Area‐Level Poverty Is Associated with Greater Risk of Ambulatory–Care–Sensitive Hospitalizations in Older Breast Cancer Survivors

OBJECTIVES: To estimate the frequency of ambulatory care–sensitive hospitalizations (ACSHs) and to compare the risk of ACSH in breast cancer survivors living in high‐poverty with that of those in low‐poverty areas. DESIGN: Prospective, multilevel study. SETTING: National, population‐based 1991 to 1999 National Cancer Institute Surveillance, Epidemiology, and End Results Program data linked with Medicare claims data throughout the United States. PARTICIPANTS: Breast cancer survivors aged 66 and older. MEASUREMENTS: ACSH was classified according to diagnosis at hospitalization. The percentage of the population living below the U.S. federal poverty line was calculated at the census‐tract level. Potential confounders included demographic characteristics, comorbidity, tumor and treatment factors, and availability of medical care. RESULTS: Of 47,643 women, 13.3% had at least one ACSH. Women who lived in high‐poverty census tracts (≥30% poverty rate) were 1.5 times (95% confidence interval (CI)=1.34–1.72) as likely to have at least one ACSH after diagnosis as women who lived in low‐poverty census tracts (<10% poverty rate). After adjusting for most confounders, results remained unchanged. After adjustment for comorbidity, the hazard ratio (HR) was reduced to 1.34 (95% CI=1.18–1.52), but adjusting for all variables did not further reduce the risk of ACSH associated with poverty rate beyond adjustment for comorbidity (HR=1.37, 95% CI=1.19–1.58). CONCLUSION: Elderly breast cancer survivors who lived in high‐poverty census tracts may be at increased risk of reduced posttreatment follow‐up care, preventive care, or symptom management as a result of not having adequate, timely, and high‐quality ambulatory primary care as suggested by ACSH.     

Delphi Consensus Study Toward a Comprehensive Classification System for Angioplasty-Induced Femoropopliteal Dissection: The DISFORM Study

ObjectivesThe aim of this study was to seek expert consensus regarding the features that predict adverse outcomes in order to develop a dedicated angiographic classification system for femoropopliteal artery dissection.BackgroundDissection of the femoral and popliteal arteries is common after percutaneous angioplasty. Its classification is important. However, all current classification systems have significant limitations.MethodsDelphi consensus methodology was performed over 3 rounds, using an expert panel of 17 interventionalists. Each was asked to rank dissection features with the potential to lead to acute technical failure and/or early restenosis and then which combination of features would require the placement of a metallic scaffold to avoid those outcomes. Results were used to develop a novel grading system and dissection treatment algorithm.ResultsFour main characteristics were identified from a comprehensive preliminary list. There was a good level of agreement between panelists from 773 responses (48 combinations). All panelists recommended scaffolding if a dissection produced a ≥50% diameter reduction (100%). Most recommended scaffolding if the dissection had a spiral shape (73%-100%), was severely flow limiting (93%-100%), or had complex morphology defined by long and multiple dissections (65%-100%). Multiple combinations of those features were more likely to receive a recommendation to scaffold.ConclusionsScaffolding of a postangioplasty dissection is recommended in the presence of significant diameter reduction, spiral shape, flow impairment, or adverse morphology (DISFORM). The DISFORM classification system has been developed as a tool to provide uniform language to standardize reporting and for discussion of dissection treatment and prognosis.     

Designing a Primary Care–Based Deprescribing Intervention for Patients with Dementia and Multiple Chronic Conditions: a Qualitative Study

BackgroundPatients with dementia and multiple chronic conditions (MCC) frequently experience polypharmacy, increasing their risk of adverse drug events.ObjectivesTo elucidate patient, family, and physician perspectives on medication discontinuation and recommended language for deprescribing discussions in order to inform an intervention to increase awareness of deprescribing among individuals with dementia and MCC, family caregivers and primary care physicians. We also explored participant views on culturally competent approaches to deprescribing.DesignQualitative approach based on semi-structured interviews with patients, caregivers, and physicians.ParticipantsPatients aged ≥ 65 years with claims-based diagnosis of dementia, ≥ 1 additional chronic condition, and ≥ 5 chronic medications were recruited from an integrated delivery system in Colorado and an academic medical center in Maryland. We included caregivers when present or if patients were unable to participate due to severe cognitive impairment. Physicians were recruited within the same systems and through snowball sampling, targeting areas with large African American and Hispanic populations.ApproachWe used constant comparison to identify and compare themes between patients, caregivers, and physicians.Key ResultsWe conducted interviews with 17 patients, 16 caregivers, and 16 physicians. All groups said it was important to earn trust before deprescribing, frame deprescribing as routine and positive, align deprescribing with goals of dementia care, and respect caregivers’ expertise. As in other areas of medicine, racial, ethnic, and language concordance was important to patients and caregivers from minority cultural backgrounds. Participants favored direct-to-patient educational materials, support from pharmacists and other team members, and close follow-up during deprescribing. Patients and caregivers favored language that explained deprescribing in terms of altered physiology with aging. Physicians desired communication tips addressing specific clinical situations.ConclusionsCulturally sensitive communication within a trusted patient-physician relationship supplemented by pharmacists, and language tailored to specific clinical situations may support deprescribing in primary care for patients with dementia and MCC.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06063-y) contains supplementary material, which is available to authorized users.KEY WORDS: deprescribing, patient-physician communication, dementia     

