The Challenges of Multimorbidity from the Patient Perspective

BACKGROUND Although multiple co-occurring chronic illnesses within the same individual are increasingly common, few studies have examined the challenges of multimorbidity from the patient perspective. OBJECTIVE The aim of this study is to examine the self-management learning needs and willingness to see non-physician providers of patients with multimorbidity compared to patients with single chronic illnesses. DESIGN. This research is designed as a cross-sectional survey. PARTICIPANTS Based upon ICD-9 codes, patients from a single VHA healthcare system were stratified into multimorbidity clusters or groups with a single chronic illness from the corresponding cluster. Nonproportional sampling was used to randomly select 720 patients. MEASUREMENTS Demographic characteristics, functional status, number of contacts with healthcare providers, components of primary care, self-management learning needs, and willingness to see nonphysician providers. RESULTS Four hundred twenty-two patients returned surveys. A higher percentage of multimorbidity patients compared to single morbidity patients were "definitely" willing to learn all 22 self-management skills, of these only 2 were not significant. Compared to patients with single morbidity, a significantly higher percentage of patients with multimorbidity also reported that they were "definitely" willing to see 6 of 11 non-physician healthcare providers. CONCLUSIONS Self-management learning needs of multimorbidity patients are extensive, and their preferences are consistent with team-based primary care. Alternative methods of providing support and chronic illness care may be needed to meet the needs of these complex patients.US Department of Veterans Affairs (01-110, 02-197); Agency for Healthcare Research and Quality (K08 HS013008-02

Ergocalciferol in New-onset Type 1 diabetes: A Randomized Controlled Trial

Background: The impact of the anti-inflammatory and immunomodulatory actions of Vitamin D on the duration of partial clinical remission (PR) in youth with type 1 diabetes (T1D) is unclear. Objective: To determine the effect of adjunctive ergocalciferol on residual β-cell function (RBCF) and PR in youth with newly-diagnosed T1D who were maintained on a standardized insulin treatment protocol. Hypothesis: Ergocalciferol supplementation increases RBCF and prolongs PR. Methods: A 12-month randomized, double-blind, placebo-controlled trial of 50,000 IU of ergocalciferol per week for 2 months, and then once every 2 weeks for 10 months, versus placebo in 36 subjects of ages 10-21years(y), with T1D ofmonths, and a stimulated C-peptide (SCP) level of ≥0.2nmol/L (≥0.6ng/mL). The ergocalciferol group had 18 randomized subjects (10m/ 8f), mean age 13.3±2.8y; while the control group had 18 subjects (14m/4f), age 14.3±2.9y. Results: The ergocalciferol treatment group had significantly higher serum 25-hydroxyvitamin D at 6 months (p=0.01) and 9 months (p=0.02) than the placebo group. At 12 months, the ergocalciferol group had a significantly lower serum TNF-α concentration (p=0.03). There were no significant differences between the groups at each timepoint from baseline to 12 months for SCP concentration (p=0.08), HbA1c (p=0.09), insulin-dose-adjusted A1c (IDAA1c), or total daily dose of insulin. Temporal trends for rising HbA1c (p=0.044) and IDAA1c (p=0.015) were significantly blunted in the ergocalciferol group. Conclusions: Ergocalciferol significantly reduced serum TNF-α concentration and the rates of increase in both A1c and IDAA1c suggesting a protection of RBCF and PR in youth with newly-diagnosed T1D

Patterns of initiation of second generation antipsychotics for bipolar disorder: a month-by-month analysis of provider behavior

