Can a Chronic Care Model Collaborative Reduce Heart Disease Risk in Patients with Diabetes?

BACKGROUND: There is a need to identify effective practical interventions to decrease cardiovascular disease risk in patients with diabetes. OBJECTIVE: We examine the impact of participation in a collaborative implementing the chronic care model (CCM) on the reduction of cardiovascular disease risk in patients with diabetes. DESIGN: Controlled pre- and postintervention study. PATIENTS/PARTICIPANTS: Persons with diabetes receiving care at 13 health care organizations exposed to the CCM collaborative and controls receiving care in nonexposed sites. MEASUREMENTS AND MAIN RESULTS: Ten-year risk of cardiovascular disease; determined using a modified United Kingdom Prospective Diabetes Study risk engine score. A total number of 613 patients from CCM intervention sites and 557 patients from usual care control sites met the inclusion criteria. The baseline mean 10-year risk of cardiovascular disease was 31% for both the intervention group and the control group. Participants in both groups had improved blood pressure, lipid levels, and HbA1c levels during the observation period. Random intercept hierarchical regression models showed that the intervention group had a 2.1% (95% CI -3.7%, -0.5%) greater reduction in predicted risk for future cardiovascular events when compared to the control group. This would result in a reduced risk of one cardiovascular disease event for every 48 patients exposed to the intervention. CONCLUSIONS: Over a 1-year interval, this collaborative intervention using the CCM lowered the cardiovascular disease risk factors of patients with diabetes who were cared for in the participating organization's settings. Further work could enhance the impact of this promising multifactorial intervention on cardiovascular disease risk reduction.     

Can Primary Care Visits Reduce Hospital Utilization Among Medicare Beneficiaries at the End of Life?

Background  Medical care at the end of life is often expensive and ineffective. Objective  To explore associations between primary care and hospital utilization at the end of life. Design  Retrospective analysis of Medicare data. We measured hospital utilization during the final 6 months of life and the number of primary care physician visits in the 12 preceding months. Multivariate cluster analysis adjusted for the effects of demographics, comorbidities, and geography in end-of-life healthcare utilization. Subjects  National random sample of 78,356 Medicare beneficiaries aged 66+ who died in 2001. Non-whites were over-sampled. All subjects with complete Medicare data for 18 months prior to death were retained, except for those in the End Stage Renal Disease program. Measurements  Hospital days, costs, in-hospital death, and presence of two types of preventable hospital admissions (Ambulatory Care Sensitive Conditions) during the final 6 months of life. Results  Sample characteristics: 38% had 0 primary care visits; 22%, 1–2; 19%, 3–5; 10%, 6–8; and 11%, 9+ visits. More primary care visits in the preceding year were associated with fewer hospital days at end of life (15.3 days for those with no primary care visits vs. 13.4 for those with ≥9 visits, P < 0.001), lower costs ($24,400 vs. $23,400, P < 0.05), less in-hospital death (44% vs. 40%, P < 0.01), and fewer preventable hospitalizations for those with congestive heart failure (adjusted odds ratio, aOR = 0.82, P < 0.001) and chronic obstructive pulmonary disease (aOR = 0.81, P = 0.02). Conclusions  Primary care visits in the preceding year are associated with less, and less costly, end-of-life hospital utilization. Increased primary care access for Medicare beneficiaries may decrease costs and improve quality at the end of life.     

Does Incorporating Medications in the Surveyors' Interpretive Guidelines Reduce the Use of Potentially Inappropriate Medications in Nursing Homes?

OBJECTIVES: To quantify the association between including specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes and the prevalence of use. DESIGN: Quasi-experimental. SETTING: One thousand one hundred forty-one nursing homes in four U.S. states. PARTICIPANTS: Residents living in one of the included nursing homes in operation during 1997 (before Beers; n=130,250) and 2000 (after Beers; n=164,889). INTERVENTION: Inclusion of specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes. MEASUREMENTS: Logistic regression models adjusting for clustering effects of residents residing in homes provided estimates of the relationship between the survey process and use of any medications targeted as potentially inappropriate as part of the survey process, as well as those deemed inappropriate but not included. RESULTS: The use of any potentially inappropriate medication decreased from 42.5% in 1997 to 39.8% in 2000. After adjustment for resident characteristics, residents were less likely to receive any potentially inappropriate medication (odds ratio (OR)=0.85, 95% confidence interval (95% CI)=0.84-0.87), those considered high-severity drugs (those with a high likelihood of a clinically significant adverse event) (OR=0.67, 95% CI=0.65-0.69), or Beers' medications not included in the surveyors' guidelines (OR=0.76, 95% CI=0.74-0.79) in 2000 than in 1997 after the changes to the drug regulations and interpretive guidelines. CONCLUSION: Targeting specific drugs in the surveyor's interpretive guidelines as a method to reduce potentially inappropriate medication use may not produce desired gains in medication-use quality improvement. Alternative strategies for nursing homes should be evaluated.     

