Health care costs and utilization of progressive fibrosing lung disease by underlying interstitial lung disease type.

BACKGROUND: Fibrosing interstitial lung disease (ILD) encompasses more than 200 diverse pulmonary disorders, of which up to 40% become progressive. The 4 underlying ILD types most likely to result in progression are unclassified ILD/idiopathic interstitial pneumonia (IIP), autoimmune ILDs, exposure-related ILD/hypersensitivity pneumonitis, and sarcoidosis. OBJECTIVE: To compare health care resource utilization (HCRU) and costs among patients with fibrosing ILD that has progressed ("progressive" fibrosing cohort) vs patients whose fibrosis did not meet criteria set for progression ("not yet progressed" cohort). METHODS: This was a noninterventional study of commercial enrollees and Medicare Advantage with Part D beneficiaries, which used administrative claims data for the period from October 1, 2015, through May 31, 2021. Adult patients (aged ≥18 years) with fibrosing ILD and 12 months of continuous health plan enrollment were included. Patients with idiopathic pulmonary fibrosis, baseline ILD diagnoses, or missing demographic data were excluded. Patients were first classified according to the underlying type of fibrosing ILD. For statistical analyses of outcomes, 2 cohorts were compared within each subtype: progressive fibrosing ILD vs not yet progressed ILD. The final study population included propensity score-matched (PSM) patients (1:1) based on pre-ILD baseline demographic and clinical characteristics. HCRU categories included inpatient hospitalization counts and the number of inpatient days and total costs (in 2021 US dollars), analyzed descriptively and weighted by the per-patient-per-month cost. Lin's regression was used to predict 12-month total cost estimates for comparison by cohort. RESULTS: The distribution by underlying conditions was as follows: autoimmune ILD (n = 4,156), HP (n = 8,181), sarcoidosis (n = 775), and unclassified ILD/IIP (n = 18,635). After PSM, pre-ILD baseline variables were generally well balanced between the progressive and not yet progressed fibrosing ILD cohorts. For all underlying subtypes of ILD, patients in the progressive cohort had significantly more utilization and higher costs compared with patients in the not yet progressed cohort. Progressive cohorts had significantly higher adjusted rates of inpatient days among patients with at least 1 inpatient stay compared with the not yet progressed cohorts (all P < 0.01). In addition, the progressive cohorts had significantly higher adjusted 12-month total costs, with the differences ranging from $24,493 to $55,072 (all comparisons P < 0.001). CONCLUSIONS: Irrespective of underlying ILD type, patients with progressive fibrosing ILD had significantly increased HCRU and cost relative to those whose fibrosing ILD had not yet progressed.

Outcomes of Patients with COPD Treated with ICS/LABA Before and After Initiation of Single-Inhaler Triple Therapy with Fluticasone Furoate/Umeclidinium/Vilanterol (FF/UMEC/VI).

INTRODUCTION: Triple therapy (fluticasone furoate/umeclidinium/vilanterol; FF/UMEC/VI) has been shown to improve symptoms and reduce exacerbations in patients with chronic obstructive pulmonary disease (COPD) and a history of exacerbations. This real-world study compared exacerbation rates and healthcare resource utilization (HCRU) before and after initiation of FF/UMEC/VI in patients with COPD previously treated with inhaled corticosteroid (ICS)/long-acting ß2-agonist (LABA). METHODS: This retrospective cohort study included commercial and Medicare Advantage with Part D administrative claims data from September 01, 2016, to March 31, 2020, of patients diagnosed with COPD. The index date was the date of the first FF/UMEC/VI claim (September 2017-March 2019). The 12 months prior to index (baseline) were used to assess patient characteristics and outcomes; the 12 months following index (follow-up) were used to assess study outcomes. All patients had ≥ 30 consecutive days' supply of any ICS/LABA dual therapy during the 12 months prior to FF/UMEC/VI initiation. Subgroup analyses included patients with ≥ 30 consecutive days' supply of budesonide/formoterol (BUD/FORM) during baseline. Analyses of patients with ≥ 1 COPD exacerbation during baseline were reported as well. RESULTS: The overall population included 1449 patients (mean age 70.75 years; 54.18% female), of whom 540 were patients in the BUD/FORM subgroup. Significantly fewer patients experienced any exacerbation during follow-up versus baseline (overall population 53.49% vs 62.59%; p < 0.001; BUD/FORM subgroup 55.00% vs 62.41%; p = 0.004). Effects on exacerbation reduction were more pronounced among patients with ≥ 1 exacerbation during baseline. Lower COPD-related HCRU was observed during the follow-up compared with baseline for both the overall population and the BUD/FORM subgroup. CONCLUSION: Patients with COPD treated with ICS/LABA during baseline, including patients specifically treated with BUD/FORM and those with a history of ≥ 1 exacerbation, had fewer COPD exacerbations and lower COPD-related HCRU after initiating FF/UMEC/VI.

