Enhancing availability of services to control hypertension through a team-based care approach that includes pharmacists.

BACKGROUND: Primary care physician (PCP) shortages are expected to increase. The Michigan Medicine Hypertension Pharmacists' Program uses a team-based care (TBC) approach to redistribute some patient care responsibilities from PCPs to pharmacists for patients with diagnosed hypertension. OBJECTIVE: This evaluation analyzed whether the Michigan Medicine Hypertension Pharmacists' Program increased the availability of hypertension management services and described facilitators that addressed barriers to program sustainability and replicability. METHODS: We conducted a retrospective observational study that used a mixed methods approach. We examined the availability of hypertension management services using the number of pharmacists' referrals of patients to other services and the number of PCP appointments. We analyzed qualitative interviews with program staff and site-level quantitative data to examine the program's impact on the availability of services, the impact of TBC that engaged pharmacists, and program barriers and facilitators. RESULTS: Patients who visited a pharmacist had fewer PCP visits over 3- and 6-month periods compared to a matched comparison group that did not see a pharmacist and were 1.35 times more likely to receive a referral to a specialist within a 3-month period. Support from leaders and physicians, shared electronic health record access, and financial backing emerged as leading factors for program sustainability and replicability. CONCLUSION: Adding pharmacists to the care team reduced the number of PCP appointments per patient while increasing the availability of hypertension management services; this may in turn improve PCPs' availability. Similar models may be sustainable and replicable by relying on organizational buy-in, accessible infrastructure, and financing.

Racial disparities in patients hospitalized for COVID-19.

BACKGROUND: The COVID-19 pandemic has demonstrated the significance of health disparities across populations with older adults and minoritized groups being disproportionately affected. Data during the COVID-19 pandemic demonstrated higher infection rates, hospitalization rates, morbidity, and potentially greater mortality in Black, Hispanic, and Native Americans compared to Whites. METHODS: This is a retrospective cohort study of de-identified patient data from 178 hospitals across the United States. Outcome variables were the length of stay, in-hospital mortality, disease severity, and discharge disposition. Outcomes were stratified by sex and racial groups. RESULTS: Of 45,360 patients, 22% were Black, 35% were Hispanic, 37% were White, and 6% were Other. The overall mortality rate was 15% across all groups but was 17% for White patients, 10% for Black patients, 14% for Hispanic patients, and 15% for patients categorized as Other. However, White patients have higher median age on admission (71 years) compared to Blacks (60 years), Hispanics (57 years), and Other (61 years). Race remained statistically significant in a multivariable model that included age, sex, and race. 6484 patients required ICU admission, intubation, and hemodynamic support. This burden was disproportionate across racial groups, with 15.6% of Blacks and 13.9% of non-Blacks having such critical disease (p < 0.0001, z-test for proportions). CONCLUSIONS: In this national study of admitted patients with COVID-19, White patients admitted were older on average compared to other racial/ethnic groups and had a higher mortality rate compared to non-Whites hospitalized for COVID-19. Black patients were significantly more likely to require admission to the ICU, mechanical ventilation, and hemodynamic support. These COVID-19 health disparities highlight the importance of addressing social and structural determinants of health.

Evaluation of a Pharmacists' Patient Care Process Approach for Hypertension.

INTRODUCTION: An estimated 116 million American adults (47.3%) have hypertension. Most adults with hypertension do not have it controlled-3 in 4 (92.1 million) U.S. adults with hypertension have a blood pressure ≥130/80 mmHg. The Pharmacists' Patient Care Process is a standardized patient-centered approach to the provision of pharmacist care that is done in collaboration with other healthcare providers. Through the Michigan Medicine Hypertension Pharmacists' Program, pharmacists use the Pharmacists' Patient Care Process to provide hypertension management services in collaboration with physicians in primary care and community pharmacy settings. In 2019, the impact of Michigan Medicine Hypertension Pharmacists' Program patient participation on blood pressure control was evaluated. METHODS: Propensity scoring was used to match patients in the intervention group with patients in the comparison group and regression analyses were then conducted to compare the 2 groups on key patient outcomes. Negative binomial regression was used to examine the number of days with blood pressure under control. The findings presented in this brief are part of a larger multimethod evaluation. RESULTS: More patients in the intervention group than in the comparison group achieved blood pressure control at 3 months (66.3% vs 42.4%) and 6 months (69.1% vs 56.5%). The intervention group experienced more days with blood pressure under control within a 3-month (18.6 vs 9.5 days) and 6-month period (57.0 vs 37.4 days) than the comparison group did. CONCLUSIONS: Findings support the effectiveness of the Michigan Medicine Hypertension Pharmacists' Program approach to implementing the Pharmacists' Patient Care Process to improve blood pressure control.

