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1.
Purpose of Review
Cardiovascular disease remains the leading cause of death among women globally, majority of which are due to ischemic heart disease. Despite the recent advances in the overall management of CVD, there are unique challenges in the diagnosis and management of women as well as poorer outcomes.Recent Findings
Women with ischemic cardiomyopathy experience significant morbidity and mortality. Differences in underlying pathology, delays in presentation, diagnosis, and treatment as well as the under-representation of women in clinical trials contribute to these poor outcomes.Summary
In this review, we discuss the nuances of gender-specific differences in the burden, clinical presentation, and outcomes of ischemic cardiomyopathy in women, in addition to discussion of areas needing further research.2.
Polly Hitchcock Noël Michael L. Parchman John W. WilliamsJr. John E. Cornell Lee Shuko John E. Zeber Lewis E. Kazis Austin F. S. Lee Jacqueline A. Pugh 《Journal of general internal medicine》2007,22(3):419-424
Background
Although multiple co-occurring chronic illnesses within the same individual are increasingly common, few studies have examined the challenges of multimorbidity from the patient perspective.Objective
The aim of this study is to examine the self-management learning needs and willingness to see non-physician providers of patients with multimorbidity compared to patients with single chronic illnesses.Design
This research is designed as a cross-sectional survey.Participants
Based upon ICD-9 codes, patients from a single VHA healthcare system were stratified into multimorbidity clusters or groups with a single chronic illness from the corresponding cluster. Nonproportional sampling was used to randomly select 720 patients.Measurements
Demographic characteristics, functional status, number of contacts with healthcare providers, components of primary care, self-management learning needs, and willingness to see nonphysician providers.Results
Four hundred twenty-two patients returned surveys. A higher percentage of multimorbidity patients compared to single morbidity patients were “definitely” willing to learn all 22 self-management skills, of these only 2 were not significant. Compared to patients with single morbidity, a significantly higher percentage of patients with multimorbidity also reported that they were “definitely” willing to see 6 of 11 non-physician healthcare providers.Conclusions
Self-management learning needs of multimorbidity patients are extensive, and their preferences are consistent with team-based primary care. Alternative methods of providing support and chronic illness care may be needed to meet the needs of these complex patients.3.
Definition of terms
Under the term non-alcoholic fatty liver disease (NAFLD) both simple hepatic fat accumulation and non-alcoholic steatohepatitis (NASH) are combined. NASH is associated with liver fibrosis, cirrhosis and hepatocellular carcinoma (HCC).Epidemiological importance
In 2020, NAFLD will be the leading cause for liver transplantation in the USA, with rising financial costs for the healthcare system.Comorbidities, diagnosis, and treatment
Type 2 diabetes (T2D) and metabolic syndrome (MetS) are important risk factors for the development of NAFLD, whereby these three diseases share similar pathophysiologic conditions, e.g., insulin resistance, obesity, and metabolic inflammation. Due to the rising number of patients with T2D and MetS, clinicians should aim to diagnose NAFLD early in this patient population and if necessary start treatment.Goal
The aim of this work is to give an overview over the topic of NAFLD and diagnostic approaches in patients with T2D.4.
Lena M. Biehl Rebeca Cruz Aguilar Fedja Farowski Werner Hahn Angela Nowag Hilmar Wisplinghoff Maria J. G. T. Vehreschild 《Infection》2018,46(6):871-874
Purpose
We report on a kidney transplant recipient treated with fecal microbiota transplantation (FMT) for recurrent urinary tract infections.Methods
FMT was administered via frozen capsulized microbiota. Before and after FMT, urinary, fecal and vaginal microbiota compositions were analyzed.Results
The patient remained without symptoms after FMT.Conclusions
Underlying mechanisms of action need to be addressed in depth by future research.5.
Melissa M. Farmer Danielle E. Rose Lisa V. Rubenstein Gordon Schectman Richard Stark Elizabeth M. Yano 《Journal of general internal medicine》2014,29(2):555-562
BACKGROUND
While the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality.OBJECTIVE
Prior to the design and implementation of the Veterans Health Administration’s (VA) national PCMH model—Patient Aligned Care Teams (PACT)—we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges.DESIGN AND PARTICIPANTS
A national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sampleMAIN MEASURES
PC directors were asked to rate the degree to which they faced 48 management challenges in eight PCMH-related domains (access, preventive care, chronic diseases requiring care in PC, challenging medical conditions, mental health/substance abuse, special populations, PC coordination of care, and clinical informatics). Responses were dichotomized as moderately-to-extremely challenging versus somewhat-slightly-not at all challenging. Items were rank ordered; chi square or regression techniques were used to examine variations in facility size, type, urban/rural location, and region.KEY RESULTS
On average, VA PC directors reported 16 moderate-to-extreme challenges, and the top 20 challenges spanned all eight PCMH domains. Four of the top 20 challenges, including the top two challenges, were from the clinical informatics domain. Management of chronic non-malignant pain requiring opiate therapy was the third most reported challenge nationwide. Significant organizational and area level variations in reported challenges were found especially for care coordination.CONCLUSIONS
Better understanding of PC challenges ahead of PCMH implementation provides important context for strategic planning and redesign efforts. As a national healthcare system, the VA provides a unique opportunity to examine organizational and area determinants relevant to other PCMH models.6.
