Ambient Air Pollution and Asthma-Related Outcomes in Children of Color of the USA: a Scoping Review of Literature Published Between 2013 and 2017

Purpose of Review

Given racial disparities in ambient air pollution (AAP) exposure and asthma risk, this review offers an overview of the literature investigating the ambient air pollution-asthma relationship in children of color between 2013 and 2017.

Recent Findings

AAP is likely a key contributor to the excess burden of asthma in children of color due to pervasive exposure before birth, at home, and in school. Recent findings suggest that psychosocial stressors may modify the relationship between AAP and asthma.

Summary

The effect of AAP on asthma in children of color is likely modulated by multiple unique psychosocial stressors and gene-environment interactions. Although children of color are being included in asthma studies, more research is still needed on impacts of specific criteria pollutants throughout the life course. Additionally, future studies should consider historical factors when analyzing current exposure profiles.

     

Die Rolle der Selbsthilfegruppen in der Onkologie

Background

Little is known about self-help associations and their possibilities. Obstacles often prevent early contacts between affected people.

Objectives

The psychosocial support given by self-help associations in different phases is evaluated.

Materials and methods

Based on the experience of the Deutsche ILCO and from cooperation with other organizations and institutions, various dimensions of self-help groups are investigated.

Results

On the professional side, there is a lack of knowledge and of attitude. Suitable structures are rare.

Conclusions

The removal of barriers and development of effective structures are overdue.

     

Factors Associated with HIV Testing among African American Female Adolescents in Juvenile Detention Centers

Background

Little is known about sexual and psychosocial factors associated with HIV testing among detained African American female adolescents—an understudied group at risk for HIV.

Methods

188 detained African American female adolescents completed assessments on HIV testing, sexual risk behaviors, and psychosocial factors.

Results

Unprotected vaginal sex, history of STI-positivity or pregnancy, higher STI knowledge, and lower partner availability were associated with a higher likelihood of ever being tested for HIV.

Discussion

HIV testing is the gateway to important services for high-risk HIV-positive and HIV-negative adolescents. More research is needed to address barriers and to inform programmatic changes to increase testing among youth.

     

Out of Office Blood Pressure Measurement in Pregnancy and the Postpartum Period

Purpose

Hypertensive disorders of pregnancy are increasing in prevalence and associated with significant maternal and perinatal morbidity and mortality.

Recent Findings

Increased emphasis has been placed recently on the use of out-of-office (i.e., home and ambulatory) blood pressure (BP) monitoring to diagnose and manage hypertension in the general population. Current guidelines offer limited recommendations on the use of out-of-office BP monitoring during pregnancy and postpartum.

Summary

This review will discuss the recent literature on BP measurement outside of the office and its use for screening, diagnosis, and treatment in pregnancy and postpartum, and will illuminate areas for future research.

     

Correlates of Suicide Among Veterans Treated in Primary Care: Case–Control Study of a Nationally Representative Sample

BACKGROUND

Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death.

OBJECTIVE

Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care.

DESIGN

This was a retrospective case–control study.

SUBJECTS

The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician.

MAIN MEASURES

Demographic, diagnosis, and utilization data were obtained from VA’s Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide.

KEY RESULTS

Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR?=?0.51; 95 % CI?=?0.27–0.98) and VA service-connected disability (OR?=?0.54; 95 % CI?=?0.36–0.80) were associated with decreased odds of suicide, while anxiety disorder (OR?=?3.52; 95 % CI?=?1.79–6.92), functional decline (OR?=?2.52; 95 % CI?=?1.55–4.10), depression (OR?=?1.82; 95 % CI?=?1.07–3.10), and endorsement of suicidal ideation (OR?=?2.27; 95 % CI?=?1.07–4.83) were associated with greater odds of suicide.

CONCLUSIONS

Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.

     

Team-Based Care with Pharmacists to Improve Blood Pressure: a Review of Recent Literature

Purpose of Review

We review studies published since 2014 that examined team-based care strategies and involved pharmacists to improve blood pressure (BP). We then discuss opportunities and challenges to sustainment of team-based care models in primary care clinics.

Recent Findings

Multiple studies presented in this review have demonstrated that team-based care including pharmacists can improve BP management. Studies highlighted the cost-effectiveness of a team-based pharmacy intervention for BP control in primary care clinics. Little information was found on factors influencing sustainability of team-based care interventions to improve BP control.

