After the fall: improving osteoporosis treatment following hip fracture.

Osteoporotic hip fractures can be life changing and can increase mortality. Treatment of osteoporosis following hip fracture is often delayed. We began offering osteoporosis medication during hospitalization for hip fracture, dramatically increasing the number of patients meeting standard of care. INTRODUCTION: Osteoporotic hip fracture is a debilitating condition with major morbidity and mortality implications. Osteoporosis medication given within 90 days of hip fracture improves mortality and reduces risk of future fractures. The aim of this project was to improve rates of timely osteoporosis treatment following fragility hip fracture. METHODS: This was a two-step intervention utilizing the Plan-Do-Study-Act cycle, beginning with resident-focused education in cycle 1. In cycle 2, we offered osteoporosis medication to inpatients for hip fracture with help from a new electronic order set. RESULTS: Prior to this intervention, 32% of patients received osteoporosis medication within 90 days of fragility hip fracture; this improved to 81% after intervention. CONCLUSIONS: Resident education and an electronic order set dramatically improved the percentage of patients meeting standard of care with osteoporosis pharmacotherapy following fragility fracture.

Information technology in the service of diabetes prevention and treatment.

In the year since the first ATTD yearbook was published the field of internet and cell phone interventions has made major advances. This chapter contains clinical studies and reviews of the state-of-the-art regarding the ability of technology-enabled self-management education and support to improve outcomes for patients with, or at risk for, diabetes. The reviews and papers in this chapter demonstrate increased understanding of the underlying basis for effective interventions - a prerequisite for improving the effectiveness and efficiency of these approaches. The research studies described demonstrate that internet interventions are effective for a variety of patients and for specific outcomes (e.g. diabetes self-management for teens as well as older patients, medication adherence, empowerment, psychosocial well-being, helping patients become more active, and helping patients lose weight and keep it off). As additional and more sophisticated studies are completed and the evidence base is expanded one can hope that payors will recognise their value and begin to pay for these treatments. That is what ultimately will bring effective treatments to those who need them. The associate editors' mission was to choose articles that would give the non-technology skilled reader a general overview of the field of information technology and the prevention and treatment of obesity and diabetes. Articles were selected because they either provided a significant review of the state-of the art of the field or were the results from studies that could give the reader a better understand of the benefits and challenges associated with information technology use in clinical settings.

Internet and information technology use in treatment of diabetes.

This chapter contains clinical studies and reviews of the state-of-the-art regarding how information technology can help improve outcomes for patients with diabetes through enhanced education and support. With the increasing sophistication of diabetes treatment protocols and diabetes-related devices this new modality offers a remarkable opportunity for clinicians and patients. For the first time, with online tools clinicians are in a position to have a major impact on diabetes outcomes by providing robust and affordable just-in-time support to large numbers of patients who want to improve their diabetes outcomes through enhanced self-management of the complex behaviours so essential for good outcomes. Patients with diabetes often need a complex set of services and support ranging from glucose monitoring, insulin and other medication management, psychotherapy and social support, to physical activity promotion, nutrition counselling and more. Integrating these supports into a patient's therapeutic regimen presents challenges that need to be addressed through a variety of strategies. Patient self-management of diabetes enabled by information technology is becoming an important factor in the way providers deliver healthcare. Approaches using information technology to support clinical services are being dramatically altered by the confluence of several trends. * Patients want an active role in managing their own health and a collaborative relationship with their healthcare providers. * Widespread, low-cost internet access is erasing existing geographic, economic and demographic barriers to obtaining health information online, and with advanced Web 2.0 technologies high levels of interactivity can engage the patient. * Clinicians and researchers now have a deeper understanding of how people learn and respond online, and that knowledge can be crafted into solutions that produce effective, long-term behaviour change. Technology enabled approaches that show great promise to improve outcomes use new models of service provision in which technology enabled self-management support (SMS) provides patients with * just-in-time delivery of tailored messages and experience that speak to each person based on their unique characteristics, their performance on key behaviours and their needs at that moment in time; * ways to easily and accurately keep track of their performance and use that knowledge to plan and implement new approaches to reaching their goals; * ways to link directly to family and friends for critical support, and to link to their many providers to help integrate medical care with everyday life. Online tools can extend health practices and provide this support through cost-effective programmes that help clinicians guide their patients to better manage their diabetes. The best internet self-management education and support programmes are rich in pertinent content, provide engaging interactive elements, and offer a tailored, personalised learning experience. They contain self-assessment tools and ways for the individual to monitor performance and changes in biological measurements such as blood sugar, insulin dosage, physical activity, weight, blood pressure and mood. The patient can access their information, input their data, and receive support 24 h a day - at a time and place most convenient for them, and not limited to clinicians' office hours. Web-based learning and support technology benefits both clinician and patient; patients learn to overcome barriers and to self-document activities and interactions, permitting clinician review and feedback at any time. In addition to automating much of the educational content, this time shifting element is one of the keys to making the process efficient and low cost. The ability to perform an automated review of the patient's activities and performance also provides the clinician with a valuable tool that increases both effectiveness and efficiency. As with online intervention, a 'virtual coach' can provide individualised guidance and support based on readily available analyses of each patient's characteristics and performance. In addition, the clinician can communicate frequently and efficiently, offering personalised email support to each patient without requiring in-person meetings, as well as monitor 'virtual support groups' where patients interact with others online via informational chat rooms and blogs. By incorporating web-based patient self-management and support into traditional treatment methods, one clinician can effectively support many patients - one patient at a time.

