Teresa Cutts

Is gastric electrical stimulation superior to standard pharmacologic therapy in improving GI symptoms, healthcare resources, and long-term health care benefits?

Abstract  Context:  Severe upper gastrointestinal (GI) motor disorders, including gastroparesis (GP), can consume significant health care resources. Many patients are refractory to traditional drug therapy.

Gastric Electrical Stimulation Is Safe and Effective: A Long-Term Study in Patients with Drug-Refractory Gastroparesis in Three Regional Centers

Background: Drug-refractory gastroparesis has previously been without acceptable alternative therapies. Although gastric electrical stimulation has been used for over a decade, no long-term multicenter data exist. Methods: We studied 214 consecutive drug-refractory patients with the symptoms of gastroparesis (146 idiopathic, 45 diabetic, 23 after surgery) who consented to participate in a variety of clinical research and clinical protocols at three centers from January 1992 through January 2005, resulting in 156 patients implanted with a gastric electrical stimulation device and the other 58 patients serving as controls. The patients were stratified into three groups: (1) consented but never permanently implanted; (2) implanted with permanent device, and (3) consented while awaiting a permanent device. The patients were followed over time for gastrointestinal symptoms, solid gastric emptying, health-related quality of life, survival, device retention, and complications. Demographics, descriptive statistics, and t tests were used for comparison between baseline and latest follow-up. Results: At latest follow-up, median 4 years for 5,568 patient months, most patients implanted (135 of 156) were alive with intact devices, significantly reduced gastrointestinal symptoms, and improved health-related quality of life, with evidence of improved gastric emptying, and 90% of the patients had a response in at least 1 of 3 main symptoms. Most patients explanted, usually for pocket infections, were later reimplanted successfully. There were no deaths directly related to the device. Conclusion: Based on this sample of patients, implanted with gastric electrical stimulation devices at three centers and followed for up toward a decade, gastric electrical stimulation for drug-refractory gastroparesis is both safe and effective.

Predictors of response to a behavioral treatment in patients with chronic gastric motility disorders.

Chronic gastric motility disorders have proven intractable to most traditional therapies. Twenty-six patients with chronic nausea and vomiting were treated with a behavioral technique, autonomic training (AT) with directed imagery (verbal instructions), to help facilitate physiological control. After treatment, gastrointestinal symptoms decreased by >30% in 58% of the treated patients. We compared those improved patients to the 43% who did not improve significantly. No significant differences existed in baseline symptoms and autonomic measures between both groups. However, baseline measures of gastric emptying and autonomic function predicted treatment outcome. Patients who improved manifested mild to moderate delay in baseline gastric emptying measures. The percent of liquid gastric emptying at 60 mins and the sympathetic adrenergic measure of percent of change in the foot cutaneous blood flow in response to cold stress test predicted improvement in AT outcome, with clinical diagnostic values of 77% and 71%, respectively. We conclude that AT treatment can be efficacious in some patients with impaired gastric emptying and adrenergic dysfunction. More work is warranted to compare biofeedback therapy with gastric motility patients and controls in population-based studies.

Serum Catecholamines and Dysautonomia in Diabetic Gastroparesis and Liver Cirrhosis

Background:Plasma catecholamine influences autonomic function and control, but there are few reports correlating them. In this study, 47 individuals (mean age, 38 years) were studied: 19 diabetes mellitus (DM) patients with gastroparesis, 16 with liver disease and 12 control subjects. Methods:Noninvasive autonomic function was assessed for sympathetic adrenergic functions as peripheral vasoconstriction in response to cold stress test and postural adjustment ratio (PAR) and cholinergic function as Valsalva ratio, represented by change in R-R intervals. Measurements were compared by analysis of variance and Spearmans correlation, and results were reported as mean ± standard error. Results:Plasma norepinephrine (1902.7 ± 263.3; P = 0.001) and epinephrine (224.5 ± 66.5; P = 0.008) levels, as well as plasma dopamine levels (861.3 ± 381.7), and total plasma catecholamine levels were highest for patients with liver disease, who also had significant negative correlation between norepinephrine level and vasoconstriction (P = 0.01; r = −0.5), PAR1 (P = 0.01; r = −0.5), sympathetic adrenergic functions (P = 0.005; r = −0.6), total autonomic index (P = 0.01–0.5) and total autonomic function (P = 0.01; r = −0.2) and also negative correlation between epinephrine plasma level and total autonomic function (P = 0.04; r = 0.4). DM patients were next highest in norepinephrine level (133.26 ± 7.43), but lowest for plasma catecholamine; a positive correlation between dopamine level and PAR1 (P = 0.008; r = 0.6) was also seen in this group. Plasma dopamine levels and spider score correlated negatively (P = 0.04; r = −0.5) and total plasma catecholamine positively with encephalopathy (P = 0.04; r = 0.5) in patients with liver disease. Conclusions:Plasma catecholamine levels correlated with adrenergic functions in control subjects and patients with DM and liver disease, with no significant correlation seen for cholinergic function.

