Sodium-glucose co-transporter-2 inhibitor cardiovascular outcome trials and generalizability to English primary care.

AIM: To identify people in English primary care with equivalent cardiovascular risk to participants in the sodium-glucose co-transporter-2 inhibitor (SGLT-2i) cardiovascular outcome trials (CVOTs). A secondary objective was to report the usage of SGLT-2is. METHODS: Cross-sectional analysis of people registered with participating practices in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network on the 31 December 2016. We derived: (1) proportions of the primary care population eligible for inclusion in each SGLT-2i CVOT (CANVAS, DECLARE, EMPA-REG and VERTIS); (2) characteristics of the eligible population compared with trial participants (demographics, disease duration and vascular risk); and (3) differences within the eligible population prescribed SGLT-2is. RESULTS: The proportions of people with type 2 diabetes (N = 84 394) meeting the inclusion criteria for each CVOT were: DECLARE 27% [95% confidence interval (CI) 26.5-27.1]; CANVAS 17% (16.6-17.1); VERTIS 7% (7.1-7.4); and EMPA-REG 7% (6.5-6.8). Primary care populations fulfilling inclusion criteria were 5-8 years older than trial cohorts, and <10% with inclusion criteria of each trial were prescribed an SGLT-2i; a greater proportion were men, and of white ethnicity. CONCLUSIONS: There was variation in proportions of the primary care type 2 diabetes population fulfilling inclusion criteria of SGLT-2i CVOTs. The more stringent the inclusion criteria, the lower the proportion identified in a primary care setting. Prescription rates for SGLT-2is were low in this national database, and there were demographic disparities in prescribing.

Obstructive sleep apnoea in Type 2 diabetes mellitus: increased risk for overweight as well as obese people included in a national primary care database analysis.

AIMS: To determine obstructive sleep apnoea prevalence in people with Type 2 or Type 1 diabetes in a national primary care setting, stratified by BMI category, and to explore the relationship between patient characteristics and obstructive sleep apnoea. METHODS: Using the Royal College of General Practitioners Research and Surveillance Centre database, a cross-sectional analysis was conducted. Diabetes type was identified using a seven-step algorithm and was grouped by Type 2 diabetes, Type 1 diabetes and no diabetes. The clinical characteristics of these groups were analysed, BMI-stratified obstructive sleep apnoea prevalence rates were calculated, and a multilevel logistic regression analysis was completed on the Type 2 diabetes group. RESULTS: Analysis of 1 275 461 adult records in the Royal College of General Practitioners Research and Surveillance Centre network showed that obstructive sleep apnoea was prevalent in 0.7%. In people with Type 2 diabetes, obstructive sleep apnoea prevalence increased with each increasing BMI category, from 0.5% in those of normal weight to 9.6% in those in the highest obesity class. By comparison, obstructive sleep apnoea prevalence rates for these BMI categories in Type 1 diabetes were 0.3% and 4.3%, and in those without diabetes 1.2% and 3.9%, respectively. Obstructive sleep apnoea was more prevalent in men than women in both diabetes types. When known risk factors were adjusted for, there were increased odds ratios for obstructive sleep apnoea in people with Type 2 diabetes in the overweight and higher BMI categories. CONCLUSIONS: Obstructive sleep apnoea was reported in people with both types of diabetes across the range of overweight categories and not simply in the highest obesity class.

Measuring Quality of Healthcare Outcomes in Type 2 Diabetes from Routine Data: a Seven-nation Survey Conducted by the IMIA Primary Health Care Working Group.

Background: The Institute of Medicine framework defines six dimensions of quality for healthcare systems: (1) safety, (2) effectiveness, (3) patient centeredness, (4) timeliness of care, (5) efficiency, and (6) equity. Large health datasets provide an opportunity to assess quality in these areas. Objective: To perform an international comparison of the measurability of the delivery of these aims, in people with type 2 diabetes mellitus (T2DM) from large datasets. Method: We conducted a survey to assess healthcare outcomes data quality of existing databases and disseminated this through professional networks. We examined the data sources used to collect the data, frequency of data uploads, and data types used for identifying people with T2DM. We compared data completeness across the six areas of healthcare quality, using selected measures pertinent to T2DM management. Results: We received 14 responses from seven countries (Australia, Canada, Italy, the Netherlands, Norway, Portugal, Turkey and the UK). Most databases reported frequent data uploads and would be capable of near real time analysis of healthcare quality.The majority of recorded data related to safety (particularly medication adverse events) and treatment efficacy (glycaemic control and microvascular disease). Data potentially measuring equity was less well recorded. Recording levels were lowest for patient-centred care, timeliness of care, and system efficiency, with the majority of databases containing no data in these areas. Databases using primary care sources had higher data quality across all areas measured. Conclusion: Data quality could be improved particularly in the areas of patient-centred care, timeliness, and efficiency. Primary care derived datasets may be most suited to healthcare quality assessment.

