David C. Aron

Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts. The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct. The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.

Unnecessary use of antimicrobials contributes to the emergence and dissemination of antimicrobial-resistant nosocomial pathogens in part through elimination of normal anaerobic bacterial flora that inhibit overgrowth of pathogenic microorganisms.A prospective observational study was conducted in a 650-bed, university-affiliated hospital. All adult nonintensive care inpatients for whom new antimicrobials were prescribed during a 2-week period were monitored throughout their hospitalization. We examined how often antimicrobials, in particular those with antianaerobic activity, were used unnecessarily. The reasons for unnecessary therapy were assessed and common patterns of unnecessary use were identified.A total of 1941 antimicrobial days of therapy were prescribed for 129 patients. A total of 576 (30%) of the 1941 days of therapy were deemed unnecessary. The most common reasons for unnecessary therapy included administration of antimicrobials for longer than recommended durations (192 days of therapy), administration of antimicrobials for noninfectious or nonbacterial syndromes (187 days of therapy), and treatment of colonizing or contaminating microorganisms (94 days of therapy). Antianaerobic agents accounted for 203 (35%) of the 576 unnecessary antimicrobial days of therapy, and these agents were also frequently prescribed (98 days of therapy) when equally efficacious alternative regimens with minimal antianaerobic activity were available.In our institution, hospitalized patients frequently received unnecessary antimicrobial therapy, and antianaerobic agents were often prescribed when this spectrum of activity was not indicated.

Abstract We examined the frequency of acquisition of bacterial pathogens on investigators' hands after contacting environmental surfaces near hospitalized patients. Hand imprint cultures were positive for one or more pathogens after contacting surfaces near 34 (53%) of 64 study patients, with Staphylococcus aureus and vancomycin-resistant Enterococcus being the most common isolates.

THE finding of an adrenal mass in the course of abdominal computerized tomography (CT) performed for other reasons poses an increasingly common clinical problem. The prevalence of such incidentally recognized masses ranges from 0.6 to 1.3 percent.1 2 3 An autopsy study performed in conjunction with one study of CT scans revealed a 1.9 percent prevalence of cortical adenoma in patients for whom no evidence of endocrinopathy was recorded during life.2 In addition, a single pheochromocytoma was found (prevalence, 0.1 percent). Another autopsy study found an 8.7 percent prevalence of adrenocortical adenoma.4 These data suggest that as scanning techniques continue to improve, . . .

Changing clinical practice is a difficult process, best illustrated by the time lag between evidence and use in practice and the extensive use of low-value care. Existing models mostly focus on the barriers to learning and implementing new knowledge. Changing clinical practice, however, includes not only the learning of new practices but also unlearning old and outmoded knowledge. There exists sparse literature regarding the unlearning that takes place at a physician level. Our research objective was to elucidate the experience of trying to abandon an outmoded clinical practice and its relation to learning a new one.We used a grounded theory-based qualitative approach to conduct our study. We conducted 30-min in-person interviews with 15 primary care physicians at the Cleveland VA Medical Center and its clinics. We used a semi-structured interview guide to standardize the interviews.Our two findings include (1) practice change disturbs the status quo equilibrium. Establishing a new equilibrium that incorporates the change may be a struggle; and (2) part of the struggle to establish a new equilibrium incorporating a practice change involves both the "evidence" itself and tensions between evidence and context.Our findings provide evidence-based support for many of the empirical unlearning models that have been adapted to healthcare. Our findings differ from these empirical models in that they refute the static and unidirectional nature of change that previous models imply. Rather, our findings suggest that clinical practice is in a constant flux of change; each instance of unlearning and learning is merely a punctuation mark in this spectrum of change. We suggest that physician unlearning models be modified to reflect the constantly changing nature of clinical practice and demonstrate that change is a multi-directional process.

Clinical interviewing is the basic method to understand how a person feels and what are the presenting complaints, obtain medical history, evaluate personal attitudes and behavior related to health and disease, give the patient information about diagnosis, prognosis, and treatment, and establish a bond between patient and physician that is crucial for shared decision making and self-management. However, the value of this basic skill is threatened by time pressures and emphasis on technology. Current health care trends privilege expensive tests and procedures and tag the time devoted to interaction with the patient as lacking cost-effectiveness. Instead, the time spent to inquire about problems and life setting may actually help to avoid further testing, procedures, and referrals. Moreover, the dialogue between patient and physician is an essential instrument to increase patient’s motivation to engage in healthy behavior. The aim of this paper was to provide an overview of clinical interviewing and its optimal use in relation to style, flow and hypothesis testing, clinical domains, modifications according to settings and goals, and teaching. This review points to the primacy of interviewing in the clinical process. The quality of interviewing determines the quality of data that are collected and, eventually, of assessment and treatment. Thus, interviewing deserves more attention in educational training and more space in clinical encounters than it is currently receiving.

No AccessJournal of UrologyCLINICAL UROLOGY: Original Articles1 Mar 2000SEXUAL FUNCTION IN MEN WITH DIABETES TYPE 2: ASSOCIATION WITH GLYCEMIC CONTROL JUNE H. ROMEO, ALLEN D. SEFTEL, ZUHAYR T. MADHUN, and DAVID C. ARON JUNE H. ROMEOJUNE H. ROMEO , ALLEN D. SEFTELALLEN D. SEFTEL , ZUHAYR T. MADHUNZUHAYR T. MADHUN , and DAVID C. ARONDAVID C. ARON View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)67805-6AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: We evaluated the association of glycemic control with erectile dysfunction in men with diabetes type 2. Materials and Methods: A convenience sample of men with diabetes type 2 at the Cleveland Veterans Affairs Medical Center completed questions 1 to 5 of the International Index of Erectile Function. The primary outcome measure was erectile function score, calculated as the sum of questions 1 to 5. Details of disease duration, complications, medication use, patient age and level of glycosylated hemoglobin were obtained by reviewing the medical record. Results: Mean subject age plus or minus standard deviation was 62.0 ± 12.3 years, mean hemoglobin A1c was 8.1% ± 1.9% and mean erectile function score was 16.6 ± 5.9 (range 5 to 23). Stratified analysis revealed that mean erectile function score decreased as hemoglobin A1c increased (analysis of variance p = 0.002). The test for linearity was also significant (p = 0.001). There were no statistically significant associations of levels of glycemic control with α-blocker, β-blocker or diuretic use. Bivariate analysis showed a significant correlation of hemoglobin A1c with neuropathy but not with patient age, duration of diabetes, α-blockers, β-blockers or diuretics. Multivariate analysis demonstrated that hemoglobin A1c was an independent predictor of erectile function score (p <0.001) even after adjusting for peripheral neuropathy, which was also an independent predictor (p = 0.023). Conclusions: Our data add to the growing body of literature suggesting that erectile dysfunction correlates with the level of glycemic control. Peripheral neuropathy and hemoglobin A1c but not patient age were independent predictors of erectile dysfunction. References 1 : Impotence in diabetes: the neurologic factor. Ann Intern Med1971; 75: 213. Google Scholar 2 : Sexual dysfunction in diabetic men. Diabetes1974; 23: 306. Google Scholar 3 : The prevalence of diabetic impotence. Diabetologia1980; 18: 279. Google Scholar 4 : Prevalence of self-reported erectile dysfunction in people with long-term IDDM. Diabetes Care1996; 19: 135. Google Scholar 5 : Erectile dysfunction in men with and without diabetes mellitus: a comparative study. Diabet Med1996; 13: 84. 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Diabet Med1995; 12: 77. Google Scholar 15 : Prevalence of diabetic peripheral neuropathy and its relation to glycaemic control and potential risk factors: the EURODIAB IDDM Complications Study. Diabetologia1996; 39: 1377. Google Scholar 16 : The aetiology and management of erectile, ejaculatory, and fertility problems in men with diabetes mellitus. Diabet Med1996; 13: 700. Google Scholar 17 : The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New Engl J Med1993; 329: 977. Google Scholar 18 : The effect of intensive diabetes therapy on the development and progression of neuropathy. Ann Int Med1995; 122: 561. Google Scholar 19 : Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet1998; 352: 837. Google Scholar 20 : Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet1998; 352: 854. Google Scholar 21 : The International Index of Erectile Function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology1997; 49: 822. Google Scholar 22 Rosen, R.C.: Personal communication. Google Scholar 23 : The natural history of impotence in diabetic men. Diabetologia1984; 26: 437. Google Scholar 24 : Erectile dysfunction in diabetic subjects in Italy. Gruppo Italiano Studio Deficit Erettile Nei Diabetici. Diabetes Care1998; 21: 1973. Google Scholar From the Departments of Medicine and Urology, Louis Stokes Cleveland Veterans Affairs Medical Center and Case Western Reserve University, Cleveland, Ohio© 2000 by American Urological Association, Inc.FiguresReferencesRelatedDetailsCited byWessells H (2018) Insights and Interventions in Diabetes Associated Erectile DysfunctionJournal of Urology, VOL. 190, NO. 1, (15-16), Online publication date: 1-Jul-2013.Wessells H, Penson D, Cleary P, Rutledge B, Lachin J, McVary K, Schade D and Sarma A (2018) Effect of Intensive Glycemic Therapy on Erectile Function in Men With Type 1 DiabetesJournal of Urology, VOL. 185, NO. 5, (1828-1834), Online publication date: 1-May-2011.Burnett A (2018) Erectile DysfunctionJournal of Urology, VOL. 175, NO. 3S, (S25-S31), Online publication date: 1-Mar-2006.De BERARDIS G, PELLEGRINI F, FRANCIOSI M, BELFIGLIO M, DI NARDO B, GREENFIELD S, KAPLAN S, ROSSI M, SACCO M, TOGNONI G, VALENTINI M and NICOLUCCI A (2018) Identifying patients with type 2 diabetes with a higher likelihood of erectile dysfunction: the role of the interaction between clinical and psychological factorsJournal of Urology, VOL. 169, NO. 4, (1422-1428), Online publication date: 1-Apr-2003.BODIE J, LEWIS J, SCHOW D and MONGA M (2018) Laboratory Evaluations of Erectile Dysfunction: An Evidence Based ApproachJournal of Urology, VOL. 169, NO. 6, (2262-2264), Online publication date: 1-Jun-2003.SEFTEL A (2018) Erectile Dysfunction in the Elderly: Epidemiology, Etiology and Approaches to TreatmentJournal of Urology, VOL. 169, NO. 6, (1999-2007), Online publication date: 1-Jun-2003.COSTABILE R (2018) Optimizing Treatment for Diabetes Mellitus Induced Erectile DysfunctionJournal of Urology, VOL. 170, NO. 2S, (S35-S39), Online publication date: 1-Aug-2003.Kadioglu A, Tefekli A, Erol B, Oktar T, Tunc M and Tellaloglu S (2018) A Retrospective Review of 307 Men With Peyronie’s DiseaseJournal of Urology, VOL. 168, NO. 3, (1075-1079), Online publication date: 1-Sep-2002.FEDELE D, COSCELLI C, CUCINOTTA D, FORTI G, SANTEUSANIO F, VIAGGI S, FIORI G, VELONÀ T and LAVEZZARI M (2018) INCIDENCE OF ERECTILE DYSFUNCTION IN ITALIAN MEN WITH DIABETESJournal of Urology, VOL. 166, NO. 4, (1368-1371), Online publication date: 1-Oct-2001. Volume 163Issue 3March 2000Page: 788-791 Advertisement Copyright & Permissions© 2000 by American Urological Association, Inc.Keywordshemoglobin A, glycosylatedquestionnairespenisdysfunction, erectilediabetes mellitus, type 2MetricsAuthor Information JUNE H. ROMEO More articles by this author ALLEN D. SEFTEL More articles by this author ZUHAYR T. MADHUN More articles by this author DAVID C. ARON More articles by this author Expand All Advertisement PDF downloadLoading ...

Abstract Low bone mineral density (BMD) is a major risk factor for development of osteoporosis; increasing evidence suggests that attainment and maintenance of peak bone mass as well as bone turnover and bone loss have strong genetic determinants. We examined the association of BMD levels and their change over a 3‐year period, and polymorphisms of the estrogen receptor (ER), vitamin D receptor (VDR), type I collagen, osteonectin, osteopontin, and osteocalcin genes in pre‐ and perimenopausal women who were part of the Michigan Bone Health Study, a population‐based longitudinal study of BMD. Body composition measurements, reproductive hormone profiles, bone‐related serum protein measurements, and life‐style characteristics were also available on each woman. Based on evaluation of women, ER genotypes (identified by Pvu II [ n = 253] and Xba I [ n = 248]) were significantly predictive of both lumbar spine ( p &lt; 0.05) and total body BMD level, but not their change over the 3‐year period examined. The VDR Bsm I restriction fragment length polymorphism was not associated with baseline BMD, change in BMD over time, or any of the bone‐related serum and body composition measurements in the 372 women in whom it was evaluated. Likewise, none of the other polymorphic markers was associated with BMD measurements. However, we identified a significant gene × gene interaction effect ( p &lt; 0.05) for the VDR locus and Pvu II ( p &lt; 0.005) and Xba I ( p &lt; 0.05) polymorphisms, which impacted BMD levels. Women who had the (−/−) Pvu II ER and bb VDR genotype combination had a very high average BMD, while individuals with the (−/−) Pvu II ER and BB VDR genotype had significantly lower BMD levels. This contrast was not explained by differences in serum levels of osteocalcin, parathyroid hormone, 1,25‐dihydroxyvitamin D, or 25‐dihydroxyvitamin D. These data suggest that genetic variation at the ER locus, singly and in relation to the vitamin D receptor gene, influences attainment and maintenance of peak bone mass in younger women, which in turn may render some individuals more susceptible to osteoporosis than others.

Five-year mortality rates after new-onset diabetic ulceration have been reported between 43% and 55% and up to 74% for patients with lower-extremity amputation. These rates are higher than those for several types of cancer including prostate, breast, colon, and Hodgkin’s disease. These alarmingly high 5-year mortality rates should be addressed more aggressively by patients and providers alike. Cardiovascular diseases represent the major causal factor, and early preventive interventions to improve life expectancy in this most vulnerable patient cohort are essential. New-onset diabetic foot ulcers should be considered a marker for significantly increased mortality and should be aggressively managed locally, systemically, and psychologically. (J Am Podiatr Med Assoc 98(6): 489–493, 2008)

The tetradecapeptide hormone somatostatin arises from proteolytic processing of a large precursor, pre-prosomatostatin. Studies of other hormone precursors predict that the NH2 terminus of pre-prosomatostatin comprises a leader, or signal, region which is cleaved during its translation. Such co-translational cleavage would generate prosomatostatin. In these studies, we present the complete sequence of rat pre-prosomatostatin, deduced from the nucleotide sequence of cDNAs derived from a somatostatin-rich medullary thyroid carcinoma. These findings indicate that rat pre-prosomatostatin contains 116 amino acids (12,737 daltons). Cell-free translations of medullary thyroid carcinoma mRNA with dog pancreas microsomal membranes were performed to identify the cleavage point of the leader region from prosomatostatin. Partial microsequencing data indicates that the cleavage occurs between the glycine and alanine at positions 24 and 25 of pre-prosomatostatin. Thus, rat prosomatostatin contains 92 amino acids (10,388 daltons). Comparison of the amino acid sequences of the rat and human pre-prosomatostatins reveals only four amino acid substitutions. In view of the high degree of homology between rat and human pre-prosomatostatin, we expect a similar cleavage site and NH2-terminal structure for human prosomatostatin. The high level of conservation between rodents and humans of the entire pre-prosomatostatin molecule further suggests the possibility of biologic functions of the NH2-terminal portions of prosomatostatin.

