Implementation of a virtual community of practice to promote the empowerment of middle-aged people with multimorbidity: study protocol of a randomised controlled trial.

INTRODUCTION: Empowering people living with multimorbidity (multiple chronic conditions) to gain greater confidence in managing their health can enhance their quality of life. Education focused on self-management is a key tool for fostering patient empowerment and is mostly provided on an individual basis. Virtual communities of practice (VCoP) present a unique opportunity for online education in chronic condition self-management within a social context. This research aims to evaluate the effectiveness/cost-effectiveness of individualised, online self-management education compared with VCoP among middle-aged individuals living with multiple chronic conditions. METHODS AND ANALYSIS: People aged 30-60, living with ≥2 chronic conditions and receiving care in primary care (PC) centres and outpatient hospital-based clinics in Madrid and Canary Islands will enrol in an 18-month parallel-design, blinded (intervention assessment and data analysts), pragmatic (adhering to the intention-to-treat principle), individually randomised trial. The trial will compare two 12-month web-based educational offers of identical content; one delivered individually (control) and the other with online social interaction (VCoP, intervention). Using repeated measures mixed linear models, with the patient as random effect and allocation groups and time per group as fixed effects, we will estimate between-arm differences in the change in Patient Activation Measure from baseline to 12 months (primary endpoint), including measurements at 6-month and 18-month follow-up. Other outcomes will include measures of depression and anxiety, treatment burden, quality of life. In addition to a process evaluation of the VCoP, we will conduct an economic evaluation estimating the relative cost-effectiveness of the VCoP from the perspectives of both the National Health System and the Community. ETHICS AND DISSEMINATION: The trial was approved by Clinical Research Ethics Committees of Gregorio Marañón University Hospital in Madrid/Nuestra Señora Candelaria University Hospital in Santa Cruz de Tenerife. The results will be disseminated through workshops, policy briefs, peer-reviewed publications and local/international conferences. TRIAL REGISTRATION NUMBER: NCT06046326.

Multimorbidity patterns in chronic older patients, potentially inappropriate prescribing and adverse drug reactions: protocol of the multicentre prospective cohort study MoPIM.

INTRODUCTION: Multimorbidity is a major challenge for current healthcare systems and professionals. From the different approaches that have been proposed to analyse this issue, the hypothesis of the existence of association patterns of different chronic conditions is gaining visibility. In addition, multimorbidity can be associated to polypharmacy, which can lead to a higher risk of potentially inappropriate prescribing (PIP) and consequently to adverse drug reactions (ADRs). The general objective of this novel study is to identify the association between PIP, multimorbidity patterns, polypharmacy and the presence of ADRs in older patients admitted for exacerbation of chronic diseases. METHODS AND ANALYSIS: The MoPIM (morbidity, potentially inappropriate medication) study is a multicentre prospective cohort study of an estimated sample of 800 older (≥65 years) patients admitted to five general hospitals in Spain due to an exacerbation of a chronic disease. Patients referred to home hospitalisation, admitted due to an acute process or with a fatal outcome expected at the time of admission are excluded. Sociodemographic data, chronic morbidities and geriatric syndromes, number of chronic prescribed medications, PIP at admission to hospital and on discharge, according to the newest screening tool of older screening tool of older person's potentially inappropriate prescriptions/screening tool to alert doctors to right treatment criteria, and ADRs during hospitalisation are being collected. Multimorbidity patterns will be identified using cluster analyses techniques, and the frequency of polypharmacy, PIP and ADRs will be calculated. Finally, the possible relationship between those indicators will be identified through bivariate and multivariate analyses. ETHICS AND DISSEMINATION: The project has been approved by the clinical research ethics committees of each centre: Comité Ético de investigación Clínica del Parc Taulí, Comitè Ètic d'Investigació Clínica Osona per a la Recerca i Educació Sanitàries (FORES), Comité de Ètica de la Investigación con Medicamentos (CEIm)-Parc de Salut MAR, Comité Ético de Investigación Clínica de Euskadi, Comité de Ética de Investigación del Hospital Universitario de Canarias. The results will be actively and mainly disseminated through publication in peer-reviewed journals and communications in scientific conferences. TRIAL REGISTRATION NUMBER: NCT02830425.

The Error of Estimated GFR in Type 2 Diabetes Mellitus.

