The Patient’s Experience of Gout: New Insights to Optimize Management

Despite the high prevalence of disease, gout management is frequently poor, with low patient adherence to urate-lowering therapy and attainment of recommended serum urate targets. Recent research has explored the patient’s experience of gout, providing new understanding of the impact of disease. Pain is central to the patient’s experience of gout. Poorly controlled gout leads to limitation of activities, reduced participation, and poor health-related quality of life. Although effective gout management with urate-lowering therapy improves many patient-reported outcomes in clinical trials, major gaps exist in patient understanding of disease and adherence to long-term urate-lowering therapy. Furthermore, a large mismatch in the perceptions of gout and its therapy exists between patients and health care practitioners. These issues may contribute to progressive and poorly controlled disease despite the availability of effective treatment. These findings provide potential pathways to improved clinical care of patients with gout. Work is now required to identify the optimal models of care for patients with gout that can be tested in clinical trials using outcome measures of relevance to individuals with this disease.     

Bronchial Auscultation: An Effective Adjunct to Speech and Language Therapy Bedside Assessment When Detecting Dysphagia and Aspiration?

Detection of aspiration by bedside examination has frequently been found to be clinically inadequate when compared with videofluoroscopy (VF) as the gold standard. In Doncaster, UK, a new multidisciplinary approach to bedside assessment was devised using physiotherapists (PT) performing bronchial auscultation (BA) in combination with the speech and language therapists (SLT) clinical examination of dysphagia. In this study 105 patients referred for VF examination of dysphagia were first tested by the BA team. Comparison was made between the results of the VF team and the results of the BA team in classifying the patients as aspirating or at risk of aspirating. A high degree of agreement was found for risk of aspiration (sensitivity 87%), although specificity was low (37%). BA was highly specific (88%) when confirming the absence of aspiration, but sensitivity to the presence of aspiration was 45%. From the 105 patients tested, the BA team would have failed to modify the diet in only one subject who was aspirating and would have unnecessarily modified the diet of 17 subjects. In conclusion, in the sample population of individuals with complex dysphagia, the BA team approach reliably detected patients identified by VF as at risk of aspiration. In the group of patients identified by VF as aspirating, the BA team proved unreliable in detecting the presence of aspiration, although it did reliably identify patients who were not aspirating. BA is a potentially useful clinical tool which requires further research.Work performed at Doncaster Royal Infirmary and Royal Hallamshire Hospital, Sheffield, UK.     

Why Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes

Background  

There is a growing awareness that patients should be more active and effective managers of their health and health care. Recent studies have found patient activation—or having the knowledge, skills, and confidence to manage one’s health, to be related to health-related outcomes. These studies have often relied on self-reported outcomes and often have used small samples.     

Neuromuscular Electrical Stimulation Versus Traditional Therapy in Patients with Parkinson’s Disease and Oropharyngeal Dysphagia: Effects on Quality of Life

This study compares the effects of traditional logopedic dysphagia treatment with those of neuromuscular electrical stimulation (NMES) as adjunct to therapy on the quality of life in patients with Parkinson's disease and oropharyngeal dysphagia. Eighty-eight patients were randomized over three treatment groups. Traditional logopedic dysphagia treatment and traditional logopedic dysphagia treatment combined with NMES at sensor or motor level stimulation were compared. At three times (pretreatment, post-treatment, and 3?months following treatment), two quality-of-life questionnaires (SWAL-QOL and MD Anderson Dysphagia Inventory) and a single-item Dysphagia Severity Scale were scored. The Functional Oral Intake Scale was used to assess the dietary intake. After therapy, all groups showed significant improvement on the Dysphagia Severity Scale and restricted positive effects on quality of life. Minimal group differences were found. These effects remained unchanged 3?months following treatment. No significant correlations were found between dietary intake and quality of life. Logopedic dysphagia treatment results in a restricted increased quality of life in patients with Parkinson's disease. In this randomized controlled trial, all groups showed significant therapy effects on the Dysphagia Severity Scale and restricted improvements on the SWAL-QOL and the MDADI. However, only slight nonsignificant differences between groups were found.     

Effects of Therapy for Dysphagia in Parkinson’s Disease: Systematic Review

This systematic review explores the effects of dysphagia treatment for Parkinson’s disease. The review includes rehabilitative, surgical, pharmacologic, and other treatments. Only oropharyngeal dysphagia is selected for this literature search, excluding dysphagia due to esophageal or gastric disorders. The effects of deep brain stimulation on dysphagia are not included. In general, the literature concerning dysphagia treatment in Parkinson’s disease is rather limited. Most effect studies show diverse methodologic problems. Multiple case studies and trials are identified by searching biomedical literature databases PubMed and Embase, and by hand-searching reference lists. The conclusions of most studies cannot be compared with one another because of heterogeneous therapy methods and outcome measures. Further research based on randomized controlled trials to determine the effectiveness of different therapies for dysphagia in Parkinson’s disease is required.

