1. Review: Docs legally allowed to inquire about guns, disclose information to third parties when necessary
Review clarifies statutes and addresses common barriers to counseling patients on the dangers of firearms
Free content: http://www.annals.org/article.aspx?doi=10.7326/M15-2905
Editorail: http://www.annals.org/article.aspx?doi=10.7326/M16-0968
URL goes live when the embargo lifts
Physicians are legally allowed to ask their patients about firearms, counsel them as they would on any other health matter, and disclose that information to third parties when necessary, according to a review published in Annals of Internal Medicine.
A growing body of evidence shows that having a firearm in the home or purchasing a handgun substantially increases a person's risk for violent death. While physicians have a responsibility to diagnose and treat illness, they also have a broader obligation to prevent illness and injury and to improve population health. Many prominent physicians' organizations believe that this includes counseling their patients on firearm safety. However, some physicians believe that it is against the law to discuss firearms with their patients and many are unsure what they are legally allowed to say about guns in practice.
Authors reviewed current federal and state statutes and found that none prohibit physicians from asking about firearms when that information is directly relevant to the health of the patient or others. As such, the authors recommend, at a minimum, that clinicians determine access to firearms for patients who fall into any of the high-risk categories for firearm violence, such as those who have suicidal or homicidal ideas or intent; those with a history of intentional or unintentional violence to themselves or others caused by alcohol or drug abuse, serious mental illness or other conditions that impair judgment; and patients who are members of high-risk demographic groups, such as middle-aged and older white men, young African American men, and children and adolescents.
The authors write that although many physicians believe they have the responsibility to counsel patients to help prevent firearm-related injuries, they lack the training to counsel patients in clinical practice. The physicians cite lack of familiarity with firearms, lack of knowledge about the risks and benefits of firearm ownership, and what to say to patients about the issue as the main barriers to intervention. The authors suggest that with training and the development of referral resources, physicians can overcome these barriers. They summarize a list of resources to assist physicians in educating patients about firearm safety.
Steven E. Weinberger, MD, MACP, FRCP, Executive Vice President and Chief Executive Officer of the American College of Physicians (ACP) authored an accompanying editorial. According to Dr. Weinberger, physicians should not shirk their responsibility to seek information about gun ownership. He writes that it is essential for individual physicians and other health care providers, the organizations that represent them, and the legal community to band together to ensure that clinicians understand what they can and should do to assess and mitigate the risk for firearm-related injury and death. Dr. Weinberger's words echo a policy position paper released by ACP in 2015 Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association (http://www.annals.org/article.aspx?articleid=2151828).
Note: For an embargoed PDF or an interview with the editorialist from ACP, please contact Cara Graeff. For an interview with the lead author, Dr. Garen J. Wintemute, please contact David Ong at dong@ucdavis.org or 916-734-9049.
2. Tai Chi improves pain and well-being in patients with knee osteoarthritis
Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-2143
URL goes live when the embargo lifts
Tai Chi improves pain and related health outcomes in patients with knee osteoarthritis as well as standard physical therapy, according to a comparative effectiveness trial published in Annals of Internal Medicine. Tai Chi was also shown to produce significantly greater improvements in depression and the physical component of quality of life.
Knee osteoarthritis is a leading cause of age-related pain and disability. Over-the-counter pain medications often fail to relieve symptoms and are associated with serious adverse effects. Physical therapy is globally recommended, but benefits are modest. As such, identifying new and effective treatments is an urgent clinical and public health priority. Tai Chi, a multicomponent traditional Chinese mind-body practice that combines meditation with slow, gentle, graceful movements; deep breathing; and relaxation, has been shown to alleviate symptoms of knee osteoarthritis, but no trials have directly compared Tai Chi with standard care.
Researchers sought to compare Tai Chi with standard physical therapy for relieving pain, physical function, depression, medication use, and quality of life in patients with knee osteoarthritis. Just over 200 participants were randomly assigned to one of two treatment groups: Tai Chi or standard physical therapy. Patients in the Tai Chi group performed Tai Chi with a trained instructor 2 times per week for 12 weeks. Patients in the physical therapy group had standard physical therapy 2 times per week for 6 weeks, followed by 6 weeks of monitored home exercise.
After 12 weeks, patients in both groups showed significant improvements in pain as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, with benefits maintained up to 52 weeks. In addition, patients in the Tai Chi group had significantly greater improvements in well-being compared to those in the physical therapy group. According to the authors, these findings support Tai Chi as an effective therapeutic option for knee osteoarthritis.
Note: For an embargoed PDF, please contact Cara Graeff. To schedule an interview with lead author, Dr. Chenchen Wang, please contact Jeremy Lechan at 617-636-0104 or jlechan@tuftsmedicalcenter.org.
3. Wells rule with age-adjusted D-Dimer test can safely rule out pulmonary embolism in some high-risk older patients
Abstract: http://www.annals.org/article.aspx?doi=10.7326/M16-0031
URL goes live when the embargo lifts
Using the Wells Rule with age-adjusted D-dimer testing can safely and effectively rule out pulmonary embolism (PE) in subgroups of older patients. The findings are published in Annals of Internal Medicine.
PE cannot be diagnosed based on clinical features alone because symptoms are not specific. Objective imaging tests, such as computed tomography pulmonary angiography (CTPA), are often warranted but are not appropriate first-line tests because of radiation exposure, cost, and risk for contrast-induced nephropathy. Since only about 15 to 25 percent of presenting patients have PE, clinicians need safe and accurate ways to assess which patients should be referred for imaging. One frequently used algorithm consists of the sequential application of the dichotomized Wells rule, which estimates the clinical probability of PE, and D-dimer testing. PE can be considered ruled out in patients with a Wells score of 4 or less and a negative D-dimer test result. It has recently been shown that the efficiency of this algorithm can be safely increased by applying an age-adjusted D-dimer test for patients older than 50, but important clinical questions still remain.
Researchers reviewed published research to evaluate and compare the efficiency and safety of the Wells rule with fixed or age-adjusted D-dimer testing for excluding PE in inpatients and persons with cancer, chronic obstructive pulmonary disease, previous venous thromboembolism, delayed presentation, and who were at least 75 years of age. The data showed that the proportion of patients managed without imaging and who have no need for anticoagulation can be safely increased from 28 percent to 33 percent by applying the age-adjusted D-dimer test in those who were unlikely to have PE based on their Wells score. The absolute increase was more prominent in patients with COPD and elderly patients presenting with suspected PE, but is less prominent in the remaining subgroups studied.
Note: For an embargoed PDF, please contact Cara Graeff. For an interview with the lead author, Dr. Nick Van Es, please contact the Academic Medical Center press office at pers@amc.nl or 00031-20-56-62929.
Also new in this issue:
Surveying the Landscape of Ovarian Cancer Research and Care
Ronald D. Alvarez, MD, MBA; Jerome F. Strauss, III, MD, PhD
Ideas and Opinions
http://www.annals.org/article.aspx?doi=10.7326/M16-0604
The Firearm for Protection? A Risky Bet
Erik A. Wallace, MD, University of Colorado School of Medicine
On Being a Doctor
http://www.annals.org/article.aspx?doi=10.7326/M15-2100
He Says You Are Finished
Christine Todd, MD, Southern Illinois University
On Being a Doctor
http://www.annals.org/article.aspx?doi=10.7326/M15-2009
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Journal
Annals of Internal Medicine