N. Junge J. Dingemann C. Petersen M. P. Manns N. Richter J. Klempnauer U. Baumann A. Schneider 《Der Internist》2018,59(11):1146-1156
Background
A growing number of patients with biliary atresia and congenital cholestatic syndromes are reaching adulthood. These patients often have a number of typical medical features, including specific characteristics of liver transplantation medicine.Objective
What are the special features in the care of adults suffering from liver diseases with manifestation in childhood and adolescence, both before and after liver transplantation (LTX). How does the progression of individual diseases differ depending on age at manifestation? What are specific aspects following pediatric LTX?Patients and methods
Evaluation and discussion of existing guidelines and recommendations of the individual disciplines and professional societies as well as the current literature. Joint discussion of the recommendations between disciplines (gastroenterology, pediatric gastroenterology, surgery). Inclusion of center-specific experiences with transition from existing transition outpatient departments and training.Results
The recommendations are presented specifically for each disease. Special features in individual diseases after LTX are also discussed. Diagnosis-independent general treatment concepts for cholestasis and chronic liver disease are presented.Conclusion
Patients with biliary atresia and congenital cholestatic syndromes have a life-long chronic liver disease with and without LTX and require specific medical care. The patients benefit from the pooling of expertise in the individual disciplines.7.
Purpose of Review
Solid organ transplantation is the treatment of choice for many patients with end organ damage. Hepatitis C (HCV) infection is prevalent among solid organ candidates and recipients and remains to be a significant source of morbidity and mortality for this population. New therapies are currently available for this population. In the following review, we will outline HCV treatment strategies in non-liver transplantation candidates and recipients.Recent Findings
Direct-acting antivirals (DAAs) have drastically modified the treatment landscape of HCV. New DAA agents have been studied in patients with chronic diseases, transplantation candidates, and transplantation recipients.Summary
The safety and efficacy of DAAs in patients awaiting liver transplantation and liver transplantation recipients has provided us with guidance on how to use them effectively for patients who received or are awaiting non-liver solid organ transplantations.8.
Background and objectives
Radiological imaging is of central importance for diagnosing acute and chronic diverticular disease. The indications for the various radiological imaging modalities and their most important findings are discussed in this review article.Methods
The current literature on this topic was reviewed and summarized.Results
Contrast-enhanced computed tomography of the abdomen is the method choice in cases of suspected acute diverticulitis and should enable a differentiation between complicated and uncomplicated forms. In suspected chronic diverticular disease virtual colonoscopy represents an equivalent alternative to classical colonoscopy.Conclusion
Based on imaging findings therapeutic decisions can be made and the radiological findings can have some prognostic value in the follow-up of patients.9.
Julie K. Johnson Donna M. Woods David P. Stevens Judith L. Bowen Lloyd P. Provost Connie S. Sixta Ed H. Wagner 《Journal of general internal medicine》2010,25(4):581-585
BACKGROUND
Two chronic care collaboratives (The National Collaborative and the California Collaborative) were convened to facilitate implementing the chronic care model (CCM) in academic medical centers and into post-graduate medical education.OBJECTIVE
We developed and implemented an electronic team survey (ETS) to elicit, in real-time, team member’s experiences in caring for people with chronic illness and the effect of the Collaborative on teams and teamwork.DESIGN
The ETS is a qualitative survey based on Electronic Event Sampling Methodology. It is designed to collect meaningful information about daily experience and any event that might influence team members’ daily work and subsequent outcomes.PARTICIPANTS
Forty-one residency programs from 37 teaching hospitals participated in the collaboratives and comprised faculty and resident physicians, nurses, and administrative staff.APPROACH
Each team member participating in the collaboratives received an e-mail with directions to complete the ETS for four weeks during 2006 (the National Collaborative) and 2007 (the California Collaborative).KEY RESULTS
At the team level, the response rate to the ETS was 87% with team members submitting 1,145 narrative entries. Six key themes emerged from the analysis, which were consistent across all sites. Among teams that achieved better clinical outcomes on Collaborative clinical indicators, an additional key theme emerged: professional work satisfaction, or “Joy in Work”. In contrast, among teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments—“lack of professional satisfaction” and awareness of “system failures”.CONCLUSIONS
The ETS provided a unique perspective into team performance and the day-to-day challenges and opportunities in chronic illness care. Further research is needed to explore systematic approaches to integrating the results from this study into the design of improvement efforts for clinical teams.10.
