The Patient-Centered Medical Home: Preparation of the Workforce,More Questions than Answers

As American medicine continues to undergo significant transformation, the patient-centered medical home (PCMH) is emerging as an interprofessional primary care model designed to deliver the right care for patients, by the right professional, at the right time, in the right setting, for the right cost. A review of local, state, regional and national initiatives to train professionals in delivering care within the PCMH model reveals some successes, but substantial challenges. Workforce policy recommendations designed to improve PCMH effectiveness and efficiency include 1) adoption of an expanded definition of primary care, 2) fundamental redesign of health professions education, 3) payment reform, 4) responsiveness to local needs assessments, and 5) systems improvement to emphasize quality, population health, and health disparities.Key words: Health policy, Workforce, Patient-centered care, Medical education—financing and administration, Medical education—interprofessional training, faculty development, undergraduate and graduate training     

Accuracy of EBRA-cup measurements after reconstruction of severe acetabular defects at revision THR

Radiostereometric analysis (RSA) is the most accurate method of measuring component migration using radiographs but is restricted to use in prospective studies. Ein-Bild-Roentgen-analyze (EBRA)-Cup can be used retrospectively, but its accuracy to measure component migration following revision is unknown. This study aimed to determine the accuracy of EBRA-Cup measurements of uncemented acetabular component migration after revision total hip replacement (THR). The secondary aim was to compare the number of cases identified using EBRA-Cup and RSA as having proximally migrated above and below 1 mm at 2 years postoperatively. EBRA-Cup measurements were performed on plain antero-posterior pelvic radiographs taken at the same time as RSA radiographs in a prospective cohort of 53 hips undergoing acetabular revision. At 2 years, the mean difference between the RSA and EBRA-Cup measurements for 17 components used to treat pelvic discontinuity was 0.90 mm, significantly greater than the mean difference of 0.28 mm for 36 components without discontinuity (P = .0001). The mean difference between the RSA and EBRA-Cup measurements at 2 years for hips that were reconstructed with an acetabular component alone, 0.28 mm, was significantly lower than hips that were reconstructed with an acetabular component in combination with an augment and/or cage, 0.74 mm (P = .0005). In conclusion, EBRA-Cup can accurately measure migration of uncemented acetabular components used at revision THR. The presence of pelvic discontinuity, and addition of augments and cages, significantly influenced the accuracy of EBRA-Cup measurements. EBRA-Cup and RSA had good agreement on classification of components that migrated proximally above or below 1 mm at 2 years, with 100% sensitivity, and 87% specificity.     

Angiotensin receptors in Dupuytren’s disease: a target for pharmacological treatment?

Background: Attempts at the pharmacological treatment of Dupuytren’s disease have so far been unsuccessful, and the disease is not yet fully understood on a cellular level. The Renin-Angiotensin System has long been understood to play a circulating hormonal role. However, there is much evidence showing Angiotensin II to play a local role in wound healing and fibrosis, with ACE inhibitors being widely used as an anti-fibrotic agent in renal and cardiac disease.

Methods: This study was designed to investigate the presence of Angiotensin II receptors 1 (AT1) and 2 (AT2) in Dupuytren’s tissue to form a basis for further study into the pharmacological treatment of this condition. Tissue was harvested from 11 patients undergoing surgery for Dupuytren’s disease. Each specimen was processed into frozen sections and immunostaining was employed to identify AT1 and AT2 receptors.

Results: Immunostaining for AT1 receptors was mildly positive in one patient and negative in all the remaining patients. However, all specimens stained extensively for AT2 receptors. This suggests that the expression of AT2 receptors is more prominent than AT1 receptors in Dupuytren’s disease.

Conclusion: These findings have opened a new avenue for future research involving ACE inhibitors, AT2 agonists, and AT2 antagonists in Dupuytren’s disease.     

Open-label Extension Study Evaluating Long-term Safety and Efficacy of FMX103 1.5% Minocycline Topical Foam for the Treatment of Moderate-to-Severe Papulopustular Rosacea

BACKGROUND: Efficacy and safety of FMX103 1.5% for papulopustular rosacea were previously demonstrated in two 12-week, Phase 3 studies. OBJECTIVE: We sought to evaluate the safety and efficacy of FMX103 1.5% foam for up to 52 weeks of treatment. METHODS: Following the completion of two 12-week, double-blind, vehicle-controlled, Phase 3 studies, subjects were invited to enter a 40-week open-label extension study in which all subjects applied FMX103 1.5% once daily. Efficacy endpoints were the reduction in inflammatory lesions and the rate of IGA treatment success from the double-blind baseline. Safety assessments included adverse events, vital signs, laboratory tests, and facial tolerability signs and symptoms. RESULTS: The favorable safety profile of FMX103 1.5% observed in the double-blind studies was maintained over extended treatment lasting up to one year. There were no serious treatment-related adverse events. Long-term treatment with FMX103 1.5% was associated with a greater than 82-percent reduction in inflammatory lesions from baseline and with over 79 percent of subjects achieving treatment success. At the end of the open-label treatment period, over 82 percent of subjects indicated they were overall “satisfied” or “very satisfied” with FMX103 1.5%. All facial local tolerability symptoms improved through Week 52. LIMITATIONS: Due to the nature of the open-label study, lacking a vehicle-treated control, no statistical comparisons can be made. CONCLUSION: FMX103 1.5% demonstrated a favorable safety and tolerability profile for up to 52 weeks. Long-term efficacy was demonstrated by progressive reductions in inflammatory lesions and increasing IGA treatment success, suggesting that FMX103 1.5% may be a suitable option for the treatment for papulopustular rosacea.     

The independent association of massive blood loss with mortality in cardiac surgery

BACKGROUND: Although the association between massive perioperative blood loss (MBL) and adverse outcomes is well recognized, it is unclear whether MBL is an independent risk factor or, instead, simply a marker for other adverse events or severity of illness. The objective of this cohort study was to quantify the independent association of MBL in cardiac surgery with all-cause in-hospital mortality. STUDY DESIGN AND METHODS: Data were prospectively collected on consecutive patients who underwent cardiac surgery with cardiopulmonary bypass at a quaternary-care academic center from 1999 to 2003. The number of red blood cell (RBC) units transfused within 1 day of surgery was used as a surrogate measure of perioperative blood loss. Receiver-operating characteristic curve analyses were employed to identify the most appropriate cutoff for defining MBL. The independent association of MBL with mortality was determined with multivariable logistic regression analyses. Bootstrapping and sensitivity analyses were used to confirm the validity of the results. RESULTS: MBL was defined as receiving at least 5 units of RBCs within 1 day of surgery. Of 9215 patients analyzed, 1.8 percent (n = 169) died and 9.7 percent (n = 890) had MBL. After adjusting for multiple potential confounders (including perioperative adverse events), MBL was associated with an 8.1-fold (95% confidence interval, 3.9-17.0) increase in the odds of death. This risk estimate was stable across different modeling conditions as well as in bootstrap sampling. CONCLUSION: MBL after cardiac surgery has a strong, independent association with in-hospital mortality.