Medication intensification in diabetes in rural primary care: a cluster-randomised effectiveness trial

OBJECTIVE: To determine the effectiveness of a provider-based intervention to improve medication intensification among patients with diabetes. DESIGN: Effectiveness cluster-randomised trial. Baseline and follow-up cross-sections of diabetes physicians\u27 patients. SETTING: Eleven U.S. Southeastern states, 2006-2008. PARTICIPANTS: 205 Rural primary care physicians, 95 completed the study. INTERVENTION: Multicomponent interactive intervention including web-based continuing medical education (CME), performance feedback and quality improvement tools. PRIMARY OUTCOME MEASURES: Medication intensification, a dose increase of an existing medication or the addition of a new class of medication for glucose, blood pressure and lipids control on any of the three most recent office visits. RESULTS: Of 364 physicians attempting to register, 102 were randomised to the intervention and 103 to the control arms; 95 physicians (intervention, n=48; control, n=47) provided data on their 1182 of their patients at baseline (intervention, n=715; control, n=467) and 945 patients at follow-up (intervention, n=479; control, n=466). For A1c control, medication intensification increased in both groups (intervention, pre 26.4% vs post 32.6%, p=0.022; control, pre 24.8% vs post 31.1%, p=0.033) (intervention, adjusted OR (AOR) 1.37; 95% CI 1.06 to 1.76; control, AOR 1.41 (95% CI 1.06 to 1.89)); however, we observed no incremental benefit solely due to the intervention (group-by-time interaction, p=0.948). Among patients with the worst glucose control (A1c \u3e9%), intensification increased in both groups (intervention, pre 34.8% vs post 62.5%, p=0.002; control, pre 35.7% vs post 61.4%, p=0.008). CONCLUSIONS: A wide-reach, low-intensity, web-based interactive multicomponent intervention had no significant incremental effect on medication intensification for control of glucose, blood pressure or lipids for patients with diabetes of physicians practising in the rural Southeastern USA. TRIAL REGISTRATION: NCT00403091

Salmonella infection of breast implant associated with traveler's diarrhea: A case report

We present the first case of traveler's diarrhea resulting in breast implant infection. An otherwise healthy 34-year-old female underwent breast augmentation. Five months later, while vacationing in Cancun, Mexico, she developed abdominal pain and diarrhea that progressed to include fevers and chills. Her symptoms persisted until she returned to the United States, at which point her primary care physician evaluated her on the fourth day of her illness. An abdominal CT scan was unremarkable; however, a complete metabolic panel demonstrated elevated transaminases. Her symptoms soon resolved without treatment. Fourteen days after symptom resolution, the patient developed right breast pain. She was evaluated in the surgical clinic where the breast was tender to palpation, swollen and without erythema. An ultrasound demonstrated a small amount of homogenous fluid surrounding the implant. She was prescribed amoxicillin–clavulanate 875–125 mg BID; however, she presented three days later with worsening pain, swelling and new erythema. She was taken to the operating room, where the abscess was incised, drained and the implant removed. Cultures grew Salmonella serogroup C. Patients should be counseled regarding the potential for hematogenous seeding of the breast cavity and implant following severe illness and bacteremia. It may be reasonable to provide patients with breast implants who are traveling to areas at high-risk for traveler's diarrhea or areas with limited medical resources with an antibiotic to take if moderate to severe symptoms of traveler's diarrhea were to develop while away. Keywords: Traveler's diarrhea, Salmonella, Breast, Infection, Implan