The relative importance of patient-reported barriers to colorectal cancer screening

BACKGROUND

Colorectal cancer (CRC) screening rates are suboptimal. The most important barriers identified by patients are poorly understood. A comprehensive assessment of barriers to all recommended modalities is needed.

METHODS

In 2007, a questionnaire was mailed to 6100 patients, aged 50-75 years, from 12 family medicine practices in the Virginia Ambulatory Care Outcomes Research Network. People aged 65-75 years and African Americans were oversampled. Patients were asked to rate 19-21 barriers to each of four recommended tests. In 2008, responses were coded on a 5-point scale; higher scores reflected stronger barrier endorsement.

RESULTS

The response rate was 55% (n=3357). Approximately 40% of respondents were aged >/=65 years, 30% were African-American, and 73% were adherent to screening. A clinician's failure to suggest screening and not knowing testing was necessary received the highest mean scores as barriers. Financial concerns and misconceptions were also cited. Barrier scores differed depending on whether respondents were never screened, overdue for screening, or adherent to guidelines. The top five barriers for each modality included test-specific barriers (e.g., handling stool, bowel preparation), which often outranked generic barriers to screening. Not knowing testing was necessary was a top barrier for all tests but colonoscopy.

CONCLUSIONS

Although physician advice and awareness of the need for screening are important, barriers to screening are not homogenous across tests, and test-specific barriers warrant consideration in designing strategies to improve screening rates. Barrier scores differ by screening status, highlighting the need to address prior screening experience. Evidence that patients are more familiar with colonoscopy than with other modalities suggests an opportunity to improve screening rates by educating patients about alternative tests.

High-performance liquid-chromatographic separation and fluorescence measurement of biogenic amines in plasma, urine, and tissue

We describe a high-performance liquid-chromatographic method for measuring histamine, norepinephrine, octopamine, normetanephrine, dopamine, serotonin, and tyramine in plasma (2 ml), brain (0.2 g), or urine. These amines are modifed by pre-column derivatization with o-phthalaldehyde, which stabilizes the molecules, facilitates extraction, and improves detection of nanogram amounts. Before separation, samples were neutralized with KOH and immediately derivatized and extracted into ethyl acetate, in which derivatives were stable for longer than 24 h. Interfering amino acids were removed from ethyl acetate by partitioning twice with Na2HPO4 buffer (pH 10.0). Separation was complete in about 90 min on a "mu Bondapak/phenyl" column, with which a stepwise gradient of methanol/phosphate buffer (pH 5.1) was used. A variable-wavelength fluorometer was used (exciting wavelength, 340 nm; emission wavelength, 480 nm). Amount and response were linearly related from 1 to 200 pmol. Precision (CV) for retention times was 1%, for derivatization and injection 2.5%. Analytical recoveries of the seven amines from 2 ml of plasma fortified with 200 pmol averaged 65% (CV approximately 8%). Data on rat-brain tissue samples are compared with results by the trihydroxyindole method. Application of the method to urine from normal persons and a patient with a brain tumor is demonstrated.

Commutability Limitations Influence Quality Control Results with Different Reagent Lots

BACKGROUND

Good laboratory practice includes verifying that each new lot of reagents is suitable for use before it is put into service. Noncommutability of quality control (QC) samples with clinical patient samples may preclude their use to verify consistency of results for patient samples between different reagent lots.

METHODS

Patient sample results and QC data were obtained from reagent lot change verification records for 18 QC materials, 661 reagent lot changes, 1483 reagent lot change–QC events, 82 analytes, and 7 instrument platforms. The significance of between-lot differences in the results for QC samples compared with those for patient samples was assessed by a modified 2-sample t test adjusted for heterogeneity of QC and patient sample measurement variances.

RESULTS

Overall, 40.9% of reagent lot change–QC events had a significant difference (P < 0.05) between results for QC samples compared with results for patient samples between 2 reagent lots. For QC results with differences <1.0 SD interval (83.1% of total), 37.7% were significantly different from the changes observed for patient samples. For QC results with differences ≥1.0 SD interval (16.9% of total), 57.0% were significantly different from those for patient samples.

CONCLUSIONS

Occurrence of noncommutable results for QC materials was frequent enough that the QC results could not be used to verify consistency of results for patient samples when changing lots of reagents.

