Racial differences in patients’ perceptions of debilitated health states

OBJECTIVE: To determine health utility scores for specific debilitated health states and to identify whether race or other demographic differences predict significant variation in these utility scores. DESIGN: Utility analysis. SETTING: A community hospital general internal medicine clinic, a private internal medicine practice, and a private pulmonary medicine practice. PARTICIPANTS: Sixty-four consecutive patients aged 50 to 75 years awaiting appointments. In order to participate, patients at the pulmonary clinic had to meet prespecified criteria of breathing impairment. MEASUREMENTS: Individuals' strength of preference concerning specific states of limited physical function as measured by the standard gamble technique. MAIN RESULTS: Mean utility scores used to quantitate limitations in physical function were extremely low. Using a scale for which 0 represented death and 1.0 represented normal health, limitation in activities of daily living was rated 0. 19 (95% confidence interval [CI] 0.13, 0.25), tolerance of only bed-to-chair ambulation 0.17 (95% CI 0.11, 0.23), and permanent nursing home placement 0.16 (95% CI 0.10, 0.22). Bivariate analysis identified female gender and African-American race as predictors of higher utility scores ( p 相似文献   

Phenotyping Before Starting Treatment in COPD?

Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous and complex disease with great morbidity and mortality. Despite the new developments in the managements of COPD, it was recognized that not all patients benefit from the available medications. Therefore, efforts to identify subgroups or phenotypes had been made in order to predict who will respond to a class of drugs for COPD. This review will discuss phenotypes, endotypes, and subgroups such as the frequent exacerbator, the one with systemic inflammation, the fast decliner, ACOS, and the one with co-morbidities and their impact on therapy. It became apparent, that the “inflammatory” phenotypes: frequent exacerbator, chronic bronchitic, and those with a number of co-morbidities need inhaled corticosteroids; in contrast, the emphysematous type with dyspnea and lung hyperinflation, the fast decliner, need dual bronchodilation (deflators). However, larger, well designed studies clustering COPD patients are needed, in order to identify the important subgroups and thus, to lead to personalize management in COPD.     

Transforming Clinical Practice to Eliminate Racial–Ethnic Disparities in Healthcare

Racial–ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial–ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial–ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial–ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. Funding: Drs. Washington (#RCD-00-017), Saha (#RCD-00-028), and Moody (#RCD-03-183) are supported by grants from the Department of Veterans Affairs, Health Services Research and Development Service. Dr. Saha is supported by a Generalist Physician Faculty Scholar award from the Robert Wood Johnson Foundation. Drs. Horowitz (#P60 MD00270) and Brown (#P20MD00148) are supported by grants from the National Center on Minority Health and Health Disparities. Dr. Brown also received support from the University of California, Los Angeles, Resource Center in Minority Aging Research (#AG02004) and the Beeson Career Development Award (#AG26748). Dr. Cooper is supported by a grant from the National Heart, Lung, and Blood Institute (K24HL083113).     

Racial Differences in H. pylori Infection and Disease Outcomes in a Mutiracial Asian Country

Malaysia epitomizes the multiraciality of a South East Asian country where three major Asian races: Malay, Chinese and Indians live together. The distribution of Hp infection amongst the differences in Malaysia show an interesting pattern with the Malays having a consistently low prevalence compared to the Chinese and Indians. In our seroepidemiological studies and in a large endoscopic survey, Chinese and Indian race remained as independent predictive factors for H.pylori infection, after adjusting for possible confounding factors such as social class and age.     

Advances in the Treatment of Travelers’ Diarrhea

Diarrhea is the most common complaint reported by travelers from industrialized countries visiting developing nations. High-risk areas for travelers’ diarrhea (TD) include South Asia, Sub-Saharan Africa, and Latin America, while moderate-risk areas include Southeast Asia, Middle East, Oceania and the Caribbean. Bacterial pathogens are the major cause of TD. Recent advances in the therapy for diarrhea include a better understanding of the potential benefit of symptomatic and antimicrobial therapy. The mainstay of treatment includes antibacterial therapy with one of three drugs, a fluoroquinolone, rifaximin, or azithromycin. Probiotics have been used in preliminary studies for both treatment and prevention of TD, but more studies are needed with these biologic agents. The aim of this review is to identify the recent advances in the therapy of TD and to provide recommendations for treatment during international travel.     

