Do the benefits of participation in a hypertension self-management trial persist after patients resume usual care?

BACKGROUND

Hypertension self-management has been shown to improve systolic blood pressure (BP) control, but longer-term economic and clinical impacts are unknown. The purpose of this article is to examine clinical and economic outcomes 18 months after completion of a hypertension self-management trial.

METHODS AND RESULTS

This study is a follow-up analysis of an 18-month, 4-arm, hypertension self-management trial of 591 veterans with hypertension who were randomized to usual care or 1 of 3 interventions. Clinic-derived systolic blood pressure obtained before, during, and after the trial were estimated using linear mixed models. Inpatient admissions, outpatient expenditures, and total expenditures were estimated using generalized estimating equations. The 3 telephone-based interventions were nurse-administered health behavior promotion, provider-administered medication adjustments based on hypertension treatment guidelines, or a combination of both. Intervention calls were triggered by home BP values transmitted via telemonitoring devices. Clinical and economic outcomes were examined 12 months before, 18 months during, and 18 months after trial completion. Compared with usual care, patients randomized to the combined arm had greater improvement in proportion of BP control during and after the 18-month trial and estimated proportion of BP control improved 18 months after trial completion for patients in the behavioral and medication management arms. Among the patients with inadequate baseline BP control, estimated mean systolic BP was significantly lower in the combined arm as compared with usual care during and after the 18-month trial. Utilization and expenditure trends were similar for patients in all 4 arms.

CONCLUSIONS

Behavioral and medication management can generate systolic BP improvements that are sustained 18 months after trial completion.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00237692.

Organizational factors associated with readiness to implement and translate a primary care based telemedicine behavioral program to improve blood pressure control: the HTN-IMPROVE study

Background

Hypertension is prevalent and often sub-optimally controlled; however, interventions to improve blood pressure control have had limited success.

Objectives

Through implementation of an evidence-based nurse-delivered self-management phone intervention to facilitate hypertension management within large complex health systems, we sought to answer the following questions: What is the level of organizational readiness to implement the intervention? What are the specific facilitators, barriers, and contextual factors that may affect organizational readiness to change?

Study design

Each intervention site from three separate Veterans Integrated Service Networks (VISNs), which represent 21 geographic regions across the US, agreed to enroll 500 participants over a year with at least 0.5 full time equivalent employees of nursing time. Our mixed methods approach used a priori semi-structured interviews conducted with stakeholders (n = 27) including nurses, physicians, administrators, and information technology (IT) professionals between 2010 and 2011. Researchers iteratively identified facilitators and barriers of organizational readiness to change (ORC) and implementation. Additionally, an ORC survey was conducted with the stakeholders who were (n = 102) preparing for program implementation.

Results

Key ORC facilitators included stakeholder buy-in and improving hypertension. Positive organizational characteristics likely to impact ORC included: other similar programs that support buy-in, adequate staff, and alignment with the existing site environment; improved patient outcomes; is positive for the professional nurse role, and is evidence-based; understanding of the intervention; IT infrastructure and support, and utilization of existing equipment and space.

The primary ORC barrier was unclear long-term commitment of nursing. Negative organizational characteristics likely to impact ORC included: added workload, competition with existing programs, implementation length, and limited available nurse staff time; buy-in is temporary until evidence shows improved outcomes; contacting patients and the logistics of integration into existing workflow is a challenge; and inadequate staffing is problematic. Findings were complementary across quantitative and qualitative analyses.

Conclusions

The model of organizational change identified key facilitators and barriers of organizational readiness to change and successful implementation. This study allows us to understand the needs and challenges of intervention implementation. Furthermore, examination of organizational facilitators and barriers to implementation of evidence-based interventions may inform dissemination in other chronic diseases.

The implementation of a translational study involving a primary care based behavioral program to improve blood pressure control: The HTN-IMPROVE study protocol (01295)

BACKGROUND

Despite the impact of hypertension and widely accepted target values for blood pressure (BP), interventions to improve BP control have had limited success.

