Addressing Rural Health Challenges Head On.

Providing health care to patients and families living in rural America presents significant challenges, but comes with unique rewards. The physician who chooses a rural life typically cares for an underserved and aging population, which is often less healthy and affluent than its urban and suburban counterparts. At the same time, rural clinicians feel deeply connected to their patients and their communities. Physicians cite strong doctor-patient relationships as a primary motivator to practice in a rural setting, in addition to lower cost of living and slower pace of life1. Those who choose primary care specialties also enjoy the challenge of caring for multiple, interrelated aspects of health for their patients and community. During Kansas City University of Medicine and Biosciences' (KCU) century-long history, we have offered our osteopathic medical students the opportunity to learn in rural areas during the third and fourth years. As our new, state-of-the-art medical school campus opens in Joplin, Missouri, we will build on our commitment to rural health by offering first- and second-year KCU-Joplin students training opportunities in rural settings, and expanding third- and fourth-year rural clinical rotations. The rich experience to learn rural medicine offers the potential to connect medical students, patients and community in new and exciting ways, building on the firm foundation of osteopathic medical training grounded in strong patient-centered primary care.

Faculty Development Directed at Curricular Reforms Designed to Improve Patient Outcomes.

Three initiatives involving quality of patient outcomes that evolved in the late 1990s must be considered in the design of 21st century undergraduate medical curricula. They involve (1) the question of how to best teach and assess medical competencies, (2) growing concerns regarding the frequency and severity of error in medical care, and (3) the role physicians might play in weaving together the overlapping elements of population-, community-, and systems-based practice into a codified approach to medical care. With these initiatives in mind, the University of North Texas Health Science Center Texas College of Osteopathic Medicine has formed an Academy of Medical Educators whose goal is to develop faculty programs intended to expedite curricular modifications and reforms.

Outcomes-Oriented Medical Training: A Critical Curricular Design Consideration in Developing 21st Century Health Care Professionals.

The core competencies of medical schools and residencies have initiated a change in curricular design but have been limited in their execution of systems-based practice. The introduction of milestones and entrustable professional activities has emerged to enhance the current educational paradigm. Linking public health systemic approaches with evidence-based practices focused on population-level health care will affect patients more than current non-systems-based approaches. Curricular redesign, including population health-based strategies, public health competency, health care policy, and education linking the "determinants of health" to patient care, will better prepare future physicians to practice in the emerging paradigm of health care of the future. Thus, the University of North Texas Health Science Center Texas College of Osteopathic Medicine has launched a 3-phase model that addresses the specific foundational needs required to instantiate fundamental systems-based concepts in faculty, undergraduate medical curricula, and clinical practice.

Impact of a community health workers-led structured program on blood glucose control among latinos with type 2 diabetes: the DIALBEST trial.

OBJECTIVE: Latinos with type 2 diabetes (T2D) face major healthcare access and disease management disparities. We examined the impact of the Diabetes Among Latinos Best Practices Trial (DIALBEST), a community health worker (CHW)-led structured intervention for improving glycemic control among Latinos with T2D. RESEARCH DESIGN AND METHODS: A total of 211 adult Latinos with poorly controlled T2D were randomly assigned to a standard of healthcare (n = 106) or CHW (n = 105) group. The CHW intervention comprised 17 individual sessions delivered at home by CHWs over a 12-month period. Sessions addressed T2D complications, healthy lifestyles, nutrition, healthy food choices and diet for diabetes, blood glucose self-monitoring, and medication adherence. Demographic, socioeconomic, lifestyle, anthropometric, and biomarker (HbA1c, fasting blood glucose, and lipid profile) data were collected at baseline and 3, 6, 12, and 18 months (6 months postintervention). Groups were equivalent at baseline. RESULTS: Participants had high HbA1c at baseline (mean 9.58% [81.2 mmol/mol]). Relative to participants in the control group, CHWs had a positive impact on net HbA1c improvements at 3 months (-0.42% [-4.62 mmol/mol]), 6 months (-0.47% [-5.10 mmol/mol]), 12 months (-0.57% [-6.18 mmol/mol]), and 18 months (-0.55% [-6.01 mmol/mol]). The overall repeated-measures group effect was statistically significant (mean difference -0.51% [-5.57 mmol/mol], 95% CI -0.83, -0.19% [-9.11, -2.03 mmol/mol], P = 0.002). CHWs had an overall significant effect on fasting glucose concentration that was more pronounced at the 12- and 18-month visits. There was no significant effect on blood lipid levels, hypertension, and weight. CONCLUSIONS: DIALBEST is an effective intervention for improving blood glucose control among Latinos with T2D.

