The U.S. Preventive Services Task Force (USPSTF) develops evidence-based recommendations about preventive care based on comprehensive systematic reviews of the best available evidence. Decision ...models provide a complementary, quantitative approach to support the USPSTF as it deliberates about the evidence and develops recommendations for clinical and policy use. This article describes the rationale for using modeling, an approach to selecting topics for modeling, and how modeling may inform recommendations about clinical preventive services. Decision modeling is useful when clinical questions remain about how to target an empirically established clinical preventive service at the individual or program level or when complex determinations of magnitude of net benefit, overall or among important subpopulations, are required. Before deciding whether to use decision modeling, the USPSTF assesses whether the benefits and harms of the preventive service have been established empirically, assesses whether there are key issues about applicability or implementation that modeling could address, and then defines the decision problem and key questions to address through modeling. Decision analyses conducted for the USPSTF are expected to follow best practices for modeling. For chosen topics, the USPSTF assesses the strengths and limitations of the systematically reviewed evidence and the modeling analyses and integrates the results of each to make preventive service recommendations.
Abstract As the US health care delivery system undergoes rapid transformation, there is an urgent need to define a comprehensive, evidence-based role for the family physician. A Role Definition Group ...made up of members of seven family medicine organizations developed a statement defining the family physician's role in meeting the needs of individuals, the health care system, and the country. The Role Definition Group surveyed more than 50 years of foundational manuscripts including published works from the Future of Family Medicine project and Keystone III conference, external reviews, and a recent Accreditation Council on Graduate Medical Education Family Medicine Milestones definition. They developed candidate definitions and a “foil” definition of what family medicine could become without change. The following definition was selected: “Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health.” This definition will guide the second Future of Family Medicine project and provide direction as family physicians, academicians, clinical networks, and policy-makers negotiate roles in the evolving health system.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Trimethylamine-
-oxide (TMAO), a choline-derived gut microbiota-dependent metabolite, is a newly recognized risk marker for cardiovascular disease. We sought to determine: (1) TMAO response to meals ...containing free versus lipid-soluble choline and (2) effects of gut microbiome on TMAO response.
In a randomized, controlled, double-blinded, crossover study, healthy men (
= 37) were provided meals containing 600 mg choline either as choline bitartrate or phosphatidylcholine, or no choline control.
Choline bitartrate yielded three-times greater plasma TMAO AUC (
= 0.01) and 2.5-times greater urinary TMAO change from baseline (
= 0.01) compared to no choline and phosphatidylcholine. Gut microbiota composition differed (permutational multivariate analysis of variance, PERMANOVA;
= 0.01) between high-TMAO producers (with ≥40% increase in urinary TMAO response to choline bitartrate) and low-TMAO producers (with <40% increase in TMAO response). High-TMAO producers had more abundant lineages of
from
and
compared to low-TMAO producers (analysis of composition of microbiomes, ANCOM;
< 0.05).
Given that phosphatidylcholine is the major form of choline in food, the absence of TMAO elevation with phosphatidylcholine counters arguments that phosphatidylcholine should be avoided due to TMAO-producing characteristics. Further, development of individualized dietary recommendations based on the gut microbiome may be effective in reducing disease risk.
Phytosterol supplementation of 2 g/d is recommended by the National Cholesterol Education Program to reduce LDL cholesterol. However, the effects of different intakes of phytosterol on cholesterol ...metabolism are uncertain.
We evaluated the effects of 3 phytosterol intakes on whole-body cholesterol metabolism.
In this placebo-controlled, crossover feeding trial, 18 adults received a phytosterol-deficient diet (50 mg phytosterols/2000 kcal) plus beverages supplemented with 0, 400, or 2000 mg phytosterols/d for 4 wk each, in random order. All meals were prepared in a metabolic kitchen; breakfast and dinner on weekdays were eaten on site. Primary outcomes were fecal cholesterol excretion and intestinal cholesterol absorption measured with stable-isotope tracers and serum lipoprotein concentrations.
Phytosterol intakes (diet plus supplements) averaged 59, 459, and 2059 mg/d during the 3 diet periods. Relative to the 59-mg diet, the 459- and 2059-mg phytosterol intakes significantly (P < 0.01) increased total fecal cholesterol excretion (36 +/- 6% and 74 +/- 10%, respectively) and biliary cholesterol excretion (38 +/- 7% and 77 +/- 12%, respectively) and reduced percentage intestinal cholesterol absorption (-10 +/- 1% and -25 +/- 3%, respectively). Serum LDL cholesterol declined significantly only with the highest phytosterol dose (-8.9 +/- 2.3%); a trend was observed with the 459-mg/d dose (-5.0 +/- 2.1%; P = 0.077).
