Carlos Palacio

Black cohosh for the management of menopausal symptoms : a systematic review of clinical trials.

Alternative medicine preparations represent a significant industry worldwide. Black cohosh (Cimicifuga racemosa), a buttercup plant grown in North America, is one such popular preparation for the treatment of menopausal symptoms. Because the proportion of women experiencing climacteric symptoms is high, black cohosh merits further study as to its efficacy and safety. Convincing evidence for its efficacy in this setting remains to be demonstrated. The purpose of this systematic review was to assess the current literature on the benefits of black cohosh for women experiencing climacteric symptoms. To this end, a PubMed search was conducted on 1 November 2007 using the search terms ‘black cohosh’ AND ‘menopause’. The search was limited to randomized controlled trials in the English language involving adults. Several additional reviews dealing with alternative therapies for menopause were included to capture additional older and non-English language literature. Ultimately, 16 studies eligible for review were identified. Many of the studies had conflicting results. Methodological flaws included lack of uniformity of the drug preparation used, variable outcome measures and lack of a placebo group. The benefits of black cohosh in the management of climacteric symptoms remain to be proven. Case studies suggest an additional unexplored area of adverse events that also needs to be addressed.

Benchmarking electronic medical records initiatives in the US: a conceptual model.

This article provides a conceptual model for benchmarking the use of clinical information systems within healthcare organizations. Additionally, it addresses the benefits of clinical information systems which include the reduction of errors, improvement in clinical decision-making and real time access to patient information. The literature suggests that clinical information systems provide financial benefits due to cost-savings from improved efficiency and reduction of errors. As a result, healthcare organizations should adopt such clinical information systems to improve quality of care and stay competitive in the marketplace. Our research clearly documents the increased adoption of electronic medical records in U.S. hospitals from 2005 to 2007. This is important because the electronic medical record provides an opportunity for integration of patient information and improvements in efficiency and quality of care across a wide range of patient populations. This was supported by recent federal initiatives such as the establishment of the Office of the National Coordinator of Health Information Technology (ONCHIT) to create an interoperable health information infrastructure. Potential barriers to the implementation of health information technology include cost, a lack of financial incentives for providers, and a need for interoperable systems. As a result, future government involvement and leadership may serve to accelerate widespread adoption of interoperable clinical information systems.

Increasing Access to Health Care Providers Through Medical Home Model May Abolish Racial Disparity in Diabetes Care: Evidence From a Cross-sectional Study

OBJECTIVES We hypothesized that the medical home model is an effective intervention to decreasing health care disparities in minority patients with diabetes. SETTING Set in a community-based health initiative in Jacksonville, Florida, the studys mission was to support and enhance the primary care infrastructure in an effort to improve quality of care and increase access while reducing costs. INTERVENTION We preformed a retrospective analysis of outcomes on 457 patients identified by registry specialists and enrolled in the diabetes rapid access program (DRAP). Data were obtained on 457 diabetic patients enrolled in the 6 clinic centers of the program between June 1, 2006, and December 31, 2009. MAIN OUTCOME MEASURES Improvements in hemoglobin A1c and proportion of patients with hemoglobin A1c of more than 8% according to gender, race, and clinic location. RESULTS The average hemoglobin A1c at the beginning of the study was 8.2% (+/-2.3), and decreased significantly by an average of 0.5% (p<.005). The mean improvement in hemoglobin A1c did not differ significantly by clinic location, race, or gender. Both African American and Caucasian patients as well as men and women with a hemoglobin A1c of at least 8% showed a significant improvement in their A1c after the intervention (p<.005). CONCLUSIONS The DRAP medical home model presents an opportunity to decrease disparities in care and improve diabetes care.

Gender variation in oesophageal motor function: analysis of 129 healthy individuals.