A Comparative Evaluation of Visual, Refractive, and Patient-Reported Outcomes of Three Extended Depth of Focus (EDOF) Intraocular Lenses.

OBJECTIVE: To compare visual, refractive, and patient-reported outcomes of patients implanted with one of three types of extended depth of focus (EDOF) intraocular lenses. SETTING: Asian Eye Institute, Philippines. DESIGN: Retrospective cohort study. METHODS: Subjects implanted with Symfony (Johnson and Johnson, USA), IC-8 (AcuFocus, USA), and WIOL (Medicem, Czech Republic) EDOF intraocular lenses were recruited. Spherical equivalent, uncorrected and corrected visual acuity, defocus curve, and modulation-transfer function, Strehl ratio, and visual Strehl optical transfer function values, photic phenomena, and questionnaire answers were measured and assessed. RESULTS: A total of 32 eyes with the Symfony lens, 30 with the IC-8 lens, and 32 with the WIOL lens were included in the study. Mean postoperative spherical equivalent was -0.24 D for the Symfony, -0.17 D for the IC-8, and 0.27 D for WIOL. There were no significant differences in postoperative monocular and binocular uncorrected and corrected visual acuity. On a monocular defocus curve, the IC-8 and Symfony showed significantly better vision than WIOL. The Symfony had significantly better modulation-transfer function, Strehl ratio, and visual Strehl optical transfer function. No difference was seen among the three lenses with regard to glare or starburst, while patient satisfaction remained high in all groups for far, intermediate, and near vision. CONCLUSION: All eyes implanted with the three EDOF designs achieved excellent far and intermediate vision, with acceptable near vision. The IC-8 and Symfony exhibited a better range of vision on defocus-curve testing. The Symfony showed superior results in quality of vision. Patient satisfaction was high in all three EDOF groups.

New Diagnoses among HIV+ Men and Women in Puerto Rico: Data from the HIV Surveillance System 2003-2014.

OBJECTIVE: Describe the age-standardized rates of new HIV diagnoses and compare sex and time disparities using data from the HIV/AIDS Surveillance System in Puerto Rico (PR). METHODS: The study comprises data of new HIV diagnoses of persons 13 years of age and older in PR reported from 2003-2014. Other variables included were age, sex, and health regions. We computed male to female ratio of new HIV diagnoses and assessed the trends in new HIV diagnoses using the annual percent change (APC) of the age-standardized rates (ASRs). The relative risk (RR) was estimated with 95% confidence intervals using Poisson regression models to assess the risk of new HIV diagnoses. RESULTS: The highest HIV diagnosis rates were observed in the metropolitan area. These rates decreased overall for both sexes for the periods 2007 onward. The risk of getting a new HIV diagnosis was significantly higher among males, ranging from an increased risk of more than 50% to almost 5-fold (p<0.05). Overall, a trend was observed in the 2011-2014 period were the risk increases as the age decreases. For the 13-24 age group, we observed a significant increased risk in new HIV diagnosis of 53% in the 2011-2014 period, when compared to 2003-2006 (p<0.05). CONCLUSION: Our findings suggest a shift in the risk of getting a HIV diagnosis from older to younger males. A possible explanation could be that HIV spread among young men that have sex with men might be increasing. Targeted prevention strategies should be implemented in this age group.

Comparison of clinical outcomes between femtosecond laser-assisted versus conventional phacoemulsification.

