Qingjiang Hou

Gastric Electrical Stimulation Improves Outcomes of Patients With Gastroparesis for up to 10 Years

BACKGROUND & AIMS We assessed the long-term clinical outcomes of gastric electrical stimulation (GES) therapy with Enterra (Enterra Therapy System; Medtronic, Minneapolis, MN) in a large cohort of patients with severe gastroparesis. METHODS Gastroparesis patients (n=221; 142 diabetic, 48 idiopathic, and 31 postsurgical) treated with Enterra (Medtronic) for 1-11 years were retrospectively assessed; 188 had follow-up visits and data were collected for at least 1 year (mean 56 months, range 12-131 months). Total symptom scores (TSSs), gastric emptying, nutritional status, weight, hospitalizations, use of prokinetic and/or antiemetic medications, levels of HbA1c levels (in diabetic patients), and adverse events were evaluated at the beginning of the study (baseline) and during the follow-up period. RESULTS TSS, hospitalization days, and use of medications were significantly reduced among all patients (P<.05). More patients with diabetic (58%) and postsurgical gastroparesis (53%) had a greater than 50% reduction in TSS than those with idiopathic disease (48%; P=.32). Weight significantly increased among all groups, and 89% of J-tubes could be removed. At end of the follow-up period, all etiological groups had similar, abnormal delays in mean gastric retention. Thirteen patients (7%) had their devices removed because of infection at the pulse generator site. CONCLUSIONS GES therapy significantly improved subjective and objective parameters in patients with severe gastroparesis; efficacy was sustained for up to 10 years and was accompanied by good safety and tolerance profiles. Patients with diabetic or postsurgical gastroparesis benefited more than those with idiopathic disease.

The prevalence of and factors associated with chronic atrial fibrillation in Medicare/Medicaid-eligible dialysis patients

Atrial fibrillation is an important comorbidity with substantial therapeutic implications in dialysis patients but its prevalence varies in different studies. We used a database that includes patients in the United States on hemodialysis who were eligible for government assistance with prescription drugs. We then used ICD-9 codes from billing claims in this database to identify patients with chronic atrial fibrillation. Multivariable logistic regression was used to determine adjusted prevalence odds ratios for associated factors. Of 63,884 individuals, the prevalence of chronic atrial fibrillation was 7%. The factors of age over 60 years, male, Caucasian, body mass index over 25 kg/m(2), coronary artery disease, and heart failure were all significantly associated with chronic atrial fibrillation. Prevalence rates, particularly in younger patients, were far higher than those reported in an age group-matched nondialysis population. Thus, given its clinical impact, future efforts are needed to examine risk factors for adverse outcomes in chronic atrial fibrillation, and to identify appropriate management strategies for this disorder, as well as opportunities for quality improvement in this vulnerable population.

Discussing Weight with Obese Primary Care Patients: Physician and Patient Perceptions

AbstractsObjectiveTo evaluate patient–provider agreement on whether weight and related behaviors were discussed during routine visits.DesignPost-visit survey assessments of patients and providers.ParticipantsObese patients make up the majority of all patients seen in primary care (PC). The patients and physicians were recruited at the time of PC visits.Measurements and Main ResultsPercent patient–physician agreement and patient, provider and practice characteristics associated with agreement. Patients (456) and physicians (30) agreed about whether or not they discussed weight, physical activity (PA), and diet for 61% of office visits. There was disagreement on one of the items (weight, PA, or diet) for 23% of office visits, and for 2 or more of the items for 16% of the visits. Agreement was relatively greater for discussing weight than for discussing diet or physical activity. Physicians reported discussing weight issues more often than did patients. Overall patient–physician agreement was 0.51–0.59 (weighted Kappa statistic). In a multivariate analyses of factors associated with patient–physician agreement, health insurance (odds ratio [OR]=3.67, p value = 0.002), physician description of patient weight status (OR = 2.27, p value = 0.002), patient report of how weight relates to health (OR = 1.70, p value = 0.04), and female patient gender (OR = 1.62, p = value = 0.02) were significantly related to agreement.ConclusionsPatients and providers disagreed about whether or not weight issues were discussed in a large number of primary care encounters in this study. Physicians may be able to improve care for their obese patients by focusing discussions on specific details of diet and physical activity behaviors, and by clarifying that patients perceive weight-related information has been shared.

