We sought to determine whether there are signs of improvement in the rates of heart failure (HF) hospitalizations given the recent reports of improvement in national trends.
HF admissions data from the Tennessee Hospital Discharge Data System were analyzed.
Hospitalization for primary diagnosis of HF (HFPD) in adults (aged 20 years old or older) decreased from 4.5% in 2006 to 4.2% in 2008. Similarly, age-adjusted HF hospitalization (per 10,000 population) declined by 19.1% (from 45.5 in 2006 to 36.8 in 2008). The age-adjusted rates remain higher among blacks than whites and higher among men than women. Notably, the rate ratio of black-to-white men ages 20 to 34 years admitted with HFPD increased from 8.5 in 2006 to 11.1 in 2008; similarly, the adjusted odds ratios for HFPD were 4.75 (95% confidence interval 3.29–6.86) and 5.61 (95% confidence interval 3.70–8.49), respectively. There was, however, a significant improvement in odds ratio for HF rates among young black women, as evidenced by a decrease from 4.60 to 3.97 (aged 20–34 years) and 4.21 to 3.12 (aged 35–44 years) between 2006 and 2008, respectively. Among patients aged 20 to 34 and 35 to 44 years, hypertension was the strongest independent predictor for HF. Diabetes and myocardial infarction emerged as predictors for HF among patients aged 35 years and older.
The overall rate of HF hospitalization declined during the period surveyed, but the persistent disproportionate involvement of blacks with evidence of worsening among younger black men, requires close attention.
heart failure; prevention; blacks; disparities; risk factors
Noninvasive assessment of right heart function and hemodynamics in patients with pulmonary arterial hypertension (PAH) is most often performed at rest, whereas the symptoms, in general, present with exertion. Assessment during exertion is limited to symptom assessment and the 6-minute walk distance. We investigated the feasibility of obtaining echocardiographic data that could accurately reflect pulmonary artery pressures (PAP), particularly mean PAP and right ventricular function during exercise in patients with PAH.
We investigated right ventricular function and hemodynamics using echocardiography during symptom-limited exercise in 10 consecutive patients undergoing right heart catheterization (RHC) as part of their clinical evaluation for PAH. We further assessed these measurements for correlation with known predictors of outcome in PAH in an exploratory analysis.
We were able to successfully obtain complete right heart measurements by echocardiography, including mean PAP, in the majority (9 of 10) of the subjects. One patient had an incomplete tricuspid regurgitation jet at rest and with exercise. Echocardiographic pulmonary vascular resistance correlated with RHC cardiac output and brain natriuretic peptide level, whereas tricuspid annular plane systolic excursion during exercise correlated with right atrial pressure on RHC, brain natriuretic peptide, and 6-minute walk distance. Tricuspid regurgitation velocity and mean PAP with exercise correlated moderately with mean PAP and cardiac output by RHC.
Exercise echocardiography can provide meaningful data in patients with PAH, including measuring mean PAP. The presence of correlations in this small number of patients indicates promising targets for future investigation.
pulmonary arterial hypertension; exercise echocardiography; right ventricular function
This study examined how physicians perceive pharmaceutical companies’ medication assistance programs (MAPs).
The study was conducted using a survey of 373 primary care physicians from four southern states; they were surveyed within the formative evaluation phase of a larger study (MI-Plus). Respondents were queried about use and usefulness of MAPs for patients who cannot afford drugs, and barriers to using them. Bivariate associations between physician-level variables (patients without drug coverage) and usefulness and barriers to using MAPs were assessed using Chi square tests. Independence of associations was assessed using multiple logistic regressions.
Of the 364 (97.6%) respondents who used MAPs, 70% used them regularly, the rest occasionally; 63% found MAPs very useful in caring for patients who cannot afford drugs. About 89% reported one or more barriers to using MAPs; 47% saw “inability of patients to apply directly;” and 57% saw “enrollment process being time-consuming for staff” as barriers. Compared to physicians with fewer elderly patients without drug coverage, those with more of these patients were less likely to find MAPs very useful; less likely to report no barriers to using MAPs; and more likely to see “low income thresholds” and “inability of patients to apply directly” as barriers.
While MAPs are considered useful in caring for patients in need of assistance, there are many barriers to their use. Pharmaceutical companies should address these barriers. Limitations include a low response rate (about 10%).
drug affordability; indigent patients; pharmaceutical medication assistance programs; primary care physician
Florida has the second highest incidence of melanoma in the United States, and more than 600 Floridians die from melanoma annually. Given the lack of population-based data on skin cancer screening among the different US geographic regions, we compared skin cancer screening rates among Floridians to those in the rest of the South, the Northeast, the Midwest, and the West.