BACKGROUND: To compare femtosecond laser-assisted versus conventional phacoemulsification in terms of visual and refractive outcomes, cumulative dissipated energy, anterior chamber inflammation and endothelial cell loss. METHODS: In this retrospective cohort study, records of eyes that underwent femtosecond laser-assisted cataract surgery (FLACS) or conventional phacoemulsification (CP) were reviewed. The Victus femtosecond laser (Bausch and Lomb, Germany) was used to carry out corneal incisions, anterior capsulotomy, and lens fragmentation in FLACS procedures. Manifest refraction spherical equivalence (MRSE), uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), cumulative dissipated energy (CDE), postoperative cells and flare and endothelial cell count data were collected. Subgroup analysis of the visual acuity tests was performed based on the type of intraocular lens implanted (monofocal, monofocal toric, multifocal, multifocal toric, accommodating). RESULTS: A total of 735 eyes were included in the study (296 eyes for the FLACS group and 439 eyes for the CP group). At one year follow-up, 120 eyes comprised the FLACS group and 265 eyes for the CP group. MRSE in the FLACS group was - 0.16 ± 0.58 D and - 0.20 ± 0.52 D in the CP group (P = 0.50). UDVA in the FLACS group was 20/25 (mean logMAR 0.12 ± 0.13) and 20/25 (mean logMAR 0.11 ± 0.13) in the CP group (P = 0.48). CDVA was 20/20 (mean logMAR 0.03 ± 0.07) in the FLACS group and 20/20 (mean logMAR 0.02 ± 0.06) in the CP group (P = 0.15). No statistically significant trend was seen for FLACS versus CP by intraocular type for visual acuity. CDE for the different cataract grades ranged from 6.97 ± 5.74 to 29.02 ± 16.07 in the FLACS group and 7.59 ± 6.42 to 35.69 ± 18.30 in the CP group. The FLACS group was significantly lower for post-operative central corneal edema (P = 0.05), cells and flare (P = 0.01), and endothelial cell loss (P = 0.04). CONCLUSIONS: Femtosecond laser-assisted cataract surgery and conventional phacoemulsification had similar refractive and visual outcomes. Phacoemulsification energy, anterior chamber inflammation and corneal endothelial cell loss were less in the femtosecond laser group.

Giant Condylomata Acuminata of Buschke-Lowenstein Associated With Paraneoplastic Hypercalcemia.

Low-risk human papillomavirus types 6 and 11 can manifest as giant condylomata acuminata (GCA) of Buschke-Lowenstein. Up to 50% of GCA can slowly progress over years to fungating, invasive tumors. The malignant potential is attributed to unique immune evading abilities of the human papillomavirus. A 42-year-old male presented with pain and foul-smelling discharge from his genital warts. The histopathological examination of the mass showed invasive squamous cell carcinoma, and it was associated with paraneoplastic hypercalcemia. The timely removal of long-standing GCA in order to prevent a carcinomatous transition is a priority.

Original title: HIV infection and unawareness among men who have sex with men in Puerto Rico: data from The National HIV behavioral surveillance system 2011-2014.

BACKGROUND: Unawareness of HIV infection is a public health challenge that needs to be addressed, particularly in the case of men who have sex with men (MSM), since recent data are reporting increasing rates of HIV in this population in Puerto Rico. OBJECTIVES: We examined differences in the prevalence of HIV infection and unawareness among MSM in 2011 and 2014 using data from the National HIV Behavioral Surveillance System, 2011 and 2014. METHODS: Bivariate analyses was used to compare demographical and behavioral characteristics in both cycles (2011 and 2014). Prevalence ratio (PR) was assessed with Poisson regression models to determine changes in HIV prevalence and unawareness across cycles, using the 2011 NHBS-MSM cycle as reference group. RESULTS: A stable rate in HIV prevalence was observed in 2011 and 2014. There was a higher prevalence in 2014 than in 2011 in multiple behavioral characteristics such as age at sexual initiation, the number of sexual partners in the 12 months prior to being interviewed, HIV testing in the year prior to being interview, and the disclosure of sexual orientation to a healthcare provider. A significant decrease in HIV unawareness was reported (76.67%, 2011; 46.51%, 2014). Age-adjusted regression models showed a marginal reduction of 55% in HIV unawareness for men who disclosed their sexual orientation to their healthcare providers. CONCLUSION: Behavioral surveillance systems in groups such as MSM in on the island will aid to monitor prospectively the effectiveness of HIV testing outreach and engagement, as well as capacity capacity-building strategies targeted towards health care providers, aimed to increase HIV testing and awareness among this group.