Association of the status of interstitial cells of Cajal and electrogastrogram parameters, gastric emptying and symptoms in patients with gastroparesis

Abstract  Our goal was to investigate associations between the status of interstitial cells of Cajal (ICC) and electrogastrogram (EGG) parameters, gastric emptying and symptoms in a large cohort of patients with gastroparesis. Forty‐one patients with refractory gastroparesis who were referred for gastric electrical stimulation (GES) underwent full thickness gastric (antrum) biopsy during the surgery to place the GES device. The biopsy samples were stained with c‐kit and scored for the presence of ICC based on criteria obtained from 10 controls. All patients underwent EGG recordings, a 4‐h standardized scintigraphic gastric emptying study and symptom assessment prior to the surgery. Based on antral biopsy, 15 patients (36%) had almost no ICC (ICC− group) and 26 patients had adequate cell numbers (ICC+ group). EGG recordings in the ICC− group displayed significantly less normal slow waves than in the ICC+ group both in the fasting and fed states. Tachygastria in the ICC− group was significantly more than in the ICC+ group both in the fasting (32 ± 8%vs 11 ± 2%) and fed states (27 ± 9%vs 12 ± 2%). There was no statistical difference in gastric emptying, symptom severity of gastroparesis, aetiology, age and gender between the two groups. Severely depleted ICC occurs in up to 36% of gastroparetic patients and significantly correlates with an abnormal EGG. Severely depleted ICC does not correlate with the severity of gastroparesis as assessed by gastric emptying or symptom status but did result in a poorer symptomatic response to GES. These data suggest that the EGG may have a role for predicting ICC status during clinical evaluation of gastroparetic patients.

Association between changes in symptoms and gastric emptying in gastroparetic patients treated with gastric electrical stimulation

Abstract  To investigate whether there is an association between gastric emptying rate and symptom improvement in gastroparetic patients treated with gastric electrical stimulation (GES), we retrospectively reviewed 63 gastroparetic patients who received GES therapy for at least 1 year. Patient characteristics, seven upper gastrointestinal (GI) symptoms and 4‐h standardized gastric emptying test (GET) were evaluated at baseline and at 1 year of GES. All symptoms were significantly reduced (P < 0.001). Mean gastric retention was reduced by 7% (P = 0.102) for measurement at 4 h. Of the 63 patients, 14 had their GET normalized and 49 remained delayed after 1 year. Normalized GET patients had a similar symptom improvement as those whose GET remained delayed. Of all upper GI symptoms, the improvements in vomiting (P = 0.04), nausea (P = 0.002) and epigastric pain (P = 0.001) were significantly correlated with reduction in 4‐h gastric retention between baseline and 12 months of GES therapy for patients with normalized gastric emptying but there were no correlations with any symptoms and change in gastric emptying for those patients who remained delayed. In summary, overall gastric emptying is not significantly accelerated at 4 h after successful symptomatic improvement with GES but nausea, vomiting and epigastric pain can be correlated with normalization of GET in a subset of patients.