We used data from the 2000 and 2005 National Health Interview Survey. Data were grouped according to whether participants reported ever receiving a skin cancer examination in their lifetime. Data were pooled, and analyses accounted for sample weights and design effects. Multivariable logistic regression analyses were performed with self-reported skin screening as the outcome of interest.
Results showed that compared to the rest of the US, Floridians who were women 70 years old and older, reported being of “other” race, of non-Hispanic ethnicity, having a high school education, having health insurance, and employed in the service industry or unemployed, had significantly higher lifetime skin cancer screening rates than their subgroup counterparts residing in the other regions. Multivariable logistic regression showed that Floridians remained significantly more likely to have ever been screened for skin cancer compared to the other US regions after controlling for a variety of sociodemographic variables.
Increasing melanoma detection remains a national cancer goal for the US, and future identification of underlying causal factors for higher screening rates in Florida could inform intervention strategies in the other US regions.
skin cancer screening; cancer surveillance; Florida; US geographic regions; melanoma
Although conceptually there is agreement on how the Patient Centered Medical Home (PCMH) should be organized, there is no such agreement on what components constitute a PCMH. Considering that patients perspectives should be included in the design of a PCMH we evaluated patient opinion on PCMH based on National Committee for Quality Assurance (NCQA) elements.
An anonymous, voluntary survey was administered to patients at three US Academic Medical Centers. Questions sought opinion on the NCQA key components of essential elements of the PCMH. Analysis of the survey responses was conducted using SAS version 9.1
780 surveys were returned. There were no differences in response to the survey according to age, by sex, race, or site. Differences did exist in patient insurance status by site (chi-sq<.0001) and by race (chi-sq<.0012). Patients felt strongly that the ability to coordinate care, the ability to help patients manage their own disease, and the ability to rack lab results were important. Patients listed care coordination, patient self-management, and improved access to care as one of their top 5 attributes of a PCMH.
Patients were consistent in their opinions that care coordination, and patient self-management we important elements of a PCMH. They also believe that improved access to care is another core component.
The objective of this investigation is to review existing research pertaining to cognitive impairment and decline following critical illness and describe a case involving a 49-year-old female with sepsis and acute respiratory distress syndrome (ARDS) with no prior neurologic history who, compared to baseline neuropsychological test data, experienced dramatic cognitive decline and brain atrophy following treatment in the medical intensive care unit (ICU) at Vanderbilt University Medical Center. The patient participated in detailed clinical interviews and underwent comprehensive neuropsychological testing and neurological magnetic resonance imaging (MRI) at approximately 8 months and 3.5 years after ICU discharge. Compared to pre-ICU baseline test data, her intellectual function declined approximately 2 standard deviations from 139 to 106 (from the 99th to the 61st percentile) on a standardized intelligence test 8 months post-discharge, with little subsequent improvement. Initial diffusion tensor brain magnetic resonance imaging (DT-MRI) at the end of ICU hospitalization showed diffuse abnormal hyperintense areas involving predominately white matter in both hemispheres and the left cerebellum. A brain MRI nearly 4 years after ICU discharge demonstrated interval development of profound and generalized atrophy with sulcal widening and ventricular enlargement. The magnitude of cognitive decline experienced by ICU survivors is difficult to quantify due to the unavailability of pre-morbid neuropsychological data. The current case, conducted on a patient with baseline neuropsychological data, illustrates the trajectory of decline occurring after critical illness and ICU-associated brain injury with marked atrophy and concomitant cognitive impairments.
ARDS; brain injury; critical care; executive dysfunction; sepsis
A major challenge facing contemporary cancer educators is how to optimize the dissemination of breast cancer prevention and control information to African American women in the Deep South who are believed to be cancer free. The purpose of this research was to provide insight into the breast cancer information-acquisition experiences of African American women in Alabama and Mississippi and to make recommendations on ways to better reach members of this high-risk, underserved population.
Focus group methodology was used in a repeated, cross-sectional research design with 64 African American women, 35 years old or older who lived in one of four urban or rural counties in Alabama and Mississippi.
Axial-coded themes emerged around sources of cancer information, patterns of information acquisition, characteristics of preferred sources, and characteristics of least-preferred sources.