Mortality Disparities among HIV+ Men and Women in Puerto Rico: Data from the HIV/AIDS Surveillance System 2003-2014.

OBJECTIVE: Describe the trend of the indirect standardized death rate of HIV for different modes of HIV transmission from 2003 to 2014 in Puerto Rico. Estimate the magnitude of the association between mode of HIV transmission and mortality at different time periods in Puerto Rico. METHODS: ISDRs by sex and mode of transmission were computed using data from the PR National HIV/AIDS Surveillance System (2003-2014). Poisson models were used to assess the annual percent change of the ISDRs and RRs by sex. RESULTS: Injection drug users (IDUs) showed the highest decrease in ISDR (-10.56, for men; -9.32 for women). Compared to men who have sex with men (MSM), IDU men also had the highest RR, representing an increase of 93% (2009-2011) (RRIDU vs MSM: 1.93, 95% CI: 1.66-2.23). Compared to women who were IDUs, heterosexual (HET) women had less risk of dying (48% for the period of 2006 to 2008). CONCLUSION: Mortality has been decreasing in each mode of transmission for both sexes. In addition, though IDUs present the highest decrease of ISDR, it is still the group whose members have the highest risk of dying, both men and women. To better describe health disparities as related to HIV/AIDS mortality, future analyses should be performed using specific causes of death and the evaluation of other relevant clinical and sociodemographic factors. Such data might increase our understanding of mortality in people with HIV/AIDS on the island, as well as help in future efforts to develop intervention strategies for the aforementioned risk groups.

A five-year review of refractive procedures, outcomes and complications

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To evaluate the visual and refractive outcomes of LASIK, PRK, phakic IOL, and Supracor as treatment for errors of refraction, including presbyopia, performed at a private eye center.<br /><br /><strong>METHODS:</strong> This is a retrospective, single-center, single-surgeon study that reviewed the surgical outcomes of patients who underwent LASIK, PRK, phakic IOL, and Supracor from January 2010 to December 2014. Main outcome measures were postoperative uncorrected and corrected distance, intermediate, and near visual acuity (for Supracor), and mean manifest-refraction spherical equivalent (MRSE) of patients who had at least 1 month follow up. Complications and enhancements were analyzed independently.<br /><br /><strong>RESULTS:</strong> Data were analyzed from 1,366 eyes of 771 patients. LASIK was the most commonly performed procedure (68%), followed by PRK (18.3%), Supracor (10.2%), and phakic IOL (3.7%). The postoperative mean MRSE at 1 month for LASIK, PRK, and phakic IOL were -0.08 ± 0.36, +0.06 ± 0.52 and -0.11 ± 0.44, respectively. The mean postoperative logMAR uncorrected distance visual acuity (UDVA) at 1 month for LASIK, PRK, and phakic IOL were 0.02 ± 0.10, 0.07 ± 0.12, 0.001 ± 0.09, respectively. In the Supracor group, the mean preoperative and postoperative spherical equivalent were +1.12 ± 0.8 and -0.76 ± 0.62, respectively. The mean postoperative logMAR UDVA and uncorrected near visual acuity (UNVA) for Supracor were 0.24 ± 0.19 and 0.02 ± 0.08, respectively. The most common postoperative complication was symptomatic dry eye (13%). Regression and off-target outcomes occurred in 24 (1.8%) and 13 eyes (1%), respectively. Overall enhancement rate was 2%.<br /><br /><strong>CONCLUSION:</strong> LASIK remained to be the most common refractive procedure, with femtosecond laser-created flap becoming the norm. Refractive and visual outcomes showed good efficacy with all the refractive procedures. Complication and enhancement rates were low.</p>

Demographic and clinical profile of patients who underwent refractive surgery screening