Interactive preventive health record to enhance delivery of recommended care: a randomized trial

PURPOSE

Americans receive only one-half of recommended preventive services. Information technologies have been advocated to engage patients. We tested the effectiveness of an interactive preventive health record (IPHR) that links patients to their clinician's record, explains information in lay language, displays tailored recommendations and educational resources, and generates reminders.

METHODS

This randomized controlled trial involved 8 primary care practices. Four thousand five hundred patients were randomly selected to receive a mailed invitation to use the IPHR or usual care. Outcomes were measured using patient surveys and electronic medical record data and included IPHR use and service delivery. Comparisons were made between invited and usual-care patients and between users and nonusers among those invited to use the IPHR.

RESULTS

At 4 and 16 months, 229 (10.2%) and 378 (16.8%) of invited patients used the IPHR. The proportion of patients up-to-date with all services increased between baseline and 16 months by 3.8% among intervention patients (from 11.4% to 15.2%, P <.001) and by 1.5% among control patients (from 11.1% to 12.6%, P = .07), a difference of 2.3% (P = .05). Greater increases were observed among patients who used the IPHR. At 16 months, 25.1% of users were up-to-date with all services, double the rate among nonusers. At 4 months, delivery of colorectal, breast, and cervical cancer screening increased by 19%, 15%, and 13%, respectively, among users.

CONCLUSIONS

Information systems that feature patient-centered functionality, such as the IPHR, have potential to increase preventive service delivery. Engaging more patients to use systems could have important public health benefits.

High-performance liquid chromatographic analysis of biogenic amines in biological materials as o-phthalaldehyde derivatives

A remarkably sensitive, simple and selective reversed-phase high-performance liquid chromatographic (HPLC) method has been developed, allowing, for the first time, the direct measurement of histamine, norepinephrine, octopamine, normetanephrine, dopamine, serotonin and tyramine in a single sample of plasma (2 ml), tissue (0.2 g), or urine. The biogenic amines were modified by pre-column derivatization with o-phthalaldehyde which stabilizes the molecules, aids in extraction, and improves HPLC detection at the nanogram level. To minimize losses during the sampling procedure a careful collection procedure was designed. We developed a simple sample cleanup in which the samples were thawed, neutralized with KOH, immediately derivatized, extracted into ethyl acetate (EtOAc) and then chromatographed by HPLC. The derivatives were stable in EtOAc for more then 24 h. Interfering amino acids were removed from the EtOAc by partitioning twice with Na2HPO4 buffer (pH 10.0). Complete separation was achieved in ca. 60--90 min on a muBondapak phenyl column using a stepwise gradient of acetonitrile and/or methanol-phosphate buffer (pH 5.1). A variable wavelength fluorometer with a 5-microliter flow-cell was used (excitation 340 nm; emission 480 nm). Linearity ranged from 200 pg to 50 ng onto the column. Precision (R.S.D.) for retention times was 1% and for derivatization and injection 2.5%. Recoveries of the seven biogenic amines from plasma spiked with 25 ng/ml averaged 70%, with a relative standard deviation of 6%. Separation studies were also done using a muBondapak C18 column. The effects of various eluents are presented. Gas-liquid chromatography was also investigated but lacked the sensitivity achieved by HPLC. The HPLC method is used routinely for the determination of biogenic amines in plasma from pigs with malignant hyperthemia and thermally stressed bovine. Significant differences in levels of biogenic amines were noted between stressed and non-stressed animals. Data on rat brain tissue samples were compared with the trihydroxyindole method and canine heart tissue was analyzed for ventricular norepinephrine and dopamine. Application of the method to urine from normal persons and a patient with a brain tumor has been demonstrated.

Bacterial Vaginosis and Subclinical Markers of Genital Tract Inflammation and Mucosal Immunity