Objective. To determine prevalence of chronic kidney disease (CKD) in patients with diabetes, and accuracy of International Classification of Diseases, 9th Revision, Clinical Modification (ICD‐9‐CM) codes to identify such patients. Data Sources/Study Setting. Secondary data from 1999 to 2000. We linked all inpatient and outpatient administrative and clinical records of U.S. veterans with diabetes dually enrolled in Medicare and the Veterans Administration (VA) health care systems. Study Design. We used a cross‐sectional, observational design to determine the sensitivity and specificity of renal‐related ICD‐9‐CM diagnosis codes in identifying individuals with chronic kidney disease. Data Collection/Extraction Methods. We estimated glomerular filtration rate (eGFR) from serum creatinine and defined CKD as Stage 3, 4, or 5 CKD by eGFR criterion according to the Kidney Disease Outcomes Quality Initiative guidelines. Renal‐related ICD‐9‐CM codes were grouped by algorithm. Principal Findings. Prevalence of CKD was 31.6 percent in the veteran sample with diabetes. Depending on the detail of the algorithm, only 20.2 to 42.4 percent of individuals with CKD received a renal‐related diagnosis code in either VA or Medicare records over 1 year. Specificity of renal codes for CKD ranged from 93.2 to 99.4 percent. Patients hospitalized in VA facilities were slightly more likely to be correctly coded for CKD than patients hospitalized in facilities reimbursed by Medicare (OR 5.4 versus 4.1, p =.0330) Conclusions. CKD is a common comorbidity for patients with diabetes in the VA system. Diagnosis codes in administrative records from Medicare and VA systems are insensitive, but specific markers for patients with CKD.

We have developed a high-dose dexamethasone suppression test that can be administered overnight with a single 8-mg dose and used the new procedure in the differential diagnosis of 83 patients with Cushing's syndrome. In 76 patients with surgically or pathologically proven cause--60 with Cushing's disease, 7 with the ectopic adrenocorticotrophic hormone syndrome, and 9 with adrenal tumors--suppression of plasma cortisol levels to less than 50% of baseline indicated a diagnosis of Cushing's disease. The test had a sensitivity of 92%, a specificity of 100%, and a diagnostic accuracy of 93%. These values equal or exceed those of the standard 2-day test whether based on suppression of urinary 17-hydroxycorticosteroids or plasma cortisol. We conclude that this overnight, high-dose dexamethasone suppression test is practical and reliable in the differential diagnosis of Cushing's syndrome.

Although serious hypoglycemia is a common adverse drug event in ambulatory care, current performance measures do not assess potential overtreatment.To identify high-risk patients who had evidence of intensive glycemic management and thus were at risk for serious hypoglycemia.Cross-sectional study of patients in the Veterans Health Administration receiving insulin and/or sulfonylureas in 2009.Intensive control was defined as the last hemoglobin A1c (HbA1c) measured in 2009 that was less than 6.0%, less than 6.5%, or less than 7.0%. The primary outcome measure was an HbA1c less than 7.0% in patients who were aged 75 years or older who had a serum creatinine value greater than 2.0 mg/dL or had a diagnosis of cognitive impairment or dementia. We also assessed the rates in patients with other significant medical, neurologic, or mental comorbid illness. Variation in rates of possible glycemic overtreatment was evaluated among 139 Veterans Health Administration facilities grouped within 21 Veteran Integrated Service Networks.There were 652,378 patients who received insulin and/or a sulfonylurea with an HbA1c test result. Fifty percent received sulfonylurea therapy without insulin; the remainder received insulin therapy. We identified 205,857 patients (31.5%) as the denominator for the primary outcome measure; 11.3% had a last HbA1c value less than 6.0%, 28.6% less than 6.5%, and 50.0% less than 7.0%. Variation in rates by Veterans Integrated Service Network facility ranged 8.5% to 14.3%, 24.7% to 32.7%, and 46.2% to 53.4% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The magnitude of variation by facility was larger, with overtreatment rates ranging from 6.1% to 23.0%, 20.4% to 45.9%, and 39.7% to 65.0% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The maximum rate was nearly 4-fold compared with the minimum rates for HbA1c less than 6.0%, followed by 2.25-fold for HbA1c less than 6.5% and less than 2-fold for HbA1c less than 7.0%. When comorbid conditions were included, 430,178 patients (65.9%) were identified as high risk. Rates of overtreatment were 10.1% for HbA1c less than 6.0%, 25.2% for less than 6.5%, and 44.3% for less than 7.0%.Patients with risk factors for serious hypoglycemia represent a large subset of individuals receiving hypoglycemic agents; approximately one-half had evidence of intensive treatment. A patient safety indicator derived from administrative data can identify high-risk patients for whom reevaluation of glycemic management may be appropriate, consistent with meaningful use criteria for electronic medical records.

<b>Objective:</b> The epidemic proportions and management complexity of diabetes have prompted efforts to improve clinic throughput and efficiency. One method of system redesign based on the chronic care model is the Shared Medical Appointment (SMA) in which groups of patients (8–20) are seen by a multi-disciplinary team in a 1–2 h appointment. Evaluation of the impact of SMAs on quality of care has been limited. The purpose of this quality improvement project was to improve intermediate outcome measures for diabetes (A1c, SBP, LDL-cholesterol) focusing on those patients at highest cardiovascular risk. <b>Setting:</b> Primary care clinic at a tertiary care academic medical center. <b>Subjects:</b> Patients with diabetes with one or more of the following: A1c &gt;9%, SBP blood pressure &gt;160 mm Hg and LDL-c &gt;130 mg/dl were targeted for potential participation; other patients were referred by their primary care providers. Patients participated in at least one SMA from 4/05 to 9/05. <b>Study design:</b> Quasi-experimental with concurrent, but non-randomised controls (patients who participated in SMAs from 5/06 through 8/06; a retrospective period of observation prior to their SMA participation was used). <b>Intervention:</b> SMA system redesign <b>Analytical methods:</b> Paired and independent t tests, χ² tests and Fisher Exact tests. <b>Results:</b> Each group had up to 8 patients. Patients participated in 1–7 visits. At the initial visit, 83.3% had A1c levels &gt;9%, 30.6% had LDL-cholesterol levels &gt;130 mg/dl, and 34.1% had SBP ⩾160 mm Hg. Levels of A1c, LDL-c and SBP all fell significantly postintervention with a mean (95% CI) decrease of A1c 1.4 (0.8, 2.1) (p&lt;0.001), LDL-c 14.8 (2.3, 27.4) (p = 0.022) and SBP 16.0 (9.7, 22.3) (p&lt;0.001). There were no significant differences at baseline between control and intervention groups in terms of age, baseline intermediate outcomes, or medication use. The reductions in A1c in % and SBP were greater in the intervention group relative to the control group: 1.44 vs –0.30 (p = 0.002) for A1c and 14.83 vs 2.54 mm Hg (p = 0.04) for SBP. LDL-c reduction was also greater in the intervention group, 16.0 vs 5.37 mg/dl, but the difference was not statistically significant (p = 0.29). <b>Conclusions:</b> We were able to initiate a programme of group visits in which participants achieved benefits in terms of cardiovascular risk reduction. Some barriers needed to be addressed, and the operations of SMAs evolved over time. Shared medical appointments for diabetes constitute a practical system redesign that may help to improve quality of care.

An undecanucleotide extended hybridization probe has been used to screen a rat medullary thyroid carcinoma cDNA library for clones which contain preprosomatostatin sequences.The nucleotide sequence encoding rat preprosomatostatin is reported.The sequence of cDNA contains 6 7 nucleotides in the 3'noncoding region, 8 4 nucleotides in the 5"untranslated region, and 458 bases corresponding to the coding region.The mRNA codes for a somatostatin precursor 116 amino acids in length (Mr = 12,773).The preprosomatostatin has a sequence of hydrophobic amino acids at the NH2 terminus, followed by a peptide of approximately 78 residues, which precedes somatostatin-14.The amino acid sequences of rat and human preprosomatostatin (Shen, L.

Mobile health (mHealth) interventions may improve heart failure (HF) self-care, but standard models do not address informal caregivers' needs for information about the patient's status or how the caregiver can help.We evaluated mHealth support for caregivers of HF patients over and above the impact of a standard mHealth approach.We identified 331 HF patients from Department of Veterans Affairs outpatient clinics. All patients identified a "CarePartner" outside their household. Patients randomized to "standard mHealth" (n=165) received 12 months of weekly interactive voice response (IVR) calls including questions about their health and self-management. Based on patients' responses, they received tailored self-management advice, and their clinical team received structured fax alerts regarding serious health concerns. Patients randomized to "mHealth+CP" (n=166) received an identical intervention, but with automated emails sent to their CarePartner after each IVR call, including feedback about the patient's status and suggestions for how the CarePartner could support disease care. Self-care and symptoms were measured via 6- and 12-month telephone surveys with a research associate. Self-care and symptom data also were collected through the weekly IVR assessments.Participants were on average 67.8 years of age, 99% were male (329/331), 77% where white (255/331), and 59% were married (195/331). During 15,709 call-weeks of attempted IVR assessments, patients completed 90% of their calls with no difference in completion rates between arms. At both endpoints, composite quality of life scores were similar across arms. However, more mHealth+CP patients reported taking medications as prescribed at 6 months (8.8% more, 95% CI 1.2-16.5, P=.02) and 12 months (13.8% more, CI 3.7-23.8, P<.01), and 10.2% more mHealth+CP patients reported talking with their CarePartner at least twice per week at the 6-month follow-up (P=.048). mHealth+CP patients were less likely to report negative emotions during those interactions at both endpoints (both P<.05), were consistently more likely to report taking medications as prescribed during weekly IVR assessments, and also were less likely to report breathing problems or weight gains (all P<.05). Among patients with more depressive symptoms at enrollment, those randomized to mHealth+CP were more likely than standard mHealth patients to report excellent or very good general health during weekly IVR calls.Compared to a relatively intensive model of IVR monitoring, self-management assistance, and clinician alerts, a model including automated feedback to an informal caregiver outside the household improved HF patients' medication adherence and caregiver communication. mHealth+CP may also decrease patients' risk of HF exacerbations related to shortness of breath and sudden weight gains. mHealth+CP may improve quality of life among patients with greater depressive symptoms. Weekly health and self-care monitoring via mHealth tools may identify intervention effects in mHealth trials that go undetected using typical, infrequent retrospective surveys.ClinicalTrials.gov NCT00555360; https://clinicaltrials.gov/ct2/show/NCT00555360 (Archived by WebCite at http://www.webcitation.org/6Z4Tsk78B).

Shared medical appointments (SMAs) are doctor-patient visits in which groups of patients are seen by one or more health care providers in a concurrent session. There is a growing interest in understanding the potential benefits of SMAs in various contexts to improve clinical outcomes and reduce healthcare costs. This study builds upon the existing evidence base that suggests SMAs are indeed effective. In this study, we explored how they are effective in terms of the underlying mechanisms of action and under what circumstances.Realist review methodology was used to synthesize the literature on SMAs, which included a broad search of 800+ published articles. 71 high quality primary research articles were retained to build a conceptual model of SMAs and 20 of those were selected for an in depth analysis using realist methodology (i.e.,middle-range theories and and context-mechanism-outcome configurations).Nine main mechanisms that serve to explain how SMAs work were theorized from the data immersion process and configured in a series of context-mechanism-outcome configurations (CMOs). These are: (1) Group exposure in SMAs combats isolation, which in turn helps to remove doubts about one's ability to manage illness; (2) Patients learn about disease self-management vicariously by witnessing others' illness experiences; (3) Patients feel inspired by seeing others who are coping well; (4) Group dynamics lead patients and providers to developing more equitable relationships; (5) Providers feel increased appreciation and rapport toward colleagues leading to increased efficiency; (6) Providers learn from the patients how better to meet their patients' needs; (7) Adequate time allotment of the SMA leads patients to feel supported; (8) Patients receive professional expertise from the provider in combination with first-hand information from peers, resulting in more robust health knowledge; and (9) Patients have the opportunity to see how the physicians interact with fellow patients, which allows them to get to know the physician and better determine their level of trust.Nine overarching mechanisms were configured in CMO configurations and discussed as a set of complementary middle-range programme theories to explain how SMAs work. It is anticipated that this innovative work in theorizing SMAs using realist review methodology will provide policy makers and SMA program planners adequate conceptual grounding to design contextually sensitive SMA programs in a wide variety of settings and advance an SMA research agenda for varied contexts.

Abstract Rationale and objectives One way to understand medical overuse at the clinician level is in terms of clinical decision‐making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision‐making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De‐implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition. Results We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as “the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines.” We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience “reactance,” ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together. Conclusions By taking into account the dual process model of cognition, we may be able to design de‐implementation strategies matched to clinicians' decision‐making processes and avoid unintended consequence.

In April 2017, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the management of type 2 diabetes mellitus.The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through June 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.This synopsis summarizes key features of the guideline in 7 areas: patient-centered care and shared decision making, glycemic biomarkers, hemoglobin A1c target ranges, individualized treatment plans, outpatient pharmacologic treatment, glucose targets for critically ill patients, and treatment of hospitalized patients.

Low-dose dexamethasone suppression testing has been recommended for biochemical screening when Cushing's syndrome is suspected. The criterion for normal suppression of cortisol after dexamethasone is controversial. To assess diagnostic utility (sensitivity), we report the results of low-dose dexamethasone suppression testing in 103 patients with spontaneous Cushing's syndrome. There were 80 patients with Cushing's disease (78%), 13 with the ectopic ACTH syndrome (13%), and 10 with cortisol-producing adrenocortical adenomas (10%). Fourteen (18%) of 80 patients with Cushing's disease suppressed serum cortisol to less than 5 micro g/dl (<135 nmol/liter) after the overnight 1-mg test, whereas six patients (8%) actually showed suppression of serum cortisol to less than 2 micro g/dl (<54 nmol/liter). In addition, the 2-d, low-dose dexamethasone suppression test yielded false-negative results in 38% of patients when urine cortisol was used and 28% when urinary 17-hydroxycorticosteroids were used. Serum cortisol after the 1-mg test correlated with baseline urinary free cortisol (r = 0.705, P < 0.001), plasma ACTH level (r = 0.322, P = 0.001), and urinary free cortisol after the 2-d test (r = 0.709, P = 0.001). This study provides evidence that low-dose dexamethasone may suppress either plasma cortisol or urinary steroids to levels previously thought to exclude Cushing's syndrome and that these tests should not be used as the sole criterion to exclude the diagnosis of endogenous hypercortisolism.