Colorectal cancer screening, perceived discrimination, and low-income and trust in doctors: a survey of minority patients

BackgroundCompletion of colorectal cancer (CRC) screening testing is lower among low-income and minority groups than the population as a whole. Given the multiple cancer screening health disparities known to exist within the U.S., this study investigated the relationship between perceived discrimination, trust in most doctors, and completion of Fecal Occult Blood Testing (FOBT) among a low-income, minority primary care population in an urban setting.MethodsWe recruited a convenience sample of adults over age 40 (n = 282) from a federally qualified community health center (70% African American). Participants completed a survey which included measures of trust in most doctors, perceived discrimination, demographics and report of cancer screening.ResultsParticipants reported high levels of trust in most doctors, regardless of sex, race, education or income. High trust was associated with low perceived discrimination (p < 0.01). The trend was for older participants to express more trust (p = 0.09) and less perceived discrimination (p < 0.01). Neither trust nor discrimination was associated with race or education. Trust was higher among participants over 50 who were up-to-date on FOBT screening vs. those who were not (31 vs. 29 (median), p < 0.05 by T-test). Among those over 50, up-to-date FOBT screening was nearly associated with high trust (p < 0.06; 95% CI 0.99, 1.28) and low perceived discrimination (p < 0.01; 95% CI 0.76, 0.96). Nevertheless, in multivariate-modeling, age and income explained FOBT completion better than race, trust and discrimination.ConclusionPerceived discrimination was related to income, but not race, suggesting that discrimination is not unique to minorities, but common to those in poverty. Since trust in most doctors trended toward being related to age, FOBT screening could be negatively influenced by low trust and perceived discrimination in health care settings. A failure to address these issues in middle-aged, low income individuals could exacerbate future disparities in CRC screening.

Geographic Variation in Cardioprotective Antihypertensive Medication Usage in Dialysis Patients

BACKGROUND Despite their high risk of adverse cardiac outcomes, persons on long-term dialysis therapy have had lower use of antihypertensive medications with cardioprotective properties, such as angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), β-blockers, and calcium channel blockers, than might be expected. We constructed a novel database that permits detailed exploration into the demographic, clinical, and geographic factors associated with the use of these agents in hypertensive long-term dialysis patients. STUDY DESIGN National cross-sectional retrospective analysis linking Medicaid prescription drug claims with US Renal Data System core data. SETTING & PARTICIPANTS 48,882 hypertensive long-term dialysis patients who were dually eligible for Medicaid and Medicare services in 2005. FACTORS Demographics, comorbid conditions, functional status, and state of residence. OUTCOMES Prevalence of cardioprotective antihypertensive agents in Medicaid pharmacy claims and state-specific observed to expected ORs of medication exposure. MEASUREMENTS Factors associated with medication use were modeled using multilevel logistic regression models. RESULTS In multivariable analyses, cardioprotective antihypertensive medication exposure was associated significantly with younger age, female sex, nonwhite race, intact functional status, and use of in-center hemodialysis. Diabetes was associated with a statistically significant 28% higher odds of ACE-inhibitor/ARB use, but congestive heart failure was associated with only a 9% increase in the odds of β-blocker use and no increase in ACE-inhibitor/ARB use. There was substantial state-by-state variation in the use of all classes of agents, with a greater than 2.9-fold difference in adjusted-rate ORs between the highest and lowest prescribing states for ACE inhibitors/ARBs and a 3.6-fold difference for β-blockers. LIMITATIONS Limited generalizability beyond study population. CONCLUSIONS In publicly insured long-term dialysis patients with hypertension, there were marked differences in use rates by state, potentially due in part to differences in Medicaid benefits. However, geographic characteristics also were associated with exposure, suggesting clinical uncertainty about the utility of these medications.

Competitive Foods in Schools: Availability and Purchasing in Predominately Rural Small and Large High Schools

