Implications of the Patient-Physician Relationship for People with Diabetes

The purpose of this study was to assess race differences (African Americans and Caucasians) in aspects of the patient-physician relationship, and then determine how the patientphysician relationship influences patient satisfaction, diabetes self-care behaviors and diabetes knowledge among adults with diabetes. Participants consisted of 99 adults with diabetes who were currently receiving treatment for their diabetes. Participants were asked to complete a 15- minute questionnaire that assessed aspects of the patient-physician relationship, including patient’s expectations of physician, actual patient-physician interactions, patient’s desire for involvement in the health care process, and collaboration between the patient and physician regarding the patient’s treatment plan. We expected lower expectation scores and less involvement in the health care process for African Americans than for Caucasians. We predicted that higher expectation scores would be associated with lower levels of patient satisfaction with their physician. We also predicted that a greater desire for involvement and a more collaborative health care situation would be correlated with greater diabetes knowledge and better self-care behaviors. Results indicate few race differences in the patient-physician relationship. Patient expectation was not significantly associated with patient satisfaction but the discrepancy between expectations and actual receipt was associated with satisfaction. There were trends indicating that patient desire for involvement and collaborative care were associated with better self-care behaviors. Only one aspect of desire for involvement was related to diabetes knowledge. Although few race differences in the patient-physician relationship appeared, aspects of that relationship were associated with patient satisfaction and diabetes management and those relations may vary by race.</p

Arthroscopic-Assisted Coracoclavicular and Acromioclavicular Ligament Reconstruction for Chronic AC Joint Separation

Background: Management of acromioclavicular joint (ACJ) separations depends on the type, chronicity of injury, and patient demographics. Indications: Coracoclavicular and acromioclavicular ligament reconstruction may be indicated for patients with chronic type 3 ACJ separation who have failed conservative treatment. We describe an arthroscopic-assisted approach to facilitate graft passage around the coracoid. Technique: Patients are placed in a beach chair position. A longitudinal incision at the midline of the distal clavicle is utilized for access to the ACJ, the distal clavicle, and the coracoid. The anterior, posterior, and undersurface of the distal clavicle are exposed. A standard posterior viewing and anterolateral working portals are created. A shuttling suture is passed arthroscopically and used to pass allograft and nonbiologic augmentation around the coracoid. The nonbiologic sutures are passed through a singular hole in the distal clavicle and secured with a DogBone button. The allograft is wrapped around the clavicle to recreate the coracoclavicular ligaments and secured with sutures. The ACJ capsule is reconstructed by suturing the posterior/medial limb, which is kept long, to the capsule and periosteum. Meticulous, layered closure is performed with particular attention to closing the deltotrapezial fascia. Results: A postoperative x-ray at 2 weeks and 6 months are obtained to confirm proper positioning. The sling is discontinued at 6 weeks, and supervised physical therapy is initiated. At 6 months, patients are typically cleared to full unrestricted activity. Discussion/Conclusion: Arthroscopic-assisted coracoclavicular and acromioclavicular ligament reconstruction in patients with chronic type 3 ACJ separation who fail conservative management can have excellent outcomes. The use of arthroscopic assistance may ease the passage of graft and nonbiologic suture around the coracoid. A 70° scope is helpful for coracoid visualization, and biologic reconstruction of the ligament with tendon graft with suture augmentation in chronic cases is vital in achieving a good outcome. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication

Body-mass index, blood pressure, diabetes and cardiovascular mortality in Cuba: prospective study of 146,556 participants

Background: cardiovascular disease accounts for about one-third of all premature deaths (ie, age &lt; 70) in Cuba. Yet, the relevance of major risk factors, including systolic blood pressure (SBP), diabetes, and body-mass index (BMI), to cardiovascular mortality in this population remains unclear.Methods: in 1996–2002, 146,556 adults were recruited from the general population in five areas of Cuba. Participants were interviewed, measured (height, weight and blood pressure) and followed up by electronic linkage to national death registries until Jan 1, 2017; in 2006–08, 24,345 participants were resurveyed. After excluding all with missing data, cardiovascular disease at recruitment, and those who died in the first 5 years, Cox regression (adjusted for age, sex, education, smoking, alcohol and, where appropriate, BMI) was used to relate cardiovascular mortality rate ratios (RRs) at ages 35–79 years to SBP, diabetes and BMI; RR were corrected for regression dilution to give associations with long-term average (ie, ‘usual’) levels of SBP and BMI.Results: after exclusions, there were 125,939 participants (mean age 53 [SD12]; 55% women). Mean SBP was 124 mmHg (SD15), 5% had diabetes, and mean BMI was 24.2 kg/m2 (SD3.6); mean SBP and diabetes prevalence at recruitment were both strongly related to BMI. During follow-up, there were 4112 cardiovascular deaths (2032 ischaemic heart disease, 832 stroke, and 1248 other). Cardiovascular mortality was positively associated with SBP (&gt;=120 mmHg), diabetes, and BMI (&gt;=22.5 kg/m2): 20 mmHg higher usual SBP about doubled cardiovascular mortality (RR 2.02, 95%CI 1.88–2.18]), as did diabetes (2.15, 1.95–2.37), and 10 kg/m2 higher usual BMI (1.92, 1.64–2.25). RR were similar in men and in women. The association with BMI and cardiovascular mortality was almost completely attenuated following adjustment for the mediating effect of SBP. Elevated SBP (&gt;=120 mmHg), diabetes and raised BMI (&gt;=22.5 kg/m2) accounted for 27%, 14%, and 16% of cardiovascular deaths, respectively.Conclusions: this large prospective study provides direct evidence for the effects of these major risk factors on cardiovascular mortality in Cuba. Despite comparatively low levels of these risk factors by international standards, the strength of their association with cardiovascular death means they nevertheless exert a substantial impact on premature mortality in Cuba