OBJECTIVES

We describe the design of a 'translational' study that examines the implementation, impact, sustainability, and cost of an evidence-based nurse-delivered tailored behavioral self-management intervention to improve BP control as it moves from a research context to healthcare delivery. The study addresses four specific aims: assess the implementation of an evidence-based behavioral self-management intervention to improve BP levels; evaluate the clinical impact of the intervention as it is implemented; assess organizational factors associated with the sustainability of the intervention; and assess the cost of implementing and sustaining the intervention.

METHODS

The project involves three geographically diverse VA intervention facilities and nine control sites. We first conduct an evaluation of barriers and facilitators for implementing the intervention at intervention sites. We examine the impact of the intervention by comparing 12-month pre/post changes in BP control between patients in intervention sites versus patients in the matched control sites. Next, we examine the sustainability of the intervention and organizational factors facilitating or hindering the sustained implementation. Finally, we examine the costs of intervention implementation. Key outcomes are acceptability and costs of the program, as well as changes in BP. Outcomes will be assessed using mixed methods (e.g., qualitative analyses--pattern matching; quantitative methods--linear mixed models).

DISCUSSION

The study results will provide information about the challenges and costs to implement and sustain the intervention, and what clinical impact can be expected.

Electrophysiologic findings in two patients with digital neuropathy of the thumb

Repetitive trauma to a finger can result in compressive neuropathy of one or more digital nerves. The thumb is commonly affected in bowlers, hence the term "bowler's thumb". However, this condition can involve other fingers and non-bowlers. To our knowledge, none of the cases reported had undergone neurophysiologic testing. We describe the neurophysiologic findings in two patients who had a history consistent with digital neuropathy of the thumb.

Archival, formalin-fixed tissue: its use in the study of Alzheimer's type changes

Preparing for a retrospective study of senile degeneration in schizophrenia, we had occasion to explore the suitability of an old collection formalin-fixed brains and paraffin blocks for study by modern staining methods. Tissue that had been in formalin for 50 years was embedded in paraffin. Sections were then stained with thioflavine S and with immunoperoxidase stains using Alz 50 and antibodies to paired helical filaments, ubiquitin, and beta-amyloid. In all 4 cases that had originally (50 years earlier) received neuropathologic diagnoses of Alzheimer's disease, large numbers of neocortical senile plaques and neurofibrillary tangles were clearly demonstrated by thioflavine S stain and by immunohistochemistry for paired helical filaments, ubiquitin, and beta-amyloid. In each of 4 other cases, in which the original neuropathologic examination had not revealed Alzheimer's disease, no plaques or tangles were observed. Immunoreactivity with Alz 50 was completely absent after 50 years in formalin. Examination of additional cases of Alzheimer's disease revealed that Alz 50 immunoreactivity was well preserved after 10 years in formalin and completely absent after 30 years in formalin. Alzheimer's disease tissue stored in paraffin for 30 years was clearly stained by all modalities. We conclude that immunohistochemical identification of senile plaques and neurofibrillary tangles is practical even after decades of storage in formalin or paraffin. The applicability of techniques that did not exist when these specimens were collected indicates that the systematic, permanent retention of formalin-fixed material may yield unanticipated future benefits.

Differential diagnosis and pitfalls in electrodiagnostic studies and special tests for diagnosing compressive neuropathies

The differential diagnosis of compressive neuropathies in the arms includes syndromes involving the nerve roots and brachial plexus, as well as the peripheral nerves. Often these conditions coexist. Nerve conduction velocity studies as well as electromyography have a role along with the clinical evaluation in differentiating these conditions. Limitations in routine electrodiagnostic testing are present, which necessitate several specialized techniques for identifying compressive neuropathies.

Movement disorders in the eosinophilia-myalgia syndrome: tremor, myoclonus, and myokymia

OBJECTIVE

To describe the development of tremor, myoclonus, and myokymia as chronic sequelae of eosinophilia-myalgia syndrome (EMS).

METHODS

Four patients among a cohort of 57 individuals with EMS followed prospectively were identified to have objective movement disorders. Electrophysiologic findings were assessed by recording of electromyographic activity from pairs of upper extremity antagonist muscles using 2 input channels.

RESULTS

Clinical and electrophysiologic studies documented the presence of tremor (4 patients), myoclonus (3 patients), and myokymia (1 patient) as late sequelae of EMS.

CONCLUSION

The recognition of these movement disorders extends the spectrum of chronic neurologic disease in EMS.