It is important to invest in lay health educators to optimize the dissemination of breast cancer information to African American women who are believed to be cancer free in the Deep South.
African American women; breast cancer; focus group; information acquisition
The objective of this study was to investigate risk factors associated with tuberculosis (TB) transmission that was caused by Mycobacterium tuberculosis strain MS0006 from 2004 to 2009 in Hinds County, Mississippi.
DNA fingerprinting using spoligotyping, mycobacterial interspersed repetitive unit, and IS6110-based restriction fragment length polymorphism of culture-confirmed cases of TB was performed. Clinical and demographic factors associated with strain MS0006 were analyzed by univariate and multivariate analysis.
Of the 144 cases of TB diagnosed during the study period, 117 were culture positive with fingerprints available. There were 48 different strains, of which 6 clustered strains were distributed among 74 patients. The MS0006 strain accounted for 46.2% of all culture-confirmed cases. Risk factors for having the MS0006 strain in a univariate analysis included homelessness, HIV co-infection, sputum smear negativity, tuberculin skin test negativity, and noninjectable drug use. Multivariate analysis identified homelessness (odds ratio 7.88, 95% confidence interval 2.90-21.35) and African American race (odds ratio 5.80, 95% confidence interval 1.37-24.55) as independent predictors of having TB caused by the MS0006 strain of M tuberculosis.
Our findings suggest that a majority of recently transmitted TB in the studied county was caused by the MS0006 strain. African American race and homelessness were significant risk factors for inclusion in the cluster. Molecular epidemiology techniques continue to provide in-depth analysis of disease transmission and play a vital role in effective contact tracing and interruption of ongoing transmission.
tuberculosis; HIV; Mississippi; homeless; molecular epidemiology
The benefit of improved health outcomes for blacks receiving highly active antiretroviral therapy (HAART) lags behind that of whites. This project therefore sought to determine whether the reason for this discrepancy in health outcomes could be attributed to disparities in use of antiretroviral therapy between black and white patients with HIV.
Materials and Methods
The 1996–2006 National Hospital Ambulatory Medical Care Surveys were used to identify hospital outpatient visits that documented antiretrovirals. Patients younger than 18 years, of nonblack or nonwhite race, and lacking documentation of antiretrovirals were excluded. A multivariable logistic regression model was constructed with race as the independent variable and use of HAART as the dependent variable.
Approximately 3 million HIV/AIDS patient visits were evaluated. Blacks were less likely than whites to use HAART and protease inhibitors (odds ratio, 95% CI 0.81 [0.81–0.82] and 0.67 [0.67–0.68], respectively). More blacks than whites used non-nucleoside reverse transcriptase inhibitors (odds ratio, 95% CI 1.18 [1.17–1.18]). In 1996, the crude rates of HAART were relatively low for both black and white cohorts (5% vs 6%). The rise in HAART for blacks appeared to lag behind that of whites for several years, until 2002, when the proportion of blacks receiving HAART slightly exceeded the proportion of whites receiving HAART. In later years, the rates of HAART were similar for blacks and whites (81% vs 82% in 2006). Blacks appeared less likely than whites to use protease inhibitors and more likely than whites to use non-nucleoside reverse transcriptase inhibitors from 2000 to 2004.
Blacks experienced a lag in the use of antiretrovirals at the beginning of the study; this discrepancy dissipated in more recent years.
HIV/AIDS; highly active antiretroviral therapy; racial disparities
The purpose of this study was to determine the relation among multiple morbidities and the prevalence of colorectal cancer (CRC) screening among older adult Appalachian residents of Kentucky. This is the first known study to address multiple morbidities exclusively with a health-disparities population.
This was a cross-sectional study of 1153 subjects, aged 50 to 76 years, from Appalachian Kentucky.
White race, post–high school education, and perception of having more than enough income on which to survive were associated with higher rates of any guideline concordant CRC screening. Statistically significant trends in the outcome of adjusted odds ratios for colonoscopy with greater number of morbidities (P < 0.05) were noted; the higher number of morbidities, the higher rates of screening.