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To describe the demographic and clinical profile of patients who underwent refractive surgery screening.<br /><br /><strong>METHODS:</strong> Medical records of patients who sought consult for refractive surgery from January 2010 to December 2014 at a refractive center were reviewed and analyzed. The preoperative clinical conditions, optical characteristics of myopes and hyperopes, refractive screening tests, and causes for disqualification were determined.<br /><br /><strong>RESULTS:</strong> A total of 1215 patients who sought consult for refractive surgery had a mean age of 36.45 ± 11.60 years. Seven hundred ten (58.44%) were females and 860 (70.78%) were Filipinos. Nine hundred eighty eight (81%) were myopes. The mean manifest refractive spherical equivalent (MRSE) for myopic patients was -4.41D±2.98 with mean uncorrected distance vision (UCDVA) of 20/400 (logMAR 1.26) and mean best-corrected distance vision (BCDVA) of 20/20 (logMAR 0.02). For hyperopic patients, the mean MRSE was +1.33D±3.76 with mean UCDVA of 20/40 (logMAR 0.33) and mean BCDVA of 20/20 (logMAR 0.001). Reasons for disqualification from undergoing a refractive procedure included thin cornea (5.27%), irregular corneal topography (2.39%), steep cornea (0.78%), high refractive errors (0.41%), optic nerve (0.41%), and retina (0.25%) pathologies.<br /><br /><strong>CONCLUSION:</strong> Patients who underwent screening for refractive surgery were young, mostly female, with myopic refractive errors. LASIK remained the most popular refractive surgery procedure. </p>

Community health workers as an integral strategy in the REACH U.S. program to eliminate health inequities.

Mounting evidence indicates that community health workers (CHWs) contribute to improved behavioral and health outcomes and reductions in health disparities. We provide an overview (based on grantee reports and community action plans) that describe CHW contributions to 22 Racial and Ethnic Approaches to Community Health (REACH) programs funded by the Centers for Disease Control and Prevention from 2007 to 2012, offering additional evidence of their contributions to the effectiveness of community public health programs. We then highlight how CHWs helped deliver REACH U.S. community interventions to meet differing needs across communities to bridge the gap between health care services and community members, build community and individual capacity to plan and implement interventions addressing multiple chronic health conditions, and meet community needs in a culturally appropriate manner. The experience, skills, and success gained by CHWs participating in the REACH U.S. program have fostered important individual community-level changes geared to increase health equity. Finally, we underscore the importance of CHWs being embedded within these communities and the flexibility they offer to intervention strategies, both of which are characteristics critical to meeting needs of communities experiencing health disparities. CHWs served a vital role in facilitating and leading changes and will continue to do so.

Racial and ethnic approaches to community health: reducing health disparities by addressing social determinants of health.

Poor people and people of color are more likely to live shorter and sicker lives and are less likely to survive a host of chronic illnesses. Policies and organizational practices that improve the environments in which people live, work, learn, and play can reduce these disparities. Using the World Health Organization's "Call to Action" principles as a discussion framework, we highlight the Centers for Disease Control and Prevention's Racial and Ethnic Approaches to Community Health programs that have developed and applied such strategies to address chronic illnesses. Several, in turn, foster health equity.

Health promotion practice and the road ahead: addressing enduring gaps and encouraging greater practice-to-research translation.

A decade ago, Lancaster and Roe described four critical gaps (i.e., communications, accessibility, credibility, and expectations) between research and practice in health education and health promotion that formed the framework for this department. Despite considerable attention and some progress, these gaps persist and are barriers to interaction and translation between health promotion and health education research and practice. Looking to the next several years as the new Associate Editors for this department, we renew the department's commitment toward addressing these enduring gaps around which we frame new questions and invite continued dialogue.

Georgia's Utilization Minigrant Program: promoting Medicaid/CHIP outreach.

Funded community-based organizations improved utilization of children's health services by developing innovative staffing patterns, creating new data systems for scheduling appointments and maintaining records, and forging new collaborative relationships to leverage financial support. These strategies were rooted in collaboration with community-based organizations, health care providers, and the state Medicaid agency.

Obesity prevention and diabetes screening at local health departments.

