Influence of a transitional care clinic on subsequent 30-day hospitalizations and emergency department visits in individuals discharged from a skilled nursing facility.

OBJECTIVES: To evaluate an intervention to improve care transitions at the time of skilled nursing facility (SNF) discharge. DESIGN: Natural experiment using a pre-post design. SETTING: Veterans Affairs hospital, community SNF, and outpatient clinic. PARTICIPANTS: The pre-intervention group comprised 134 individuals discharged to the community from posthospitalization SNF care, and the intervention group was 217 individuals who received a postdischarge clinic (PDC) intervention at SNF discharge after receiving posthospitalization care at the SNF. INTERVENTION: This study is a natural experiment using a pre-post design. The intervention was a one-time visit to a PDC before SNF discharge, where an advanced nurse practitioner conducted medication reconciliation, ordered medical supplies and equipment and home health services if needed, provided individual and caregiver education, and communicated the information to the individual's primary outpatient care provider through electronic medical records. MEASUREMENTS: The pre-PDC and PDC intervention groups were compared on various measures of hospital utilization within 30 days of the SNF discharge (number of rehospitalizations, acute care inpatient days, and emergency department (ED) visits). RESULTS: Although there was a 23% rehospitalization rate in the pre-PDC group, participants in the PDC intervention group had a 14% rehospitalization rate within 30 days of SNF discharge (P = .02). Those who received the PDC intervention had significantly fewer acute care inpatient days during the 30-day follow-up (P < .001). Although the difference in the number of ED visits between the two groups was not statistically significant, the number of ED visits per 1,000 patient follow-up days during the 30-day interval was significantly lower in the PDC intervention group (P = .03). CONCLUSION: Comprehensive care coordination at the time of SNF discharge can reduce postdischarge hospital use in settings with shared electronic records.

Auxiliary role for D-alanylated wall teichoic acid in Toll-like receptor 2-mediated survival of Staphylococcus aureus in macrophages.

We previously reported that Staphylococcus aureus avoids killing within macrophages by exploiting the action of Toll-like receptor 2 (TLR2), which leads to the c-Jun N-terminal kinase (JNK)-mediated inhibition of superoxide production. To search for bacterial components responsible for this event, a series of S. aureus mutants, in which the synthesis of the cell wall was interrupted, were screened for the level of JNK activation in macrophages. In addition to a mutant lacking the lipoproteins that have been suggested to act as a TLR2 ligand, two mutant strains were found to activate the phosphorylation of JNK to a lesser extent than the parental strain, and this defect was recovered by acquisition of the corresponding wild-type genes. Macrophages that had phagocytosed the mutant strains produced more superoxide than those engulfing the parental strain, and the mutant bacteria were more efficiently killed in macrophages than the parent. The genes mutated, dltA and tagO, encoded proteins involved in the synthesis of D-alanylated wall teichoic acid. Unlike a cell wall fraction rich in lipoproteins, D-alanine-bound wall teichoic acid purified from the parent strain by itself did not activate JNK phosphorylation in macrophages. These results suggest that the d-alanylated wall teichoic acid of S. aureus modulates the cell wall milieu for lipoproteins so that they effectively serve as a ligand for TLR2.

Prevalence of type 2 diabetes among women with a previous history of gestational diabetes mellitus.

We compared the prevalence of diabetes in women who experienced gestational diabetes mellitus (GDM) with that in the general population and identified risk factors for the development of diabetes. The analysis included 868 subjects (620 GDM and 248 single positive (SP) for one of the diagnostic criteria). The post-partum examinations included 2 h 75 g oral glucose tolerance tests, lipid profiles, anthropometric measurements, and documentation of medical history, diet, and lifestyle. All participants were followed up at 6 weeks after parturition and subsequent follow-ups were conducted annually. General population subjects were identified from the 2001 Korean National Health and Nutrition Survey and age-matched for case-control analysis. Eleven (4.4%) and 71 (11.5%) subjects in the SP and GDM groups, respectively, developed diabetes, while 22 (2.5%) subjects in the general population group presented with diabetes. The risk of developing diabetes was 3.5 times greater for GDM subjects than for general population subjects, after adjusting for confounding factors. A multiple logistic regression model revealed that GDM, a family history of diabetes, and waist circumference were independently associated with the development of diabetes. We concluded that GDM women in Korea are at high risk of diabetes irrespective of the absence of putative risk factors.