Separated response function ratios in exclusive, forward π(±) electroproduction.

The study of exclusive π(±) electroproduction on the nucleon, including separation of the various structure functions, is of interest for a number of reasons. The ratio RL=σL(π-)/σL(π+) is sensitive to isoscalar contamination to the dominant isovector pion exchange amplitude, which is the basis for the determination of the charged pion form factor from electroproduction data. A change in the value of RT=σT(π-)/σT(π+) from unity at small -t, to 1/4 at large -t, would suggest a transition from coupling to a (virtual) pion to coupling to individual quarks. Furthermore, the mentioned ratios may show an earlier approach to perturbative QCD than the individual cross sections. We have performed the first complete separation of the four unpolarized electromagnetic structure functions above the dominant resonances in forward, exclusive π(±) electroproduction on the deuteron at central Q(2) values of 0.6, 1.0, 1.6 GeV(2) at W=1.95 GeV, and Q(2)=2.45 GeV(2) at W=2.22 GeV. Here, we present the L and T cross sections, with emphasis on RL and RT, and compare them with theoretical calculations. Results for the separated ratio RL indicate dominance of the pion-pole diagram at low -t, while results for RT are consistent with a transition between pion knockout and quark knockout mechanisms.

Marriage and family therapy: examining the impact of licensure on an evolving profession.

Regulatory responsibilities for the profession of marriage and family therapy have shifted from the American Association of Marriage and Family Therapy (AAMFT) to state regulatory boards. The impact of these changes has not been adequately addressed. The purpose of this article is to highlight many of these changes and explore their implications. The educational, experience, and supervision requirements of states regulating the profession of marriage and family therapy in 2007 are examined using descriptive data from 47 regulatory entities and then compared with the current (2012) regulatory standards from 51 regulatory entities. In turn, these are compared with AAMFT prelicensure clinical membership requirements. Results indicate a marked difference between AAMFT prelicensure and state licensure requirements in both 2007 and 2012, but that state requirements continue to evolve. Additionally, the changing roles of the AAMFT and the Association of Marital and Family Therapy Regulatory Boards (AMFTRB) within the profession are explored.

Polarization components in π0 photoproduction at photon energies up to 5.6 GeV.

We present new data for the polarization observables of the final state proton in the (1)H(γ,p)π(0) reaction. These data can be used to test predictions based on hadron helicity conservation and perturbative QCD. These data have both small statistical and systematic uncertainties and were obtained with beam energies between 1.8 and 5.6 GeV and for π(0) scattering angles larger than 75° in the center-of-mass frame. The data extend the polarization measurements database for neutral pion photoproduction up to E(γ)=5.6 GeV. The results show a nonzero induced polarization above the resonance region. The polarization transfer components vary rapidly with the photon energy and π(0) scattering angle in the center-of-mass frame. This indicates that hadron helicity conservation does not hold and that the perturbative QCD limit is still not reached in the energy regime of this experiment.

Search for effects beyond the born approximation in polarization transfer observables in e(over→)p elastic scattering.

Intensive theoretical and experimental efforts over the past decade have aimed at explaining the discrepancy between data for the proton electric to magnetic form factor ratio, G(E)/G(M), obtained separately from cross section and polarization transfer measurements. One possible explanation for this difference is a two-photon-exchange contribution. In an effort to search for effects beyond the one-photon-exchange or Born approximation, we report measurements of polarization transfer observables in the elastic H(e[over →],e(')p[over →]) reaction for three different beam energies at a Q(2)=2.5 GeV(2), spanning a wide range of the kinematic parameter ε. The ratio R, which equals µ(p)G(E)/G(M) in the Born approximation, is found to be independent of ε at the 1.5% level. The ε dependence of the longitudinal polarization transfer component P(ℓ) shows an enhancement of (2.3±0.6)% relative to the Born approximation at large ε.

Probing the high momentum component of the deuteron at high Q2.

The (2)H(e,e'p)n cross section at a momentum transfer of 3.5 (GeV/c)(2) was measured over a kinematical range that made it possible to study this reaction for a set of fixed missing momenta as a function of the neutron recoil angle θ(nq) and to extract missing momentum distributions for fixed values of θ(nq) up to 0.55 GeV/c. In the region of 35°≤θ(nq)≤45° recent calculations, which predict that final-state interactions are small, agree reasonably well with the experimental data. Therefore, these experimental reduced cross sections provide direct access to the high momentum component of the deuteron momentum distribution in exclusive deuteron electrodisintegration.

Recoil polarization measurements of the proton electromagnetic form factor ratio to Q2 = 8.5 GeV2.