Summary

Future work is needed to determine the best populations to target with team-based BP programs and how to implement team-based approaches utilizing pharmacists in diverse clinical settings. Future studies need to not only identify unmet clinical needs but also address reimbursement issues and stakeholder engagement that may impact sustainment of team-based care interventions.

     

Impact of a Population Health Management Intervention on Disparities in Cardiovascular Disease Control

Background

Healthcare systems use population health management programs to improve the quality of cardiovascular disease care. Adding a dedicated population health coordinator (PHC) who identifies and reaches out to patients not meeting cardiovascular care goals to these programs may help reduce disparities in cardiovascular care.

Objective

To determine whether a program that used PHCs decreased racial/ethnic disparities in LDL cholesterol and blood pressure (BP) control.

Design

Retrospective difference-in-difference analysis.

Participants

Twelve thousdand five hundred fifty-five primary care patients with cardiovascular disease (cohort for LDL analysis) and 41,183 with hypertension (cohort for BP analysis).

Intervention

From July 1, 2014–December 31, 2014, 18 practices used an information technology (IT) system to identify patients not meeting LDL and BP goals; 8 practices also received a PHC. We examined whether having the PHC plus IT system, compared with having the IT system alone, decreased racial/ethnic disparities, using difference-in-difference analysis of data collected before and after program implementation.

Main Measures

Meeting guideline concordant LDL and BP goals.

Key Results

At baseline, there were racial/ethnic disparities in meeting LDL (p?=?0.007) and BP (p?=?0.0003) goals. Comparing practices with and without a PHC, and accounting for pre-intervention LDL control, non-Hispanic white patients in PHC practices had improved odds of LDL control (OR 1.20 95% CI 1.09–1.32) compared with those in non-PHC practices. Non-Hispanic black (OR 1.15 95% CI 0.80–1.65) and Hispanic (OR 1.29 95% CI 0.66–2.53) patients saw similar, but non-significant, improvements in LDL control. For BP control, non-Hispanic white patients in PHC practices (versus non-PHC) improved (OR 1.13 95% CI 1.05–1.22). Non-Hispanic black patients (OR 1.17 95% CI 0.94–1.45) saw similar, but non-statistically significant, improvements in BP control, but Hispanic (OR 0.90 95% CI 0.59–1.36) patients did not. Interaction testing confirmed that disparities did not decrease (p?=?0.73 for LDL and p?=?0.69 for BP).

Conclusions

The population health management intervention did not decrease disparities. Further efforts should explicitly target improving both healthcare equity and quality.Clinical Trials #: NCT02812303 (ClinicalTrials.gov).

     

Association of social worker-assessed psychosocial factors with 30-day hospital readmissions among hemodialysis patients

Background

Evidence regarding the effect of psychosocial factors on hospital readmission in the setting of hemodialysis is limited. We examined whether social worker-assessed factors were associated with 30-day readmission among prevalent hemodialysis patients.

Methods

Data on 14 factors were extracted from the first available psychosocial assessment performed by social workers at three metropolitan Atlanta dialysis centers. Index admissions (first admission preceded by ≥30?days without a previous hospital discharge) were identified in the period 2/1/10–12/31/14, using linked national administrative hospitalization data. Readmission was defined as any admission within 30?days after index discharge. Associations of each of the psychosocial factors with readmission were assessed using multivariable logistic regression with adjustment for patient and index admission characteristics.

Results

Among 719 patients with index admissions, 22.1% were readmitted within 30?days. No psychosocial factors were statistically significantly associated with readmission risk. However, history of substance abuse vs. none was associated with a 29% higher risk of 30-day readmission [OR: 1.29, 95% CI: 0.75–2.23], whereas depression/anxiety was associated with 20% lower risk [OR: 0.80, 95% CI: 0.47–1.36]. Patients who were never married and those who were divorced, or widowed had 38 and 17% higher risk of 30-day readmission, respectively, than those who were married [OR: 1.38, 95% CI: 0.84–2.72; OR: 1.17, 95% CI: 0.73–1.90].

Conclusions

Results suggest that psychosocial issues may be associated with risk of 30-day readmission among dialysis patients. Despite the limitations of lack of generalizability and potential misclassification due to patient self-report of psychosocial factors to social workers, further study is warranted to determine whether addressing these factors through targeted interventions could potentially reduce readmissions among hemodialysis patients.

