IgA and IgG antineutrophil cytoplasmic antibody engagement of Fc receptor genetic variants influences granulomatosis with polyangiitis.

Granulomatosis with polyangiitis (Wegener's) is a rare autoimmune neutrophil-mediated vasculitis that can cause renal disease and mucosal manifestations. Antineutrophil cytoplasmic antibodies (ANCA) are present in many patients, vary in level over time, and induce neutrophil activation through engagement with Fc receptors (FcRs). Given roles for FcRs in ANCA-mediated neutrophil activation and IgA antibodies in mucosal immunity, we hypothesized that FcR genetics and previously unappreciated IgA ANCA affect clinical presentation. We assembled a total of 673 patients and 413 controls from two multicenter cohorts, performed ELISA and immunofluorescence assays to determine IgA and IgG ANCA positivity, and used Illumina, TaqMan, or Pyrosequencing to genotype eight haplotype-tagging SNPs in the IgA FcR (FCAR) and to determine NA1/NA2 genotype of FCGR3B, the most prevalent neutrophil IgG FcR. We evaluated neutrophil activation by measuring degranulation marker CD11b with flow cytometry or neutrophil extracellcular trap formation with confocal microscopy. Functional polymorphisms in FCGR3B and FCAR differed between patient groups stratified by renal involvement. IgA ANCA were found in ∼30% of patients and were less common in patients with severe renal disease. Neutrophil stimulation by IgA or IgG ANCA led to degranulation and neutrophil extracellcular trap formation in a FcR allele-specific manner (IgA:FCAR P = 0.008; IgG:FCGR3B P = 0.003). When stimulated with IgA and IgG ANCA together, IgG ANCA induced neutrophil activation was reduced (P = 0.0001). FcR genotypes, IgA ANCA, and IgG ANCA are potential prognostic and therapeutic targets for understanding the pathogenesis and presentation of granulomatosis with polyangiitis (Wegener's).

Comparison of traditional and nontraditional weight loss methods: an analysis of the national health and nutrition examination survey.

OBJECTIVES: To evaluate the real-world use of various weight loss techniques and to compare the effectiveness of nontraditional methods with diet and exercise in helping nongeriatric adults lose weight. METHODS: A cross-sectional analysis of the 2005-2010 National Health and Nutrition Examination Survey was performed. Adult, nonpregnant participants aged 20 to 65 years with a body mass index of ≥ 18.5 who tried to lose weight in the previous year were analyzed (weighted n = 53,570,979). Outcome measures included the proportion of patients who used nontraditional weight loss methods and a comparison of weight loss between those who used diet and exercise and those who used nontraditional methods. RESULTS: During the previous year, 56.9% (95% confidence interval 54.5-59.4) of participants used nontraditional methods (nonexclusive of diet and exercise) as their attempted weight loss methods. Overall, individuals gained a mean (standard error) of 4.9 (0.3) lb in the 12 months preceding the National Health and Nutrition Examination Survey questionnaire. Only 19.6% (95% confidence interval 18.0-21.2) of the sample lost weight within the previous 12 months. Those who used nontraditional methods gained more weight during the previous year than those who used diet and exercise only (for body mass index ≥ 18.5, 5.5 vs 3.5 lb; P < 0.01) in the overall sample, but there was no difference in the obese subgroup. CONCLUSIONS: Physicians need to reaffirm that diet and exercise are better methods for weight loss, and they need to advise their patients to avoid other methods when attempting to lose weight because they do not enhance weight loss attempts.

Inpatient bariatric surgery among eligible black and white men and women in the United States, 1999-2010.

OBJECTIVES: We examined national trends in bariatric surgery for adults, focusing on differences in utilization by race and access to health care. METHODS: We analyzed subjects eligible for bariatric surgery in the National Hospital Discharge Survey and the National Health and Nutrition Examination Survey for 1999-2010. Primary outcome measures included population-based estimates and comparison of blacks and whites eligible for surgery with those who actually received it. RESULTS: A higher percentage of black than white women and of black than white men were eligible for bariatric surgery. But a higher proportion of eligible white women and men than black women and men received bariatric surgery. 69.8% of eligible white women and 72.9% of white women who received bariatric surgery had private health insurance, compared with 49.9% and 71.1% of black women. 71.4% of eligible white men and 75.9% of white men who received bariatric surgery had private health insurance, compared with 52.4% and 74.7% of black men. Among men eligibility and surgery rates were lower than for women of the same race, and significant differences were found by race in the same directions as for women. CONCLUSIONS: Eligible whites received bariatric surgery at higher levels than eligible blacks, apparently partly because of differences in insurance coverage.

Calcium channel blocker use and serum ferritin in adults with hypertension.

