Renal assessment practices and the effect of nurse case management of health maintenance organization patients with diabetes

OBJECTIVE

To examine baseline renal screening practices and the effect of nurse case management of patients with diabetes in a group model health maintenance organization (HMO).

RESEARCH DESIGN AND METHODS

We performed both 1-year retrospective and 1-year prospective studies of renal assessment practices and ACE inhibitor usage in a cohort of 133 diabetic patients enrolled in a randomized controlled trial of a diabetes nurse case management program in a group model HMO. In accordance with American Diabetes Association recommendations, urine dipstick and quantitative protein and microalbuminuria testing rates were calculated.

RESULTS

At baseline, 77% of patients were screened for proteinuria with dipsticks or had quantitative urine testing. Of patients with negative dipstick findings, 30% had appropriate quantitative protein or microalbumin follow-up at baseline. Baseline ACE inhibitor usage was associated with decreased follow-up testing (relative risk = 0.47). Nurse case management was associated with increased quantitative protein or or microalbumin testing and increased follow-up testing (relative risk = 1.65 and 1.60, respectively).

CONCLUSIONS

We found a higher degree of adherence to recommendations for renal testing than has been reported previously. Nurse case management intervention further increased renal screening rates. The inverse association between ACE inhibitor usage and microalbumin testing highlights a potentially ambiguous area of current clinical pathways.

Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial

BACKGROUND

Control of hyperglycemia delays or prevents complications of diabetes, but many persons with diabetes do not achieve optimal control.

OBJECTIVE

To compare diabetes control in patients receiving nurse case management and patients receiving usual care.

DESIGN

Randomized, controlled trial.

SETTING

Primary care clinics in a group-model health maintenance organization (HMO).

PATIENTS

17 patients with type 1 diabetes mellitus and 121 patients with type 2 diabetes mellitus.

INTERVENTION

The nurse case manager followed written management algorithms under the direction of a family physician and an endocrinologist. Changes in therapy were communicated to primary care physicians. All patients received ongoing care through their primary care physicians.

MEASUREMENTS

The primary outcome, hemoglobin A1c (HbA1c) value, was measured at baseline and at 12 months. Fasting blood glucose levels, medication type and dose, body weight, blood pressure, lipid levels, patient-perceived health status, episodes of severe hypoglycemia, and emergency department and hospital admissions were also assessed.

RESULTS

72% of patients completed follow-up. Patients in the nurse case management group had mean decreases of 1.7 percentage points in HbA1c values and 43 mg/dL (2.38 mmol/L) in fasting glucose levels; patients in the usual care group had decreases of 0.6 percentage points in HbA1c values and 15 mg/dL (0.83 mmol/L) in fasting glucose levels (P < 0.01). Self-reported health status improved in the nurse case management group (P = 0.02). The nurse case management intervention was not associated with statistically significant changes in medication type or dose, body weight, blood pressure, or lipids or with adverse events.

CONCLUSIONS

A nurse case manager with considerable management responsibility can, in association with primary care physicians and an endocrinologist, help improve glycemic control in diabetic patients in a group-model HMO.

EMS-initiated refusal and alternative methods of transport

OBJECTIVES

1) To describe characteristics of patient transport protocols in those U.S. cities that sanction EMS-initiated refusal of transport; and 2) to describe the frequency and type of alternatives to emergency ambulance transport.

METHODS

EMS systems in every one of the 200 largest cities in the United States were surveyed by telephone regarding EMS-initiated refusal policies, involvement of physicians in the decision-making process, and the presence or absence of alternatives to EMS transport.

RESULTS

100% of the target population responded to the telephone survey. Only 34 (17%) EMS systems have written protocols that allow EMS providers to refuse emergency ambulance transport for patients judged to have minor illness or injury after examination. Twenty-one (62%) of these EMS systems do not require on-line physician approval for EMS-initiated refusals. Seven (21%) EMS systems that allow refusal of transport also have a formalized alternative transport program in place. Nationwide, only 19 (10%) cities surveyed offer some type of alternative to ambulance transport, most commonly taxi and minivan.

CONCLUSION

The authors report the first national survey of EMS-initiated refusal practices. Few urban EMS systems have implemented this policy to decrease utilization by persons with low-acuity illness or injury. This may be related to the fact that few EMS systems currently have alternatives to emergency ambulance transport.

