Evaluation of a collaborative chronic care approach to improve outcomes in kidney transplant recipients.

Several studies found that renal transplant recipients with chronic kidney disease have untreated complications and do not attain recommended clinical targets. Using a before/after design with propensity score-matched controls, we evaluated whether an advanced practice nurse-led interprofessional collaborative chronic care approach could improve clinical outcomes for CKD transplant patients compared with a traditional physician-led model. The intervention included strategies for disease self-management, shared decision making, and healthcare system reorganization. The primary outcome was the proportion of patients attaining at least seven of nine targets as per published guidelines. A greater proportion of intervention patients achieved the outcome (68% vs. 10%; p = 0.0001) and had discussions about end-stage treatment options (88% vs. 13%; p = 0.0001) compared with controls. The intervention patients had significantly fewer emergency room visits (incidence rate ratio [IRR] 0.53; 95% CI 0.29-0.91; p = 0.02) and hospital admissions (IRR 0.34; 95% CI 0.16-0.68; p = 0.001) compared with the control patients. There were no significant differences found between the groups in systolic/diastolic blood pressure, carbon dioxide, hemoglobin, or phosphate parameters. An advanced practice nurse-led approach, based on the chronic care model, has the potential to improve clinical outcomes for renal transplant recipients and needs to be tested in a multicenter randomized controlled trial.

Shifts in expectations: evaluating physicians' perceptions as pharmacists become integrated into family practice.

The objective of this study was to measure how primary care family physicians perceived their own and pharmacists' contributions to medication processes as pharmacists become integrated into primary care group family practices. The 22- item Family Medicine Medication Use Processes Matrix was mailed to physicians in seven sites at the 3rd, 12th and 19th month of pharmacist integration. Paired sample t-tests for the third month results were conducted to compare perceptions between pharmacist and physician contributions. One way repeated measure ANOVA test was conducted to determine significant changes over time. Physicians initially perceived their own contributions to be significantly higher than pharmacists in three subscales: Diagnosis & Prescribing, Monitoring and Administration/Documentation and their own contributions to be significantly lower than the pharmacists in the Education subscale. Over time, physicians perceived increases in the pharmacists' contribution to the Diagnosis & Prescribing, Monitoring and Medication Review subscales and decreases in their own contribution to the Diagnosis & Prescribing and Education subscales. Changes in family physicians' perceptions of pharmacists' contribution demonstrate an initial underestimate of pharmacists' role in primary care family practice and a gradual recognition of expertise and competence. This may have led to increased comfort in sharing aspects of contribution to medication use processes.

The role of community matrons in supporting patients with long-term conditions.

The new emphasis on patients with long-term conditions offers a vision of a primary health care service that will reduce the need for hospital admission. This article debates the implications of introducing the new advanced nursing role of community matron for patients with long-term conditions and the opportunities this may offer nursing.

Abundance of plaque microvessels is associated with constrictive remodeling in angioplastied human coronary arteries.

This study investigated if specific histological features correlate with remodeling in human coronary arteries treated by balloon angioplasty (PTCA). Segments of perfusion-fixed coronary arteries that had undergone antemortem PTCA were obtained from 15 patients and primary atherosclerotic (CAD) lesions obtained from these hearts were used as control lesions. Arterial segments were serially divided to yield 108 sub-segments for PTCA lesions and 38 sub-segments for CAD lesions. A linear regression analysis was used to determine the relationship between 14 histological parameters and an arbitrary index of compensatory arterial enlargement, the external elastic lamina (EEL) index (EELI), defined as the ratio of the area encompassed by the EEL to the sum of the intimal area (IA) + medial area (MA). In PTCA arteries the abundance of plaque microvessels negatively correlated with the EELI (p=0.04), but in CAD arteries there was no relationship between histology and the EELI. The abundance of plaque microvessels correlates with the magnitude of constriction in coronary artery lesions subjected to PTCA. This study provides descriptive insights into the biology of remodeling in human coronary arteries after angioplasty, and suggests that the endothelium may play an important role.

Predictors of long-term outcome after stent implantation in a saphenous vein graft.

Stenting of saphenous vein graft (SVG) lesions is associated with significant clinical events at late follow-up. We sought to determine predictors of clinical outcome after this procedure. One hundred twenty-eight balloon-expandable stents were implanted in the SVGs of 106 patients. Baseline clinical and angiographic characteristics were analyzed. All grafts, including those not stented, were scored for extent of disease involving the luminal surface of the graft, and for the presence of low profile lesions (< 50% graft stenosis) and/or high profile lesions (> or = 50% graft stenosis). The in-hospital success rate was 98.1%. Before discharge, no patient died, required bypass surgery, or had repeat angioplasty of the same graft. Follow-up was obtained on all the patients. At a median of 18 months, 15% had died, 17% had experienced myocardial infarction, 20% had required repeat bypass surgery, and 37% needed repeat angioplasty to either the same site or a different lesion. Event-free survival was recorded in only 44% of the patients. The cumulative Kaplan-Meier survival at 2.4 years was 78.7%. Using the Cox proportional hazards model, predictors of survival were the absence of a high profile lesion in any nonstented patent graft (p = 0.004), and the use of lipid-lowering agents at follow-up (p = 0.01). Stenting SVG lesions can be performed with a high degree of procedural success, but at long-term follow-up there is a high rate of cardiac events. The absence of a high profile lesion in any nonstented patent graft is the strongest predictor of survival.

Delay in revascularization is associated with increased mortality rate in patients with severe left ventricular dysfunction and viable myocardium on fluorine 18-fluorodeoxyglucose positron emission tomography imaging.

BACKGROUND: The identification of high-risk patients who require early revascularization has become increasingly important with the present emphasis on reducing health care resources. This is particularly relevant to health care systems with prolonged waiting times for interventions. Myocardial viability imaging with the use of fluorine 18-fluorodeoxyglucose (FDG) PET may help to identify high-risk patients with severe left ventricular dysfunction. The aim of this study was to evaluate the consequences of prolonged waiting time on cardiac outcomes in patients with left ventricular dysfunction directed to revascularization based on FDG PET imaging. METHODS AND RESULTS: Forty-six patients with coronary disease and an ejection fraction of < or = 35% were considered candidates for revascularization based on FDG PET viability imaging. Thirty-five of 46 patients were subsequently accepted for revascularization. Patients were divided into 2 groups based on the median waiting time after PET: an early group (< 35 days; n = 18) and a late group (> or = 35 days; n = 17). Preoperative mortality rates were significantly increased in the late group (4 of 17 [24%] versus 0 of 18 in the early group; P < 0.05). In postoperative follow-up (17 +/- 7 months), cardiac events occurred in 2 of 18 (11%) and 1 of 13 (7.8%) patients in the early and late groups, respectively. Left ventricular ejection fraction increased after early revascularization (24 +/- 7% to 29 +/- 8%, P < 0.001, baseline versus 3 months) but not in the late group (27 +/- 5% to 28 +/- 6%, P = NS). CONCLUSIONS: Preoperative FDG PET can be used to identify a high-risk group of patients who may benefit from early revascularization. A long waiting time for revascularization is associated with a high mortality rate and suggests that early revascularization is desirable after the identification of hibernating viable myocardium.