Therapy modifications in response to poorly controlled hypertension, dyslipidemia, and diabetes mellitus.

BACKGROUND: Poorly controlled cardiovascular risk factors are common. Evaluating whether physicians respond appropriately to poor risk factor control in patients may better reflect quality of care than measuring proportions of patients whose conditions are controlled. OBJECTIVES: To evaluate therapy modifications in response to poor control of hypertension, dyslipidemia, or diabetes in a large clinical population. DESIGN: Retrospective cohort study within an 18-month period in 2002 to 2003. SETTING: Kaiser Permanente of Northern California. PATIENTS: 253,238 adult members with poor control of 1 or more of these conditions. MEASUREMENTS: The authors assessed the proportion of patients with poor control who experienced a change in pharmacotherapy within 6 months, and they defined "appropriate care" as a therapy modification or return to control without therapy modification within 6 months. RESULTS: A total of 64% of patients experienced modifications in therapy for poorly controlled systolic blood pressure, 71% for poorly controlled diastolic blood pressure, 56% for poorly controlled low-density lipoprotein cholesterol level, and 66% for poorly controlled hemoglobin A1c level. Most frequent modifications were increases in number of drug classes (from 70% to 84%) and increased dosage (from 15% to 40%). An additional 7% to 11% of those with poorly controlled blood pressure, but only 3% to 4% of those with elevated low-density lipoprotein cholesterol level or hemoglobin A1c level, returned to control without therapy modification. Patients with more than 1 of the 3 conditions, higher baseline values, and target organ damage were more likely to receive "appropriate care." LIMITATIONS: Patient preferences and suboptimal adherence to therapy were not measured and may explain some failures to act. CONCLUSIONS: As an additional measure of the quality of care, measuring therapy modifications in response to poor control in a large population is feasible. Many patients with poorly controlled hypertension, dyslipidemia, or diabetes had their therapy modified and, thus, seemed to receive clinically "appropriate care" with this new quality measure.

Influence of noninjecting and injecting drug use on mortality, retention in the cohort, and antiretroviral therapy, in participants in the Swiss HIV Cohort Study.

OBJECTIVES: We studied the influence of noninjecting and injecting drug use on mortality, dropout rate, and the course of antiretroviral therapy (ART), in the Swiss HIV Cohort Study (SHCS). METHODS: Cohort participants, registered prior to April 2007 and with at least one drug use questionnaire completed until May 2013, were categorized according to their self-reported drug use behaviour. The probabilities of death and dropout were separately analysed using multivariable competing risks proportional hazards regression models with mutual correction for the other endpoint. Furthermore, we describe the influence of drug use on the course of ART. RESULTS: A total of 6529 participants (including 31% women) were followed during 31 215 person-years; 5.1% participants died; 10.5% were lost to follow-up. Among persons with homosexual or heterosexual HIV transmission, noninjecting drug use was associated with higher all-cause mortality [subhazard rate (SHR) 1.73; 95% confidence interval (CI) 1.07-2.83], compared with no drug use. Also, mortality was increased among former injecting drug users (IDUs) who reported noninjecting drug use (SHR 2.34; 95% CI 1.49-3.69). Noninjecting drug use was associated with higher dropout rates. The mean proportion of time with suppressed viral replication was 82.2% in all participants, irrespective of ART status, and 91.2% in those on ART. Drug use lowered adherence, and increased rates of ART change and ART interruptions. Virological failure on ART was more frequent in participants who reported concomitant drug injections while on opiate substitution, and in current IDUs, but not among noninjecting drug users. CONCLUSIONS: Noninjecting drug use and injecting drug use are modifiable risks for death, and they lower retention in a cohort and complicate ART.

Pharmacogenomics of HIV Therapy: Summary of a Workshop Sponsored by the National Institute of Allergy and Infectious Diseases

Approximately 1 million people in the United States and over 30 million worldwide are living with human immunodeficiency virus type 1 (HIV-1). While mortality from untreated infection approaches 100%, survival improves markedly with use of contemporary antiretroviral therapies (ART). In the United States, 25 drugs are approved for treating HIV-1, and increasing numbers are available in resource-limited countries. Safe and effective ART is a cornerstone in the global struggle against the acquired immunodeficiency syndrome. Variable responses to ART are due at least in part to human genetic variants that affect drug metabolism, drug disposition, and off-site drug targets. Defining effects of human genetic variants on HIV treatment toxicity, efficacy, and pharmacokinetics has far-reaching implications. In 2010, the National Institute of Allergy and Infectious Diseases sponsored a workshop entitled, Pharmacogenomics A Path Towards Personalized HIV Care. This article summarizes workshop objectives, presentations, discussions, and recommendations derived from this meeting.