OBJECTIVES Schools have an important role to play in obesity prevention, but little is known about the food environment in small, predominately rural schools. The primary purpose of this study was to compare the availability and student purchasing of foods sold outside of the reimbursable meals program through à la carte or vending (ie, competitive foods) in small (n=7) and large (n=6) Kansas high schools. METHODS A cross-sectional observational study design was used to capture the number of à la carte and vending items available and purchased, and the fat and energy content of all available and purchased items on a single school day between January and May 2005. RESULTS Small schools had significantly fewer vending machines than large schools (median 3.0 [range 2.0 to 5.0] vs 6.5 [range 4.0 to 8.0], P<0.01]. Vending and à la carte items at small schools contained a median of 2.3 fewer fat grams per item (P< or =0.05), whereas vending products contained a median of 25 kcal fewer per item (P< or =0.05) than at large schools. Significantly less fat (median -15.4 g/student) and less energy (median -306.8 kcal/student) were purchased per student from all competitive food sources and from à la carte (median -12.9 g fat and -323.3 kcal/student) by students in small schools compared to students in large schools (P< or =0.05). CONCLUSIONS The findings, which highlight less availability and lower energy content from competitive foods at small compared to large schools, have implications for understanding how small schools support their foodservice programs with limited dependence on competitive foods and the influence that food and nutrition professionals can have on school environments by providing more oversight into the nutritional quality of foods available.

The Box-Cox power transformation on nursing sensitive indicators: Does it matter if structural effects are omitted during the estimation of the transformation parameter?

BackgroundMany nursing and health related research studies have continuous outcome measures that are inherently non-normal in distribution. The Box-Cox transformation provides a powerful tool for developing a parsimonious model for data representation and interpretation when the distribution of the dependent variable, or outcome measure, of interest deviates from the normal distribution. The objectives of this study was to contrast the effect of obtaining the Box-Cox power transformation parameter and subsequent analysis of variance with or without a priori knowledge of predictor variables under the classic linear or linear mixed model settings.MethodsSimulation data from a 3 × 4 factorial treatments design, along with the Patient Falls and Patient Injury Falls from the National Database of Nursing Quality Indicators (NDNQI®) for the 3rd quarter of 2007 from a convenience sample of over one thousand US hospitals were analyzed. The effect of the nonlinear monotonic transformation was contrasted in two ways: a) estimating the transformation parameter along with factors with potential structural effects, and b) estimating the transformation parameter first and then conducting analysis of variance for the structural effect.ResultsLinear model ANOVA with Monte Carlo simulation and mixed models with correlated error terms with NDNQI examples showed no substantial differences on statistical tests for structural effects if the factors with structural effects were omitted during the estimation of the transformation parameter.ConclusionsThe Box-Cox power transformation can still be an effective tool for validating statistical inferences with large observational, cross-sectional, and hierarchical or repeated measure studies under the linear or the mixed model settings without prior knowledge of all the factors with potential structural effects.

Validation of the support provided measure among spouses of smokers receiving a clinical smoking cessation intervention

Studies indicate a positive association between social support and smoking cessation. However, clinic-based interventions designed to increase social support have had limited success. Most studies have relied on only the smokers perceptions of support received while few have assessed the support providers report of support delivered. Understanding supportive interactions between support providers and recipients may assist in developing effective support interventions for cessation. The current investigation examined the perceptions of smoking-specific support provided by the spouse of a partner who smokes and was seen for a nicotine dependence consultation. Specifically, we examined spouse reported willingness to help their spouse quit, interest in learning ways to help their spouse quit, and characteristics associated with the provision of smoking-specific supportive behaviors (as assessed via the Support Provided Measure, SPM), in the 2-weeks prior to the consultation. The current investigation also examined the concurrent validity of the SPM with a validated measure of support provided to a smoker, the Partner Interaction Questionnaire (PIQ), accounting for social desirability bias and smoker readiness to change. The sample comprised 84 adult cigarette smokers seen for a clinical smoking cessation intervention and their spouses (N = 84). Results indicate that a high percentage of spouses are willing to help their partner who smokes and interested in learning way to help. As expected, spouses who were females and had never smoked had higher scores on the SPM than males or current smokers. The SPM was significantly correlated with the PIQ positive (r = 0.50, p < 0.01) and negative (r = 0.44, p <0.01) item scales overall and for spouses whose partners reported higher levels of readiness to quit smoking (r = 0.54, p < 0.01; r = 0.50, p < 0.01, respectively). Suggestions for future research are offered.