Type 2 diabetes mellitus represents 30-50% of the cases of end stage renal disease worldwide. Thus, a correct evaluation of renal function in patients with diabetes is crucial to prevent or ameliorate diabetes-associated kidney disease. The reliability of formulas to estimate renal function is still unclear, in particular, those new equations based on cystatin-C or the combination of creatinine and cystatin-C. We aimed to assess the error of the available formulas to estimate glomerular filtration rate in diabetic patients. We evaluated the error of creatinine and/or cystatin-C based formulas in reflecting real renal function over a wide range of glomerular filtration rate (from advanced chronic kidney disease to hyperfiltration). The error of estimated glomerular filtration rate by any equation was common and wide averaging 30% of real renal function, and larger in patients with measured glomerular filtration rate below 60 mL/min. This led to chronic kidney disease stages misclassification in about 30% of the individuals and failed to detect 25% of the cases with hyperfiltration. Cystatin-C based formulas did not outperform creatinine based equations, and the reliability of more modern algorithms proved to be as poor as older equations. Formulas failed in reflecting renal function in type 2 diabetes mellitus. Caution is needed with the use of these formulas in patients with diabetes, a population at high risk for kidney disease. Whenever possible, the use of a gold standard method to measure renal function is recommended.

Correction: Two Variants of the C-Reactive Protein Gene Are Associated with Risk of Pre-Eclampsia in an American Indian Population.

[This corrects the article on p. e71231 in vol. 8.].

IBC CARe microarray allelic population prevalences in an American Indian population.

BACKGROUND: The prevalence of variant alleles among single nucleotide polymorphisms (SNPs) is not well known for many minority populations. These population allele frequencies (PAFs) are necessary to guide genetic epidemiology studies and to understand the population specific contribution of these variants to disease risk. Large differences in PAF among certain functional groups of genes could also indicate possible selection pressure or founder effects of interest. The 50K SNP, custom genotyping microarray (CARe) was developed, focusing on about 2,000 candidate genes and pathways with demonstrated pathophysiologic influence on cardiovascular disease (CVD). METHODS: The CARe microarray was used to genotype 216 unaffected controls in a study of pre-eclampsia among a Northern Plains, American Indian tribe. The allelic prevalences of 34,240 SNPs suitable for analysis, were determined and compared with corresponding HapMap prevalences for the Caucasian population. Further analysis was conducted to compare the frequency of statistically different prevalences among functionally related SNPs, as determined by the DAVID Bioinformatics Resource. RESULTS: Of the SNPs with PAFs in both datasets, 9.8%,37.2% and 47.1% showed allele frequencies among the American Indian population greater than, less than and either greater or less than (respectively) the HapMap Caucasian population. The 2,547 genes were divided into 53 functional groups using the highest stringency criteria. While none of these groups reached the Bonferroni corrected p value of 0.00094, there were 7 of these 53 groups with significantly more or less differing PAFs, each with a probability of less than 0.05 and an overall probability of 0.0046. CONCLUSION: In comparison to the HapMap Caucasian population, there are substantial differences in the prevalence among an American Indian community of SNPs related to CVD. Certain functional groups of genes and related SNPs show possible evidence of selection pressure or founder effects.

Two variants of the C-reactive protein gene are associated with risk of pre-eclampsia in an American Indian population.

BACKGROUND: The etiology of pre-eclampsia (PE) is unknown; but it is accepted that normal pregnancy represents a distinctive challenge to the maternal immune system. C-reactive protein is a prominent component of the innate immune system; and we previously reported an association between PE and the CRP polymorphism, rs1205. Our aim was to explore the effects of additional CRP variants. The IBC (Cardiochip) genotyping microarray focuses on candidate genes and pathways related to the pathophysiology of cardiovascular disease. METHODS: This study recruited 140 cases of PE and 270 matched controls, of which 95 cases met criteria as severe PE, from an American Indian community. IBC array genotypes from 10 suitable CRP SNPs were analyzed. A replication sample of 178 cases and 427 controls of European ancestry was also genotyped. RESULTS: A nominally significant difference (p value <0.05) was seen in the distribution of discordant matched pairs for rs3093068; and Bonferroni corrected differences (P<0.005) were seen for rs876538, rs2794521, and rs3091244. Univariate conditional logistic regression odds ratios (OR) were nominally significant for rs3093068 and rs876538 models only. Multivariate logistic models with adjustment for mother's age, nulliparity and BMI attenuated the effect (OR 1.58, P = 0.066, 95% CI 0.97-2.58) for rs876538 and (OR 2.59, P = 0.050, 95% CI 1.00-6.68) for rs3093068. An additive risk score of the above two risk genotypes shows a multivariate adjusted OR of 2.04 (P = 0.013, 95% CI 1.16-3.56). The replication sample also demonstrated significant association between PE and the rs876538 allele (OR = 1.55, P = 0.01, 95% CI 2.16-1.10). We also show putative functionality for the rs876538 and rs3093068 CRP variants. CONCLUSION: The CRP variants, rs876538 and rs3093068, previously associated with other cardiovascular disease phenotypes, show suggestive association with PE in this American Indian population, further supporting a possible role for CRP in PE.

Anaerobic spondylodiscitis: case series and systematic review.

