Sexual minority men and the experience of undergoing treatment for prostate cancer: An integrative review.

INTRODUCTION: Gay, bisexual and queer (GBQ) men with prostate cancer have unique experiences of the prostate cancer journey. The current integrative review aimed to synthesise existing scientific literature for the purpose of identifying GBQ men's psychosocial experience of undergoing treatment for prostate cancer. METHODS: We utilised the Whittemore and Knafl (Journal of Advanced Nursing, 52, 546-553) integrative review methodology and the Garrard (Health sciences literature review made easy. Jones & Bartlett Publishers) matrix method. RESULTS: After a systematic search, 18 quantitative and non-empirical studies were included for thematic analysis. Three themes emerged: (a) Prostate cancer, and its treatment affect sexual wellbeing, including negatively affecting their relationships and sense of self. (b) Health care is heteronormative, exemplified by clinicians dismissing GBQ men's concerns, leading GBQ men to fare worse on psychosocial outcomes, including treatment satisfaction, in comparison with heterosexual counterparts. (c) Prostate cancer affects social support. GBQ men rely on an expansive support network, but often isolate themselves during prostate cancer treatment as to not be burden others. CONCLUSION: Psychosocial supportive care needs to address GBQ men's sexual, emotional and social needs. Future psycho-oncologic trials are needed, especially on GBQ-specific peer-support interventions.

Can the American College of Surgeons Risk Calculator Predict 30-Day Complications After Knee and Hip Arthroplasty?

Accurate risk stratification of patients undergoing total hip (THA) and knee (TKA) arthroplasty is essential in the highly scrutinized world of pay-for-performance, value-driven healthcare. We assessed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator's ability to predict 30-day complications using 1066 publicly-reported Medicare patients undergoing primary THA or TKA. Risk estimates were significantly associated with complications in the categories of any complication (P = .005), cardiac complication (P < .001), pneumonia (P < .001) and discharge to skilled nursing facility (P < .001). However, predictability of complication occurrence was poor for all complications assessed. To facilitate the equitable provision and reimbursement of patient care, further research is needed to develop accurate risk stratification tools in TKA and THA surgery.

Dose reduction and compliance with pediatric CT protocols adapted to patient size, clinical indication, and number of prior studies.

PURPOSE: To assess compliance and resultant radiation dose reduction with new pediatric chest and abdominal computed tomographic (CT) protocols based on patient weight, clinical indication, number of prior CT studies, and automatic exposure control. MATERIALS AND METHODS: The study was institutional review board approved and HIPAA compliant. Informed consent was waived. The new pediatric CT protocols, which were organized into six color zones based on clinical indications and number of prior CT examinations in a given patient, were retrospectively assessed. Scanning parameters were adjusted on the basis of patient weight. For gradual dose reduction, pediatric CT (n = 692) examinations were performed in three phases of incremental stepwise dose reduction during a 17-month period. There were 245 male patients and 193 female patients (mean age, 12.6 years). Two radiologists independently reviewed CT images for image quality. Data were analyzed by using multivariate analysis of variance. RESULTS: Compliance with the new protocols in the early stage of implementation (chest CT, 58.9%; abdominal CT, 65.2%) was lower than in the later stage (chest CT, 88%; abdominal CT, 82%) (P < .001). For chest CT, there was 52.6% (9.1 vs 19.2 mGy) to 85.4% (2.8 vs 19.2 mGy) dose reduction in the early stage of implementation and 73.5% (4.9 vs 18.5 mGy) to 83.2% (3.1 vs 18.5 mGy) dose reduction in the later stages compared with dose at noncompliant examinations (P < .001); there was no loss of clinically relevant image quality. For abdominal CT, there was 34.3% (9.0 vs 13.7 mGy) to 80.2% (2.7 vs 13.7 mGy) dose reduction in the early stage of implementation and 62.4% (6.5 vs 17.3) to 83.8% (2.8 vs 17.3 mGy) dose reduction in the later stage (P < .001). CONCLUSION: Substantial dose reduction and high compliance can be obtained with pediatric CT protocols tailored to clinical indications, patient weight, and number of prior studies.

The imaging of paediatric thoracic trauma.