OBJECTIVES: We assessed whether local health departments (LHDs) were conducting obesity prevention programs and diabetes screening programs, and we examined associations between LHD characteristics and whether they conducted these programs. METHODS: We used the 2005 National Profile of Local Health Departments to conduct a cross-sectional analysis of 2300 LHDs nationwide. We used multivariate logistic regressions to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Approximately 56% of LHDs had obesity prevention programs, 51% had diabetes screening programs, and 34% had both. After controlling for other factors, we found that employing health educators was significantly associated with LHDs conducting obesity prevention programs (OR = 2.08; 95% CI = 1.54, 2.81) and diabetes screening programs (OR = 1.63; 95% CI = 1.23, 2.17). We also found that conducting chronic disease surveillance was significantly associated with LHDs conducting obesity prevention programs (OR = 1.66; 95% CI = 1.26, 2.20) and diabetes screening programs (OR = 2.44; 95% CI = 1.90, 3.15). LHDs with a higher burden of diabetes prevalence were more likely to conduct diabetes screening programs (OR = 1.20; 95% CI = 1.11, 1.31) but not obesity prevention programs. CONCLUSIONS: The presence of obesity prevention and diabetes screening programs was significantly associated with LHD structural capacity and general performance. However, the effectiveness and cost-effectiveness of both types of programs remain unknown.

A distinct translation initiation mechanism generates cryptic peptides for immune surveillance.

MHC class I molecules present a comprehensive mixture of peptides on the cell surface for immune surveillance. The peptides represent the intracellular protein milieu produced by translation of endogenous mRNAs. Unexpectedly, the peptides are encoded not only in conventional AUG initiated translational reading frames but also in alternative cryptic reading frames. Here, we analyzed how ribosomes recognize and use cryptic initiation codons in the mRNA. We find that translation initiation complexes assemble at non-AUG codons but differ from canonical AUG initiation in response to specific inhibitors acting within the peptidyl transferase and decoding centers of the ribosome. Thus, cryptic translation at non-AUG start codons can utilize a distinct initiation mechanism which could be differentially regulated to provide peptides for immune surveillance.

Gap-based estimation: choosing the smoothing parameters for probabilistic and general regression neural networks.

Probabilistic neural networks (PNN) and general regression neural networks (GRNN) represent knowledge by simple but interpretable models that approximate the optimal classifier or predictor in the sense of expected value of the accuracy. These models require the specification of an important smoothing parameter, which is usually chosen by cross-validation or clustering. In this article, we demonstrate the problems with the cross-validation and clustering approaches to specify the smoothing parameter, discuss the relationship between this parameter and some of the data statistics, and attempt to develop a fast approach to determine the optimal value of this parameter. Finally, through experimentation, we show that our approach, referred to as a gap-based estimation approach, is superior in speed to the compared approaches, including support vector machine, and yields good and stable accuracy.

Health communications in rural America: lessons learned from an arthritis campaign in rural Arkansas.

CONTEXT: Lack of awareness about diseases and associated risk factors could partially account for some rural health disparities. Health communications campaigns can be an effective means of increasing awareness in these areas. PURPOSE: To review findings and lessons learned from a rural health communications campaign. METHODS: The health communications campaign titled "Physical Activity. The Arthritis Pain Reliever," developed by the Centers for Disease Control and Prevention, was implemented in a rural Arkansas county to promote awareness about arthritis and the beneficial effects of physical activity among residents 45-64 years of age with arthritis. The campaign was implemented through radio spots, print ads in local newspapers, and distribution of brochures and posters. A survey of 193 residents with arthritis assessed the reach of the campaign. FINDINGS: Whereas 86% of respondents reported having seen or heard the messages related to arthritis during the 13-week period of the campaign, only 11% recalled messages from the "Physical Activity. The Arthritis Pain Reliever" campaign. Challenges faced during campaign implementation included limited fiscal resources, distrust, and staff and time constraints. CONCLUSION: Challenges to health communications campaigns in rural areas can decrease campaign reach and effectiveness. If resource constraints exist, leveraging partnerships and building trust among residents of the community are important for achieving campaign success.