seizures persisted in 56% of these adult patients. Over 80% of the patients were classified as symptomatic epilepsy. Seventy-eight percent of the cases were combined with physical or mental disability. Six percent of the patients had psychological disorders and 11% of the patients had internal diseases. Fifteen percent of the patients had jobs, 4% were married, and 8% had driver's licenses. Seventy percent of the patients were not independent because of their handicap. In our children's hospital, adult patients with epilepsy are increasing, and a countermeasure is necessary. It is important to join networks between regional adult hospitals and clinics. On the other hand, pediatric neurologists must study psychological and internal diseases, management of women with epilepsy, and employment and driving in patients with epilepsy.

Maureen Murphy-Ryan offers a clinical look at attention deficit hyperactivity disorder (ADHD). Her thorough definition of ADHD and the diagnoses that may occur simultaneously offer teachers an awareness of what this could look like in a classroom. However, it is only with professional medical input that a true diagnosis can be made and appropriate interventions can be put in place. Behavioral interventions are outlined, as well as the extremely sensitive issue of medication. By partnering these support systems with the Montessori environment and creating a conversation that includes the needs of the child and family, there is a greater chance to successfully help children find their focus. [This talk was presented at the NAMTA conference titled "Finding the Hook: Montessori Strategies to Support Concentration," October 6-9, 2016, in Columbia, MD.]

Pancreatic cancer is associated with a very poor prognosis; however, in selected patients, resection may improve survival. Several recent reports have demonstrated that concentration of treatment activity for patients with pancreatic cancer has resulted in improved outcomes. The aim of this study was to ascertain if there was any evidence of benefit for specialised care of patients with pancreatic cancer in Scotland. Records of patients diagnosed with pancreatic cancer during the period 1993-1997 were identified. Three indicators of co-morbidity were calculated for each patient. Operative procedures were classified as resection, other surgery or biliary stent. Prior to analysis, consultants were assigned as specialist pancreatic surgeons, clinicians with an interest in pancreatic disease or nonspecialists. Data were analysed with regard to 30-day mortality and survival outcome. The final study population included 2794 patients. The 30-day mortality following resection was 8%, and hospital or consultant volume did not affect postoperative mortality. The 30-day mortality rate following palliative surgical operations was 20%, and consultants with higher case loads or with a specialist pancreatic practice had significantly fewer postoperative deaths (P=0.014 and 0.002, respectively). For patients undergoing potentially curative or palliative surgery, the adjusted hazard of death was higher in patients with advanced years, increased co-morbidity, metastatic disease, and was lower for those managed by a specialist (RHR 0.63, 95% CI 0.50-0.78) or by a clinician with an interest in pancreatic disease (RHR 0.63, 0.48-0.82). The risk of death 3 years after diagnosis of pancreatic cancer is higher among patients undergoing surgical intervention by nonspecialists. Specialisation and concentration of cancer care has major implications for the delivery of health services.

In 2002, the Health Council of the Netherlands published two reports on drug addiction. One concerned the treatment of drug addicts in general and the other focused on addicted detainees. At present 'addiction medicine' does not exist as a specialisation in its own right. Inpatient and outpatient clinics for addicts are mainly staffed by social workers and psychologists. This is in stark contrast with the need to address somatic and psychiatric comorbidity. Furthermore, addicts should be viewed as patients suffering from a chronic disease as opposed to a social nuisance. The variety of medications available for both substitution-oriented and abstinence-oriented treatment necessitates a stronger medical approach. The medical treatment of imprisoned addicts requires specific attention, as in such a setting control has a greater priority than treatment.

Background: It is not known whether subspecialty care by cardiologists improves outcomes in heart failure patients from the community over care by other physicians., Methods and Results: Using administrative data, we monitored 38 702 consecutive patients with first-time hospitalization for heart failure in Ontario, Canada, between April 1994 and March 1996 and examined differences in processes of care and clinical outcomes between patients attended by physicians of different disciplines. We found that patients attended by cardiologists had lower 1-year risk-adjusted mortality than those attended by general internists, family practitioners, and other physicians (28.5% versus 31.7%, 34.9%, and 35.9%, respectively; all pairwise comparisons, P<0.001). The 1-year risk-adjusted composite outcome of death and readmission for heart failure was also lower for the cardiologists compared with family practitioners and other physicians but not general internists (54.7% versus 58.1%, 58.3%, and 55.4%; P<0.001, P<0.001, and P=0.39, respectively). Multivariable hierarchical modeling demonstrated a significant physician-level effect for both outcomes in favor of the cardiologists, particularly against non-general internists. Cardiologist care was associated with higher adjusted rates of invasive interventions and postdischarge prescriptions of heart failure medications., Conclusions: In this population-based cohort, heart failure patients attended by cardiologists in hospital had lower risk of death as well as the composite risk of death or readmission than patients attended by noncardiologists. These data raise the need to identify specialty-driven differences in processes of care for heart failure patients, which may explain the observed disparity in clinical outcomes that presently favor cardiologist care.