Outcomes Following Initiation of Triple Therapy with Fluticasone Furoate/Umeclidinium/Vilanterol versus Multiple-Inhaler Triple Therapy Among Medicare Advantage with Part D Beneficiaries and Those Commercially Enrolled for Health Care Insurance in the United States.

Purpose: Patients with chronic obstructive pulmonary disease (COPD) have been shown to benefit from triple therapy commonly delivered by multiple-inhaler triple therapy (MITT); however, the complexity of MITT regimens may decrease patient adherence. Fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI), a once-daily single-inhaler triple therapy (SITT), became available in the United States (US) in 2017, but real-world data comparing outcomes for SITT versus MITT are currently limited. This study compared outcomes among patients with COPD initiating MITT versus SITT with FF/UMEC/VI who were either Medicare Advantage with Part D (MAPD) beneficiaries or commercial enrollees in the US. Methods: Retrospective study using administrative claims data from the Optum Research Database for patients with COPD who initiated FF/UMEC/VI or MITT between September 1, 2017, and March 31, 2019 (index date: first pharmacy claim for FF/UMEC/VI cohort; earliest day of ≥30 consecutive days-long period of overlap in the day's supply of all triple therapy components for MITT cohort). COPD exacerbations, adherence to triple therapy, and all-cause and COPD-related health care resource utilization (HCRU) and costs were compared between FF/UMEC/VI and MITT initiators. Results: In total, 4659 FF/UMEC/VI initiators and 9845 MITT initiators for the MAPD population, and 821 FF/UMEC/VI initiators and 1893 MITT initiators for the commercial population were included in the study. MAPD beneficiaries initiating FF/UMEC/VI had a significantly lower annual rate of severe exacerbations compared to MITT initiators (0.26 vs 0.29; p=0.014). They also had a significantly higher mean adherence (proportion of days covered) (0.51 vs 0.37; p<0.001) and significantly lower all-cause and COPD-related inpatient stays compared to MITT initiators ([32.02% vs 34.27%; p=0.017], [16.09% vs 17.72%; p=0.037]). Trends were similar among the commercial population, but the results were not statistically significant. Conclusion: FF/UMEC/VI initiators had significantly fewer severe exacerbations, higher triple therapy adherence, and lower HCRU costs compared to MITT initiators for MAPD beneficiaries.

Feasibility of an mHealth self-management intervention for children and adolescents with sickle cell disease and their families.

Sickle cell disease (SCD) is an inherited hemoglobinopathy that leads to blood vessel occlusion and multiorgan complications, including pain, that may be experienced daily. Symptom management often begins at home, and tools are needed to support self-management strategies that can be implemented by children with SCD and families. The purpose of this study was to assess the feasibility of the mHealth self-management intervention (application) Voice Crisis Alert V2 for children with SCD and families. Feasibility assessment was guided by the Reach, Efficacy, Adoption, Implementation, and Maintenance framework. Data were collected with 60 dyads (children with SCD/caregivers) at four time points. Self-management data were collected via application use, and postintervention interviews were conducted. Analyses included descriptive statistics and constant comparison with directed content analysis. Recruitment was completed in 28 weeks, with 82% retention at end-of-intervention. Mobile Application Rating Scale scores and interview data indicated high satisfaction. From baseline to mid-intervention, 94% of dyads used the application (75% of total use); 45% used the application from mid-intervention to the end-of-intervention. Dyads made 2,384 actions in the application; the most commonly used features were recording health history and recording and tracking symptoms. Few reported issues with the application; most issues occurred early in the study and were corrected. After the intervention period was completed, 37% continued to use the application. Feasibility was confirmed by meeting recruitment and retention goals, high adoption of the application, and high reported satisfaction with the application. Challenges with sustained use were encountered, and areas for improvement were identified.

Health economic analysis of curative-intent gastrectomy for gastric carcinoma and the costs related to post-operative complications.