Pregnancy is a rare occurrence in women with Cushing's syndrome. Amenorrhea or oligomenorrhea occurs in about 75% of premenopausal women with Cushing's syndrome as a result of suppression of gonadotropin secretion primarily by excess glucocorticoids. We have reviewed pregnancies in women with Cushing's syndrome (63 cases from the literature and four cases of our own). Since pregnant women without Cushing's syndrome develop some features of Cushing's syndrome, such as hypertension, hyperglycemia, and striae, a high index of clinical suspicion must be maintained to prevent delay in diagnosis. The physiologic changes in adrenocorticosteroid metabolism during pregnancy further complicate the diagnosis. Maternal and fetal risks increase markedly when pregnancy does occur in women with hypercortisolism. However, the wide spectrum of severity of the disease mandates an individualized approach to the therapy in each case. (AM J OBsTET GYNECOL 1990;162:244-52.) Pregnancy is a rare occurrence in women with Cushing's syndrome. Amenorrhea or oligomenorrhea occurs in about 75% of premenopausal women with Cushing's syndrome as a result of suppression of gonadotropin secretion primarily by excess glucocorticoids. We have reviewed pregnancies in women with Cushing's syndrome (63 cases from the literature and four cases of our own). Since pregnant women without Cushing's syndrome develop some features of Cushing's syndrome, such as hypertension, hyperglycemia, and striae, a high index of clinical suspicion must be maintained to prevent delay in diagnosis. The physiologic changes in adrenocorticosteroid metabolism during pregnancy further complicate the diagnosis. Maternal and fetal risks increase markedly when pregnancy does occur in women with hypercortisolism. However, the wide spectrum of severity of the disease mandates an individualized approach to the therapy in each case. (AM J OBsTET GYNECOL 1990;162:244-52.)

The optimal strategy for hormonal screening of a patient with any incidentally discovered adrenal or pituitary mass is unknown. Our review of the endocrinologic literature supports the view that such patients are at slightly increased risk for morbidity and mortality. There is a benefit of early diagnosis for at least for some of the disorders, suggesting the importance of case finding. The data in Tables 1 and 4 illustrate that clinically diagnosed hormone-secreting adrenal and pituitary tumors are far less common than incidentalomas. From a clinical perspective, our ability to determine accurately those at increased risk among the vast majority who are not at increased risk is poor. Given the limitations of diagnostic tests, effective hormonal screening requires a sufficiently high pretest probability to limit the number of false-positive results. This condition is met to varying degrees in the patient with an adrenal mass or small incidentally discovered pituitary mass but no signs or symptoms of hormone excess. Even the more common lesions such as pheochromocytoma and prolactinoma are relatively rare. Subjecting patients to unnecessary testing and treatment carries its own set of risks. Initial costs aside, testing may result in further expense and harm as false-positive results are pursued, producing the cascade effect described by Mold and Stein as a "chain of events (which) tends to proceed with increasing momentum, so that the further it progresses the more difficult it is to stop." The extensive evaluations performed in some patients with incidentally discovered masses may reflect the unwillingness of many physicians to accept uncertainty, even in the case of extremely unlikely diagnoses. This unwillingness may be driven, in part, by fear of potential malpractice liability, the failure to appreciate the influence of prevalence data on the interpretation of diagnostic testing, or other factors. Indeed, the major justification for further evaluation of these patients is not so much to avoid morbidity and mortality for rate patients who truly are at increased risk but rather to reassure those in whom further testing is negative (and to reassure ourselves). Physicians must take care not to create inappropriate anxiety in patients by overemphasizing the importance of an incidental finding unless it is associated with a realistic clinical risk. Our recommendations utilize currently available information to minimize the untoward effects of the cascade. As evidence accumulates, recommendations may need to be revised. The benefit of diagnosis of one of these adrenal or pituitary disorders must be considered in the context of the patient's overall condition. Studies are needed to analyze the utility in clinical practice of hormonal screening for these common radiologic findings. We need to use these studies to identify the critical gaps in our knowledge and to adopt the epidemiologic methods of evaluation of evidence that have been applied to preventive measures. We must be careful to recognize lead-time bias in which survival can seem to be lengthened when screening simply advances the time of diagnosis, lengthening the period of time between diagnosis and death without any true prolongation of life. Length bias refers to the tendency of screening to detect a disproportionate number of cases of slowly progressive disease and to miss aggressive cases that, by virtue of rapid progression, are present in the population only briefly. Endocrinologists must avoid the pitfalls of overestimation of disease prevalence and of the benefits of therapy resulting from advances in diagnostic imaging. Clinical judgment based on the best available evidence should be complemented and not replaced by laboratory data.

While most newly qualified physicians are well prepared in the science base of medicine and in the skills that enable them to look after individual patients, few have the skills necessary to improve care and patient safety continuously. We apply a systems analysis from the field of human error to identify ways in which medical school education can increase the number of graduates prepared to reflect on and improve professional practice. Doing so requires a systematic approach involving entrance requirements, the curriculum, the organizational culture of training environments, student assessment, and program evaluation.

Of 12 patients with Cushing’s disease who had successful selective microadenoma resection documented by clinical remission and reversal of hypercortisolism, 11 developed postoperative hypoadrenalism with deficient adrenal responsiveness to exogenous ACTH. In addition, of 11 patients tested with hypoglycemia, all had subnormal cortisol responses, and 10 had deficient ACTH responses. Pituitary-adrenal function then gradually returned to normal; at last testing, normal cortisol responses to ACTH stimulation and insulin hypoglycemia were present in 8 of 12 and 6 of 11 patients, respectively, and 9 of 11 had normal plasma ACTH responses to hypoglycemia. Two patients with persistent hypoadrenalism had had prior incomplete bilateral adrenalectomies. The ACTH and glucocorticoid deficiency was not caused by the surgical procedure or hydrocortisone replacement, since it resolved despite replacement therapy; further, adrenal insufficiency did not occur in 10 acromegalic patients who received the same operation and identical glucocorticoid therapy. Other pituitary functions were not impaired postoperatively. The GH response to insulin-induced hypoglycemia, normal in only 2 of 7 patients tested preoperatively, improved after surgery so that 9 of 11 patients were normal. Baseline LH levels, suppressed preoperatively, increased significantly, and the response to gonadotropin-releasing hormone was normal in all patients. PRL and TSH responses to TRH were generally not different pre- and postoperatively. All patients were and remain clinically euthyroid. We conclude that: 1) the hypercortisolism caused by an ACTH-secreting pituitary microadenoma suppresses the normal pituitary secretion of ACTH and often that of GH and LH; 2) this suppression persists postoperatively, but gradually resolves in most patients; 3) a normal cortisol response to ACTH is a good indication that the pituitary-adrenal axis has recovered; 4) there was no evidence of a persisting hypothalamic defect after removal of ACTH-secreting microadenomas; and 5) pituitary microadenomas appear to be the primary cause of Cushing's disease in these patients. (J Clin Endocrinol Metab54: 413, 1982)

Cushing's syndrome, an unusual group of disorders characterized by hypercortisolism, must be considered in the differential diagnosis of such common clinical problems as hirsutism, menstrual irregularity, hypertension, diabetes mellitus, and obesity. Its distinct forms--pituitary-dependent Cushing's syndrome (Cushing's disease), adrenal tumor and ectopic ACTH syndrome--must be identified correctly so that specific therapy can be administered. In the majority of cases, use of a relatively simple diagnostic sequence will provide accurate and rapid diagnosis. However, in our experience with more than 60 patients, diagnostic difficulties may arise from a variety of conditions (e.g., drug interference, alcohol ingestion, and depression). In addition, unusual circumstances, such as unexpected responses to dexamethasone, may complicate the diagnosis. Our approach to these problems is illustrated through a report of seven cases, and we emphasize that the proper management of Cushing's syndrome mandates a thorough marshalling of all the available data.

Intestinal colonization by Staphylococcus aureus among hospitalized patients has been associated with increased risk of staphylococcal infection and could potentially contribute to transmission. We hypothesized that S. aureus intestinal colonization is associated with increased frequency of S. aureus on patients' skin and nearby environmental surfaces.Selected inpatients were cultured weekly for S. aureus from stool, nares, skin (groin and axilla), and environmental surfaces (bed rail and bedside table). Investigator's hands were cultured after contacting the patients' skin and the environmental surfaces.Of 71 subjects, 32 (45.1%) had negative nares and stool cultures, 23 (32.4%) had positive nares and stool cultures, 13 (18.3%) were nares carriers only, and 3 (4.2%) were stool carriers only. Of the 39 patients with S. aureus carriage, 30 (76.9%) had methicillin-resistant isolates. In comparison to nares colonization only, nares and intestinal colonization was associated with increased frequency of positive skin cultures (41% versus 77%; p = 0.001) and trends toward increased environmental contamination (45% versus 62%; p = 0.188) and acquisition on investigator's hands (36% versus 60%; p = 0.057). Patients with negative nares and stool cultures had low frequency of S. aureus on skin and the environment (4.8% and 11.3%, respectively).We found that hospitalized patients with S. aureus nares and/or stool carriage frequently had S. aureus on their skin and on nearby environmental surfaces. S. aureus intestinal colonization was associated with increased frequency of positive skin cultures, which could potentially facilitate staphylococcal infections and nosocomial transmission.

To describe the roles of nurse practitioners (NPs) in a novel model of healthcare delivery for patients with chronic disease: shared medical appointments (SMAs)/group visits based on the chronic care model (CCM). To map the specific skills of NPs to the six elements of the CCM: self-management, decision support, delivery system design, clinical information systems, community resources, and organizational support.Case studies of three disease-specific multidisciplinary SMAs (diabetes, heart failure, and hypertension) in which NPs played a leadership role.NPs have multiple roles in development, implementation, and sustainability of SMAs as quality improvement interventions. Although the specific skills of NPs map out all six elements of the CCM, in our context, they had the greatest role in self-management, decision support, and delivery system design.With the increasing numbers of patients with chronic illnesses, healthcare systems are increasingly challenged to provide necessary care and empower patients to participate in that care. NPs can play a key role in helping to meet these challenges.

A young woman developed intermittent headaches and progressive hyperpigmentation after bilateral adrenalectomy for Cushing's disease. Results of sellar polytomography were abnormal. Her plasma ACTH levels increased to 4750–7340 pg/ml and did not rise with insulin-induced hypoglycemia. Although she experienced no clinical features-associated with spontaneous infarction of a pituitary tumor, plasma ACTH levels fell to 474–575 pg/ml, and hemorrhagic necrosis was found in a 5-mm chromophobe adenoma at transsphenoidal surgery. Postoperatively, ACTH levels returned to normal (51–88 pg/ml), with the rest of her anterior pituitary function remaining intact 4 yr later. Spontaneous infarction of pituitary microadenomas may be subclinical, resulting in improvement of pituitary hormone hypersecretion without impairment of other anterior pituitary hormone secretion.

Cushing's syndrome due to nodular adrenal hyperplasia comprises a clinically and biochemically heterogeneous group of disorders whose pathogenesis is unclear. We describe two patients with atypical steroid dynamics and large unilateral adrenal nodules who had pituitary ACTH-dependent disease. In the differential diagnosis of Cushing's syndrome, we recommend repeated ACTH measurement and selective venous sampling-particularly in those patients with impaired dexamethasone suppressibility and abnormal findings on computerized tomography.

Many countries have implemented pay-for-performance programs to improve the quality of care. The structure of these programs, however, can have perverse consequences beyond improving care for patients. To investigate this possibility, we studied the pattern of enrollment of patients with diabetes in the first five years of a pay-for-performance program in Taiwan's National Health Insurance Program from 2001 through 2005. Taiwan's program did sharply improve quality of care for enrolled patients, producing 100 percent or nearly 100 percent adherence to all process measures. But at the same time, only a minority of the nation's patients with diabetes were enrolled, because the program's design encouraged physicians not to enroll their most complicated patients. By "cherry-picking" the healthiest patients most likely to perform well on selected measures, physicians were able to game the system and potentially reap the rewards of higher pay-for-performance payments without actually improving the care of all of their diabetic patients. Our study provides a cautionary tale, emphasizing the importance of proper program design so that quality is improved on the broadest scale.

Introduction There is a widening discrepancy between the increasing number of patients with diabetes mellitus and the health care resources available to manage these patients. Telemedicine has been used in a number of instances to improve and deliver health care where traditional care delivery methods may encounter difficulty. We conducted a cluster randomised controlled trial of telemedicine consultation to manage patients with diabetes mellitus. Methods Eleven primary care centres attached to one Veteran Administration tertiary care centre were randomised to provide patients with diabetes consultation referral either by usual consultation in diabetes clinic or telemedicine consultations via videoconference. Results Altogether, 199 patients were managed by telemedicine consultation and 83 by usual consultation. Patients in both groups showed a small decrease in haemoglobin A1c, with no statistical difference between the groups (telemedicine consultation -1.01% vs usual consultation -0.68%, p = 0.19). Surveys of patients and semi-structured interviews with primary care providers showed better response and satisfaction with telemedicine consultations. Discussion This study shows similar clinical outcomes as measured by glycaemic control for patients with diabetes mellitus having a specialist consultation using real-time telemedicine consultation as compared to in-clinic consultation. Telemedicine consultation was also associated with better patient and primary care provider satisfaction.

Health is an adaptive state unique to each person. This subjective state must be distinguished from the objective state of disease. The experience of health and illness (or poor health) can occur both in the absence and presence of objective disease. Given that the subjective experience of health, as well as the finding of objective disease in the community, follow a Pareto distribution, the following questions arise: What are the processes that allow the emergence of four observable states-(1) subjective health in the absence of objective disease, (2) subjective health in the presence of objective disease, (3) illness in the absence of objective disease, and (4) illness in the presence of objective disease? If we consider each individual as a unique biological system, these four health states must emerge from physiological network structures and personal behaviors. The underlying physiological mechanisms primarily arise from the dynamics of external environmental and internal patho/physiological stimuli, which activate regulatory systems including the hypothalamic-pituitary-adrenal axis and autonomic nervous system. Together with other systems, they enable feedback interactions between all of the person's system domains and impact on his system's entropy. These interactions affect individual behaviors, emotional, and cognitive responses, as well as molecular, cellular, and organ system level functions. This paper explores the hypothesis that health is an emergent state that arises from hierarchical network interactions between a person's external environment and internal physiology. As a result, the concept of health synthesizes available qualitative and quantitative evidence of interdependencies and constraints that indicate its top-down and bottom-up causative mechanisms. Thus, to provide effective care, we must use strategies that combine person-centeredness with the scientific approaches that address the molecular network physiology, which together underpin health and disease. Moreover, we propose that good health can also be promoted by strengthening resilience and self-efficacy at the personal and social level, and via cohesion at the population level. Understanding health as a state that is both individualized and that emerges from multi-scale interdependencies between microlevel physiological mechanisms of health and disease and macrolevel societal domains may provide the basis for a new public discourse for health service and health system redesign.