Racial Differences in Disease Activity and Quality of Life in Patients with Crohn’s Disease

Background

The existing literature on racial differences in Crohn’s disease (CD) activity and quality of life (QOL) is limited and extrapolated from surrogate measures.

Aim

The aim of our study was to compare objective markers of disease activity and QOL over time by race.

Study

A clinical data repository of inflammatory bowel disease (IBD) patients at University of Maryland, Baltimore IBD Program, was used. CD patients from 2004 to 2009 were included if they had greater than or equal to two clinic visits with disease activity and QOL scores during the study period. Differences in disease activity and QOL were compared by race over time.

Results

A total of 296 patients with CD met inclusion criteria; of these, 19 % (56/296) were African Americans (AA) and 81 % (240/296) were Caucasian. Baseline disease activity and QOL scores did not differ by race (p > 0.05). Caucasians had a steady decline in disease activity and increase in QOL. AA experienced a similar pattern of change in disease activity and QOL scores over time; however, the declines were not statistically significant between groups. At each time point post-baseline, disease activity and QOL scores were similar between races.

Conclusion

We found that Caucasian and AA patients with CD had similar disease activity and QOL scores at initial presentation and over time. Thus, AA do not represent a more severe subgroup of CD patients to treat. These findings have important implications for clinicians that care for patients with CD.     

Racial Disparity in Blood Pressure: is Vitamin D a Factor?

Background  

Higher prevalence of hypertension among African Americans is a key cause of racial disparity in cardiovascular morbidity and mortality. Explanations for the difference in prevalence are incomplete. Emerging data suggest that low vitamin D levels may contribute.     

Treatment of oral dryness in Sjögren's syndrome

PURPOSE: In Sj?gren's syndrome (SS), oral dryness is frequently the most bothersome symptom of sicca syndrome with negative affects on quality of life. A review of treatments of oral dryness is proposed. CURRENT KNOWLEDGE AND KEY POINTS: To date, so specific DMARD has demonstrated its efficacy in SS. Hydroxychloroquine is frequently used but did not demonstrate any clinical benefit in te only small randomized control study versus placebo available. Thus, the only treatments are symptomatic. The most recent data show that systemic cholinergic agonist (pilocarpine and cevimeline) are effective in the symptomatic treatment of dryness. Pilocarpine (Salagen) is the only systemic cholinergic agonist available in Europe. It has been agreed in France since July 2003. FUTURE PROSPECTS AND PROJECTS: Use of immunosuppressive drugs may be useful in some complications of SS. Unfortunately, promising results from an open study with infliximab (Remicade) were not confirmed by a large randomized control study involving more than 100 patients. New control studies with old drugs such as hydroxychloroquine, or new ones such as rituximab, are mandatory.     

How we Provide Nutritional Treatment in Hospitalized Patients?

Background: In this study, we aimed to evaluate enteral nutrition (EN), parenteral nutrition (PN) and supplemental parenteral nutrition (SPN) in terms of achieving nutritional goals. Methods: Patients receiving either EN, PN, or SPN treatment followed up by the clinical nutrition team between January and December 2017 at the university research and training hospital were included in the study. Daily nutritional requirements were calculated according to the recommendations. Total energy intake during nutritional treatment (NT) and all metabolic, mechanical, technical complications of NT were recorded. Results: A total of 603 inpatients were included in the study. The nutritional goal was achieved in the majority of the SPN group patients (87.5%) statistically significant relation was found between the achievement of the target (or not) and PN access route (peripheral or central) (P < .001). However, none of the complications found statistically related to achieving the target, including gastrointestinal complications of EN (P = .46), metabolic complications of EN (P = .07), mechanical complications of EN (P = .79), metabolic complications of PN (P = .89), gastrointestinal complications in SPN group (P = .45), and metabolic complications in SPN group (P = .68).Conclusion: Nutritional goals could be achieved with SPN without increasing complications in the majority of patients. Commencement of SPN should be considered for positive outcomes in patients who failed to achieve desired nutritional outcomes.     