The role of teriparatide in sequential and combination therapy of osteoporosis.

Osteoporosis is complicated by the occurrence of fragility fractures. Over past years, various treatment options have become available, mostly potent antiresorptive agents such as bisphosphonates and denosumab. However, antiresorptive therapy cannot fully and rapidly restore bone mass and structure that has been lost because of increased remodelling. Alternatively recombinant human parathyroid hormone (rhPTH) analogues do increase the formation of new bone material. The bone formation stimulated by intermittent PTH analogues not only increases bone mineral density (BMD) and bone mass but also improves the microarchitecture of the skeleton, thereby reducing incidence of vertebral and nonvertebral fractures. Teriparatide, a recombinant human PTH fragment available in Switzerland, is reimbursed as second-line treatment in postmenopausal women and men with increased fracture risk, specifically in patients with incident fractures under antiresorptive therapy or patients with glucocorticoid-induced osteoporosis and intolerance to antiresorptives. This position paper focuses on practical aspects in the management of patients on teriparatide treatment. Potential first-line indications for osteoanabolic treatment as well as the benefits and limitations of sequential and combination therapy with antiresorptive drugs are discussed.

Adult native septic arthritis: a review of 10 years of experience and lessons for empirical antibiotic therapy.

Objectives To review the epidemiology of native septic arthritis to establish local guidelines for empirical antibiotic therapy as part of an antibiotic stewardship programme. Methods We conducted a 10 year retrospective study based on positive synovial fluid cultures and discharge diagnosis of septic arthritis in adult patients. Microbiology results and medical records were reviewed. Results Between 1999 and 2008, we identified 233 episodes of septic arthritis. The predominant causative pathogens were methicillin-susceptible Staphylococcus aureus (MSSA) and streptococci (respectively, 44.6% and 14.2% of cases). Only 11 cases (4.7%) of methicillin-resistant S. aureus (MRSA) arthritis were diagnosed, among which 5 (45.5%) occurred in known carriers. For large-joint infections, amoxicillin/clavulanate or cefuroxime would have been appropriate in 84.5% of cases. MRSA and Mycobacterium tuberculosis would have been the most frequent pathogens that would not have been covered. In contrast, amoxicillin/clavulanate would have been appropriate for only 75.3% of small-joint infections (82.6% if diabetics are excluded). MRSA and Pseudomonas aeruginosa would have been the main pathogens not covered. Piperacillin/tazobactam would have been appropriate in 93.8% of cases (P < 0.01 versus amoxicillin/clavulanate). This statistically significant advantage is lost after exclusion of diabetics (P = 0.19). Conclusions Amoxicillin/clavulanate or cefuroxime would be adequate for empirical coverage of large-joint septic arthritis in our area. A broad-spectrum antibiotic would be significantly superior for small-joint infections in diabetics. Systematic coverage of MRSA is not justified, but should be considered for known carriers. These recommendations are applicable to our local setting. They might also apply to hospitals sharing the same epidemiology.

Mechanical circulatory support for destination therapy.

Patients with chronic heart failure who are not eligible for heart transplant and whose life expectancy depends mainly on the heart disease may benefit from mechanical circulatory support. Mechanical circulatory support restores adequate cardiac output and organ perfusion and eventually improves patients' clinical condition, quality of life and life expectancy. This treatment is called destination therapy (DT) and we estimate that in Switzerland more than 120 patients per year could benefit from it. In the last 10 years, design of the devices, implantation techniques and prognoses have changed dramatically. The key to successful therapy with a left ventricular assist device is appropriate patient selection, although we are still working on the definition of reliable inclusion and exclusion criteria and optimal timing for surgical implantation. Devices providing best long-term results are continuous flow, rotary or axial blood pumps implanted using minimally invasive techniques on a beating heart. These new devices (Thoratec HeartMate II and HeartWare HVAD) have only a single moving part, and have improved durability with virtually 10 years freedom from mechanical failure. In selected patients, the overall actuarial survival of DT patients is 75% at 1 year and 62% at 2 years, with a clear improvement in quality of life compared with medical management only. Complications include bleeding and infections; their overall incidence is significantly lower than with previous devices and their management is well defined. DT is evolving into an effective and reasonably cost-effective treatment option for a growing population of patients not eligible for heart transplant, showing encouraging survival rates at 2 years and providing clear improvement in quality of life. The future is bright for people suffering from chronic heart failure.