The Impact of Ulcerative Colitis on Patients’ Lives Compared to Other Chronic Diseases: A Patient Survey

Purpose  

This study was designed to identify the impact chronic ulcerative colitis (UC) has on the lives of patients compared to other chronic conditions. Overall, 451 patients with UC, 309 with rheumatoid arthritis, 305 with asthma, and 305 with migraine headaches were recruited in an Internet survey designed to assess a variety of disease-impact indices.     

An Analysis of Data Management Tools for Diabetes Self-Management: Can Smart Phone Technology Keep Up?

In this issue of Journal of Diabetes Science and Technology, Rao and colleagues present a comparison of three iPhone diabetes data management applications: the Diamedic Diabetes Logbook, Blood Sugar Diabetes Control, and WaveSense Diabetes Manager. These applications provide patients the ability to enter blood glucose readings manually, view graphs and simple statistics, and email data to health care providers. While these applications show promise, they are limited in their current forms. All require manual data entry and none convert insulin-to-carbohydrate ratios to insulin dose. Future development of these types of technology should consider integration with blood glucose meters and expanded calculation capabilities, as well as monitoring of other risk factors, e.g., blood pressure and lipids, and tracking of preventive examinations, e.g., eye, foot, and renal.     

Certolizumab Pegol Compared to Natalizumab in Patients with Moderate to Severe Crohn’s Disease: Results of a Decision Analysis

Introduction  

A significant proportion of patients with Crohn’s disease (CD) lose response to antibodies directed against tumor necrosis factor α (TNF). Prior TNF-antagonist failure is associated with lower rates of response to subsequent TNF-antagonist therapy. In patients failing two anti-TNF agents, a choice exists between using a third-anti-TNF therapy or natalizumab (NAT), an α-4 integrin inhibitor. A cost-effectiveness analysis comparing these competing strategies has not been performed.     

Postcricoid Hemangioma: An Overlooked Cause of Dysphagia in Infants?–A Case Report

Feeding and swallowing disorders in children remain a major challenge owing to a wide differential diagnosis. Hemangioma of the upper aerodigestive tract represents one of the numerous non-neoplastic causes of dysphagia. We report two cases of postcricoid hemangioma causing inhalation and recurrent respiratory infections, treated successfully with systemic corticotherapy alone. To our knowledge, these are the second and third cases described in the literature. After a short review of the literature, the diagnostic procedures are discussed and a management strategy is proposed for this clinical entity, by far underestimated.     

When to Repatriate? Clinicians’ Perspectives on the Transfer of Patient Management from Specialty to Primary Care

BACKGROUND

Subspecialty ambulatory care visits have doubled in the past 10 years and nearly half of all visits are for follow-up care. Could some of this care be provided by primary care providers (PCPs)?

OBJECTIVE

To determine how often PCPs and specialists agree that a mutual patient’s condition could be managed exclusively by the PCP, and to understand PCPs’ perspectives on factors that influence decisions about ‘repatriation,’ or the transfer of patient management to primary care.

DESIGN

A mixed method approach including paired surveys of PCPs and specialists about the necessity for ongoing specialty care of mutual patients, and interviews with PCPs about care coordination practices and reasons for differing opinions with specialists.

PARTICIPANTS

One hundred and eighty-nine PCPs and 59 physicians representing five medicine subspecialties completed paired surveys for 343 patients. Semi-structured interviews were conducted with 16 PCPs.

MEASUREMENTS

For each patient, PCPs and specialists were asked, “Could this diagnosis be managed exclusively by the PCP?”

RESULTS

Specialists and PCPs agreed that transfer to primary care was appropriate for 16 % of patients, whereas 36 % had specialists and PCPs who agreed that ongoing specialty care was appropriate. Specialists were half as likely as PCPs to identify patients as appropriate for transfer to primary care. PCPs identified several factors that influence the likelihood that patients will be transferred to primary care, including perceived patient preferences, limited access to physician appointments, excessive workload, inter-clinician communication norms, and differences in clinical judgment. We group these factors into two domains: ‘push-back’ and ‘pull-back’ to primary care.

CONCLUSIONS

At a large academic medical center, approximately one in six patients receiving ongoing specialty care could potentially be managed exclusively by a PCP. PCPs identified several non-clinical factors to explain continuation of specialty care when patient transfer to PCP is clinically appropriate.     

