Citations

Many primary care providers feel uncomfortable discussing end-of-life care. The aim of this intervention was to assess internal medicine residents’ advance care planning (ACP) practices and improve residents’ ACP confidence. Residents participated in a facilitated ACP quality improvement workshop, which included an interactive presentation and chart audit of their own patients. Pre- and postintervention surveys assessed resident ACP-related confidence. Only 24% of the audited patients had an advance directive (AD), and 28% of the ACP-documentation was of no clinical utility. Terminally ill patients (odds ratio 2.8, P < .001) were more likely to have an AD. Patients requiring an interpreter were less likely to have participated in ACP. Residents reported significantly improved confidence with ACP and identified important training gaps. Future studies examining the impact on ACP quality are needed.

Stress and its attendant psychosocial and lifestyle variables have been associated with coronary artery disease (CAD), yet the contribution of socioeconomic status (SES) has not been addressed. The aim of this study is to determine if stress assessment is associated with CAD independent of SES, and is incremental to the Framingham Score. The study group consisted of 325 executive patients undergoing comprehensive health assessment. Stress was assessed utilizing the validated “Self-Rated Stress” (SRS) instrument. Coronary artery calcification (CAC) served to assess the degree of atherosclerosis, a CAD equivalent and risk assessment tool. The relationship between SRS and CAC was assessed, with adjustment by potential confounders. CAC was modeled by a variety of cut points (>0, ≥5, ≥100, ≥200) for the test of trend across stress levels per Mantel-Haenszel chi-square (1 df) with nonsignificant P values of 0.9960, 0.5242, 0.1692, 0.3233, respectively. A logistic regression model with SRS as a categorically ranked and continuous variable to predict binary outcome of calcification yielded P values of 0.2366 and 0.9644; this relationship, further adjusted by age, fruit and vegetable consumption, exercise, and education, yielded no statistically significant association. No improvement of fit was observed for the established Framingham Score to CAC relation utilizing SRS. The study concluded that SRS did not play a role in early CAD when focusing on a population in higher socioeconomic strata, and SRS did not add predictive value beyond patient age or calculated Framingham risk. Future studies should focus on additional validated instruments of stress to differentiate between subtypes of stress for varying SES strata. ( Population Health Management 2013;16:332–340)

Background/Aim: Despite existing diagnostic criteria for Charles Bonnet syndrome (CBS), clinical manifestations vary greatly. We examined the clinical course and mortality of patients diagnosed with CBS. Methods: We conducted a retrospective chart review of patients with CBS. We collected demographic and clinical information and medical burden scores. Kaplan-Meier mortality curves were compared using log-rank test. Cox proportional hazard model was used for multivariate analysis and hazard ratio (HR). Mortality was compared to expected mortality from Minnesota population. Results: Seventy-seven patients with CBS had a mean age of 79.5 (standard deviation ± 13.0) and were predominantly Caucasian (97%) and female (73%). In all, 20 (26%) subsequently developed a dementia syndrome, most often Lewy body. A total of 46 (60%) deaths occurred with an average follow-up time of 33.0 months. Characteristics associated with mortality included older age (75-84 [HR 3.34, P = .029], >85 [HR 4.58, P = .007]) and renal disease (HR 3.39 with 95% confidence interval 1.31-8.80, P = .012). Medical burden scores were not associated with overall mortality. Mortality was high compared to Minnesota population ( P < .0001). Conclusions: A large proportion of patients with CBS developed dementia, and there was a high mortality rate associated with older age and renal disease. Medical burden was not associated with mortality.

Background The etiology of carpal tunnel syndrome (CTS) remains idiopathic in many cases. Noninflammatory fibrosis of the subsynovial connective tissue (SSCT) within the carpal tunnel is common in CTS, and some clinicians have hypothesized that this fibrosis might be a cause rather than an effect of CTS. An animal model in which to test this hypothesis would be useful. The principal objective of this study was to investigate the effect of a surgical injury on SSCT fibrosis and median nerve function within the carpal tunnel in an in vivo rabbit model. Methods Rabbits were sacrificed 12 weeks after surgery and were evaluated by mechanical testing, histology, transmission and scanning electron microscopy, and electrophysiology. Results SSCT fibroblast density ( p<0.0001) and collagen fiber size ( p=0.0004) were significantly higher, and the median nerve distal motor amplitude was significantly lower ( p=0.0018), in the tendon injury group SSCT than in either the sham or control groups. Conclusions Our findings are similar to those seen in patients with carpal tunnel syndrome and suggest that the tendon injury procedure may be the basis of a new animal model of SSCT injury and, possibly, CTS.