J. Daryl Thornton Catherine Sullivan Jeffrey M. Albert Maria Cedeño Bridget Patrick Julie Pencak Kristine A. Wong Margaret D. Allen Linda Kimble Heather Mekesa Gordon Bowen Ashwini R. Sehgal 《Journal of general internal medicine》2016,31(8):832-839
BACKGROUND
Low organ donation rates remain a major barrier to organ transplantation.OBJECTIVE
We aimed to determine the effect of a video and patient cueing on organ donation consent among patients meeting with their primary care provider.DESIGN
This was a randomized controlled trial between February 2013 and May 2014.SETTING
The waiting rooms of 18 primary care clinics of a medical system in Cuyahoga County, Ohio.PATIENTS
The study included 915 patients over 15.5 years of age who had not previously consented to organ donation.INTERVENTIONS
Just prior to their clinical encounter, intervention patients (n?=?456) watched a 5-minute organ donation video on iPads and then choose a question regarding organ donation to ask their provider. Control patients (n?=?459) visited their provider per usual routine.MAIN MEASURES
The primary outcome was the proportion of patients who consented for organ donation. Secondary outcomes included the proportion of patients who discussed organ donation with their provider and the proportion who were satisfied with the time spent with their provider during the clinical encounter.KEY RESULTS
Intervention patients were more likely than control patients to consent to donate organs (22 % vs. 15 %, OR 1.50, 95%CI 1.10–2.13). Intervention patients were also more likely to have donation discussions with their provider (77 % vs. 18 %, OR 15.1, 95%CI 11.1–20.6). Intervention and control patients were similarly satisfied with the time they spent with their provider (83 % vs. 86 %, OR 0.87, 95%CI 0.61–1.25).LIMITATION
How the observed increases in organ donation consent might translate into a greater organ supply is unclear.CONCLUSION
Watching a brief video regarding organ donation and being cued to ask a primary care provider a question about donation resulted in more organ donation discussions and an increase in organ donation consent. Satisfaction with the time spent during the clinical encounter was not affected.TRIAL REGISTRATION
clinicaltrials.gov Identifier: NCT0169713711.
Purpose of Review
Acute rejection is one of the most feared complications of cardiac transplantation. Developing non-invasive methods for detection and surveillance of acute rejection have long been a goal for post-transplant care.Recent Findings
Here, we will review molecular diagnostic tests that are currently in use or under development to diagnose acute cellular rejection after cardiac transplantation.Summary
Gene expression, microRNA, molecular microscope, and cell-free DNA assays offer non-invasive alternatives to the endomyocardial biopsy for acute rejection surveillance.12.
Jason M. Glanz Komal J. Narwaney Shane R. Mueller Edward M. Gardner Susan L. Calcaterra Stanley Xu Kristin Breslin Ingrid A. Binswanger 《Journal of general internal medicine》2018,33(10):1646-1653
Background
Naloxone is a life-saving opioid antagonist. Chronic pain guidelines recommend that physicians co-prescribe naloxone to patients at high risk for opioid overdose. However, clinical tools to efficiently identify patients who could benefit from naloxone are lacking.Objective
To develop and validate an overdose predictive model which could be used in primary care settings to assess the need for naloxone.Design
Retrospective cohort.Setting
Derivation site was an integrated health system in Colorado; validation site was a safety-net health system in Colorado.Participants
We developed a predictive model in a cohort of 42,828 patients taking chronic opioid therapy and externally validated the model in 10,708 patients.Main Measures
Potential predictors and outcomes (nonfatal pharmaceutical and heroin overdoses) were extracted from electronic health records. Fatal overdose outcomes were identified from state vital records. To match the approximate shelf-life of naloxone, we used Cox proportional hazards regression to model the 2-year risk of overdose. Calibration and discrimination were assessed.Key Results
A five-variable predictive model showed good calibration and discrimination (bootstrap-corrected c-statistic?=?0.73, 95% confidence interval [CI] 0.69–0.78) in the derivation site, with sensitivity of 66.1% and specificity of 66.6%. In the validation site, the model showed good discrimination (c-statistic?=?0.75, 95% CI 0.70–0.80) and less than ideal calibration, with sensitivity and specificity of 82.2% and 49.5%, respectively.Conclusions
Among patients on chronic opioid therapy, the predictive model identified 66–82% of all subsequent opioid overdoses. This model is an efficient screening tool to identify patients who could benefit from naloxone to prevent overdose deaths. Population differences across the two sites limited calibration in the validation site.13.