Rapidly progressive frontal-type dementia associated with Lyme disease

The authors report a case of fatal neuropsychiatric Lyme disease (LD) that was expressed clinically by progressive frontal lobe dementia and pathologically by severe subcortical degeneration. Antibiotic treatment resulted in transient improvement, but the patient relapsed after the antibiotics were discontinued. LD must be considered even in cases with purely psychiatric presentation, and prolonged antibiotic therapy may be necessary.

Late-onset Lafora's disease with typical intraneuronal inclusions

We describe a patient with progressive myoclonus epilepsy (late-onset Lafora's disease). Onset was in early adult life, and death was at age fifty-four. The initial symptoms were epileptic seizures and progressive dementia, with later occurrence of myoclonus. Lafora bodies were ubiquitous and in neuronal perikarya in many areas. Dust-like granular bodies predominated in the neuropil of cerebral cortex, substantia nigra, and striatum. Abnormal deposits were also found in the myocardium.

Alzheimer-type neuropathology in elderly schizophrenia patients

Traditionally, schizophrenia has been studied in early adulthood. Its course and outcome during senescence are largely unknown and subject to controversy. We reviewed the consecutive neuropathologic records of 1,046 patients who were chronically hospitalized in New York State mental institutions, and we selected for analysis all 802 patients who died after age 50 with a clinical antemortem diagnosis, as recorded in the autopsy notes, of schizophrenia (n = 544) or dementia (n = 258). The prevalence of neuropathologic diagnoses consistent with Alzheimer's disease (AD) was 51 percent in the dementia group and 28 percent in the schizophrenia sample. This prevalence rate in the schizophrenia sample (mean age = 77) was considerably higher than that estimated for the general population. When evaluated against age of death, AD findings in demented patients were age invariant, whereas the rate of such findings in schizophrenia patients rose monotonously from under 5 percent below age 60 to 50 percent at age 90 and over. The age-relative rate of AD diagnosis in schizophrenia patients was similar to a curve postulated for first-degree relatives of familial AD patients and was markedly higher than population estimates. These findings as a basis for comparison with other retrospective studies of pathological records are presented. Our own study, as well as others, suffers from three intrinsic limitations. The clinical diagnoses are taken from death notes and have no formal verification. Likewise, neuropathologic diagnoses were based upon informal criteria in use at the time; since that time, formal diagnostic criteria have been evolving, and new staining methods have become available. Finally, it is not possible to determine from this material whether these patients are representative of all elderly schizophrenia patients or even of those who are institutionalized. Therefore, despite the large sample size on which our current findings are based, a new study has begun to address these weaknesses by complete review and rediagnosis of medical records and neuropathological material, using current methods, standardized criteria, and quantitative measures of degenerative changes. Specifically, the new ongoing study examines whether autopsied patients are representative by performing detailed diagnostic reviews of a control sample of nonautopsied patients from the same institutions. These results, if confirmed in the new study, demonstrate substantially greater vulnerability of chronic schizophrenia patients to the development of AD (or, at least, to histological changes typical of this disease). Possible association with chronic neuroleptic treatment and pathophysiological mechanisms remains to be elucidated.

Effect of epinephrine on intrathecal fentanyl analgesia in patients undergoing postpartum tubal ligation

Eighty women receiving spinal anesthesia for postpartum tubal ligation were entered into a double-blind, randomized protocol studying the effects of epinephrine on intrathecal fentanyl-induced postoperative analgesia. All patients received 70 mg hyperbaric lidocaine with either 0.2 mg epinephrine (LE), 10 micrograms fentanyl (LF), epinephrine and fentanyl (LFE), or 0.4 ml saline (L). Onset and regression of anesthesia, degree of intraoperative comfort, incidence of pruritus, and extent of postoperative analgesia were evaluated. The simultaneous administration of epinephrine and fentanyl prolonged the duration of complete analgesia (137 +/- 47 min (LFE); 76 +/- 32 min (LE); 85 +/- 44 min (LF); 65 +/- 36 min (L)) and the duration of effective analgesia (562 +/- 504 min (LFE); 227 +/- 201 min (LE); 203 +/- 178 min (LF); 198 +/- 342 min (L)). Administration of epinephrine decreased the incidence of pruritus associated with intrathecal fentanyl (1/18 (LFE); 1/21 (LE); 8/19 (LF); 2/19 (L)).