Major chest trauma in a child is associated with significant morbidity and mortality. It is most frequently encountered within the context of multisystem injury following high-energy trauma such as a motor vehicle accident. The anatomic-physiologic make-up of children is such that the pattern of ensuing injuries differs from that in their adult counterparts. Pulmonary contusion, pneumothorax, haemothorax and rib fractures are most commonly encountered. Although clinically more serious and potentially life threatening, tracheobronchial tear, aortic rupture and cardiac injuries are seldom observed. The most appropriate imaging algorithm is one tailored to the individual child and is guided by the nature of the traumatic event as well as clinical parameters. Chest radiography remains the first and most important imaging tool in paediatric chest trauma and should be supplemented with US and CT as indicated. Multidetector CT allows for the accurate diagnosis of most traumatic injuries, but should be only used in selected cases as its routine use in all paediatric patients would result in an unacceptably high radiation exposure to a large number of patients without proven clinical benefit. When CT is used, appropriate modifications should be incorporated so as to minimize the radiation dose to the patient whilst preserving diagnostic integrity.

Detection of chronic kidney disease in patients with or at increased risk of cardiovascular disease: a science advisory from the American Heart Association Kidney And Cardiovascular Disease Council; the Councils on High Blood Pressure Research, Cardiovascular Disease in the Young, and Epidemiology and Prevention; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: developed in collaboration with the National Kidney Foundation.

Chronic kidney disease (CKD) occurs commonly in patients with cardiovascular disease. In addition, CKD is a risk factor for the development and progression of cardiovascular disease. In this advisory, we present recommendations for the detection of CKD in patients with cardiovascular disease. CKD can be reliably detected with the combined use of the Modification of Diet in Renal Disease equation to estimate glomerular filtration rate and a sensitive test to detect microalbuminuria. All patients with cardiovascular disease should be screened for evidence of kidney disease with these two determinations.

Addressing the global cardiovascular risk of hypertension, dyslipidemia, diabetes mellitus, and the metabolic syndrome in the southeastern United States, part II: treatment recommendations for management of the global cardiovascular risk of hypertension, dyslipidemia, diabetes mellitus, and the metabolic syndrome.

An aggressive global approach to screening and to the management of the metabolic syndrome is recommended to slow the growth of the syndrome throughout the United States. Prevention should begin in childhood with healthy nutrition, daily physical activity, and annual measurement of weight, height, and blood pressure beginning at 3 years of age. Such screenings will identify cardiovascular risk factors early, allow the health care provider to define global cardiovascular risk with the COSEHC Cardiovascular Risk Assessment Tool, and allow treatment of each risk factor. Lifelong lifestyle modifications and pharmacologic therapy will be required in most patients. Antihypertensive therapy for these patients should begin with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker unless a compelling indication for another drug is present. Metformin should be considered the first drug for glucose control in the patient with type 2 diabetes. A statin should be used initially for hyperlipidemia unless contraindicated. Combinations of antihypertensive, antiglycemic, and lipid-lowering agents will often be required.

Addressing the global cardiovascular risk of hypertension, dyslipidemia, and insulin resistance in the southeastern United States.

An expanded occurrence of the metabolic syndrome in the U.S. population, especially in the Southeastern United States, has raised awareness of a need to revise our approach to the management of global cardiovascular risk factors while underscoring a need for more aggressive interventions and prevention measures. In defining the components of the metabolic syndrome and the interrelationship among obesity, hypertension, dyslipidemia, and insulin resistance, a basic framework for the medical management of this syndrome has been defined. In Part I of the consensus report prepared by the Workgroup on Medical Guidelines of the Consortium for Southeastern Hypertension Control (COSEHC), we analyze the components of the metabolic syndrome, discuss its pathophysiology, and recommend an approach to the quantitative analysis of the risk factors contributing to excess cardiovascular death in the region.

Improving the managed care of hypertension with angiotensin II antagonists.

