Improved outcomes in diabetes care for rural African Americans.

PURPOSE: Rural low-income African American patients with diabetes have traditionally poorer clinical outcomes and limited access to state-of-the-art diabetes care. We determined the effectiveness of a redesigned primary care model on patients' glycemic, blood pressure, and lipid level control. METHODS: In 3 purposively selected, rural, fee-for-service, primary care practices, African American patients with type 2 diabetes received point-of-care education, coaching, and medication intensification from a diabetes care management team made up of a nurse, pharmacist, and dietitian. In 5 randomly selected control practices matched for practice and patient characteristics, African American patients received usual care. Using univariate and multivariate adjusted models, we evaluated the effects of the intervention on intermediate (median 18 months) and long-term (median 36 months) changes in glycated hemoglobin (hemoglobin A1c) levels, blood pressure, and lipid levels, as well as the proportion of patients meeting target values. RESULTS: Among 727 randomly selected rural African American diabetic patients (368 intervention, 359 control), intervention patients had a significantly greater reduction in mean hemoglobin A1c levels at intermediate (-0.5 % vs -0.2%; P <.05) and long-term (-0.5% vs -0.10%; P <.005) follow-up in univariate and multivariate models. The proportion of patients achieving a hemoglobin A1c level of less than 7.5% (68% vs 59%, P <.01) and/or a systolic blood pressure of less than 140 mm Hg (69% vs 57%, P <.01) was also significantly greater in intervention practices in multivariate models. CONCLUSION: Redesigning care strategies in rural fee-for-service primary care practices for African American patients with established diabetes results in significantly improved glycemic control relative to usual care.

Glycemic control patterns and kidney disease progression among primary care patients with diabetes mellitus.

BACKGROUND: Reducing glycosylated hemoglobin (HbA1c) to near or less than 7% in patients with diabetes is associated with diminished microvascular complications, but this level is not consistently achieved. The purpose of this study was to examine the relationship between fluctuations in HbA1c and changes in estimated glomerular filtration rate (eGFR) and estimated stage of chronic kidney disease (CKD) in an academic primary care practice. METHODS: We analyzed data from 791 diabetic primary care patients (25% white; 75% African American) enrolled between 1998 to 2002 and followed through 2008 (mean follow-up, 7.6 ± 1.9 years). We calculated baseline and final follow-up eGFR using the Modification of Diet in Renal Disease equation. We examined the relationship between fluctuations in HbA1c and changes in eGFR and stage of CKD using multivariable linear and logistic regression models that controlled for demographic and clinical variables associated with CKD progression. RESULTS: From baseline to follow-up, mean eGFR in African Americans declined to a greater extent and more rapidly than in whites. Age, mean systolic blood pressure, initial HbA1c, initial eGFR, and number of HbA1c values (all P<.01) were significant predictors of change in eGFR. Among HbA1c fluctuation measures, the strongest predictor of change in eGFR was the proportion of HbA1c values >7% (P=.02); however, this contributed little to explaining model variance. CONCLUSION: These data suggest that traditional demographic and clinical risk factors remain significantly associated with changes in eGFR and that the pattern of variability in HbA1c is only modestly important in contributing to changes in eGFR among African-American and white diabetic patients in primary care.

Body mass index and outcomes in critically injured blunt trauma patients: weighing the impact.

BACKGROUND: The influence of increased body mass index (BMI) on morbidity and mortality in critically injured trauma patients has been studied, with conflicting results. The objective of this study was to investigate the relationship between stratified BMI and outcomes in blunt injured patients. STUDY DESIGN: Consecutive adult trauma patients from July 2001 to November 2005 with Injury Severity Score (ISS) > or = 16 and blunt mechanism were evaluated using the National Trauma Registry of the American College of Surgeons. Demographics, injury severity, hospital course, complications, and mortality were compared among standard BMI strata. Logistic regression was used to determine odds ratios (OR) with 95% confidence intervals and evaluate BMI as an independent risk factor for morbidity and mortality. Statistical significance was set at p < 0.05. RESULTS: The study group consisted of 1,543 patients. Controlling for age, gender, Injury Severity Score, and Revised Trauma Score, and using BMI 18.5 to 24.9 kg/m(2) as the reference category, morbid obesity (BMI> or =40 kg/m(2)) was associated with acute respiratory distress syndrome (OR 3.675, 95% CI, 1.237 to 10.916), acute respiratory failure (OR 2.793, 95% CI, 1.633 to 4.778), acute renal failure (OR 13.506, 2.388 to 76.385), multisystem organ failure (OR 2.639, 95% CI, 1.085 to 6.421), pneumonia (OR 2.487, 95% CI, 1.483 to 4.302), urinary tract infection (OR 2.332, 95% CI, 1.229 to 4.427), deep venous thrombosis (OR 4.112, 95% CI, 1.253 to 13.496), and decubitus ulcer (OR 2.841, 95% CI, 1.382 to 5.841). Morbid obesity was not associated with increased mortality (OR 0.810, 95% CI, 0.353 to 1.856). CONCLUSIONS: This is the largest study to date evaluating the relationship between BMI and outcomes in critically injured trauma patients. Increasing BMI increases morbidity while having no proved influence on mortality.

