Antiplatelet treatment patterns and outcomes of secondary stroke prevention in the United States.

Objective: Patients who have an ischemic stroke (IS) or transient ischemic attack (TIA) are at risk of having a secondary stroke. Single antiplatelet therapy (SAPT) or dual antiplatelet therapy (DAPT) may be recommended for secondary stroke prevention (SSP), depending on severity and etiology. This study evaluated outpatient antiplatelet treatment patterns for SSP and outcomes after first hospitalization for IS/TIA among adults without atrial fibrillation in the United States. Materials and methods: This retrospective observational study utilized data from an adjudicated administrative health claims database. Eligible patients had an imputed National Institutes of Health Stroke Scale index event score ≤7. Over-the-counter medication use (eg, aspirin) was not captured. Results: Of 154,273 patients, 41,622 (27%) were prescribed antiplatelet therapy within 90 days of the event; 93.8% received SAPT, 6.1% received DAPT. The first line of antiplatelet therapy after discharge was started a mean of 17.0 days after the event; mean treatment duration was 61.9 days. The incidence rate for secondary IS was 5.53, 2.03, and 1.17 per person-year 90-days, 1-year, and 3-years following treatment initiation, respectively. Among patients matched for demographic and clinical characteristics, the risk of secondary IS was increased with DAPT versus SAPT (hazard ratio [95% CI]: 1.27 [1.20-1.34]; p < 0.0001). Conclusions: Many patients were not prescribed or discontinued antiplatelet therapy within 90 days of hospitalization for IS/TIA and, in most cases, prescriptions were not compliant with SSP consensus guidelines. Patients remained at risk for IS, which was highest within 90 days. More effective strategies for SSP are needed to improve outcomes in this patient population.

Characteristics, management, and blood pressure control in patients with apparent resistant hypertension in the US.

Background: Per treatment guidelines, resistant hypertension is defined as uncontrolled blood pressure (BP) while taking 3 concomitant antihypertensives (AHTs) or controlled BP while taking ≥4 AHTs. Characteristics, AHT therapy use, and BP control were analyzed in US patients with hypertension who were prescribed ≥3 classes of AHT medications. Methods: This retrospective analysis of the Optum® Electronic Health Record Database evaluated patients ≥18 years of age with a diagnosis of hypertension classified based on the number of prescribed AHT medication classes (3, 4, or ≥5). For the primary analysis, uncontrolled hypertension was defined as systolic BP (SBP) ≥140 mmHg or diastolic BP (DBP) ≥90 mmHg. For secondary analyses, uncontrolled hypertension was defined as SBP ≥130 mmHg or DBP ≥80 mmHg. Results: 207,705 patients with hypertension and concurrent use of ≥3 AHT medication classes were included. Diuretics, beta blockers, ACE inhibitors and/or ARBs, and CCBs were the most prescribed classes; thiazides and thiazide-like agents were the most prescribed diuretics. Among patients who were prescribed 3, 4, or ≥5 AHT medication classes, approximately 70% achieved a BP goal of <140/90 mmHg; approximately 40% achieved BP <130/80 mmHg. After ≥1 year of follow-up, the number of concurrent AHT medication classes was unchanged from baseline in the majority of patients and the prevalence of uncontrolled hypertension (≥140/90 mmHg) was similar. Conclusions: This study illustrates suboptimal BP control in many patients with apparent resistant hypertension despite the use of multidrug regimens and suggests a need for new drug classes and regimens that effectively manage resistant hypertension.

Production of zirconium-88 via proton irradiation of metallic yttrium and preparation of target for neutron transmission measurements at DICER.

A process for the production of tens to hundreds of GBq amounts of zirconium-88 (88Zr) using proton beams on yttrium was developed. For this purpose, yttrium metal targets (≈20 g) were irradiated in a ~16 to 34 MeV proton beam at a beam current of 100-200 µA at the Los Alamos Isotope Production Facility (IPF). The 88Zr radionuclide was produced and separated from the yttrium targets using hydroxamate resin with an elution yield of 94(5)% (1σ). Liquid DCl solution in D2O was selected as a suitable 88Zr sample matrix due to the high neutron transmission of deuterium compared to hydrogen and an even distribution of 88Zr in the sample matrix. The separated 88Zr was dissolved in DCl and 8 µL of the obtained solution was transferred to a tungsten sample can with a 1.2 mm diameter hole using a syringe and automated filling station inside a hot cell. Neutron transmission of the obtained 88Zr sample was measured at the Device for Indirect Capture Experiments on Radionuclides (DICER).