Early manifestation of cardiovascular disease risk factors in offspring of mothers with previous history of gestational diabetes mellitus.

This study investigated the long-term adverse effects of maternal gestational diabetes mellitus (GDM) on cardiovascular disease (CVD) risk factors in offspring. A total of 298 offspring (202 offspring of GDM mothers and 96 offspring of mothers with impaired glucose tolerance [IGT]) participated in the study. CVD risk factors included elevated body mass index (BMI), skinfold thickness, body fat, blood pressure, lipid profiles, and glucose values measured with a 2h oral glucose tolerance test. The BMI of offspring >or=5 years of age of GDM mothers was significantly higher than that of offspring of mothers with IGT when analysed according to age. In offspring of GDM mothers, CVD risk factors were positively correlated with age, except for lipid profiles. A significant negative relationship between age and BMI was observed in offspring of IGT mothers. The slope of the linear regression lines for BMI and fasting plasma insulin levels with age were significantly steeper for the offspring of GDM mothers than for those of IGT mothers. We conclude that childhood obesity, as well as altered glucose metabolism influenced by the maternal uterine environment, is more likely with advancing years in the offspring of GDM mothers than in the offspring of IGT mothers.

Waist circumference is the key risk factor for diabetes in Korean women with history of gestational diabetes.

This study investigated relationships between various obesity indices and an onset of type 2 diabetes mellitus (TY2DM) in Korean women with history of gestational diabetes mellitus (GDM). A total of 909 women with history of GDM were enrolled from the four major hospitals, and the first postpartum follow-up examination was made at 6 weeks, and annually thereafter. During postpartum follow-up period, mean 2.13+/-1.75 years, we conducted 2h 75 g OGTT and measured glucose, insulin, c-peptide, lipid profiles, lifestyle and dietary evaluation. For obesity parameters, we measured body weight, body mass index (BMI), waist and hip circumference, subcutaneous fat thickness, body fat percent and weight using bioelectrical impedance tests. Diabetes incidence for 6 years was 12.8% and all the obesity indices were significantly higher in subjects with diabetes or glucose intolerance than those with normal glucose tolerance (p<0.001). When obesity indices were compared between <25th versus >75th percentile, the waist circumference presented with the strongest relationship (odds ratio=5.8, 95% CI 2.8-11.8). This relationship persisted, OR=3.86 (95% CI 1.8-8.2), even after adjusting for the potential confounders. This prospective study revealed that waist circumference is one of the key risk factors for the onset of diabetes in Korean women with history of GDM.

Elevated homocysteine as a risk factor for the development of diabetes in women with a previous history of gestational diabetes mellitus: a 4-year prospective study.

OBJECTIVE: To investigate the potential use of the plasma homocysteine level as a predictor of diabetes in women with a previous history of gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: At 6 weeks' postpartum, baseline examination was performed in 177 GAD-negative subjects. Of these subjects, 7 who were diagnosed with diabetes at baseline were excluded from further evaluation, and 170 with normal or impaired glucose tolerance (IGT) at baseline were followed annually over 4 years. The follow-up examinations included 2-h 75-g oral glucose tolerance tests (OGTTs), lipid profiles, homocysteine levels, anthropometric measurements, history taking, diet, and lifestyle. During the OGTTs, insulin and glucose levels were assayed every 30 min. Plasma homocysteine levels were determined by ion-exchange chromatography. RESULTS: Of the 170 women, 18 (10.6%) converted to diabetes during the 4-year follow-up period. Mean age, BMI, fasting insulin, and total cholesterol at baseline (6 weeks' postpartum test) were similar in the three study groups (i.e., normal, IGT, and diabetes). Fasting glucose levels, insulin-to-glucose ratios, and homocysteine levels were significantly higher in the diabetic group (P < 0.05). Higher glucose at the time of the diagnosis of GDM and higher homocysteine levels at baseline were independently associated with the onset of postpartum diabetes. These relationships were independent of age, BMI, and family history of diabetes. CONCLUSIONS: This prospective study identified homocysteine level as a significant risk factor for development of diabetes in women with previous GDM.