Jeffrey D. Kravetz

Association of Psoriasis With Coronary Artery, Cerebrovascular, and Peripheral Vascular Diseases and Mortality

OBJECTIVE To examine the cardiovascular risk factors in patients with psoriasis and the association between psoriasis and coronary artery, cerebrovascular, and peripheral vascular diseases. DESIGN Observational study. SETTING Large Department of Veterans Affairs hospital. PATIENTS The study included 3236 patients with psoriasis and 2500 patients without psoriasis (controls). MAIN OUTCOME MEASURES Using International Classification of Diseases, Ninth Revision, Clinical Modification, codes, we compared the prevalence of traditional cardiovascular risk factors and other vascular diseases as well as mortality between patients with psoriasis and controls. RESULTS Similar to previous studies, we found a higher prevalence of diabetes mellitus, hypertension, dyslipidemia, and smoking in patients with psoriasis. After controlling for these variables, we found a higher prevalence not only of ischemic heart disease (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.51-2.11) but also of cerebrovascular (OR, 1.70; 95% CI, 1.33-2.17) and peripheral vascular (OR, 1.98; 95% CI, 1.32-2.82) diseases in patients with psoriasis compared with controls. Psoriasis was also found to be an independent risk factor for mortality (OR, 1.86; 95% CI, 1.56-2.21). CONCLUSIONS Psoriasis is associated with atherosclerosis. This association applies to coronary artery, cerebrovascular, and peripheral vascular diseases and results in increased mortality.

Prevention of toxoplasmosis in pregnancy: knowledge of risk factors.

BACKGROUND: Infection with Toxoplasma gondii is common and usually asymptomatic, although it can have catastrophic consequences in a pregnant woman if passed to her developing fetus. Counseling of pregnant women about risk factor reduction may reduce the risk of congenital toxoplasmosis. This study was undertaken to assess and compare the knowledge of obstetricians and internists or family practitioners regarding well-established risk factors for toxoplasmosis infection. METHODS: The study surveyed 102 obstetricians, internists and family practitioners to assess their knowledge of risk factors for toxoplasmosis infection as well as their practices for primary prevention counseling of pregnant women. Responses were analyzed for differences. RESULTS: Obstetricians were more likely than internists or family practitioners to provide appropriate counseling on reducing the two most common risk factors for toxoplasmosis infection (undercooked meat consumption and gardening without gloves). However, over one quarter of all participants inappropriately advised pregnant women to avoid all cat contact. Obstetricians, internists and family practitioners were all likely to fail to identify undercooked meat consumption as the primary risk factor for toxoplasmosis transmission. CONCLUSIONS: Obstetricians appear to provide more appropriate counseling for primary prevention of toxoplasmosis than internists and family practitioners, but both groups of physicians inappropriately advised avoidance of all cat contact. Education of obstetricians, internists and family practitioners on risk factors for toxoplasmosis transmission is needed and may lower the rate of congenital toxoplasmosis as well as decrease the frequency of cat abandonment during pregnancy.

Organizational factors associated with readiness to implement and translate a primary care based telemedicine behavioral program to improve blood pressure control: the HTN-IMPROVE study

BackgroundHypertension is prevalent and often sub-optimally controlled; however, interventions to improve blood pressure control have had limited success.ObjectivesThrough implementation of an evidence-based nurse-delivered self-management phone intervention to facilitate hypertension management within large complex health systems, we sought to answer the following questions: What is the level of organizational readiness to implement the intervention? What are the specific facilitators, barriers, and contextual factors that may affect organizational readiness to change?Study designEach intervention site from three separate Veterans Integrated Service Networks (VISNs), which represent 21 geographic regions across the US, agreed to enroll 500 participants over a year with at least 0.5 full time equivalent employees of nursing time. Our mixed methods approach used a priori semi-structured interviews conducted with stakeholders (n = 27) including nurses, physicians, administrators, and information technology (IT) professionals between 2010 and 2011. Researchers iteratively identified facilitators and barriers of organizational readiness to change (ORC) and implementation. Additionally, an ORC survey was conducted with the stakeholders who were (n = 102) preparing for program implementation.ResultsKey ORC facilitators included stakeholder buy-in and improving hypertension. Positive organizational characteristics likely to impact ORC included: other similar programs that support buy-in, adequate staff, and alignment with the existing site environment; improved patient outcomes; is positive for the professional nurse role, and is evidence-based; understanding of the intervention; IT infrastructure and support, and utilization of existing equipment and space.The primary ORC barrier was unclear long-term commitment of nursing. Negative organizational characteristics likely to impact ORC included: added workload, competition with existing programs, implementation length, and limited available nurse staff time; buy-in is temporary until evidence shows improved outcomes; contacting patients and the logistics of integration into existing workflow is a challenge; and inadequate staffing is problematic. Findings were complementary across quantitative and qualitative analyses.ConclusionsThe model of organizational change identified key facilitators and barriers of organizational readiness to change and successful implementation. This study allows us to understand the needs and challenges of intervention implementation. Furthermore, examination of organizational facilitators and barriers to implementation of evidence-based interventions may inform dissemination in other chronic diseases.