Pulmonary arterial hypertension in adults: novel drugs and catheter ablation techniques show promise? Systematic review on pharmacotherapy and interventional strategies.

This systematic review aims to provide an update on pharmacological and interventional strategies for the treatment of pulmonary arterial hypertension in adults. Currently US Food and Drug Administration approved drugs including prostanoids, endothelin-receptor antagonists, phosphodiesterase type-5 inhibitors, and soluble guanylate-cyclase stimulators. These agents have transformed the prognosis for pulmonary arterial hypertension patients from symptomatic improvements in exercise tolerance ten years ago to delayed disease progression today. On the other hand, percutaneous balloon atrioseptostomy by using radiofrequency perforation, cutting balloon dilatation, or insertion of butterfly stents and pulmonary artery catheter-based denervation, both associated with very low rate of major complications and death, should be considered in combination with specific drugs at an earlier stage rather than late in the progression of pulmonary arterial hypertension and before the occurrence of overt right-sided heart failure.

Treatment of acute pulmonary embolism: update on newer pharmacologic and interventional strategies.

Acute pulmonary embolism (PE) is a common complication in hospitalized patients, spanning multiple patient populations and crossing various therapeutic disciplines. Current treatment paradigm in patients with massive PE mandates prompt risk stratification with aggressive therapeutic strategies. With the advent of endovascular technologies, various catheter-based thrombectomy and thrombolytic devices are available to treat patients with massive or submassive PE. In this paper, a variety of newer treatment strategies for PE are analyzed, with special emphasis on various interventional treatment strategies. Clinical evidence for utilizing endovascular treatment modalities, based on our institutional experience as well as a literature review, is provided.

Pharmacology, benefits, unaddressed questions, and pragmatic issues of the newer oral anticoagulants for stroke prophylaxis in non-valvular atrial fibrillation and proposal of a management algorithm.

This systematic review aims to provide an update on pharmacology, efficacy and safety of the newer oral direct thrombin and factor Xa inhibitors, which have emerged for the first time in ~60 years as cogent alternatives to warfarin for stroke prophylaxis in non-valvular atrial fibrillation. We also discuss on four of the most common clinical scenarios with several unsolved questions and areas of uncertainty that may play a role in physicians' reluctance to prescribe the newer oral anticoagulants such as 1) patients with renal failure; 2) the elderly; 3) patients presenting with atrial fibrillation and acute coronary syndromes and/or undergoing coronary stenting; and 4) patients planning to receive AF ablation with the use of pulmonary vein isolation. New aspects presented in current guidelines are covered and we also propose an evidence-based anticoagulation management algorithm.

The Hachinski ischemic scale and cognition: the influence of ethnicity.