The "Medical Plot Thickens": Bad Medicine and Good Health in the Contagious Diseases Acts Repeal Campaign.

Britain's Contagious Diseases Acts (1864, 1866, 1869) mandated the use of medical detention and speculum exams to manage the bodies of "common prostitutes" and thereby reduce sexually transmitted diseases among enlisted men. Repeal advocates challenged the gendered power structure of the Acts but also used melodramatic frameworks to produce a broader critique of nineteenth-century Britain's centralizing medical orthodoxy and to argue for unregulated traditional approaches to medicine. Across a variety of repeal speeches and documents, advocates idealized alternative health practices in order to challenge institutionalized modern medicine and the governmental interests that extended its authority. J. J. Garth Wilkinson's Forcible Introspection of Women for the Army and Navy by the Oligarchy, Considered Physically (1870) exemplifies the multivocal and intertextual medicolegal plots of repeal melodrama as it cast professionalized modern medicine as corrupt, villainous, and in collusion with the state while presenting alternative medicine as authentically preventative, curative, and democratic.

Developing the 134Ce and 134La pair as companion positron emission tomography diagnostic isotopes for 225Ac and 227Th radiotherapeutics.

Developing targeted α-therapies has the potential to transform how diseases are treated. In these interventions, targeting vectors are labelled with α-emitting radioisotopes that deliver destructive radiation discretely to diseased cells while simultaneously sparing the surrounding healthy tissue. Widespread implementation requires advances in non-invasive imaging technologies that rapidly assay therapeutics. Towards this end, positron emission tomography (PET) imaging has emerged as one of the most informative diagnostic techniques. Unfortunately, many promising α-emitting isotopes such as 225Ac and 227Th are incompatible with PET imaging. Here we overcame this obstacle by developing large-scale (Ci-scale) production and purification methods for 134Ce. Subsequent radiolabelling and in vivo PET imaging experiments in a small animal model demonstrated that 134Ce (and its 134La daughter) could be used as a PET imaging candidate for 225AcIII (with reduced 134CeIII) or 227ThIV (with oxidized 134CeIV). Evaluating these data alongside X-ray absorption spectroscopy results demonstrated how success relied on rigorously controlling the CeIII/CeIV redox couple.

Lifetime benefits of early detection and treatment of diabetic kidney disease.

OBJECTIVES: Diabetic kidney disease (DKD) is a frequent complication of diabetes with potentially devastating consequences that may be prevented or delayed. This study aimed to estimate the health and economic benefit of earlier diagnosis and treatment of DKD. METHODS: Life expectancy and medical spending for people with diabetes were modeled using The Health Economics Medical Innovation Simulation (THEMIS). THEMIS uses data from the Health and Retirement Study to model cohorts of individuals over age 50 to project population-level lifetime health and economic outcomes. DKD status was imputed based on diagnoses and laboratory values in the National Health and Nutrition Examination Survey. We simulated the implementation of a new biomarker identifying people with diabetes at an elevated risk of DKD and DKD patients at risk of rapid progression. RESULTS: Compared to baseline, the prevalence of DKD declined 5.1% with a novel prognostic biomarker test, while the prevalence of diabetes with stage 5 chronic kidney disease declined 3.0%. Consequently, people with diabetes gained 0.2 years in life expectancy, while per-capita annual medical spending fell by 0.3%. The estimated cost was $12,796 per life-year gained and $25,842 per quality-adjusted life-year. CONCLUSIONS: A biomarker test that allows earlier treatment reduces DKD prevalence and slows DKD progression, thereby increasing life expectancy among people with diabetes while raising healthcare spending by less than one percent.

Preliminary Evaluation of a Novel Rigid Bronchoscopy Simulator.