Outcomes of Radiofrequency Ablation Compared to Liquid Nitrogen Spray Cryotherapy for the Eradication of Dysplasia in Barrett’s Esophagus

Digestive Diseases and Sciences - Current guidelines recommend endoscopic eradication therapy (EET) for Barrett’s esophagus (BE) with dysplasia and intramucosal adenocarcinoma using either...     

Using the modern Silverhawk™ atherectomy catheter to characterize biliary structures that appear malignant: review of initial experience

BackgroundDiagnosis of a biliary stricture often hinges on cytological interpretation. In the absence of accompanying stroma, these results can often be equivocal. In theory, advanced shave biopsy techniques would allow for the preservation of tissue architecture and a more accurate definition of biliary pathology.ObjectivesWe sought to determine the initial diagnostic utility of the modern Silverhawk? atherectomy (SA) catheter in the evaluation of biliary strictures that appear to be malignant.MethodsA total of 141 patients with biliary pathology were identified during a retrospective review of medical records for the years 2006–2011. The SA catheter was employed 12 times in seven patients for whom a tissue diagnosis was otherwise lacking.ResultsNeoplasia was definitively excluded in seven specimens from four patients. These four individuals were followed for 1–5 years to exclude the development of cholangiocarcinoma (CC). Samples were positive for CC in three patients, one of whom became eligible for neoadjuvant therapy and orthotopic liver transplantation.ConclusionsThe SA catheter appears to be a useful adjunct in diagnosing patients with biliary pathology. The existence of this technique, predicated on tissue architecture, may impact therapy, allow more timely diagnosis, and exclude cases of equivocal cytology. Although the initial results of SA use are promising, more experience is required to effectively determine its clinical accuracy.     

Assessment of Glycated Hemoglobin Using A1CNow+? Point-of-Care Device as Compared to Central Laboratory Testing

Background

Hemoglobin A1c monitoring is routine care for patients with diabetes and may be obtained as often as every 3 months. Most family practice clinics are not equipped to evaluate a hemoglobin A1c result in the office. Obtaining a hemoglobin A1c result from a central laboratory can result in a delay, added expense, and inconvenience for the patient. To date, there are no published studies on the accuracy of the A1CNow+™, a point-of-care hemoglobin A1c monitoring device.

Methods

Seventy patients having type 1 or type 2 diabetes were enrolled from three pharmacy-managed diabetes clinics. Subjects were required to have a venous blood draw within 1 week of the point-of-care test. The study then evaluated the statistical and clinical significance between both tests.

Results

A good correlation was seen between the A1CNow+ and laboratory values with a correlation coefficient of r = 0.893. The best correlation between the A1CNow+ and the laboratory was seen among hemoglobin A1c values in the range of 7–8.5%.

Conclusion

The access of the A1CNow+ device at point of care makes a hemoglobin A1c evaluation economically and therapeutically beneficial after proving its accuracy in a primary care setting. Advantages of this device may go beyond convenience and economic benefit by allowing patients to acknowledge their level of glucose control at the point of care and to be counseled appropriately.     

Management of Coronary Restenosis via the Radial Artery: An Elegant Approach to the AchillesÕ Heel of PTCA

In spite of many efforts, the most effective treatment for restenosis after coronary angioplasty remains repeat angioplasty. Although the second procedure is known to be at lower risk, it is usually performed by the same technique, thus requiring hospitalization. In such a group of patients, the feasibility of using the radial route for repeat coronary angiography and angioplasty when needed and the safety of early discharge were evaluated prospectively. Coronary angiography via the radial artery was attempted in 51 patients referred within 6 months of initial coronary angioplasty with the clinical suspicion of restenosis. Successful cannulation of the radial artery was possible in 48 (94%). Following placement of a 4 Fr arterial sheath, coronary angiography was completed successfully in all but one patient. Restenosis was confirmed angiographically in 25 patients (one via the femoral route) and a new lesion was observed in 3. Repeat angioplasty was attempted via the radial route (25 patients) or via the femoral route (one patient) using a fixed-wire balloon catheter through the 4 Fr diagnostic catheter (n=22). Angioplasty via the radial route including elective stent implantation (5 patients) was a technical success in 92% of the patients. Immediate arterial sheath withdrawal and mechanical compression of the radial artery provided satisfactory hemostasis after 186 +/- 126 minutes. The radial pulse was absent post-procedure without clinical consequence in 3 patients (6%). Of the 46 patients without a femoral artery puncture, 39 (85%) were discharged the same day without any cardiac or local complications. Thus, early discharge after repeat coronary angiography and angioplasty for restenosis is feasible and safe using the transradial route in the majority of patients.