Monitoring and prevalence rates of metabolic syndrome in military veterans with serious mental illness

Background: Cardiovascular disease is the leading cause of mortality among patients with serious mental illness (SMI) and the prevalence of metabolic syndrome-a constellation of cardiovascular risk factors-is significantly higher in these patients than in the general population. Metabolic monitoring among patients using second generation antipsychotics (SGAs)-a risk factor for metabolic syndrome-has been shown to be inadequate despite the release of several guidelines. However, patients with SMI have several factors independent of medication use that predispose them to a higher prevalence of metabolic syndrome. Our study therefore examines monitoring and prevalence of metabolic syndrome in patients with SMI, including those not using SGAs. Methods and Findings: We retrospectively identified all patients treated at a Veterans Affairs Medical Center with diagnoses of schizophrenia, schizoaffective disorder or bipolar disorder during 2005-2006 and obtained demographic and clinical data. Incomplete monitoring of metabolic syndrome was defined as being unable to determine the status of at least one of the syndrome components. Of the 1,401 patients included (bipolar disorder: 822; schizophrenia: 222; and schizoaffective disorder: 357), 21.4% were incompletely monitored. Only 54.8% of patients who were not prescribed SGAs and did not have previous diagnoses of hypertension or hypercholesterolemia were monitored for all metabolic syndrome components compared to 92.4% of patients who had all three of these characteristics. Among patients monitored for metabolic syndrome completely, age-adjusted prevalence of the syndrome was 48.4%, with no significant difference between the three psychiatric groups. Conclusions: Only one half of patients with SMI not using SGAs or previously diagnosed with hypertension and hypercholesterolemia were completely monitored for metabolic syndrome components compared to greater than 90% of those with these characteristics. With the high prevalence of metabolic syndrome seen in this population, there appears to be a need to intensify efforts to reduce this monitoring gap

Changes in County-Level Economic Prosperity Are Associated With Liver Disease–Related Mortality Among Working-Age Adults

There is significant variability in county-level rates of liver disease–related mortality. Although this variability is explained partly by demographics, risk factors for liver disease, and access to specialty liver care, little is known about temporal changes in mortality, and its association with economic prosperity. Therefore, we sought to explore the association between changes in county-level economic prosperity and liver disease–related mortality. We performed a retrospective cohort study using county-level mortality data from the Centers for Disease Control and Prevention, economic prosperity measures from the Distressed Communities Index, and county-level markers of demographics, risk factors for liver disease, and access to health care. Primary analyses focused on adults aged 20 to 64 years of age. We used generalized linear mixed models (outcome = annual percentage change in age-adjusted liver disease–related mortality), with the primary exposure being an interaction between year and change in economic prosperity. There was an inverse relationship between county-level changes in economic prosperity and changes in county-level age-adjusted liver disease–related mortality rates (eg, counties with the smallest increase in economic prosperity had the biggest annual increase in liver disease–related mortality). In generalized linear mixed models accounting for county-level covariates, there was a significant association between economic prosperity and liver disease–related mortality, that is, for every 10-point higher mean rank for change in economic prosperity, there was an additional 0.65% decrease (95% CI, 0.19%–1.10%; P = .006) in mortality per year. County-level changes in economic prosperity, independent of other county-level clinical, demographic, and access-to-care variables, may play a role in population-level trends in liver disease–related deaths among the working age population

Impact of Medicaid Expansion on Liver-Related Mortality

The Affordable Care Act provided the opportunity for states to expand Medicaid for low-income individuals. Not all states adopted Medicaid expansion, and the timing of adoption among expansion states varied. Prior studies have shown that Medicaid expansion improved mortality rates for several chronic conditions. Although there are data on the association between Medicaid expansion on insurance type among patients waitlisted for a liver transplant, there are no published data to date on its impact on liver disease-related mortality in the broader population. We therefore sought to evaluate the association between Medicaid expansion and state-level liver disease–related mortality using a quasi-experimental study design. We evaluated age-adjusted, state-level, liver disease–related mortality rates using the Centers for Disease Control and Prevention data. We fit multivariable linear regression models that accounted for sociodemographic, clinical, and access-to-care variables at the state level, and a difference-in-difference estimator to evaluate the association between Medicaid expansion and liver disease–related mortality. In multivariable linear regression models, there was a significant association between Medicaid expansion and liver disease–related mortality (P = .02). Medicaid expansion was associated with 8.3 (95% CI, 1.6–15.1) fewer deaths from liver disease per 1,000,000 adult residents per year after Medicaid expansion compared with what would have been expected to occur if those states followed the same trajectory as nonexpansion states. The impact of Medicaid expansion translated to 870 fewer liver-related deaths per year in expansion states (4350 in the postexpansion study period from 2014 to 2018). These data support the contention that Medicaid expansion has been associated with significantly decreased liver disease–related mortality. Universal Medicaid expansion could further decrease liver disease–related mortality in the United States

Is there a cost of virus resistance in marine cyanobacteria?

