Toward a reliable distinction between patients with mild cognitive impairment and Alzheimer-type dementia versus major depression.

BACKGROUND: Cerebrospinal fluid (CSF) levels of soluble amyloid precursor protein (sAPP) and its alpha-secreted form (alpha-sAPP) were investigated as a means to distinguish between individuals with mild cognitive impairment (MCI) and Alzheimer-type dementia (DAT) and those with major depressive episode (MDE) showing secondary memory deficits. METHODS: Twenty-seven patients with MCI, 32 with probable DAT, and 24 with MDE attending a memory clinic were studied. Cerebrospinal fluid levels of sAPP/amyloid precursor-like protein 2 (APLP2) and alpha-sAPP were detected by Western blotting. RESULTS: Patients with MDE had the highest CSF levels of total sAPP/APLP2 as compared with MCI and DAT patients (p < .001); sAPP/APLP2 levels were higher in MCI than in DAT subjects. Whereas alpha-sAPP levels did not differ between the MCI and DAT groups, median levels of this peptide were significantly lower in MCI and DAT versus MDE patients. CONCLUSIONS: Soluble amyloid precursor protein/APLP2 and alpha-sAPP concentrations in CSF can differentiate between DAT and MCI versus MDE, facilitating early ameliorative interventions and appropriate treatment regimens.     

The Effectiveness of a Physician-Only and Physician–Patient Intervention on Colorectal Cancer Screening Discussions Between Providers and African American and Latino Patients

BACKGROUND

Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities.

OBJECTIVE

Our purpose was to assess the effectiveness of physician-only and physician–patient interventions on increasing rates of CRC screening discussions as compared to usual care.

DESIGN

This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention.

PARTICIPANTS

Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study.

INTERVENTION

Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment.

MAIN MEASURES

Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test.

KEY RESULTS

The physician–patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests.

CONCLUSIONS

Compared to usual care and a physician-only intervention, a physician–patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.KEY WORDS: colorectal cancer screening, health literacy, randomized trial, physician communication of preventive care     

Recommendations for managing patients with diabetes mellitus in cardiopulmonary rehabilitation: an American Association of Cardiovascular and Pulmonary Rehabilitation statement

Diabetes mellitus is a highly prevalent condition in patients participating in cardiopulmonary rehabilitation. However, research and subsequent guidelines specifically applicable to patients with diabetes, participating in cardiopulmonary rehabilitation, are limited. Recognizing this limitation, the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) initiated this statement, with the goal of developing a template that incorporated recommendations provided in the AACVPR Core Components and the American Association of Diabetes Educators 7 Self-Care Behaviors. This statement describes key processes regarding evaluation, interventions, and expected outcomes in each of the core components for the management of patients with diabetes in a cardiopulmonary rehabilitation program.     

Why do families still not receive the child support grant in South Africa? A longitudinal analysis of a cohort of families across South Africa

Background

Child cash transfers are increasingly recognised for their potential to reduce poverty and improve health outcomes. South Africa‘s child support grant (CSG) constitutes the largest cash transfer in the continent. No studies have been conducted to look at factors associated with successful receipt of the CSG. This paper reports findings on factors associated with CSG receipt in three settings in South Africa (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal).

Methods

This study used longitudinal data from a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding by peer-counsellors in South Africa (ClinicalTrials.gov: NCT00397150). 1148 mother-infant pairs were enrolled in the study and data on the CSG were collected at infant age 6, 12, 24 weeks and 18–24 months. A stratified cox proportional hazards regression model was fitted to the data to investigate factors associated with CSG receipt.

Results

Uptake of the CSG amongst eligible children at a median age of 22 months was 62% in Paarl, 64% in Rietvlei and 60% in Umlazi. Possessing a birth certificate was found to be the strongest predictor of CSG receipt (HR 3.1, 95% CI: 2.4 -4.1). Other factors also found to be independently associated with CSG receipt were an HIV-positive mother (HR 1.2, 95% CI: 1.0-1.4) and a household income below R1100 (HR1.7, 95% CI: 1.1 -2.6).

Conclusion

Receipt of the CSG was sub optimal amongst eligible children showing administrative requirements such as possessing a birth certificate to be a serious barrier to access. In the spirit of promoting and protecting children’s rights, more efforts are needed to improve and ease access to this cash transfer program.