Bacterial vaginosis (BV) has been linked to an increased risk of human immunodeficiency virus (HIV) acquisition and transmission in observational studies, but the underlying biological mechanisms are unknown. We measured biomarkers of subclinical vaginal inflammation, endogenous antimicrobial activity, and vaginal flora in women with BV and repeated sampling 1 week and 1 month after completion of metronidazole therapy. We also compared this cohort of women with BV to a healthy control cohort without BV. A longitudinal, open label study of 33 women with a Nugent score of 4 or higher was conducted. All women had genital swabs, cervicovaginal lavage (CVL) fluid, and cervicovaginal biopsies obtained at enrollment and received 7 days of metronidazole treatment. Repeat sampling was performed approximately 1 week and 1 month after completion of therapy. Participant's baseline samples were compared to a healthy, racially matched control group (n=13) without BV. The CVL from women with resolved BV (Nugent 0-3) had significantly higher anti-HIV activity, secretory leukocyte protease inhibitor (SLPI), and growth-related oncogene alpha (GRO-α) levels and their ectocervical tissues had significantly more CD8 cells in the epithelium. Women with persistent BV after treatment had significantly higher levels of interleukin-1β, tumor necrosis factor alpha (TNF-α), and intercellular adhesion molecule 1 (ICAM-1) in the CVL. At study entry, participants had significantly greater numbers of CCR5(+) immune cells and a higher CD4/CD8 ratio in ectocervical tissues prior to metronidazole treatment, compared to a racially matched cohort of women with a Nugent score of 0-3. These data indicate that BV is associated with changes in select soluble immune mediators, an increase in HIV target cells, and a reduction in endogenous antimicrobial activity, which may contribute to the increased risk of HIV acquisition.

Is Self-Reported Sleep Duration Associated with Osteoporosis? Data from a 4-Year Aggregated Analysis from the National Health and Nutrition Examination Survey

OBJECTIVES

To examine the association between self-reported sleep duration and osteoporosis in a national sample of the U.S. elderly population.

DESIGN

Population-based cross-sectional study.

SETTING

Four-year National Health and Nutrition Examination Survey data from two survey cycles between 2005-06 and 2007-08.

PARTICIPANTS

Men and women aged 50 and older with data in the surveys and medical examination data files (N = 5,288).

MEASUREMENTS

Osteoporosis diagnosis was based on bone mineral density measurement and self-report. Sleep duration was ascertained from the sleep survey. Simple and multiple logistic regression models were used to evaluate the association between these two factors.

RESULTS

Shorter sleep duration (<6 hours) was found to be significantly associated with osteoporosis after adjusting for potential covariates (odds ratio (OR) = 1.59, 95% confidence interval (CI) = 1.07-2.37). After stratifying according to age group, this association remained significant (OR = 1.80, 95% CI = 1.20-2.68) only in the older age group (>65).

CONCLUSION

These results underscore the possible linkage between sleep and osteoporosis and the need for additional research on this topic.

An open-label pilot study of apremilast for the treatment of moderate to severe lichen planus: a case series

BACKGROUND

Current treatments for chronic lichen planus (LP) are often ineffective and may have significant adverse side effects. An alternative safe and effective treatment for recalcitrant LP is needed.

OBJECTIVES

We sought to study the safety and efficacy of apremilast in the treatment of moderate to severe LP.

METHODS

Ten patients with biopsy-proven LP received 20 mg of apremilast orally twice daily for 12 weeks with 4 weeks of treatment-free follow-up. The primary efficacy end point was the proportion of patients achieving a 2-grade or more improvement in the Physician Global Assessment (PGA) after 12 weeks of treatment.

RESULTS

Three (30%) of the 10 patients achieved a 2-grade or more improvement in the PGA after 12 weeks of treatment; however, all patients demonstrated statistically significant clinical improvement with respect to secondary parameters between baseline and the end of treatment.

LIMITATIONS

It may be difficult to generalize the results of this study to a larger patient population with LP because of our small sample size and lack of a control group. In addition, a longer treatment period or higher dose may have been needed for therapeutic efficacy. The safety and efficacy of long-term apremilast therapy is currently unknown.

CONCLUSION

Apremilast may be efficacious in the treatment of LP, but double-blinded, controlled trials are necessary to thoroughly evaluate its safety and efficacy.

Prospective assessment of the gastroesophageal microbiome in VLBW neonates

Background

The distal GI microbiota of hospitalized preterm neonates has been established to be unique from that of healthy full-term infants; the proximal GI, more specifically gastroesophageal colonization has not been systematically addressed. We prospectively evaluated early colonization of gastroesophageal portion of the GI tract of VLBW infants.

Methods

This study involved 12 infants admitted to a level III NICU with gestational age (GA) 27 +/− 0.5 weeks and birth weight 1105 +/− 77 grams. The gastroesophageal microbial flora was evaluated using 16S rDNA analysis of aspirates collected in a sterile manner during the first 28 days of life.