BACKGROUND Oesophageal manometry is the standard for diagnosis of oesophageal motor disorders. Minimal data exist assessing the effect of gender on normal oesophageal manometry values. AIM Evaluate the impact of gender on normal oesophageal manometry values. METHODS Healthy volunteers were recruited from the Jacksonville metropolitan area. Exclusion criteria were symptoms suggestive of oesophageal disease, medication use or concurrent illness that could affect oesophageal manometry. All underwent oesophageal manometry using a solid-state system with wet swallows. RESULTS Sixty-three males and 66 females were enrolled. All completed oesophageal manometry without difficulty. Resting lower oesophageal sphincter pressure, distal oesophageal contraction duration and distal oesophageal body contraction amplitude values were significantly higher in females while distal oesophageal body contraction velocity was significantly lower in females (p<0.05). No differences were seen in other oesophageal manometry parameters. CONCLUSION Significant gender differences exist in normal oesophageal manometry. Gender-specific reference values for oesophageal manometry are needed for accurate diagnosis of oesophageal motility disorders.

Do HbA1C Levels Correlate With Delayed Gastric Emptying in Diabetic Patients

Background/Aims Gastroparesis is characterized by delayed gastric emptying without obstruction. Diabetes is frequently associated with poor glycemic control and delayed gastric emptying. Gastric emptying scintigraphy (GES) is the standard for measuring gastric emptying. Serum hemoglobin A1C (HbA1C) measures prolonged glycemic control with normal as < 7% glycated. To date, no correlation of serum HbA1C level with gastric emptying, demonstrated by GES, in diabetics has been performed. The aim of the present investigation is to determine if a relationship exists between serum HbA1C levels and gastric emptying, assessed by GES, in diabetics. Methods All diabetics, having both GES and serum HbA1C level within 3 months from July 1, 2003 - June 30, 2008 were eligible for study. Demographic data collected included gender, age and ethnicity. Abnormal gastric emptying was defined as T½ > 120 minutes and serum HbA1C as percent glycated. Results Nuclear Medicine GES database review revealed 431 examinations performed during the study interval. A total of 181 were not eligible due to the following: 29 duplicates, 22 diabetes not documented and 130 without HbA1C levels, resulting a study group of 250 cases. No significant correlation was observed between gastric emptying time, HbA1C or age. Among patients with HbA1C ≥ 7%, HbA1C was inversely related to age with a coefficient of correlation of r = -0.175 (p = 0.038). Conclusions There is no correlation observed between gastric emptying time, using GES, and serum HbA1C levels. In diabetics, serum HbA1C is not as important as daily glycemic control regarding gastric emptying.

A comparative study of unscheduled hospital readmissions in a resident-staffed teaching service and a hospitalist-based service.

Background: The rate of unscheduled readmissions is an important quality indicator with financial implications for hospitals. Objective: To determine if resident-staffed services have more favorable outcomes compared to hospitalist services, predictors of readmissions were determined within an academic hospital. Methods: From November 1, 2006 to April 30, 2007, 5943 admissions were assigned to a resident-staffed teaching service (n = 2244) or to a hospitalist-based service (n = 3699). Data on age, race, sex, insurance status, case mix index (CMI), length of stay (LOS), and unscheduled hospital readmission within 30 days were analyzed. Results: Patients admitted to the hospitalist service were older and more likely to be female compared with those admitted to the teaching service. There were no significant differences in the health care insurance carrier of the patients admitted to the two services. The rate of unscheduled hospital readmissions within 30 days was significantly higher in the teaching service compared to the hospitalist service (14.1% vs 10.4%; P < 0.001). LOS was significantly higher (4.95 ± 7.77 vs 4.14 ± 5.95; P < 0.001), and the CMI was significantly lower (1.04 ± 0.94 vs 1.14 ± 1.02; P < 0.001) in the hospitalist service compared to the resident-staffed service. Probability of readmission was significantly reduced with increasing LOS and discharge home with self care. Conclusions: The modestly increased unscheduled readmission rate to the resident-staffed service compared to the hospitalist service may be related to lower LOS. Increased CMI of patients in the resident service may have contributed to the increased rate of readmissions.

