Healthcare professionals frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.
 
The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

/pdf/physician-advice-for-smoking-cessation-3keveyx1e5.pdf

Physician advice for smoking cessation

Diabetes mellitus (DM) is highly prevalent and increasing in persons aged 65 and older, particularly among racial and ethnic minorities. The purpose of this guideline is to improve the care of older persons with DM by providing a set of evidence-based recommendations that include DM-specific recommendations individualized to persons with DM who are aged 65 and older and recommendations for the screening and detection of geriatric syndromes.

Guidelines for improving the care of the older person with diabetes mellitus.

Objective This review evaluates the effectiveness of quality improvement (QI) strategies in reducing disparities in health and health care. Data sources We identified papers published in English between 1983 and 2011 from the MEDLINE® database, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science Social Science Index, and PsycINFO. Review methods All abstracts and full-text articles were dually reviewed. Studies were eligible if they reported data on effectiveness of QI interventions on processes or health outcomes in the United States such that the impact on a health disparity could be measured. The review focused on the following clinical conditions: breast cancer, colorectal cancer, diabetes, heart failure, hypertension, coronary artery disease, asthma, major depressive disorder, cystic fibrosis, pneumonia, pregnancy, and end-stage renal disease. It assessed health disparities associated with race or ethnicity, socioeconomic status, insurance status, sexual orientation, health literacy/numeracy, and language barrier. We evaluated the risk of bias of individual studies and the overall strength of the body of evidence based on risk of bias, consistency, directness, and precision. Results Nineteen papers, representing 14 primary research studies, met criteria for inclusion. All but one of the studies incorporated multiple components into their QI approach. Patient education was part of most interventions (12 of 14), although the specific approach differed substantially across the studies. Ten of the studies incorporated self-management; this would include, for example, teaching individuals with diabetes to check their blood sugar regularly. Most (8 of 14) included some sort of provider education, which may have focused on the clinical issue or on raising awareness about disparities affecting the target population. Studies evaluated the effect of these strategies on disparities in the prevention or treatment of breast or colorectal cancer, cardiovascular disease, depression, or diabetes. Overall, QI interventions were not shown to reduce disparities. Most studies have focused on racial or ethnic disparities, with some targeted interventions demonstrating greater effect in racial minorities--specifically, supporting individuals in tracking their blood pressure at home to reduce blood pressure and collaborative care to improve depression care. In one study, the effect of a language-concordant breast cancer screening intervention was helpful in promoting mammography in Spanish-speaking women. For some depression care outcomes, the collaborative care model was more effective in less-educated individuals than in those with more education and in women than in men. Conclusions The literature on QI interventions generally and their ability to improve health and health care is large. Whether those interventions are effective at reducing disparities remains unclear. This report should not be construed to assess the general effectiveness of QI in the health care setting; rather, QI has not been shown specifically to reduce known disparities in health care or health outcomes. In a few instances, some increased effect is seen in disadvantaged populations; these studies should be replicated and the interventions studied further as having potential to address disparities.

Closing the quality gap: revisiting the state of the science (vol. 3: quality improvement interventions to address health disparities).

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic form of renal phosphate wasting that results in severe hypophosphatemia, a defect in vitamin D metabolism, and osteomalacia. This debilitating disorder is illustrated by the clinical presentation of a 55-year-old woman with progressive fatigue, weakness, and muscle and bone pain with fractures. After a protracted clinical course and extensive laboratory evaluation, tumor-induced osteomalacia was identified as the basis of her clinical presentation. In this article, the distinctive clinical characteristics of this syndrome, the advances in diagnosis of TIO, and new insights into the pathophysiology of this disorder are discussed.