Results

Bacteria were detected in 9 of the 12 neonates. Ureaplasma was the dominant species in the first week of life, however, staphylococci were the predominant bacteria overall. By the fourth week, Gram (−) bacteria increased in abundance to account for 50% of the total organisms. Firmicutes were present in the majority of the neonates and persisted throughout the 4 weeks comprising nearly half of the sequenced clones. Noticeably, only two distinct species of Staphylococcus epidermidis were found, suggesting acquisition from the environment.

Conclusions

In our neonates, the esophagus and stomach environment changed from being relatively sterile at birth to becoming colonized by a phylogenetically diverse microbiota of low individual complexity. By the fourth week, we found predominance of Firmicutes and Proteobacteria. Bacteria from both phyla (CONS and Gram (−) organisms) are strongly implicated as causes of hospital-acquired infections (HAI). Evaluation of the measures preventing colonization with potentially pathogenic and pathogenic microorganisms from the hospital environment may be warranted and may suggest novel approaches to improving quality in neonatal care.

Patient costs as a barrier to intensive health behavior counseling

BACKGROUND

Although intensive health behavior counseling has been demonstrated to help patients lose weight and quit smoking, many payers offer limited coverage for such counseling.

PURPOSE

This mixed-methods case study examined how coverage affected utilization of an electronic linkage system (eLinkS) to help adult patients obtain intensive health behavior counseling, provided through a collaboration of primary care practices and community programs.

METHODS

Grant support enabled patients to obtain counseling at no cost, but funds were exhausted within 5 weeks as a result of an overwhelming response. To study the influence of cost as a barrier, referrals were resumed for an additional 3 weeks, but patients were required to pay for them. Use of eLinkS, level of clinician counseling and referrals, and patient interest in referrals were measured using electronic medical record data and patient and clinician interviews.

RESULTS

When counseling was free, approximately one in five patients with an unhealthy behavior and an eLinkS prompt was referred for intensive counseling. However, when patient charges were instituted, referrals decreased by 97% (from 21.8% to 0.7%, p<0.001); clinicians asked fewer patients about health behaviors (37% vs 29%, p<0.001); clinicians offered fewer patients referrals (29% vs 6%, p<0.001); and patients were less interested in accepting referrals (76% vs 14%, p<0.001). In interviews, patients and clinicians cited cost as a major barrier.

CONCLUSIONS

Coverage for intensive health behavior counseling is important to utilization, particularly for interventions that involve clinician-community partnerships. The potential public health benefits of such collaborations to reduce unhealthy behaviors justify the elimination of financial barriers (e.g., copayments) by payers.

Comparison of osteoporosis in US adults with type 1 and type 2 diabetes mellitus

PURPOSE

We examined bone mineral density (BMD) and osteoporosis prevalence in those with type 1 compared to type 2 diabetes derived from a nationally representative sample from the civilian community in the United States.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) for 2005-2006, 2007-2008, 2009-2010, and 2013-2014 were merged to obtain a large sample of diabetics at least 20 years of age with participation in the interview and medical examination. Osteoporosis status was defined by BMD at the total femur, femoral neck, or total lumbar spine. Self-reported diabetics that were prescribed insulin within the first year of diagnosis, are currently taking insulin, and reported no prescriptions for any diabetic pills were classified as type 1. Remaining self-reported diabetics were deemed as having type 2.

RESULTS

A total of 2050 diabetics were included in which 87 (4%) were classified as type 1. Type 1 diabetics were found to have a significantly lower BMD at the total femur and femoral neck, but not at the lumbar spine in the adjusted models. Diabetics with type 1 were 4.7 times more likely to have osteoporosis than those with type 2. There was no significant relationship between diabetes type and BMD or osteoporosis prior to adjustment for confounders.

CONCLUSIONS

Although our results show an increased likelihood of osteoporosis among those with type 1 diabetes, future studies including a larger sample from a community population are needed. It may benefit diabetics, especially those with type 1, to initiate osteoporosis screening methods including evaluation of fracture risk, bone quality, and BMD measurements at multiple sites earlier than recommended.