Termination of nontraumatic cardiac arrest resuscitative efforts in the field: a national survey

OBJECTIVES

1) To describe elements of adult nontraumatic cardiac arrest protocols in those U.S. cities in which resuscitative efforts are being terminated in the out-of-hospital setting. 2) To determine the prevalence and methods of on-scene family grief counseling delivered in this setting.

METHODS

Emergency medical services (EMS) systems in each of the 200 largest cities in the United States were surveyed by telephone regarding the content of their adult cardiac arrest protocols. Type of arrest (medical vs trauma), final dysrhythmia, termination policies, and presence or absence of a grief counseling protocol were recorded.

RESULTS

All of the target population responded to the telephone survey. Most (135; 68%) EMS systems currently have written protocols that allow in-field termination of resuscitative efforts for adult nontraumatic cardiac arrest patients who remain asystolic. Only 47 (24%) EMS systems allow cessation of efforts for patients without return of spontaneous circulation regardless of the dysrhythmia. Base station contact is required for authorization to end resuscitative efforts in 120/135 (89%) EMS systems. Only 26/135 (19%) EMS systems that cease efforts in the field have written policies concerning on-scene family grief counseling. This counseling is most likely to be conducted by the out-of-hospital providers themselves.

CONCLUSION

Many U.S. urban EMS systems are terminating efforts for selected adult nontraumatic cardiac arrest patients, although few have written policies to address grief intervention for family members at the scene.

Cigarette smoking increases endothelial-derived vasorelaxation in the rat carotid artery in a dose-dependent manner

While there is clear-cut epidemiologic, morphologic, and functional evidence to suggest that cigarette smoking is deleterious to the cardiovascular system and endothelium, previous experiments with regard to the effect of cigarette smoking on endothelial-derived vasorelaxation are not conclusive. This study examines the effect of cigarette smoking on endothelium-derived vasorelaxation and its relationship to serum nitric oxide concentrations. Fourteen Sprague-Dawley rats (350-500 g) were divided into two groups (N = 7). The experimental group was exposed to six cigarettes (Kentucky 1R4F) per day for 50 days using a Griffith snout exposure method. The two groups were sacrificed and the carotid arteries were mounted on isometric force transducers in a physiologic bath. The arteries were constricted with norepinephrine (1 x 10(-4) M). Vasorelaxation to acetylcholine (Ach) was measured in a dose response manner. Vasorelaxation to nitroglycerin was measured at 10(-4) M. After the rats were sacrificed, blood samples from each rat were examined for total nitrate/nitrite concentration with serum chemiluminescence on a vanadium column. The results were analyzed with ANOVA and the Student's t test. Vasorelaxation to nitroglycerin was 17.42% +/- 0. 44 versus 16.25% +/- 0.42 in the control and smoke exposure groups, respectively (P = 0.19). This experiment counterintuitively demonstrates that cigarette smoking augments endothelial-derived vasorelaxation. No effect was noted in the endothelium-independent vasorelaxation to nitroglycerin. Alternative mechanisms including the presence of hypoxia and exogenous nitric oxide, which lead to endothelial-dependent and -independent vasorelaxation secondary to cigarette smoking, may serve to explain the apparent augmentation of endothelial-derived vasorelaxation. Further experiments with isolated components of smoke will need to be done to resolve the debate.

Medical education. Speak to me before it's too late

Doctors' failure to communicate with patients is at the root of many complaints. But an increasing number of medical schools are now teaching their students how to talk to patients. Wendy Moore reports.

The genetic and bacteriological aspects of Peyronie's disease

PURPOSE

Peyronie's disease has been associated with HLA tissue types, including HLA-A1, DR3, DQw2 and HLA-B7 cross-reactive group antigens which include HLA-B27. This association was tested as was the process of molecular mimicry where the host HLA surface antigen cross-reacts with a microorganism.

MATERIALS AND METHODS

HLA tissue typing was performed on 51 white patients with Peyronie's disease, of whom 15 also had Dupuytren's contracture of the hand. Fecal, urine and urethral samples were taken from patients with Peyronie's disease who had proved penile inflammation on biopsy. The samples were cultured for species of Campylobacter, Shigella, Salmonella, Yersinia, Chlamydia and gonococcus, all known to cross-react with the HLA-B27 surface antigen. Antibodies to Klebsiella species, Proteus species and Escherichia coli were also assessed in the sera of 65 patients with Peyronie's disease.