Half of all Veterans experience chronic pain yet many face geographical barriers to specialty pain care. In 2011, the Veterans Health Administration (VHA) launched the Specialty Care Access Network-ECHO (SCAN-ECHO), which uses telehealth technology to provide primary care providers with case-based specialist consultation and pain management education. Our objective was to evaluate the pilot SCAN-ECHO pain management program (SCAN-ECHO-PM).This was a longitudinal observational evaluation of SCAN-ECHO-PM in seven regional VHA healthcare networks.We identified the patient panels of primary care providers who submitted a consultation to one or more SCAN-ECHO-PM sessions. We constructed multivariable Cox proportional hazards models to assess the association between provider SCAN-ECHO-PM consultation and 1) delivery of outpatient care (physical medicine, mental health, substance use disorder, and pain medicine) and 2) medication initiation (antidepressants, anticonvulsants, and opioid analgesics).Primary care providers (N = 159) who presented one or more SCAN-ECHO-PM sessions had patient panels of 22,454 patients with chronic noncancer pain (CNCP). Provider consultation to SCAN-ECHO-PM was associated with utilization of physical medicine [hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.05-1.14] but not mental health (HR 0.99, 95% CI 0.93-1.05), substance use disorder (HR 0.93, 95% CI 0.84-1.03) or specialty pain clinics (HR 1.01, 95% CI 0.94-1.08). SCAN-ECHO-PM consultation was associated with initiation of an antidepressant (HR 1.09, 95% CI 1.02-1.15) or anticonvulsant medication (HR 1.13, 95% CI 1.06-1.19) but not an opioid analgesic (HR 1.05, 0.99-1.10).SCAN-ECHO-PM was associated with increased utilization of physical medicine services and initiation of nonopioid medications among patients with CNCP. SCAN-ECHO-PM may provide a novel means of building pain management competency among primary care providers.

Insulin-like growth factor I (IGF-I) stimulates hematopoiesis. We examined whether bone marrow stromal cells synthesize IGF-I. Secretion of IGF-I immunoreactivity by cells from TC-1 murine bone marrow stromal cells was time-dependent and inhibited by cycloheximide. Gel filtration chromatography under denaturing conditions of TC-1 conditioned medium demonstrated two major peaks of apparent IGF-I immunoreactivity with molecular weights of approximately 7.5-8.0 kD, the size of native IGF-I, and greater than 25 kD. Expression of IGF-I mRNA was identified by both RNase protection assay and reverse transcription/polymerase chain reaction. To determine whether the greater than 25-kD species identified by RIA possessed IGF-binding activity, a potential cause of artifactual IGF-I immunoreactivity, charcoal adsorption assay of these gel filtration fractions was performed. The peak of IGF-binding activity coeluted with apparent IGF-I immunoreactivity suggesting that TC-1 cells secrete IGF-binding protein(s). Unfractionated conditioned medium exhibited linear dose-dependent increase in specific binding of [125I]-IGF-I with a pattern of displacement (IGF-I and IGF-II much greater than insulin) characteristic of IGF-binding proteins. Western ligand analysis of conditioned medium showed three IGF-I binding species of approximately 31, 38, and 40 kD. These data indicate that TC-1 bone marrow stromal cells synthesize and secrete IGF-I and IGF-binding proteins and constitute a useful model system to study their regulation and role in hematopoiesis.

High dose dexamethasone suppression testing has been widely employed in the differentiation between pituitary ACTH-dependent hypercortisolism [Cushing's disease (CD)] and the ectopic ACTH syndrome. We hypothesized that the high dose dexamethasone suppression test as it is performed in practice does not improve the ability to differentiate between these two types of ACTH-dependent Cushing's syndrome. Cases were drawn from 112 consecutive patients with ACTH-dependent Cushing's syndrome, who were then classified based upon results of inferior petrosal sinus sampling for ACTH levels. Analysis of test characteristics of high dose dexamethasone suppression testing was performed in the 73 patients for whom results are available. Statistical modeling was performed using the 68 cases with complete data on all assessed variables. Logistic regression models were used to predict the probability of pituitary-dependent Cushing's syndrome (CD) given the results of high dose dexamethasone suppression testing before and after adjustment for the contribution of a series of potential covariates. Of the 112 patients with ACTH-dependent Cushing's syndrome, 15.2% had the ectopic ACTH syndrome, and the remainder had pituitary-dependent Cushing's syndrome (CD). Patients with the ectopic ACTH syndrome were significantly older (mean, 51.9 vs. 40.2), were more likely to be male (58.8% vs. 27.4%), had shorter duration of clinical findings (mean, 11.6 vs. 39.9 months), were more likely to have hypokalemia (50% vs. 8.6%), had higher baseline 24-h urinary free cortisol [mean, 8317 vs. 1164 nmol/day (3015 vs. 422 microg)] and plasma ACTH levels [mean, 47 vs. 17 pmol/L (210 vs. 78 pg/mL)] and were less likely to suppress urinary free cortisol or plasma cortisol with high dose dexamethasone using the standard criterion of 50% or more suppression compared with patients with pituitary-dependent Cushing's syndrome. Based upon the standard criterion, the sensitivity and specificity of the high dose dexamethasone suppression test for the diagnosis of pituitary-dependent Cushing's syndrome were 81.0% and 66.7%, respectively. Although the mean percent suppression was significantly greater for patients with CD than for those with the ectopic ACTH syndrome (72.2% vs. 41.3%), the range of suppression was 0-99% for each diagnosis. The area under the receiver operating characteristic curve was 0.710 (95% confidence interval, 0.541-0.879). Logistic regression models were used to evaluate the probability of CD given the responsiveness to high dose dexamethasone suppression testing before and after adjustment for the potential contributions of other factors. A model including all of the variables (age, sex, duration, presence of hypokalemia, urinary free cortisol, and plasma ACTH) had a diagnostic accuracy of 92.7%. A model including all of these variables plus a binary variable indicating whether the patient met the criterion of suppression by 50% or more resulted in 95.6% accuracy, whereas substitution of this binary variable by percent suppression resulted in a model with 94.1% accuracy. There were no statistically significant differences among these models; their values for the c statistic, which is equivalent to the area under the curve in a receiver operating characteristic analysis, were all greater than 0.9. Logistic regression models indicate that the results of the dexamethasone suppression test add little to the differential diagnosis of ACTH-dependent Cushing's syndrome, especially after taking other clinical information into account. In our patient population, the sensitivity and specificity of the dexamethasone suppression test were less than those reported by others. However, because 20-33% of cases of ectopic ACTH syndrome are misdiagnosed with these logistic regression models, other techniques are necessary to achieve greater diagnostic accuracy.

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Previous observational research confirms abundant variation in primary care practice. While variation is sometimes viewed as problematic, its presence may also be highly informative in uncovering ways to enhance health care delivery when it represents unique adaptations to the values and needs of people within the practice and interactions with the local community and health care system. We describe a theoretical perspective for use in developing interventions to improve care that acknowledges the uniqueness of primary care practices and encourages flexibility in the form of intervention implementation, while maintaining fidelity to its essential functions.

Previous observational research confirms abundant variation in primary care practice. While variation is sometimes viewed as problematic, its presence may also be highly informative in uncovering ways to enhance health care delivery when it represents unique adaptations to the values and needs of people within the practice and interactions with the local community and health care system. We describe a theoretical perspective for use in developing interventions to improve care that acknowledges the uniqueness of primary care practices and encourages flexibility in the form of intervention implementation, while maintaining fidelity to its essential functions.

We have employed region-specific RIAs directed against amino-terminal (N), midregion (M), or carboxyl-terminal (C) regions of parathyroid hormone (PTH) to analyze glandular and circulating PTH species in normal subjects and in persons with primary hyperparathyroidism. Immunoaffinity methods have been developed for validation of RIA measurements and for extraction of circulating PTH species. Chromatographic analyses of normal and adenomatous parathyroid-gland extracts and electrophoretic analyses of parathyroid-gland immunoextracts revealed at least four PTH species, each with a distinct pattern of cross-reactivity in the sequence-specific RIAs. Intact PTH (mol wt, 9500) was detected by each type of RIA. The large carboxyl-fragment (mol wt, 5500), was detected only by M and C RIAs. A somewhat smaller fragment (mol wt, 4000) was identified that was detected by M RIA but not by C RIA. We also detected in parathyroid extracts a small N-fragment (mol wt, 3400), which had no reactivity in M or C RIAs. In normal and hyperparathyroid plasmas the predominant PTH species is a large C-fragment (mol wt, 5500) with cross-reactivity in both M and C RIAs. N RIA results indicated relatively low levels of intact PTH or small N-fragments in immunoextracts of peripheral plasmas. However, plasmas from persons with primary hyperparathyroidism did contain an additional prominent PTH species (mol wt, 4000) that was similar to M-fragment(s) found in parathyroid-gland extracts. Since small M-fragment(s) cross-reacts only with the M-antisera, we were able to develop, for isolation and measurement of the fragment(s), a sequential immunoextraction procedure that does not use chromatography. Using this procedure we found that normal basal sera have no detectable small M-fragment(s). However, circulating M-fragment(s) is detectable in normal persons during EDTA-induced hypocalcemia; the relative increase in M-fragment(s) is three times greater than that observed for total anti-C-immunoreactivity, which includes large C-fragment(s) and intact PTH. The accumulation of circulating small M-fragment(s) in hypercalcemic hyperparathyroid persons and in normal persons during EDTA-induced hypocalcemia suggests that it may somehow indicate the level of parathyroid secretory activity. Since a small M-species in parathyroid tissues has size and immunochemical characteristics similar to circulating M-fragment(s), this species might be secreted by parathyroid tissue.

Incorporating shared medical appointments (SMAs) or group visits into clinical practice to improve care and increase efficiency has become a popular intervention, but the processes to implement and sustain them have not been well described. The purpose of this study was to describe the process of implementation of SMAs in the local context of a primary care clinic over time.The setting was a primary care clinic of an urban academic medical center of the Veterans Health Administration. We performed an in-depth case analysis utilizing both an innovations framework and a nested systems framework approach. This analysis helped organize and summarize implementation and sustainability issues, specifically: the pre-SMA local context; the processes of tailoring and implementation of the intervention; and the evolution and sustainability of the intervention and its context.Both the improvement intervention and the local context co-adapted and evolved during implementation, ensuring sustainability. The most important promoting factors were the formation of a core team committed to quality and improvement, and the clinic leadership that was supported strongly by the team members. Tailoring had to also take into account key innovation-hindering factors, including limited resources (such as space), potential to alter longstanding patient-provider relationships, and organizational silos (disconnected groups) with core team members reporting to different supervisors.Although interventions must be designed to meet the needs of the sites in which they are implemented, specific guidance tailored to the practice environment was lacking. SMAs require complex changes that impact on care routines, collaborations, and various organizational levels. Although the SMA was not envisioned originally as a form of system redesign that would alter the context in which it was implemented, it became clear that tailoring the intervention alone would not ensure sustainability, and therefore adjustments to the system were required. The innovation necessitated reconfiguring some aspects of the primary care clinic itself and other services from which the patients and the team were derived. In addition, the relationships among different parts of the system were altered.

The term adrenal incidentaloma (AI) is usually defined as an adrenal mass unexpectedly detected through an imaging procedure performed for reasons a priori unrelated to adrenal dysfunction or suspected dysfunction. The preferred approach to their management in terms of diagnosis, follow-up, and treatment remain controversial despite a state-of-the-science conference sponsored by the U.S. National Institutes of Health. Although most experts' recommendations tend to be relatively minor variations of the conference's approach, dissenting voices have been heard. Despite their frequent appearance, the challenge remains to recognize and treat the small percentage of AI that do pose a significant risk, either because of their hormonal activity or because of their malignant histology, while leaving the rest alone. Although the differential diagnosis of an incidentally discovered mass is quite extensive, most AIs are non-secreting cortical adenomas. The noninvasive differentiation of benign and malignant lesions depends upon imaging characteristics, and sometimes radiologic diagnosis can be definitive, but often it is not, Among function lesions, autonomous cortisol production seems to be the most common and may be associated with increased cardiovascular risk and clinical features of the "metabolic syndrome." Follow-up of cases in which a specific diagnosis is not made initially involves assessment for growth and development of hormonal function, but even here, controversy about the extent of evaluation persists.

This article shows how sentiment analysis (an artificial intelligence procedure that classifies opinions expressed within the text) can be used to design real-time satisfaction surveys. To improve participation, real-time surveys must be radically short. The shortest possible survey is a comment card. Patients' comments can be found online at sites organized for rating clinical care, within e-mails, in hospital complaint registries, or through simplified satisfaction surveys such as "Minute Survey." Sentiment analysis uses patterns among words to classify a comment into a complaint, or praise. It further classifies complaints into specific reasons for dissatisfaction, similar to broad categories found in longer surveys such as Consumer Assessment of Healthcare Providers and Systems. In this manner, sentiment analysis allows one to re-create responses to longer satisfaction surveys from a list of comments. To demonstrate, this article provides an analysis of sentiments expressed in 995 online comments made at the RateMDs.com Web site. We focused on pediatrician and obstetrician/gynecologist physicians in District of Columbia, Maryland, and Virginia. We were able to classify patients' reasons for dissatisfaction and the analysis provided information on how practices can improve their care. This article reports the accuracy of classifications of comments. Accuracy will improve as the number of comments received increases. In addition, we ranked physicians using the concept of time-to-next complaint. A time-between control chart was used to assess whether time-to-next complaint exceeded historical patterns and therefore suggested a departure from norms. These findings suggest that (1) patients' comments are easily available, (2) sentiment analysis can classify these comments into complaints/praise, and (3) time-to-next complaint can turn these classifications into numerical benchmarks that can trace impact of improvements over time. The procedures described in the article show that real-time satisfaction surveys are possible.

The purpose of this study was to investigate the potential benefits for medication adherence of integrating a patient-selected support person into an automated diabetes telemonitoring and self-management program, and to determine whether these benefits vary by patients' baseline level of psychological distress.The study was a quasi-experimental patient preference trial.The study included patients with type 2 diabetes who participated in three to six months of weekly automated telemonitoring via interactive voice response (IVR) calls, with the option of designating a supportive relative or friend to receive automated updates on the patient's health and self-management, along with guidance regarding potential patient assistance. We measured long-term medication adherence using the four-point Morisky Medication Adherence Scale (MMAS-4, possible range 0-4), weekly adherence with an IVR item, and psychological distress at baseline with the Mental Composite Summary (MCS) of the SF-12.Of 98 initially nonadherent patients, 42% opted to involve a support person. Participants with a support person demonstrated significantly greater improvement in long-term adherence than those who participated alone (linear regression slopes: -1.17 vs. -0.57, respectively, p =0.001). Among distressed patients in particular, the odds of weekly nonadherence tended to decrease 25% per week for those with a support person (p =0.030), yet remained high for those who participated alone (p =0.820).Despite their multiple challenges in illness self-management, patients with diabetes who are both nonadherent and psychologically distressed may benefit by the incorporation of a support person when they receive assistance via automated telemonitoring.