PURPOSE: Emergent retrieval of airway foreign bodies (AFBs) in children remains a priority skill set for pediatric surgeons. In the setting of low procedural volume, simulation-based education with deliberate practice is essential to ensure trainees reach expected surgical competency. The purposes of this work were to (1) create a realistic rigid bronchoscopy for AFB retrieval simulation model and (2) to evaluate preliminary validity evidence of a novel simulator for the use of training and assessing pediatric surgical trainees' rigid bronchoscopy skills. METHODS: After institutional review board exemption determination, 18 participants performed AFB retrieval of two different objects on a novel simulator that represented an 18-month-old pediatric tracheobronchial airway. Participants reported their experience and comfort level, and rated the simulator across two domains-Authenticity and their Ability to perform tasks. Authenticity was measured by 23 items across five subdomains (Visual Attributes, Materials' Response, Realism of Experience, Value and Relevance, and Global Value). Participants who had previously performed ≥10 rigid bronchoscopies were categorized as "experienced," while those reporting <10 were considered "novice." Validity evidence relevant to test content and internal structure was evaluated using a many-facet Rasch model. RESULTS: Novice surgeons (n = 12) had previously performed a mean of 2.7 (±2.0) rigid bronchoscopies, compared to 15.4 (±7.7) by experienced surgeons (n = 6). For both models, the Value and Relevance subdomain received the highest ratings (observed average [OA] = 3.9, while Materials' Response received the lowest (OA <3.0). Participants' Global Value rating for this model was consistent with "requires minor improvements before it can be considered for use in rigid bronchoscopy training." CONCLUSIONS: We successfully designed, assembled, and evaluated a novel pediatric rigid bronchoscopy model for AFB retrieval. The model was considered as relevant to educational needs and valuable as a testing and training tool. With recommended improvements, the model could be used for implementation with a Mastery Learning curriculum.

Evaluation of a pediatric fluoroscopy training module to improve performance of upper gastrointestinal procedures in neonates with bilious emesis.

BACKGROUND: Life-threatening midgut volvulus usually occurs in infants with malrotation and requires rapid diagnosis and surgical treatment to prevent bowel necrosis and death. However, because of the low frequency of upper gastrointestinal studies performed in infants younger than 1 month, many diagnostic radiology residents finish their residency training having limited or no opportunity to perform or observe an upper gastrointestinal (GI) series for evaluation of bilious emesis in a neonate. OBJECTIVE: To determine whether adding simulated upper GI series on neonates with bilious emesis to the curriculum improves residents' skill and accuracy in diagnosing midgut volvulus. MATERIALS AND METHODS: We assessed the performance of 12 residents in training whose curriculum included simulated upper GI series (study group) and 10 traditionally trained residents (control group) using a multiple-choice test, checklist procedure evaluation and diagnostic accuracy scores for 3 randomly selected simulated upper GI series. We then compared the results from the study group that had simulation curriculum to the scores for the control group using the Mann-Whitney test. We also analyzed the scores for the study group obtained prior to and after simulation curriculum using Wilcoxon signed rank test. RESULTS: There was a significant difference in test scores (study group median = 84.5%, control group median = 67.2%, P=0.001), overall diagnostic accuracy (study group median = 100%, control group median = 50%, P=0.011) and checklist evaluation (study group median = 83.3%, control group median = 70.8%, P=0.025) for the residents in the study group who completed simulation curriculum compared with the control group. There was also a significant difference in multiple-choice test scores for the study group before and after completion of simulation curriculum (before simulation curriculum median = 56.9%, after simulation curriculum median = 84.5%, P=0.002), checklist evaluation (before simulation curriculum median = 58.3%, after simulation curriculum median = 83.3%, P=0.002) and overall diagnostic accuracy scores (before simulation curriculum median = 50%, after simulation curriculum median = 100%, P=0.024). CONCLUSION: Radiology residents had significantly higher scores on a multiple-choice test, checklist procedure evaluation and overall diagnostic accuracy after completing a structured pediatric fluoroscopy curriculum that included simulated neonatal upper GI series and when compared to a control group of traditionally trained residents.

Upper gastrointestinal fluoroscopic simulator for neonates with bilious emesis.