Vogt-Koyanagi-Harada Syndrome and Ulcerative Colitis

The Vogt-Koyanagi-Harada (VKH) syndrome is an uncommon disorder characterized by uveitis and neurologic and cutaneous abnormalities, including tinnitus, vertigo, headache, meningoencephalitis, vitiligo, alopecia, and poliosis. The VKH syndrome has been reported to occur in association with other autoimmune disorders. We report a case of a patient with severe ulcerative colitis who developed VKH syndrome. We postulate that the patient’s history of a traumatic brain injury might have been responsible for an abnormal “immunologic milieu” and the occurrence of ulcerative colitis, VKH syndrome, and severe reactive arthritis.

Valproic acid-induced eosinophilic pleural effusion.

Valproic acid is a carboxylic acid used for the treatment of both seizure and mood disorders. Its association with pleural fluid eosinophilia has been reported once in the English language literature. We present another case of valproic acid-induced pleural fluid eosinophilia associated with fever and peripheral blood eosinophilia. Extensive evaluation failed to reveal any other cause of eosinophilic pleural effusion, and the effusion resolved with discontinuance of valproic acid. Rechallenge with valproic acid produced recurrent symptoms. Valproic acid should be considered a possible cause of eosinophilic pleural effusion.

Are Screening Guidelines for Abdominal Aortic Aneurysms Being Implemented within a Large VA Primary Health Care System

Abstract Background: Screening men aged 65 to 75 years who have ever smoked for abdominal aortic aneurysm (AAA) has been recommended to reduce AAA-related mortality. However, it is unknown whether the evidence-based recommendation has been implemented within primary care. Objective: The aim of this study was to determine whether screening for AAA is being performed within a large Veterans Affairs (VA) primary health care system. Methods: This was a retrospective cohort study examining AAA screening practices within the VA Connecticut Healthcare System. Any of the following imaging procedures were considered screening tests for AAA: abdominal ultrasound, computed tomography (CT) of the abdomen, CT colography, or magnetic resonance imaging of the abdomen. Results: A total of 279 patients were included in the cohort: 83 (30%) were offered screening for AAA or had recent imaging performed that would have allowed for detection of an AAA. Seventy-three patients (26%) underwent AAA screening or had recent imaging of their abdomens, while 10 patients either refused imaging or were awaiting ultrasonographic screening at the time of this study. Of the 73 patients who had undergone screening or other abdominal imaging evaluations, 9 (12.3%) were found to have AAAs. Conclusions: There appears to be a low rate of screening for AAA within 1 primary care setting in a large VA health care system. If this finding is replicated within other VA primary health care settings, then the VA health care system should consider implementing a performance metric within primary care to improve AAA screening rates.

Patient gender affects skin cancer screening practices and attitudes among veterans.