     

Establishing a General Medical Outpatient Clinic for Cancer Survivors in a Public City Hospital Setting

INTRODUCTION

Many cancer centers and community hospitals are developing novel models of survivorship care. However, few are specifically focused on services for socio-economically disadvantaged cancer survivors.

AIMS

To describe a new model of survivorship care serving culturally diverse, urban adult cancer patients and to present findings from a feasibility evaluation.

SETTING

Adult cancer patients treated at a public city hospital cancer center.

PROGRAM DESCRIPTION

The clinic provides comprehensive medical and psychosocial services for patients within a public hospital cancer center where they receive their oncology care.

PROGRAM EVALUATION

Longitudinal data collected over a 3-year period were used to describe patient demographics, patient needs, and services delivered. Since inception, 410 cancer patients have been served. Demand for services has grown steadily. Hypertension was the most frequent comorbid condition treated. Pain, depression, cardiovascular disease, hyperlipidemia, and bowel dysfunction were the most common post-treatment problems experienced by the patients. Financial counseling was an important patient resource.

DISCUSSION

This new clinical service has been well-integrated into its public urban hospital setting and constitutes an innovative model of health-care delivery for socio-economically challenged, culturally diverse adult cancer survivors.

     

The Psychosocial Treadmill: the Road to Improving High-risk Behavior in Advanced Therapy Candidates

Purpose of Review

The purpose of this review is to explore the evaluation and identification of psychosocial risk factors during the heart transplant evaluation process with the goal of improving psychosocial candidacy prior to transplant listing. Subsequently, more patients will be able to receive life-saving heart transplant and experience success after transplant.

Recent Findings

Evaluating and identifying psychosocial risk factors is an essential component of the transplant evaluation process. Less research exists demonstrating how patients may be able to reduce psychosocial risk factors over time to improve their candidacy for transplant. This review will describe a program developed for patients undergoing heart transplant evaluation at The Ohio State University Wexner Medical Center to improve their psychosocial risk.

Summary

By implementing a comprehensive, multidisciplinary intervention to address psychosocial risk factors pre-transplant, patients can improve their psychosocial candidacy and go on to be listed for heart transplant.

     

Frailty in surgical patients

Objective

To describe the current definitions, aetiology, assessment tools and clinical implications of frailty in modern surgical practice.

Background

Frailty is a critical issue in modern surgical practice due to its association with adverse health events and poor post-operative outcomes. The global population is rapidly ageing resulting in more older patients presenting for surgery. With this, the number of frail patients presenting for surgery is also increasing. Despite the identification of frailty as a significant predictor of poor health outcomes, there is currently no consensus on how to define, measure and diagnose this important syndrome.

Methods

Relevant references were identified through keyword searches of the Cochran, MEDLINE and EMbase databases.

Results

Despite the lack of a gold standard operational definition, frailty can be conceptualised as a state of increased vulnerability resulting from a decline in physiological reserve and function across multiple organ systems, such that the ability to withstand stressors is impaired. Multiple studies have shown a strong association between frailty and adverse peri-operative outcomes. Frailty may be assessed using multiple tools; however, the ideal tool for use in a clinical setting has yet to be identified. Despite the association between frailty and adverse outcomes, few interventions have been shown to improve outcomes in these patients.

Conclusion

Frailty encompasses a group of individuals at high risk of adverse post-operative outcomes. Further work exploring ways to optimally assess and target interventions towards these patients should be the focus of ongoing research.

     

Gender Differences Among Veterans Deployed in Support of the Wars in Afghanistan and Iraq

BACKGROUND

The changing scope of women’s roles in combat operations has led to growing interest in women’s deployment experiences and post-deployment adjustment.

OBJECTIVES

To quantify the gender-specific frequency of deployment stressors, including sexual and non-sexual harassment, lack of social support and combat exposure. To quantify gender-specific post-deployment mental health conditions and associations between deployment stressors and posttraumatic stress disorder (PTSD), to inform the care of Veterans returning from the current conflicts.

DESIGN

National mail survey of OEF/OIF Veterans randomly sampled within gender, with women oversampled.

SETTING

The community.