Ellen H. Chen David H. Thom Danielle M. Hessler La Phengrasamy Hali Hammer George Saba Thomas Bodenheimer 《Journal of general internal medicine》2010,25(4):610-614
Background
Team care can improve management of chronic conditions, but implementing a team approach in an academic primary care clinic presents unique challenges.Objectives
To implement and evaluate the Teamlet Model, which uses health coaches working with primary care physicians to improve care for patients with diabetes and/or hypertension in an academic practice.Design
Process and outcome measures were compared before and during the intervention in patients seen with the Teamlet Model and in a comparison patient group.Participants
First year family medicine residents, medical assistants, health workers, and adult patients with either type 2 diabetes or hypertension in a large public health clinic.Intervention
Health coaches, in coordination with resident primary care physicians, met with patients before and after clinic visits and called patients between visits.Measurements
Measurement of body mass index, assessment of smoking status, and formulation of a self-management plan prior to and during the intervention period for patients in the Teamlet Model group. Testing for LDL and HbA1C and the proportion of patients at goal for blood pressure, LDL, and HbA1C in the Teamlet Model and comparison groups in the year prior to and during implementation.Results
Teamlet patients showed improvement in all measures, though improvement was significant only for smoking, BMI, and self-management plan documentation and testing for LDL (p?=?0.02), with a trend towards significance for LDL at goal (p?=?0.07). Teamlet patients showed a greater, but non-significant, increase in the proportion of patients tested for HbA1C and proportion reaching goal for blood pressure, HgbA1C, and LDL compared to the comparison group patients. The difference for blood pressure was marginally significant (p?=?0.06). In contrast, patients in the comparison group were significantly more likely to have had testing for LDL (P?=?0.001).Conclusions
The Teamlet Model may improve chronic care in academic primary care practices.14.
Purpose of Review
There has been an explosion in the number of published systematic reviews on chronic rhinosinusitis in the last decade.Recent Findings
While the aim of these reviews in facilitating evidence-based practice is laudable, poor quality reviews may contain significant bias that can mislead a non-discerning reader.Summary
Attention therefore must be given to review methodology before implanting findings. Organisations such as the Cochrane Collaboration promote high-quality reviews, but are limited in chronic sinus disease by heterogeneous outcomes and a paucity of randomised trials.15.
INTRODUCTION
While the Chronic Care Model (CCM) has been shown to improve the care of patients with chronic illnesses, primary care physicians have been unprepared in its use, and residencies have encountered challenges in introducing it into the academic environment.AIM
Our residency program has implemented a diabetes management program modeled on the CCM to evaluate its impact on health outcomes of diabetic patients and educational outcomes of residents.SETTING
University-affiliated, community-based family medicine residency program.PROGRAM DESCRIPTION
Six residents, two faculty clinicians, and clinic staff formed a diabetes management team. We redesigned the outpatient experience for diabetic patients by incorporating elements of the CCM: multidisciplinary team care through planned and group visits; creation of a diabetes registry; use of guidelines-based flow sheets; and incorporation of self-management goal-setting. Residents received extensive instruction in diabetes management, quality improvement, and patient self-management.PROGRAM EVALUATION
We achieved overall improvement in all metabolic and process measures for patients, with the percentage achieving HbA1c, LDL, and BP goals simultaneously increasing from 5.7% to 17.1%. Educational outcomes for residents, as measured by compliance with review of provider performance reports and self-management goal-setting with patients, also significantly improved.DISCUSSION
Through a learning collaborative experience, residency programs can successfully incorporate chronic care training for residents while addressing gaps in care for patients with diabetes.16.
