Abstract Purpose The paradox of primary care is the observation that primary care is associated with apparently low levels of evidence-based care for individual diseases, but systems based on primary ...care have healthier populations, use fewer resources, and have less health inequality. The purpose of this article is to explore, from a complex systems perspective, mechanisms that might account for the effects of primary care beyond disease-specific care. Methods In an 8-session, participatory group model-building process, patient, caregiver, and primary care clinician community stakeholders worked with academic investigators to develop and refine an agent-based computer simulation model to test hypotheses about mechanisms by which features of primary care could affect health and health equity. Results In the resulting model, patients are at risk for acute illness, acute life-changing illness, chronic illness, and mental illness. Patients have changeable health behaviors and care-seeking tendencies that relate to their living in advantaged or disadvantaged neighborhoods. There are 2 types of care available to patients: primary and specialty. Primary care in the model is less effective than specialty care in treating single diseases, but it has the ability to treat multiple diseases at once. Primary care also can provide disease prevention visits, help patients improve their health behaviors, refer to specialty care, and develop relationships with patients that cause them to lower their threshold for seeking care. In a model run with primary care features turned off, primary care patients have poorer health. In a model run with all primary care features turned on, their conjoint effect leads to better population health for patients who seek primary care, with the primary care effect being particularly pronounced for patients who are disadvantaged and patients with multiple chronic conditions. Primary care leads to more total health care visits that are due to more disease prevention visits, but there are reduced illness visits among people in disadvantaged neighborhoods. Supplemental appendices provide a working version of the model and worksheets that allow readers to run their own experiments that vary model parameters. Conclusion This simulation model provides insights into possible mechanisms for the paradox of primary care and shows how participatory group model building can be used to evaluate hypotheses about the behavior of such complex systems as primary health care and population health.
•A questionnaire was constructed to assess patient-reported outcomes in minimally invasive glaucoma surgery.•The questionnaire was constructed based upon inputs from physicians and patients.•The ...Glaucoma Outcomes Survey will be administered to patients before and after minimally invasive glaucoma surgery.•The survey aims to incorporate patient preference into minimally invasive glaucoma surgery evaluations.
To develop a vision-targeted health-related quality-of-life instrument for patients with glaucoma who are candidates for minimally invasive glaucoma surgery (MIGS).
Development of a health-related quality-of-life instrument.
Twelve practicing ophthalmologists and 41 glaucoma patients.
A questionnaire was constructed to assess functional limitations, vision-related symptoms, aesthetics, psychosocial issues, and surgical satisfaction for MIGS candidates. Questions were drafted after a review of the literature and subsequently refined based upon input from 1 physician and 4 patient focus groups. Nineteen cognitive interviews were used to ensure that questions were understandable to respondents.
The focus group identified the following key issues and concerns as being important to glaucoma patients: functional limitations (eg, driving), bodily discomfort (eg, stinging from drops), changes in appearance (eg, drooping eyelid), and psychosocial concerns (eg, mental burden associated with a diagnosis of glaucoma, financial burden of treatment). Cognitive interviews resulted in the following improvements to the questionnaire: changes in wording to clarify lighting conditions, and additional questions addressing psychosocial issues, such as job loss, severity of disease, and perception of MIGS.
A patient-reported outcomes instrument, the Glaucoma Outcomes Survey, was developed to evaluate MIGS for patients with mild to moderate glaucoma. Next steps include electronic administration to patients selected from the American Academy of Ophthalmology Intelligent Research in Sight (IRIS) registry. An electronic patient-reported outcomes platform will be used to administer the questionnaire before and after MIGS. The questionnaire will improve understanding of how surgical interventions such as MIGS impact vision-targeted health-related quality-of-life in glaucoma patients.
People with cancer are at increased risk of hospitalisation and death following infection with SARS-CoV-2. Therefore, we aimed to conduct one of the first evaluations of vaccine effectiveness against ...breakthrough SARS-CoV-2 infections in patients with cancer at a population level.
In this population-based test-negative case-control study of the UK Coronavirus Cancer Evaluation Project (UKCCEP), we extracted data from the UKCCEP registry on all SARS-CoV-2 PCR test results (from the Second Generation Surveillance System), vaccination records (from the National Immunisation Management Service), patient demographics, and cancer records from England, UK, from Dec 8, 2020, to Oct 15, 2021. Adults (aged ≥18 years) with cancer in the UKCCEP registry were identified via Public Health England's Rapid Cancer Registration Dataset between Jan 1, 2018, and April 30, 2021, and comprised the cancer cohort. We constructed a control population cohort from adults with PCR tests in the UKCCEP registry who were not contained within the Rapid Cancer Registration Dataset. The coprimary endpoints were overall vaccine effectiveness against breakthrough infections after the second dose (positive PCR COVID-19 test) and vaccine effectiveness against breakthrough infections at 3–6 months after the second dose in the cancer cohort and control population.
