John A. Merenich

Endocrine profiles for outcome prediction from the intensive care unit

ObjectiveTo evaluate the discriminating ability of various specific endocrine studies on patient outcome from the intensive care unit (ICU). DesignProspective cohort study of patients requiring intensive care. SettingAdult medical and coronary care units in a military referral hospital. PatientsA total of 61 consecutive patients requiring intensive care over a 5-month period and 20 control subjects. InterventionsPatients were evaluated within 24 hrs of ICU admission (day 1) with determination of the following variables: serum triiodothyronine, thyroxine, triiodothyronine resin uptake, thyrotropin, luteinizing hormone, follicle-stimulating hormone, testosterone, basal cortisol, adrenocorticotropic hormone-stimulated cortisol, cortisol increment, and Acute Physiology and Chronic Health Evaluation (APACHE II) score. A total of 24 hrs later (day 2), the same battery of tests was repeated with the exception of the adrenocorticotropic hormone-stimulated cortisol, cortisol increment, and APACHE II score. Individual variables were compared between survivors and nonsurvivors. Measurements and Main ResultsThe best discriminators of patient outcome in descending order were the basal serum cortisol and triiodothyronine concentrations obtained on day 2 and the APACHE II score with predictive abilities of 81%, 74%, and 70%, respectively. No combination of variables was superior to the day 2 basal cortisol concentration for discrimination of outcome. ConclusionsThe basal cortisol and triiodo thyronine concentrations obtained from blood samples collected within 48 hrs of ICU admission appear to be better discriminators of patient outcome than the APACHE II score. (Crit Care Med 1993; 21:543–550)

Effects of a brief computer-assisted diabetes self-management intervention on dietary, biological and quality-of-life outcomes

Objective: There is a need for practical, efficient and broad-reaching diabetes self-management interventions that can produce changes in lifestyle behaviours such as healthy eating and weight loss. The objective of this study was to evaluate such a computer-assisted intervention. Methods: Type 2 diabetes primary care patients (n=335) from fee-for-service and health maintenance organization settings were randomized to social cognitive theory-based tailored self-management (TSM) or computer-aided enhanced usual care (UC). Intervention consisted of computer-assisted self-management assessment and feedback, tailored goal-setting, barrier identification, and problem-solving, followed by health counsellor interaction and follow-up calls. Outcomes were changes in dietary behaviours (fat and fruit/vegetable intake), haemoglobin A1c (HbA1c), lipids, weight, quality of life, and depression. Results: TSM patients reduced dietary fat intake and weight significantly more than UC patients at the 2-month follow-up. Among patients having elevated levels of HbA1c, lipids or depression at baseline, there were consistent directional trends favouring intervention, but these differences did not reach significance. The intervention proved feasible and was implemented successfully by a variety of staff. Conclusions: This relatively low-intensity intervention appealed to a large, generally representative sample of patients, was well implemented, and produced improvement in targeted behaviours. Implications of this practical clinical trial for dissemination are discussed.

Mortality Reduction Benefits of a Comprehensive Cardiac Care Program for Patients with Occlusive Coronary Artery Disease

Study Objective. To determine the effect of early and sustained enrollment in a comprehensive cardiac care (CCC) program on all‐cause mortality in patients with coronary artery disease (CAD).

Low Myopathy Rates Associated with Statins as Monotherapy or Combination Therapy with Interacting Drugs in a Group Model Health Maintenance Organization

Study Objective. Because the risk for myopathy increases when 3‐hydroxy‐3‐methylglutaryl coenzyme A inhibitors (statins) are used with other agents known to inhibit cytochrome P450 3A4 in patients with dyslipidemia, we sought to quantify this risk in a diverse, real‐world sample of patients receiving statin therapy.

Azidothymidine-Induced Hyperpigmentation Mimicking Primary Adrenal Insufficiency

N ail hyperpigmentation has recently been reported in patients taking zidovudine (formerly called azidothymidine [AZT]) [1,2]. In addition to progressive nail changes, we observed diffuse macular skin lesions and oral mucosal hyperpigmented patches in a patient being treated with oral AZT. These lesions mimicked those seen in primary adrenal insufficiency and prompted empiric corticosteroid therapy until adequate adrenal function was documented.