Contrary to much existing research, within a health-disparities population, we found a dose-response relation between comorbidities and greater likelihood of CRC screening. Future research in this area should focus on explanations for this seldom-described finding. In addition, this finding has meaningful clinical and behavioral implications, including ensuring provider screening recommendation during routine office visits and outreach, perhaps through community clinics and public health departments, to extremely vulnerable populations lacking access to preventive care.
colorectal cancer; screening; multimorbidity; epidemiology
Hepatitis B (HBV) screening; Asian Americans; sociocultural factors
The prevalence of childhood overweight and obesity in southern Appalachia is among the highest in the United States (US). Primary care providers are in a unique position to address the problem; however, little is known about attitudes and practices in these settings.
A 61-item healthcare provider questionnaire assessing current practices, attitudes, perceived barriers, and skill levels in managing childhood overweight and obesity was distributed to physicians in four primary care clinics. Questionnaires were obtained from 36 physicians.
Physicians’ practices to address childhood overweight and obesity were limited, despite the fact that most physicians shared the attitude that childhood overweight and obesity need attention. While 71% of physicians reported talking about eating and physical activity habits with parents of overweight or obese children, only 19% reported giving these parents the tools they needed to make changes. Approximately 42% determined the parents’ readiness to make small changes for their overweight or obese children. Physicians’ self-perceived skill level in managing childhood overweight and obesity was found to be a key factor for childhood overweight and obesity related practices.
Primary care physicians in southern Appalachia currently play a limited role in prevention/intervention of childhood overweight and obesity. Training physicians to improve their skills in managing childhood overweight and obesity may lead to an improvement in practice.
Klebsiella pneumoniae carbapenemase (KPC)-producing bacteria are a group of emerging highly drug-resistant Gram-negative bacilli causing infections associated with significant morbidity and mortality. Once confined to outbreaks in the northeastern United States (US), they have spread throughout the US and most of the world. KPCs are an important mechanism of resistance for an increasingly wide range of Gram-negative bacteria and are no longer limited to K pneumoniae. KPC-producing bacteria are often misidentified by routine microbiological susceptibility testing and incorrectly reported as sensitive to carbapenems; however, resistance to the carbapenem antibiotic ertapenem is common and a better indicator of the presence of KPCs. Carbapenem antibiotics are generally not effective against KPC-producing organisms. The best therapeutic approach to KPC-producing organisms has yet to be defined; however, common treatments based on in vitro susceptibility testing are the polymyxins, tigecycline, and less frequently aminoglycoside antibiotics. The purpose of this review is to identify the various challenges that KPC-producing bacteria present to clinicians. These include the need for special techniques for microbiological detection, the potential for nosocomial transmission, and therapeutic challenges related to limited, relatively unproven antimicrobial treatment options.
Enterobacteriaceae; multi-drug resistant; carbapenem-resistant; Klebsiella
Autosomal dominant hyperimmunoglobulin E syndrome (HIES, Job syndrome) is a rare primary immunodeficiency characterized by elevated immunoglobulin E (IgE), eosinophilia, recurrent skin and pulmonary infections, dermatitis, and connective tissue and skeletal abnormalities. A 26-year-old male with known HIES presented with abdominal pain and diarrhea. Imaging showed sigmoid diverticulitis without abscess or perforation. Conservative management with antibiotics failed, and he developed a peridiverticular abscess, which was percutaneously drained with plans for elective resection. He returned four days later with progression of his diverticulitis, requiring partial colectomy with primary anastomosis. To our knowledge, this is the first case of diverticulitis in HIES. Diverticulitis is rare in younger individuals, raising the possibility that the connective tissue abnormalities of HIES patients may predispose them to colonic diverticula. Although the majority of complications are sinopulmonary and skin infections, diverticulitis should be considered in the differential of intra-abdominal processes in HIES.
Hyper IgE Syndrome; diverticulitis
We sought to examine the preoperative time for hip stabilization procedure among Hispanics, non-Hispanic blacks (blacks) and non-Hispanic whites (whites).
This was a secondary data analysis using Medicare claims data. Our analysis included 40,321 patients admitted for hip fracture hospitalization from 2001-2005. Our primary analysis was generalized linear modeling, and our dependent variable was preoperative time. Our independent variable was race/ethnicity (Hispanics, blacks versus whites), and covariates were age, gender, income, type of hip fracture and comorbidities.
Bivariate analyses showed that both Hispanics and blacks experienced a longer preoperative time (P<0.01). The average (mean) of days to surgery was 1.2 for whites, 1.6 for blacks and 1.7 for Hispanics. The delayed preoperative time among Hispanics and blacks persisted after adjusting for covariates.
