Hoda Mojazi Amiri

Screening for osteoporosis in men aged 70 years and older in a primary care setting in the United States.

Osteoporosis in men is an underrecognized and undertreated condition. Despite the National Osteoporosis Foundation recommending osteoporosis screening in men aged 70 years and older since 2008, screening rates in the United States remain undefined. In our study, we analyzed dual-energy X-ray absorptiometry (DXA) screening rates in a primary care setting. Overall, screening rates were low (11.3%). Although there was an increase with age in both the 10-year osteoporotic and 10-year hip fracture probabilities, no association was found between increased age and bone mineral density testing using DXA. Only 23.2% of patients were prescribed bone protective treatments. The performance of DXA screening strongly predicted prescription of bone protective treatment. Increased age raised the likelihood of bone protective treatment prescriptions; however, smokers were less likely to be prescribed these medications. As the population in the United States ages, an increased awareness of this major public health problem is warranted.

Oropharyngeal flora in patients admitted to the medical intensive care unit: clinical factors and acid suppressive therapy

Acid suppression therapy in critically ill patients significantly reduces the incidence of stress ulceration and gastrointestinal (GI) bleeding; however, recent studies suggest that proton pump inhibitors (PPIs) increase the risk of pneumonia. We wanted to test the hypothesis that acid suppressive therapy promotes alteration in the bacterial flora in the GI tract and leads to colonization of the upper airway tract with pathogenic species, potentially forming the biological basis for the observed increased incidence of pneumonia in these patients. This was a prospective observational study on patients (adults 18 years or older) admitted to the medical intensive care unit (MICU) at a tertiary care centre. Exclusion criteria included all patients with a diagnosis of pneumonia at admission, with infection in the upper airway, or with a history of significant dysphagia. Oropharyngeal cultures were obtained on day 1 and days 3 or 4 of admission. We collected data on demographics, clinical information, and severity of the underlying disease using APACHE II scores. There were 110 patients enrolled in the study. The mean age was 49±16 years, 50 were women, and the mean APACHE II score was 9.8 ± 6.5. Twenty per cent of the patients had used a PPI in the month preceding admission. The first oropharyngeal specimen was available in 110 cases; a second specimen at 72-96 h was available in 68 cases. Seventy-five per cent of the patients admitted to the MICU had abnormal flora. In multivariate logistic regression, diabetes mellitus and PPI use were associated with abnormal oral flora on admission. Chronic renal failure and a higher body mass index reduced the frequency of abnormal oral flora on admission. Most critically ill patients admitted to our MICU have abnormal oral flora. Patients with diabetes and a history of recent PPI use are more likely to have abnormal oral flora on admission.

Pulmonary rehabilitation improves only some domains of health-related quality of life measured by the Short Form-36 questionnaire.

BACKGROUND: Pulmonary rehabilitation (PR) has inconsistent effects on health-related quality of life (HRQL) in patients with chronic lung diseases. We evaluated the effect of PR on HRQL outcomes using the 36-item short form of the medical outcomes (SF-36). METHODS: We retrospectively reviewed the files of all patients who completed PR in 2010, 2011, and first half of 2012. We collected information on demographics, symptoms, pulmonary function tests, 6-minute walk tests (6-MWT), and responses on the SF-36 survey, including the physical component score (PCS) and mental component score (MCS). RESULTS: The study included 19 women and 22 men. The mean age was 69.8 ± 8.5 years. The diagnoses included chronic obstructive pulmonary disease (COPD; n = 31), asthma (n = 3), interstitial lung disease (n = 5), and obstructive sleep apnea (OSA; n = 2). The mean forced expiratory volume-one second (FEV1) was 1.16 ± 0.52 L (against 60.5 ± 15.9% of predicted value). There was a significant improvement in 6-MWT (P < 0.0001). The PCS improved post-PR from 33.8 to 34.5 (P = 0.02); the MCS did not change. CONCLUSION: These patients had low SF-36 scores compared to the general population; changes in scores after PR were low. These patients may need frequent HRQL assessment during rehabilitation, and PR programs should consider program modification in patients with small changes in mental health.

The Repeatability of Gait Speed and Physiological Cost Index Measurements in Working Adults

Objectives: To determine the performance characteristics of gait speed measurements and the physiological cost index (PCI; heart rate change/gait speed) in working adults. Methods: Gait speeds, heart rate changes, andnon–steady state PCIs were calculated in 61 volunteers who worked in our health sciences center. These subjects completed 9 separate 100-foot walk tests in 3 separate sessions. Results: The mean heart rate change after a 100-foot walk was 16.6 ± 8.1 beats per minute. The mean gait speed was 76.1 ± 9.6 meters per minute, and the mean PCI was 0.22 ± 0.11 beats per meter. There were highly significant correlations among all measurements on the 9 separate tests (correlation coefficients 0.41-0.95); gait speed measurements had the highest correlations (0.91-0.95). In a multivariable model hypertension and arthritis were associated with reduced gait speeds. Conclusion: Gait speed, heart rate changes, and non–steady state PCIs have good repeatability when measured over short walks. This information provides a rapid physiological assessment and a method for measuring changes in functional status in healthy subjects and most patients.