The United States Preventive Services Task Force and the National Osteoporosis Foundation recommend routine osteoporosis screening for women aged 65 years or older. Previous studies have shown that the use of a clinical decision-support tool significantly improves screening rates. In a recently published study, a statistically significant improvement was found in the screening rates for eligible women with use of the tool. To evaluate whether a clinical decision-support tool independently predicts completion of osteoporosis screening tests and to identify predictors of screening completion, we examined the records of 2462 female patients who were eligible for osteoporosis screening but had no prior baseline screening and who were seen in our primary care practices in 2007 and 2008. Patient and provider characteristics and clinic visit type were identified, and their association with screening test completion was statistically analyzed using both univariate and multivariate models. Screening completion rates increased significantly from 2007 to 2008. Factors associated with increased likelihood of screening completion included race, marital status, residence, presence of comorbidity (cancer, rheumatologic disease), and the year and type of visit. Screening was less likely for women aged 80 years or older. The use of a point-of-care decision-support tool not only improved osteoporosis screening rates significantly but appeared to be an independent predictor of screening completion. It potentially can facilitate the systematic and effective delivery of preventive health services to patients in the primary care setting. ( Population Health Management 2011;14:243–247)

This study is a retrospective chart review to determine the association of Charlson Comorbidity Index (CCI), age, body mass index (BMI), and admission glucose with the incidence of postoperative 30-day mortality in older patients undergoing hip fracture surgery from January 1, 2000, to June 30, 2002. A total of 40 (8%) of 485 eligible patients died within 30 days after hip fracture surgery. The factors associated with 30-day mortality were age > 90 years (odds ratio [OR] = 2.74; confidence interval [CI] = 1.27-5.95; P = .012), BMI < 18.5 (OR = 3.98; CI 1.48-10.65; P = .006), and CCI ≥ 6 (OR = 2.6; CI = 1.20-5.65; P = .015). There was no relationship between admission glucose concentration and 30-day mortality. Advanced age, low BMI, and high CCI can be identified prospectively and are independently associated with postoperative 30-day mortality in older, chronically ill patients.

Tendon disuse, or stress deprivation, frequently accompanies clinical disorders and treatments, yet the metabolism of tendons subject to stress deprivation has rarely been investigated systematically. The effects of stress deprivation on canine flexor tendon were investigated in this study. One adult canine forepaw was suspended for 21 or 42 days. Control forepaws were collected from dogs that had no intervention on their limbs and paws. The expression of collagen I and III was not significantly altered in the tendons disused for 21 days but was significantly decreased at 42 days ( P < 0.03). The expression of collagen II, aggrecan, decorin, and fibronectin was significantly decreased in the tendons in the suspended limbs at 21 days ( P < 0.002) and further reduced at 42 days. With stress deprivation, the expression of matrix metalloproteinase 2 (MMP2) was significantly increased ( P < 0.004) at 21 and 42 days. The expression of MMP3 was significantly decreased at 21 and 42 days ( P < 0.03). The expression of MMP13 was not altered with stress deprivation at 21 and 42 days. The expression of MMP14 was significantly increased at 21 days ( P = 0.0015) and returned to the control level at 42 days. Tissue inhibitor of metalloproteinase 1 (TIMP1) expression was decreased after the limbs were suspended for 42 days ( P = 0.0043), but not 21 days. However, TIMP2 expression was not significantly different from control at 21 or 42 days. Furthermore, the cross-sectional area of the stress-deprived tendons at 42 days was decreased compared with the control group ( P < 0.01). The intervention method in this study did not result in any alteration of stiffness of the tendon. Our study demonstrated that stress deprivation decreases the anabolic process and increases the catabolic process of extracellular matrix in flexor tendon.