The cancer cohort comprised 377 194 individuals, of whom 42 882 had breakthrough SARS-CoV-2 infections. The control population consisted of 28 010 955 individuals, of whom 5 748 708 had SARS-CoV-2 breakthrough infections. Overall vaccine effectiveness was 69·8% (95% CI 69·8–69·9) in the control population and 65·5% (65·1–65·9) in the cancer cohort. Vaccine effectiveness at 3–6 months was lower in the cancer cohort (47·0%, 46·3–47·6) than in the control population (61·4%, 61·4–61·5).
COVID-19 vaccination is effective for individuals with cancer, conferring varying levels of protection against breakthrough infections. However, vaccine effectiveness is lower in patients with cancer than in the general population. COVID-19 vaccination for patients with cancer should be used in conjunction with non-pharmacological strategies and community-based antiviral treatment programmes to reduce the risk that COVID-19 poses to patients with cancer.
University of Oxford, University of Southampton, University of Birmingham, Department of Health and Social Care, and Blood Cancer UK.
Dual coil implantable cardioverter-defibrillator (ICD) leads with a superior vena cava (SVC) electrode have been considered standard of care despite sparse data suggesting improved ICD defibrillation ...efficacy. SVC coils increase lead complexity, cost, risk of lead failure, and lead removal.
To compare all-cause mortality, sudden cardiac death, implant defibrillation threshold (DFT) test energies, appropriate shock rates, and first shock efficacy for ventricular tachyarrhythmias for dual coil vs single coil leads in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT).
In SCD-HeFT, 811 patients with heart failure received a single lead transvenous ICD (Medtronic model 7223) and underwent protocol-driven DFT testing. The selection of a dual vs single coil right ventricular (RV) lead was at the physician's discretion. DFT data were available in 717 patients.
Dual coil leads were used in 563 and single coil in 246 patients. After 45.5-month follow-up, overall mortality was similar (19.4% for dual coil vs 21.5% for single coil; adjusted hazard ratio 0.95; 95% confidence interval 0.68-1.34; P = .78). Sudden cardiac death was also similar (3.6% for dual coil vs 3.7% for single coil; P = .96). First shock efficacy was 82.2% vs 91.9% (dual coil vs single coil; unadjusted odds ratio 0.41; 95% confidence interval 0.15-1.13; P = .085). Mean DFT was 12.1 ± 4.7 J vs 12.8 ± 4.8 J (dual coil vs single coil; P = .087).
In the SCD-HeFT, the addition of an SVC coil for left-sided implants was not associated with improved outcome measures. We advocate returning to single coil RV ICD leads as the standard of care to decrease chronic lead complications.
Abstract Background Surgical procedures in the United States are increasingly performed in the ambulatory setting, including freestanding ambulatory surgery centers (ASCs). However, there is a lack ...of research and tracking of surgical outcomes in this setting. Materials and methods We analyzed data from a state all-payer claims database to produce a retrospective cohort study on the rate of acute care use (emergency department ED visits and inpatient admissions) within 7 d after operations performed in freestanding ASCs in South Carolina. Two-level reliability-adjusted generalized linear mixed models accounting for random facility-level effects were used to adjust for patient-level and facility-level characteristics. Results A total of 1,328,708 procedures were performed in 86 freestanding ASCs in South Carolina from 2006-2013. The overall rate of postoperative acute care per 1000 procedures within 7 d was 17.3 (95% confidence interval CI, 15.3-19.5). Patient characteristics associated with the highest postoperative acute care use within 7 d included Medicaid insurance (adjusted odds ratio aOR, 1.79; 95% CI, 1.70-1.90), lowest median household income (aOR, 1.36; 95% CI, 1.30-1.43), and preoperative Charlson Comorbidity Index (CCI) score 3+ (aOR, 4.14; 95% CI, 3.95-4.34). Total charges for postoperative ED visits ( n = 14,682) and inpatient admissions ( n = 8945) within 7 d were approximately $51.4 and $361.1 million, respectively from 2006-2013. Conclusions Acute care use within 7 d was commonly ≥10 per 1000 procedures performed in freestanding ASCs in South Carolina. These measures may be targets for quality and cost improvement and innovation. Patients at risk for acute care utilization may benefit from improvements in postoperative follow-up after procedures in ASCs.