RESULTS

A significant association between Peyronie's disease and HLA-B27 was found (p = 0.02). The remaining antigens of the HLA-B7 group were not significantly associated with the disease individually (HLA-B7 p > 0.2, HLA-B22 p > 0.6, HLA-B40 p > 0.7) or as a group (p = 0.69). The previously found associations did not reach significance in this study (HLA-A1 p > 0.5, HLA-B8 p > 0.2, HLA-Cw7 p = 0.1, HLA-DR3 p > 0.4, HLA-DQ2 p > 0.4). Cultures for all enteric and urethral organisms were negative, and patients with Peyronie's disease did not have elevated serum titers of anti Klebsiella, anti Proteus or anti E. coli antibodies.

CONCLUSIONS

Although there is an association between Peyronie's disease and HLA-B27, molecular mimicry does not occur with the organisms tested, and an infectious agent has not been found in this study.

Validation of a knowledge-based boundary detection algorithm: a multicenter study

A completely operator-independent boundary detection algorithm for multigated blood pool (MGBP) studies has been evaluated at four medical centers. The knowledge-based boundary detector (KBBD) algorithm is nondeterministic, utilizing a priori domain knowledge in the form of rule sets for the localization of cardiac chambers and image features, providing a case-by-case method for the identification and boundary definition of the left ventricle (LV). The nondeterministic algorithm employs multiple processing pathways, where KBBD rules have been designed for conventional (CONV) imaging geometries (nominal 45 degrees LAO, nonzoom) as well as for highly zoomed and/or caudally tilted (ZOOM) studies. The resultant ejection fractions (LVEF) from the KBBD program have been compared with the standard LVEF calculations in 253 total cases in four institutions, 157 utilizing CONV geometry and 96 utilizing ZOOM geometries. The criteria for success was a KBBD boundary adequately defined over the LV as judged by an experienced observer, and the correlation of KBBD LVEFs to the standard calculation of LVEFs for the institution. The overall success rate for all institutions combined was 99.2%, with an overall correlation coefficient of r=0.95 (P<0.001). The individual success rates and EF correlations (r), for CONV and ZOOM geometers were: 98%, r=0.93 (CONV) and 100%, r=0.95 (ZOOM). The KBBD algorithm can be adapted to varying clinical situations, employing automatic processing using artificial intelligence, with performance close to that of a human operator.

Induction of vascular permeability enhancement by human tryptase: dependence on activation of prekallikrein and direct release of bradykinin from kininogens

Tryptase is a trypsin-type serine protease that is released from mast cells. Bradykinin (BK) is released directly from kininogens or through activation of either Hageman factor or subsequent plasma prekallikrein. Its nasal administration or inhalation induces allergy-like symptoms. Although elevated levels of tryptase and BK in allergic fluids have been detected, the role of this proteinase and the mechanism of BK production at allergic reaction sites are still unknown. To investigate the pathologic functions of tryptase, the enzyme, purified from human lung, was incubated with normal human plasma, deficient plasmas, kininogens, or prekallikrein. High molecular weight kininogen was then added, and the mixtures were examined for vascular permeability enhancement (VPE) activity, a representative function of bradykinin, using guinea pig skin. Tryptase-treated plasma induced VPE in a dose-dependent manner; activity was lost in the absence of a kininase inhibitor but not an antihistamine drug. Tryptase produced VPE activity from normal or Hageman factor-deficient plasma, but only 30% of this activity was produced from prekallikrein-deficient plasma. Significantly, no activity was obtained from kininogen-deficient plasma. Deficient plasma that were reconstituted with each missing factor resulted in VPE-inducing capacity by tryptase, equivalent to that found with normal plasma. Incubation of tryptase with high or low molecular weight kininogen induced VPE activity in a dose- and incubation time-dependent manner. Prekallikrein incubated with tryptase also generated a soybean trypsin inhibitor-sensitive VPE-inducing activity from high molecular weight kininogen. The loss of tryptase VPE-producing activity as a function of incubation time was found to be a result of spontaneous inactivation of the enzyme and not of the degradation of high molecular weight kininogen by the enzyme. We conclude that tryptase induces VPE by releasing BK, primarily through prekallikrein activation, but also through direct release from kininogens. This indicates that this mast cell-derived proteinase contributes to kinin production in allergic diseases.