Dietary phytosterols in moderate and high doses favorably alter whole-body cholesterol metabolism in a dose-dependent manner. A moderate phytosterol intake (459 mg/d) can be obtained in a healthy diet without supplementation. This trial was registered at clinicaltrials.gov as NCT00860054.
Nearly half of US adults with diagnosed hypertension have uncontrolled blood pressure. Clinical inertia may contribute, including patient-physician uncertainty about how variability in blood ...pressures impacts overall control. Better information display may support clinician-patient hypertension decision making through reduced cognitive load and improved situational awareness.
A multidisciplinary team employed iterative user-centered design to create a blood pressure visualization EHR prototype that included patient-generated blood pressure data. An attitude and behavior survey and 10 focus groups with patients (N = 16) and physicians (N = 24) guided iterative design and confirmation phases. Thematic analysis of qualitative data yielded insights into patient and physician needs for hypertension management.
Most patients indicated measuring home blood pressure, only half share data with physicians. When receiving home blood pressure data, 88% of physicians indicated entering gestalt averages as text into clinical notes. Qualitative findings suggest that including a data visualization that included home blood pressures brought this valued data into physician workflow and decision-making processes. Data visualization helps both patients and physicians to have a fuller understanding of the blood pressure 'story' and ultimately promotes the activated engaged patient and prepared proactive physician central to the Chronic Care Model. Both patients and physicians expressed concerns about workflow for entering and using home blood pressure data for clinical care.
Our user-centered design process with physicians and patients produced a well-received blood pressure visualization prototype that includes home blood pressures and addresses patient-physician information needs. Next steps include evaluating a recent EHR visualization implementation, designing annotation functions aligned with users' needs, and addressing additional stakeholders' needs (nurses, care managers, caregivers). This significant innovation has potential to improve quality of care for hypertension through better patient-physician understanding of control and goals. It also has the potential to enable remote monitoring of patient blood pressure, a newly reimbursed activity, and is a strong addition to telehealth efforts.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Conventional clinic blood pressure (BP) measurements are routinely used for hypertension management and physician performance measures. We aimed to check home BP measurements after elevated ...conventional clinic BP measurements for which physicians did not intensify treatment, to differentiate therapeutic inertia from appropriate inaction.
We conducted a pre and post study of home BP monitoring for patients with uncontrolled hypertension as determined by conventional clinic BP measurements for which physicians did not intensify hypertension management. Physicians were notified of average home BP 2-4 weeks after the initial clinic visit. Outcome measures were the proportion of patients with controlled hypertension using average home BP measurements, changes in hypertension management by physicians, changes in physicians' hypertension metrics, and factors associated with home-clinic BP differences.
Of 90 recruited patients who had elevated conventional clinic BP recordings, 65.6% had average home BP measurements that were <140/90 mm Hg. Physicians changed treatment plans for 61% of patients with average home BP readings of ≥140/90 mm Hg, whereas decisions to not change treatment for the remaining patients were based on contextual factors. Substituting average home BP for conventional clinic BP for 4% of patients from 2 physicians' hypertension registries improved the physicians' hypertension control rates by 3% to 5%. Greater body mass index and increased number of BP medications were associated with home BP measurement ≥140/90 mm Hg. Clinic BP levels did not estimate normal home BP levels.