The Mixtec, or the people of Savi ("Nation of the Rain God"), one of the major civilizations of ancient Mesoamerica, made their home in the highlands of Oaxaca, where they resisted both Aztec ...military expansion and the Spanish conquest. This book presents and interprets the sacred histories narrated in the Mixtec codices, the largest surviving collection of pre-Columbian manuscripts in existence. In these screenfold books, ancient painter-historians chronicled the politics of the Mixtec from approximately a.d. 900 to 1521, portraying the royal families, rituals, wars, alliances, and ideology of the times. By analyzing and cross-referencing the codices, which have been fragmented and dispersed in far-flung archives, the authors attempt to reconstruct Mixtec history. Adding useful interpretation and commentary, Jansen and Perez Jimenez synthesize the large body of surviving documents into the first unified narrative of Mixtec sacred history.
Cocaine addiction is a major problem affecting all societal and economic classes for which there is no effective therapy. We hypothesized an effective anti-cocaine vaccine could be developed by using ...an adeno-associated virus (AAV) gene transfer vector as the delivery vehicle to persistently express an anti-cocaine monoclonal antibody in vivo, which would sequester cocaine in the blood, preventing access to cognate receptors in the brain. To accomplish this, we constructed AAVrh.10antiCoc.Mab, an AAVrh.10 gene transfer vector expressing the heavy and light chains of the high affinity anti-cocaine monoclonal antibody GNC92H2. Intravenous administration of AAVrh.10antiCoc.Mab to mice mediated high, persistent serum levels of high-affinity, cocaine-specific antibodies that sequestered intravenously administered cocaine in the blood. With repeated intravenous cocaine challenge, naive mice exhibited hyperactivity, while the AAVrh.10antiCoc.Mab-vaccinated mice were completely resistant to the cocaine. These observations demonstrate a novel strategy for cocaine addiction by requiring only a single administration of an AAV vector mediating persistent, systemic anti-cocaine passive immunity.
Background. The American Association of Poison Control Centers (AAPCC;
http://www.aapcc.org
) maintains the national database of information logged by the country's 61 Poison Control Centers (PCCs). ...Case records in this database are from self-reported calls: they reflect only information provided when the public or healthcare professionals report an actual or potential exposure to a substance (e.g., an ingestion, inhalation, or topical exposure.), or request information/educational materials. Exposures do not necessarily represent a poisoning or overdose. The AAPCC is not able to completely verify the accuracy of every report made to member centers. Additional exposures may go unreported to PCCs, and data referenced from the AAPCC should not be construed to represent the complete incidence of national exposures to any substance(s). U.S. Poison Centers make possible the compilation and reporting of this report through their staffs' meticulous documentation of each case using standardized definitions and compatible computer systems. The 61 participating poison centers in 2005 are:
1
Regional Poison Control Center, Birmingham, AL
Alabama Poison Center, Tuscaloosa, AL
Arizona Poison and Drug Information Center, Tucson, AZ;
Banner Poison Control Center, Phoenix, AZ
Arkansas Poison and Drug Information Center, Little Rock, AK
California Poison Control System-Fresno/Madera Division, CA
California Poison Control System-Sacramento Division, CA
California Poison Control System-San Diego Division, CA
California Poison Control System-San Francisco Division, CA
Rocky Mountain Poison and Drug Center, Denver, CO
Connecticut Poison Control Center, Farmington, CT
National Capital Poison Center, Washington, DC
Florida Poison Information Center, Tampa, FL
Florida Poison Information Center, Jacksonville, FL;
Florida Poison Information Center, Miami, FL
Georgia Poison Center, Atlanta, GA
Illinois Poison Center, Chicago, IL
Indiana Poison Center, Indianapolis, IN
Iowa Statewide Poison Control Center, Sioux City, IA
Mid-America Poison Control Center, Kansas City, KA
Kentucky Regional Poison Center, Louisville, KY
Louisiana Drug and Poison Information Center, Monroe, LA
Northern New England Poison Center, Portland, ME
Maryland Poison Center, Baltimore, MD
Regional Center for Poison Control and Prevention Serving Massachusetts and Rhode Island, Boston, MA
Children's Hospital of Michigan Regional Poison Control Center, Detroit, MI
DeVos Children's Hospital Regional Poison Center, Grand Rapids, MI
Hennepin Regional Poison Center, Minneapolis, MN
Mississippi Regional Poison Control Center, Jackson, MS
Missouri Regional Poison Center, St Louis, MO
