Methods and initial findings from the Durham Diabetes Coalition: Integrating geospatial health technology and community interventions to reduce death and disability.

OBJECTIVE: The Durham Diabetes Coalition (DDC) was established in response to escalating rates of disability and death related to type 2 diabetes mellitus, particularly among racial/ethnic minorities and persons of low socioeconomic status in Durham County, North Carolina. We describe a community-based demonstration project, informed by a geographic health information system (GHIS), that aims to improve health and healthcare delivery for Durham County residents with diabetes. MATERIALS AND METHODS: A prospective, population-based study is assessing a community intervention that leverages a GHIS to inform community-based diabetes care programs. The GHIS integrates clinical, social, and environmental data to identify, stratify by risk, and assist selection of interventions at the individual, neighborhood, and population levels. RESULTS: The DDC is using a multifaceted approach facilitated by GHIS to identify the specific risk profiles of patients and neighborhoods across Durham County. A total of 22,982 patients with diabetes in Durham County were identified using a computable phenotype. These patients tended to be older, female, African American, and not covered by private health insurance, compared with the 166,041 persons without diabetes. Predictive models inform decision-making to facilitate care and track outcomes. Interventions include: 1) neighborhood interventions to improve the context of care; 2) intensive team-based care for persons in the top decile of risk for death or hospitalization within the coming year; 3) low-intensity telephone coaching to improve adherence to evidence-based treatments; 4) county-wide communication strategies; and 5) systematic quality improvement in clinical care. CONCLUSIONS: To improve health outcomes and reduce costs associated with type 2 diabetes, the DDC is matching resources with the specific needs of individuals and communities based on their risk characteristics.

Vulvar pain after spondylosyndesis procedure: a presentation of 2 cases.

Vulvar pain can be a difficult and frustrating problem for patients and practitioners. Often, no specific etiology can be determined for these symptoms. Treatment can be long and difficult as well.Spondylosyndesis is a common surgical procedure where the vertebrae are fused to decrease motion. There are several indications for this procedure. We report 2 patients who developed vulvar pain postoperatively after a spondylosyndesis procedure. Neither patient had a history of vulvar pain before their procedure. Of note, both patients had had a previous spondylosyndesis procedure in the past.Damage to lumbar nerves during spondylosyndesis procedures may precipitate vulvar pain in some patients.

Successful treatment of orgasmic dysfunction using specialized physical therapy: a case report.

BACKGROUND: Sexual dysfunction in women is a challenging and difficult problem to treat. There can be multiple etiologies for these problems, and they can present differently in patients. Practitioners and patients can become frustrated when treatment becomes elusive. CASE: A patient complained of unilateral pelvic pain only with orgasm. Treatment involved specialized physical therapy. CONCLUSION: Pelvic pain related to intercourse is a common complaint in gynecologic practice. Specialized physical therapy may play a role in resolving sexual dysfunction in certain patients.

Evaluation of gabapentin in the treatment of generalized vulvodynia, unprovoked.

OBJECTIVE: To determine the efficacy of gabapentin in the treatment of generalized vulvodynia, unprovoked, to determine the most common presenting symptoms in patients with this diagnosis, to evaluate the prevalence of comorbidities in these patients and to determine the possibility of comorbidities or specific presenting symptoms that decrease the efficacy of this drug. STUDY DESIGN: The charts of all women seen in our facility with a diagnosis of generalized vulvodynia between January 1, 2002, and September 30, 2004, were reviewed. A total of 601 charts were reviewed. Patients were included in the study if they had a diagnosis of generalized vulvodynia, they were treated with single-agent gabapentin, had follow-up for 30 months or more and had adequately documented follow-up. RESULTS: A total of 152 patients were included in the study. Ninety-eight (64%) patients treated with gabapentin had resolution of at least 80% of their symptoms during the study period. Forty-nine (32%) did not have adequate resolution. There was a high percentage of comorbidities in patients with generalized vulvodynia. Sleep disturbance was the only comorbidity that negatively affected the efficacy of gabapentin. In addition, there appeared to be a trend toward a less favorable response in patients with a longer period of untreated illness (p value not less than 0.05). Side effects of gabapentin were few. Forty (26%) reported some side effects. Fatigue was the most common complaint. Seventeen patients (11%) discontinued the medication secondary to side effects. CONCLUSION: Gabapentin appears to be very effective in the treatment of generalized vulvodynia, unprovoked. It has a very low side effect profile. Certain patients may be less likely to benefit from gabapentin, including those with the comorbidity of sleep disturbance. Patients with symptoms of longer-standing generalized vulvodynia, unprovoked, may also be less likely to benefit from this treatment.

Limits of life in MgCl2-containing environments: chaotropicity defines the window.