Interleukin-9 and interleukin-17C in chronic rhinosinusitis

BACKGROUND

Interleukin (IL)-9 and IL-17C have been known to play a role in allergic inflammation, yet, their roles in chronic rhinosinusitis (CRS) are not well defined. IL-9 induces changes in epithelial cell gene expression leading to goblet cell metaplasia, whereas IL-17C is functionally distinct in that its expression can be induced by bacterial challenge and inflammatory stimuli. This study aimed to compare levels of IL-9 and IL-17C in CRS with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) as well as atopy.

METHODS

Nasal polyp or sinus mucosal specimens from CRSwNP (n = 36), CRSsNP (n = 9), and control (n = 9) groups were collected and processed. Patient atopy status was determined by history of skin-prick test and pulmonary function test. Immunohistochemistry was carried out using anti-human IL-9 and IL-17C antibodies. Positively-stained cells were enumerated under high-power (×400) magnification in 5 consecutive fields.

RESULTS

The level of expression of IL-9 was higher in CRSwNP than CRSsNP and control. Similar findings were demonstrated in IL-17C with higher expression in CRSwNP than CRSsNP and control. Both the averages of positively-stained cells expressing IL-9 and IL-17C were higher in CRS with asthma and allergy compared to control. This suggested that IL-9 and IL-17C were both involved in the pathogenesis of CRS, allergy, and asthma.

CONCLUSION

Inflammatory cell expression of IL-9 and IL-17C were increased in CRS, particularly with allergy and asthma. These interleukins may contribute to the pathogenesis of CRSwNP as well as atopy and may serve as therapeutic targets for disease management.

Tracheostomy Complications in Institutionalized Children with Long-term Tracheostomy and Ventilator Dependence

Objectives

(1) To identify tracheostomy complications in institutionalized children with chronic tracheostomy. (2) To determine factors that predispose to development of tracheostomy complications in institutionalized children with chronic tracheostomy.

Study Design

Case series with chart review over 10 years.

Setting

Tertiary children’s hospital.

Subjects and Methods

Children were included if they underwent tracheostomy before 21 years of age and resided at a pediatric nursing facility. Most children were ventilator dependent and had severe comorbid medical conditions, including developmental delay and cerebral palsy. The number of tracheostomy complications and unplanned hospital admissions were recorded. Interventions for tracheostomy complications were also reviewed.

Results

Thirty-two institutionalized children with chronic tracheostomy were included. The mean age at time of tracheostomy was 5.4 years, with a mean duration of institutionalization of 9.1 years. Twenty-seven children (84%) experienced tracheostomy complications. The total number of complications was 79. The most common tracheostomy complications identified were peristomal granulation (n = 13) and suprastomal granulation (n = 12). Age at time of tracheostomy, duration of institutionalization, and ventilator dependence did not predict the likelihood of developing a complication. Of 32 patients, 20 were evaluated in the emergency room during the study, and there were 48 unplanned admissions for tracheostomy-related complications during the study. Forty-five urgent direct laryngoscopy and bronchoscopy procedures were performed in a total of 20 children with tracheostomy complications.

Conclusions

Tracheostomy complications are common in institutionalized children with chronic tracheostomy and are challenging to manage. Further research is necessary to determine novel ways to reduce tracheostomy complications in this population.

The impact of osteoporotic fractures compared with other health conditions in older adults living in Virginia, United States

This study compared length of stay, hospital costs, 30-day readmission, and mortality for patients admitted primarily for osteoporotic fractures to those admitted for five other common health conditions. The results indicated that osteoporotic fractures were associated with highest hospital charges and the second highest hospital stay after adjusting for confounders.

INTRODUCTION

This study aimed to compare the effect of osteoporotic fractures and other common hospitalized conditions in both men and women age 55 years and older on a large in-patient sample.

METHODS

De-identified patient level and readmission and transfer data from the Virginia Health Information (VHI) system for 2008 through 2014 were merged. Logistic regression models were used to assess mortality and 30-day readmission, while generalized linear models were fitted to assess LOS and hospital charges.

RESULTS

After adjustment for confounders, osteoporotic fractures had the second longest LOS (6.0 days, 95 % CI = 5.9-6.0) and the highest average total hospital charges ($47,386.0, 95 % CI = $46,707.0-$48,074.0) compared to the other five common health problems.