Grant R. Martsolf Ryan Kandrack Robert A. Gabbay Mark W. Friedberg 《Journal of general internal medicine》2016,31(7):723-731
Background
Medical home initiatives encourage primary care practices to invest in new structural capabilities such as patient registries and information technology, but little is known about the costs of these investments.Objectives
To estimate costs of transformation incurred by primary care practices participating in a medical home pilot.Design
We interviewed practice leaders in order to identify changes practices had undertaken due to medical home transformation. Based on the principles of activity-based costing, we estimated the costs of additional personnel and other investments associated with these changes.Setting
The Pennsylvania Chronic Care Initiative (PACCI), a statewide multi-payer medical home pilot.Participants
Twelve practices that participated in the PACCI.Measurements
One-time and ongoing yearly costs attributed to medical home transformation.Results
Practices incurred median one-time transformation-associated costs of $30,991 per practice (range, $7694 to $117,810), equivalent to $9814 per clinician ($1497 to $57,476) and $8 per patient ($1 to $30). Median ongoing yearly costs associated with transformation were $147,573 per practice (range, $83,829 to $346,603), equivalent to $64,768 per clinician ($18,585 to $93,856) and $30 per patient ($8 to $136). Care management activities accounted for over 60% of practices’ transformation-associated costs. Per-clinician and per-patient transformation costs were greater for small and independent practices than for large and system-affiliated practices.Limitations
Error in interviewee recall could affect estimates. Transformation costs in other medical home interventions may be different.Conclusions
The costs of medical home transformation vary widely, creating potential financial challenges for primary care practices—especially those that are small and independent. Tailored subsidies from payers may help practices make these investments.Primary Funding Source
Agency for Healthcare Research and Quality17.
Rebekah L. Gardner Rouba Youssef Blake Morphis Alyssa DaCunha Kimberly Pelland Emily Cooper 《Journal of general internal medicine》2018,33(11):1892-1898
Background
Physicians spend significant time outside of regular office visits caring for complex patients, and this work is often uncompensated. In 2015, the Centers for Medicare & Medicaid Services (CMS) introduced a billing code for care coordination between office visits for beneficiaries with multiple chronic conditions.Objective
Characterize use of the Chronic Care Management (CCM) code in New England in 2015.Design
Retrospective observational analysis.Participants
All Medicare fee-for-service beneficiaries in New England continuously enrolled in Parts A and B in 2015.Intervention
None.Main measures
The primary outcome was the number of beneficiaries with a CCM claim per 1000 eligible beneficiaries. Secondary outcomes included the total number of CCM claims, total reimbursement, mean number of claims per beneficiary, and beneficiary characteristics independently associated with receiving CCM services.Key results
Of the more than two million Medicare fee-for-service beneficiaries in New England, almost 1.7 million were potentially eligible for CCM services. Among eligible beneficiaries, 10,951 (0.65%) had a CCM claim in 2015. Massachusetts had the highest penetration of CCM use (9.40 claims per 1000 eligible beneficiaries); Vermont had the lowest (0.54 claims per 1000 eligible beneficiaries). Mean reimbursement per physician was $1745.98. Age, race/ethnicity, dual-eligible status, income, number of chronic conditions, and state of residence were associated with receiving CCM services in an adjusted model.Conclusions
The CCM code is likely underutilized in New England; the program may therefore not be achieving its intended goal of encouraging consistent, team-based chronic care management for Medicare’s most complex beneficiaries. Or practices may be foregoing reimbursement for care coordination that they are already providing. Recently implemented revisions may improve uptake of CCM services; it will be important to compare our results with future utilization.18.
Background
Despite widespread use of antiviral cytomegalovirus (CMV) prophylaxis, active CMV infections with progression to CMV disease remain of paramount importance after renal transplantation, which can lead to severe complications particularly in CMV seronegative recipients of a CMV seropositive donor kidney.Objective
Risk stratification of active CMV infections and CMV disease, immune reactivity, clinical challenges, and development of approaches to disease management.Methods
Discussion of recent developments and expert recommendations.Results
There is a particularly high risk for the development of active CMV infections and CMV disease in CMV seronegative recipients of a CMV seropositive donor kidney. In this case CMV prophylaxis followed by preemptive therapy is recommended. The focus of this combined strategy is to prevent severe tissue-invasive CMV disease and to reduce the indirect effects of active CMV infections with inferior patient and transplant survival. Patients at increased risk who do not generate adequate CMV-specific cellular immunity after transplantation, nevertheless develop severe and occasionally recurrent active CMV infections after termination of prophylactic measures. In the case of life-threatening therapy-resistant CMV disease, adoptive transfer of CMV-specific T?cells has been proven to be a safe and effective therapy option.Conclusion
Clinically problematic courses of active CMV infections are limited to those patients with severely impaired CMV-specific immunity. The quantification of CMV-specific cellular immunity represents an appropriate instrument to achieve a better stratification of the risk of active CMV infections in patients at increased risk and is the subject of current research studies.19.