Nebraska Regional Poison Center, Omaha, NE
New Jersey Poison Information and Education System, Newark, NJ
New Mexico Poison and Drug Information Center, Albuquerque, NM
New York City Poison Control Center, New York, NY
Long Island Regional Poison and Drug Information Center, Mineola, NY
Ruth A. Lawrence Poison and Drug Information Center, Rochester, NY
Upstate (formerly Central) New York Poison Center, Syracuse, NY
Western New York Poison Center, Buffalo, NY
Carolinas Poison Center, Charlotte, NC
Cincinnati Drug and Poison Information Center, Cincinnati, OH
Central Ohio Poison Center, Columbus, OH
Greater Cleveland Poison Control Center, Cleveland, OH
Oklahoma Poison Control Center, Oklahoma City, OK
Oregon Poison Center, Portland, OR
Pittsburgh Poison Center, Pittsburgh, PA
The Poison Control Center, Philadelphia, PA;
Puerto Rico Poison Center, San Juan, PR
Palmetto Poison Center, Columbia, SC
Tennessee Poison Center, Nashville, TN
Central Texas Poison Center, Temple, TX
North Texas Poison Center, Dallas, TX
Southeast Texas Poison Center, Galveston, TX
Texas Panhandle Poison Center, Amarillo, TX
West Texas Regional Poison Center, El Paso, TX
South Texas Poison Center, San Antonio, TX
Utah Poison Control Center, Salt Lake City, UT
Virginia Poison Center, Richmond, VA
Blue Ridge Poison Center, Charlottesville, VA
Washington Poison Center, Seattle, WA
West Virginia Poison Center, Charleston, WV
Wisconsin Poison Center, Milwaukee, WI
To compare the efficacy and safety of iv nicardipine with sodium nitroprusside in the treatment of postoperative hypertension after both cardiac and noncardiac surgery.
Multicenter, prospective, ...randomized, open-label study.
Six tertiary referral medical centers (recovery rooms and surgical ICUs).
A total of 139 patients with postoperative hypertension: i.v. nicardipine (n = 71), sodium nitroprusside (n = 68).
Administration of i.v. nicardipine or sodium nitroprusside.
Vital signs (BP, heart rate), hemodynamic variables, medication dosage, total number of dose changes, and time to achieve BP control were recorded.
Both medications were equally effective in reducing BP in both the cardiac and noncardiac surgical groups. Under the conditions of the study, i.v. nicardipine controlled hypertension more rapidly than sodium nitroprusside (i.v. nicardipine 14.0 +/- 1.0 mins and sodium nitroprusside 30.4 +/- 3.5 mins, p = .0029). The total number of dose changes required to achieve therapeutic BP response was significantly less in the i.v. nicardipine-treated patients (i.v. nicardipine 1.5 +/- 0.2 vs. sodium nitroprusside 5.1 +/- 1.4, p < .05). Adverse effects were observed with both drugs (i.v. nicardipine 7% 5/71 and sodium nitroprusside 18% 12/68 NS).
Intravenous nicardipine is as effective as sodium nitroprusside in the therapy of postoperative hypertension. Specific advantages have been identified. The use of i.v. nicardipine should be considered in the therapy of postoperative hypertension.
OBJECTIVEMany genetic variants have been associated with glucose homeostasis and type 2 diabetes in genome-wide association studies. Zinc is an essential micronutrient that is important for β-cell ...function and glucose homeostasis. We tested the hypothesis that zinc intake could influence the glucose-raising effect of specific variants.RESEARCH DESIGN AND METHODSWe conducted a 14-cohort meta-analysis to assess the interaction of 20 genetic variants known to be related to glycemic traits and zinc metabolism with dietary zinc intake (food sources) and a 5-cohort meta-analysis to assess the interaction with total zinc intake (food sources and supplements) on fasting glucose levels among individuals of European ancestry without diabetes.RESULTSWe observed a significant association of total zinc intake with lower fasting glucose levels (β-coefficient ± SE per 1 mg/day of zinc intake: -0.0012 ± 0.0003 mmol/L, summary P value = 0.0003), while the association of dietary zinc intake was not significant. We identified a nominally significant interaction between total zinc intake and the SLC30A8 rs11558471 variant on fasting glucose levels (β-coefficient ± SE per A allele for 1 mg/day of greater total zinc intake: -0.0017 ± 0.0006 mmol/L, summary interaction P value = 0.005); this result suggests a stronger inverse association between total zinc intake and fasting glucose in individuals carrying the glucose-raising A allele compared with individuals who do not carry it. None of the other interaction tests were statistically significant.CONCLUSIONSOur results suggest that higher total zinc intake may attenuate the glucose-raising effect of the rs11558471 SLC30A8 (zinc transporter) variant. Our findings also support evidence for the association of higher total zinc intake with lower fasting glucose levels.
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