Treatment of fistulizing Crohn’s disease in children

Opinion statement Patients with Crohn’s disease are at risk for developing both internal and external fistulae. These can be asymptomatic incidental radiologic findings or causes of incontinence, chronic pain, abscesses, and sepsis. They can have a devastating impact on quality of life. Careful prospective studies of therapy are few in adult medicine and entirely lacking in the pediatric age group. Assessment and management require a coordinated effort between gastroenterologist, radiologist, and surgeon. Principles of management include surgical drainage of infection combined with medical therapy. Only infliximab has been studied in prospective, double-blinded fashion and clearly shown to be of use in the short term. There is good evidence that metronidazole may be useful acutely and that 6-mercaptopurine azathioprine may help to maintain closure. Diverting ostomies are of very limited value and corticosteroids seem to make matters worse. There are many other therapies that have been reported to be helpful in small, uncontrolled studies.     

Treatment of peri-anal fistula in Crohn’s disease

Anal fistulas are a common manifestation of Crohn’s disease(CD). The first manifestation of the disease is often in the peri-anal region, which can occur years before a diagnosis, particularly in CD affecting the colon and rectum. The treatment of peri-anal fistulas is difficult and always multidisciplinary. The European guidelines recommend combined surgical and medical treatment with biologic drugs to achieve best results. Several different surgical techniques are currently em-ployed. However, at the moment, none of these tech-niques appear superior to the others in terms of healing rate. Surgery is always indicated to treat symptomatic, simple, low intersphincteric fistulas refractory to medi-cal therapy and those causing disabling symptoms. Ut-most attention should be paid to correcting the balance between eradication of the fistula and the preservationof fecal continence.     

Divergent pathways? Racial/ethnic differences in older women's labor force withdrawal

OBJECTIVES: The purpose of this study was to investigate how women's labor force withdrawal behavior varies across race/ethnicity and to identify life course factors that generate these differences. METHODS: Using a sample of 7,235 women from the 1992-2004 Health and Retirement Study, we estimated cross-sectional multinomial logit models to explore racial/ethnic differences in labor force status at first interview. We then examined the prospective risk of exiting the labor force via retirement, work disability, or death using discrete-time hazard models. RESULTS: Black and Hispanic women had twice the odds of Whites of being work-disabled at first interview. Whereas younger minorities had lower odds of being retired at first interview, older minorities had higher odds. The prospective results showed that both Blacks and Hispanics had higher risks of work disability but not of retirement or of dying in the labor force. Overall, racial/ethnic differences in mid- and later life work behavior stemmed primarily from disparities in life course capital. DISCUSSION: This study shows that substantial racial/ethnic disparities in labor force exit behavior have already emerged by midlife. It is important to note that distinguishing between alternative pathways out of the labor force demonstrates that work disability is a more common experience for Black and Hispanic women than for Whites.     

Ageism in rectal carcinoma? Treatment and outcome variations

Background. Rectal cancer adjuvant and neo-adjuvant therapies are associated with improved survival and local control rates. Concerns regarding adverse treatment effects tend to reduce administration in the elderly—the very population this disease affects. Purpose. To determine the extent to which age alters rectal cancer treatment and its outcome. Methods and Materials. Using the population based provincial cancer registry, patients with adenocarcinoma of the rectum diagnosed between 1991 and 1998 were identified. From this cohort, a random subsample of patients seen at the regional cancer center were selected for detailed analysis. Demographic and clinical data between the provincial cohort and the subsample were compared for homogeneity. Log rank tests and Kaplan-Meier survival estimates were carried out on the subsample. Results. The population cohort (n=1979) and the subsample (n = 259) were similar in age, sex, and treatment distributions. Elderly patients (≥ 75 yr) made up 23% of the rectal cancer population in Alberta. Age had a highly significant (p=0.001) impact on whether patients received surgery alone or had surgery plus chemoradiotherapy. This corresponded to a considerable survival advantage for those elderly patients who did receive multimodality therapy (p=0.008). Conclusion. The advantage of multimodality therapy in rectal cancer is confirmed in this population-based study. Although a significant number of elderly patients are fit enough to tolerate major surgery they are being denied adjuvant therapies, presumably on the basis of potentially high treatment-related complication rates, with a subsequent reduction in survival. Strategies must be developed to ensure that maximum treatment benefit is obtained without increased harm in the elderly rectal cancer patient.     