Coronary Artery Disease and Hypertension: Outcomes of a Pharmacist‐Managed Blood Pressure Program

Study Objective. To assess the effectiveness of a pharmacist‐managed service in improving hypertension control among patients with coronary artery disease.

Collaborative Cardiac Care Service: A Multidisciplinary Approach to Caring for Patients with Coronary Artery Disease

BACKGROUND Coronary artery disease (CAD) remains the leading cause of death in the US. In 1996, Kaiser Permanente of Colorado (KPCO) developed the Collaborative Cardiac Care Service (CCCS) with the goal of improving the health of patients with CAD. DESCRIPTION CCCS consists of a nursing team (the KP Cardiac Rehabilitation program) and a pharmacy team (the Clinical Pharmacy Cardiac Risk Service). CCCS works collaboratively with patients, primary care physicians, cardiologists, and other health care professionals to coordinate proven cardiac risk reduction strategies for patients with CAD. Activities such as lifestyle modification, medication initiation and adjustment, patient education, laboratory monitoring, and management of adverse events are all coordinated through CCCS. The CCCS uses an electronic medical record and patient-tracking software to document all interactions with patients, track patient appointments, and collect data for evaluation of both short- and long-term outcomes. OUTCOMES The CCCS currently follows over 12,000 patients with CAD. The CCCS has demonstrated improvement in surrogate outcomes including: cholesterol screening (55% to 96.3%), the proportion of patients with a goal of low-density lipoprotein cholesterol (LDL-c) <100 mg/dL (22% to 76.9%), and has reduced the average LDL-c to 78.3 mg/dL for the CAD population it follows. The CCCS has shown a reduction in all-cause mortality associated with CAD by 76% in the patients followed by the service. Patient and physician satisfaction have been high with CCCS. CONCLUSION The CCCS coordinates many aspects of cardiac risk reduction care resulting in excellent continuity of care. The CCCS has continued to grow and expand the number of patients enrolled by using innovative strategies and technology and has resulted in excellent care and improved outcomes of the CAD population at KPCO.

Correlation of liver density by magnetic resonance imaging and hepatic iron levels. A noninvasive means to exclude homozygous hemochromatosis.

The diagnosis of hemochromatosis requires liver biopsy and the quantification of hepatic iron. Magnetic resonance imaging (MRI) of the liver shows a characteristic decrease in tissue signal intensity in iron overload states, but its role in the diagnosis of hemochromatosis has not been fully delineated. Forty-three patients (31 men and 12 women) were referred for the evaluation of hemochromatosis based upon a fasting transferrin saturation > 55% and/or a serum ferritin > 400 ng/ml in males or > 300 ng/ml in females. Each patient prospectively underwent MRI of the liver prior to percutaneous liver biopsy and quantitative hepatic iron determination. Homozygous hemochromatosis was diagnosed in 10 patients based upon an hepatic iron/age index > or = 2. MRI was performed with a 1.5 Tesla system using standard spin-echo sequences (T1; TR = 300-500 ms, TE = 13-17 ms, PD; TR = 2,000-2,600 ms, TE = 30 ms). Signal intensity values were blindly determined for regions of interest in liver and skeletal muscle at T1 and proton density. Ratios of liver to muscle (LM) for T1 and proton density (PD) calculated from these values showed a significant correlation with quantitative iron by multiple regression analysis. The LMPD ratio provided the best correlation with hepatic iron (r = -0.6946; p < 0.001). Linear regression analysis also provides an equation that can be used to predict hepatic iron based upon the LMPD ratio; micrograms/g of hepatic iron = (-5,174 x LMPD) + 9,932. All patients with LMPD ratios of > 0.5 had hepatic iron/age indices of < 2.0, thereby excluding homozygous hemochromatosis. These results suggest that LMPD ratios derived from MRI of the liver can accurately predict hepatic iron content. These ratios can be clinically useful in the evaluation of hemochromatosis among patients who either refuse or have contraindications to liver biopsy.

Transient isolated thyrotropin deficiency in the postpartum period

Report of a woman in the postpartum period in whom an isolated deficiency of thyrotropin (TSH) resulted in transient hypothyroidism

Reduced Health Care Expenditures After Enrollment in a Collaborative Cardiac Care Service

Study Objective. To assess the impact of a collaborative cardiovascular risk reduction service (Collaborative Cardiac Care Service [CCCS]) on total health care expenditures after an incident acute coronary event.