     

Integration of syndromic surveillance data into public health practice at state and local levels in North Carolina

Objectives

We sought to describe the integration of syndromic surveillance data into daily surveillance practice at local health departments (LHDs) and make recommendations for the effective integration of syndromic and reportable disease data for public health use.

Methods

Structured interviews were conducted with local health directors and communicable disease nursing staff from a stratified random sample of LHDs from May through September 2009. Interviews captured information on direct access to the North Carolina syndromic surveillance system and on the use of syndromic surveillance information for outbreak management, program management, and the creation of reports. We analyzed syndromic surveillance system data to assess the number of signals resulting in a public health response.

Results

Syndromic surveillance data were used for outbreak investigation (19% of respondents) and program management and report writing (43% of respondents); a minority reported use of both syndromic and reportable disease data for these purposes (15% and 23%, respectively). Receiving data from frequent system users was associated with using data for these purposes (p=0.016 and p=0.033, respectively, for syndromic and reportable disease data). A small proportion of signals (<25%) resulted in a public health response.

Conclusions

Use of syndromic surveillance data by North Carolina local public health authorities resulted in meaningful public health action, including both case investigation and program management. While useful, the syndromic surveillance data system was oriented toward sensitivity rather than efficiency. Successful incorporation of new surveillance data is likely to require systems that are oriented toward efficiency.Effective use of surveillance data is essential to good public health practice. In recent years, public health agencies have experienced a significant increase in the amount of data available for surveillance (e.g., data used for syndromic surveillance), and this increase is likely to continue. For example, the federal Health Information Technology for Economic and Clinical Health Act (HITECH Act) supports forwarding medical record data to public health agencies. Published work demonstrates that better data are needed for communicable disease surveillance; communicable disease reporting is not complete,¹ and many cases are reported later than is necessary for public health action.² While the medical record data that may be provided to public health have the potential to improve completeness and timeliness, these datasets are likely to have many records that are not usable for public health purposes.³ Furthermore, limited staff are available to review these data.^4,5 Effective use of these new data for public health surveillance will require efficient identification of and access to the usable data elements present in new datasets.The implementation of syndromic surveillance is an example of the incorporation of new data sources. Syndromic surveillance systems were established to facilitate early detection of events requiring a rapid response, such as outbreaks caused by bioterrorism agents. Events that may require public health intervention are identified using aberration detection algorithms and individual record review. Most states have a system of this type,⁶ and their value for public health event detection and characterization has been demonstrated.^6–10 Lessons learned from attempts to integrate syndromic data for public health surveillance and response can inform future management of new data.While syndromic surveillance data can be valuable to public health practice, the design of these systems frequently limits their use to jurisdictions with greater capacity. Alerts created by system algorithms are often of low positive predictive value,^11,12 and these systems can require a high level of staff time for detecting events that require public health action.⁸ Therefore, syndromic surveillance data are most commonly used by state and large city public health departments that have enough staff time for reviewing alerts and individual case records.^6,13,14 Although these data can be useful to health departments of all sizes, little is known about how best to make these data usable in situations with limited surveillance staff. The use of syndromic surveillance data in smaller population settings, such as most local health departments (LHDs), has not been described.North Carolina can provide an example of the integration of syndromic surveillance data into public health surveillance practice. Current electronic surveillance for communicable disease in the state includes a population-based syndromic surveillance system, the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT), and a population-based reportable communicable disease surveillance system, the North Carolina Electronic Disease Surveillance System (NC EDSS). Both syndromic and reportable disease data have been used for public health surveillance since 2006. NC DETECT use is the responsibility of syndromic surveillance staff, which includes two state-level epidemiologists and 11 hospital-based epidemiologists. All other public health agency staff may use NC DETECT. NC EDSS use is required for and restricted to staff responsible for communicable disease reporting at state and local levels.The objectives of this study were to quantitatively assess the use of syndromic surveillance data at state and local public health agencies in North Carolina, to describe how syndromic surveillance is incorporated into public health practice in the state, and to make recommendations for the effective integration of syndromic and reportable disease data for public health use.