Iron overload cardiomyopathy is becoming more prevalent, and early recognition and intervention may alter outcomes. Calcium channels are key transporters of iron under iron-overloaded conditions, and potentially represent a new therapeutic target for iron overload. The purpose of this study was to examine the relationship between Calcium channel blocker (CCB) use and serum ferritin among adults with diagnosed hypertension. We analyzed the nationally representative NHANES (National Health and Nutrition Examination Survey) 1999-2002 for adults ≥40 years with diagnosed hypertension. The association between CCBs and serum ferritin was assessed using a t-test and adjusted multiple regressions.The study population included 2143 individuals (representing 37.4 million individuals, 42.0 % males). 12.6 % of the population reported taking CCBs in the last month. Individuals taking CCBs had lower mean serum ferritin (129.3 ng/mL versus 154.5 ng/mL, p = 0.02). After adjusting for age, sex, menopause and hysterectomy status for women, race/ethnicity, and C-reactive protein, mean serum ferritin for individuals taking CCBs was 26.3 ng/mL lower than for those not taking CCBs (p = 0.01). In an adjusted regression, individuals who took CCBs and had a daily vitamin C intake of ≥500 mg had a mean serum ferritin that was 60.1 ng/mL lower than people not taking CCBs and with daily vitamin C < 500 mg (p < 0.001). In conclusion, this study found an association between use of CCBs and lower serum ferritin levels in individuals with hypertension. Further studies are needed to assess the possible use of CCBs as non-traditional chelating agents for treatment of iron overload cardiomyopathy.

Cardiovascular and diabetes risk perception in a Hispanic community sample.

PURPOSE: We examined perceptions of 10-year coronary heart disease (CHD) risk or likelihood of having undiagnosed diabetes or impaired fasting glucose (IFG) with actual risk in a community sample of Hispanic adults. METHODS: We conducted a survey of 183 Hispanic adults (> or =18 years) recruited at community events around Charleston, SC. Likelihood of having undiagnosed diabetes/IFG as well as 10-year CHD risk were calculated. Perceived risk was assessed with questions based on the Risk Perception Survey-Diabetes Mellitus. RESULTS: Over half of respondents (54.8%) underestimated their likelihood of undiagnosed diabetes/IFG and 14.8% underestimated their 10-year CHD risk. Older and overweight respondents were more likely to underestimate their likelihood of undiagnosed diabetes/IFG. Respondents with family history of diabetes were the least likely to underestimate their likelihood of current undiagnosed diabetes/IFG. Respondents with diagnosed hypertension, diabetes, high cholesterol or a family history of heart attack were more likely to underestimate their 10-year CHD risk. Men were more likely to underestimate their risk for diabetes/IFG and CHD risk. CONCLUSIONS: Health education to improve accurate risk perception could improve health promotion for this population.

Academic family physicians' perception of genetic testing and integration into practice: a CERA study.

BACKGROUND AND OBJECTIVES: Genetic testing for a variety of diseases is becoming more available to primary care physicians, but it is unclear how useful physicians perceive these tests to be. We examined academic family physicians' perception of and experiences with clinical genetic testing and direct-to-consumer genetic testing. METHODS: This study is an analysis of a survey conducted as part of the Council of Academic Family Medicine Educational Research Alliance (CERA). Academic family physicians in the United States and Canada were queried about their perception of genetic testing's utility, how frequently patients ask about genetic testing, and the importance of genetic testing in future practice and education of students and residents. RESULTS: The overall survey had a response rate of 45.1% (1,404/3,112). A majority (54.4%) of respondents felt that they were not knowledgeable about available genetic tests. Respondents perceived greater utility of genetic tests for breast cancer (94.9%) and hemochromatosis (74.9%) than for Alzheimer's disease (30.3%), heart disease (25.4%), or diabetes (25.2%). Individuals with greater self-perceived knowledge of genetic tests were more likely to feel that genetic testing would have a significant impact on their future practice (23.1%) than those with less knowledge (13.4%). Respondents had little exposure to direct-to-consumer genetic tests, but a majority felt that they were more likely to cause harm than benefit. CONCLUSIONS: Academic family physicians acknowledge their lack of knowledge about genetic tests. Educational initiatives may be useful in helping them incorporate genetic testing into practice and in teaching these skills to medical students and residents.

Factors affecting HPV vaccine use among recent family medicine residency graduates.

BACKGROUND AND OBJECTIVES: Many adolescents seek care by family physicians for well visits and have the opportunity for HPV vaccination during these visits. Limited information is available regarding what affects physicians in offering the vaccine. The purpose of this study was to examine factors that affect family physician administration of the HPV vaccine. METHODS: We used a mail survey of recent graduates from family medicine residencies affiliated with the South Carolina Area Health Education Consortium. RESULTS: The response rate was 51.3%. Almost 79% offer the HPV vaccine at least most of the time to their adolescent female patients in their practice. Approximately 83% of respondents reported supporting the use of the HPV vaccine in males, but less than 8% reported having actually offered the vaccine to males. Those physicians who are female (OR=8.95, 95% CI=1.56--51.3), practice full time in an office setting (OR=9.08, 95% CI=1.71--48.3), are involved in teaching (OR=8.86, 95% CI=1.75--44.9), and practice in a family medicine setting (OR=8.20, 95% CI=1.69-39.8) had greater odds of offering the vaccine. Those who currently practiced in the southeastern United States were less likely to offer the vaccine (OR=0.04, 95% CI=0.002--0.59). CONCLUSIONS: Recent graduates of family medicine training programs frequently offer the HPV vaccine to adolescent females. Multiple practice factors affected the odds of offering the vaccine. Though most respondents agree with using the vaccine in males, most do not offer it to males.