Modeling survival in colon cancer: a methodological review.

The Cox proportional hazards model is the most widely used model for survival analysis because of its simplicity. The fundamental assumption in this model is the proportionality of the hazard function. When this condition is not met, other modifications or other models must be used for analysis of survival data. We illustrate in this review several methodological approaches to deal with the violation of the proportionality assumption, using survival in colon cancer as an illustrative example.

Mild traumatic brain injury: effects on naming in word retrieval and discourse.

PRIMARY OBJECTIVE: To investigate differences between a group with mild traumatic brain injury (MTBI) and a control group relative to standard scores and error type during word retrieval in both naming and discourse tasks. METHODS AND PROCEDURES: Ten participants with MTBI were age-, gender- and education-matched with 10 participants without injury. Pre-experimental tasks for the participants with MTBI included the Scales of Cognitive Ability for Traumatic Brain Injury and the Raven's Coloured Progressive Matrices and both groups received the Peabody Picture Vocabulary Test-III. Experimental tasks included the Test of Adolescent/Adult Word Finding and the Test of Word Finding in Discourse. MAIN OUTCOMES AND RESULTS: Few participants (three on each experimental task) demonstrated psychometrically-based word retrieval deficits (standard score < 85); however, a significant difference in performance for the TAWF as compared to the TWFD was observed between groups. More word finding errors occurred with confrontational naming than with discourse tasks for both groups, with latency as the primary error type. CONCLUSIONS: Confrontational naming tasks may be more sensitive to subtle language difficulties occurring after MTBI. The study of adults with MTBI and their performance on semantically-based tasks offers important information for the advancement of therapeutic intervention and education.

Safety and completion rate of short-course therapy for treatment of latent tuberculosis infection.

BACKGROUND: Nine months of isoniazid therapy is the recommended regimen for treatment of latent tuberculosis infection, but low completion rates are a serious problem. The search for shorter regimens, compared with the standard isoniazid regimen, is of vital importance. We describe our experience using short-course regimens for the treatment of latent tuberculosis infection. METHODS: We conducted a nonrandomized, observational study of 459 patients in a county health department from June 2000 to January 2006. Short-course therapy was defined as pyrazinamide and rifampin taken daily or twice weekly for 2 months or rifampin taken daily for 4-6 months. Conventional therapy consisted of a 9-month regimen of isoniazid. Liver function testing was performed for both groups in accordance with clinical guidelines. Treatment completion and hepatotoxicity (according to the World Health Organization classification) were determined for the short-course and conventional therapy groups. RESULTS: Treatment was completed by 241 (77.7%) of 310 patients in the short-course group and by 98 (65.8%) of 149 patients in the isoniazid group (P = .009). Moderate to severe hepatotoxicity (grades 3 and 4) occurred in 6.1% of patients receiving short-course therapy and in 2.0% of patients receiving isoniazid (P=.09). The hepatotoxicity observed in the short-course group was confined to patients receiving pyrazinamide and rifampin daily and was self limited in all cases after the medications were discontinued. CONCLUSIONS: The rate of treatment completion was significantly higher with short-course regimens, compared with the isoniazid regimen. Although the overall risk of hepatotoxicity in patients receiving pyrazinamide and rifampin daily for the treatment of latent tuberculosis infection was higher, liver functions returned to normal after the medications were discontinued.

Auditory pattern recognition and brief tone discrimination of children with reading disorders.