Smokeless tobacco use among professional baseball players: survey results, 1998 to 2003.

OBJECTIVE: The use of smokeless tobacco (ST) (snuff and chewing tobacco) has long been associated with baseball in the USA. This article reviews six years of survey data from major and minor league baseball players to evaluate trends in tobacco use and quitting patterns over time in order to gain insight into the effects of past interventions and to document continued intervention needs. METHOD: Surveys were distributed by athletic trainers to major and minor league professional baseball players during spring training session in the six years from 1998 to 2003. The surveys were anonymous and identified only by team, level of league, and other self reported demographic data. RESULTS: ST use among professional baseball players remains much higher than among young males in the general population, and use is most prevalent among white non-Hispanic players. There was a significant decrease in ST use among minor league players from 1998 to 2003, with seven day self reported use declining from 31.7% in 1998 to 24.8% in 2003. No significant year to year changes were observed for major league players. Major league players' self reported past week use rates, estimated at 35.9% in 1998 and at 36% in 2003, were consistently higher than those of minor league players. Self reported prevalence of past month cigarette and cigar smoking was much lower than ST use for both major and minor league players. CONCLUSIONS: Six years of survey data confirm a continuing high use of ST among professional baseball players. Results suggest that the effects of the broad spectrum ST control efforts launched over the past decade may have been stronger among minor than major league players. Stronger policy interventions at the major league level and multi-level efforts, including programmes to increase the use of effective quitting aids and assistance, at both levels of play are needed. Future research is needed to further clarify changes in ST practices among professional players and set policy intervention directions.

Impact of comorbidity on a cognitive-behavioral group treatment for adolescent depression.

OBJECTIVE: Examine hypotheses concerning the negative impact of lifetime psychiatric comorbidity on participation in, and benefit from, a cognitive-behavioral group treatment for depression in adolescents (e.g., greater severity at intake, less recovery and more recurrence, less participation in treatment). METHOD: Across two previous studies conducted between 1986 and 1993, 151 depressed adolescents (aged 14-18) were randomly assigned to one of three treatment conditions (two active treatments and a waitlist control) and followed for 24 months posttreatment. Forty percent of participants had one or more lifetime comorbid diagnoses at intake. RESULTS: Comorbid anxiety disorders were associated with higher depression measure scores at intake and greater decrease in depression scores by posttreatment. Overall lifetime comorbidity was unrelated to diagnostic recovery, but lifetime substance abuse/dependence was associated with slower time to recovery. Participants with attention-deficit and disruptive behavior disorders were more likely to experience depression recurrence posttreatment. Associations between comorbidity and participation or therapy process measures were nonsignificant. CONCLUSIONS: Although some outcomes were worse for some comorbid diagnoses, the reassuring overall conclusion is that the presence of psychiatric comorbidity is generally not a contraindication for the use of structured group cognitive-behavioral interventions for depressed adolescents.