Background: Skin cancer screening (SCS) with a full body skin examination (FBSE) has the potential to reduce morbidity and mortality. Little is known about gender differences with respect to SCS practices and attitudes between men and women. Methods: Data from two previously published studies based on questionnaires administered to veterans were combined and analyzed according to patient gender. The participants consisted of a convenience sample of 437 patients awaiting primary care, women’s health, or dermatology clinic appointments at the West Haven Veterans Affairs Medical Center. Results: Male veterans were more likely to report undergoing FBSE than female veterans (32 versus 18%), but less likely to perform self-examination (42 versus 48%). Female veterans were more likely to report embarrassment than men, but both genders expressed that providers who perform SCS are thorough. Gender discordance between patient and examining physician is more likely to lead to refusal for women than men (16 versus 2%). Conclusion: We found low rates of SCS in both male and female veterans in different clinic settings at a Veterans Affairs Medical Center. Female veterans are less likely to report undergoing FBSE and more likely than male veterans to perform self-examination for skin cancer, to report embarrassment with FBSE, and refuse FBSE if the examining physician is of the opposite gender.

Improving Diabetes Control Using Shared Medical Appointments

The management of diabetes mellitus is often complex and requires significant self-management skills. The American Diabetes Association recommends that patients with diabetes receive self-management education and support. Effectively teaching patients to apply self-management skills poses a significant challenge. To varying degrees, patients with diabetes often need to use healthy eating recommendations, self-monitoring of blood glucose, adherence to medication regimens that include oral or injectable agents, and attendance to specialist appointments. A shared medical appointment is a format for healthcare delivery that allows patients to relate their experiences with others who share similar circumstances and challenges. In addition, shared medical appointments allow patients to access an interdisciplinary team in a short period of time. Several controlled studies have demonstrated benefits of shared medical appointments in improving diabetes-related end points compared with usual care. We sought to assess the effectiveness of implementation of a diabetes group shared medical appointment in a veteran population.

Improving Human Immunodeficiency Virus Testing Rates with an Electronic Clinical Reminder

Human immunodeficiency virus (HIV) is a major global public health problem. In the United States alone, 1 to 1.18 million people are affected, of whom approximately one quarter are unaware of their diagnosis. In the early stage of the epidemic, when effective therapy was not available, testing for HIV was done primarily to protect the nation’s blood supply. However, with the advent of highly active antiretroviral therapy, HIV is highly treatable, and those infected can live longer. Because more than one third of patients diagnosed with HIV are diagnosed with acquired immunodeficiency syndrome within 1 year after diagnosis, it is likely that many patients are infected for many years before diagnosis. Furthermore, beause approximately 20,000 new infections in the United tates are transmitted by people unaware of their HIV positive tatus, early detection of HIV has the potential to decrease ew infections and prevent complications from advanced disase and has been shown to be cost-effective. The Centers for Disease Control and Prevention recommends offering routine screening for HIV in health care settings for all patients aged 13 to 64 years, unless the prevalence of undiagnosed infection has been documented to be less than 0.1%.

Team-Based Hypertension Management to Improve Blood Pressure Control.

Objective: Hypertension is the most common condition seen in primary care, occurring in 1 in 3 adults in the United States. The patient-centered medical home provides an opportunity for proactive, team-based care of hypertension. The purpose of this pilot study was to measure the effectiveness of a team-based approach to blood pressure management in a busy, primary care setting. Methods: Using panel management within 2 primary care clinics, a cohort of patients with blood pressures >160/100 mm Hg, was identified. The patients at 1 clinic were contacted by the primary care team and offered multiple interventions aimed at improving blood pressure control; including discussion of medication compliance, medication titration, home blood pressure monitoring, nutritional counseling, and motivational interviewing. The change in blood pressure for these patients at 4 months was compared to a parallel primary care clinic within the same medical center whose patients were treated with usual primary care. Results: A total of 350 and 315 patients were included in the intervention and usual care cohorts, respectively. At 4 months, the decrease of systolic blood pressure in the intervention group was significantly greater than in the usual care group (15.6 vs 9.9 mm Hg; P < .001). Sixty-two percent of patients in the intervention group had lower systolic blood pressures post intervention, compared with 41% of usual care patients (P < .001). Reduction in diastolic blood pressure occurred in 54% of intervention patients, compared with 37% of usual care patients (P < .001). Conclusions: Our findings demonstrate the effectiveness of a team-based approach to blood pressure management. This can provide a framework for implementation of team-based care for hypertension in the patient-centered medical home.