BACKGROUND: The management of post-gastrectomy complications requires considerable resources and is likely associated with a substantial economic burden. The objectives of this study were to perform a cost analysis of admissions following gastrectomy for gastric carcinoma and then to quantify the financial impact of post-operative complications. METHODS: A retrospective analysis was conducted in patients that underwent a gastrectomy from 2008 to 2019. Demographic data, operative information, post-operative complications and facility costs were compared. RESULTS: A total of 74 patients underwent a curative-intent gastrectomy during the study period. The 36 (48.6%) patients that had no complications had a median total admission cost of AU$29 228. A total of 21 (28.4%) patients had a minor complication and 17 (23.0%) patients had a major complication, with a median total admission cost of AU$36 592 and AU$71 808, respectively. The difference across all three groups was statistically significant. In patients who had major complications compared to those without complications, there was a significant increase in the cost of intensive care services, theatre resources and nursing care. Across the whole cohort, the principal cost centres accounting for the largest proportion of total cost were theatre equipment and resources (33.9%), nursing care on the ward (23.0%) and staffing time of the surgical team (16.7%). CONCLUSION: The surgical management of gastric cancer carries a substantial cost burden. The presence and severity of post-operative complications is strongly associated with increasing cost. Minimizing complications, in addition to obvious clinical benefits, enables a large reduction in costs of care.

Prenatal Care for American Indian Women.

Early and regular prenatal care, which aims to prevent and identify complications associated with pregnancy, birth, and newborn health, is associated with improved health of pregnant women and their infants. American Indian/Alaska Native (AI/AN) women are at risk for pregnancy, birth, and newborn health complications associated with health disparities including poverty, lower educational levels, limited access to healthcare, and adverse childhood events. American Indian/Alaska Native women in the United States experience barriers specifically related to prenatal care, including lack of access, dissimilar communication styles, and inconsistent continuity of care. Culturally appropriate prenatal care should be provided to reduce maternal and newborn morbidity and mortality. Community-based interventions such as home visiting, that may potentially improve prenatal care, focusing on the American Indian tribes of the Northern Great Plains, specifically North Dakota, are discussed.

Position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior: Food and Nutrition Programs for Community-Residing Older Adults.

Given the increasing number and diversity of older adults and the transformation of health care services in the United States, it is the position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior that all older adults should have access to evidence-based food and nutrition programs that ensure the availability of safe and adequate food to promote optimal nutrition, health, functionality, and quality of life. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, in partnership with other practitioners and nutrition educators, should be actively involved in programs that provide coordinated services between the community and health care systems that include regular monitoring and evaluation of programming outcomes. The rapidly growing older population, increased demand for integrated continuous support systems, and rising cost of health care underscore the need for these programs. Programs must include food assistance and meal programs, nutritional screening and assessment, nutrition education, medical nutrition therapy, monitoring, evaluation, and documentation of evidence-based outcomes. Coordination with long-term care services and support systems is necessary to allow older adults to remain in their homes; improve or maintain their health and manage chronic disease; better navigate transitions of care; and reduce avoidable hospital, acute, or long-term care facility admissions. Funding of these programs requires evidence of their effectiveness, especially regarding health, functionality, and health care-related outcomes of interest to individuals, caregivers, payers, and policy makers. Targeting of food and nutrition programs involves addressing unmet needs for services, particularly among those at high risk for poor nutrition. Registered dietitian nutritionists and nutrition and dietetics technicians, registered must increase programmatic efforts to measure outcomes to evaluate community-based food and nutrition services.

Position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior: Food and Nutrition Programs for Community-Residing Older Adults.