What makes a winner? Key characteristics of peak performing hospitals.

Peak-performing hospitals and systems not only provide high-quality care, they were actually able to report rising profit margins over the last year. Learn in detail about the eight characteristics that these peak performers share.

A 49-residue peptide from adhesin F1 of Streptococcus pyogenes inhibits fibronectin matrix assembly.

F1 is an adhesin of Streptococcus pyogenes which binds the N-terminal 70-kDa region of fibronectin with high affinity. The fibronectin binding region of F1 is comprised of a 43-residue upstream domain and a repeat domain comprised of five tandem 37-residue sequences. We investigated the effects of these domains on the assembly of fibronectin matrix by human dermal fibroblasts, MG63 osteosarcoma cells, or fibroblasts derived from fibronectin-null stem cells. Subequimolar or equimolar concentrations of recombinant proteins containing both the upstream and repeat domains or just the repeat domain enhanced binding of fibronectin or its N-terminal 70-kDa fragment to cell layers; higher concentrations of these recombinant proteins inhibited binding. The enhanced binding did not result in greater matrix assembly and was caused by increased ligand binding to substratum. In contrast, recombinant or synthetic protein containing the 43 residues of the upstream domain and the first 6 residues from the repeat domain exhibited monophasic inhibition with an IC(50) of approximately 10 nm. Truncation of the 49-residue sequence at its N or C terminus caused loss of inhibitory activity. The 49-residue upstream sequence blocked incorporation of both endogenous cellular fibronectin and exogenous plasma fibronectin into extracellular matrix and inhibited binding of 70-kDa fragment to fibronectin-null cells in a fibronectin-free system. Inhibition of matrix assembly by the 49-mer had no effect on cell adhesion to substratum, cell growth, formation of focal contacts, or formation of stress fibers. These results indicate that the 49-residue upstream sequence of F1 binds in an inhibitory mode to N-terminal parts of exogenous and endogenous fibronectin which are critical for fibronectin fibrillogenesis.

Women and tobacco: moving from policy to action.

A gender perspective contributes to a better understanding of the epidemiological trends, social marketing strategies, economic policies, and international actions relating to women and the tobacco epidemic. Evidence is provided in this article for the negative impact of tobacco use by women and of passive smoking on the health of women and children. Use of tobacco by women is increasing and this is related to the tobacco industry's aggressive advertising, sponsorship and promotion strategies. Policy directions are proposed in this article. At all levels, a multi-pronged strategy--including changes in legislation and fiscal policies, improvements in gender-sensitive health services, and cessation programmes--should be considered. Much more gender-specific research on tobacco use is needed, particularly in developing countries. Women's empowerment and leadership should be at the centre of all tobacco control efforts and are essential for the success of national programmes and the recently introduced Framework Convention on Tobacco Control.

Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study.

OBJECTIVE: To determine the relation between extent of restrictions on smoking at home, at school, and in public places and smoking uptake and smoking prevalence among school students. DESIGN: Cross sectional survey with merged records of extent of restrictions on smoking in public places. SETTING: United States. PARTICIPANTS: 17 287 high school students. MAIN OUTCOME MEASURES: Five point scale of smoking uptake; 30 day smoking prevalence. RESULTS: More restrictive arrangements on smoking at home were associated with a greater likelihood of being in an earlier stage of smoking uptake (P<0.05) and a lower 30 day prevalence (odds ratio 0.79 (95% confidence interval 0.67 to 0.91), P<0.001). These findings applied even when parents were smokers. More pervasive restrictions on smoking in public places were associated with a higher probability of being in a earlier stage of smoking uptake (P<0.05) and lower 30 day prevalence (0.91 (0.83 to 0.99), P=0.03). School smoking bans were related to a greater likelihood of being in an earlier stage of smoking uptake (0.89 (0.85 to 0.99), P<0.05) and lower prevalence (0. 86 (0.77 to 0.94), P<0.001) only when the ban was strongly enforced, as measured by instances when teenagers perceived that most or all students obeyed the rule. CONCLUSIONS: These findings suggest that restrictions on smoking at home, more extensive bans on smoking in public places, and enforced bans on smoking at school may reduce teenage smoking.