Young adult-form of dementia with neurofibrillary changes and Lewy bodies

Alzheimer's neurofibrillary tangles, Lewy bodies and chromatolytic neurons were found in the brain at autopsy of a 28-year-old male with pyramidal and extrapyramidal signs, and severe dementia of 7-year duration prior to his death. Review of histological material showed generalized changes involving both cortical and subcortical structures. These changes were characterized by the presence of neurofibrillary myelin in long tracts and in subcortical regions. The neurofibrillary tangles were mostly composed of Alzheimer's paired helical filaments (PHF), PHF were immunostained with both polyclonal and monoclonal antibodies to PHF and the microtubule-associated protein tau. Some Lewy bodies were immunolabelled with monoclonal antibodies to PHF. To the best of our knowledge it is the first reported case of a young adult-form of dementia with extensive formation of neurofibrillary changes and Lewy bodies.

Cochlear summating potential to broadband clicks detected from the human external auditory meatus. A study of subjects with normal hearing for age

The cochlear summating potential (SP) preceding the auditory nerve compound action potential (AP) was elicited by broadband alternating condensation and rarefaction clicks and recorded by noninvasive electrodes from the external auditory meatus (EAM) of 60 volunteers of both sexes, 12 to 67 years old, who had normal hearing for age. Quantitative data were obtained on: the number of ears displaying measurable SPs; the SP detection level; the SP onset, peak and rise times; the duration of the SP-AP complex; the SP amplitude; and the SP/AP amplitude ratio. Previously unknown relationships were unveiled between the amplitude, but not the temporal, measures of the SP and laterality, sex, age, and audiometrically determined hearing thresholds to 4 to 8 kHz tones. The highest correlations were obtained with these last thresholds, which suggested that receptors in the basal turn of the cochlea played a dominant role in the generation of the EAM-detected SP. To improve on existing techniques for determining abnormal SP elevation, a multiple regression method was devised that utilized sex, age, 4 to 8 kHz hearing thresholds, and AP voltage to establish upper normal limits of SP amplitude for individual subjects and ears.

Circadian rhythm of intestinal sucrase activity in rats. Mechanism of enzyme change

Past investigation has revealed that the circadian rhythm of intestinal sucrase activity in rats is primarily cued by the time of feeding. We examined the mechanism of the circadian rhythm by methods involving quantitative immunoprecipitation of sucrase-isomaltase protein and study of decay of radioactively labeled protein. Rats were placed on a controlled feeding regimen (1000-1500 h) and then sacrificed at 3-h intervals over a 24-h period. Immunotitration experiments indicated that the circadian rhythm was the result of changes in the absolute amount of sucrase-isomaltase protein present and not of changes in the enzyme's catalytic efficiency. To study the mechanism of this circadian variation in sucrase-isomaltase mass, [(14)C]sodium carbonate was injected and, after maximum incorporation into brush border protein, the rats were sacrified at 3-h intervals. Sucrase-isomaltase protein was isolated by immunoprecipitation, and the decrease in total disintegrations per minute over time was used to study degradation of the protein. Enzyme degradation was not constant but exhibited a clear circadian rhythm. The period of increasing enzyme mass was characterized by virtual cessation of enzyme degradation (t((1/2)) of 38 h), and the period of declining enzyme mass by rapid degradation (t((1/2)) of 6 h or less). We found similar changes in enzyme degradation in fasted animals, demonstrating that the changes were not the result of decreased isotope reutilization during feeding. We found no evidence of a circadian rhythm in [(14)C]leucine incorporation into the protein, suggesting that enzyme synthesis was constant. These results indicate that the circadian rhythm of sucrase activity represents changes in the total amount of enzyme protein that are, at least in large part, secondary to changes in the enzyme's degradation rate.

An unusual intracerebral connective tissue mass

A sharply circumscribed, vascular, connective tissue mass which replaced the cortex of several adjoining cerebral gyri is described. The histology of the lesion differs from that of previously reported central nervous system maldevelopments and neoplasms. However, there are a number of similarities to the pathology found in late phases of syphilitic "colloid" or "hyaline" degeneration of the brain.