Background: Treatment of the cancer patient is multifaceted. In addition to treating the cancer itself, there are additional important, "noncancer" issues to consider concomitantly, such as the patient's coexistent diseases, their health behaviors, and preventive care measures. While the need for coordination among surgeons, oncologists, and radiation oncologists has been well documented for treatment of the cancer, little attention has been paid to the importance of "noncancer" issues. In an attempt to characterize such issues, we performed a study to describe the prevalence of comorbid diseases as well as other "noncancer" issues (i.e., presence of poor health habits and use of preventive care measures) for four common, surgically related cancers. Finally, we describe the use of provider resources for these cancer patients., Methods: Using a large population-based, nationwide patient survey, a cross-sectional analysis of lung, prostate, breast, and colon cancer patients who were less than 3 years from their diagnosis was performed. Prevalence of comorbid disease, health behaviors, receipt of preventive health care services, and contact with the health care system were characterized. Comparisons were made with a cohort of age-matched controls without cancer., Results: Three hundred one cancer patients (29 lung, 88 prostate, 119 breast, 65 colon) and 6745 control patients were analyzed. Among the cancer patients, 81% had a coexistent disease, with 59% reporting cardiovascular comorbidity and 17% reporting pulmonary comorbidity. The range of comorbidities was substantial: hypertension (24-48%), coronary disease (8-24%), angina (4-10%), myocardial infarction (8-31%), arrhythmia (8-19%), stroke (3-8%), emphysema (4-10%), asthma (5-12%), diabetes (8-18%), bronchitis (8-13%), renal insufficiency (3-6%), severe arthritic symptoms (34-57%). Of note, 27-39% of cancer patients continued to smoke tobacco (P = 0.03 vs controls), of whom 85% continued to smoke daily. Finally, the rates of preventive care influenza vaccinations in high-risk individuals for the cancer cohort was no higher than the rate in controls, even though the cancer patients saw a health professional significantly more often. Of note, the frequency of "specialists" and surgeon visits was significantly higher for the cancer cohort., Conclusion: To optimize cancer outcomes, successful treatment of both the cancer and the "noncancer" issues is required. This study demonstrates that the burden of coexistent diseases is considerable. We also found the prevalence of continued poor health behaviors (i.e., use of tobacco) as well as suboptimal performance of preventive care measures to be notable. Since cancer patients see specialists twice as often as controls, it appears paramount that specialists (surgeons included) maintain diligence in addressing patient comorbidities, health habits, and other "noncancer" measures. If the substantial rates of smoking and suboptimal performance of preventive care measures are an indication of the "noncancer" quality of care that is being provided to the typical cancer patient, then a more concerted effort by all providers needs to be made regarding these and other "noncancer" issues.

Objective: To study the referral pattern of physical diseases in psychiatric in-patients in a university teaching general hospital., Methods: A longitudinal prospective study, over 12 months with a consecutive series of referrals from psychiatric in-patient unit to other specialties, in King Khalid University Hospital, using a predesigned format that included information on age, sex, physical examination on admission, consulted medical specialties and opinion of the consulted physician., Results: Referral rate was 38% of the total psychiatric in-patients. The most common consulted specialties were endocrinology (14.5%), dermatology (12.5%) and cardiology (12%). About three quarters of the patients were below 30 years of age. Physical examination on admission was not carried out for 16% of cases. Forty-four percent of clinicians responses were within 48 hours of the consultation. There were no responses in 12% of the consultations and no life-threatening physical conditions. About one-third of referred patients were schizophrenics., Conclusion: Physical diseases in psychiatric in-patients are common. Evaluation of psychiatric patients should include a detailed physical examination, thorough medical and psychiatric history, as well as appropriate laboratory testing. Improving psychiatrist trainees' skills in detecting and assessing physical conditions in psychiatric patients is essential.

Background: The new diabetes protocol, formulated in Belgium as a consensus between the National Institution of Health Insurance and diabetologists, implicitly assumes the care of type 1 diabetic patients to be more efficient at the specialist level (SP) in hospital, although GPs frequently are involved in diabetes care., Objectives: A study was carried out in order to highlight differences in diabetes care between three different treatment settings (SP alone, combined SP-GP and GP alone), Methods: Out of a group of known diabetics, 325 patients were selected according to a stratified cluster sampling technique, in such a way that the three types of diabetes (formerly called type 1, type 2a and type 2b) occurred sufficiently in the three above-defined treatment settings. Outcome data on co-morbidity and diabetes health profile as well as output data on laboratory results were collected for each patient and compared between the different subgroups., Results: On the basis of a response rate of 47.9%, equally distributed over the different levels, we demonstrated that GPs and SPs score equally low on the different measures and that a better follow-up is indicated in all settings., Conclusion: Diabetes care in Flanders can be upgraded significantly. There is no evidence that specialists are performing better. Therefore, one could argue for better follow-up of diabetes care in a primary health care setting.