Background: Several second generation antipsychotics (SGAs) received FDA approval for bipolar disorder in the 2000s. Although efficacious, they have been costly and may cause significant side effects. Little is known about the factors associated with prescribers’ decisions to initiate SGA prescriptions for this condition. Methods: We gathered administrative data from the Department of Veterans Affairs on 170,713 patients with bipolar disorder between fiscal years 2003–2010. Patients without a prior history of taking SGAs were considered eligible for SGA initiation during the study (n =126,556). Generalized estimating equations identified demographic, clinical, and comorbidity variables associated with initiation of an SGA prescription on a month-by-month basis. Results: While the number of patients with bipolar disorder using SGAs nearly doubled between 2003 and 2010, analyses controlling for patient characteristics and the rise in the bipolar population revealed a 1.2% annual decline in SGA initiation during this period. Most medical comorbidities were only modestly associated with overall SGA initiation, although significant differences emerged among individual SGAs. Several markers of patient severity predicted SGA initiation, including previous hospitalizations, psychotic features, and a history of other antimanic prescriptions; these severity markers became less firmly linked to SGA initiation over time. Providers in the South were somewhat more likely to initiate SGA treatment. Conclusions: The number of veterans with bipolar disorder prescribed SGAs is rising steadily, but this increase appears primarily driven by a corresponding increase in the bipolar population. Month-by-month analyses revealed that higher illness severity predicted SGA initiation, but that this association may be weakening over time

Tardy posterior interosseous nerve palsy resulting from residual dislocation of the radial head in a Monteggia fracture: a case report

<p>Abstract</p> <p>Introduction</p> <p>We report an extremely rare case of tardy posterior interosseous nerve palsy that developed 40 years after unreduced anterior dislocation of the radial head in a Monteggia fracture.</p> <p>Case presentation</p> <p>A 46-year-old Asian woman was diagnosed with tardy posterior interosseous nerve palsy resulting from residual dislocation of the radial head in a Monteggia fracture. The patient remembered that she had sustained a fracture to the right elbow when she was 6 years old but could not remember the details of either the injury or its treatment. Intra-operatively, the posterior interosseous nerve was compressed at the radial head, wrapped around the medial side of the radial neck, and ran into the distorted supinator muscle, and was stretched. We therefore excised the radial head and performed neurolysis. The function of the right hand was normal at a follow-up examination 8 months after surgery.</p> <p>Conclusion</p> <p>We theorize that excessive repeated motion with loss of elasticity of surrounding tissues because of long-term dislocation of the radial head may cause delayed posterior interosseous nerve palsy. It is necessary to make an accurate diagnosis and render proper treatment when a Monteggia fracture occurs, making sure that the radial head does not remain dislocated, to avoid possible posterior interosseous nerve palsy due to excessive pronation and supination even several decades later.</p

Storm-induced inner-continental shelf circulation and sediment transport : Long Bay, South Carolina

This paper is not subject to U.S. copyright. The definitive version was published in Continental Shelf Research 42 (2012): 51–63, doi:10.1016/j.csr.2012.05.001.Long Bay is a sediment-starved, arcuate embayment located along the US East Coast connecting both South and North Carolina. In this region the rates and pathways of sediment transport are important because they determine the availability of sediments for beach nourishment, seafloor habitat, and navigation. The impact of storms on sediment transport magnitude and direction were investigated during the period October 2003–April 2004 using bottom mounted flow meters, acoustic backscatter sensors and rotary sonars deployed at eight sites offshore of Myrtle Beach, SC, to measure currents, water levels, surface waves, salinity, temperature, suspended sediment concentrations, and bedform morphology. Measurements identify that sediment mobility is caused by waves and wind driven currents from three predominant types of storm patterns that pass through this region: (1) cold fronts, (2) warm fronts and (3) low-pressure storms. The passage of a cold front is accompanied by a rapid change in wind direction from primarily northeastward to southwestward. The passage of a warm front is accompanied by an opposite change in wind direction from mainly southwestward to northeastward. Low-pressure systems passing offshore are accompanied by a change in wind direction from southwestward to southeastward as the offshore storm moves from south to north. During the passage of cold fronts more sediment is transported when winds are northeastward and directed onshore than when the winds are directed offshore, creating a net sediment flux to the north–east. Likewise, even though the warm front has an opposite wind pattern, net sediment flux is typically to the north–east due to the larger fetch when the winds are northeastward and directed onshore. During the passage of low-pressure systems strong winds, waves, and currents to the south are sustained creating a net sediment flux southwestward. During the 3-month deployment a total of 8 cold fronts, 10 warm fronts, and 10 low-pressure systems drove a net sediment flux southwestward. Analysis of a 12-year data record from a local buoy shows an average of 41 cold fronts, 32 warm fronts, and 26 low-pressure systems per year. The culmination of these events would yield a cumulative net inner-continental shelf transport to the south–west, a trend that is further verified by sediment textural analysis and bedform morphology on the inner-continental shelf.This research was funded by the South Carolina Coastal Erosion Project(http://pubs.usgs.gov/fs/2005/3041/), a cooperative study supported by the US Geological Survey and the South Carolina Sea Grant Consortium(Sea Grant Project no:R/CP-11)