The last resort : spa therapy and the docile body in Victorian St. Catharines /

By relying on existing cultural models, the Victorian spa promoted health and wellness. Advertising, together with other forms of promotion, strengthened the legitimacy of its claims to cure a variety of health problems. By the use of some links to science and a mystical folk belief about the efficacy of the local mineral waters, three spas emerged in St.Catharines: the Stephenson House, the WeIland House, and the Springbank. As the twentieth century approached, the spa movement declined and institutionalized medicine struggled to establish a monopoly on health care. This thesis argues that the health spas in St. Catharines occupied that transitional space in nineteenth century medicine between home remedy and hospital. The interplay between scientific discovery and business enterprise produced a climate in which the Victorian health resort flourished. This phenomenon, combined with the various maladies brought on by industrialization, nineteenth-century lifestyle, and the absence of medical options, created a surge in the popularity of health spas and mineral spring therapies. By the tum of the twentieth century, interest in mineral water treatments had declined. The health resorts that had blossomed between 1850 and 1899 began to experience a serious decrease in business. This popular movement became outmoded in the face of emerging medical and scientific knowledge. In St. Catharines, the last resort to remain standing, the WeIland House, finished out the city's spa era as a hospital.

Our future in geriatrics : an examination of the knowledge, attitudes and career choices of physical therapy students in Ontario : a pretest-posttest study /

There continues to be a shortage of health professionals interested in providing care for the older adult. Part of the problem seems to stem from the negative perceptions of geriatrics as a clinical speciality. This study examines the knowledge, attitudes and career decisions of physical therapy students in Ontario before and after an educational intervention. Surveys were conducted with 144 physical therapy students from five universities before and after their geriatrics course in order to measure their knowledge, attitudes and interest in working with older adults. The incoming class of physical therapy students (n = 1 86) acted as control subjects for the study. The Revised Palmore Facts On Aging Quiz measured the students' knowledge of aging (Miller & Dodder, 1980). The Revised Tuckman-Lorge (Axelrod & Eisdorfer, 1961) and the Kogan Old People Scales (Kogan, 1961) were used to examine attitude. An environmental scale was developed based on the work of Snape (1986) to measure the impact of the working conditions on the students' career choices. A 10-point Likert-type scale based on the work of Michlelutte & Diseker (1985) was modified and used to measure career interest in working with the elderly. On independent sample t-tests, positive attitudes were related to the demographic characteristic of gender; ethnicity was negatively related; and marital status was found to be unrelated to attitude (fi<.05). Having a relationship with an older adult and taking courses in gerontology were also found to be positively related to attitude (fi<.05). Results on a betweensubjects design which compared students before and after the course found that knowledge scores improved from pretest to posttest (fi<.05). In general, attitude scores improved from T1 to T2 on both measurement tools (b<.05). The environmental and vocational interest scales yielded statistically significant differences between the control and experimental groups during the intervention period (p<.05). The results of this research indicated that knowledge and attitudes improve after an educational intervention; however, there was little impact on the students' overall career decisions. Further research is indicated to examine the complex relationship between attitude and behaviour and its impact on students' career choices. In addition, the impact of geriatric clinical environment on students' attitudes and career decisions needs to be further explored.

The use of relaxation therapy as an adjunct to traditional psoriasis therapy /

This research investigated the impact of stress management and relaxation techniques on psoriasis. It had a dual purpose to see if stress management and relaxation techniques, as an adjunct to traditional medical treatment, would improve the skin condition of psoriasis. In addition it attempted to provide psoriasis patients with a sense of control over their illness by educating them about the connection between mind and body through learning stress management and relaxation techniques. The former purpose was addressed quantitatively, while the latter was addressed qualitatively. Using an experimental design, the quantitative study tested the efficacy of stress management and relaxation techniques on 38 dermatological patients from St. John's, Newfoundland. The study which lasted ten weeks, suggested a weak relationship between psoriasis and stress. These relationships were not statistically significant. The qualitative data were gathered through unstructured interviews and descriptive/interpretative analysis was used to evaluate them. Patients in the experimental group believed in the mind body connection as it related to their illness and stress. The findings also showed that the patients believed that the stress reduction and relaxation techniques improved their quality of life, their level of psoriasis, and their ability to live with the condition. Based on the contradictory nature of the findings, further research is needed. It is posited that replication of this study would be vastly improved by increasing the sample size to increase the possibility of significant findings. As wel~ increasing the length of time for the experiment would control for the possibility of a lag effect. Finally, the study looked at linear relationships between stress and psoriasis. Further study should ascertain whether the relationship might be nonlinear