Among the most fundamental observables of nucleon structure, electromagnetic form factors are a crucial benchmark for modern calculations describing the strong interaction dynamics of the nucleon's quark constituents; indeed, recent proton data have attracted intense theoretical interest. In this Letter, we report new measurements of the proton electromagnetic form factor ratio using the recoil polarization method, at momentum transfers Q2=5.2, 6.7, and 8.5 GeV2. By extending the range of Q2 for which G(E)(p) is accurately determined by more than 50%, these measurements will provide significant constraints on models of nucleon structure in the nonperturbative regime.

Compton-scattering cross section on the proton at high momentum transfer.

Cross-section values for Compton scattering on the proton were measured at 25 kinematic settings over the range s=5-11 and -t=2-7 GeV2 with a statistical accuracy of a few percent. The scaling power for the s dependence of the cross section at fixed center-of-mass angle was found to be 8.0+/-0.2, strongly inconsistent with the prediction of perturbative QCD. The observed cross-section values are in fair agreement with the calculations using the handbag mechanism, in which the external photons couple to a single quark.

Audit of epidural analgesia in children undergoing thoracotomy for decortication of empyema.

BACKGROUND: Uncertainty remains over the risk of epidural space infection after neuraxial blockade in the presence of systemic sepsis. For many years, we have provided epidural analgesia to children undergoing thoracotomy for the decortication of parapneumonic empyemas. Following recent publications asserting that epidural analgesia is absolutely contraindicated in this situation, we audited our management. The purpose of this audit was to document the effectiveness and the incidence of complications after epidural insertion in children with active sepsis from empyemas. METHODS: This is a retrospective single-centre audit over a 10-yr period. RESULTS: Forty-six epidurals were performed in children with empyema, and three children were treated with systemic opioids. We found no infective complications of the epidural space or insertion sites. The epidurals provided excellent analgesia. The incidence of moderate-severe pain was 18%, and 2% for severe pain in the first 24 h after surgery. Minor complications of epidural analgesia were uncommon. Two children receiving systemic opioids for pain relief suffered respiratory complications, one of which resulted in a prolonged admission to the intensive care unit. CONCLUSIONS: Epidural analgesia provides excellent pain relief after thoracotomy in children with empyema, with a low complication rate. Until evidence to the contrary emerges, it remains our technique of choice for thoracotomy, even in the presence of empyema.

Onset of quark-hadron duality in pion electroproduction.

A large data set of charged-pion (pi+/-) electroproduction from both hydrogen and deuterium targets has been obtained spanning the low-energy residual-mass region. These data conclusively show the onset of the quark-hadron duality phenomenon, as predicted for high-energy hadron electroproduction. We construct several ratios from these data to exhibit the relation of this phenomenon to the high-energy factorization ansatz of electron-quark scattering and subsequent quark-->pion production mechanisms.

Q2 dependence of the neutron spin structure function g2(n) at low Q2.

We present the first measurement of the Q2 dependence of the neutron spin structure function g2(n) at five kinematic points covering 0.57 (GeV/c)2 < or = Q2 < or = 1.34 (GeV/c)2 at x approximately = 0.2. Though the naive quark-parton model predicts g2 = 0, nonzero values occur in more realistic models of the nucleon which include quark-gluon correlations, finite quark masses, or orbital angular momentum. When scattering from a noninteracting quark, g2(n) can be predicted using next-to-leading order fits to world data for g1(n). Deviations from this prediction provide an opportunity to examine QCD dynamics in nucleon structure. Our results show a positive deviation from this prediction at lower Q2, indicating that contributions such as quark-gluon interactions may be important. Precision data obtained for g1(n) are consistent with next-to-leading order fits to world data.

Precision Rosenbluth measurement of the proton elastic form factors.

We report the results of a new Rosenbluth measurement of the proton electromagnetic form factors at Q2 values of 2.64, 3.20, and 4.10 GeV2. Cross sections were determined by detecting the recoiling proton, in contrast to previous measurements which detected the scattered electron. Cross sections were determined to 3%, with relative uncertainties below 1%. The ratio mu(p)G(E)/G(M) was determined to 4%-8% and showed mu(p)G(E)/G(M) approximately 1. These results are consistent with, and much more precise than, previous Rosenbluth extractions. They are inconsistent with recent polarization transfer measurements of similar precision, implying a systematic difference between the techniques.

Precision measurement of the neutron spin asymmetryA(n)(1) and spin-flavor decomposition in the valence quark region.

We have measured the neutron spin asymmetry A(n)(1) with high precision at three kinematics in the deep inelastic region at x=0.33, 0.47, and 0.60, and Q(2)=2.7, 3.5, and 4.8 (GeV/c)(2), respectively. Our results unambiguously show, for the first time, that A(n)(1) crosses zero around x=0.47 and becomes significantly positive at x=0.60. Combined with the world proton data, polarized quark distributions were extracted. Our results, in general, agree with relativistic constituent quark models and with perturbative quantum chromodynamics (PQCD) analyses based on the earlier data. However they deviate from PQCD predictions based on hadron helicity conservation.

