Diabetes Care Trends in the MA Patient Centered Medical Home Initiative (MA PCMHI) at Mid-Point

Background: The MA PCMHI is a multi-payer demonstration involving 45 primary care practices. Thirty-one (31) practices receive additional financial support; all receive technical assistance. Objectives: To assess data trends in diabetes quality measures from participating adult practices. Study Design: Quality improvement study utilizing practices’ self-reported data on clinical quality measures. Diabetes measures included blood pressure, LDL cholesterol and hemoglobin A1C control and depression screening. Methods: Monthly quality data from 38 practices reported June 2011 (baseline) through November 2012 were evaluated. Using a general linear mixed model Analysis of Variance (ANOVA), an overall comparison across time and pair-wise comparisons between times were made to identify periods with significant changes. The analysis also identified the effect of each practice’s performance on aggregate performance and practice performance in change over time for each measure, to determine high and low performers. Results: On aggregate, the change over time performance was statistically significant for two measures: hemoglobin A1C \u3e9% and depression screening. Some practices were either high or low performers on most measures. Some practices were high performers on some but low performers on other measures. Practices with and without financial support were equally represented in high and low performer categories. Conclusions: In the first 18 months of the MA PCMHI, participating practices have significantly improved diabetes care by reducing the percentage of patients with poorly controlled diabetes and by more consistently screening patients for depression. Certain sites are excelling – consistently or only in certain measures. Financial support does not appear to be a factor but practice payer mix, size and leadership engagement may be important factors. Analysis of the impact of these factors and a qualitative analysis of best practices implemented by high performing sites, are planned. Policy Impact: Findings will inform the technical assistance provided to practices undergoing transformation to PCMHs

Physician Referral Rather than Proxy Referral to an Organ Procurement Organization Following Asystolic Death Results in Higher Tissue Donation Rates

Timely referral of patients following asystolic death to an organ procurement organization (OPO) may increase tissue donation rates. Notification of the OPO following asystolic death was formerly the responsibility of the admitting office. We hypothesized that changing the responsibility from the admitting department to the declaring physician for calling the OPO would increase timely referral and tissue donation rates. In 2006, the instructions accompanying the working copy of the death certificate were altered to require the patient’s physician to call the OPO within one hou r of death. From 10/2006 to 2/2007 intensive communication and in-servicing was carried out in all intensive care units. Timely referral and donation rates were tabulated before and after the intervention. Data were modeled longitudinally using Generalized Linear Mixed Models (SAS). There timely referral rates rose 2.1 fold on campus 1 (p\u3c0.05) and 1.3 fold on campus 2 (p= NS). The tissue donation rate rose significantly (2.6 fold, p\u3c0.05). In 2005, the donation rate was 21 cases/year and rose to 56 cases/year by 2008 (p\u3c0.05). The rate has held steady since that time (2009-2012). Physician referral rather than referral by other parties following asystolic death results in higher tissue donation rates

Association between gastric intramucosal pH and splanchnic endotoxin, antibody to endotoxin, and tumor necrosis factor-alpha concentrations in patients undergoing cardiopulmonary bypass

OBJECTIVES: To determine the association between gastric intramucosal pH, a minimally invasive marker reflecting the adequacy of oxygen delivery to the gastrointestinal tract, and splanchnic endotoxin, antibody to endotoxin, and tumor necrosis factor (TNF)-alpha concentrations in patients undergoing cardiopulmonary bypass. DESIGN: Single-arm, prospective study. SETTING: University hospital. PATIENTS: Adults (n = 10) free of hepatic, pulmonary, and renal disease undergoing nonemergent coronary artery bypass surgery. INTERVENTIONS: After induction of general anesthesia and endotracheal intubation, a tonometer nasogastric tube was positioned in the stomach, and triple-lumen fiberoptic catheters were inserted into the hepatic vein and pulmonary artery. Hepatic venous and mixed venous blood samples were analyzed for endotoxin, antibody to endotoxin, and TNF-alpha at six times: 30 mins after induction of anesthesia (time 1); during vena caval cannulation (time 2); after 15 mins of hypothermic cardiopulmonary bypass (time 3); during spontaneous left ventricular ejection after release of the aortic cross-clamp, but before termination of cardiopulmonary bypass (time 4); 15 mins after termination of cardiopulmonary bypass (time 5); and 1 hr after termination of cardiopulmonary bypass (time 6). Gastric intramucosal pH, systemic oxygen delivery (DO2), mixed venous oxygen saturation, hepatic venous oxygen saturation, and hepatic venous lactate concentrations were recorded at these same times. Data for each variable were compared with baseline values (time 1) for statistical significance. MEASUREMENTS AND MAIN RESULTS: Cardiopulmonary bypass was associated with an increase (p \u3c .05) in systemic endotoxin concentrations from ventricular ejection until the end of the study. Virtually identical changes in the splanchnic circulation at this time approached, but did not reach, statistical significance, because hepatic venous endotoxin concentrations were higher than the mixed venous endotoxin concentrations at baseline (41.6 +/- 11.2 vs. 16.9 +/- 4.9 pg/mL). Gastric intramucosal pH was abnormal (\u3c 7.35) at 15 mins (p \u3e .05) and at 1 hr after termination of cardiopulmonary bypass (p \u3e .05). The relationship between endotoxin and gastric intramucosal pH was not statistically significant (p = .15). The decrease in endotoxin antibody was small and statistically insignificant. TNF-alpha was not detected in any patient. Systemic DO2 decreased (p \u3c .05) after 15 mins of hypothermic cardiopulmonary bypass, but returned to baseline values thereafter. There were no significant changes in mixed venous and hepatic venous oxygen saturation values. Splanchnic lactate concentrations increased at cannulation (p \u3c .05), after 15 mins of hypothermic cardiopulmonary bypass (p \u3c .05), and 15 mins after termination of cardiopulmonary bypass (p \u3c .05). CONCLUSIONS: These observations are consistent with the hypothesis that impaired gut-barrier function is responsible for endotoxemia occurring during cardiopulmonary bypass. It is unclear whether increased mucosal permeability and mucosal acidosis are causally related phenomena or simply independent markers of damage to gut epithelium

