Volume 110, Issue 12

Insomnia is one of the more common complaints patients present to their physicians. Sleep problems affect up to one-third of all Americans, and the loss of workplace productivity and increased healthcare utilization result in costs approaching $100 billion a year. Patients with acute insomnia generally respond well to various sedative hypnotic medications, but chronic insomnia is a different challenge. Physicians and patients may raise concerns about the long-term use of sedative hypnotic medications. Even in light of these concerns, however, the chronic insomnia remains, ostensibly leaving the physician few choices. A number of promising nonpharmacologic strategies are available that physicians can easily implement. Through the use of self-rating instruments and a sleep log, physicians can bring the sleep problem into better focus and monitor the efficacy of clinical interventions. Certain behavioral techniques, such as sleep hygiene, stimulus control, and sleep restriction, can be effective remedies for chronic insomnia. The use of cranial electric stimulation for insomnia is also showing promising results. Through careful assessment and the adoption of simple nonpharmacologic strategies, the physician's interventions may result in a good night's sleep.

Context: While estimates suggest that between 1.4% and 5.4% of older adults experience abuse, only 1 of 14 cases of elder abuse or neglect is ever reported to authorities. It is critical for clinicians to be aware of elder abuse in order to improve primary care. Objective: To understand Michigan primary care physicians' knowledge of and reporting practices for elder abuse, including the type of elder abuse education they received, the nature of their clinical practice, and the barriers that prevent them from reporting elder abuse. Methods: A 17-item survey was mailed to 855 primary care physicians in Michigan in 2 waves between October 2007 and December 2007. Results: Of the 855 surveys mailed, 222 were returned for a response rate of 26%. The majority of physicians (131 [67%] of 197 physicians) believed that their training about elder abuse was not very adequate or not adequate at all. Physicians with fewer than 10 hours of training were more likely to rate their training as not adequate when compared to those who had more than 10 hours of clinical training (χ 2 =64.340, P <.001). Whether abuse was reported was highly correlated with whether it was suspected (χ 2 =26.195, P <.001). Those physicians who reported receiving formal training on the topic of elder abuse in residency programs and those who reported participating in CME activities while in practice were less likely to identify not recognizing abuse at time of patient visits as a barrier to reporting. Conclusion: Recognizing the subtle signs of elder abuse continues to be a barrier for physicians who treat older adult patients. However, education may improve primary care physicians' ability to detect and recognize elder abuse.

Context: An estimated 252,000 to 312,000 individuals have undiagnosed human immunodeficiency virus (HIV) infection in the United States. To date, little has been known about osteopathic physicians' attitudes and practices regarding routine HIV testing. Objectives: To understand osteopathic primary care physicians' attitudes and practices toward HIV testing and sexual history taking and to examine factors associated with osteopathic physicians' recommendations of HIV testing at the initial patient visit. Methods: A cross-sectional survey of osteopathic physicians was conducted at the 106th Annual Convention of the Florida Osteopathic Medical Association in February 2009. Survey participants were asked 36 questions about osteopathic physician and patient sociodemographic factors and osteopathic physician attitudes and office practices regarding HIV testing and sexual history taking. Results: A total of 233 osteopathic physicians completed the survey, but only 160 respondents (69%) met inclusion criteria of working in primary care and spending more than 50% of their time with patients. Almost two-thirds of participants were men, 80% were white, and the age range was 28 to 83 years. Twenty-two percent of participants recommended HIV testing at the initial patient visit, and 18% recommended annual HIV testing for all patients. Eighty-seven percent obtained a separate consent form for HIV testing, and 19% included HIV testing in general consent forms. About two-thirds of participants recommended annual HIV testing for homosexual men. Three factors were associated with recommending HIV testing at the initial patient visit: (1) recommending an annual HIV test for sexually active patients (odds ratio [OR], 12.82; 95% confidence interval [CI], 3.97-41.67); (2) having an agree/strongly agree attitude toward HIV testing (OR, 5.59; 95% CI, 1.63-19.23); and (3) obtaining a general consent form that included permission for HIV testing (OR, 3.25; 95% CI, 1.07-9.90). Conclusion: Osteopathic physicians who practice primary care medicine can play a crucial role in reducing the number of individuals with undiagnosed HIV infection. More concerted efforts are needed to help osteopathic physicians incorporate HIV testing as part of routine care for all patients.

The field of gastroenterology has had an abundance of technological advances in recent years, especially in the field of endoscopy. These advances are helpful to clinicians approaching gastrointestinal blood loss, especially in the small bowel. The authors report a case of a man who presented to the emergency department with obscure gastrointestinal blood loss. Results of an esophagogastroduodenoscopy and a colonoscopy suggested the source of the blood loss was within the small bowel. On an outpatient basis, the patient underwent video capsule endoscopy, which revealed scattered distal duodenal arteriovenous malformations. He then underwent oral double balloon endoscopy with ablation of the arteriovenous malformations, with no further bleeding or drop in hemoglobin. The authors review advances in small bowel imaging and endoscopy, including video capsule endoscopy, double balloon endoscopy, and computed tomography enterography. A comprehensive data review was conducted by searching the National Library of Medicine's PubMed database to identify recent published literature in the fields of radiology and gastroenterology. The authors apply these findings to the workup and diagnosis of obscure gastrointestinal blood loss.

Osteopathic medicine represents a valid tradition in Western medicine, but there are concerns about whether it is a viable tradition: will it end up a “poorer cousin” of the allopathic tradition or will it eventually simply be absorbed by the dominant model? This is particularly the case in psychiatry, where osteopathic medicine has never established a firm presence. Currently, the dominant ethos in psychiatry is reductive biologism, which tries to eliminate the notion of mind as a causative factor in behavior. The author's case is that this has failed to give rise to a human-centered psychiatry. His own model of mental disorder, the biocognitive model , is based on a molecular resolution of the mind-body problem (ie, the ancient question of how the immaterial mind and the material body interact). It is manifestly dualist (ie, it accords causative primacy to mind). This is firmly in the osteopathic medical tradition and is offered as a means of developing a distinctive model of psychiatry and hence a holistic general medicine.

Recurrent pulmonary infections are common among patients with chronic obstructive pulmonary disease. Imaging of the thorax beyond a routine chest radiograph, such as computed tomography imaging, should be considered for these patients. Fiberoptic bronchoscopy should also be considered for these patients, especially in cases in which respiratory cultures do not provide guidance for antibiotic therapy. The patient in the present case report experienced recurrent pneumonias despite adequate treatment with intravenous and oral antibiotics. He underwent computed tomography imaging of the thorax, which demonstrated a suspicious lesion in the left mainstem bronchus. This finding prompted a fiberoptic bronchoscopy, which revealed an endobronchial tumor. Given the patient's history of cigarette smoking, it was surprising to find that he had a benign endobronchial neurogenic tumor, which was removed in subsequent rigid bronchoscopy.