A Community Health Record: Improving Health Through Multisector Collaboration, Information Sharing, and Technology

We present a framework for developing a community health record to bring stakeholders, information, and technology together to collectively improve the health of a community. It is both social and technical in nature and presents an iterative and participatory process for achieving multisector collaboration and information sharing. It proposes a methodology and infrastructure for bringing multisector stakeholders and their information together to inform, target, monitor, and evaluate community health initiatives. The community health record is defined as both the proposed framework and a tool or system for integrating and transforming multisector data into actionable information. It is informed by the electronic health record, personal health record, and County Health Ranking systems but differs in its social complexity, communal ownership, and provision of information to multisector partners at scales ranging from address to zip code.

The Life of Leaders: An Intensive Health Program for Clergy

Clergy suffer from chronic disease rates that are higher than those of non-clergy. Health interventions for clergy are needed, and some exist, although none to date have been described in the literature. Life of Leaders is a clergy health intervention designed with particular attention to the lifestyle and beliefs of United Methodist clergy, directed by Methodist LeBonheur Healthcare Center of Excellence in Faith and Health. It consists of a two-day retreat of a comprehensive executive physical and leadership development process. Its guiding principles include a focus on personal assets, multi-disciplinary, integrated care, and an emphasis on the contexts of ministry for the poor and community leadership. Consistent with calls to intervene on clergy health across multiple ecological levels, Life of Leaders intervenes at the individual and interpersonal levels, with potential for congregational and religious denominational change. Persons wishing to improve the health of clergy may wish to implement Life of Leaders or borrow from its guiding principles.

Community Health Asset Mapping Partnership Engages Hispanic/Latino Health Seekers and Providers

BACKGROUND The Hispanic/Latino population in Forsyth County, North Carolina, is growing quickly and experiencing significant disparities in access to care and health outcomes. Assessing community perceptions and utilization of health care resources in order to improve health equity among Hispanics/Latinos at both the county and state levels is critical. METHODS Our community engagement process was guided by the Community Health Assets Mapping Partnerships (CHAMP) approach, which helps identify gaps in health care availability and areas for immediate action to improve access to and quality of health care. Specifically, we invited and encouraged the Hispanic/Latino population to participate in 4 different workshops conducted in Spanish or English. Participants were identified as either health care providers, defined as anyone who provides health care or a related service, or health care seekers, defined as anyone who utilizes such services. RESULTS The most commonly cited challenges to access to care were cost of health care, documentation status, lack of public transportation, racism, lack of care, lack of respect, and education/language. These data were utilized to drive continued engagement with the Hispanic community, and action steps were outlined. LIMITATIONS While participation in the workshops was acceptable, greater representation of health care seekers and community providers is needed. CONCLUSIONS This process is fundamental to multilevel initiatives under way to develop trust and improve relationships between the Hispanic/Latino community and local health care entities in Forsyth County. Follow-through on recommended action steps will continue to further identify disparities, close gaps in care, and potentially impact local and state policies with regard to improving the health status of the Hispanic/Latino community.

Prognosis in a Smoking Cessation Program

In an attempt to develop a heuristic model of outcome in smoking cessation programs, pretreatment measures of smoking behavior, smoking severity, chronicity of smoking, addictive liability, and health functioning were utilized in order to predict outcome on the number of cigarettes smoked and carbon monoxide (CO) levels at 6-month follow-up. The results of multiple regression analyses supported the view that addictive liability, as indicated by high nicotine ingestion, contributed to higher levels of smoking on follow-up. Poor health status also predicted higher smoking levels on follow-up, as did pretreatment measures of the number of cigarettes smoked per day. However, measures of smoking severity (carbon monoxide and thiocyanate levels) at pretreatment were negatively related to smoking behavior on follow-up. The number of years of smoking history was negatively related to smoking behavior on follow-up. These results need to be cross-validated with larger samples, but the results suggest that prognosis in smoking cessation is worsened by addictive liability and poor health, but not by severe levels of smoking behavior or chronicity in smoking.

Decent Care for Life

Decent care clarifies the relationship between those who offer care and those who receive it. This chapter suggests that the dynamic human relationship implied in decent care should be defined by the way decent care contributes to and nurtures the lives of everyone involved. In upholding decency, we hold ourselves accountable to much more than just satisfying an arbitrary standard of technical intervention or medical process. How can we push beyond survival indicators and move towards a concept of human decency rooted in the question ‘What is necessary for human life to flourish?’ Decency is fundamental to what makes us human; to presume less is to diminish the lives of all involved in caring relationships.

Implications for Public Health Systems and Clinical Practitioners: Strengths of Congregations, Religious Health Assets and Leading Causes of Life

Historically and in current times, religious, public health and health system partnerships have been essential in improving health at community scale, ranging from ending infectious disease epidemics to improving the health of the vulnerable dealing with chronic conditions. This chapter sketches that historical background, situating recent efforts against the backdrop of more than a century of public health practice and describes the roles of public health professionals and of empirical evidence in fostering community partnerships between religious organizations and health systems. We also offer seven key principles for religion/health partnerships distilled from the last three decades of practice and theory crafted and conducted by Gary Gunderson, Teresa Cutts and others, built upon the specific frameworks of strengths of congregations, religious health assets and Leading Causes of Life and, in some cases, backed by empirical evidence. These points are illustrated by two case studies of religion/health partnerships in Memphis and North Carolina that exemplify some of those principles. We summarize and draw conclusions, with a particular emphasis on offering useful information for public health practitioners.