Control via electron count of the competition between magnetism and superconductivity in cobalt and nickel doped NaFeAs

Using a combination of neutron, muon and synchrotron techniques we show how the magnetic state in NaFeAs can be tuned into superconductivity by replacing Fe by either Co or Ni. Electron count is the dominant factor, since Ni-doping has double the effect of Co-doping for the same doping level. We follow the structural, magnetic and superconducting properties as a function of doping to show how the superconducting state evolves, concluding that the addition of 0.1 electrons per Fe atom is sufficient to traverse the superconducting domain, and that magnetic order coexists with superconductivity at doping levels less than 0.025 electrons per Fe atom.Comment: 4 pages, 6 figure

Short-term rhGH increases PIIINP, a biomarker of endothelial dysfunction

Objectives: In arterial hypertension, amino-terminal propeptide of type III procollagen (PIIINP) is elevated in arterial aneurysm tissue and associated with a poor prognosis following acute myocardial infarction (MI). Recombinant human growth hormone (rhGH) administration attenuates endothelial dysfunction but increases PIIINP. This study was conducted to establish if short-term rhGH administration affects PIIINP, endothelial function and selected cardiovascular disease (CVD) risk factors, in healthy males. Design: Method: Male subjects (n=48) were randomly assigned into two groups: (1): control group (C) n=24, mean ± SD, age 32 ± 11 years; height 1.8 ± 0.06 metres; (2): rhGH administration group (rhGH) n=24, mean ± SD, age 32 ± 9 years; height 1.8 ± 0.07 metres. Blood pressure (BP), heart rate (HR), arterial pulse wave velocity (APWV), and biochemical indices were investigated. Results: PIIINP (0.28±0.1 vs. 0.42±0.2, U/ml); Insulin like growth factor-I (159±54 vs. 323±93, ng.mL-1); resting HR (72±14 vs. 78±11, b.p.m.) and rate pressure product (RPP) (90±18 vs. 97±14, bpm x mm.Hg x 10-2) all significantly increased (P<0.05). Total cholesterol (4.7±0.9 vs. 4.4±0.7, mmol.L-1); high sensitivity C-reactive protein (1.77±2.1 vs. 1.29±1.6, mg.L-1); serum homocysteine (13.2±4.0 vs. 11.7±3.1, μmol.L-1) and APWV (9.97±1.38 vs. 9.18±1.6, m.s-1) all significantly decreased (P<0.05). Conclusion: Paradoxically, there was an improvement in CVD inflammatory markers and APWV; but PIIINP and resting RPP increased. Elevated PIIINP may have a confounding adverse effect on the endothelium, but may also provide clinical prognostic information in monitoring arterial hypertension, left ventricular function in the sub-acute phase following MI and endothelial function in aortic aneurysms

Human CD4+ T Cell Epitopes from Vaccinia Virus Induced by Vaccination or Infection

Despite the importance of vaccinia virus in basic and applied immunology, our knowledge of the human immune response directed against this virus is very limited. CD4+ T cell responses are an important component of immunity induced by current vaccinia-based vaccines, and likely will be required for new subunit vaccine approaches, but to date vaccinia-specific CD4+ T cell responses have been poorly characterized, and CD4+ T cell epitopes have been reported only recently. Classical approaches used to identify T cell epitopes are not practical for large genomes like vaccinia. We developed and validated a highly efficient computational approach that combines prediction of class II MHC-peptide binding activity with prediction of antigen processing and presentation. Using this approach and screening only 36 peptides, we identified 25 epitopes recognized by T cells from vaccinia-immune individuals. Although the predictions were made for HLA-DR1, eight of the peptides were recognized by donors of multiple haplotypes. T cell responses were observed in samples of peripheral blood obtained many years after primary vaccination, and were amplified after booster immunization. Peptides recognized by multiple donors are highly conserved across the poxvirus family, including variola, the causative agent of smallpox, and may be useful in development of a new generation of smallpox vaccines and in the analysis of the immune response elicited to vaccinia virus. Moreover, the epitope identification approach developed here should find application to other large-genome pathogens