Tumour-infiltrating regulatory T cell density before neoadjuvant chemoradiotherapy for rectal cancer does not predict treatment response

Neoadjuvant (preoperative) chemoradiotherapy (CRT) decreases the risk of rectal cancer recurrence and reduces tumour volume prior to surgery. However, response to CRT varies considerably between individuals and factors associated with response are poorly understood. Foxp3+ regulatory T cells (Tregs) inhibit anti-tumour immunity and may limit any response to chemotherapy and radiotherapy. We have previously reported that a low density of Tregs in the tumour stroma following neoadjuvant CRT for rectal cancer is associated with improved tumour regression. Here we have examined the association between Treg density in pre-treatment diagnostic biopsy specimens and treatment response, in this same patient cohort. We aimed to determine whether pre-treatment tumour-infiltrating Treg density predicts subsequent response to neoadjuvant CRT. Foxp3+, CD8+ and CD3+ cell densities in biopsy samples from 106 patients were assessed by standard immunohistochemistry (IHC) and evaluated for their association with tumour regression grade and survival. We found no association between the density of any T cell subset pre-treatment and clinical outcome, indicating that tumour-infiltrating Treg density does not predict response to neoadjuvant CRT in rectal cancer. Taken together with the findings of the previous study, these data suggest that in the context of neoadjuvant CRT for rectal cancer, the impact of chemotherapy and/or radiotherapy on anti-tumour immunity may be more important than the state of the pre-existing local immune response

Evidence for Shape Co-existence at medium spin in 76Rb

Four previously known rotational bands in 76Rb have been extended to moderate spins using the Gammasphere and Microball gamma ray and charged particle detector arrays and the 40Ca(40Ca,3pn) reaction at a beam energy of 165 MeV. The properties of two of the negative-parity bands can only readily be interpreted in terms of the highly successful Cranked Nilsson-Strutinsky model calculations if they have the same configuration in terms of the number of g9/2 particles, but they result from different nuclear shapes (one near-oblate and the other near-prolate). These data appear to constitute a unique example of shape co-existing structures at medium spins.Comment: Accepted for publication in Physics Letters

Immunohistological characterization of intraepithelial and lamina propria lymphocytes in control ileum and colon and in inflammatory bowel disease

Using monoclonal antibodies to T and B lymphocytes, to natural killer cells, and to HLA-DR antigen, we characterized the lymphocyte population within the epithelial and lamina propria regions in control intestine and colon, and in grossly involved and in grossly uninvolved intestine and colon of patients with active inflammatory bowel disease. There were significantly more intraepithelial T cells in control ileum than in control colon. In comparison to control, there was a heterogeneity of alterations in intraepithelial and lamina propria T lymphocyte subsets (T11 + , T8 + , T4 + ) in inflammatory bowel disease. B lymphocytes were not detected within the lamina propria, except when found in and adjacent to lymphoid aggregates. Leu 7 + cells were uncommon in the lamina propria of control ileum and colon and in diseased tissues. The majority of intraepithelial lymphocytes did not express HLA-DR. Epithelial cells of control colon did not express HLA-DR while epithelial cells of control ileal tissues and of diseased colonic and ileal specimens expressed HLA-DR antigen. Only small numbers of lamina propria T cells expressed HLA-DR in both control and disease tissues. There was intense expression of HLA-DR by monocytes and modest expression of HLA-DR by capillary and lymphatic endothelial cells. The induction of HLA-DR expression by diseased colonic epithelium and the observation that lymphatic endothelium expresses HLA-DR are new observations, and we established that Leu 7 + cells are present in very small numbers in both normal and diseased intestine and colon.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/44401/1/10620_2005_Article_BF01318690.pd