Limited English Proficient Patient Visits and Emergency Department Admission Rates for Ambulatory Care Sensitive Conditions in California: a Retrospective Cohort Study

BackgroundLittle is known about the risk of admission for emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) by limited English proficient (LEP) patients.ObjectiveEstimate admission rates from ED for ACSCs comparing LEP and English proficient (EP) patients and examine how these rates vary at hospitals with a high versus low proportion of LEP patients.DesignRetrospective cohort study of California’s 2017 inpatient and ED administrative dataParticipantsCommunity-dwelling individuals ≥ 18 years without a primary diagnosis of pregnancy or childbirth. LEP patients had a principal language other than English.Main MeasuresWe used a series of linear probability models with incremental sets of covariates, including patient demographics, primary diagnosis, and Elixhauser comorbidities, to examine admission rate for visits of LEP versus EP patients. We then added an interaction covariate for high versus low LEP-serving hospital. We estimated models with and without hospital-level random effects.Key ResultsThese analyses included 9,641,689 ED visits; 14.7% were for LEP patients. . Observed rate of admission for all ACSC ED visits was higher for LEP than for EP patients (26.2% vs. 25.2; p value < .001). Adjusted rate of admission was not statistically significant (27.3% [95% CI 25.4–29.3%] vs. 26.2% [95% CI 24.3–28.1%]). For COPD, the difference was significant (36.8% [95% CI 35.0–38.6%] vs. 33.3% [95% CI 31.7–34.9%]). Difference in adjusted admission rate for LEP versus EP visits did not differ in high versus low LEP-serving hospitals.ConclusionsIn adjusted analyses, LEP was not a risk factor for admission for most ACSCs. This finding was observed in both high and low LEP-serving hospitals.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06523-5.KEY WORDS: limited English proficiency, health disparities, ambulatory care sensitive conditions     

A Novel Approach to Proactive Primary Care–Based Case Finding and Multidisciplinary Management of Falls,Syncope, and Dizziness in a One‐Stop Service: Preliminary Results

National and international evidence and guidelines on falls prevention and management in community‐dwelling elderly adults recommend that falls services should be multifactorial and their interventions multicomponent. The way that individuals are identified as having had or being at risk of falls in order to take advantage of such services is far less clear. A novel multidisciplinary, multifactorial falls, syncope, and dizziness service model was designed with enhanced case ascertainment through proactive, primary care–based screening (of individual case notes of individuals aged ≥60) for individual fall risk factors. The service model identified 4,039 individuals, of whom 2,232 had significant gait and balance abnormalities according to senior physiotherapist assessment. Significant numbers of individuals with new diagnoses ranging from cognitive impairment to Parkinson's disease to urgent indications for a pacemaker were discovered. More than 600 individuals were found who were at high risk of osteoporosis according to World Health Association Fracture Risk Assessment Tool score, 179 with benign positional paroxysmal vertigo and 50 with atrial fibrillation. Through such screening and this approach, Comprehensive Geriatric Assessment Plus (Plus falls, syncope and dizziness expertise), unmet need was targeted on a scale far outside the numbers seen in clinical trials. Further work is needed to determine whether this approach translates into fewer falls and decreases in syncope and dizziness.     

North American musculoskeletal ultrasound scanning protocol of the shoulder,elbow, wrist,and hand: update of a Delphi Consensus Study

Clinical Rheumatology - There has been an increase in the proficiency and utilization of ultrasound among North American rheumatologists over the past decade. This study aims to create an updated...     

Prognostic Value of Ambulatory Blood Pressure in the Obese: The Ambulatory Blood Pressure‐International Study

The purpose of this study was to compare the predictive value of ambulatory blood pressure (BP) vs office BP for cardiovascular events during a 5.8‐year follow‐up period in the obese and nonobese participants of the Ambulatory Blood Pressure‐International Study (n=10,817). Both ambulatory BP and office BP considered separately were predictive of cardiovascular events. However, in Cox models including both pressures, only ambulatory BP was associated with outcome. Among obese patients, the hazard ratios for a 10‐mm Hg increase in 24‐hour and office systolic BPs were 1.37 (95% confidence interval, 1.20–1.53) and 0.91 (95% confidence interval, 0.76–1.07), respectively. Among nonobese patients, the corresponding hazard ratios were 1.39 (95% confidence interval, 1.31–1.47) and 0.94 (95% confidence interval, 0.88–1.00) (P=not significant vs obese). Similar results were obtained for diastolic BP and for daytime and nighttime BPs. Ambulatory BP has similar predictive capacity in obese and nonobese patients, suggesting that ambulatory BP monitoring is a useful diagnostic tool for the assessment of obese individuals.     