Given the increasing number and diversity of older adults and the transformation of health care services in the United States, it is the position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior that all older adults should have access to evidence-based food and nutrition programs that ensure the availability of safe and adequate food to promote optimal nutrition, health, functionality, and quality of life. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, in partnership with other practitioners and nutrition educators, should be actively involved in programs that provide coordinated services between the community and health care systems that include regular monitoring and evaluation of programming outcomes. The rapidly growing older population, increased demand for integrated continuous support systems, and rising cost of health care underscore the need for these programs. Programs must include food assistance and meal programs, nutritional screening and assessment, nutrition education, medical nutrition therapy, monitoring, evaluation, and documentation of evidence-based outcomes. Coordination with long-term care services and support systems is necessary to allow older adults to remain in their homes; improve or maintain their health and manage chronic disease; better navigate transitions of care; and reduce avoidable hospital, acute, or long-term care facility admissions. Funding of these programs requires evidence of their effectiveness, especially regarding health, functionality, and health care-related outcomes of interest to individuals, caregivers, payers, and policy makers. Targeting of food and nutrition programs involves addressing unmet needs for services, particularly among those at high risk for poor nutrition. Registered dietitian nutritionists and nutrition and dietetics technicians, registered must increase programmatic efforts to measure outcomes to evaluate community-based food and nutrition services. POSITION STATEMENT: It is the position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior that older adults should have access to evidence-based food and nutrition programs that ensure the availability of safe and adequate food to promote optimal nutrition, health, functionality, and quality of life. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, in partnership with other practitioners and nutrition educators, should be actively involved in programs that provide coordinated services between the community and health care systems that include regular monitoring and evaluation of programming outcomes. The rapidly growing older population, increased demand for integrated continuous support systems, and rising cost of health care underscore the need for these programs.

Automated insulin dosing guidance to optimise insulin management in patients with type 2 diabetes: a multicentre, randomised controlled trial.

BACKGROUND: Insulin therapy is most effective if dosage titrations are done regularly and frequently, which is seldom practical for most clinicians, resulting in an insulin titration gap. The d-Nav Insulin Guidance System (Hygieia, Livonia, MI, USA) is a handheld device that is used to measure glucose, determine glucose patterns, and automatically determine the appropriate next insulin dose. We aimed to determine whether the combination of the d-Nav device and health-care professional support is superior to health-care professional support alone. METHODS: In this multicentre, randomised, controlled study, we recruited patients from three diabetes centres in the USA (in Detroit MI; Minneapolis, MN; and Des Moines IA). Patients were eligible if they were aged 21-70 years, diagnosed with type 2 diabetes with a glycated haemoglobin (HbA1c) concentration of 7·5% or higher (≥58 mmol/mol) and 11% or lower (≤97 mmol/mol), and had been using the same insulin regimen for the previous 3 months. Exclusion criteria included body-mass index of 45 kg/m2 or higher; severe cardiac, hepatic, or renal impairment; and more than two severe hypoglycaemic events in the past year. Eligible participants were randomly assigned (1:1), with randomisation blocked within each site, to either d-Nav and health-care professional support (intervention group) or health-care professional support alone (control group). Both groups were contacted seven times (three face-to-face and four phone visits) during 6 months of follow-up. The primary objective was to compare average change in HbA1c from baseline to 6 months. Safety was assessed by the frequency of hypoglycaemic events. The primary objective and safety were assessed in the intention-to-treat population. We used Student's t test to assess the primary outcome for statistical significance. This study was registered with ClinicalTrials.gov, number NCT02424500. FINDINGS: Between Feb 2, 2015, and March 17, 2017, 236 patients were screened for eligibility, of whom 181 (77%) were enrolled and randomly assigned to the intervention (n=93) and control (n=88) groups. At baseline, mean HbA1c was 8·7% (SD 0·8; 72 mmol/mol [SD 8·8]) in the intervention group and 8·5% (SD 0·8; 69 mmol/mol [SD 8·8]) in the control group. The mean decrease in HbA1c from baseline to 6 months was 1·0% (SD 1·0; 11 mmol/mol [SD 11]) in the intervention group, and 0·3% (SD 0·9; 3·3 mmol/mol [9·9]) in the control group (p<0·0001). The frequency of hypoglycaemic events per month was similar between the groups (0·29 events per month [SD 0·48] in the intervention group vs 0·29 [SD 1·12] in the control group; p=0·96). INTERPRETATION: The combination of automated insulin titration guidance with support from health-care professionals offers superior glycaemic control compared with support from health-care professionals alone. Such a solution facilitated safe and effective insulin titration in a large group of patients with type 2 diabetes, and now needs to be evaluated across large health-care systems to confirm these findings and study cost-effectiveness. FUNDING: US National Institutes of Health, National Institute of Digestive and Kidney Diseases.

Hidden Hunger: Solutions for America's Aging Populations.