Background The Consolidated Framework for Implementation Research was used to evaluate implementation facilitators and barriers of Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) within the Veterans Health Administration. SCAN-ECHO is a video teleconferencing-based programme where specialist teams train and mentor remotely-located primary care providers in providing routine speciality care for common chronic illnesses. The goal of SCAN-ECHO was to improve access to speciality care for Veterans. The aim of this study was to provide guidance and support for the implementation and spread of SCAN-ECHO. Methods Semi-structured telephone interviews with 55 key informants (primary care providers, specialists and support staff) were conducted post-implementation with nine sites and analysed using Consolidated Framework for Implementation Research constructs. Data were analysed to distinguish sites based on level of implementation measured by the numbers of SCAN-ECHO sessions. Surveys with all SCAN-ECHO sites further explored implementation information. Results Analysis of the interviews revealed three of 14 Consolidated Framework for Implementation Research constructs that distinguished between low and high implementation sites: design quality and packaging; compatibility; and reflecting and evaluating. The survey data generally supported these findings, while also revealing a fourth distinguishing construct – leadership engagement. All sites expressed positive attitudes toward SCAN-ECHO, despite struggling with the complexity of programme implementation. Conclusions Recommendations based on the findings include: (a) expend more effort in developing and distributing educational materials; (b) restructure the delivery process to improve programme compatibility; (c) establish an audit and feedback mechanism for monitoring and improving the programme; (d) engage in more upfront planning to reduce complexity; and (e) obtain local leadership support for providing primary care providers with dedicated time for participation.

Hospitals and health plans are often ranked on rates of cesarean delivery, under the assumption that lower rates reflect more appropriate, more efficient care. However, most rankings do not account for patient factors that affect the likelihood of cesarean delivery.To compare hospital cesarean delivery rates before and after adjusting for clinical risk factors that increase the likelihood of cesarean delivery.Retrospective cohort study.Twenty-one hospitals in northeast Ohio.A total of 26127 women without prior cesarean deliveries admitted for labor and delivery from January 1993 through June 1995.Hospital rankings based on observed and risk-adjusted cesarean delivery rates.The overall cesarean delivery rate was 15.9% and varied (P<.001) from 6.3% to 26.5% in individual hospitals. Adjusted rates varied from 8.4% to 22.0%. The correlation between unadjusted and adjusted hospital rankings (ie, 1-21) was only modest (R=0.35, P=.12). Whereas 7 hospitals were classified as outliers (ie, had rates higher or lower [P<.05] than overall rate) on the basis of both unadjusted and adjusted rates, outlier status changed for 5 hospitals (24%), including 2 that changed from outliers to nonoutliers, 2 that changed from nonoutliers to outliers, and 1 that changed from a high outlier to a low outlier.Cesarean delivery rates varied across hospitals in a single metropolitan region. However, rankings that fail to account for clinical factors that increase the risk of cesarean delivery may be methodologically biased and misleading to the public.

The optimal strategy for hormonal screening of a patient with any incidentally discovered pituitary mass is unknown. The authors' review of the endocrinologic literature supports the view that such patients are at slightly increased risk for morbidity and mortality. This risk implies a benefit of early diagnosis for at least for some of the disorders, suggesting the importance of case finding. Nevertheless, the data in Table 1 illustrate that clinically diagnosed hormone-secreting pituitary tumors are far less common than incidentalomas. Clinically, one cannot accurately determine the approximately 0.5% of patients with incidentaloma who are at increased risk among the vast majority who are not. Given the limitations of diagnostic tests, effective hormonal screening requires a sufficiently high pretest probability to limit the number of false-positive results. This condition is met to varying degrees in the patient with a small incidentally discovered pituitary mass but no signs or symptoms of hormone excess. Even the more common lesions, such as prolactinoma, are relatively rare. [table: see text] Subjecting patients to unnecessary testing and treatment is associated with risk. In addition to its initial cost, testing may result in further expense and harm as false-positive results are pursued, producing the "cascade effect" described by Mold and Stein as a "chain of events (which) tends to proceed with increasing momentum, so that the further it progresses the more difficult it is to stop." The extensive evaluations performed for some patients with incidentally discovered masses may reflect the unwillingness of many physicians to accept uncertainty, even in the case of an extremely unlikely diagnosis. This unwillingness may be driven, in part, by fear of potential malpractice liability, the failure to appreciate the influence of prevalence data on the interpretation of diagnostic testing, or other factors. The major justification for further evaluation of these patients is not so much to avoid morbidity and mortality for the rare patient who truly is at increased risk but to reassure patients in whom further testing is negative and the physician. Physicians must take care not to create inappropriate anxiety in patients by overemphasizing the importance of an incidental finding unless it is associated with a realistic clinical risk. The authors' recommendations are based on currently available information to minimize the untoward effects of the cascade. As evidence accumulates, these recommendations may need to be revised. The benefit of the diagnosis of an adrenal or pituitary disorder must be considered in the context of the patient's overall condition. Additional studies are needed to analyze the clinical utility of hormonal screening for these common radiologic findings. Data from these studies can be used to identify critical gaps in knowledge and to adopt the epidemiologic methods of evaluation of evidence that have been applied to preventive measures. One must be careful to recognize lead-time bias, in which survival can appear to be lengthened when screening simply advances the time of diagnosis, lengthening the period of time between diagnosis and death without any true prolongation of life; and length bias, which refers to the tendency of screening to detect a disproportionate number of cases of slowly progressive disease and to miss aggressive cases that, by virtue of rapid progression, are present in the population only briefly. Physicians must avoid the pitfalls of overestimation of disease prevalence and of the benefits of therapy resulting from advances in diagnostic imaging. Clinical judgment based on the best available evidence should be complemented and not replaced by laboratory data.

The potential for transfer of vancomycin-resistance genes from enterococci to Staphylococcus aureus exists when these organisms share an ecologic niche. We performed an 8-month prospective study to determine the frequency at which S. aureus and vancomycin-resistant enterococci (VRE) coexist in the intestinal tracts of VRE-colonized patients and evaluated whether antianaerobic antibiotic therapy promoted increased density of S. aureus colonization. Of 37 patients colonized with vancomycin-resistant Enterococcus faecium, 23 (62%) had S. aureus recovered from stool specimens and 20 (87%) had methicillin-resistant strains. There was no significant difference in the mean density (+/- standard deviation) of S. aureus during versus > or =1 month after discontinuation of antianaerobic antibiotic therapy (5.1+/-1.5 vs. 4.7+/-1.6 log10 colony-forming units per gram of stool; P=.34). No S. aureus isolates were resistant to vancomycin. S. aureus and VRE often coexist in the intestinal tract, providing a potential reservoir for the emergence of vancomycin-resistant S. aureus isolates.

Insulin-like growth factor I (IGF-I) has been found in the kidney, but its precise cellular localization is not known. Since there is evidence that IGF-I is an autocrine factor in many tissues and since murine mesangial cells have IGF-I receptors, we examined whether human mesangial cells produce IGF-I. Culture medium conditioned by mesangial cells was concentrated by reverse phase chromatography and applied to a Sephadex G-100 column equilibrated in a denaturing buffer. Two major species with apparent mol wt (MW) of 7,500 and 25,000 daltons were identified by IGF-I RIA. To determine whether the high MW species possessed IGF-I binding activity, appropriate fractions were desalted, incubated with [125I]Thr59-IGF-I for 2 h at 30 C, and applied to a Sephadex G-100 column equilibrated in a nondissociating buffer. The major peak of radioactivity was confined to a high MW region; there was no radioactivity in the fractions corresponding to 7,500 daltons. Further characterization of 7,500 dalton IGF-I immunoreactive species by reverse phase high performance liquid chromatography showed that it coeluted with synthetic human IGF-I. Isoelectric focusing revealed it to have a pI between 8.1 and 8.5, corresponding to the pI of human IGF-I of 8.25. Northern blot analyses of poly(A)+ RNA from human mesangial cells and human liver using a cDNA probe for human IGF-I showed that a 2.0-kilobase transcript predominated in the mesangial cells, whereas the liver contained 1.1- and 2.0-kilobase species. Specific binding of IGF-I to mesangial cells was demonstrated, and competition curves indicated a rank order of potency (IGF-I greater than IGF-II greater than insulin) consistent with type I IGF receptors. We conclude that human mesangial cells 1) express IGF-I mRNA transcripts, 2) secrete IGF-I and IGF-I-binding activity, and 3) possess specific IGF-I receptors. These data suggest that IGF-I may act as an autocrine or paracrine factor that regulates glomerular cell functions.

Insulin-like growth factor (IGF-I) is synthesized in multiple organs, including the liver, and may play a role in tissue growth and repair. We report that liver fat-storing cells (FSC) secrete IGF-I immunoreactivity in the culture medium. Secretion of IGF-I immunoreactivity was blocked in the presence of cycloheximide, suggesting de novo synthesis. Culture medium conditioned by FSC was concentrated and applied to a Sephadex G100 column equilibrated in a denaturing buffer. Two major species with apparent mol wts of 7.5 and greater than 25 k were identified by IGF-I RIA. Reverse phase HPLC of the 7.5 kilodalton species (the size of IGF-I) showed that it eluted in a single peak. To determine whether the higher mol wt species possessed IGF-I binding activity, appropriate fractions were desalted, incubated with [125I]IGF-I for 2 h at 30 C and applied to a Sephadex G100 column equilibrated in a nondissociating buffer. The major peak of radioactivity was confined to a high mol wt region. Western blot ligand analysis revealed the presence of two insulin-like growth factor binding proteins of approximately 28 and 31 kilodaltons. Platelet-derived growth factor, a potent mitogen for FSC, resulted in a 230% increase in release of IGF-I immunoreactivity that could be accounted for by an increase in IGF-I binding activity. In addition IGF-I increased DNA synthesis in FSC and this effect was additive to that of platelet-derived growth factqr. IGF-I treatment also resulted in an increase in cell number. IGF-I and insulin-like growth factor binding proteins secreted by FSC may play a role in the hepatic tissue response to injury via autocrine and/or paracrine mechanisms. (Endocrinology127: 2343–2349, 1990)

The importance and complexity of handovers is well-established. Progress for intervening in the emergency department change of shift handovers may be hampered by lack of a conceptual framework. The objectives were to gain a better understanding of strategies used for change of shift handovers in an emergency care setting and to further expand current understanding and conceptualizations.Observations, open-ended questions and interviews about handover strategies were collected at a Veteran's Health Administration Medical Center in the United States. All relevant staff in the emergency department was observed; 31 completed open-ended surveys; 10 completed in-depth interviews. The main variables of interest were strategies used for handovers at change of shift and obstacles to smooth handovers.Of 21 previously identified strategies, 8 were used consistently, 4 were never used, and 9 were used occasionally. Our data support ten additional strategies. Four agent types and 6 phases of the process were identified via grounded theory analysis. Six general themes or clusters emerged covering factors that intersect to define the degree of handover smoothness.Including phases and agents in conceptualizations of handovers can help target interventions to improve patient safety. The conceptual model also clarifies unique handover considerations for the emergency department setting.

Cushing's disease is a form of Cushing's syndrome, persistent inappropriate hypercortisolism, that results from pituitary ACTH hypersecretion. It currently accounts for 70 per cent of adult cases of Cushing's syndrome and affects mainly women of childbearing age. The pathology, cause, and clinical and laboratory features of the disease are discussed. The initial step in diagnosis is documentation of endogenous hypercortisolism, which is followed by identification of the cause. Selective transsphenoidal resection of ACTH-producing pituitary adenomas is the initial treatment of choice. The roles of radiotherapy and medical therapy are discussed.

The Department of Veterans Affairs (VA) National Quality Scholars Fellowship Program (VAQS) was established in 1998 as a postgraduate medical education fellowship to train physicians in new methods of improving the quality and safety of health care for veterans and the nation. The VAQS curriculum is based on adult learning theory, with a national core curriculum of face-to-face components, technologically mediated distance learning components, and a unique local curriculum that draws from the strengths of regional resources. VAQS has established strong ties with other VA programs. Fellows' research and quality improvement projects are integrated with local and regional VA leaders' priorities, enhancing the relevance and visibility of the fellows' efforts and promoting recruitment of fellows to VA positions. VAQS has enrolled 98 fellows since 1999; 75 have completed the program and 24 are currently enrolled. Fellowship graduates have pursued a variety of career paths: 17% are continuing training (most in VA), 31% hold a VA faculty/staff position, 66% are academic faculty, and 80% conduct clinical or research work related to health care improvement. Graduates have held leadership positions in VA, Department of Defense, academic medicine, and public health agencies. Combining knowledge about the improvement of health care with adult learning strategies, distance learning technologies, face-to-face meetings, local mentorship, and experiential projects has been successful in improving care in VA and preparing physicians to participate in, study, and lead the improvement of health care quality and safety.

In most models of health care delivery, the bulk of services are provided in primary care and there is frequent request for the input of specialty consultants. A critical issue for current and future health care systems is the effective and efficient delivery of specialist expertise for clinicians and patients. Input on a patient's care from specialty consultants usually requires a face-to-face visit between the patient and the consultant. New and complementary models of knowledge sharing have emerged. We describe a framework assessment of a spectrum of knowledge-sharing methods in the context of a patient-centered medical home. This framework is based on our experience in the Veterans Health Administration and a purposive review of the literature. These newer modes of specialty consultation include electronic consultation, secure text messaging, telemedicine of various types, and population preemptive consults. In addition to describing these modes of consultation, our framework points to several important areas in which further research is needed to optimize effectiveness.

To explore whether Video-Shared Medical Appointments (video-SMA), where group education and medication titration were provided remotely through video-conferencing technology would improve diabetes outcomes in remote rural settings. We conducted a pilot where a team of a clinical pharmacist and a nurse practitioner from Honolulu VA hospital remotely delivered video-SMA in diabetes to Guam. Patients with diabetes and HbA1c ≥7% were enrolled into the study during 2013–2014. Six groups of 4–6 subjects attended 4 weekly sessions, followed by 2 bi-monthly booster video-SMA sessions for 5 months. Patients with HbA1c ≥7% that had primary care visits during the study period but not referred/recruited for video-SMA were selected as usual-care comparators. We compared changes from baseline in HbA1c, blood-pressure, and lipid levels using mixed-effect modeling between video-SMA and usual care groups. We also analyzed emergency department (ED) visits and hospitalizations. Focus groups were conducted to understand patient’s perceptions. Thirty-one patients received video-SMA and charts of 69 subjects were abstracted as usual-care. After 5 months, there was a significant decline in HbA1c in video-SMA vs. usual-care (9.1 ± 1.9 to 8.3 ± 1.8 vs. 8.6 ± 1.4 to 8.7 ± 1.6, P = 0.03). No significant change in blood-pressure or lipid levels was found between the groups. Patients in the video-SMA group had significantly lower rates of ED visits (3.2% vs. 17.4%, P = 0.01) than usual-care but similar hospitalization rates. Focus groups suggested patient satisfaction with video-SMA and increase in self-efficacy in diabetes self-care. Video-SMA is feasible, well-perceived and has the potential to improve diabetes outcomes in a rural setting.