Curricular framework: core competencies in multicultural geriatric care.

Strategies to reduce the documented disparities in health and health care for the rapidly growing numbers of older patients from diverse ethnic populations include increased cultural competence of providers. To assist geriatric faculty in medical and other health professional schools develop cultural competence training for their ethnogeriatric programs, the University of California Academic Geriatric Resource Program partnered with the Ethnogeriatric Committee of the American Geriatrics Society to develop a curricular framework. The framework includes core competencies based on the format of the Core Competencies for the Care of Older Patients developed by the Education Committee of the American Geriatrics Society. Competencies in attitudes, knowledge, and skills for medical providers caring for elders from diverse populations are specified. Also included are recommended teaching strategies and resources for faculty to pursue the development of full curricula.

Angular distributions for (3,4)(Lambda)H bound states in the (3,4)He(e,e(')K+) reaction.

The (3,4)(Lambda)H and (4)(Lambda)H hypernuclear bound states have been observed for the first time in kaon electroproduction on (3,4)He targets. The production cross sections have been determined at Q(2)=0.35 GeV2 and W=1.91 GeV. For either hypernucleus the nuclear form factor is determined by comparing the angular distribution of the (3,4)He(e,e(')K+)(3,4)(Lambda)H processes to the elementary cross section 1H(e,e K+)Lambda on the free proton, measured during the same experiment.

High resolution spectroscopy of the 12Lambda B hypernucleus produced by the (e,e'K+) reaction.

High-energy, cw electron beams at new accelerator facilities allow electromagnetic production and precision study of hypernuclear structure, and we report here on the first experiment demonstrating the potential of the (e,e'K+) reaction for hypernuclear spectroscopy. This experiment is also the first to take advantage of the enhanced virtual photon flux available when electrons are scattered at approximately zero degrees. The observed energy resolution was found to be approximately 900 keV for the (12)(Lambda)B spectrum, and is substantially better than any previous hypernuclear experiment using magnetic spectrometers. The positions of the major excitations are found to be in agreement with a theoretical prediction and with a previous binding energy measurement, but additional structure is also observed in the core excited region, underlining the future promise of this technique.

Longitudinal electroproduction of charged pions from (1)H, (2)H, and (3)He.

Separated longitudinal and transverse cross sections for charged pion electroproduction from (1)H, (2)H, and (3)He were measured at Q(2) = 0.4 (GeV/c)(2) for two values of the invariant mass, W = 1.15 GeV and W = 1.60 GeV, in a search for a mass dependence which would signal the effect of nuclear pions. This is the first such study that includes recoil momenta significantly above the Fermi surface. The longitudinal cross section, if dominated by the pion-pole process, should be sensitive to nuclear pion currents. Comparisons of the longitudinal cross section target ratios to a quasifree calculation reveal a significant suppression in (3)He at W = 1.60 GeV. The W = 1.15 GeV results are consistent with simple estimates of the effect of nuclear pion currents, but are also consistent with pure quasifree production.

Posttraumatic concerns: a patient-centered approach to outcome assessment after traumatic physical injury.

BACKGROUND: Approximately 2.5 million Americans are admitted to the hospital after traumatic physical injury each year. Few investigations have elicited patients' perspectives regarding posttraumatic outcomes. OBJECTIVE: To identify and categorize physically injured trauma survivors' posttraumatic concerns. RESEARCH DESIGN: Prospective longitudinal investigation; trauma survivors were interviewed during the post-injury hospitalization and again 1, 4, and 12 months after the trauma. SUBJECTS: Ninety-seven, randomly selected, English speaking, hospitalized survivors of motor vehicle-crashes or assaults. MEASURES: At the end of each interview patients were asked, "Of all the things that have happened to you since you were injured, what concerns you the most?" Using an iterative process and working by consensus, investigators categorized patient concerns in content domains. Concern domains were then compared with established measures of posttraumatic stress disorder (PTSD) symptoms and limitations in physical functioning. RESULTS: Seven categories of posttraumatic concerns were identified. During the course of the year, 73% of patients expressed physical health concerns, 58% psychological concerns, 53% work and finance concerns, 40% social concerns, 10% legal concerns, 10% medical concerns, and 20% uncodable concerns. Rater agreement on concern categorization was substantial (kappa = 0.72). The mean number of concerns expressed per patient gradually decreased over time (1 month mean = 1.51; 12 month mean = 1.26) and resembled the trajectories of PTSD symptoms and functional limitations. CONCLUSIONS: The concerns of physically injured trauma survivors are readily elicited and followed up during the course of the year after injury. Open-ended inquiry regarding posttraumatic concerns may complement standardized outcome assessments by identifying and contextualizing the outcomes of greatest importance to patients.