CONCLUSION

Recognizing risk and susceptibility to osteoporotic fractures is an important motivator for individual behaviors that mitigate this disease. Furthermore, acknowledging the economic impact and disabling burden of osteoporotic fractures on society are compelling reasons to promote bone health as well as to prevent, diagnose, and manage osteoporosis.

Design effects for sample size computation in three-level designs

Experiments with multiple nested levels where randomization can take place at any level bring challenges to the computation of sample sizes. Formulas derived under simple single-level experiments must be adjusted using multiplicative factors or design effects. In this work, we take a unified approach to finding the design effects in terms of intracluster correlations and present formulas to compute sample sizes of different levels. Equal cluster sample sizes and homogeneous within cluster variances are assumed.

Impact of montelukast and fluticasone on quality of life in mild pediatric sleep apnea

OBJECTIVES

Research has shown improvement in apnea-hypopnea index in children with mild obstructive sleep apnea treated with anti-inflammatory medications. Data on quality of life outcomes in children receiving these medications is lacking. We aim to assess quality of life in children with mild obstructive sleep apnea treated with montelukast and fluticasone.

METHODS

Children between 3 and 16 years old with mild sleep apnea (apnea-hypopnea index > 1 and ≤ 5) presenting to a pediatric otolaryngology clinic were recruited prospectively and treated with 4 months of montelukast and fluticasone. Subjects' caregivers completed the OSA-18, a validated quality of life survey, at baseline and 4 months. Children with ongoing obstruction at follow-up underwent adenotonsillectomy.

RESULTS

Thirty-one patients were included. Mean (SD) age was 6.8 (3.9) years. Most subjects (54.8%) were black and 48% were obese. Mean (SD) apnea-hypopnea index of the subjects was 2.8 (1.0). The mean (SD) baseline OSA-18 score was 60.2 (18.5), indicating a moderate impact of sleep disturbance on quality of life. Following treatment, there was significant improvement (p < 0.005) in mean OSA-18 score. Four children discontinued montelukast due to behavioral side effects. Seven children (22%) underwent adenotonsillectomy after failing medical therapy. Demographic factors such as obesity [OR 0.63 (0.11, 3.49)] and apnea hypopnea index [OR 1.38 (0.59, 3.66)] failed to predict which children would respond to anti-inflammatory medications.

CONCLUSIONS

Children with mild obstructive sleep apnea treated with montelukast and fluticasone experience significant improvements in quality of life. Further research is needed to determine optimal duration of therapy.

Effectiveness of a Screening and Brief Intervention protocol for heavy drinkers in dental practice: A cluster-randomized trial

Results of a cluster-randomized trial of a Screening and Brief Intervention for heavy drinkers in dental practice are reported. Data were obtained from 103 heavy drinking patients recruited from randomized intervention (7; n = 50) and control (6; n = 53) practices. Analysis of data revealed that 6-month decreases in total drinks per week were significantly ( p < .05) greater for heavy drinking intervention (43%) than control patients (21%)—a 4 drink per week difference. Similar decreases were obtained for quantity and frequency among intervention patients compared to control patients. Despite power limitations, the 6-month results support the effectiveness of the Screening and Brief Intervention.

Osteoporosis treatment disparities: a 6-year aggregate analysis from national survey data

We studied factors to determine the receipt of osteoporosis treatment in individuals with osteoporosis. Treatment was associated with age, gender, race, body mass index (BMI), family history, arthritis and thyroid problems, daily glucocorticoid use, number of prescriptions and healthcare visits, and insurance type.

INTRODUCTION

Osteoporosis is underrecognized and undertreated. Few studies have examined factors associated with osteoporosis treatment in a large, national sample of men and women.

METHODS

We aggregated National Health and Nutrition Examination Survey (NHANES) data from 2005 to 2010 and created a subsample which included individuals 50 years or older who were identified to have osteoporosis either by self-report data or by bone density measurements. The primary outcome was the receipt of osteoporosis treatment either from self-report or from prescription records. Covariates included sociodemographics, clinical characteristics, and access to healthcare variables. Logistic regression analyses were performed to determine factors that associate with osteoporosis treatment.