The delayed preoperative time among minorities suggests the need to closely monitor care among minorities with hip fracture to determine how to best address their developing needs.
preoperative time; hip fractures; Medicare; disparities; Hispanic
Vitamin D regulates calcium homeostasis in the body and may play a major role in regulating immune responses to tuberculosis (TB). Pilot studies suggest that vitamin D supplementation may improve outcomes in pulmonary TB (PTB), but clinical evidence using vitamin D in TB treatment is limited. We present a case of vitamin D deficiency in a woman with refractory drug-susceptible PTB. Antituberculous therapy and the correction of vitamin D deficiency resulted in clinical and microbiologic improvement at month 13 of her treatment. The basis for vitamin D/TB interactions and a brief literature review are discussed. Data from controlled trials are needed to evaluate the efficacy of vitamin D as adjunctive TB therapy.
immunity; treatment; tuberculosis; vitamin D
The purpose of this study was to determine pediatricians’ attitudes about the human papillomavirus (HPV) vaccine and to compare their attitudes with those expressed by the general public.
Eight-hundred and fifty pediatricians from the American Academy of Pediatrics were surveyed, including general pediatricians (n = 450), and members of the sections of adolescent medicine (n = 200) and infectious diseases (n = 200). Pediatricians were asked to answer four items that had been included on a Wall Street Journal (WSJ) poll of the general public shortly after the HPV vaccine was approved by the Food and Drug Administration.
Of 752 eligible pediatricians, 373 (50%) responded. Compared to the general public, pediatricians were less likely to agree that routine Papanicolaou smears are a better strategy for preventing cervical cancer than HPV vaccination (12% vs 45%, P < 0.001), that abstinence programs are a better strategy for preventing the spread of HPV (17% vs 44%, P < 0.001), and that HPV vaccination may encourage sexual activity (4% vs 27%, P < 0.001). Pediatricians were more likely to support HPV vaccination without parental permission (77% vs 47%, P < 0.001). There were no differences between pediatricians based on gender. General pediatricians were more likely than pediatricians affiliated with the sections of infectious diseases and adolescent medicine to endorse abstinence programs over HPV vaccination (22% vs 16% and 8%, respectively, P = 0.01).
Pediatricians are much more supportive of HPV vaccination than the general public. Pediatricians should be aware of these differences when counseling patients and their families.
abstinence; attitudes; cervical cancer; human papillomavirus vaccine; Pap smears
Osteoporosis is a growing health concern as the number of senior adults continues to increase worldwide. Falls and fractures are very common among frail older adults requiring home health and long-term care. Preventative strategies for reducing falls have been identified and many therapies (both prescription and non-prescription) with proven efficacy for reducing fracture risk are available. However, many practitioners overlook the fact that a fragility fracture is diagnostic for osteoporosis even without knowledge of bone mineral density testing. As a result, osteoporosis is infrequently diagnosed and treated in the elderly after a fracture. Based on existing literature, we have developed an algorithm for the assessment and treatment of osteoporosis among persons with known prior fracture(s) living in long-term care facilities or receiving home health care.
Despite the proven benefits conferred by early human immunodeficiency virus (HIV) diagnosis and presentation to care, delays in HIV medical care are common; these delays are not fully understood, especially in the southern United States.
We evaluated the extent of, and characteristics associated with, delayed presentation to HIV care among 1,209 patients at an HIV/AIDS Outpatient Clinic in Birmingham, Alabama between 1996 and 2005.
Two out of five (41.2%) patients first engaged care only after they had progressed to CDC-defined AIDS. Among these, 53.6% were diagnosed with HIV in the year preceding entry to care. Recent presentation (2002 – 2005), male sex, age ≥25, Medicare or Medicaid insurance coverage, and presentation within six months of HIV diagnosis were independently associated with initiating care after progression to AIDS.
A high proportion of patients entered clinical care after experiencing substantial disease progression. Interventions that effectively improve the timing of HIV diagnosis and presentation to care are needed.
HIV; AIDS; health care; access; Alabama; delay
90-year-old man was diagnosed with monoarticular arthritis due to pseudogout and Abiotrophia defectiva infection. A. defectiva is recognized as a cause of endocarditis, but is rarely described in septic arthritis. To our knowledge, this is one of the few case reports of septic arthritis due to this organism, and the first in association with pseudogout. This report supports the routine culture of synovial fluid and is further evidence for the role of A. defectiva in septic arthritis.
Abiotrophia defectiva; septic arthritis; calcium pyrophosphate disease; pseudogout; endocarditis