OBJECTIVE: cardiovascular burden is considered a risk factor for the development of cognitive dysfunction and dementia. While this link is well established in the literature, implementing this work in primary care settings remains a challenge. The goal of this study is to examine the utility of the Hachinski Ischemic Scale (HIS) in identifying cognitive dysfunction and diagnosis of mild cognitive impairment (MCI) in an ethnically diverse sample. METHODS: data were analysed on 517 participants (211 Mexican Americans and 306 non-Hispanic Whites) recruited from Project FRONTIER, a study of rural health. Neuropsychological measures were utilised to assess for cognitive functioning. RESULTS: among non-Hispanic Whites, HIS scores were significantly related to poorer performance on tasks of global cognition [B (SE) = -0.13 (0.06), P = 0.02], immediate memory [B (SE) = -0.85 (0.26), P < 0.001], attention [B (SE) = -1.6 (0.36), P < 0.001] and executive functioning [B (SE) = 0.46 (0.12), P < 0.001], and significantly predicted diagnosis of MCI [odds ratio (OR) = 1.4; 95% confidence interval (CI) = 1.2-1.6]. For Mexican Americans, HIS scores were significantly related to immediate memory [B (SE) = -0.78 (0.28), P = 0.01], attention [B (SE) = -0.74 (0.36), P = 0.04] and executive functioning [B (SE) = 0.37 (0.14), P = 0.01]; however, HIS scores were not significantly related to diagnosis of MCI in Mexican Americans (OR = 1.2, 95% CI = 0.96-1.4, P = 0.116). CONCLUSION: HIS scores were related to cognitive functioning; however, these results differed by ethnicity. It is possible that these findings indicate that vascular factors may increase risk for MCI among non-Hispanic Whites but not for Mexican Americans. These findings are consistent with past research that suggests risk factors for MCI may differ by ethnicity.

Triglyceride screening may improve cardiometabolic disease risk assessment in Latinos with poorly controlled type 2 diabetes.

To characterize metabolic syndrome (MetS) prevalence and cardiometabolic risk, HbA1c, fasting plasma glucose (FPG), plasma lipids, blood pressure, BMI, and waist circumference were measured in 211 Latino adults with type 2 diabetes. Participants were obese (BMI=33.7±7.8 kg/m2) and had poor glycemic control (HbA1c=9.6±1.8 %; FPG=190±85 mg/dL), but normal LDL and HDL cholesterol concentrations (98±38 mg/dL, and 52±14 mg/dL, respectively). Relative to the lowest, participants in the highest quintile of plasma triglycierides had higher total cholesterol (23%; p<.0001), FPG (47%; p<.0001), systolic blood pressure (3%; p<.05) and diastolic blood pressure (6%; p<.05), and lower HDL cholesterol (23%; p<.01). Comparable relationships were observed in an age-adjusted regression model. Framingham risk was equivalent to 9.4±6.4% and 12.2±9.6% 10-year CHD risk in men and women, respectively (p<.05). Cardiometabolic risk in this population is associated with a high prevalence of the MetS despite the relatively low cholesterol concentrations. Triglyceride screening may help identify individuals at higher risk.

Determinants of fasting plasma glucose and glycosylated hemoglobin among low income Latinos with poorly controlled type 2 diabetes.

The objective of this study was to identify demographic, socio-economic, acculturation, lifestyle, sleeping pattern, and biomedical determinants of fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c), among Latinos with type 2 diabetes (T2D). Latino adults (N = 211) with T2D enrolled in the DIALBEST trial were interviewed in their homes. Fasting blood samples were also collected in the participants' homes. Because all participants had poor glucose control, above-median values for FPG (173 mg/dl) and HbA1c (9.2%) were considered to be indicative of poorer glycemic control. Multivariate analyses showed that receiving heating assistance (OR: 2.20; 95% CI: 0.96-4.96), and having a radio (3.11, 1.16-8.35), were risk factors for higher FPG levels, and lower income (10.4, 1.54-69.30) was a risk factor for higher HbA1c levels. Lower carbohydrate intake during the previous day (0.04; 0.005-0.37), as well as regular physical activity (0.30; 0.13-0.69), breakfast (2.78; 1.10-6.99) and dinner skipping (3.9; 1.03-14.9) during previous week were significantly associated with FPG concentrations. Being middle aged (2.24, 1.12-4.47), 30-60 min of sleep during the day time (0.07, 0.01-0.74) and having medical insurance (0.31, 0.10-0.96) were predictors of HbA1c. Results suggest that contemporaneous lifestyle behaviors were associated with FPG and contextual biomedical factors such as health care access with HbA1c. Lower socio-economic status indicators were associated with poorer FPG and HbA1c glycemic control.