RESULTS

From a sample of 31,0134 participants, 1,133 subjects (3.65 %) met the study criteria. Treatment was associated with age (odds ratio (OR) = 1.14), gender (OR = 13.25), race (OR = 2.23, White vs. Black; OR = 1.76, other vs. Black), BMI (OR = 1.67, normal vs. obese; OR = 2.68, overweight vs. obese), family history of osteoporosis (OR = 1.94), arthritis (OR = 1.43), daily glucocorticoid use (OR = 1.43), number of prescriptions (OR = 1.01), and number of healthcare visits in the past year (OR = 1.44, 4-9 vs. 0-3 visits). All odds ratios were statistically significant.

CONCLUSION

A large number of individuals diagnosed with osteoporosis above the age of 50 remain untreated. It is important for healthcare providers to better assess older adults with osteoporosis, including individuals who frequently receive medical care.

Statewide assessment of surgical outcomes and the acute care surgery model

BACKGROUND

The acute care surgery (ACS) model has been widely implemented with single institution studies demonstrating improved outcomes. Recent multicenter studies have raised questions about the economics and efficacy of ACS. This study compares traditional and ACS outcomes across an entire state.

METHODS

A retrospective review of Virginia's Health Information administrative database was completed. Adults admitted with appendicitis or cholecystitis between 2008 and 2014 were included. Hospital administration was contacted to determine surgical model. To compare patient characteristics, t-test and chi-square analyses were used. Total charges and length of stay (LOS) differences between ACS and traditional were examined using generalized linear models, whereas logistic regression was used for the presence of complications and 30-day mortality.

RESULTS

Overall, the ACS model showed an increased proportion of uninsured patients with a higher rate of comorbidities. In the appendicitis subgroup, (n = 22,011; ACS n = 1993), ACS patients had higher total charges ($30,060 versus $28,460, P = 0.013), longer LOS (3.31 versus 2.92 d, P < 0.001), and higher chance of complications (odds ratio [OR] = 1.2, P = 0.016) and mortality (OR = 2.4, P = 0.029). After adjustment for comorbidities and insurance, mortality was no longer significantly different. In the cholecystitis group (n = 6936; ACS n = 777), ACS patients had a longer LOS (4.55 versus 4.13 d; P = 0.009) without significant differences in mortality, complications, or cost. There were no significant differences after adjustment for patient characteristics.

CONCLUSIONS

ACS patients in Virginia have a higher rate of medical comorbidities and uninsured status, with slightly worse outcomes than the traditional model for appendicitis. Further studies to determine which patients benefit the most from ACS are warranted.

Association of time since pneumococcal polysaccharide vaccine receipt and CD4 count with antibody response to the 13-valent pneumococcal conjugate vaccine in HIV-infected adults

INTRODUCTION

Pneumococcal infection is a leading cause of illness and death in HIV-infected adults. Current United States guidelines for HIV-infected adults recommend a single dose of the 13-valent pneumococcal conjugate vaccine (PCV-13) at any CD4 count and at least 1 y after receipt of the 23-valent pneumococcal polysaccharide vaccine (PPV). PPV is known to lead to hyporesponsiveness to subsequent pneumococcal vaccines for at least 1 y Whether PCV-13 would be more immunogenic if administered later after PPV receipt or at higher CD4 counts has not been tested.

METHODS

We prospectively collected serum from 96 HIV-infected adults before and after PCV-13 receipt, and measured antibody concentrations against 4 pneumococcal serotypes (3, 6A, 7F, and 19A) via indirect ELISA according to the WHO protocol. Post-booster antibody concentrations and fold-rise in antibody concentrations were compared according to time from PPV receipt and baseline CD4 count using univariate and multivariate analyses.

RESULTS

PPV receipt >3 versus 1-3 y prior did not significantly change post-vaccination antibody concentrations, but was associated with slightly higher fold-rise in antibody concentration for the 3 tested serotypes included in PPV, though this only reached significance for serotype 7F. CD4 count was significantly associated with post-vaccination antibody concentrations for 3 of 4 serotypes, but not for fold-rise in antibody concentration for any serotype.

CONCLUSION

Waiting longer than 1 y after PPV receipt to administer PCV-13 may slightly improve the antibody response to serotypes included in both vaccines. While higher CD4 count at PCV-13 administration results in higher post-vaccination antibody concentrations, this is likely because higher CD4 count is also associated with higher pre-vaccination antibody concentrations.

Association between pelvic organ prolapse types and levator-urethra gap as measured by 3D transperineal ultrasound

OBJECTIVES

To evaluate the association between pelvic organ prolapse (POP) types and levator-urethra gap (LUG) as measured by 3-dimensional transperineal tomographic ultrasound.

