Mary Mullen

Web-based Collaborative Care for Type 2 Diabetes: a Pilot Randomized Trial

OBJECTIVE—To test Web-based care management of glycemic control using a shared electronic medical record with patients who have type 2 diabetes. RESEARCH DESIGN AND METHODS—We conducted a trial of 83 adults with type 2 diabetes randomized to receive usual care plus Web-based care management or usual care alone between August 2002 and May 2004. All patients had GHb ≥7.0%, had Web access from home, and could use a computer with English language–based programs. Intervention patients received 12 months of Web-based care management. The Web-based program included patient access to electronic medical records, secure e-mail with providers, feedback on blood glucose readings, an educational Web site, and an interactive online diary for entering information about exercise, diet, and medication. The primary outcome was change in GHb. RESULTS—GHb levels declined by 0.7% (95% CI 0.2−1.3) on average among intervention patients compared with usual-care patients. Systolic blood pressure, diastolic blood pressure, total cholesterol levels, and use of in-person health care services did not differ between the two groups. CONCLUSIONS—Care management delivered through secure patient Web communications improved glycemic control in type 2 diabetes.

A multifaceted intervention in support of diabetes treatment guidelines: a cont trial

OBJECTIVE in an academic family practice clinic, we performed a controlled trial of a multifaceted intervention versus usual care for managing diabetes. Providers received didactic training and computerized compliance feedback to support staged diabetes management, an evidenced-based approach to diabetes care. RESEARCH DESIGN AND METHODS one firm of the clinic practice received the intervention, the other served as the control group during a 14-month baseline period and a 14-month study period. HbA1(c) was the principal outcome measure. RESULTS there was a significant 0.71% difference in change in HbA1(c) values between the intervention and control firms (P=0.02). The subgroup with the greatest improvement in HbA1(c) was those subjects who started the intervention with a HbA1(c) above 8%. The overall improvement in glycemic control could not be explained by differences in visit frequency or the aggressiveness of drug therapy. There were no changes in healthcare utilization or costs between the two firms. CONCLUSION in an academic family practice clinic, a multifaceted intervention in support of diabetes treatment guidelines modestly improved glycemic control without incurring additional costs. The improvement was mostly due to mitigation of the natural deterioration in control usually seen. Further efforts are required to involve all patients in co-managing their diabetes.

A clinic-based mammography intervention targeting inner-city women.

ObjectiveThe objective was to evaluate the effect of a clinic-based intervention program on mammography use by inner-city women.DesignA randomized controlled trial employing firm system methodology was conducted.SettingThe study setting was a general internal medicine clinic in the university-affiliated county hospital serving metropolitan Seattle.ParticipantsWomen aged 50 to 74 years with at least one routine clinic appointment (when they were due for mammography) during the study period were enrolled in the trial (n=314).InterventionsThe intervention program emphasized nursing involvement and included physician education, provider prompts, use of audiovisual an printed patient education materials, transportation assistance in the form of bus passes, preppointment telephone or postcard reminders, and rescheduling assistance. Control firm women received usual care.Measurement and Main ResultsMammography completion within 8 weeks of clinic visits was significantly higher among intervention (49%) than control (22%) firm women (p<.001). These effects persisted after adjustment for potential confounding by age, race, medical insurance coverage, and previous mammography experience at the hospital (odds ratio 3.5; 95% confidence interval 1.9, 6.5). The intervention effect was modified by type of insurance coverage as well as prior mammography history. Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screening participation.ConclusionsA clinic-based program incorporating physician education, provider prompts, patient education materials, and appointment reminders and emphasizing nursing involvement can facilitate adherence to breast cancer screening guidelines among inner-city women.

Wound Complication Rates After Staples or Suture for Midline Vertical Skin Closure in Obese Women: A Randomized Controlled Trial

OBJECTIVE To compare wound complication rates after skin closure with staples and subcuticular suture in obese gynecology patients undergoing laparotomy through a midline vertical incision. METHODS In this randomized controlled trial, women with body mass indexes (BMIs) of 30 or greater undergoing surgery by a gynecologic oncologist through a midline vertical incision were randomized to skin closure with staples or subcuticular 4-0 monofilament suture. The primary outcome was the rate of wound complication, defined as the presence of a wound breakdown, or infection, within 8 weeks postoperatively. Secondary outcomes included operative time, Stony Brook scar cosmetic score, and patient satisfaction. A sample size of 162 was planned to detect a 50% reduction in wound complications. At planned interim review (n=82), there was no significant difference in primary outcome. RESULTS Between 2013 and 2016, 163 women were analyzed, including 84 who received staples and 79 suture. Women who received staples were older (mean age 59 compared with 57 years), had lower mean BMI (37.3 compared with 38.9), and fewer benign indications for surgery (22 compared with 27). There were no differences in wound complication rates between staple compared with suture skin closure (28 [33%] compared with 25 [32%], relative risk 1.05, 95% confidence interval [CI] 0.68-1.64). Women with staples reported worse median cosmetic scores (four of five compared with five of five, P<.001), darker scar color (37 [49%] compared with 13 [18%], relative risk 2.69, 95% CI 1.57-4.63), and more skin marks (30 [40%] compared with three [4%], relative risk 9.47, 95% CI 3.02-29.65) compared with women with suture closure. There was no group difference regarding satisfaction with their scar. Stepwise multivariate analysis revealed BMI (odds ratio [OR] 1.13, 95% CI 1.07-1.20), maximum postoperative glucose (OR 1.01, 95% CI 1.00-1.01), and cigarette smoking (OR 4.96, 95% CI 1.32-18.71) were correlates of wound complication. CONCLUSION Closure of midline vertical skin incisions with subcuticular suture does not reduce surgical site wound complications compared with staples in obese gynecology patients. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT01977612.

A rare case of endometrial cancer metastatic to the uveal choroid

Highlights • Choroid metastases are extremely rare in endometrial cancer.• Choroid metastases can present as many different eye complaints.• Comprehensive eye exams are important in patients with visual complaints.

A Transperineal Approach to Hysterectomy of a Retained Didelphic Uterine Horn

BACKGROUND Gynecologic surgeries are performed through abdominal, vaginal, laparoscopic, or robot-assisted laparoscopic routes. However, if the pelvis is not accessible by one of these routes, there are no published reports to guide pelvic surgeons. CASE A 34-year-old conjoined twin status postseparation with uterine didelphys and absence of her left colon and sacrum underwent hemihysterectomy, at which time her müllerian anomaly was unknown. She re-presented with vaginal bleeding and pain eventually attributed to a retained uterine horn. Conservative management failed. Given dense adhesions, traditional approaches to hysterectomy were not successful. She underwent a transperineal hemisupracervical hysterectomy. CONCLUSION We propose a novel approach to the pelvis to guide surgeons when traditional approaches are not feasible. We also describe an instance of a retained uterine didelphys horn.