An Investigation of Associations Between Clinicians’ Ethnic or Racial Bias and Hypertension Treatment,Medication Adherence and Blood Pressure Control

BACKGROUND

Few studies have directly investigated the association of clinicians’ implicit (unconscious) bias with health care disparities in clinical settings.

OBJECTIVE

To determine if clinicians’ implicit ethnic or racial bias is associated with processes and outcomes of treatment for hypertension among black and Latino patients, relative to white patients.

RESEARCH DESIGN AND PARTICIPANTS

Primary care clinicians completed Implicit Association Tests of ethnic and racial bias. Electronic medical records were queried for a stratified, random sample of the clinicians’ black, Latino and white patients to assess treatment intensification, adherence and control of hypertension. Multilevel random coefficient models assessed the associations between clinicians’ implicit biases and ethnic or racial differences in hypertension care and outcomes.

MAIN MEASURES

Standard measures of treatment intensification and medication adherence were calculated from pharmacy refills. Hypertension control was assessed by the percentage of time that patients met blood pressure goals recorded during primary care visits.

KEY RESULTS

One hundred and thirty-eight primary care clinicians and 4,794 patients with hypertension participated. Black patients received equivalent treatment intensification, but had lower medication adherence and worse hypertension control than white patients; Latino patients received equivalent treatment intensification and had similar hypertension control, but lower medication adherence than white patients. Differences in treatment intensification, medication adherence and hypertension control were unrelated to clinician implicit bias for black patients (P?=?0.85, P?=?0.06 and P?=?0.31, respectively) and for Latino patients (P?=?0.55, P?=?0.40 and P?=?0.79, respectively). An increase in clinician bias from average to strong was associated with a relative change of less than 5 % in all outcomes for black and Latino patients.

CONCLUSIONS

Implicit bias did not affect clinicians’ provision of care to their minority patients, nor did it affect the patients’ outcomes. The identification of health care contexts in which bias does not impact outcomes can assist both patients and clinicians in their efforts to build trust and partnership.     

Physician Effects on Racial and Ethnic Disparities in Patients’ Experiences of Primary Care

Background  Few studies have clarified the mechanisms that contribute to racial and ethnic disparities in primary care quality among comparably-insured patients. Objective  To examine relative contribution of “between-” and “within-” physician effects on disparities in patients’ experiences of primary care. Design  Regression models using physician fixed effects to account for patient clustering were specified to assess “between-” and “within-”physician effects on observed racial and ethnic disparities in patients’ experiences of primary care. Participants  The Ambulatory Care Experiences Survey (ACES) was administered to patients visiting 1,588 primary care physicians (PCPs) from 27 California medical groups. The analytic sample included 49,861 patients (31.4 per PCP) who confirmed a PCP visit during the preceding 12 months. Main Results  Most racial and ethnic minority groups were significantly clustered within physician practices (p < 0.001). “Between-physician” effects were mostly negative and larger than “within-physician” effects for Latinos, Blacks, and American Indian/Alaskan Natives, indicating that disparities are mainly attributable to patient clustering within physician practices with lower performance on patient experience measures. By contrast, “within-physician” effects accounted for most disparities for Asians and Pacific Islanders, indicating these groups report worse experiences relative to Whites in the same practices. Practices with greater concentration of Blacks, Latinos and Asians had lower performance on patient experience measures (p < 0.05). Conclusions  Targeting patient experience improvement efforts at low performing practices with high concentrations of racial and ethnic minorities might efficiently reduce disparities. Urgent study is needed to assess the contribution of “within-” and “between-” physician effects to racial and ethnic disparities in the technical quality of primary care.     

New Developments in the Diagnosis and Treatment of Pancreatic Cancer

The prognosis of pancreatic cancer is poor. Less than 5% of patients diagnosed with pancreatic cancer survive more than 5 years. Generally, the advanced stage, the late diagnosis and the poor therapeutic options are assumed to be responsible for this poor prognosis. Nonetheless, in recent years our knowledge of the pathogenesis of pancreatic cancer has dramatically improved and will give rise to new therapeutic options based on molecular alterations, which contribute to pancreatic carcinogenesis. Furthermore, new diagnostic procedures offer a new perspective towards a better and earlier diagnostic management of these individuals affected with this malignancy.