Documented home BP in cases of clinical uncertainty helped differentiate therapeutic inertia from appropriate inaction and improved physicians' hypertension metrics.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Abstract Background Studies of adult subjects have found a strong correlation between serum carotenoids and skin carotenoids measured by resonance Raman spectroscopy (RRS). No published studies have ...examined correlations between skin and serum carotenoids among children. Objectives We aimed to validate skin RRS methodology against serum carotenoid measurements by high-performance liquid chromatography and to determine whether RRS can be used as a valid biomarker of fruit and vegetable (F/V) intake among children. Design In our cross-sectional study, participants were 45 healthy children aged 5 to 17 years who provided three blood samples used to assess serum carotenoid concentrations and three RRS skin measurements of the palm within a 4-week period. Dietary intake of F/V was assessed three times within 4 weeks using a 27-item food frequency questionnaire (FFQ) and an automated multiple-pass 24-hour daily recall. Estimates of intake from three FFQs, completed at least 7 days apart, were averaged. Estimates of intake from 24-hour daily recalls were collected on 2 weekdays and 1 weekend day and averaged. Results Levels of skin and serum carotenoids were highly correlated ( R2 =0.62; P <0.001). A linear regression model, controlling for child's weight and scanner unit, predicted that for every unit increase of total F/V from FFQ and total F/V as assessed by 24-hour daily recall, RRS intensity was predicted to increase by 3,798 ( P =0.001) and 3,504 ( P =0.001), respectively. Similar results were observed for reported high-carotenoid vegetable intake. Total carotenoid and beta carotene levels from 24-hour daily recalls correlated to total serum carotenoids levels ( P <0.01 and P <0.05, respectively). Total carotenoid, alpha carotene, and beta carotene levels from the 24-hour daily recalls correlated to RRS ( P <0.01). Conclusions Skin carotenoids measured by RRS were strongly correlated with serum carotenoid levels and were positively associated with estimates of intake from FFQ and an automated multiple-pass 24-hour daily recall among children aged 5 to 17 years. Skin carotenoids may be used as valid biomarker of F/V intake among children.
Since the 1980s, the U.S. Preventive Services Task Force (USPSTF) has developed and used rigorous methods to make evidence-based recommendations about preventive services to promote health and ...well-being for all Americans. Recommendations are based on the evidence of magnitude of net benefit (benefits minus harms). Expert opinion is not substituted when evidence is lacking. Evidence gaps are common. Few preventive services are supported by high-quality studies that directly and comprehensively determine the overall magnitude of benefits and harms in the same study. When assessing the body of evidence, studies may not have been conducted in primary care settings, studies may not have sufficiently included populations of interest, and long-term outcomes may not have been directly assessed. When direct evidence is not available, the USPSTF uses the methodologies of applicability to determine whether evidence can be generalized to an asymptomatic primary care population; coherence to link bodies of evidence and create an indirect evidence pathway; extrapolation to make inferences across the indirect evidence pathway, extend evidence to populations not specifically studied, consider service delivery intervals, and infer long-term outcomes; and conceptual bounding to set theoretical lower or upper limits for plausible benefits or harms. The USPSTF extends the evidence only so far as to maintain at least moderate certainty that its findings are preserved. This manuscript details with examples of how the USPSTF uses these methods to make recommendations that truly reflect the evidence.
Insulin receptor substrate (IRS) has been suggested as a molecular target of free fatty acids (FFAs) for insulin resistance. However, the signaling pathways by which FFAs lead to the inhibition of ...IRS function remain to be established. In this study, we explored the FFA-signaling pathway that contributes to serine phosphorylation and degradation of IRS-1 in adipocytes and in dietary obese mice. Linoleic acid, an FFA used in this study, resulted in a reduction in insulin-induced glucose uptake in 3T3-L1 adipocytes. This mimics insulin resistance induced by high-fat diet in C57BL/6J mice. The reduction in glucose uptake is associated with a decrease in IRS-1, but not IRS-2 or GLUT4 protein abundance. Decrease in IRS-1 protein was proceeded by IRS-1 (serine 307) phosphorylation that was catalyzed by serine kinases inhibitor κB kinase (IKK) and c-JUN NH2-terminal kinase (JNK). IKK and JNK were activated by linoleic acid and inhibition of the two kinases led to prevention of IRS-1 reduction. We demonstrate that protein kinase C (PKC) θ is expressed in adipocytes. In 3T3-L1 adipocytes and fat tissue, PKCθ was activated by fatty acids as indicated by its phosphorylation status, and by its protein level, respectively. Activation of PKCθ contributes to IKK and JNK activation as inhibition of PKCθ by calphostin C blocked activation of the latter kinases. Inhibition of either PKCθ or IKK plus JNK by chemical inhibitors resulted in protection of IRS-1 function and insulin sensitivity in 3T3-L1 adipocytes. These data suggest that: 1) activation of PKCθ contributes to IKK and JNK activation by FFAs; 2) IKK and JNK mediate PKCθ signals for IRS-1 serine phosphorylation and degradation; and 3) this molecular mechanism may be responsible for insulin resistance associated with hyperlipidemia.
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