The global population, including the United States, is experiencing a demographic shift with the proportion of older adults (aged ≥ 65 years) growing faster than any other age group. This demographic group is at higher risk for developing nutrition-related chronic conditions such as heart disease and diabetes as well as infections such as influenza and pneumonia. As a result, an emphasis on nutrition is instrumental for disease risk reduction. Unfortunately, inadequate nutrient status or deficiency, often termed hidden hunger, disproportionately affects older adults because of systematic healthcare, environmental, and biological challenges. This report summarizes the unique nutrition challenges facing the aging population and identifies strategies, interventions, and policies to address hidden hunger among the older adults, discussed at the scientific symposium "Hidden Hunger: Solutions for America's Aging Population", on March 23, 2018.

'How deep are your pockets?' Autoethnographic reflections on the cost of raising a child with autism.

BACKGROUND: In this article, we reflected on our experience of the cost of parenting a child with autism, including our ongoing search for educational and therapeutic intervention. OBJECTIVES: We aimed to give an academic insight into the state of autism education and care in South Africa as seen by us, with special attention to its cost and sustainability. METHODS: Using evocative autoethnography as storied scholarship together with critical autism studies, we reflected on stories of the past 5 years since our son's diagnosis. RESULTS: Our experiences agree with international studies that establish autism as the most expensive disability. In addition to the high costs of diagnosis, existing intervention and support approaches are unaffordable for the majority of South Africans. We recommend that teachers should be trained to participate in early screening and diagnosis, as well as co-therapists, to strengthen the implementation of inclusive education. CONCLUSION: The kind of autism intervention currently offered in South Africa is financially and socially unsustainable. Instead of positioning autism as an individual or family dilemma, it should be addressed as an educational and societal issue. Future research should explore cost-effective options for a developing country context, while promoting best practice within inclusive settings.

Subjective well-being in centenarians: a comparison of Japan and the United States.

OBJECTIVE: The present study examined the cultural differences and similarities in the levels and predictors of subjective well-being in Japanese and American centenarians. METHOD: We analyzed data on cognitively intact Japanese (N = 59) and American (N = 125) participants from the Tokyo and Georgia Centenarian Studies, respectively. The Philadelphia Geriatric Center Morale Scale was used to measure subjective well-being, while sociodemographic, social, and health resources were assessed as potential predictors. RESULTS: The American participants reported higher scores on well-being (satisfaction with social relations and psychological comfort). However, cultural differences in the levels of well-being disappeared after we controlled for its predictors. The regression models revealed that health resources (cognitive function, hearing problems, and activities of daily living) were strong predictors of well-being in both countries. Social resources (living with others) were strongly associated with one dimension of well-being (attitude toward one's aging) among the Japanese participants. DISCUSSION: The findings support the existing lifespan and cross-cultural literature, indicating that declines in health impose certain limitations on adaptive capacity in oldest-old age irrespective of cultures, and that social embeddedness is valued in Eastern cultures. The authors speculate that cultural values, i.e. personal autonomy versus relational harmony, play an important role for well-being in oldest-old age.

An innovative health-care delivery model for children with medical complexity.

Children with medical complexity (CMC) account for a disproportionate share of pediatric health-care utilization and cost that is largely attributable to long hospitalizations, frequent hospital readmissions, and high use of emergency departments. In response, the Centers for Medicare and Medicaid Services Health Care Innovation Center supports the development and testing of innovative health-care payment and service delivery models. The purpose of this article is to describe the CMS-funded coordinated health care for complex kids (CHECK) program, an innovative system of health-care delivery that provides improved, comprehensive, and well-coordinated services to CMC. The CHECK program uses a combination of high-tech and low-tech interventions to connect patients, stakeholders, and providers. It is anticipated that the investment in additional support services to CMC will result in improved quality of care that leads to a reduction in unnecessary inpatient hospitalizations, readmissions, and emergency department visits and a total cost savings. The CHECK program has the potential to inform future cost-effective health-care models aimed at improving the quality of life and care for CMC and their families.

The Relationship of Fertility, Lifestyle, and Longevity Among Women.

Longevity in women has been found to be associated with several reproductive factors; the age of women when they give birth, their total number of children, and the age at which they experience menopause. In the context of expectations from the evolutionary theory of aging, the focus of this study examined relationships between lifetime reproduction, age at menopause and longevity, while accounting for various lifestyle factors. The purpose of this study was to assess fertility and age at onset of menopause in 197 women of the Georgia Centenarian Study. It was hypothesized that greater lifetime reproduction would predict earlier menopause and subsequently an earlier death. An independent t test was computed to assess ethnic differences between Caucasian and African American participants. Two block-wise multiple regression analyses were computed to evaluate the impact of low socioeconomic status in childhood, the age at the time of the first childbirth, the total number of children, smoking and alcohol use, incidence of heart disease and stroke, and the age at onset of menopause on longevity. Results from this study suggest a positive association between the total number of children to the age at onset of menopause and longevity. However, when considering the lifestyle factor of smoking, the association of the total number of children to longevity is diminished.