Exposure to non-therapeutic INR in a high risk cardiovascular patient: potential hazard reduction with genotype-guided warfarin (Coumadin) dosing.

A case to illustrate the utility of genetic screening in warfarin (Coumadin) management is reported. A 45 year-old woman of Puerto Rican ancestry was admitted to the emergency room twice within one month with chest pain. She was diagnosed with congestive heart failure, which was stabilized both times. At her second release, warfarin therapy was initiated at 5 mg/ day to prevent thrombus formation and was lowered to 3.75 mg/day at day 7 by her primary physician. International Normalized Ratio (INR) test results in the follow-up period at days 1, 7, and 10 of warfarin therapy were 4.5, 6.5, and 7.3, respectively-far in excess of the therapeutic range, despite the lower dosage in effect from day 7 onward. The patient achieved target INR over the next 43 days after downward adjustment of the dose to a dose of 1.5 mg/day by trial and error. DNA-typing specific for the CYP2C9*2,*3,*4,*5,*6 alleles and seven variants in the VKORC1 gene, including the VKORC1-1639 G > A polymorphism, revealed the presence of combinatorial CYP2C9*2/*3 and VKORC1-1639 G/A genotypes in this patient. Entering the patient's demographic and genotype status data into independent algorithms available in the public domain to predict effective warfarin dose yielded predicted doses which ranged from 1.5 to 1.8 mg/day. Notably, the prediction of 1.5 mg/day, which was generated by the online resource www.warfarindosing.org, coincided with the patient's actual effective warfarin dose. We conclude that the rapid rise in INR observed upon the initiation of warfarin therapy and the final effective warfarin dose of 1.5 mg/day, are attributable in some part to the presence of two minor alleles in CYP2C9, which together significantly reduce warfarin metabolism. Warfarin genotyping can therefore inform the clinician of the predicted effective warfarin dose. The results highlight the potential for warfarin genetic testing to improve patient care.

Prevalence of combinatorial CYP2C9 and VKORC1 genotypes in Puerto Ricans: implications for warfarin management in Hispanics.

Polymorphisms in the cytochrome P450 2C9 (CYP2C9) and vitamin K epoxide reductase complex subunit 1 (VKORC1) genes significantly alter the effective warfarin dose. We determined the frequencies of alleles, single carriers, and double carriers of single nucleotide polymorphisms (SNPs) in the CYP2C9 and VKORC1 genes in a Puerto Rican cohort and gauged the impact of these polymorphisms on warfarin dosage using a published algorithm. A total of 92 DNA samples were genotyped using Luminex x-MAP technology. The polymorphism frequencies were 6.52%, 5.43% and 28.8% for CYP2C9 *2, *3 and VKORC1-1639 C>A polymorphisms, respectively. The prevalence of combinatorial genotypes was 16% for carriers of both the CYP2C9 and VKORC1 polymorphisms, 9% for carriers of CYP2C9 polymorphisms, 35% for carriers of the VKORC1 polymorphism, and the remaining 40% were non-carriers for either gene. Based on a published warfarin dosing algorithm, single, double and triple carriers of functionally deficient polymorphisms predict reductions of 1.0-1.6, 2.0-2.9, and 2.9-3.7 mg/day, respectively, in warfarin dose. Overall, 60% of the population carried at least a single polymorphism predicting deficient warfarin metabolism or responsiveness and 13% were double carriers with polymorphisms in both genes studied. Combinatorial genotyping of CYP2C9 and VKORC1 can allow for individualized dosing of warfarin among patients with gene polymorphisms, potentially reducing the risk of stroke or bleeding.