To assess the association between race and insurance and Cesarean delivery rates after adjusting for clinical risk factors that increase the likelihood of cesarean delivery.Retrospective cohort study in 21 hospitals in northeast Ohio.25,697 women without prior cesarean deliveries admitted for labor and delivery January 1993 through June 1995.Demographic and clinical data were abstracted from patients' medical records. The risk of cesarean delivery was adjusted for 39 maternal and neonatal risk factors that were included in a previously developed risk-adjustment model using nested logistic regression analysis.Odds ratios for cesarean delivery in nonwhite patients relative to whites and for patients with government insurance or who were uninsured relative to patients with commercial insurance.The overall rate of cesarean delivery was similar in white and nonwhite patients (15.8% and 16.1%, respectively), but rates varied (P < 0.001) according to insurance (17.0%, 14.2%, 10.7% in patients with commercial insurance, government insurance, and without insurance, respectively). However, after adjusting for clinical factors, the adjusted odds ratio (OR) of cesarean delivery was higher in nonwhite patients (OR = 1.34; 95% CI: 1.14-1.57; P < 0.001), but similar for patients with government insurance (OR = 1.01; 95% CI: 0.90-1.14; P = 0.84) and lower for uninsured patients (OR = 0.65; 95% CI, 0.41, 1.03; P = 0.067), albeit not statistically significant. In analyses stratified according to quintiles of predicted risk of cesarean delivery, racial differences were largely limited to patients in the lower risk quintiles. However, differences in odds ratios for uninsured patients were seen across the risk quintiles, although odds ratios were not statistically significant.After adjusting for clinical factors, race and insurance status may independently influence the use of cesarean delivery. The higher rates in nonwhites and lower rates in the uninsured may reflect differences in patient preferences or expectations, differences in physician practice, or unmeasured risk factors. The lower odds of cesarean delivery in uninsured women, particularly women at high risk, may raise the issue of underutilization of services and warrants further study.

Acquired immunodeficiency syndrome (AIDS) is a multisystem disorder characterized by defects in the immune system that result in opportunistic infections and neoplasms. While endocrine dysfunction has not been a prominent clinical feature of AIDS, all endocrine glands may be affected by the opportunistic infections and neoplasms or by agents used in their treatment. Adrenal cortical insufficiency related to cytomegalovirus and ketoconazole therapy, hypoglycemia related to pentamidine therapy, and hyponatremia secondary to diverse causes are the most serious endocrine abnormalities that commonly occur. As the numbers of patients with AIDS increase, the development of these and other endocrine complications will occur more often. Because the clinical manifestations of endocrine dysfunction may be nonspecific or subtle, they may be overlooked, particularly in the setting of chronically and severely ill patients. Recognition and prompt therapy for endocrine dysfunction is essential for optimal treatment of these patients.

Central venous sampling (CVS) is used frequently in the evaluation of ACTH-dependent Cushing's syndrome. However, several controversies exist including the diagnostic accuracy, the sampling site of choice (cavernous sinus vs. inferior petrosal sinus) and the use of lateralization data in tumour localization. We have analysed our experience with CVS to address these controversies.We retrospectively reviewed CVS data in patients with ACTH-dependent Cushing's syndrome, in whom cavernous sinus sampling (CSS), inferior petrosal sinus sampling (IPSS) and IPSS after administration of ovine corticotrophin releasing hormone (oCRH) were performed.Data on 95 patients were analysed, including 79 patients with suspected Cushing's disease (CD) and 16 patients with suspected ectopic ACTH syndrome (EAS).For the differential diagnosis of ACTH-dependent Cushing's syndrome, the diagnostic accuracy of IPSS after oCRH stimulation was 97% compared to 86% for CSS. While no single sampling site was perfect in diagnostic accuracy, sampling both CS and IPS achieved a combined diagnostic accuracy of 100%. Lateralization data predicted tumour location in 62-68% of the patients with various central venous drainage patterns and in 77-80% of the patients with symmetrical drainage. CSS was not significantly superior to IPSS in tumour lateralization. In patients with suspected CD based on CVS and in whom an adenoma was not found on magnetic resonance imaging (MRI) and not located by the surgeon intraoperatively, hemihypophysectomy based on lateralization data was successful in only 10 of the 18 patients (56%) with various central venous drainage patterns and in 5 of 10 patients with symmetrical drainage.CVS is a powerful method for differentiating CD from the EAS. CSS without oCRH was not superior to IPSS after oCRH stimulation; however, we achieved a 100% diagnostic accuracy if at least two sites were sampled. Tumour localization by CVS did not accurately predict the tumour site at surgery and should not be used to guide surgical resection.

Adrenal incidentalomas (AI), adrenal tumors detected through an imaging procedure done for reasons unrelated to adrenal dysfunction, is becoming a common clinical problem with the more frequent utilization of different imaging techniques. Most such tumors are benign and hormonally inactive. A variety of diagnostic strategies have been developed to distinguish the latter; however, they are still controversial. Even after a commissioned systematic review of the literature and a state of the science conference sponsored by the National Institutes of Health, the optimal strategy for hormonal screening of a patient with AI is unknown, but we anticipate further refinements and major advances in the field. Surgery is the ultimate solution for the diagnostic-therapeutic dilemma of AI. Careful planning is required, and the learning curve which influences clinical decision making is especially relevant to immediate outcomes. The benefit of making a diagnosis of a clinically significant AI must be considered in the context of the patient’s overall condition and preferences.

SINCE the time of Harvey Cushing, great advances have been made in understanding the pathophysiology of Cushing's syndrome (CS). Delineation of the different forms of spontaneous hypercortisolism—pituitary-dependent disease, adrenal tumor, and the ectopic ACTH syndrome—has permitted the development of specific therapies. As Orth and Liddle (1) have defined the ideal treatment, it would lower cortisol secretion to normal, eradicate any tumor threatening the health of the patient, avert permanent endocrine deficiency, and avoid permanent dependence on medication. A variety of therapies—surgical, radiotherapeutic, and medical—has been used. However, the frequent difficulty in establishing the specific cause of hypercortisolism (2) and the inadequacies of current methods of treatment continue to complicate the management of patients with CS. We present seven cases that illustrate our approach to therapeutic dilemmas. This 22-yr-old woman developed amenorrhea, a plethoric moon facies, truncal obesity, purple striae, easy bruisability, hirsutism, and emotional lability. In addition to having this classic cushingoid appearance, she was hypertensive (blood pressure, 150/100 mm Hg) and hyperglycemic (fasting blood glucose, 206 mg/dl) and had a normal serum potassium value.

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To compare medical students' and physician residents' satisfaction with Veterans Affairs (VA) training to determine the factors that were most strongly associated with trainee satisfaction ratings.Each year from 2001 to 2006, all medical students and residents in VA teaching facilities were invited to complete the Learners' Perceptions Survey. Participants rated their overall training satisfaction on a 100-point scale and ranked specific satisfaction in four separate educational domains (learning environment, clinical faculty, working environment, and physical environment) on a five-point Likert scale. Each domain was composed of unique items.A total of 6,527 medical students and 16,583 physician residents responded to the survey. The overall training satisfaction scores for medical students and physician residents were 84 and 79, respectively (P < .001), with significant differences in satisfaction reported across the training continuum. For both medical students and residents, the rating of each of the four educational domains was statistically significantly associated with the overall training satisfaction score (P < .001). The learning environment domain had the strongest association with overall training satisfaction score, followed by the clinical preceptor, working environment, and physical environment domains; no significant differences were found between medical students and physician residents in the rank order. Satisfaction with quality of care and faculty teaching contributed significantly to training satisfaction.Factors that influence training satisfaction were similar for residents and medical students. The domain with the highest association was the learning environment; quality of care was a key item within this domain.

The care of elderly patients with diabetes should be individualized, taking into account the patient's comorbidities, other medications, cognitive abilities, home care situation, and life expectancy. Especially in frail, elderly patients, there should be less emphasis on strict glycemic control than on avoiding malnutrition and hypoglycemia and achieving the best quality of life possible.

THE MODERN ERA IN DIABETES PERFORMANCE MEAsurement began in 1997, when the Diabetes Quality Improvement Project (DQIP), the first national disease-specific measure, set recommended thresholds for intermediate outcomes (glycated hemoglobin [HbA1c] levels, blood pressure, and low-density lipoprotein cholesterol [LDL-C] levels). These thresholds, if not achieved, would clearly result in greater population morbidity and mortality. The DQIP explicitly stated that such threshold measures were neither guidelines nor standards and that lower intermediate outcome values should not be used for public reporting owing to lack of evidence for efficacy and the absence of validated risk-adjustment models that would allow for fair comparisons. Also in the 1990s, major randomized trials such as the Diabetes Control and Complications Trial, Scandinavian Simvastatin Survival Study, United Kingdom Prospective Diabetes Study, West of Scotland Coronary Prevention Study, and Hypertension Optimal Treatment Study established stronger evidence for treatment of intermediate-outcome risk factors. These pivotal studies provided the impetus for studies conducted from 2000 onward to determine optimal values for these risk factors to reduce cardiovascular risk in patients with longer duration of disease. The successor to the DQIP, the National Quality Improvement Alliance (Alliance), made few major changes to the measure set from 2001 through 2005 other than to decrease threshold levels for HbA1c from 9.5% to 9.0% and for blood pressure from 140/90 mm Hg to 140/80 mm Hg and to add a threshold level for LDL-C of less than 100 mg/dL. The Alliance members, including liaisons from federal agencies and major professional societies, were aware that planned major trials would inform the choice of threshold values for optimal measures by the end of the decade. However, beginning in 2004, the National Committee for Quality Assurance (NCQA) added optimal measures for HbA1c, blood pressure, and cholesterol to the Diabetes Physician Recognition Program—HbA1c values less than 7%, blood pressure less than 130/80 mm Hg, and LDL-C values less than 100 mg/dL—which were adopted by the Bridges to Excellence pay-for-performance program. In 2005 the Minnesota Community Measurement Program developed a composite measure, termed the Diabetes 5 (D5), that was based on these optimal measures for HbA1c, blood pressure, and LDL-C; administration of aspirin; and nonsmoking status. Despite unanimous opposition from the Technical Advisory Panel of the Alliance, the NCQA approved the optimal measure set in May 2006. Even though inconsistent with guidelines from nonspecialty societies, these measures were widely viewed as evidence-based standards of care because they were based on the guidelines of specialty societies that lent their leadership to the industry-sponsored public service campaign. Coincidentally, 1 week after approval of the optimal measure set, scientific concerns were again raised at an Agency for Healthcare Research and Quality–sponsored conference on diabetes performance measures attended by representatives from key federal agencies, professional societies, the NCQA, and members of academic medicine. In addition to methodological concerns related to selection bias, lack of case-mix adjustment, patient preferences, and measurement variability, the possibility was raised of unintended—and unmeasured—consequences such as harms, costs, and polypharmacy. Indeed, only 2 months later the National Quality Forum did not endorse the “optimal measures.” Much has since changed. The glycemic treatment group in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) study was prematurely terminated because of increased deaths in the intensive treatment group, and the NCQA measure was then modified. Then, the hypertension treatment approach in ACCORD failed to demonstrate benefit of tighter blood pressure control, resulting in modification of NCQA’s optimal measure of 130/80 mm Hg. Although the lipid treatment intervention was designed to evaluate the efficacy of fibrates, the subanalysis did not demonstrate benefit of lower lipid levels; however, this finding needs further evaluation. In the absence of new evidence from 1998 to 2008 and despite ongoing major trials

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA Internal Medicine HomeNew OnlineCurrent IssueFor Authors Podcast Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA Internal Medicine journal

To assess the early impact of implementation of the electronic consults (e-consults) initiative by the Veterans Health Administration (VHA), designed to improve specialty care access.Observational cohort study exploiting a natural experiment begun in May 2011 at 12 VHA medical centers and expanded to 122 medical centers by December 2013.The following were assessed: 1) growth of e-consults by VHA regional networks, medical centers, and specialty; 2) location of patient's primary care provider (medical center vs community-based outpatient clinic [CBOC]); 3) potential patient miles needed to travel for a specialty care face-to-face consult in place of the observed e-consults using estimated geodesic distance; 4) use of specialty care subsequent to the e-consult.Of 11,270,638 consults completed in 13 clinics of interest, 217,014 were e-consults (adjusted rate, 1.93 e-consults per 100 consults). The e-consult rate was highest in endocrinology (5.0 per 100), hematology (3.0 per 100), and gastroenterology (3.0 per 100). The percentage of e-consult patients with CBOC-based primary care grew from 28.5% to 44.4% in the first year of implementation and to 45.6% at year 3. Of those e-consult patients from community clinics, the average potential miles needed to travel was 72.1 miles per patient (SD = 72.6; median = 54.6; interquartile range = 17.1-108), translating to a potential savings of 6,875,631 total miles and travel reimbursement costs of $2,853,387.E-consult volume increased significantly since inception within many medical and surgical specialties. For patients receiving primary care at one of more than 800 CBOCs, e-consults may decrease travel burden and direct travel costs for patients.

Epidemiologic analysis of incidental macroadenoma is limited to autopsy studies and case series. There are no published data about prevalence of incidental pituitary macroadenoma in living patients. The objective of this study was to determine the prevalence of incidental pituitary macroadenoma. It was designed as an observational study of cranial computed tomography reports. An urban department of veterans affairs medical center was used for the setting. The subject group consisted of 3,550 consecutive patients at the Cleveland Department of Veterans Affairs Medical Center from January 1993 to January 1996. Patients with known or suspected pituitary or parasellar disease were excluded. Cranial computed tomography reports were reviewed. Original films and medical charts of all patients with pituitary macroadenoma were reviewed. Seven patients with incidentally discovered pituitary macroadenoma that ranged from 1 cm to 2.5 cm were found; prevalence was 0.20% (95% confidence interval 0.05, 0.35%). Evidence of partial hypopituitarism was found in most patients. All patients had normal visual fields at initial examination despite the size of the tumor, but 1 of 4 had a field cut demonstrated by Goldmann perimetry. These data confirm that, although the prevalence of incidental pituitary macroadenoma is low, screening identified patients to detect deficiency of corticotropin, thyroid-stimulating hormone, and gonadotropins and to detect visual field defects is important.

ABSTRACT A mouse model was used to test the hypothesis that antibiotics with activity against anaerobes promote overgrowth of extended-spectrum β-lactamase-producing Klebsiella pneumoniae strains in stool. Subcutaneous clindamycin consistently promoted establishment of high-density colonization, whereas piperacillin-tazobactam, ceftriaxone, and ceftazidime promoted colonization only when a large inoculum and/or more resistant strain was administered.