Can Agitated Behavior of Nursing Home Residents with Dementia Be Prevented with the Use of Standardized Stimuli?

OBJECTIVES: To assess the relative effect of different types of stimuli on agitated behaviors of nursing home residents with dementia. DESIGN: Repeated‐measures design with randomized assignment of conditions. SETTING: Seven Maryland nursing homes. PARTICIPANTS: One hundred eleven nursing home residents with a diagnosis of dementia who exhibited agitation. INTERVENTION: Different types of stimuli (music, social stimuli, simulated social stimuli, and individualized stimuli based on the person's self‐identity) were presented. MEASUREMENTS: Agitation was directly observed and recorded using the Agitation Behavior Mapping Instrument. RESULTS: All stimulus categories were associated with significantly less physical agitation than baseline observations, and all except for manipulative stimuli were associated with significantly less total agitation. Live social stimuli were associated with less agitation than music, self‐identity, work, simulated social, and manipulative stimulus categories. Task and reading stimulus categories were each associated with significantly less agitation than work, simulated social, and manipulative stimulus categories. Music and self‐identity stimuli were associated with less agitation than simulated social and manipulative stimuli. CONCLUSION: Providing stimuli offers a proactive approach to preventing agitation in persons with dementia, with live social stimuli being the most successful.     

Can We Predict the Development of Ischemic Colitis Among Patients with Lower Abdominal Pain?

Purpose This study was performed to find clinical risk factors for developing ischemic colitis in patients experiencing lower abdominal discomfort with or without bloody diarrhea. Methods A total of 467 patients who underwent sigmoidoscopy or colonoscopy because of lower abdominal discomforts with or without blood in stool were consecutively enrolled; 147 patients were diagnosed endoscopically and histologically as having ischemic colitis. The control group was composed of the remaining 320 patients with nonspecific endoscopic/histologic findings. Clinical variables were compared between the ischemic colitis group and the control group. Results After excluding 67 patients in the ischemic colitis group, we compared the remaining 80 patients to the control group, using various clinical parameters. According to the logistic regression analysis, six factors were significantly related to ischemic colitis: older than aged 60 years (adjusted odds ratio, 5.7; 95 percent confidence interval: 2.6–11.7), hemodialysis (5; 1.2–21.6), hypertension (4.9; 2.3–10.5), hypoalbuminemia (3.5; 1.8–6.7), diabetes mellitus (3.4; 1.3–8.8), and constipation-inducing medications (2.8; 1.1–7.1). Through our analysis, we were able to predict the development of ischemic colitis for the patients with 0, 1, 2, 3, or 4+ risk factors: 8, 21, 55, 79, and 100 percent, respectively. Conclusions Old age, hemodialysis, hypertension, diabetes mellitus, hypoalbuminemia, and constipation-inducing medications are clinically important risk factors for ischemic colitis in patients experiencing lower abdominal discomfort with or without bloody stool. By considering these factors, we were able to predict with high accuracy the development of ischemic colitis. Poster presentation at the meeting of the American College of Gastroenterology, Honolulu, Hawaii, October 28 to November 2, 2005.     

Coinheritance of α-Thalassemia Decreases the Risk of Cerebrovascular Disease in a Cohort of Children with Sickle Cell Anemia

The study estimated α-thalassemia (α-thal) prevalence and assessed its associations with clinical and hematological features in a random sample of Brazilian children with sickle cell anemia (208 Hb SS and 13 Hb S-β⁰-thal). α-Thalassemia genotyping was carried out by multiplex polymerase chain reaction (m-PCR) for seven alleles. Clinical and hematological data were retrieved from the 221 children's medical files. Their ages ranged from 2.5 to 10.4 years. Of the Hb SS children, 27.9% carried –α^3.7/αα and 1.4% –α^3.7/–α^3.7. The presence of α-thal was significantly associated with reduction in MCV, MCH, WBC values and reticulocyte counts. No significant association with blood transfusion or acute chest syndrome (ACS), was found. α-Thalassemia genotypes were strongly associated with reduction in risk for cerebrovascular disease (CVD) (conditional and abnormal transcranial Doppler or stroke; p = 0.007). The interaction of α-thal with other modulating factors should be investigated in order to define subphenotypes of the disease and to use them as clinical tools in the follow-up care of patients.     