Prompt diagnosis of malrotation and midgut volvulus in infants with bilious emesis is critical. However because of the limited frequency of pediatric upper gastrointestinal (UGI) fluoroscopic procedures in neonates, many diagnostic radiology residents complete their training never having seen or performed a UGI on a baby for evaluation of malrotation and midgut volvulus. A UGI simulation model for infants with bilious emesis was created to supplement the hands-on fluoroscopic experience of residents in training. We are now studying the addition of simulated UGI studies to our pediatric radiology curriculum.

Feasibility of a virtual learning collaborative to implement an obesity QI project in 29 pediatric practices.

BACKGROUND: Quality improvement (QI) activities are required to maintain board certification in pediatrics. However, because of lack of training and resources, pediatricians may feel overwhelmed by the need to implement QI activities. Pediatricians also face challenges when caring for overweight and obese children. OBJECTIVE: To create a virtual (online) QI learning collaborative through which pediatric practices could easily develop and implement a continuous QI process. DESIGN: Prospective cohort. PARTICIPANTS: Pediatric practices that were part of the Children's National Health Network were invited to participate, with the option to receive continuing medical education and maintenance of certification credits. INTERVENTION: s) Practices conducted baseline and monthly chart audits, participated in educational webinars and selected monthly practice changes, using Plan-Do-Study-Act cycles. Practices reported activities monthly and periodic feedback was provided to practices about their performance. MAIN OUTCOME MEASURE: s) Improvement in (i) body mass index (BMI) percentile documentation, (ii) appropriate nutritional and activity counseling and (iii) follow-up management for high-risk patients. RESULTS: Twenty-nine practices (120 providers) participated, and 24 practices completed all program activities. Monthly chart audits demonstrated continuous improvement in documentation of BMI, abnormal weight diagnosis, nutrition and activity screening and counseling, weight-related health messages and follow-up management of overweight and obese patients. Impact of QI activities on visit duration and practice efficiency was minimal. CONCLUSION: A virtual learning collaborative was successful in providing a framework for pediatricians to implement a continuous QI process and achieve practice improvements. This format can be utilized to address multiple health issues.

Medicare Part D: state and local efforts to assist vulnerable beneficiaries.

Medicare Part D became available in 2006, offering millions of Americans the potential for improved access to medications. Certain aspects of the program have been problematic or confusing for vulnerable beneficiaries, but creative efforts across the country have helped individuals obtain and use the Part D benefit. Coalitions supply the information, training, and support that community partners need for outreach, education, and enrollment activities. Trusted local organizations provide one-on-one counseling for culturally and linguistically diverse populations. States have expanded eligibility criteria for the Medicare Savings Programs, thereby increasing the pool of beneficiaries deemed eligible for the Part D Low-Income Subsidy. In redesigning state-funded prescription programs, states fill coverage gaps for beneficiaries and extend coverage for others. Wider use of these practices has the potential to substantially improve the Medicare Part D program for the most vulnerable beneficiaries. Achieving this, however, will require continued and enhanced federal and state support.

Medicare Advantage: options for standardizing benefits and information to improve consumer choice.

The Medicare Advantage (MA) program offers beneficiaries a choice of private health plans as alternatives to the traditional fee-for-service Medicare program. MA plans potentially provide additional value, but as plan choices have proliferated, consumers contemplating their options have had difficulty understanding how they differ. Through "standardization" more consistent types of information and a limited number of dimensions along which plans vary--MA plans could reduce complexity and improve beneficiaries' ability to make informed choices. Such standardization steps would offer more meaningful variation in the health coverage options available to beneficiaries, Medicare officials and their community partners would find it far easier to educate beneficiaries about their health plan choices, and beneficiaries would better understand what they were buying. Standardization might also strengthen the ability of the market-based Medicare Advantage program to incorporate beneficiary preferences.

Employers' benefits from workers' health insurance.

Even though many employers believe that health insurance and health affect employees' productivity and firms' performance, health economists typically overlook and rarely measure firms' returns on health-related investments. Some research, however, suggests that firms may benefit economically by providing health insurance coverage for workers and their families. For example, health coverage may help employers recruit and retain high-quality workers. Health may contribute to productivity by reducing the costs of absenteeism and turnover and by increasing workers' productivity. This article reviews the evidence and proposes an agenda for future research. A better understanding of the benefits to employers of offering health coverage to workers may help clarify employers' behavior and help private employers and public officials make appropriate investments in health.