Ambulatory transradial percutaneous coronary intervention: A safe,effective, and cost‐saving strategy

Objectives : The aim of this prospective, multicenter study was to assess the safety, feasibility, acceptance, and cost of ambulatory transradial percutaneous coronary intervention (PCI) under the conditions of everyday practice. Background : Major advances in PCI techniques have considerably reduced the incidence of post‐procedure complications. However, overnight admission still constitutes the standard of care in most interventional cardiology centers. Methods : Eligibility for ambulatory management was assessed in 370 patients with stable angina referred to three high‐volume angioplasty centers. On the basis of pre‐specified clinical and PCI‐linked criteria, 220 patients were selected for ambulatory PCI. Results : The study population included a substantial proportion of patients with complex procedures: 115 (52.3%) patients with multivessel coronary artery disease, 50 (22.7%) patients with multilesion procedures, and 60 (21.5%) bifurcation lesions. After 4‐6 hr observation period, 213 of the 220 patients (96.8%) were cleared for discharge. The remaining seven (3.2%) patients were kept overnight for unstable angina (n = 1), atypical chest discomfort (n = 2), puncture site hematoma (n = 1), or non‐cardiovascular reasons (n = 3). Within 24 hr after discharge, no patients experienced readmission, stent occlusion, recurrent ischemia, or local complications. Furthermore, 99% of patients were satisfied with ambulatory management and 85% reported no anxiety. The average non‐procedural cost was lower for ambulatory PCI than conventional PCI (1,230 ± 98 Euros vs. 2,304 ± 1814 Euros, P < 10^?6). Conclusions : Ambulatory PCI in patients with stable coronary artery disease is safe, effective, and well accepted by the patients. It may both significantly reduce costs and optimize hospital resource utilization. © 2012 Wiley Periodicals, Inc.     

Pharmacological Profile of U‐37883A,a Channel Blocker of Smooth Muscle‐Type ATP‐Sensitive K+ Channels

U‐37883A (PNU‐37883A, guanidine; 4‐morpholinecarboximidine‐N‐1‐adamantyl‐N′‐cyclohexyl hydrochloride) was originally developed as a potential diuretic with specific binding in kidney and vascular smooth muscle rather than in brain or pancreatic β cells. U‐37883A inhibits ATP‐sensitive K⁺ channels (K_ATP channels) in vascular smooth muscle at submicromolar concentrations whilst even at high concentrations (≥10 μM) it has no inhibitory effect at pancreatic, cardiac or skeletal K_ATP channels. Thus, it is generally thought that U‐37883A is a selective inhibitor of vascular smooth muscle K_ATP channels. Approximately one decade ago, K_ATP channels were cloned and found to consist of at least two subunits: an inwardly‐rectifying K⁺ channel six family (K_ir6.x; K_ir6.1 and K_ir6.2) which forms the ion conducting pore and a modulatory sulphonylurea receptor (SUR.x; SUR1, SUR2A, and SUR2B) that accounts for several pharmacological properties. It is generally believed that different combinations of K_ir6.x and SUR.x determine the molecular properties of K_ATP channels. Thus, K_ir6.2/SUR1 channel represents the pancreatic β‐cell K_ATP channel, K_ir6.2/SUR2A channel is thought to represent the cardiac K_ATP channel, whereas K_ir6.1/SUR2B channel is likely to represent the vascular smooth muscle K_ATP channel. Recent molecular studies have shown that U‐37883A selectively suppresses the activity of recombinant K_ATP channels which contain K_ir6.1 subunits in the channel pore unit. It was thus thought that U‐37883A was a selective pharmacological tool which could be used to investigate the activity of vascular smooth muscle K_ATP channels. However, due to its multiple pharmacological actions on several ion channels and poor tissue selectivity, U‐37883A should not be viewed as a selective blocker of smooth muscle K_ATP channels.     

Development of a CENP‐A/CENP‐B–specific immune response in a patient with systemic sclerosis

Antibodies directed against an epitope motif on CENP‐A have been shown to cross‐react with mimotopes on other autoantigens and on Epstein‐Barr nuclear antigen 1 (EBNA‐1), suggesting a molecular mimicry. We describe here the gradual development of an anticentromere immune response in a patient with systemic sclerosis, which started from an antihistone response and was not mediated by molecular mimicry. Via an epitope on histone H3, the antibody response spread to a homologous epitope in the H3 homology domain of CENP‐A. This was followed by an intramolecular epitope spreading to N‐terminal peptides of CENP‐A containing the known epitope motif G‐P‐X₁‐R‐X₂. From there it spread to corresponding epitopes on CENP‐B and to mimotopes of the major CENP‐A epitope motif on other autoantigens including EBNA‐1. Whether the D‐penicillamine treatment received by this patient was involved in the triggering of this cascade remains a matter of speculation.