PARTICIPANTS

In total, 1,207 female and 1,137 male Veterans from a roster of all Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans. Response rate was 48.6 %.

MAIN MEASURES

Deployment stressors (including combat and harassment stress), PTSD, depression, anxiety and alcohol use, all measured via self-report.

KEY RESULTS

Women were more likely to report sexual harassment (OR?=?8.7, 95% CI: 6.9, 11) but less likely to report combat (OR?= 0?.62, 95 % CI: 0.50, 0.76). Women and men were equally likely to report symptoms consistent with probable PTSD (OR = 0?.87, 95 % CI: 0.70, 1.1) and symptomatic anxiety (OR ?= ?1.1, 9 5% CI: 0.86, 1.3). Women were more likely to report probable depression (OR?=?1.3, 95 % CI: 1.1, 1.6) and less likely to report problematic alcohol use (OR ?= 0?.59, 9 5% CI: 0.47, 0.72). With a five-point change in harassment stress, adjusted odds ratios for PTSD were 1.36 (95 % CI: 1.23, 1.52) for women and 1.38 (95 % CI: 1.19, 1.61) for men. The analogous associations between combat stress and PTSD were 1.31 (95 % CI: 1.24, 1.39) and 1.31 (95 % CI: 1.26, 1.36), respectively.

CONCLUSIONS

Although there are important gender differences in deployment stressors—including women’s increased risk of interpersonal stressors—and post-deployment adjustment, there are also significant similarities. The post-deployment adjustment of our nation’s growing population of female Veterans seems comparable to that of our nation’s male Veterans.

     

Do-it-yourself Artificial Pancreas – Technologiehype oder realer Nutzen?

Background

Most type 1 diabetes mellitus patients are not capable of achieving close to normal glucose levels and thus face a constant risk of severe hypoglycemia and diabetic ketoacidosis.

Objectives

Patients develop their own personal non-approved medical devices to compensate for gaps in the existing medical technology.

Materials and methods

Current studies are assessed and basic work and challenges are discussed.

Results

The authorization of such systems from patients themselves results in the development of medical devices suitable for use but approved only based on freely available algorithms. Legal framework conditions, lack of standards on the interoperability of medical devices and uncertainties about future technology trends are giving rise to ongoing controversies.

Conclusions

There is a need to validate these new approaches, agree upon success criteria and provide solid evidence of their effectiveness.

     

Effects of a Video on Organ Donation Consent Among Primary Care Patients: A Randomized Controlled Trial

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: NCT01697137

     

Cost of Transformation among Primary Care Practices Participating in a Medical Home Pilot

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 Quality

     

Treatment of acute hepatitis C: recommendations from an expert panel of the Italian Society of Infectious and Tropical Diseases

Aim

This paper is aimed at providing practical recommendations for the management of acute hepatitis C (AHC).

Methods

This is an expert position paper based on the literature revision. Final recommendations were graded by level of evidence and strength of the recommendations.

Results

Treatment of AHC with direct-acting antivirals (DAA) is safe and effective; it overcomes the limitations of INF-based treatments.

Conclusions

Early treatment with DAA should be offered when available.

     

EBUS-TBNA is Sufficient for Successful Diagnosis of Silicosis with Mediastinal Lymphadenopathy

Background

Silicosis is an occupational lung disease resulting from inhalation of respirable crystalline silica. Recently, an international silicosis epidemic has been noted among artificial stone workers.

Objective

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is currently used for patients with unexplained lymphadenopathy. Since silicosis may present with prominent lymphadenopathy, the diagnostic yield of EBUS-TBNA in diagnosing silicosis was evaluated.

Methods

Twenty-eight patients with suspected silicosis referred for outpatient evaluation in three large tertiary hospitals were evaluated. Patients with mediastinal lymphadenopathy underwent EBUS-TBNA, while others underwent TBB and/or video-assisted thoracoscopic surgery (VATS).

Results

Eleven patients with mediastinal lymphadenopathy (39%) were evaluated using EBUS-TBNA. The diagnosis was accurate in all cases, demonstrating silica particles under polarized light, with no complications. Among the remaining patients, TBB was only 76% diagnostic, therefore requiring VATS.

Conclusions

EBUS-TBNA is a useful and sufficient tool to diagnose silicosis in patients with mediastinal lymphadenopathy along compatible exposure histories.