A sequential analysis of therapist scaffolding and child concept formation in narrative therapy

Narrative therapy is a postmodern therapy that takes the position that people create self-narratives to make sense of their experiences. To date, narrative therapy has compiled virtually no quantitative and very little qualitative research, leaving gaps in almost all areas of process and outcome. White (2006a), one of the therapy's founders, has recently utilized Vygotsky's (1934/1987) theories of the zone of proximal development (ZPD) and concept formation to describe the process of change in narrative therapy with children. In collaboration with the child client, the narrative therapist formalizes therapeutic concepts and submits them to increasing levels of generalization to create a ZPD. This study sought to determine whether the child's development proceeds through the stages of concept formation over the course of a session, and whether therapists' utterances scaffold this movement. A sequential analysis was used due to its unique ability to measure dynamic processes in social interactions. Stages of concept formation and scaffolding were coded over time. A hierarchical log-linear analysis was performed on the sequential data to develop a model of therapist scaffolding and child concept development. This was intended to determine what patterns occur and whether the stated intent of narrative therapy matches its actual process. In accordance with narrative therapy theory, the log-linear analysis produced a final model with interactions between therapist and child utterances, and between both therapist and child utterances and time. Specifically, the child and youth participants in therapy tended to respond to therapist scaffolding at the corresponding level of concept formation. Both children and youth and therapists also tended to move away from earlier and toward later stages of White's scaffolding conversations map as the therapy session advanced. These findings provide support for White's contention that narrative therapists promote child development by scaffolding child concept formation in therapy.

The role of intrapartum intravenous therapy and method of delivery on newborn weight loss : challenging the 7% rule

It is common practice to initiate supplemental feeding in newborns if body weight decreases by 7-10% in the first few days after birth (7-10% rule). Standard hospital procedure is to initiate intravenous therapy once a woman is admitted to give birth. However, little is known about the relationship between intrapartum intravenous therapy and the amount of weight loss in the newborn. The present research was undertaken in order to determine what factors contribute to weight loss in a newborn, and to examine the relationship between the practice of intravenous intrapartum therapy and the extent of weight loss post-birth. Using a cross-sectional design with a systematic random sample of 100 mother-baby dyads, we examined properties of delivery that have the potential to impact weight loss in the newborn, including method of delivery, parity, duration of labour, volume of intravenous therapy, feeding method, and birth attendant. This study indicated that the volume of intravenous therapy and method of delivery are significant predictors of weight loss in the newborn (R2=15.5, p<0.01). ROC curve analysis identified an intravenous volume cut-point of 1225 ml that would elicit a high measure of sensitivity (91.3%), and demonstrated significant Kappa agreement (p<0.01) with excess newborn weight loss. It was concluded that infusion of intravenous therapy and natural birth delivery are discriminant factors that influence excess weight loss in newborn infants. Acknowledgement of these factors should be considered in clinical practice.

Dyad function-based cognitive behavioural therapy as a treatment for obsessive compulsive disorder in two school aged children with high functioning autism

Children with High-Functioning Autism (HF A) are more vulnerable to developing Obsessive Compulsive Disorder (OCD) than typically developing children and those with Low-Functioning Autism (Gadow et al., 2005). This study used a multiple baseline design across behaviours (Cooper, Heron, & Heward, 2007) to investigate if a two phase function-based Cognitive Behaviour Therapy (CBT) would decrease obsessive compulsive behaviours (OCBs) in two children ages 7 and 9 who met criteria for OCD and HF A. This multimodal treatment package consisted of treatment enhancements to meet the children's cognitive, linguistic, and social challenges associated with their HF A diagnosis, as well as a manual and accompanied children's workbook (Vause, Neil, & Feldman, in progress). In line with previous research conducted on CBT as a treatment for OCD in this population (e.g., Wood et at, 2009), the children in this study experienced clinically significant decreases in their OCBs as a result of receiving the CBT protocol.

Exploring Perceptions of Accessibility, Necessity and Use of Social Support for Wilderness Therapy Field Instructors

Organizations offering therapeutic wilderness programming have a responsibility to ensure the well-being of their front line employees. A system of social support that is formed through communication with others, either personally or professionally, can assist field instructors in effectively managing the demands arising from their work. Phenomenological analysis of semi-structured interview transcripts from seven participants provided insight on perceptions of necessity, accessibility and use of social support. Fourteen main themes and thirteen subthemes emerged from the data. Findings are presented using the six components of Parsons’ (1980) staff development model and strongly suggest program managers consider and apply specific measures aimed at increasing the social support for front line field instructors in a wilderness therapy work context.