Veterans Affairs Geriatric Scholars Program: Enhancing Existing Primary Care Clinician Skills in Caring for Older Veterans

The Veterans Affairs Geriatric Scholars Program (GSP) is a continuing professional development program to integrate geriatrics into the clinical practices of primary care providers and select associated health professions that support primary care teams. GSP uses a blended program educational format, and the minimal requirements are to attend an intensive course in geriatrics, participate in an interactive workshop on quality improvement (QI), and initiate a local QI project to demonstrate application of new knowledge to benefit older veterans. Using a retrospective post/pre survey design, the effect of GSP on clinical practices and behaviors and variation of that effect on clinicians working in rural and nonrural settings were evaluated. Significant improvement was found in the frequency of using evidence‐based brief standardized assessments, clinical decision‐making, and standards of care. Significant subgroup differences were observed in peer‐to‐peer information sharing between rural and nonrural clinicians. Overall, 77% of the sample reported greater job satisfaction after participating in GSP. The program is a successful model for advancing postgraduate education in geriatrics and a model that might be replicated to increase access to quality health care, particularly in rural areas.     

Risk factors for fatigue severity in primary brain tumor patients

BACKGROUND:

In addition to neurologic symptoms, fatigue is commonly reported in patients with primary brain tumors during radiation therapy and in long–term survivors of low–grade brain tumors. Other factors have not been explored. The aim of this study was to identify demographic and clinical factors that predict fatigue severity and to evaluate the association of fatigue with other symptoms throughout the disease trajectory.

METHODS:

Two hundred one patients with primary brain tumors completed the M. D. Anderson Symptom Inventory–Brain Tumor Module and a demographic checklist. Clinical data, including treatment, tumor grade, and performance status, were also collected. Correlations among fatigue and other recorded symptoms were evaluated. Logistic regression modeling was performed to evaluate factors associated with fatigue severity.

RESULTS:

Fatigue severity was associated with symptoms including pain, drowsiness, distress, difficulty sleeping, and weakness as well as overall symptom severity and interference. Poor performance status (Karnofsky scale) (odds ratio [OR], 5.73; P = .001), female sex (OR, 2.48; P = .005), and disease status (OR, 2.20; P = .013) were the strongest predictors of fatigue. Severity of fatigue for women was primarily predicted by disease status (OR, 3.33; P = .01) For men, antidepressant use (OR, 4.43; P = .013) in addition to opioids (OR, 3.46; P = .017) and performance status (OR, 12.47; P = .0001) predicted fatigue severity.

CONCLUSIONS:

Fatigue should not be considered a solitary symptom with 1 root cause, but a complex symptom related to the severity of other symptoms and potentially having various etiologies. Future studies should consider these factors in planning interventions and assessing response. Cancer 2010. © 2010 American Cancer Society.     

A Framework for Web‐Based Interprofessional Education for Midwifery and Medical Students

Scheduling interprofessional team‐based activities for health sciences students who are geographically dispersed, with divergent and often competing schedules, can be challenging. The use of Web‐based technologies such as 3‐dimensional (3D) virtual learning environments in interprofessional education is a relatively new phenomenon, which offers promise in helping students come together in online teams when face‐to‐face encounters are not possible. The purpose of this article is to present the experience of a nurse‐midwifery education program in a Southeastern US university in delivering Web‐based interprofessional education for nurse‐midwifery and third‐year medical students utilizing the Virtual Community Clinic Learning Environment (VCCLE). The VCCLE is a 3D, Web‐based, asynchronous, immersive clinic environment into which students enter to meet and interact with instructor‐controlled virtual patient and virtual preceptor avatars and then move through a classic diagnostic sequence in arriving at a plan of care for women throughout the lifespan. By participating in the problem‐based management of virtual patients within the VCCLE, students learn both clinical competencies and competencies for interprofessional collaborative practice, as described by the Interprofessional Education Collaborative Core Competencies for Interprofessional Collaborative Practice. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.     

Low prevalence of <Emphasis Type=Italic>H. pylori</Emphasis> Infection in HIV-Positive Patients in the Northeast of Brazil

Background  

This study conducted in Northeastern Brazil, evaluated the prevalence of H. pylori infection and the presence of gastritis in HIV-infected patients.     