Mexican American Men's Experience of Living With Tuberculosis on the U.S.-Mexico Border.

The Texas-Mexico border incidence rate of tuberculosis (TB) is 10 times the rate of TB in the United States. Additionally, this area is plagued by antibiotic-resistant TB at a rate that is 70% higher among those living along the border than among nonborder residents. Both the high rate of TB and the emergence of drug-resistant TB increases the importance of controlling TB along the U.S.-Mexico border. Men have higher rates of TB than women, which can be attributed to biological differences and increased environmental exposure. The purpose of this article is to describe the experience of TB for Mexican American men living on the Texas-Mexico border. This a qualitative descriptive study, using participants from a larger study. A purposeful sample was recruited through two south Texas TB clinics. Interviews were audio recorded, transcribed, and translated into English. Data analysis consisted of line-by-line coding, labeling, organizing, and discovering common codes to describe participants' experience of TB and TB treatment. The participants include 13 Mexican American men. Ages ranged from 22 to 76 years. Only one participant was employed during treatment. Years of education ranged from no school to an associate's degree. Five themes were discovered: misinformation, delayed diagnosis, stigma, depression, and loss of community. Participants without social support were further isolated and felt a greater burden of treatment. Two participants contemplated suicide and two others told their families to leave them because they were a burden and infectious. The burden of treatment on the patient is great, especially for Hispanic men.

Development and testing of the combined assessment of psychiatric environments: a patient-centered quality measure for inpatient psychiatric treatment.

BACKGROUND: Inpatient psychiatric treatment satisfaction measures are not constructed from patients' perspective of hospitalization experiences that they deem meaningful and important. OBJECTIVE: To develop and conduct psychometric testing of a measure that evaluates person-centered care on inpatient psychiatric units, the Combined Assessment of Psychiatric Environments (CAPE). The measure is built on a theoretical framework holding that if optimal care is to be achieved, all major stakeholders (patients and staff) need to experience a positive environment. DESIGN: An instrument development design was used to create the patient/staff nurse versions of the CAPE and to test their dimensions. The pilot versions of the CAPE were tested on six inpatient psychiatric units to determine the psychometrics of the staff/patient versions. RESULTS: The overall reliability of both versions of the CAPE (staff/patient) was .91. The test-retest reliability for both versions was significant at the .01 level. Construct validity was established via factor analysis. Criterion-related validity was demonstrated by correlations of the two versions of the CAPE to instruments that were conceptually related. CONCLUSION: The CAPE is a valid and reliable instrument that can be used to examine practice and the patient experience on inpatient psychiatric units. The CAPE highlights that patient-centered environments of care are intertwined with staff experiences of support for their role.

Poor Socioeconomic and Nutritional Status Are Associated with Osteoporosis in Korean Postmenopausal Women: Data from the Fourth Korea National Health and Nutrition Examination Survey (KNHANES) 2009.

OBJECTIVE: As the population ages, osteoporosis is a growing global public health problem. This study examined potential risk factors associated with osteoporosis in a nationally representative sample of Korean postmenopausal women. METHODS: This study used data from a nationally representative sample of Korean menopausal women participating in the Korea National Health and Nutrition Examination Survey KNHANES 2009 (n = 1467; mean age ± SE = 65.2 ± 0.3 years). Bone mineral density of total femur, femoral neck, and spine was measured by dual-energy X-ray absorptiometry. Osteoporosis was determined as t-score of -2.5 or below in at least 1 of the 3 sites. Menopausal status was confirmed by self-reports. RESULTS: About 41% of the study sample met the criteria for osteoporosis. Poor socioeconomic status, lower BMI, and shorter estrogen exposure duration were significantly associated with osteoporosis in the study sample. Poor dietary intake was also related to osteoporosis. In the age- and energy-adjusted logistic regression models, participants consuming less protein, vitamin B2, or vitamin C than the estimated average requirement (EAR) showed higher odds of having osteoporosis than their counterparts. Participants consuming no milk or milk products had 45% increased odds of having osteoporosis than those consuming milk or milk products. CONCLUSION: The findings of this study suggest several risk factors associated with osteoporosis, which can be addressed in the development and implementation of tailored nutritional interventions to promote the bone health of Korean postmenopausal women.