The ectopic ACTH syndrome accounts for a substantial number of patients with naturally occurring Cushing’s syndrome. Patients with either ectopic ACTH syndrome or the rare CRH-mediated Cushing’s syndrome may be indistinguishable from patients with pituitary ACTH Cushing’s syndrome, based on clinical grounds or simple biochemical and radiologic testing. Because their therapies differ, accurate diagnosis is essential. While clinical researchers continue to develop more effective diagnostic techniques and therapies, further advances in the molecular and cell biology of ACTH and CRH-producing tumors will undoubtedly shed light on the pathogenesis of this perplexing, fascinating, and controversial entity.

In 2002, the Accreditation Council for Graduate Medical Education (ACGME) introduced a new requirement: residents must demonstrate competency in Practice-Based Learning and Improvement (PBLI). Training in this domain is still not consistently integrated into programmes, with few, if any, adequately going beyond knowledge of basic content and addressing all components of the requirement.To summarise the implementation of a PBLI curriculum designed to address all components of the requirement and to evaluate the impact on the practice system.A case-study approach was used for identifying and evaluating the steps for delivering the curriculum, along with the Model for Improvement's successive Plan-Do-Study-Act (PDSA) cycles (July 2004-May 2006).Notes from curriculum development meetings, notes and presentation slides made by teams about their projects, resident curriculum exit evaluations curriculum and interviews.Residents reported high levels of comfort by applying PBLI-related knowledge and skills and that the curriculum improved their ability to do various PBLI tasks. The involvement of multiple stakeholders increased. Twelve of the 15 teams' suggestions with practical systems-relevant outcomes were implemented and sustained beyond residents' project periods. While using the traditional PDSA cycles was helpful, there were limitations.A PBLI curriculum that is centred around practice-based quality improvement projects can fulfil the objectives of this ACGME competency while accomplishing sustained outcomes in quality improvement. A comprehensive curriculum is an investment but offers organisational rewards. We propose a more realistic and informative representation of rapid PDSA cycle changes.

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal

Adrenal disorders may manifest during pregnancy de novo, or before pregnancy undiagnosed or diagnosed and treated. Adrenal disorders may present as hormonal hypofunction or hyperfunction, or with mass effects or other nonendocrine effects. Pregnancy presents special problems in the evaluation of the hypothalamic-pituitary-adrenal axis in addition to the usual considerations. The renin-angiotensin-aldosterone axis undergoes major changes during pregnancy. Nevertheless, the common adrenal disorders are associated with morbidity during pregnancy and their management is more complicated. A high index of suspicion must be maintained for these disorders lest they go unrecognized and untreated.

Purpose: To assess the impact on glycemic control (A1c, %) in a primary care urban Veterans Affairs (VA) shared medical appointments (SMAs). Data sources: A retrospective pretest/posttest study included all patients who had attended ≥1 SMA from 4/06 to 12/10. A1cs 810 days pre- and postinitial SMA were obtained from 90-day time periods. A1c levels were averaged within patient in these 90-day intervals and data were aggregated based upon corresponding time intervals. Conclusions: Of 1290 individuals seen in SMAs, 1288 (99.8%) had ≥1 A1c levels and 1170 (90.7%) individuals had ≥1 level collected both before and after attendance. The sample was predominantly (96%) male and middle aged or older (mean [±1 SD] age of 62.6 + 9.09 years) with a mean Diabetes Severity Index 3.01 (2.34). There were significant A1c reductions (˜1%) in A1c overall (n = 1170) and for patients with ≥1 measurement in the 180-day periods preceding and following their first SMA appointment (n = 815). Linear regression analysis showed a significant (p < .001) pre-SMA positive trend (r2 = 0.90). Implications for practice: Limitations notwithstanding (single site and design lacking a control group), the large number of patients demonstrates SMA clinical effectiveness in improving A1c for high-risk patients with diabetes.

Objective To assess how changes in curriculum, accreditation standards, and certification and licensure competencies impacted how medical students and physician residents value interprofessional team and patient‐centered care. Primary Data Source The Department of Veterans Affairs Learners’ Perceptions Survey (2003–2013). The nationally administered survey asked a representative sample of 56,569 U.S. medical students and physician residents, with a comparison group of 78,038 nonphysician trainees, to rate satisfaction with 28 elements, in two overall domains, describing their clinical learning experiences at VA medical centers. Study Design Value preferences were scored as independent adjusted associations between an element (interprofessional team, patient‐centered preceptor) and the respective overall domain (clinical learning environment, faculty, and preceptors) relative to a referent element (quality of clinical care, quality of preceptor). Principal Findings Physician trainees valued interprofessional (14 percent vs. 37 percent, p &lt; .001) and patient‐centered learning (21 percent vs. 36 percent, p &lt; .001) less than their nonphysician counterparts. Physician preferences for interprofessional learning showed modest increases over time (2.5 percent/year, p &lt; .001), driven mostly by internal medicine and surgery residents. Preferences did not increase with trainees’ academic progress. Conclusions Despite changes in medical education, physician trainees continue to lag behind their nonphysician counterparts in valuing experience with interprofessional team and patient‐centered care.

Introduction: As the population ages, the number of older adults with diabetes mellitus will continue to rise. The burden of diabetes on older adults is significant due to the disease itself, its complications, and its treatments. This is compounded by geriatric syndromes such as frailty and cognitive dysfunction. Consequently, health and diabetes-related quality of life (QoL) are diminished.Areas covered: This article reviews the value of assessing QoL in providing patient-centered care and the associations between QoL measures and health outcomes. The determinants of QoL particular to diabetes and the older population are reviewed, including psychosocial, physical, and cognitive burdens of diabetes and aging and the impact of hypoglycemia on QoL. Strategies are described to alleviate these burdens and improve QoL, and barriers to multidisciplinary patient-centered care are discussed. QoL measurement instruments are reviewed.Expert opinion: The goals of treating diabetes and its complications should be considered carefully along with each patient's capacity to withstand the burdens of treatment. This capacity is reduced by socioeconomic, psychological, cognitive, and physical factors reduces this capacity. Incorporating measurement of HRQoL into clinical practices is possible, but deficiencies in the systems of health-care delivery need to be addressed to facilitate their use.

The substitution of piperacillin/tazobactam, ampicillin/sulbactam, or both for third-generation cephalosporins has been associated with reduced vancomycin-resistant enterococci (VRE). However, piperacillin/tazobactam came into widespread use during a period in which the prevalence of VRE increased. We hypothesized that the increasing use of piperacillin/tazobactam and other agents with relatively enhanced anti-enterococcal activity (ie, piperacillin, ampicillin/sulbactam, and ampicillin) has been associated with increased or unchanged rates of VRE in some hospitals.We retrospectively evaluated the correlation between hospital antibiotic use (defined daily doses per 10,000 patient-days of care) and incidence of stool or non-stool VRE isolation. We assessed whether a high or increasing proportion of use of beta-lactam agents with relatively enhanced versus minimal (ie, third-generation cephalosporins and ticarcillin/clavulanate) anti-enterococcal activity would prevent increased VRE.Four academic medical centers.With the increasing use of piperacillin/tazobactam, the use of beta-lactam agents with enhanced activity against enterococci surpassed the combined use of third-generation cephalosporins and ticarcillin/clavulanate in each hospital. In one hospital, the incidence of VRE was positively correlated with the use of piperacillin/tazobactam or beta-lactam agents with enhanced anti-enterococcal activity (P < .0001). The incidence of VRE rose steadily in another hospital despite relatively high use of beta-lactam agents with enhanced versus minimal anti-enterococcal activity. A negative correlation between VRE and piperacillin/tazobactam or beta-lactam agents with enhanced anti-enterococcal activity was observed in one hospital, but this correlation was not statistically significant.Increasing the hospital use of piperacillin/tazobactam and other beta-lactams with relatively enhanced anti-enterococcal activity may not be an effective control measure for VRE.

The management of gallstones in diabetic patients has traditionally been considered problematic. Autopsy findings and uncontrolled studies have documented a higher prevalence of cholelithiasis in diabetics, and early reports showed dramatically increased perioperative morbidity and mortality for treatment of diabetics with acute cholecystitis. As a result, some authorities have recommended prophylactic cholecystectomy for diabetic patients with asymptomatic gallstones, which is in contrast to recommendations for nondiabetics. More recent investigators have shown comparable rates of operative morbidity and mortality for biliary surgery in diabetics when compared with the general population. Recent studies have questioned whether diabetes is an independent risk factor for gallstone formation. Decision analyses using these new data have shown that prophylactic cholecystectomy is not of clear benefit and should not be routinely recommended for diabetics with asymptomatic gallstones. We believe that available data, although limited, indicate that asymptomatic patients with diabetes do not benefit from screening for gall-stones and that cholecystectomy should only be performed in cases of symptomatic cholelithiasis, as is the case in the general population. (Arch Intern Med. 1993;153:1053-1058)

The imperative to improve both technical and service quality while simultaneously reducing costs is quite clear. The Theory of Constraints (TOC) is an emerging philosophy that rests on two assumptions: (1) systems thinking and (2) if a constraint "is anything that limits a system from achieving higher performance versus its goal," then every system must have at least one (and at most no more than a few) constraints or limiting factors. A constraint is neither good nor bad in itself. Rather, it just is. In fact, recognition of the existence of constraints represents an excellent opportunity for improvement because it allows one to focus ones efforts in the most productive area--identifying and managing the constraints. This is accomplished by using the five focusing steps of TOC: (1) identify the system's constraint; (2) decide how to exploit it; (3) subordinate/synchronize everything else to the above decisions; (4) elevate the system's constraint; and (5) if the constraint has shifted in the above steps, go back to step 1. Do not allow inertia to become the system's constraint. TOC also refers to a series of tools termed "thinking processes" and the sequence in which they are used.

In contrast to expanded-spectrum cephalosporins, beta-lactam-beta-lactamase inhibitor combinations such as piperacillin-tazobactam have rarely been associated with vancomycin-resistant Enterococcus (VRE) colonization and infection. In mice, piperacillin-tazobactam has sufficient antienterococcal activity to inhibit the establishment of colonization during treatment, but this effect has not been confirmed in human patients. We prospectively evaluated the acquisition of rectal colonization by VRE among intensive care unit patients receiving antibiotic regimens containing piperacillin-tazobactam versus those receiving cefepime, an expanded-spectrum cephalosporin with minimal antienterococcal activity. Rectal swabs were obtained weekly and were cultured for VRE. For 146 patients with a negative rectal swab for VRE prior to therapy, there was no significant difference in the frequency of VRE acquisition between patients receiving piperacillin-tazobactam- and cefepime-containing regimens (19/72 [26.4%] and 23/74 [31.1%], respectively; P = 0.28). Of the 19 patients who acquired VRE in association with piperacillin-tazobactam, 10 (53%) developed the new detection of VRE during therapy. Patients initiated on treatment with cefepime-containing regimens were significantly more likely than those initiated on treatment with piperacillin-tazobactam-containing regimens to have received antibiotic therapy in the prior 30 days (55/74 [74.3%] and 22/72 [30.6%], respectively; P < 0.001). These findings suggest that piperacillin-tazobactam- and cefepime-containing antibiotic regimens may be associated with the frequent acquisition of VRE in real-world intensive care unit settings. Although piperacillin-tazobactam inhibits the establishment of VRE colonization in mice when exposure occurs during treatment, our data suggest that this agent may not prevent the acquisition of VRE in patients.

Cushing's disease is a form of Cushing's syndrome, persistent inappropriate hypercortisolism, that results from pituitary ACTH hypersecretion. It currently accounts for 70 per cent of adult cases of Cushing's syndrome and affects mainly women of childbearing age. The pathology, cause, and clinical and laboratory features of the disease are discussed. The initial step in diagnosis is documentation of endogenous hypercortisolism, which is followed by identification of the cause. Selective transsphenoidal resection of ACTH-producing pituitary adenomas is the initial treatment of choice. The roles of radiotherapy and medical therapy are discussed.

Background Interprofessional practice has increasingly been recognized as important for chronic illness care. Recently, several health care professional-accrediting bodies have called for integration of interprofessional care and education. The shared medical appointment (SMA) is an interprofessional practice model that provides an educational opportunity. Objective A description of this innovative educational model, the challenges associated with the implementation, and the evaluation are presented. Method Mixed quantitative and qualitative analysis were utilized. Results Preliminary evaluation suggests that SMAs promote improved trainee/student understanding of both the complexity of diabetes care and the seriousness of the illness, along with an increased confidence in the ability to communicate with providers from other disciplines. Conclusion Further research to determine the efficacy of SMAs as an interprofessional training venue is needed that focuses on comprehensive assessment, necessary dose of exposure, and identification of barriers to overcome operational issues.

As the Accreditation Council on Graduate Medical Education (ACGME) deliberates over further limiting duty hours of graduate medical education (GME) trainees, few large-scale studies have shown residents to be satisfied with the effect the 2003 standards have had on clinical care, education outcomes, or working environments. This study measures the effect of the 2003 duty hours limits on resident-reported satisfaction with GME training during their rotations through the Department of Veterans Affairs (VA) medical centers from 2001 through 2007.Self-reported satisfaction with clinical care and education environments were assessed by comparing responses to VA's annual Learners' Perceptions Survey administered before 2003 with responses administered after 2003. To measure duty hours effects on satisfaction, before-after differences were adjusted for covariate biases modeled after an exhaustive covariate search with 10-fold cross-validation. Because nonteaching controls are not available in satisfaction studies, we used a robust differencing variable technique to control before-after differences for trend biases in the simultaneous presence of missing data and possible model misspecification.There were 19,605 responders. Adjusting for covariate and trend biases, after the 2003 ACGME standards, 25% more residents in medicine specialties reported satisfaction with VA clinical environment and 11% more with VA preceptors and faculty. For surgery, 33% more residents reported satisfaction with VA clinical environment and 12% more with VA preceptors and faculty. Satisfaction with working environment was mixed.The 2003 ACGME duty hours standards were associated with improved satisfaction for resident clinical training and learning environments.

The evolution of new diagnostic techniques has revolutionized the practice of medicine and in fact, the nature of medicine itself. Technology has also expanded the “visual” field of medicine: the naked eye was assisted by the light microscope and then electron microscope to see smaller and smaller features while radiology has permitted “non-invasive” identification of internal structures. However, there are unintended consequences one of which is the discovery of an anomaly during the course of looking for something else – incidental findings and incidentalomas. Technology in general and imaging specifically offer much in service to physicians and their patients. However, it behoves physicians to ensure that technology supplements but does not replace good clinical judgment. This essay aims to put the issue of incidental findings related to advancing technology (especially imaging technology) into a broader context.

IN BRIEF Successful management of patients with diabetes requires individualizing A1C and treatment goals in conjunction with identifying and managing hypoglycemia risk. This article describes the Veterans Health Administration’s Choosing Wisely Hypoglycemia Safety Initiative (CW-HSI), a voluntary program that aims to reduce the occurrence of hypoglycemia through shared decision-making about deintensifying diabetes treatment in a dynamic cohort of patients identified as being at high risk for hypoglycemia and potentially overtreated. The CW-HSI incorporates education for patients and clinicians, as well as clinical decision support tools, and has shown decreases in the proportions of high-risk patients potentially overtreated and impacts on the frequency of reported hypoglycemia.