Does the Type of Rhinitis Influence Development of Otitis Media with Effusion in Children?

The ongoing childhood obesity epidemic has garnered significant attention among healthcare providers due to its short- and long-term sequelae. Multiple diseases have been associated with obesity, not limited to hypertension, diabetes, and attention deficit hyperactivity disorder. Over the past decade, the relationships between obesity and otologic conditions have been investigated. In this setting, otitis media has remained the focus of research, representing one of the most common pediatric illnesses. Initial studies suggesting a relationship between the two conditions have been supported with epidemiological studies controlling for socioeconomic factors. The purpose of this article is to review our current understanding of the relationship between otitis media and obesity and to discuss the healthcare implications of this association. In addition, several identifiable factors associated with each condition are discussed, as are potential pathophysiologic mechanisms that may help to elucidate the complex and multifactorial relationship between the two disease entities.     

Does Helicobacter pylori Eradication Reduce the Risk of Open Angle Glaucoma in Patients With Peptic Ulcer Disease?

To investigate whether Helicobacter pylori (H pylori) eradication would influence the risk of primary open angle glaucoma (POAG) in patients with peptic ulcer disease.From the Longitudinal Health Insurance Database 2000, 6061 patients with peptic ulcer and receiving H pylori eradication therapy were recruited. The study cohort was subdivided into early (within 1 year) and late (after 1 year) eradication cohorts. The 24,244 control cohort subjects were those who without peptic ulcer and without receiving H pylori eradication therapy and were frequency-matched with the H pylori eradication cohort by age, sex, and the year of receiving H pylori eradication therapy.The higher incidence of POAG was observed in late H pylori eradication cohort and in early H pylori eradication cohort than in control cohort (1.57, 1.32, and 0.95, per 1000 person-year, respectively). However, overall risk of glaucoma was not significantly higher in the late eradication than in the early eradication (adjusted hazard ratio = 0.85, 95% confidence interval = 0.48–1.53). The POAG incidence was greater in the late H pylori eradication cohort when follow-up duration ≤5 years (1.59, per 1000 person-years). However, when follow-up duration >5 years, the incidence of POAG was greater in the early H pylori eradication cohort (1.68, per 1000 person-years). These relationships were not associated with a significantly increased or decreased risk of POAG in multivariable analyses.Either early or late H pylori eradication does not significantly reduce the risk of glaucoma in patients with peptic ulcer disease compared with normal control.     

Oral Anticoagulants to Reduce the Risk of Stroke in Atrial Fibrillation: How Should a Clinician Choose?

Atrial fibrillation (AF), a common arrhythmia that occurs with increasing frequency in the aging population, is associated with increased mortality and morbidity. To ensure that patients receive adequate anticoagulant prophylaxis, clinical guidelines for anticoagulation advocate use of validated scoring systems to stratify patients by cardiovascular risk and predict the individual patient's risk of adverse effects of therapy. Recently approved oral anticoagulants—a direct thrombin inhibitor and the factor Xa inhibitors—may offer advantages over the 50‐year standard, warfarin, for efficacy, safety, and ease of administration. Clinical trial experience with the newly approved agents and others, yet to be approved, will define their relative value in reducing the risk of thromboembolism associated with AF. This article discusses issues that may help clinicians choose among these newer agents and individualize treatment appropriately.     

Neurodevelopment in Children Exposed to Zika Virus: What Are the Consequences for Children Who Do Not Present with Microcephaly at Birth?