Patient-centered, direct-access online care for management of atopic dermatitis: a randomized clinical trial.

IMPORTANCE: New models of health care delivery for dermatological care have the potential to increase access and improve patient-centered outcomes. OBJECTIVE: To compare effectiveness of a direct-access, online model for follow-up dermatologic care in pediatric and adult patients with atopic dermatitis with that of in-person office visits. DESIGN, SETTING, AND PARTICIPANTS: This was a 1-year, randomized controlled equivalency clinical trial in medically underserved areas, outpatient clinics, and the general community. Participants included children and adults with atopic dermatitis with access to the Internet, computers, and digital cameras. INTERVENTIONS: After an initial in-person visit, patients were randomized 1:1 to direct-access online or usual in-person care for follow-up management of atopic dermatitis. In the direct-access online group, patients captured and transmitted clinical images and history asynchronously to dermatologists online; dermatologists evaluated the clinical information, provided recommendations and education, and prescribed medications online asynchronously. In the in-person group, patients visited dermatologists in their offices for follow-up care. MAIN OUTCOMES AND MEASURES: Atopic dermatitis disease severity as assessed by patient-oriented eczema measure (POEM) and investigator global assessment (IGA). RESULTS: A total of 156 children and adults were randomized. Between baseline and 12 months, the mean (SD) within-group difference in POEM score in patients in the direct-access online group was -5.1 (5.48) (95% CI, -6.32 to -3.88); in the in-person group, the within-group difference was -4.86 (4.87) (95% CI, -6.27 to -3.46). The difference in the change in POEM scores between the 2 groups was 0.24 (6.59) (90% CI, -1.70 to 1.23), which was contained within the predetermined 2.5 equivalence margin. The percentage of patients achieving clearance or near-clearance of their disease (IGA score of 0 or 1) was 38.4% (95% CI, 27.7% to 49.3%) in the direct-access online group and 43.6% (95% CI, 32.6%-54.6%) in the in-person group. The difference in the percent of patients achieving clearance or near-clearance between the 2 groups was 5.1% (90% CI, 1.7%-8.6%), which was contained within the predetermined 10% equivalence margin. CONCLUSIONS AND RELEVANCE: The direct-access online model results in equivalent improvements in atopic dermatitis clinical outcomes as in-person care. Direct-access online care may represent an innovative model of delivering dermatological services to patients with chronic skin diseases. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00985894.

Assessment of ZnT3 and PSD95 protein levels in Lewy body dementias and Alzheimer's disease: association with cognitive impairment.

The loss of zinc transporter 3 (ZnT3) has been implicated in age-related cognitive decline in mice, and the protein has been associated with plaques. We investigated the levels of ZnT3 and postsynaptic density protein 95 (PSD95), a marker of the postsynaptic terminal, in people with Parkinson's disease dementia (PDD, n = 31), dementia with Lewy bodies (DLB, n = 44), Alzheimer's disease (AD, n = 16), and controls (n = 24), using semiquantitative western blotting and immunohistochemistry in 3 cortical regions. Standardized cognitive assessments during life and semiquantitative scoring of amyloid ß (Aß), tau, and α-synuclein at postmortem were used to investigate the relationship between ZnT3 and PSD95, cognition and pathology. Associations were observed between ZnT3 and PSD95 levels in prefrontal cortex and cognitive impairment (p = 0.001 and p = 0.002, respectively) and between ZnT3 levels in the parietal cortex and cognitive impairment (p = 0.036). Associations were also seen between ZnT3 levels in cingulate cortex and severity of Aß (p = 0.003) and tau (p = 0.011) pathologies. DLB and PDD were characterized by significant reductions of PSD95 (p < 0.05) and ZnT3 (p < 0.001) in prefrontal cortex compared with controls and AD. PSD95 levels in the parietal cortex were found to be decreased in AD cases compared with controls (p = 0.02) and PDD (p = 0.005). This study has identified Zn(2+) modulation as a possible novel target for the treatment of cognitive impairment in DLB and PDD and the potential for synaptic proteins to be used as a biomarker for the differentiation of DLB and PDD from AD.