Better Respiratory Education and Treatment Help Empower (BREATHE) study: Methodology and baseline characteristics of a randomized controlled trial testing a transitional care program to improve patient-centered care delivery among chronic obstructive pulmonary disease patients

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of hospitalizations. Interventional studies focusing on the hospital-to-home transition for COPD patients are few. In the BREATHE (Better Respiratory Education and Treatment Help Empower) study, we developed and tested a patient and family-centered transitional care program that helps prepare hospitalized COPD patients and their family caregivers to manage COPD at home.

METHODS

In the study's initial phase, we co-developed the BREATHE transitional care program with COPD patients, family-caregivers, and stakeholders. The program offers tailored services to address individual patients' needs and priorities at the hospital and for 3months post discharge. We tested the program in a single-blinded RCT with 240 COPD patients who were randomized to receive the program or 'usual care'. Program participants were offered the opportunity to invite a family caregiver, if available, to enroll with them into the study. The primary outcomes were the combined number of COPD-related hospitalizations and Emergency Department (ED) visits per participant at 6months post discharge, and the change in health-related quality of life over the 6months study period. Other measures include 'all cause' hospitalizations and ED visits; patient activation; self-efficacy; and, self-care behaviors.

DISCUSSION

Unlike 1month transitional care programs that focus on patients' post-acute care needs, the BREATHE program helps hospitalized COPD patients manage the post discharge period as well as prepare them for long term self-management of COPD. If proven effective, this program may offer a timely solution for hospitals in their attempts to reduce COPD rehospitalizations.

Patient priorities and needs for diabetes care among urban African American adults

PURPOSE

This study was conducted to determine diabetes care priorities and needs in a group of urban African American adults with type 2 diabetes mellitus.

METHODS

One hundred nineteen African American adults with type 2 diabetes, aged 35 to 75, received behavioral/educational interventions from a nurse case manager, a community health worker, or both. Priorities and needs were assessed during 3 intervention visits.

RESULTS

The most frequently reported priorities for diabetes care were glucose self-monitoring (61%), medication adherence (47%), and healthy eating (36%). The most frequently addressed diabetes needs were glucose self-monitoring and medication adherence. Most of the intervention visits (77%) addressed non-diabetes-related health issues such as cardiovascular disease (36%) and social issues such as family responsibilities (30%).

CONCLUSIONS

Participants' self-reported priorities for diabetes care directly reflected the diabetes needs addressed. Needs beyond the focus of traditional diabetes care (social issues and insurance) are important to address in urban African Americans with type 2 diabetes. Interventions designed to address comprehensive health and social needs should be included in treatment and educational plans for this population.

The human connexin32 gene is transcribed from two tissue-specific promoters

The connexin32 (cx32) gene codes for the gap junction protein found in liver, pancreas and nervous tissue. Recently mutations in the coding region of this gene have been associated with the dominant X-linked form of Charcot-Marie-Tooth (CMTX1) neuropathy. Since some CMTX1 patients show no mutations in their cx32 gene coding region, it was speculated that these patients carry mutations in the promoter region of the gene. This paper describes the organization of the human cx32 gene and its tissue-specific transcription. The gene consists of three exons that are alternatively spliced to produce mRNAs with different 5'-untranslated regions (UTRs). Transcription is initiated from two tissue-specific promoters. In liver and pancreas, promoter P1, located more than 8 kb upstream of the translation start codon, is used, and the transcript is processed to remove a large intron. In contrast, in nerve cells, transcription is initiated from promoter P2, located 497 bp upstream from the translation start codon, and the transcript is processed to remove a small 355-pb intron. The downstream exon, which includes the entire coding sequence, is shared by both mRNAs. CMTX1 patients with a normal cx32 coding region are expected to have mutations in this newly described promoter P2 rather than the known promoter P1.

Management protocol for unreamed interlocking tibial nails for open tibial fractures

Over a 15-month period, 41 open grade I-IIIA tibia fractures were treated with unreamed interlocking nails. A protocol previously established by the authors to enhance fracture union was followed. The purpose of the study was to determine if union rate for the comminuted statically locked fracture could be reduced through early dynamization, bone grafting, or a combination of both. Of the 41 patients, 15 had grade I wounds, 12 had grade II wounds, and 14 had grade IIIA wounds. Fracture classification using the Orthopaedic Trauma Association Classification showed 19 42A fractures, 15 42B fractures, and seven 42C fractures. Fifteen of the 41 fractures required dynamization for rotational and axial stabilization. Of these 15 patients, five subsequently underwent dynamization only, six underwent autogenous bone grafting, and three underwent both dynamization and bone grafting, one of which also underwent exchange rodding. One patient underwent bone grafting and exchange rodding. Comparing the fractures of these 15 patients to similar fractures previously reported, union rate was reduced from 37 to 24 weeks. This was statistically significant to 0.002. It is the authors' recommendation that statically locked unreamed tibial nails be dynamized and/or bone grafted at 6-8 weeks postinjury to enhance union and reduce the time of fracture healing.

External fixation of severely comminuted and open tibial pilon fractures

Twenty patients with severely comminuted fractures about the ankle, either severely comminuted pilon fractures or open pilon fractures (three Grade II, seven Grade III), were managed with the use of a Delta-framed external fixator across the ankle joint. All fractures had open reduction and internal fixation (ORIF) with either screw fixation or small plates to stabilize the articular surface with minimal soft-tissue dissection. Average external fixator time was 2.5 months, and the time to union averaged 4.5 months. All fractures healed. Three delayed unions required bone grafting and two had plate stabilization. No infection occurred in the 12 open fractures. There was no infection of the closed injuries, no skin sloughs, and only two minor pin tract infections. Follow-up analysis averaged 12 months (range, six to 30 months). Range of motion (ROM) at last follow-up observation was excellent in six patients, good in nine, fair in three, and poor in two. Two patients required ankle arthrodesis because of posttraumatic arthritis. The ROM and outcomes of the severely comminuted or open fractures of the distal intraarticular tibia were very good.

The impact of a planned health education approach on the control of hypertension in a high risk population

This paper reports on the effectiveness of a planned health education programme on enhancing the control of hypertension in a community demonstrating the highest rates of high blood pressure, cerebrovascular disease, and diseases of the heart in the State of Maryland. Within the community intervention programme, a specific focus was directed at younger black males (ages 18-49) who demonstrated the lowest rates of awareness, treatment, and control for their hypertension, as compared to all other age/race/sex groups. The programme consisted of targeted screenings, outreach, and follow-up; influencing specific health beliefs regarding diagnosis and treatment; and family and community support strategies. Formally trained community health workers provided educational counselling, monitoring, outreach and follow-up services in coordination with a community-wide health provider task force. Results to date indicate that this planned health education approach has been successful in significantly improving the control of hypertension in a high-risk population.

Electrocardiographic values from clinically normal, anesthetized ferrets (Mustela putorius furo)

Electrocardiograms were recorded from 25 clinically normal male ferrets anesthetized with ketamine and xylazine and from 7 ferrets anesthetized with ketamine alone. Ferrets anesthetized with ketamine alone had excessive salivation, open eyes, muscle tremors, muscle twitching, paddling motions, attempts to stand, and an unstable ECG baseline. Because ketamine/xylazine combination resulted in induction and good muscle relaxation, the ECG had little interference resulting from muscular movement.