Introduction: Intellectual disability (ID) and co-morbid mental health problems are more common in developing countries such as Bangladesh. However, little is known about how Bangladeshi health practitioners diagnose mental health disorders in people with an ID. Studies in developed countries have explored the impact of the diagnostic overshadowing bias (DOB): the tendency for health practitioners to misattribute mental health symptomology to a client's ID, rather than a separate mental health disorder. To date, no study has investigated the presence of the DOB in Bangladesh. Method: A range of Bangladeshi health practitioners (N = 243) were randomly assigned a clinical vignette describing a client displaying symptoms of a mental health disorder. Vignette 1 described a client with an IQ of 105 who graduated from secondary school. Vignette 2 described a client with an IQ of 55 who attended special education. All other details were identical. Participants rated the likelihood of seven mental health diagnoses on a 5-point Likert scale. Results: Practitioners were more likely to diagnose schizophrenia, drug problems and being bullied in people with a typical IQ compared to those with an ID. Doctors, psychiatrists, and psychologists appeared to be more affected by the DOB than community health workers, traditional healers, and allied health practitioners. Conclusion: Findings indicate that the bias may be present in Bangladesh healthcare professionals. The development and implementation of specific training programs to meet the differing needs of practitioners, across the health fields are recommended.

Objective: To determine differences in the mix of patients among medical specialties and among organizational systems of care., Study Design: Cross-sectional analysis of 20,158 adults (greater than or equal to 18 years of age) who visited providers' offices during 9-day screening periods in 1986. Patient and physician information was obtained by self-administered, standardized questionnaires., Setting: Offices of 349 physicians practicing family medicine, internal medicine, endocrinology, and cardiology within health maintenance organizations, large multispecialty groups, and solo or small single-specialty group practices in three major US cities., Outcome Measures: Demographic characteristics, prevalence of chronic disease, disease-specific severity of illness, and functional status and well-being., Results: Among patients with selected physician-reported chronic illnesses (diabetes, hypertension, recent myocardial infarction, or congestive heart failure), increasing levels of severity were associated with decreasing levels of functional status and well-being and with increased hospitalizations, more physician visits, and higher numbers of prescription drugs. Compared with patients of general internists, patients of cardiologists were older (56 vs 47 years, P less than .01), had worse functional status and well-being scores (P less than .01), and carried more chronic diagnoses (mean 1.32 vs 1.02, P less than .01); patients of family practitioners were younger (40 vs 47 years, P less than .01) and more functional (P less than .01), carried fewer chronic diagnoses (0.70 vs 1.02, P less than .01), and (among diabetic patients only) had lower disease-specific severity scores (2.06 vs 2.30 on a five-point scale, P less than .01). Compared with patients in health maintenance organizations, patients visiting solo practitioners under fee-for-service payment were older (50 vs 45 years, P less than .01) and sicker (had worse physical functioning) and had a higher mean number of chronic diagnoses (1.10 vs 0.93, P less than .01)., Conclusion: Patient mix is related to utilization and differs significantly across medical specialties and systems of care. These differences must be taken into account when interpreting variations in utilization and outcomes across specialties and systems, and when considering alternative policies for payment.

The high rates of comorbidity with substance use disorders in general psychiatry patients demand enhanced competences from psychiatry residents in addiction medicine. The aim of this article is to improve knowledge, skills and attitudes in psychiatric residents in treating patients with comorbid substance-related disorders (SUD). Four seminars with all residents on relevant and actual knowledge on substance-related disorders and a small group experience of five sessions on improving skills and attitudes in dealing with patients are described and evaluated quantitatively and qualitatively. Both quantitative evaluations show that seminars and small group experiences are highly appreciated. Concerning the seminar, residents appreciated, in particular, to study and present selected up-to-date literature and the positive learning environment. The small group experience resulted in sharing feelings and thoughts about patients with SUD and mutual support. The results show that the goals of these two methods of education have been met. This means that these two methods can be integrated in the training of residents in psychiatry to increase knowledge, skills and attitudes concerning addiction.

Earlier indentification has increased the number of infants identified with hearing loss. A significant and growing proportion of children who are D/deaf or hard of hearing have a disability (DWD). Literature related to infants and toddlers who are DWD is scarce because of the heterogeneity of the population and because many disabilities may go undiagnosed until a child is older. Service availability, professional preparation, and use of evidence-based practices must improve to best meet the needs of these children and their families. An examination of theory, research, and practice in early intervention for children who are DWD revealed a lack of qualified professionals and a need for targeted instruction in teacher preparation programs and for technological advances paired with treatment (e.g., telepractice). Increased transdisciplinary collaboration and technology utilization in teacher preparation hold promise as ways of improving service provision to young children who are DWD.