Public health clinic-based hepatitis C testing and linkage to care in Baltimore.

Testing and linkage to care are important determinants of hepatitis C virus (HCV) treatment effectiveness. Public health clinics serve populations at high risk of HCV. We investigated their potential to serve as sites for HCV testing, initiation of and linkage to HCV care. Cross-sectional study of patients accessing sexually transmitted infection (STI) care at the Baltimore City Health Department (BCHD) STI clinics, from June 2013 through April 2014 was conducted. Logistic regression was used to assess factors associated with HCV infection and specialist linkage to care. Between 24 June 2013 and 15 April 2014, 2681 patients were screened for HCV infection. Overall, 189 (7%) were anti-HCV positive, of whom 185 (98%) received follow-up HCV RNA testing, with 155 (84%) testing RNA positive. Of 155 RNA-positive individuals, 138 (89%) returned to the STI clinic for HCV RNA results and initial HCV care including counselling regarding transmission and harm reduction in alcohol, and 132 (85%) were referred to a specialist for HCV care. With provision of patient navigation services, 81 (52%) attended an offsite HCV specialist appointment. Alcohol use and lack of insurance coverage were associated with lower rates of specialist linkage (OR 0.4 [95% CI 0.1-0.9] and OR 0.4 [95% CI 0.1-0.9], respectively). We identified a high prevalence of HCV infection in BCHD STI clinics. With availability of patient navigation services, a large proportion of HCV-infected patients linked to off-site specialist care.

What determines health? To where should we shift resources? Attitudes towards the determinants of health among multiple stakeholder groups in Prince Edward Island, Canada.

The population health perspective has become significant in academic and policy discourse. The purpose of this paper is to assess its significance among health care practitioners and administrators as well as the general public. Respondents in Prince Edward Island, Canada were asked to rank the broad determinants of health and comment on to where resources should be shifted to improve the health of the population. Important variations are noted between the groups with family physicians and front-line staff being similar in perceptions to the general public on most determinants than other groups. The paper concludes with discussion on the relevance of the findings for population health research and health policy.

Effectiveness of an educational strategy to improve family physicians' detection and management of depression: a randomized controlled trial.

BACKGROUND: Depression, a common disorder often treated by family physicians, may be both underdiagnosed and undertreated. The objective of this study was to determine whether the diagnosis and treatment of depression by family physicians could be improved through an educational strategy. METHODS: In this study, conducted between July and December 1997, 42 family physicians in Newfoundland were randomly assigned to an intervention group (3-hour case-based educational session on clinical practice guidelines [CPGs] for depression and access to a psychiatrist for consultation) or to a control group (receipt of CPGs without educational session or access to the psychiatrist). Physicians were asked to keep a log of patients with newly diagnosed depression and to record information on severity of depression, medications and referrals to mental health professionals. Patients were asked to complete the Centre for Epidemiologic Studies Depression (CES-D) scale before treatment and after 6 months of follow-up. The primary outcome measure was the "gain" score (difference between first and last CES-D scores). RESULTS: During the study period physicians in the intervention group diagnosed 91 new cases of depression (mean 4.1 per physician) and those in the control group diagnosed 56 (mean 2.8 per physician); the difference was not significant. Most patients (91.2% in the intervention group and 89.3% in the control group received a prescription for an antidepressant on their first visit. Similar proportions (46.2% in the intervention group and 37.5% in the control group) took their medication for the full 6 months; however, significantly more patients in the intervention group were taking an antidepressant at the 6-month follow-up (56% v. 39.3%, p = 0.02). The mean number of visits per patient was similar in the 2 groups (7.7 in the intervention group and 7.6 in the control group). Physicians in the intervention group consulted the psychiatrist 9 times. The overall rate of referrals to psychiatrists and other mental health professionals was 10.9%; however, referrals were significantly higher in the intervention group (15.4% v. 3.5%, p = 0.05). After 6 months of follow-up, a significant difference in gain scores was detected between the intervention and control groups for both the patient's self-rated CES-D scores (mean gain score 19.3 v. 15.5 respectively, p = 0.04) and the physicians' ratings of depression severity before treatment and at 6 months (mean gain 1.1 v. 0.7 respectively, p = 0.02). INTERPRETATION: The educational strategy had a modest beneficial effect on the outcomes of patients with depression, but there are still concerns regarding the low rates of drug treatment and referral to mental health professionals by family physicians.

Intracerebroventricular norepinephrine potentiation of the perforant path-evoked potential in dentate gyrus of anesthetized and awake rats: A role for both alpha- and beta-adrenoceptor activation.