The relation of Zika virus (ZIKV) with microcephaly is well established. However, knowledge is lacking on later developmental outcomes in children with evidence of maternal ZIKV infection during pregnancy born without microcephaly. The objective of this analysis is to investigate the impact of prenatal exposure to ZIKV on neuropsychomotor development in children without microcephaly. We evaluated 274 children including 235 ZIKV exposed and 39 controls using the Bayley-III Scales of Infant and Toddler Development (BSIDIII) and neurological examination. We observed a difference in cognition with a borderline p-value (p = 0.052): 9.4% of exposed children and none of the unexposed control group had mild to moderate delays. The prevalence of delays in the language and motor domains did not differ significantly between ZIKV-exposed and unexposed children (language: 12.3% versus 12.8%; motor: 4.7% versus 2.6%). Notably, neurological examination results were predictive of neurodevelopmental delays in the BSIDIII assessments for exposed children: 46.7% of children with abnormalities on clinical neurological examination presented with delay in contrast to 17.8% among exposed children without apparent neurological abnormalities (p = 0.001). Overall, our findings suggest that relative to their unexposed peers, ZIKV-exposed children without microcephaly are not at considerably increased risk of neurodevelopmental impairment in the first 42 months of life, although a small group of children demonstrated higher frequencies of cognitive delay. It is important to highlight that in the group of exposed children, an abnormal neuroclinical examination may be a predictor of developmental delay. The article contributes to practical guidance and advances our knowledge about congenital Zika.     

Can the outcome of pelvic-floor rehabilitation in patients with fecal incontinence be predicted?

Purpose Pelvic-floor rehabilitation does not provide the same degree of relief in all fecal incontinent patients. We aimed at studying prospectively the ability of tests to predict the outcome of pelvic-floor rehabilitation in patients with fecal incontinence. Materials and methods Two hundred fifty consecutive patients (228 women) underwent medical history and a standardized series of tests, including physical examination, anal manometry, pudendal nerve latency testing, anal sensitivity testing, rectal capacity measurement, defecography, endoanal sonography, and endoanal magnetic resonance imaging. Subsequently, patients were referred for pelvic-floor rehabilitation. Outcome of pelvic-floor rehabilitation was quantified by the Vaizey incontinence score. Linear regression analyses were used to identify candidate predictors and to construct a multivariable prediction model for the posttreatment Vaizey score. Results After pelvic-floor rehabilitation, the mean baseline Vaizey score (18, SD ± 3) was reduced with 3.2 points (p < 0.001). In addition to the baseline Vaizey score, three elements from medical history were significantly associated with the posttreatment Vaizey score (presence of passive incontinence, thin stool consistency, primary repair of a rupture after vaginal delivery at childbed) (R ², 0.18). The predictive value was significantly but marginally improved by adding the following test results: perineal and/or perianal scar tissue (physical examination), and maximal squeeze pressure (anal manometry; R ², 0.20; p = 0.05). Conclusion Additional tests have a limited role in predicting success of pelvic-floor rehabilitation in patients with fecal incontinence.     

Does the Theory of Planned Behaviour Explain Condom Use Behaviour Among Men Who have Sex with Men? A Meta-analytic Review of the Literature

The aim of this meta-analysis was to explore whether the constructs in the theory of planned behaviour (TPB; i.e., attitude, subjective norm, perceived behavioural control, intention) explain condom use behaviour among men who have sex with men (MSM). Electronic databases were searched for studies that measured TPB variables and MSM condom use. Correlations were meta-analysed using a random effects model and path analyses. Moderation analyses were conducted for the time frame of the behavioural measure used (retrospective versus prospective). Attitude, subjective norm and perceived behavioural control accounted for 24.0 % of the variance in condom use intention and were all significant correlates. Intention and PBC accounted for 12.4 % of the variance in condom use behaviour. However, after taking intention into account, PBC was no longer significantly associated with condom use. The strength of construct relationships did not differ between retrospective and prospective behavioural assessments. The medium to large effect sizes of the relationships between the constructs in the TPB, which are consistent with previous meta-analyses with different behaviours or target groups, suggest that the TPB is also a useful model for explaining condom use behaviour among MSM. However, the research in this area is rather small, and greater clarity over moderating factors can only be achieved when the literature expands.     

Triad of the Ischemic Cardiovascular Disease in People Living with HIV? Association Between Risk Factors,HIV Infection,and Use of Antiretroviral Therapy

Purpose of Review

This review is focused on cardiovascular risk factors in HIV-infected people.

Recent Findings

Antiretroviral therapy (ART) has significantly increased the life expectancy of HIV-infected people. Thus, this population has experienced non-HIV-related diseases, mainly cardiovascular diseases. Thus, in our review, we intend to understand the cardiovascular risk factors that trigger this situation.

Summary

We have demonstrated that both ART and traditional cardiovascular risk factors contribute to the development of cardiovascular disease in HIV-infected people. Thus, it becomes important to stratify the risk factors to reduce this scenario.