Objective To provide information about the clinical use of acupuncture at an academic medical centre in the USA. Methods A retrospective review of 904 patients (receiving 6070 treatments) who were referred for acupuncture treatment at the Mayo Clinic (Rochester, Minnesota, USA) between 1 January 2004 and 31 December 2008. Data gathered included age, sex, primary diagnosis, number of treatments per diagnosis and health insurance carrier. Results The mean (SD) age of the patients was 53.4 (16.2) years; 73.8% were female and 26.2% were male. The three most common diagnostic categories for which acupuncture was used were spinal pain (33.4%), pain (other) (25.1%) and joint pain (12.3%). About 42% of visits were not covered by health insurance carriers and hence patients had to pay themselves. For the remaining 58% of visits, health insurance carriers picked up all or part of the cost of the acupuncture treatments. Conclusion The results indicate that pain is the most common reason for use of acupuncture in an academic medical centre and that women use acupuncture more than men. This is one of the few reports of clinical use of acupuncture at academic medical centres in the USA.

Background— Contrast-induced nephropathy (CIN) is associated with significant morbidity and mortality. The objective of our meta-analysis was to assess the efficacy of iodixanol compared with low-osmolar contrast media (LOCM) for prevention of CIN. Methods and Results— We searched MEDLINE, the Cochrane Central Register of Controlled Trials, and internet sources of cardiology trial results for individual and relevant reviews of randomized, controlled trials, for the terms contrast media, contrast nephropathy, renal failure, iodixanol, Visipaque, and low-osmolar contrast media. All studies reported an incidence rate of CIN for each study group; there was no restriction on the definition of CIN. There were no restrictions on journal type or patient population. Overall, 36 trials were identified for analysis of aggregated summary data on 7166 patients; 3672 patients received iodixanol and 3494 patients received LOCM. Overall, iodixanol showed no statistically significant reduction in CIN incidence below that observed with heterogeneous comparator agents ( P =0.11). Analysis of patient subgroups revealed that there was a significant benefit of iodixanol when compared with iohexol alone (odds ratio, 0.25; 95% confidence interval, 0.11 to 0.55; P <0.001) but not when compared with LOCM other than iohexol or with other ionic dimers or among patients receiving intra-arterial contrast injections or among patients undergoing coronary angiography with or without percutaneous intervention. Conclusions— Analysis of aggregated summary data from multiple randomized, controlled trials of iodixanol against diverse LOCMs for heterogeneous procedures and definitions of CIN show an iodixanol-associated reduction that is suggestive but statistically nonsignificant.

External qigong as a pharmacotherapy adjunct was investigated in 50 subjects with chronic pain (pain lasting > 3 months with pain score of ≥ 3 on 0–10 numeric analog scale) who presented to a qigong healing center. Participants were randomized to receive either external qigong treatment (EQT) or equivalent attention time (EAT) in weekly 30-min sessions for four consecutive weeks. Outcomes were assessed before and after sessions. The primary outcome measure was intensity of pain by a 10-cm visual analog scale used to rate all pain severity measurements. At 8-week follow-up, participants were contacted by telephone and mailed a questionnaire. Most had experienced pain for > 5 years (66%); the rest, for > 3 to 5 years (8%), 1 to 3 years (10%), or < 1 year but > 3 months (10%). The most frequent concomitant diagnoses were multifactorial (26%), osteoarthritis (18%), and low back pain (12%). Most patients were also receiving other treatments (74%); none previously had EQT. Participants were randomly assigned to EQT ( n = 26) or EAT ( n = 24). These groups had no significant differences at baseline except for prior awareness of qigong (EQT 31% vs. EAT 63%; p = 0.025). Compared to the EAT group, EQT participants had a significant decrease in pain intensity in the 2nd ( p = 0.003), 3rd ( p < 0.001), and 4th weeks of treatment ( p = 0.003). At week 8, these differences in overall decreased pain intensity persisted but were not statistically significant.