Norepinephrine (NE) applied iontophoretically to the dentate gyrus in vivo, and bath applied to hippocampal slices in vitro, produces potentiation of the perforant path-evoked potential. beta-receptors mediate exogenous NE potentiation in vitro, while alpha-receptors are implicated in exogenous effects in vivo. The present study uses intracerebroventricular (i.c.v.) NE to mimic in vitro bath conditions in vivo. Short-term NE potentiation was reliably seen with 10 microg [+/-] NE in 2 microl of 0.9% saline i.c.v. Long-term potentiation occurred with higher doses of NE. The beta-agonist isoproterenol and the alpha-agonist phenylephrine also produced potentiation. Long-term effects were common with isoproterenol. The beta-antagonist metoprolol and the alpha-antagonist phentolamine attenuated NE potentiation. The results suggest that both alpha- and beta-receptors could play a role in NE potentiation in dentate gyrus in vivo. In awake animals, 10 microg NE i.c.v. reproduced the potentiation pattern seen in anesthetized rats. NE potentiation in awake rats was independent of behavioral variation.

The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review.

OBJECTIVE: To assess the evidence for the effectiveness of clinical practice guidelines (CPGs) in improving patient outcomes in primary care. DATA SOURCES: A search of the MEDLINE, HEALTHPLAN, CINAHL and FAMLI databases was conducted to identify studies published between Jan. 1, 1980, and Dec. 31, 1995, concerning the use of guidelines in primary medical care. The keywords used in the search were "clinical guidelines," "primary care," "clinical care," "intervention," "randomized controlled trial" and "effectiveness." STUDY SELECTION: Studies of the use of CPGs were selected if they involved a randomized experimental or quasi-experimental method, concerned primary care, were related to clinical care and examined patient outcomes. Of 91 trials of CPGs identified through the search, 13 met the criteria for inclusion in the critical appraisal. DATA EXTRACTION: The following data were extracted, when possible, from the 13 trials: country and setting, number of physicians, number of patients (and the proportion followed to completion), length of follow-up, study method (including random assignment method), type of intervention, medical condition treated and effect on patient outcomes (including clinical and statistical significance, with confidence intervals). DATA SYNTHESIS: The most common conditions studied were hypertension (7 studies), asthma (2 studies) and cigarette smoking (2 studies). Four of the studies followed nationally developed guidelines, and 9 used locally developed guidelines. Six studies involved computerized or automated reminder systems, whereas the others relied on small-group workshops and education sessions. Only 5 of the 13 trials (38%) produced statistically significant results. CONCLUSION: There is very little evidence that the use of CPGs improves patient outcomes in primary medical care, but most studies published to date have used older guidelines and methods, which may have been insensitive to small changes in outcomes. Research is needed to determine whether the newer, evidence-based CPGs have an effect on patient outcomes.

Predicting outcomes of community-based continuing care. Four-year prospective study of functional assessment versus clinical judgment.

OBJECTIVE: To compare the predictive power of functional assessment for death and institutionalization with the clinical judgment of continuing care nurses; to determine the rates of functional impairment in elderly community-based continuing care clients; to describe long-term group trends in this population. DESIGN: A prospective cohort study, which lasted 4 years. SETTING: Community-based continuing care nursing program. PARTICIPANTS: Two hundred thirty-seven elderly (65 years or older) clients of the program. MAIN OUTCOME MEASURES: Activities of daily living (ADL), cognitive function, and affective function were assessed when clients entered the program (using the Barthel Index, the Canadian Mental Status Questionnaire, and the Memorial University Scale of Happiness). Home care nurses were asked to predict whether individual clients would have died or dropped out of the program at 1 year after entry. RESULTS: Cognitive function and ADL function tests were significant predictors of both death and drop-out from the program; they were better than clinical judgment. Rates of cognitive and ADL functioning were as expected; the rate of affective impairment (53.6%) was much higher than anticipated. At the end of 4 years, only 22.5% of the cohort were still receiving continuing care. CONCLUSIONS: Functional assessment of cognitive and ADL domains was a better predictor of outcomes than clinical judgment. Studying the cohort enabled us to describe group trends, which could be valuable for program managers.

Cognitive function and glycosylated hemoglobin in older patients with type II diabetes.

The purpose of this study was to assess whether there is a relationship between diabetes control and cognitive function in older persons with type II diabetes. Seventy-seven patients with type II diabetes mellitus-none of whom were taking insulin-were given two cognitive function tests (the Modified Mini-Mental State and the Delayed Word Recall Test) and a HbA1C assay. All patients were living independently at home in rural communities, and under the care of their family doctor. The mean age of the subjects was 67.6 years; the sample consisted of 23 males and 54 females. The mean glycosylated hemoglobin (HbA1C) level was 8.4 (range from 3.1 to 20.0). There was a nonsignificant trend for persons with extreme lower or higher HbA1C levels to have poorer cognitive function as assessed by the Modified Mini-Mental State but not the Delayed Word Recall Test. The effect of glycemic control on cognitive function may not be as clinically relevant as other factors in elderly persons with type II diabetes.