Owing to their abundance and diversity, it is generally perceived that viruses are important for structuring microbial communities and regulating biogeochemical cycles. The ecological impact of viruses on microbial food webs, however, may be influenced by evolutionary processes, including the ability of bacteria to evolve resistance to viruses and the theoretical prediction that this resistance should be accompanied by a fitness cost. We conducted experiments using phylogenetically distinct strains of marine Synechococcus (Cyanobacteria) to test for a cost of resistance (COR) to viral isolates collected from Mount Hope Bay, Rhode Island. In addition, we examined whether fitness costs (1) increased proportionally with total resistance, the number of viruses for which a strain had evolved resistance, or (2) were determined more by compositional resistance, the identity of the viruses to which it evolved resistance. A COR was only found in half of our experiments, which may be attributed to compensatory mutations or the inability to detect a small COR. When detected, the COR resulted in a 20 reduction in relative fitness compared to ancestral strains. The COR was unaffected by total resistance, suggesting a pleiotropic fitness response. Under competitive conditions, however, the COR was dependent on compositional resistance, suggesting that fitness costs were associated with the identity of a few particular viruses. Our study provides the first evidence for a COR in marine bacteria, and suggests that Synechococcus production may be influenced by the composition of co-occurring viruses. © 2007 International Society for Microbial Ecology All rights reserved

Pharmacist-led group medical appointments for the management of type 2 diabetes with comorbid depression in older adults

BACKGROUND: Depression is associated with poor glycemic control, increased number of microvascular and macrovascular complications, functional impairment, mortality, and 4.5 times higher total health care costs in patients with diabetes. Shared medical appointments (SMAs) may be an effective method to attain national guideline recommendations for glycemic control in diabetes for patients with depression through peer support, counseling, problem solving, and improved access to care. OBJECTIVE: To test the efficacy as assessed by attainment of a hemoglobin A1c (A1C) \u3c7% of pharmacist-led group SMA visits, Veterans Affairs Multidisciplinary Education in Diabetes and Intervention for Cardiac Risk Reduction in Depression (VA-MEDIC-D), in patients with type 2 diabetes mellitus. METHODS: This was a randomized controlled trial of VA-MEDIC-D added to standard care versus standard care alone in depressed patients with diabetes with A1C \u3e6.5%. VA-MEDIC-D consisted of 4 once-weekly, 2-hour sessions followed by 5 monthly 90-minute group sessions. Each SMA session consisted of multidisciplinary education and pharmacist-led behavioral and pharmacologic interventions for diabetes, lipids, smoking, and blood pressure. No pharmacologic interventions for depression were provided. The change in the proportion of participants who achieved an A1C \u3c7% at 6 months was compared. RESULTS: Compared to standard care (n = 44), a lower proportion of patients in VAMEDIC-D (n = 44) had systolic blood pressure (SBP) \u3c130 mmHg at baseline, but were similar in other cardiovascular risk factors and psychiatric comorbidity. The change in the proportion of participants achieving an A1C \u3c7% was greater in the VA-MEDIC-D arm than in the standard care arm (29.6% vs 11.9%), with odds ratio 3.6 (95% CI 1.1 to 12.3). VA-MEDIC-D participants also achieved significant reductions in SBP, low-density lipoprotein cholesterol, and non-high-density lipoprotein (HDL) cholesterol from baseline, whereas significant reductions were attained only in non-HDL cholesterol with standard care. There was no significant change in depressive symptoms for either arm. CONCLUSIONS: Pharmacist-led group SMA visits are efficacious in attainment of glycemic control in patients with diabetes and depression without change in depression symptoms

Pharmacist-Led Shared Medical Appointments for Multiple Cardiovascular Risk Reduction in Patients With Type 2 Diabetes

Purpose To assess whether VA MEDIC-E (Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction[EM DASH] Extended for 6 months), a pharmacist-led shared medical appointments program, could improve attainment of target goals for hypertension, hyperglycemia, hyperlipidemia, and tobacco use in patients with type 2 diabetes compared to standard primary care after 6 months of intervention. Methods A randomized, controlled trial of VA MEDIC-E (n = 50) versus standard primary care (n = 49) in veterans with type 2 diabetes, hemoglobin A1c (A1C) \u3e 7%, blood pressure (BP) \u3e 130/80 mmHg, and low density lipoprotein cholesterol (LDL-C) \u3e 100mg/dl (2.59 mmol/l) in the previous 6 months was conducted. The VA MEDIC-E intervention consisted of 4 weekly group sessions followed by 5 monthly booster group sessions. Each 2-hour session included 1 hour of multidisciplinary diabetes specific healthy lifestyle education and 1 hour of pharmacotherapeutic interventions performed by a clinical pharmacist. Evaluation measures included lab values of A1C, LDL cholesterol, BP, and goal attainment of these values, and diabetes self-care behavior questionnaires at 6 months. Results The randomization groups were similar at baseline in all cardiovascular risk factors except for LDL, which was significantly lower in the MEDIC-E arm. At 6 months, significant improvements from baseline were found in the intervention arm for exercise, foot care, and goal attainment of A1C, LDL-C, and BP but not in the control arm. Conclusions The results of this study demonstrate that the pharmacist-led group intervention program for 6 months was an efficacious and sustainable collaborative care approach to managing diabetes and reducing associated cardiovascular risk. © 2011, SAGE Publications. All rights reserved

Clinical and Demographic Characteristics of Patient Population by Metabolic Syndrome Monitoring Status.

<p>*p<0.05.</p

Metabolic Syndrome Components for Completely Monitored Patients.

<p>*p<0.05 between psychiatric groups.</p