Impact of quality improvement training during residency on current practice.

BACKGROUND AND OBJECTIVES: Quality improvement (QI) has become an integral aspect of family medicine residency training. This study examines whether QI training during residency is associated with the integration of QI activities into practice following graduation. METHODS: A confidential survey was delivered to South Carolina Area Health Education Consortium (SC AHEC)-associated family medicine residency program graduates from 2005--2009. The survey evaluated QI training during residency, as well as the following QI activities in current practice: periodic patient care data review, patient care registries, specific QI projects, disease-specific QI activities, National Committee on Quality Assurance (NCQA) Recognition, having staff QI leaders, and participation in a Practice-based Research Network (PBRN). Proportions were compared using chi-square tests. Stepwise logistic regressions were performed to identify variables predictive of specific QI activities in practice. RESULTS: The response rate was 51.3% (n=136). Most participants received QI training (75.8%) and currently participated in at least one QI activity (87.1%). PBRN involvement and having staff QI leaders was associated with involvement in all other QI activities. QI training was associated with periodic patient care data review (odds ratio (OR)=3.32; 95% confidence interval (CI)=1.26--8.78) and performing specific QI projects (OR=3.17; 95% CI=1.09--9.23). CONCLUSIONS: QI training during residency is associated with involvement in specific QI activities following graduation. Further, participation in a PBRN or having staff QI leaders is also associated with involvement in QI activities. Further evaluation of residency QI curricula is warranted to identify effective strategies that positively impact future practice.

Preparation for practice in family medicine: before and after duty hours.

BACKGROUND AND OBJECTIVES: In July of 2003, the Accreditation Council for Graduate Medical Education (ACGME) adopted requirements limiting the duty hours of resident physicians. The impact of these restrictions on education and patient care activities is not clear. The purpose of this study is to examine the perception of graduates of family medicine residency programs immediately prior to and following implementation of duty hours regarding preparedness to practice and board certification status, as well as current patient care activities. METHODS: Surveys of graduates of family medicine residency programs in South Carolina were conducted. Preparation for practice and professional activities of program graduates prior to (1999--2003) and following (2005--2009) implementation of duty hours were compared. RESULTS: Response rates were 54.4% and 53.1%, respectively. No significant differences by survey years in the average age, gender, or race was noted. Recent graduates felt as well prepared for practice in most curricular areas except surgery (OR=0.50 [0.27, 0.91]) and performed similar procedures with the following exceptions: central line placement (OR=0.32 [0.11, 0.95]), flexible sigmoidoscopy (OR=0.12 [0.02, 0.80]), ICU care (OR=0.39 [0.22, 0.70]), and ventilator management (OR=0.54 [0.29, 0.99]). Higher proportion of recent graduates do not take after hours call (22.3% versus 8.6%). Similarly, fewer recent graduates care for patients in nursing homes (22.0% versus 44.9%) and hospitals (46.2% versus 68.0%). CONCLUSIONS: Implementation of resident duty hours appears to have little overall association with self-reported preparedness for practice. An association was noted in the patient care services and procedures performed.

Graduate medical education and primary care workforce: a CERA study.

BACKGROUND: In the next 10 to 15 years, the Association of American Medical Colleges (AAMC) estimates a shortage of physicians. In conjunction, the demand for primary care physicians will increase, the type of physician associated with better population health at lower health care costs. The objective of this study is to examine the opinions of family medicine residency directors (FMRD) regarding the potential impact of recent publicized recommendations on the primary care physician workforce in the United States. METHODS: This project is part of a larger CERA omnibus survey with survey methods and sample demographics presented previously. Additional analysis was conducted using chi square and logistic regression using type of residency, size of community, years as program director, year program began, gender, and geographic region as predictors of agreement. RESULTS: A large proportion of responding FMRD disagree or strongly disagree that increasing medical school size or number of total resident positions in all specialties would result in an increase in the number of medical school graduates choosing a career in primary care Most respondents feel that increasing compensation for those practicing in primary care would have greatest impact on increasing medical school graduates who choose primary care. A minority of responding directors feel the length of family medicine residency training should be 4 years. DISCUSSION: While numerous recommendations have recently been made, most responding FMRD feel that changing reimbursement for primary care physicians would have the greatest impact on the workforce.