Collet-sicard syndrome : An uncommon manifestation of metastatic prostate cancer

Metastatic spread of prostate adenocarcinoma to the temporal bone is very rare. Involvement of the jugular foramen may result in Collet-Sicard syndrome. This syndrome is characterized by paralysis of the lower four cranial nerves. A case of metastatic prostate adenocarcinoma involving the temporal bone causing Collet-Sicard syndrome is presented. This case highlights an uncommon manifestation of prostate adenocarcinoma causing symptoms referable to the occipital condyle of the temporal bone. Few cases have been reported in the literature of Collet-Sicard syndrome due to metastatic prostate cancer. This case reminds readers that awareness of atypical presentations may reduce diagnostic delay and expedite appropriate treatment.

Gram-negative versus Gram-positive bacteremia: what is more alarmin(g)?

Gram-negative bacteremia has been associated with severe sepsis, although the exact mechanism and pathophysiological differences among bacterial species are not well understood. In the previous issue of Critical Care, Abe and colleagues report results of a retrospective study that show a significantly higher incidence of Gram-negative bacteremia among adult intensive care unit patients with septic shock than in those with sepsis or severe sepsis. In this study, C-reactive protein and IL-6 levels were significantly higher in Gram-negative bacteremia than in Gram-positive bacteremia. These observations suggest a distinct immunopathophysiologic behavior of sepsis in patients with Gram-negative bacteremia that may influence clinical outcomes. Future research exploring new biomarkers and danger signals and further characterizing differences in the virulence mechanisms between Gram-negative and Gram-positive bacteria appears promising and could lead to new therapeutics and to improved clinical outcomes.

Relative Merits of Low-Carbohydrate Versus Low-Fat Diet in Managing Obesity.

Objectives Although low-fat diets (LFD) have been the cornerstone of dietary guidelines for weight reduction, low-carbohydrate diets (LCD) continue to gain attention and popularity. Which diet can achieve significant and sustainable weight loss in unclear, however. Our objective in this study was to compare LCDs with LFDs and their impact on weight loss. Methods We performed a MEDLINE/PubMed search for English-language articles of randomized controlled studies conducted with adults who were overweight or obese for at least 6 months for the time period of January 2001–October 2014. Two reviewers independently abstracted data, including participants’ characteristics, diet composition and duration, and change in weight from baseline at 6 and 12 months. Results A total of 17 studies were analyzed. At 6 months, the mean weight loss for participants on an LCD was −1.439 kg (95% confidence interval −2.319 to −0.558) compared with participants on an LFD (P < 0.001). At 12 months, the difference was smaller, −0.769 kg (95% confidence interval −1.361 to −0.178) but remained statistically significant (P < 0.010). The mean difference in the weight loss between the two diets was attenuated over time. Conclusions Reducing carbohydrate intake may help patients achieve weight loss. The mean difference in weight change between an LCD and an LFD was too small to have a meaningful impact on weight loss. More studies are needed to better elucidate the role of LCDs in weight loss efforts.

Resource-based relative value scale analysis between teaching and nonteaching hospitalist services.

Background: Resource-based relative value scale is an objective estimate of physician work that allows comparisons of physician productivity, yet few studies have explored its use to compare the productivity between teaching faculty and nonteaching hospitalists. Methods: Demographic and billing data of patients assigned either to a resident-staffed teaching service or a hospitalist service, the number of encounters per provider, relative value units (RVUs) generated, and total charges were obtained from billing records (November 2006-April 2007). Age, race, sex, insurance status, case mix index, and length of stay were also analyzed. Results: The mean RVUs generated per unit of encounter and the mean charges generated per unit of encounter were not significantly different between the 2 services. However, mean RVUs generated per full-time equivalent provider and mean charges generated per clinical full-time equivalent were significantly higher in the teaching service. Conclusions: Based on a resource-based relative value scale analysis, the clinical productivity of teaching faculty was superior to that of nonteaching hospitalists. The difference may be attributable to lower time requirements of the teaching attendings compared with full-time hospitalists.