Among the modifiable risk factors for cardiovascular disease, hypertension is the most powerful and treatable. For an asymptomatic patient to remain on a lifetime of antihypertensive treatment that might cause adverse effects is difficult for most patients. Managed care plans should treat hypertensive patients in ways that the patient can remain on therapy to prevent complications and thereby reduce the long-term costs associated with untreated hypertension. The recent disappointing outcomes achieved with antihypertensive drugs suggest there is room for improvement in the management of hypertension. Since the introduction of the first orally active angiotensin II receptor blocking drug, losartan, attention has been focused on the central role of angiotensin II in hypertension and cardiovascular disease. Studies of angiotensin II antagonists (AIIAs), which block the tissue receptor for angiotensin II, show that these agents effectively control hypertension when given once daily and cause no significant adverse effects or laboratory abnormalities. Losartan is unique among the AIIAs in that it offers 1-step titration dosing and has a uricosuric effect. Losartan, candesartan, and valsartan have been shown to improve the symptoms of congestive heart failure; losartan has been similar to an angiotensin-converting enzyme inhibitor in reducing systolic dysfunction congestive heart failure mortality. At 1 year, the refill rate for losartan in a managed care setting has been more than that for any other class of antihypertensive agents. Although there is not yet a clinical trial determining the long term mortality of AIIA treatment in hypertension compared with other antihypertensive agents, the use of AIIAs in conjunction with lifestyle modification and patient education can provide more efficient hypertension control and a provide a treatment with which patients can live.

Drugs that interrupt the renin-angiotensin system should be among the preferred initial drugs to treat hypertension.

The goal of antihypertensive therapy is to provide effective treatment that can be sustained lifelong, while lowering elevated blood pressure and preventing hypertensive end-organ damage and mortality. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II antagonists (AIIAs) control blood pressure as well as other available classes of antihypertensive drugs. The ACE inhibitors have been demonstrated to reduce the incidence of stroke, reverse left ventricular hypertrophy, and improve congestive heart failure symptomatology and mortality to a similar degree as diuretics and beta-adrenergic blockers. ACE inhibitors reduce postmyocardial infarction recurrence, improve congestive heart failure symptomatology and mortality, and slow the progression of glomerular renal disease. The AIIAs reverse left ventricular hypertrophy. Several of these agents have been shown to improve congestive heart failure symptomology and mortality, to reduce the occurrence of early atherosclerotic vascular disease, and to slow the progression of renal failure in type 2 diabetes mellitus nephropathy. One AIIA has reduced the incidence of end-stage renal disease in non-insulin-dependence diabetes mellitus nephropathy over 3 years. Ideally, antihypertensive therapy should maintain or improve the patients quality of life without creating side effects or adverse laboratory effects. Among the available nine classes of antihypertensive drugs, ACE inhibitors and the AIIAs come close to meeting the description of an ideal drug. AIIAs and ACE inhibitors, two classes of antihypertensive drugs that reduce the activity of the renin-angiotensin II system, should be among the preferred first-step drugs for the treatment of hypertension.

Impact of performance improvement continuing medical education on cardiometabolic risk factor control: the COSEHC initiative.

INTRODUCTION: The Consortium for Southeastern Hypertension Control (COSEHC) implemented a study to assess benefits of a performance improvement continuing medical education (PI CME) activity focused on cardiometabolic risk factor management in primary care patients. METHODS: Using the plan-do-study-act (PDSA) model as the foundation, this PI CME activity aimed at improving practice gaps by integrating evidence-based clinical interventions, physician-patient education, processes of care, performance metrics, and patient outcomes. The PI CME intervention was implemented in a group of South Carolina physician practices, while a comparable physician practice group served as a control. Performance outcomes at 6 months included changes in patients' cardiometabolic risk factor values and control rates from baseline. We also compared changes in diabetic, African American, the elderly (> 65 years), and female patient subpopulations and in patients with uncontrolled risk factors at baseline. RESULTS: Only women receiving health care by intervention physicians showed a statistical improvement in their cardiometabolic risk factors as evidenced by a -3.0 mg/dL and a -3.5 mg/dL decrease in mean LDL cholesterol and non-HDL cholesterol, respectively, and a -7.0 mg/dL decrease in LDL cholesterol among females with uncontrolled baseline LDL cholesterol values. No other statistical differences were found. DISCUSSION: These data demonstrate that our PI CME activity is a useful strategy in assisting physicians to improve their management of cardiometabolic control rates in female patients with abnormal cholesterol control. Other studies that extend across longer PI CME PDSA periods may be needed to demonstrate statistical improvements in overall cardiometabolic treatment goals in men, women, and various subpopulations.

Chest trauma in children: current imaging guidelines and techniques.

