Managing gluten sensitivity can mean managing patient expectations

Gluten-free diets have gotten a lot of attention recently in the lay media, and as a consequence, physicians may find themselves faced with patients convinced that gluten is their problem even before they make an appointment. The first consideration in dealing with this situation, experts say, is to try to rule out other conditions that could be causing a patient's GI symptoms, including wheat allergy, celiac disease, and irritable bowel syndrome. It's also key to ask patients questions about their diet to determine whether other things, such as fructose, could be possible culprits. In our cover story, Charlotte Huff summarizes the latest in clinical research on gluten sensitivity and talks to experts in the field for advice on managing patients who need, or even just want, to go gluten-free.

Patients scheduled for upcoming surgery will often see their internists first for a pre-op checkup, but the makeup of an ideal visit can vary by population. Those taking anticoagulants and those with diabetes, for example, will often need careful medication management. In elderly patients, meanwhile, assessment of functional and cognitive status is essential to plan for appropriate postoperative care. Our story on page 1 looks at what the preop physical should and shouldn't include, along with special considerations for certain patient subgroups and tips on communicating with surgeons.

Methadone can be an important tool for physicians treating chronic pain, but the dangers of the drug, such as its long half-life, can sometimes outweigh its benefits. In addition, patients who are candidates for methadone treatment will need careful, thorough screening and monitoring. Because of the inherent complications, experts stress, physicians who are unfamiliar or inexperienced with using methadone should seek advice, education, or both before attempting to prescribe it to patients. Our story on page 8 explains more.

The Centers for Disease Control and Prevention and the World Health Organization both recently released guidelines recommending preexposure prophylaxis for HIV in certain groups of uninfected patients at high risk for exposure to the virus. But determining which patients could benefit could be more difficult than it sounds, since doing so requires frank and sometimes uncomfortable conversations with patients who may not be entirely aware of their level of risk. Turn to our story on page 10 to learn more about the recommendations in the recent guidelines and get advice on discussing sexual history with patients, as well as information on optimal management of preexposure prophylaxis in primary care.

Have many of your patients given up gluten? Are you comfortable prescribing methadone, or managing patients at high risk for HIV? Let us know.

Sincerely,

Jennifer Kearney-Strouse