Confronting Disparities in Diabetes Care: The Clinical Effectiveness of Redesigning Care Management for Minority Patients in Rural Primary Care Practices

CONTEXT: Diabetes mellitus and its complications disproportionately affect minority citizens in rural communities, many of whom have limited access to comprehensive diabetes management services. PURPOSE: To explore the efficacy of combining care management and interdisciplinary group visits for rural African American patients with diabetes mellitus. METHODS: In the intervention practice, an advanced practice nurse visited the practice weekly for 12 months and facilitated diabetes education, patient flow, and management. Patients participated in a 4-session group visit education/support program led by a nurse, a physician, a pharmacist, and a nutritionist. The control patients in a separate practice received usual care. FINDINGS: Median hemoglobin A1c (HbA1c) was not significantly different at baseline in the intervention and control groups but was significantly different at the end of the 12-month follow-up period (P < .05). In the intervention group, median HbA1c at baseline was 8.2 +/- 2.6%, and median HbA1c at an average follow-up of 11.3 months was 7.1 +/- 2.3%, (P < .0001). In the control group, median HbA1c increased from 8.3 +/- 2.0% to 8.6 +/- 2.4% (P < .05) over the same time period. In the intervention group, 61% of patients had a reduction in HbA1c, and the percentage of patients with a HbA1c of less than 7% improved from 32% to 45% (P < 05). CONCLUSIONS: These findings suggest that a redesigned care management model that combines nurse-led case management with structured group education visits can be successfully incorporated into rural primary care practices and can significantly improve glycemic control.     

Development of esophageal metaplasia and adenocarcinoma in a rat surgical model without the use of a carcinogen

In order to establish an animal model for studying the cause and prevention of esophageal adenocarcinoma (EAC) and its frequent precursor, Barrett's esophagus (BE), factors affecting the pathogenic processes were investigated in an esophagoduodenal anastomosis model with rats. Experiments by us and others have shown that surgical treatment produced reflux esophagitis with cell hyperproliferation, but not EAC. Additional treatment with a carcinogen has been shown to be necessary for the development of EAC, squamous cell carcinomas (SCC) or EAC/SCC mixtures. We found that the surgically treated animals developed anemia due possibly to reduced iron absorption. When the operated animals were supplemented with iron, EAC occurred at a high rate (73%) after 30 weeks, and treatment with N'-nitrosonornicotine did not enhance the rate of tumorigenesis. Treatment with carcinogen, however, induced SCC in the group of rats killed after 22 weeks. The results suggest that iron overload, which is known to cause oxidative damage, is an enhancing factor for adenocarcinogenesis. The pathogenesis of EAC in the iron-supplemented, non-carcinogen treated group resembles human esophageal adenocarcinogenesis in many features. All the BE was the specialized type with goblet cells (containing sialomucin or sulfomucin) and columnar cells (containing acid or neutral mucin) as well as an incompletely developed brush border. Almost all of the BE was located at the bottom of the esophagus and was continuous with the duodenal mucosa; dysplasia became more frequent at later time points. All of the cancers were well-differentiated mucinous EAC, and most of the EAC had an adjacent area of BE with dysplasia. The results are consistent with the proposed human sequence for pathogenic events of BE progression to 'BE with dysplasia' and then to EAC. Esophagoduodenal anastomosis and iron treatment in rats produces a high rate of BE and EAC which are morphologically similar to human BE and EAC; this may be a useful animal model to study the development and prevention of EAC in humans.      

The four-and-a-half-LIM protein 2 （FHL2） is overexpressed in gliomas and associated with oncogenic activities

Four-and-a-half-LIM protein 2 （FHL2） is a member of FHL protein family, which plays a crucial role in regulating gene expression, cell survival, and migration.Ahhough its function in oncogenesis appears to be tumor type-specific, its roles in glioma formation and development are yet to be elucidated. In the present study, we demonstrated that the mRNA level of FHL2 was elevated in both low- and high-grade glioma samples.