Given the heterogeneous nature of pediatric chest trauma, the optimal imaging approach is tailored to the specific patient. Chest radiography remains the most important imaging modality for initial triage. The decision to perform a chest computed tomography scan should be based on the nature of the trauma, the child's clinical condition, and the initial radiographic findings, taking the age-related pretest probabilities of serious injury into account. The principles of as low as reasonably achievable and Image Gently should be followed. The epidemiology and pathophysiology, imaging techniques, characteristic findings, and evidence-based algorithms for pediatric chest trauma are discussed.

The impact of changing ICD code on hypertension-related mortality in the southeastern United States from 1994-2005.

Confusion surrounding cardiovascular disease trends arises when measurement and reporting of classification systems such as the International Classification of Diseases (ICD) code are revised. The current study examined the impact of ICD code revision on mortality trends for heart disease, cerebrovascular disease, and diabetes in 16 Southeast states using data published in the 1994-2005 Centers for Disease Control National Vital Statistics Reports. Data were averaged by year and analyzed separately before (1994-1998) and after (1999-2005) the ICD code change, pooled across codes using comparability ratios (1994-2005), and further compared at the year of ICD code change using standard error of 1998 data to determine whether corresponding 1999 rates fell within 95% confidence intervals. The change in classification did not alter Southeast US trends regarding a decrease in heart disease and cerebrovascular disease rates and an increase in diabetes mortality in years 1994-2005. On the other hand, the change in ICD code classification systems did impact mortality rates for heart disease, cerebrovascular disease, and diabetes, suggesting that change in code to ICD-10 in 1999 underestimates heart disease and cerebrovascular disease and overestimates diabetes mortality rates in the Southeast United States. Health and disease burden profiles, which use mortality data to measure health status, need to carefully evaluate and report the influence of ICD code revisions as they draw conclusions. Primary care health providers should question the impact and comparability of ICD revision before accepting mortality trend conclusions.

COSEHC global vascular risk management quality improvement program: rationale and design.

BACKGROUND: The Consortium for Southeastern Hypertension Control (COSEHC) promotes global risk factor management in patients with metabolic syndrome. The COSEHC Global Vascular Risk Management Study (GVRM) intends to quantify these efforts on long-term patient outcomes. The objectives of this study were to present baseline demographics of patients enrolled in the GVRM, calculate a modified COSEHC risk score using 11 variables (COSEHC-11), and compare it with the original COSEHC-17 and Framingham, Prospective Cardiovascular Münster (PROCAM), and Systemic Coronary Risk Evaluation (SCORE) risk scores. METHODS: Deidentified electronic medical records of enrolled patients were used to calculate the risk scores. The ability of the COSEHC-11 score to predict the COSEHC-17 score was assessed by regression analysis. Raw risk scores were converted to probability estimates of fatal coronary heart disease (CHD) and compared with predicted risks from other algorithms. RESULTS: Of the 177,404 patients enrolled, 43,676 had data for all 11 variables. The COSEHC-11 score (mean ± standard deviation) of these 43,676 patients was 31.75 ± 11.66, implying a five-year fatal CHD risk of 1.4%. The COSEHC-11 score was highly predictive of the COSEHC-17 score (R(2) = 0.93; P < 0.0001) and correlated well with the SCORE algorithm. CONCLUSION: The COSEHC-11 risk score is statistically similar to the COSEHC-17 risk score and should be a viable tool for evaluating its ability to predict five-year cardiovascular mortality in the coming years.

Detection of chronic kidney disease in patients with or at increased risk of cardiovascular disease: a science advisory from the American Heart Association Kidney and Cardiovascular Disease Council; the Councils on High Blood Pressure Research, Cardiovascular Disease in the Young, and Epidemiology and Prevention; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: Developed in Collaboration With the National Kidney Foundation.

Chronic kidney disease (CKD) occurs commonly in patients with cardiovascular disease. In addition, CKD is a risk factor for the development and progression of cardiovascular disease. In this advisory, we present recommendations for the detection of CKD in patients with cardiovascular disease. CKD can be reliably detected with the combined use of the Modification of Diet in Renal Disease equation to estimate glomerular filtration rate and a sensitive test to detect microalbuminuria. All patients with cardiovascular disease should be screened for evidence of kidney disease with these two determinations.