Volume 102, Issue 10

Data presented in this study were gathered in 1998 through a national mail survey of 3000 randomly selected osteopathic physicians. Of 979 (33.4%) questionnaires returned, 955 (97.5%) were usable for analysis. The use of osteopathic manipulative treatment (OMT) was determined for primary care physicians and specialists. Osteopathic manipulative treatment specialists and family physicians provided OMT significantly more frequently than other primary care physicians and non-primary care specialists. More than 50% of respondents (513) administered OMT on less than 5% of their patients. Nevertheless, it should be noted that physicians from 40 of 46 specialties and subspecialties represented in the survey (678, 71%) identified an average of 3.3 conditions and diagnoses per physician that were managed with OMT. The conditions and diagnoses for which OMT is used have been enumerated and codified. More than 50% of conditions (1135) for which respondents treated patients with OMT related to the musculoskeletal system, but extensive overlap among other body systems and body regions attests to the continued incorporation of OMT into holistic patient care by a broad range of osteopathic physicians.

Decision-making ability regarding end-of-life issues is often compromised by dementia in patients with Alzheimer's disease. This study assessed physicians' discussions of advance care planning with patients with mild to moderate Alzheimer's disease. Data were collected by a survey of full-time faculty in the departments of Medicine and Family Medicine and the Center for Aging at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, as well as physicians in private practice affiliated with the Kennedy Health System. Data consisted of questions that assessed whether advance care planning was provided, what specific topics were discussed, and what actions were taken if advance care planning was not offered. Of the 271 physicians to whom the survey was sent, 63 responded, for a return rate of 23%. Of those responding, 81% indicated that they counseled their patients regarding advance care planning issues, while 19% did not. Of those who provided advance care planning for their patients (N = 51), 88% discussed living wills; 53%, the durable power of attorney for healthcare; 47%, end-of-life care; and 35%, financial planning issues. Thirty-seven percent recommended an elder law attorney, and 31% made a referral to the Alzheimer's Association. Of those who provided advance care planning for their patients' caregivers (N = 51), 86% discussed living wills; 78%, nursing home care; 69%, driving issues; and 47%, end-of-life care. Twenty-five percent referred their patients to an elder law attorney. Results indicate that physicians need to be more knowledgeable and proactive in their approaches to advance care planning for patients with mild to moderate Alzheimer's disease.

Current clinical trials are under way to determine the safety and efficacy of temporary inferior vena cava filters for use in patients who need but have contraindications to anticoagulation medications for a short time (<10 days). To date, no data on these types of filters have been published. The authors describe a 20-year-old male trauma patient in whom a pulmonary embolism developed early in his hospital course and who was appropriately placed on anticoagulation therapy. Surgical intervention, however, was necessary to repair complex facial fractures sustained in a motorcycle collision. A filtering infusion catheter was placed until anticoagulation therapy could be resumed. The patient tolerated the surgery without further embolism and has recovered without difficulty.

This report describes a case in which a patient had a Greenfield filter placed at the time of diagnosis of deep vein thrombosis (DVT) when he was asymptomatic for pulmonary embolism. Later in the patient's hospital course, a typical clincal picture of pulmonary embolism developed. The issues examined in this report include: (1) the incidence of asymptomatic pulmonary embolism; (2) the value of the baseline ventilation perfusion (VQ) lung scan for the diagnosis of DVT; and (3) the value of an echocardiogram in diagnosing pulmonary embolism. It appears reasonable that patients in whom DVT is diagnosed undergo baseline VQ scanning. This procedure would prevent the misdiagnosis of a new pulmonary embolism while the patient is on anticoagulation therapy and possibly avoid unnecessary invasive diagnostic procedures. The case described demonstrates the usefulness of the echocardiogram and a transthoracic echo in the diagnosis of pulmonary embolism. It also points out the surprisingly high incidence of silent pulmonary embolism in patients in whom DVT is diagnosed.