一般診療ジャーナル

Background: With the return of troops from Afghanistan and Iraq, growing numbers of primary care physicians in the United States are treating veterans and their families for war-related conditions. However, little is known about civilian providers’ capacity to address the needs of this population. Objectives: This study sought to assess civilian internists and family physicians’ knowledge, confidence, practices, and training needs in treating war-related conditions of recent veterans and their family members. Method: An anonymous needs assessment survey was administered online by the Maryland Board of Physicians. A convenience sample of physicians in internal and family medicine (N=145) reported on their treatment and referral practices, knowledge and confidence in treating 14 veteran conditions, and preferred training modalities. Results: Only 12% of respondents were military veterans, but 42% of internists and 22% of family physicians reported some training in a Veterans Administration or Department of Defense facility. Although more than 70% of respondents treated veterans in their practices, approximately 60% never screened for military status and more than 40% never referred patients for VA care. Internists and family physicians did not differ significantly in their knowledge or confidence in treating any of the targeted conditions. Overall, both groups reported low knowledge of best practices and limited confidence in treating war-related conditions of veterans and family members. Respondents reported substantial interest in training to treat veteran patients through face-to-face trainings and webinars. Conclusion: Civilian primary care physicians are often the first practitioners consulted by veterans and their spouses/partners about war-related conditions. Findings reveal a clear need to enhance their capacity to treat this population. Trainings should: improve providers’ screening for military/veteran status, increase knowledge of best practices for treating war-related conditions, enhance physician confidence in providing care, and improve coordination of treatment between VA and civilian health providers.

Objective: Retrograde colonic irrigation is a treatment of choice for severe defecation disorders accompanied by congenital disorders such as anal malformations and spina bifida; however, it requires skills, effort and enough space. With the aim of making retrograde colonic irrigation easier and comfortable, we made a self-help colonic irrigation device applicable for these patients. Methods: An angled stick colonic irrigation device was made for comfortable retrograde colonic irrigation. Angulated handle colonic irrigation system was trialled by seven preschool and school age patients including four patients with spina bifida and three patients with congenital ano-rectal anomaly. Results: Four out of seven patients operated the angulated handle colonic irrigator well. The colonic irrigation device enabled the patients with severe defecation disorders to hold the cone tip securely in place and prevented backflow and contamination. Conclusion: The angulated handle colonic irrigator may help retrograde colonic irrigation more comfortable and easier in selected patients with spina bifida or ano-rectal malformations.

Bisphosphonates (BP) have been commonly used over the past 40 years to treat osteoporosis, Pagets’ disease, hypercalcemia of malignancy, osteolytic lesions of multiple myeloma and bone metastases associated with breast, prostate, lung and other soft tissue tumours. The main aims of this review are to: 1. Highlight the fundamental pharmacophysiological modes of action of both nitrogen and non-nitrogen bisphosphonates on bone 2. Explore their potential effects on oral hard and soft tissues 3. Discuss the implications of bisphosphonate therapy on dental implants, in particular their contribution to implant failure 4. Discuss the current recommendations and guidelines for dental implant therapy in patients receiving bisphosphonate therapy based on the available evidence. Two distinct types of bisphosphonates have been classified and differentiated according to their mode of action, chemical structure, potency, delivery, bioavailability, dosage and half-life. Bisphosphonates are classified as: 1) Nonnitrogen containing bisphosphonates (BP) and 2) Nitrogen containing bisphosphonates (N-BP). 27 studies met the study inclusion and exclusion criteria, with 8 retrospective studies and 2 case series studies evaluating the success rate of dental implants in patients with a history of bisphosphonate use, while the remaining 17 articles consisted of case series and case reports. While there are shortcomings associated with many of the reported studies, there does appear to be a certain risk associated with the both implant placement and the maintanence of osseointegrated implants in patients receiving oral bisphosphonates. A Southern Austrailian study estimated the risk of implant failure in patients receiving oral bisphosphonates to be 0.88%. Late implant failures appear to occur in patients treated with oral bisphosphonate exposure for a period >3 years especially in patients who have existing integrated implants,while early failures appear to occur in patients treated with bisphosphonates before or at the time of implant placement. Although the results from these retrospective studies and case series are conflicting to some extent, they have heightened awareness of the possible complication of BRONJ and bisphosphonate related implant failure from long term bisphosphonate use, be it oral or iv-bisphosphonates.