Diabetes, a chronic disease affecting over 29 million people in the United States, requires the integration of complex medical tasks into a person's daily life. Patient-centered care and compassion are recognized as essential dimensions of the quality care experience. This research examined provider attributes that influence adherence to type 2 diabetes mellitus (T2DM) regimens and sought to understand the phenomena of provider attributes, treatment adherence, and their relationship to coping ability and treatment outcomes. This quantitative study sampled 474 people with T2DM using a 62-item online survey administered to three different groups. The sample population included people over age 18 diagnosed with T2DM. The first group included 91 persons with T2DM identified through a Facebook group and personal social media connections, the second group included 120 Amazon Mechanical Turk participants with T2DM, and the third group included 263 respondents from a Qualtrics panel who had T2DM. Results indicated that perceived provider compassion (β = .41, ρ < .001) and optimism (β = .48, ρ < .001) positively affected coping ability. Additionally, full mediation effects for self-management were revealed, with coping ability positively mediating the effect of compassion on self-management and the effects of optimism on self-management. Furthermore, full mediation effects were found for treatment satisfaction, with coping ability positively mediating the effect of compassion on treatment satisfaction and the effects of optimism on treatment satisfaction. This research has implications for patients, healthcare professionals, and leaders suggesting that providers who communicate with optimism and compassion positively affect coping ability. As a result, healthcare providers and professionals have an opportunity to enhance self-management adherence by helping their patients cope with the burdens of diabetes. In addition, this study has implications for developing provider communication tools aimed at assessing patients' coping capacity and increasing compassionate communication.

Cushing’s syndrome refers to the signs and symptoms that result from excessive glucocorticoid action, usually from endogenous production or exogenous administration. This article reviews the pathophysiology of hypertension in Cushing’s syndrome and current concepts in the diagnosis and treatment of this disorder.

In 1998, the Veterans Health Administration invested in the creation of the Veterans Administration National Quality Scholars Fellowship Program (VAQS) to train physicians in new ways to improve the quality of health care. We describe the curriculum for this program and the lessons learned from our experience to date. The VAQS Fellowship program has developed a core improvement curriculum to train postresidency physicians in the scholarship, research, and teaching of the improvement of health care. The curriculum covers seven domains of knowledge related to improvement: health care as a process; variation and measurement; customer/beneficiary knowledge; leading, following, and making changes in health care; collaboration; social context and accountability; and developing new, locally useful knowledge. We combine specific knowledge about the improvement of health care with the use of adult learning strategies, interactive video, and development of learner competencies. Our program provides insights for medical education to better prepare physicians to participate in and lead the improvement of health care.

The amino acid sequence of human preprocalcitonin predicted from complementary DNA analyses indicates that the 32-amino-acid sequence of calcitonin is internally situated. Extending beyond the carboxyl-terminal proline of the calcitonin sequence is a 25-amino-acid segment which contains the tetrapeptide Gly-Lys-Lys-Arg linking calcitonin to the remaining 21 amino acids. Our objective was to examine whether human medullary thyroid carcinomas (MTCs) elaborate a noncalcitonin peptide corresponding to the carboxyl terminus of human preprocalcitonin. An acidic peptide identical to the predicted terminal 21-amino-acid sequence of human preprocalcitonin was synthesized for establishing a RIA. We used gel filtration, isoelectric focusing, and high pressure liquid chromatography to demonstrate immunoreactive peptide(s) with size, charge, and hydrophobicity similar to the 21-amino-acid synthetic peptide in MTCs and nonneoplastic thyroid. The immunoreactive noncalcitonin peptide was present in these tissue extracts in amounts approximately equimolar to calcitonin. A similar immunoreactive noncalcitonin peptide was detected in hypercalcitoninemic plasmas from MTC patients; such circulating immunoreactivity was undetectable (<0.25 ng/ml) in thyroidectomized or normal persons. The circulating levels of immunoreactive noncalcitonin peptide and calcitonin in MTC patients were directly correlated, their ratio remaining nearly equal over a 30,000-fold concentration range. Pentagastrin infusion of MTC patients concurrently raised circulating levels of calcitonin and noncalcitonin-peptide immunoreactivities. After curative thyroidectomy, serum levels of calcitonin and the noncalcitonin peptide were undetectable during pentagastrin infusion. Primary cultures of human MTC cells secreted approximately equal amounts of the immunoreactive noncalcitonin peptide and calcitonin. These results suggest that human MTCs and perhaps nonneoplastic human C cells cosecrete two peptides, calcitonin and a 21-amino-acid noncalcitonin peptide, which are probably derived from a common precursor. (J Clin Endocrinol Metab56: 802, 1983)

OBJECTIVE—Quality measures of glycemic control using threshold values do not assess incremental quality improvement. We compared health care system performance using weighted continuous versus dichotomous measures for glycemic control. RESEARCH DESIGN AND METHODS—We performed retrospective cross-sectional analysis of chart abstraction data on 37,142 diabetic patients from 141 Veterans Health Administration medical centers in 2000–2001. RESULTS—Subjects per facility ranged from 163 to 740 (mean 263). Mean overall HbA1c (A1C) was 7.58%. A continuous measure for glycemic control was calculated based on percentage of maximal quality-adjusted life-years saved (QALYsS). Overall mean facility performance using the dichotomous measure was 62% &amp;lt;8% A1C (range 48–75%) and 39% &amp;lt;7% A1C (21–57%), in comparison with 45% maximal QALYsS (31–60%). Correlation between QALYsS and A1C thresholds of &amp;lt;8 (0.848) and &amp;lt;7 (0.838) for facility rankings was excellent; correlation between facility level performance using thresholds of &amp;lt;8 and 7% was poor (r = 0.13, P = 0.14). Comparison of facility rankings between the &amp;lt;7% dichotomous measure and the QALYsS-weighted measure showed that 22% changed their ranking by ≥2 deciles with marked changes in top and bottom deciles. CONCLUSIONS—Facility rankings vary by threshold or continuous methodology. However, because significant numbers of individuals are unable to reach “optimal” target goals (thresholds) even in clinical trials with extensive exclusion criteria, we propose that a continuous measure assessing improvement toward optimal A1C, rather than a pass/fail optimal target, is both a fairer assessment clinical practice and a more accurate reflection of population health improvement.

Somatostatin (SRIF)-producing transplantable rat medullary thyroid carcinomas (MTCs) were used to establish primary monolayer cell cultures for studying SRIF secretion and production. Immunoreactive SRIF (iSRIF) and calcitonin (iCT) levels in the MTC cell cultures were 252 and 4900 ng/mg cell protein, respectively. The acute effects of calcium and glucagon on the elaboration of iSRIF and iCT were investigated in 3-h experiments. Basal secretion rates (mean ± SE, five experiments) for iSRIF and for iCT were 10.7 ± 2.5 and 297 ± 33 ng/mg cell protein, respectively. Calcium stimulated the secretion of iSRIF and iCT in a dose-dependent fashion. Maximal secretory effect of calcium was observed at 4-5 mM: iCT secretion increased 148% over basal, and iSRIF secretion increased 228% over basal. At 1 mM calcium, maximally effective doses of glucagon (1 μM) significantly increased iCT secretion (44% over basal) but not iSRIF secretion. At 5 mM calcium, as little as 10 nM glucagon had a significant stimulatory effect on secretion of both peptides. The largest stimulation was observed at 5 mM calcium and 1 im. glucagon; for iSRIF a 527% increase over basal and for iCT a 308% increase over basal were observed under this condition. At high calcium the stimulatory effect of glucagon on iSRIF secretion and on iCT secretion was significantly greater than at low calcium. In these 3-h experiments neither 5 mM calcium nor 1 JUM glucagon increased culture content (cells plus inedium) of iCT or iSRIF. However, 3-h treatment of the cell cultures with both agonists increased total culture content of iSRlF by 53% and iCT by 21%. The establishment of SRIF-producing cell cultures from transplantable rat MTCs and the identification of a synergistic secretagogue interaction for glucagon and calciumopen the way for systematic in vitro investigation of SRIF secretion and biosynthesis.

The terminal hexadecapeptide sequence of preprocalcitonin (termed carboxyl-adjacent peptide, CAP, for its position relative to calcitonin) has been synthesized to establish a radioimmunoassay for an investigation of cross-reacting peptides in extracts of normal and neoplastic calcitonin-producing tissues. Gel filtration chromatography of a rat thyroid extract revealed a major peak of immunoreactive peptide of approximately the same molecular weight as synthetic CAP. A minor peak of higher molecular weight immunoreactive material was also observed. The isoelectric point of both the thyroid peptide and synthetic material was about 5.2. Immunoreactive CAP and calcitonin were found in approximately equimolar amounts in normal thyroid and in anaplastic and well differentiated rat medullary thyroid carcinomas. Immunoreactive CAP was not detected in any tissue which did not contain calcitonin. Monolayer cultures of a rat medullary thyroid carcinoma contained and secreted equimolar amounts of immunoreactive CAP and calcitonin under basal (1 mM Ca/sup 2 +/) and stimulated (4 mM Ca/sup 2 +/ and 1 ..mu..M glucagon) conditions. These data indicate that the thyroidal peptide is probably the hexadecapeptide CAP which is derived from the same translation product as calcitonin. The similarity between the processing of precursors to the amidated peptide melanocyte-stimulating hormone and the corticotropin-like intermediate lobemore » peptide and processing of calcitonin and CAP suggests that the sequence Gly-Lys-Lys-Arg is one amidation codon in mammalian systems.« less

Elderly patients with diabetes are prone to a number of complications, some of which take precedence over or hinder or preclude the intensive glucose control recommended for younger diabetic patients. This article reviews some of these complications, including coronary artery disease, retinopathy, neuropathy, nephropathy, and others.

We explored the association of antibiotic-resistant phenotypes and genotypes in Acinetobacter spp with clinical outcomes and characteristics in 75 patients from a major military treatment facility. Amikacin resistance was associated with nosocomial acquisition of A baumannii, and carbapenem resistance and bla(OXA-23) were associated with the need for mechanical ventilation. The presence of bla(OXA-23) also correlated with longer hospital and ICU stay. Associations between bla(OXA-23) and complexity, duration, and changes made to antibiotic regimens also existed.

Abstract Background We developed a practice-based learning and improvement (PBLI) curriculum to address important gaps in components of content and experiential learning activities through didactics and participation in systems-level quality improvement projects that focus on making changes in health care processes. Methods We evaluated the impact of our curriculum on resident PBLI knowledge, self-efficacy, and application skills. A quasi-experimental design assessed the impact of a curriculum (PBLI quality improvement systems compared with non-PBLI) on internal medicine residents' learning during a 4-week ambulatory block. We measured application skills, self-efficacy, and knowledge by using the Systems Quality Improvement Training and Assessment Tool. Exit evaluations assessed time invested and experiences related to the team projects and suggestions for improving the curriculum. Results The 2 groups showed differences in change scores. Relative to the comparison group, residents in the PBLI curriculum demonstrated a significant increase in the belief about their ability to implement a continuous quality improvement project (P = .020), comfort level in developing data collection plans (P = .010), and total knowledge scores (P &amp;lt; .001), after adjusting for prior PBLI experience. Participants in the PBLI curriculum also demonstrated significant improvement in providing a more complete aim statement for a proposed project after adjusting for prior PBLI experience (P = .001). Exit evaluations were completed by 96% of PBLI curriculum participants who reported high satisfaction with team performance. Conclusion Residents in our curriculum showed gains in areas fundamental for PBLI competency. The observed improvements were related to fundamental quality improvement knowledge, with limited gain in application skills. This suggests that while heading in the right direction, we need to conceptualize and structure PBLI training in a way that integrates it throughout the residency program and fosters the application of this knowledge and these skills.

In 2011, the Veterans Health Administration (VHA) implemented electronic consults (e-consults) as an alternative to in-person specialty visits to improve access and reduce travel for veterans. We conducted an evaluation to understand variation in the use of the new e-consult mechanism and the causes of variable implementation, guided by the Consolidated Framework for Implementation Research (CFIR).Qualitative case studies of 3 high- and 5 low-implementation e-consult pilot sites. Participants included e-consult site leaders, primary care providers, specialists, and support staff identified using a modified snowball sample.We used a 3-step approach, with a structured survey of e-consult site leaders to identify key constructs, based on the CFIR. We then conducted open-ended interviews, focused on key constructs, with all participants. Finally, we produced structured, site-level ratings of CFIR constructs and compared them between high- and low-implementation sites.Site leaders identified 14 initial constructs. We conducted 37 interviews, from which 4 CFIR constructs distinguished high implementation e-consult sites: compatibility, networks and communications, training, and access to knowledge and information. For example, illustrating compatibility, a specialist at a high-implementation site reported that the site changed the order of consult options so that all specialties listed e-consults first to maintain consistency. High-implementation sites also exhibited greater agreement on constructs.By using the CFIR to analyze results, we facilitate future synthesis with other findings, and we better identify common patterns of implementation determinants common across settings.

OBJECTIVE To evaluate patient-level glycemic control and facility variation of a proposed out-of-range (OOR) measure (overtreatment [OT] [HbA1c &amp;lt;7% (53 mmol/mol)] or undertreatment [UT] [&amp;gt;9% (75 mmol/mol)]) compared with the standard measure (SM) (HbA1c &amp;lt;8% [64 mmol/mol]) in high-risk older adults. RESEARCH DESIGN AND METHODS Veterans Health Administration patients ≥65 years of age in 2012 who were taking antihyperglycemic agents in 2013 were identified. Patient-level rates and facility-level rates/rankings were calculated by age and comorbid illness burden. RESULTS We identified 303,097 patients who were taking antiglycemic agents other than metformin only. The study population comprised 193,689 patients with at least one significant medical, neurological, or mental health condition; 98.2% were taking a sulfonylurea and/or insulin; 55.2% were aged 65–75 years; and 44.8% were aged &amp;gt;75 years. The 47.4% of patients 65–75 years met the OOR measure (33.4% OT, 14% UT), and 65.7% met the SM. For patients aged &amp;gt;75 years, rates were 48.1% for OOR (39.2% OT; 8.9% UT) and 73.2% for SM. Facility-level rates for OOR for patients aged 65–75 years ranged from 33.7 to 60.4% (median 47.4%), with a strong inverse correlation (ρ = −0.41) between SM and OOR performance rankings. Among the best-performing 20% facilities on the SM, 14 of 28 ranked in the worst-performing 20% on the OOR measure; 12 of 27 of the worst-performing 20% facilities on the SM ranked in the best-performing 20% on the OOR measure. CONCLUSIONS Facility rankings that are based on an SM (potential benefits) and OOR measure (potential risks) differ substantially. An OOR for high-risk populations can focus quality improvement on individual patient evaluation to reduce the risk for short-term harms.