UNLABELLED: Auditory pattern recognition skills in children with reading disorders were investigated using perceptual tests involving discrimination of frequency and duration tonal patterns. A behavioral test battery involving recognition of the pattern of presentation of tone triads was used in which individual components differed in either frequency or duration. A test involving measurement of difference limens for long and short duration tones was also administered. In comparison to controls, children with reading disorders exhibited significantly higher error rates in discrimination of duration and frequency patterns, as well as larger brief tone frequency difference limens. These results suggest that difficulties in the recognition and processing of auditory patterns may co-occur with decoding deficits in children with reading disorders. LEARNING OUTCOMES: (1) As a result of this activity, the participant will be able to identify a relationship between reading and temporal processing. (2) As a result of this activity, the reader will be able to discuss the difference between sight-word decoding and phonological decoding. (3) As a result of this activity, the reader will be able to explain a relationship between reading skills and the identification of auditory patterns.

Heat loss prevention for preterm infants in the delivery room.

OBJECTIVE: Preterm infants are prone to hypothermia immediately following birth. Among other factors, excessive evaporative heat loss and the relatively cool ambient temperature of the delivery room may be important contributors. Most infants <29 weeks gestation had temperatures <36.4 degrees C on admission to our neonatal unit (NICU). Therefore we conducted a randomized, controlled trial to evaluate the effect of placing these infants in polyurethane bags in the delivery room to prevent heat loss and reduce the occurrence of hypothermia on admission to the NICU. METHODS: After parental consent was obtained, infants expected to be <29 weeks gestation were randomized to intervention or control groups just prior to their birth. Infants randomized to the intervention group were placed in polyurethane bags up to their necks immediately after delivery before being dried. They were then resuscitated per NRP guidelines, covered with warm blankets, and transported to the NICU, where the bags were removed and rectal temperatures were recorded. Control infants were resuscitated, covered with warm blankets, and transported without being placed in polyurethane bags. Delivery room temperatures were recorded so this potentially confounding variable could be assessed. RESULTS: Intervention patients were less likely than control patients to have temperature < 36.4 degrees C on admission , 44 vs 70% (p<0.01) and the intervention group had a higher mean admission temperature, 36.5 degrees C vs 36.0 degrees C (p<0.003). This effect remained significant (p<0.0001) when delivery room temperature was controlled in analysis. Warmer delivery room temperatures (>/=26 degrees C) were associated with higher admission temperatures in both intervention and control infants, but only the subgroup of intervention patients born in warmer delivery rooms had a mean admission temperature >36.4 degrees C. CONCLUSIONS: Placing infants <29 weeks gestation in polyurethane bags in the delivery room reduced the occurrence of hypothermia and increased their NICU admission temperatures. Maintaining warmer delivery rooms helped but was insufficient in preventing hypothermia in most of these vulnerable patients without the adjunctive use of the polyurethane bags.

A randomized, controlled trial to compare ketorolac tromethamine versus placebo after cesarean section to reduce pain and narcotic usage.

OBJECTIVE: The purpose of this study was to determine whether postcesarean section administration of ketorolac tromethamine reduces pain and narcotic usage. STUDY DESIGN: A double-blinded randomized, placebo-controlled trial of ketorolac tromethamine was performed. Patients were randomly assigned to receive either ketorolac tromethamine or placebo. Patient-controlled analgesia (PCA) was used for pain control. Visual analog scales (VAS) were administered postoperatively to assess pain levels. Morphine equivalents and attempts were recorded. RESULTS: There were 22 patients in each arm of the study. There was no significant difference between patient demographics, blood loss, and type of anesthesia. Pain scores were significantly different at 2, 3, 4, 6, 12, and 24 hours by analysis of variance (ANOVA) (P=.033). There was a significant decrease in pain medication usage (P=.008) in the study group. CONCLUSION: Ketorolac tromethamine is efficacious in reducing postoperative pain and narcotics usage after cesarean section.

Auditory temporal processing performance of young adults with reading disorders.

The present study investigated the temporal processing abilities of college students with diagnosed reading disorders. A behavioral test battery was used that involved discrimination of the pattern of presentation of tone triads in which individual components differed in either frequency or duration. An additional test involving measurement of frequency difference limens for long- and short-duration tones was also administered. The college students with reading disorders exhibited significantly higher error rates in discriminating duration patterns than the normal reading group. No group differences were found for the frequency pattern discrimination task. Both groups exhibited larger frequency difference limens with the shorter 20- and 50-ms tones than with the 200-ms tones. Significant correlations were found between reading ability measures and temporal processing abilities, specifically in word recognition and duration pattern processing, suggesting a relationship between lower level auditory temporal processing skills and decoding efficiency.