The Impact of Primary Care Practitioner Intervention as an Adjunct to a Diabetes Case Management System.

Objective The objective of this study was to assess whether additional primary care practitioner (PCP) contacts beyond the intake visit are associated with reduced hemoglobin A1c in patients with type 2 diabetes actively engaged in the Kaiser Permanente case management system. Methods This retrospective cohort study using the Kaiser Permanente electronic health record explored the effect of enhanced PCP contact among adult patients with type 2 diabetes actively working with diabetes case managers (defined as ≥ 4 case manager contacts during the study period). Results A total of 837 patients met the inclusion and exclusion criteria. On average, patients with the highest PCP contact, < 7 contacts, had Ac levels 0.53 lower than those in the lowest PCP contact quartile, < 3 contacts (p = 0.0007). A1c decreased an average of 0.20 when the PCP contact quartile was one quartile higher (p = 0.0004). Holding the baseline A1c constant, the A1c decreased an average of 0.15 when the PCP contact quartile was one quartile higher (p = 0.0024). A1c change was significantly correlated with baseline A1c; A1c decreased by 0.64 more as the baseline A1c level increased by 1 (p < 0.0001). Additionally, the A1c level decreased by 0.02 more when patient age increased by 1 (p < 0.0001). Metformin use was associated with a decrease of A1c by 0.40 (p = 0.0057), whereas insulin use was associated with an increase of A1c by 0.29 (p = 0.0280). Conclusion In summary, a significant reduction was observed in A1c in patients with increased PCP contacts. This effect was seen in patients already receiving recommended case manager support.

Effect of Bisphosphonates on Fracture Incidence in Young Adults With Low Bone Density.

OBJECTIVE: To assess the effect of bisphosphonates on fracture incidence in young adults over a 5-year follow-up period. METHODS: Based on the Kaiser Permanente electronic health record, this retrospective study investigated patients aged 19 to 40 years with abnormal bone density (either any Z-score of ≤-2 standard deviation [SD] or any T-score of ≤-2.5 SD). The incidence and time to fracture between the control (patients with <6 months of bisphosphonate exposure) and treatment (patients with ≥6 months of bisphosphonate use within 4 years of their first dual energy x-ray absorptiometry scan) groups were compared. Comparisons were analyzed with Χ2 test for categorical variables and Wilcoxon rank sum test for continuous variables. RESULTS: A total of 422 patients met the inclusion and exclusion criteria. Fractures occurred in 18 patients (5.0%) of the control group (n = 358) and 5 patients (7.8%) of the treatment group (n = 64; P = .37). T-scores were significantly lower in the treatment group (-2.53 ± 0.58 SD) than those in the control group (-2.30 ± 0.80 SD; P = .002) but did not correlate with fracture risk. No significant differences were found in total fracture incidence (hazard ratio = 1.54; 95% confidence interval, 0.26-6.26). Similarly, no correlation was noted between the length of bisphosphonate therapy and fracture incidence (odds ratio = 0.99; 95% confidence interval, 0.966-1.026). CONCLUSION: In summary, we did not find a clear correlation of fracture incidence with the use of bisphosphonates in young adults. Further research into the pathophysiology, specific etiologies, and treatment options in this population is needed.

Plasma testosterone is associated with Framingham risk score.

INTRODUCTION: The Framingham risk score predicts a patient's 10-year risk of developing cardiovascular disease. Many risk factors included in its calculation influence or are influenced by circulating testosterone. To investigate the possible association between testosterone and cardiovascular risk, as defined by the Framingham score, a Veterans Affairs (VA) database was analyzed. METHODS: A retrospective chart review was performed. Inclusion criteria were male sex and age ≥ 20 years. Exclusion criteria included pre-existing cardiovascular disease, stroke, and diabetes. Data were collected on veterans who had total plasma testosterone checked in the year 2008. RESULTS: The study included 1,479 patients (mean age 61 years). Framingham score was negatively associated with both total testosterone (p < 0.0001) and free testosterone (p = 0.0003). There was a positive association between total testosterone and high-density lipoprotein and negative associations between total testosterone and body mass index (BMI), total cholesterol, triglycerides, and blood pressure medication use. Free testosterone was positively associated with total cholesterol, low-density lipoprotein, and current smoking status and negatively associated with age, BMI, and blood pressure medication use. The BMI was not associated with Framingham score. CONCLUSIONS: Lower plasma testosterone may suggest the presence of cardiovascular risk factors and potentially increased risk for heart disease.

Revision of the duodenal switch: indications, technique, and outcomes.

BACKGROUND: Duodenal switch (DS) operation combines both restrictive and malabsorptive components and has become an accepted operation in selected patients with morbid obesity. Complications develop in some patients, which are refractory to dietary supplementation. We report a series of 33 patients who required partial revision of the DS. STUDY DESIGN: During the 10-year period after September 1992, 701 patients had DS operation performed; of these, 33 (5 men and 28 women) patients required revision. Revision was performed by side to side enteroenterostomy 100 cm proximal to the original anastamosis. Outcomes measures reviewed include postoperative complications, nutritional parameters, and weight change. RESULTS: Revision was performed a median of 17 (range 7 to 63) months after DS. Indications for revision included protein malnutrition (n = 20), diarrhea (n = 9), metabolic abnormalities (n = 5), abdominal pain (n = 3), liver disease (n = 2), emesis (n = 2), and gastrointestinal bleed (n = 1). Median body mass index at the time of revision was 28. Median serum albumin was 3.6 g/dL and improved to 4.0 g/dL postoperatively (p = 0.01). Complications occurred in 5 of 32 patients (15%) and included wound infection (n = 2), respiratory failure (n = 1), gastrointestinal bleed (n = 1), and small bowel obstruction (n = 1). There was no perioperative mortality. During a median followup period after revision of 39 months, the median weight gain was 18 pounds. Three patients requested repeat operation because of weight regain. CONCLUSIONS: Patients requiring revision of DS for malnutrition can be corrected by a technically simple procedure, but they are at considerable risk for complications. Although many patients are anxious about regaining their weight after reversal, they can be reassured that substantial weight gain is unlikely.