The biosphere of planet Earth is delineated by physico-chemical conditions that are too harsh for, or inconsistent with, life processes and maintenance of the structure and function of biomolecules. To define the window of life on Earth (and perhaps gain insights into the limits that life could tolerate elsewhere), and hence understand some of the most unusual biological activities that operate at such extremes, it is necessary to understand the causes and cellular basis of systems failure beyond these windows. Because water plays such a central role in biomolecules and bioprocesses, its availability, properties and behaviour are among the key life-limiting parameters. Saline waters dominate the Earth, with the oceans holding 96.5% of the planet's water. Saline groundwater, inland seas or saltwater lakes hold another 1%, a quantity that exceeds the world's available freshwater. About one quarter of Earth's land mass is underlain by salt, often more than 100 m thick. Evaporite deposits contain hypersaline waters within and between their salt crystals, and even contain large subterranean salt lakes, and therefore represent significant microbial habitats. Salts have a major impact on the nature and extent of the biosphere, because solutes radically influence water's availability (water activity) and exert other activities that also affect biological systems (e.g. ionic, kosmotropic, chaotropic and those that affect cell turgor), and as a consequence can be major stressors of cellular systems. Despite the stressor effects of salts, hypersaline environments can be heavily populated with salt-tolerant or -dependent microbes, the halophiles. The most common salt in hypersaline environments is NaCl, but many evaporite deposits and brines are also rich in other salts, including MgCl(2) (several hundred million tonnes of bischofite, MgCl(2).6H(2)O, occur in one formation alone). Magnesium (Mg) is the third most abundant element dissolved in seawater and is ubiquitous in the Earth's crust, and throughout the Solar System, where it exists in association with a variety of anions. Magnesium chloride is exceptionally soluble in water, so can achieve high concentrations (> 5 M) in brines. However, while NaCl-dominated hypersaline environments are habitats for a rich variety of salt-adapted microbes, there are contradictory indications of life in MgCl(2)-rich environments. In this work, we have sought to obtain new insights into how MgCl(2) affects cellular systems, to assess whether MgCl(2) can determine the window of life, and, if so, to derive a value for this window. We have dissected two relevant cellular stress-related activities of MgCl(2) solutions, namely water activity reduction and chaotropicity, and analysed signatures of life at different concentrations of MgCl(2) in a natural environment, namely the 0.05-5.05 M MgCl(2) gradient of the seawater : hypersaline brine interface of Discovery Basin - a large, stable brine lake almost saturated with MgCl(2), located on the Mediterranean Sea floor. We document here the exceptional chaotropicity of MgCl(2), and show that this property, rather than water activity reduction, inhibits life by denaturing biological macromolecules. In vitro, a test enzyme was totally inhibited by MgCl(2) at concentrations below 1 M; and culture medium with MgCl(2) concentrations above 1.26 M inhibited the growth of microbes in samples taken from all parts of the Discovery interface. Although DNA and rRNA from key microbial groups (sulfate reducers and methanogens) were detected along the entire MgCl(2) gradient of the seawater : Discovery brine interface, mRNA, a highly labile indicator of active microbes, was recovered only from the upper part of the chemocline at MgCl(2) concentrations of less than 2.3 M. We also show that the extreme chaotropicity of MgCl(2) at high concentrations not only denatures macromolecules, but also preserves the more stable ones: such indicator molecules, hitherto regarded as evidence of life, may thus be misleading signatures in chaotropic environments. Thus, the chaotropicity of MgCl(2) would appear to be a window-of-life-determining parameter, and the results obtained here suggest that the upper MgCl(2) concentration for life, in the absence of compensating (e.g. kosmotropic) solutes, is about 2.3 M.

The availability and accessibility of basic paediatric resuscitation equipment in primary healthcare centres: cause for concern?

BACKGROUND: Paediatric emergencies in primary healthcare centres are serious events that occur more commonly than envisaged. However, at present, these centres appear to lack the training and equipment to manage common paediatric emergencies. AIM: To determine the availability and accessibility of basic resuscitation equipment in primary healthcare centres. METHODS: A questionnaire survey of 27 primary healthcare centres within the Nottingham City region determined the availability and accessibility of basic paediatric resuscitation equipment and algorithms. RESULTS: No practice had all 21 basic resuscitation items, with 59% of practices having < or =10 of these items. Only 11% of practices had all seven basic airway and breathing resuscitation items, with 52% of practices having < or =4 items. No practice had all eight basic items for circulation management, with 82% of practices having < or =4 of these items. Only two practices had all six basic drug items, with 85% of practices having < or =3 of these items. Only 26% of practices had algorithms for paediatric basic life support and common emergencies, and only 30% of practices kept their resuscitation equipment together. In the last 5 y, less than a fifth of general practitioners were trained in paediatric resuscitation. CONCLUSION: Primary healthcare centres appear to lack the training and equipment to manage common paediatric emergencies. We recommend standardization of equipment and algorithms, training and assessment of key personnel, and critical incident reporting within primary healthcare centres.