BACKGROUND: Bacterial spondylodiscitis is rarely caused by anaerobic organisms. We describe two patients with lumbar vertebral osteomyelitis and discitis caused by anaerobic bacteria, including an unusual occurrence after an endodontic procedure, and review the salient clinical features and outcomes of 31 previously reported cases. METHODS: Case reports and review of the literature. RESULTS: Median age at presentation was 65 years, with a male-to-female ratio of 2:1. The most common presenting symptoms were back pain, fever, and neurologic deficits. The lumbar spine was most frequently involved (43%); an equal number of cases involved contiguous extension or hematogenous spread. Causative anaerobes were recovered from disk space or vertebrae (13), blood (4), and/or soft tissue abscess and included Bacteroides species (12), Propionibacterium acnes (7), Peptococcus species (4), Peptostreptococcus species and Clostridium species (3 each), Corynebacterium diphtheroides and Fusobacterium species (2 each), and unspecified anaerobes (3). CONCLUSIONS: Apart from specific antibiotic selection, medical treatment and outcomes for anaerobic spondylodiscitis are similar to those for aerobic vertebral disk infection.

[Pulmonary function and quality of life in relation to bronchial colonization in adults with bronchiectasis not caused by cystic fibrosis]. / Función pulmonar y calidad de vida en relación con la colonización bronquial en adultos con bronquiectasias no debidas a fibrosis quística.

BACKGROUND: We aimed at assessing the pulmonary function and life quality of patients with bronchiectasis not caused by cystic fibrosis (CF) on the basis of the presence or absence of colonization (with Pseudomonas or other microorganisms). PATIENTS AND METHOD: Prospective, randomised control-case study of patients with bronchiectasis who came to the Pneumology area of the Hospital Universitario de Canarias between January 1999 and December 2000 in a stable clinic situation. Patients must had no antibiotic therapy over last six weeks before the study. Patients with CF and patients who had an acute respiratory disease were excluded. We obtained two sputum samples for culture with an interval of six weeks between both. We determined the expiratory flow in the first second (FEV1), the forced vital capacity (FVC) and arterial gases. Quality of life was measured by the St. George respiratory questionnaire. RESULTS: We included 70 patients, 25 males (35%) and 45 females (64%), with a mean (SD) age of 56 (17) years. There were 14 patients who had Pseudomonas (Ps-group), 10 who had other microorganisms (another-group) and 46 patients who had no microorganism in sputum culture (no-group). The pulmonary function of the no-group (FEV

Función pulmonar y calidad de vida en relación con la colonización bronquial en adultos con bronquiectasias no debidas a fibrosis quística / Pulmonary function and quality of life in relation to bronchial colonization in adults with bronchiectasis not caused by cystic fibrosis

FUNDAMENTO: Comparar la función pulmonar y la calidad de vida en pacientes con bronquiectasias no debidas a fibrosis quística (FQ) en función de que se encuentren colonizados (por Pseudomonas o por otros gérmenes) o no colonizados. PACIENTES Y MÉTODO: Estudio de casos y controles no aleatorio y prospectivo en pacientes con bronquiectasias que acudieron a la consulta de Neumología del Hospital Universitario de Canarias entre enero de 1999 y diciembre de 2000 en fase de estabilidad clínica y sin tratamiento antibiótico al menos 6 semanas antes. Se excluyeron los pacientes con FQ y reagudizaciones respiratorias durante el estudio. Se recogieron dos muestras de esputo para cultivo con 6 semanas de diferencia y se determinaron el volumen espiratorio forzado en el primer segundo (FEV1), la capacidad vital forzada (FVC) y los gases arteriales. Además se valoró la calidad de vida mediante el Cuestionario Respiratorio de St. George. Las variables principales fueron FEV1, FVC, pO2 y calidad de vida. Estadística: análisis de la variancia de un factor independiente y prueba de la t de Student. RESULTADOS: Se incluyeron 70 pacientes, 25 varones (35 por ciento) y 45 mujeres (64 por ciento), con una media (DE) de edad de 56 (17) años. Catorce pacientes estaban colonizados por Pseudomonas (grupo Ps), 10 por otros gérmenes (grupo otros) y 46 no estaban colonizados (grupo no). La función pulmonar del grupo no (FEV1 por ciento: 73 [24] y FVC por ciento: 79 [21]) fue mejor que la del grupo Ps (FEV1 por ciento: 47 [27]; p = 0,00; FVC por ciento: 61 [28]; p = 0,04). La calidad de vida en el grupo no (puntuación total [PT]: 33,2 [18,9]) fue mejor que en el grupo Ps (PT: 54,3 [23,2]; p = 0,00) y que en el grupo otros gérmenes distintos de Pseudomonas (PT: 52,2 [20,4]; p = 0,02). CONCLUSIONES: Los pacientes con bronquiectasias colonizados por Pseudomonas tienen peor función pulmonar y calidad de vida que los no colonizados. Los colonizados por gérmenes distintos de Pseudomonas tienen peor calidad de vida que los no colonizados (AU)