METHODS

A retrospective study was carried out on 98 women with symptomatic POP. Three-dimensional transperineal tomographic ultrasound images and POP quantification coordinates were reviewed. Each vaginal compartment was staged for the degree of prolapse, and total number of involved compartments identified. LUG was measured on 3-dimensional tomographic sonograms as the distance between the center of the urethra and the levator insertion bilaterally. Based on prior studies, an abnormal LUG of 25 mm or greater indicated levator avulsion. The LUG and the presence or absence of unilateral/bilateral avulsions was analyzed with reference to the clinical diagnosis of prolapse (single versus multicompartment, and mild [stage II] versus severe [stage III-IV]). Generalized logit models were used to evaluate the association between avulsion and prolapse type and stage.

RESULTS

The LUG was substantially larger in women with multicompartment compared to single-compartment POP (28.9 ± 4.1 mm versus 22.7 ± 4.1 mm, P < .01). Similarly, LUG was substantially larger in women with severe (stage III-IV) compared to mild (stage II) POP (28.8 ± 4.7 mm versus 23.3 ± 4.5 mm, P < .01). Women with severe prolapse were 32 times more likely than women with mild prolapse to have bilateral levator avulsion. Those with POP involving all 3 vaginal compartments were 76 times more likely than single-compartment POP to have bilateral levator avulsions.

CONCLUSIONS

Bilateral levator ani avulsion as diagnosed by LUG measurements of 25 mm or greater at rest is associated with multicompartment, severe prolapse.

Transperineal Sonography and Urodynamic Findings in Women With Lower Urinary Tract Symptoms After Sling Placement

OBJECTIVES

To evaluate dynamic 2-dimensional (2D) transperineal pelvic sonographic findings and urodynamic studies in women with lower urinary tract symptoms after midurethral sling placement.

METHODS

Transperineal pelvic sonography and urodynamic studies were reviewed from women with a midurethral sling and lower urinary tract symptoms. The shape and sonographic dynamic change of the sling from the rest position to the maximum Valsalva maneuver and back to rest were recorded. Patients were categorized into 3 groups: group I, at rest, the sling lies parallel to the urethral lumen, and during Valsalva, the sling becomes C shaped; group 2, both at rest and during Valsalva, the sling runs parallel to the urethral lumen; and group 3, at rest, the sling is C shaped, and during Valsalva, this curved shape is maintained. For analytical purposes group 3 was compared with groups 1 and 2. Multiple logistic regressions were used to evaluate the association between transperineal pelvic sonography and urodynamic studies.

RESULTS

Seventy-seven women were enrolled. The detrusor pressure at the maximum flow rate was significantly higher in group 3 than groups 1 and 2 (mean ± SD, 36 ± 16 versus 19 ± 11 mm H₂ O; P < .001). The odds of high detrusor pressure (>20 mm H₂ O) in group 3 was approximately 12 times the odds of those in groups 1 and 2. After adjusting for other variables using a multiple logistic regression analysis, a statistically significant association between group 3 and high detrusor pressure persisted (odds ratio, 29.7; 95% confidence interval, 2.949-299.6; P = .0040) persisted.

CONCLUSIONS

Transperineal dynamic 2D sonography can help predict women with high-pressure voiding after midurethral sling placement and aid in the diagnosis of bladder outlet obstruction.

Screening elders in the emergency department at risk for mistreatment: a pilot study

Impaired functional status is associated with risk of elder mistreatment. Screening for functional impairment in elderly patients admitted to emergency departments could be performed to identify patients at risk for elder mistreatment who might benefit from further evaluation. This study utilized a modified Identification of Seniors at Risk (ISAR) screening tool to identify the proportion of elderly at risk for mistreatment due to functional difficulties presenting to two emergency departments in southeastern Virginia, one urban, the other rural. Of a 180-patient cohort (90 per site), 82 screened positive (46%), ISAR > 2 (range 0-6), indicating nearly half of all patients enrolled are at risk for mistreatment. Patients presenting to the urban emergency departments were potentially more at risk than their rural counterparts (p < 0.01). Health care professionals, particularly in urban settings, should consider screening seniors with a simple tool to identify patients at risk of elder mistreatment.