A national general pediatric clerkship curriculum: the process of development and implementation.

OBJECTIVE: To describe a new national general pediatrics clerkship curriculum, the development process that built national support for its use, and current progress in implementing the curriculum in pediatric clerkships at US allopathic medical schools. CURRICULUM DEVELOPMENT: A curriculum project team of pediatric clerkship directors and an advisory committee representing professional organizations invested in pediatric student education developed the format and content in collaboration with pediatric educators from the Council on Medical Student Education in Pediatrics (COMSEP) and the Ambulatory Pediatric Association (APA). An iterative process or review by clerkship directors, pediatric departmental chairs, and students finalized the content and built support for the final product. The national dissemination process resulted in consensus among pediatric educators that this curriculum should be used as the national curricular guideline for clerkships. MONITORING IMPLEMENTATION: Surveys were mailed to all pediatric clerkship directors before dissemination (November 1994), and in the first and third academic years after national dissemination (March 1996 and September 1997). The 3 surveys assessed schools' implementation of specific components of the curriculum. The final survey also assessed ways the curriculum was used and barriers to implementation. OUTCOMES: The final curriculum provided objectives and competencies for attitudes, skills, and 18 knowledge areas of general pediatrics. A total of 216 short clinical cases were also provided as an alternative learning method. An accompanying resource manual provided suggested strategies for implementation, teaching, and evaluation. A total of 103 schools responded to survey 1; 84 schools to survey 2; and 85 schools responded to survey 3 from the 125 medical schools surveyed. Before dissemination, 16% of schools were already using the clinical cases. In the 1995-1996 academic year, 70% of schools were using some or all of the curricular objectives/competencies, and 45% were using the clinical cases. Two years later, 90% of schools surveyed were using the curricular objectives, 88% were using the competencies, 66% were using the clinical cases. The extent of curriculum use also increased. Schools using 11 or more of the 18 curriculum's knowledge areas increased from 50% (1995-1996) to 73% (1996-1997). CONCLUSION: This new national general pediatric clerkship curriculum developed broad support during its development and has been implemented very rapidly nationwide. During this period the COMSEP and the APA have strongly supported its implementation with a variety of activities. This development and implementation process can be a model for other national curricula.

Prevalence of hypothyroidism and diabetes mellitus in elderly kibbutz members.

UNLABELLED: The aim of this study was to determine the prevalence of hypothyroidism and diabetes mellitus (DM) in elderly (aged 65-92 years) kibbutz members in Northern Israel. METHOD: The medical records of 1096 elderly (642 females and 454 males) residing in 11 kibbutzim were reviewed for data regarding thyroid function tests (TSH and FT4) and fasting blood glucose. Fasting blood glucose levels above 7.8 mmol/l was considered diagnostic for diabetes mellitus. RESULTS: The prevalence of hypothyroidism was 14% (9.7% in males and 18.2% in females) and that of DM was 11.5% (12.1% in males and 11.1% in females). In 74% of the diabetics the diagnosis was made after the age of 60 years. Distribution of treatment modalities in diabetics was as follows: diet only 42%. oral hypoglycemic agents 52% and Insulin 6%. Subclinical hypothyroidism (serum TSH levels above 4.5 mU/L with normal FT4 levels) was detected in 38% of all the hypothyroid subjects. CONCLUSION: The data suggest that diabetes mellitus and primary hypothyroidism are common disorders in elderly subjects. DM in the elderly can usually be handled with diet and oral hypoglycemic drugs. Since the clinical features of hypothyroidism in the elderly are often atypical, we suggest that elderly subjects should be screened for hypothyroidism.