/pdf/tumor-induced-osteomalacia-4fcf4z5la0.pdf

Tumor-Induced Osteomalacia

/pdf/guidelines-for-improving-the-care-of-the-older-person-with-41m5yqoa63.pdf

Guidelines for Improving the Care of the Older Person with Diabetes Mellitus

The effect of health counselling on the smoking habits of 60 diabetic patients (aged less than 40 years) was assessed. Measurement of breath carbon monoxide (CO) and urinary cotinine, a metabolite of nicotine, were used as objective markers of smoking. All patients wished to cease smoking and the impact of health counselling was reviewed in a 'Stop Smoking' clinic. In addition to routine advice on the health hazards of smoking, half the patients and their families also received further counselling during a home visit by a health visitor. After 6 months many of the 60 patients claimed to have reduced their cigarette consumption. However, the urinary cotinine concentrations did not confirm this. Only one patient actually stopped smoking and he had sustained a myocardial infarction during the study. There was a small but significant reduction of breath CO in the patients seen at home by the health visitor but the urinary cotinine concentrations were unchanged. This suggests that these patients abstained from smoking for only a few hours before attending the 'Stop Smoking' clinic.

Anti-smoking advice for young diabetic smokers: is it a waste of breath?

The educational achievements, current employment, and social class of 137 diabetic patients aged 20.9 +/- 3.0 years (mean +/- SD), attending a Young Adult Diabetic clinic in North Liverpool were surveyed. The duration of diabetes was 7.8 +/- 5.0 years. Patients who developed diabetes in childhood (age at diagnosis less than 13 years) were more likely to have achieved educational qualifications, be employed, and be of social class I or II than those developing diabetes aged 13-25 years. Compared with non-diabetic young adults from North Liverpool, diabetics achieved similar educational qualifications and were as likely to be employed after leaving full-time education. This is an encouraging finding in the present harsh economic climate. The clustering of social classes I and II in childhood diabetics found in this study requires a larger epidemiological study of social class and insulin-dependent diabetes for confirmation.

Educational achievements, employment and social class of insulin-dependent diabetics: a survey of a young adult clinic in Liverpool.

A case of oat cell carcinoma causing Cushing's syndrome and oncogenic hypophosphataemic osteomalacia is reported. The association of the two disorders in one patient is believed to be unique and this is the second reported case of oncogenic osteomalacia caused by oat cell carcinoma.

https://jcp.bmj.com/content/jclinpath/47/1/80.full.pdf

Oncogenic hypophosphataemia and ectopic corticotrophin secretion due to oat cell carcinoma of the trachea.

A 56-year-old woman presented with marked hirsutism and virilization of gradual onset. Menstruation had ceased at 43 years. The serum testosterone was grossly elevated (49 nmol/1) with levels of estradiol well above the postmenopausal range (200 pmol/1). Both serum testosterone and estradiol levels showed a marked but transient increase during the administration of the GnRH analog, buserelin. This indicated that the release of these steroids was under gonadotropin control. Bilateral oophorectomy revealed a greatly enlarged left ovary, and histology demonstrated a leiomyoma of the ovary with marked thecal reaction, which was probably responsible for the elevated serum testosterone and virilization. Testosterone levels returned to normal after bilateral oophorectomy. Excessive thecal androgen production associated with non-epithelial ovarian tumors is extremely uncommon and the response to buserelin has not previously been reported.

Thecal cell reaction associated with an ovarian leiomyoma and presenting with virilization

We studied the effect of current smoking habits in the period immediately before admission to hospital in 90 consecutive patients presenting with chest pain, 50 of whom were shown to have myocardial infarction. Urine cotinine/creatinine (cot/creat) ratio measured within 4 hours of admission was used as an objective marker of cigarette smoking in the preceding 18 hours. Fifty-seven patients had urine cot/creat ratios suggesting recent smoking, although four of these denied smoking. Patients with myocardial infarction had higher median cot/creat ratios (3.31 micrograms/mg, range 0-17.8) compared with patients with non-infarct chest pain (0.5 microgram/mg, range 0-37.2). Sixteen patients with cardiac rhythm disturbances following infarction had significantly higher cot/creat ratios than the 34 infarct patients without this complication (median and range 8.34 micrograms/mg; 0-17.8 V. 1.87 micrograms/mg; 0-16.4, P < 0.01). Tobacco use in the 24 hours before myocardial infarction may predispose to cardiac rhythm disturbance, irrespective of infarct size.

https://pmj.bmj.com/content/postgradmedj/68/801/562.full.pdf

Influence of cigarette smoking on the outcome of coronary care unit admissions with chest pain.

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