Pulmonary Rehabilitation Increases Gait Speed in Patients With Chronic Lung Diseases

Introduction: Gait speed provides an integrated index of physical performance; changes in gait speed could reflect deterioration in the underlying medical disorder or a response to medical/surgical interventions. Slower gait speeds reflect the overall level of impairment, especially in patients with chronic lung disease. Methods: We retrospectively reviewed the medical files of 119 patients who completed the pulmonary rehabilitation program at the University Medical Center in Lubbock, Texas, and collected demographic, pulmonary function, and 6-minute walk test information. Gait speed was calculated using the 6-minute walk test information. Results: The patients in this study had a mean age of 68.8 ± 10.1 years. Most patients (95) had chronic obstructive pulmonary disease/asthma. The mean forced expiratory volume in the first second of expiration (FEV1) was 1.3 ± 0.7 L (47.2% ± 19.7% predicted). The baseline gait speed was 41 ± 15 m/min before rehabilitation and 47 ± 15 m/min after rehabilitation. Baseline gait speed, body mass index, and FEV1 predicted postrehabilitation gait speed (P < .05 for each variable). Ten patients had a gait speed >60 m/min before rehabilitation; this number increased to 29 postrehabilitation. Using multivariable analysis, it was found that only the baseline gait speed predicted a speed of more than 60 m/min postrehabilitation. Seventy-four patients had an increase in 6-minute walk distance of greater than 30 m. Conclusions: Patients with chronic lung diseases have slow gait speeds. Most patients improve their speed with rehabilitation but do not increase their speed above 60 m/min and remain frail by this criterion. However, the majority of patients increase their walk distance by 30 m, a distance that represents a minimal clinically important distance.

Comprehensive and Personalized Care of the Hemodialysis Patient in Tassin, France: A Model for the Patient-Centered Medical Home for Subspecialty Patients

The Centre de Rein Artificiel in Tassin, France, provides comprehensive care to patients with chronic renal disease similar to the model proposed for Patient Center Medical Homes; patients with end-stage renal disease in the Tassin Hemodialysis Center appear to have better outcomes than patients in the United States. These differences likely reflect this centers approach to patient-centered care, the use of longer dialysis times, and focused vascular access care. Longer dialysis times provide better clearance of small and middle toxic molecules, salt, and water; 85% of patients at the Tassin center have a normal blood pressure without the use of antihypertensive medications. The observed mortality rate in patients at the Tassin Center is approximately 50% of that predicted based on the United States Renal Data system standard mortality tables. Patient outcomes at the Tassin center suggest that longer dialysis times and the use of multidiscipline teams led by nephrologists directing all health care needs probably explain the outcomes in these patients. These approaches can be imported into the U.S healthcare system and form the framework for patient-centered medical practice for ESRD patients.

Poor Compliance Makes Treatment of Latent Tuberculosis Infection Unsatisfactory

Objectives: The recommended treatment for latent tuberculosis infection is isoniazid for 9 months, but this regimen has a low completion rate. The authors wanted to compare treatment with isoniazid and treatment with isoniazid and rifampin in the typical public health setting in a large diverse state and recover as much information as possible from a state database. Methods: Patients who received latent tuberculosis infection treatment were identified in the Texas Department of State Health Services database for the years 1995-2002. Treatment completion, adverse reactions, and disease development were recorded. Results were analyzed using logistic regression to predict disease development. Results: In sum, 50 578 patients received isoniazid, and 280 received isoniazid/rifampin. Sixty-one percent of the isoniazid group and 54% of the isoniazid/rifampin group completed treatment. Eighteen percent of the isoniazid/rifampin group possibly had adverse reactions and discontinued treatment; 3% of the isoniazid group discontinued therapy because of side effects. More than 70% of patients with adverse reactions in the isoniazid/rifampin group took the treatment for more than 4 months. Overall, 168 patients in the isoniazid group with a normal chest X-ray and a positive skin test developed tuberculosis during follow-up to 2008; no patients in the isoniazid/rifampin group who had a normal X-ray and completed chemoprophylaxis developed tuberculosis during follow-up. Conclusions: The isoniazid/rifampin regimen appears to be as effective as the isoniazid regimen. However, completion rates on combination therapy were slightly lower. This regimen needs more formal clinical study since it has the potential to decrease administrative costs and improve completion rates. In addition, state departments of health need to develop networks using community-based resources to reach patients and increase completion rates.

2009 H1N1 Influenza Infection-Related Hospital Admissions: A Single Center Experience with Adult Patients in West Texas

Background. Clinical information collected during the first wave of influenza pandemics may provide important projections about disease activity during subsequent waves. Methods. We performed a retrospective study of hospitalized patients with 2009 H1N1 influenza infection during the second wave and compared our findings with literature reports from the first wave. Results. There were 31 admissions, including 15 to the intensive care unit (ICU). Twenty-five patients (81%) had at least one chronic medical condition; 12 patients (39%) were obese. Thirty-three percent of the ICU patients and 75% of the non-ICU patients were admitted within 48 hours of symptom onset (𝑃=0.03). Infiltrates on CXR were seen in 60% of the ICU group and 19% of the non-ICU group within 48 hours of admission (𝑃=0.03). Forty-three percent of the ICU patients and 71% of the non-ICU patients received oseltamivir within 48 hours of illness. All non-ICU patients survived; 73% of the ICU patients survived (𝑃=0.043). Conclusions. Our patients in the second wave resembled patients reported from the first wave of the 2009 pandemic and had similar mortality rates. Delayed medical attention possibly explains the high number of ICU admissions in our study.