Identification and management of late dysfunction in survivors of head and neck cancer: Implementation and outcomes of an interdisciplinary quality of life (IQOL) clinic.

BACKGROUND: Identifying and treating late dysfunction in survivors of head and neck cancer (HNC) is important; however, an effective way to do so is not established. METHODS: A quality improvement initiative altering our HNC survivorship clinic to include surveillance by rehabilitation providers was undertaken. The nature of dysfunction identified, along with the number and type of referrals to ancillary/support services were collected and compared to baseline. RESULTS: The baseline, single-provider, clinic evaluated 61 patients and referred 2 (3%) to ancillary/support services. Fifty-seven patients were evaluated in the interdisciplinary clinic, with 36 (63%) referred to at least one ancillary/support service for new/progressive dysfunction. Of 59 referrals made, 22 (37%) were for dysphagia, 17(29%) were for neck/shoulder dysfunction, and 28 (47%) were attended by the patient. CONCLUSION: Many HNC survivors exhibit late dysfunction appropriate for referral to ancillary/support services. A survivorship clinic including surveillance by rehabilitation specialists may optimize identification of dysfunction.

Porokeratotic eccrine nevus may be caused by somatic connexin26 mutations.

Porokeratotic eccrine ostial and dermal duct nevus, or porokeratotic eccrine nevus (PEN), is a hyperkeratotic epidermal nevus. Several cases of widespread involvement have been reported, including one in association with the keratitis-ichthyosis-deafness (KID) syndrome (OMIM #148210), a rare disorder caused by mutations in the GJB2 gene coding for the gap junction protein connexin26 (Cx26). The molecular cause is, as yet, unknown. We have noted that PEN histopathology is shared by KID. The clinical appearance of PEN can resemble that of KID syndrome. Furthermore, a recent report of cutaneous mosaicism for a GJB2 mutation associated with KID describes linear hyperkeratotic skin lesions that might be consistent with PEN. From this, we hypothesized that PEN might be caused by Cx26 mutations associated with KID or similar gap junction disorders. Thus, we analyzed the GJB2 gene in skin samples from two patients referred with generalized PEN. In both, we found GJB2 mutations in the PEN lesions but not in unaffected skin or peripheral blood. One mutation was already known to cause the KID syndrome, and the other had not been previously associated with skin symptoms. We provide extensive functional data to support its pathogenicity. We conclude that PEN may be caused by mosaic GJB2 mutations.

Differential susceptibility of Cx26 mutations associated with epidermal dysplasias to peptidoglycan derived from Staphylococcus aureus and Staphylococcus epidermidis.

Mutations in Connexin26 (Cx26) give rise to a spectrum of dominantly inherited hyperproliferating skin disorders, the severest being keratitis-ichthyosis-deafness (KID) syndrome, an inflammatory skin disorder, with patients prone to opportunistic infections. We compared the effects of peptidoglycan (PGN) extracted from the skin commensal Staphylococcus epidermidis and the opportunistic pathogen Staphylococcus aureus on interleukin-6 and connexin expression in HaCaT cells (a keratinocyte cell line) and connexin channel activity in HaCaT and HeLa (connexin deficient) cells transfected to express KID and non-KID Cx26 mutations. In both cell types, PGN from S. aureus induced hemichannel activity in cells expressing KID mutants as monitored by ATP release assays following 15-min challenge, while that from S. epidermidis evoked a response in HeLa cells. In KID mutant expressing cells, ATP release was significantly higher than in cells transfected with wild-type Cx26. No ATP release was observed in non-KID mutant transfected cells or in the presence of carbenoxolone, a connexin channel blocker. PGN isolated from S. aureus but not S. epidermidis induced interleukin-6 and Cx26 expression in HaCaT cells following 6-h challenge. Challenge by PGN from S. aureus evoked a greater interleukin-6 response in cells expressing KID mutants than in cells expressing wtCx26 or non-KID mutants. This response returned to basal levels if acute KID hemichannel signalling was blocked prior to PGN challenge. Thus, KID mutants form channels that can be triggered by the pro-inflammatory mediator PGN from opportunistic pathogens but not skin commensals, providing further insight into the genotype-phenotype relationship of Cx26 disorders.

Improving colonoscopy referral rates through computer-supported, primary care practice redesign.

This quality improvement project was designed to improve rates of referral for colonoscopy screening in the Utah Health Research Network, University of Utah Community Clinics. This study was conducted between October 2004 and June 2007 with the main intervention being a clinic workflow modification using computerized screening reminders embedded in the electronic medical record (EMR). The intervention led to sustained improvement, largely driven by the performance of two network clinics. This study demonstrates that a robust EMR, with decision prompts, accompanied by clinic workflow changes and feedback to providers, can lead to sustained change in the rates of colonoscopy referral.

Relationship of intraocular pulse pressure and spontaneous venous pulsations.

PURPOSE: To determine the influence of intraocular pulse pressure (IOPP) on the presence of spontaneous venous pulsations (SVP) in patients with normal intracranial pressure. DESIGN: Clinic-based cross-sectional study. METHODS: Forty-seven patients without signs and symptoms of elevated intracranial pressure were recruited from a general ophthalmology clinic. Patients with glaucoma or retinal vascular disease were excluded from the study. IOP was determined by applanation, and IOPP was measured with the Pascal Dynamic Contour Tonometer (Ziemer Group, Port, Switzerland). SVP were assessed by undilated (direct) and dilated indirect ophthalmoscopy. Other variables assessed included age, cup-to-disc ratio, and refractive error (spherical equivalent). The main outcome measure was the presence of SVPs with normal IOPP. RESULTS: The incidence of SVPs declined with increasing age in a nonlinear manner. Dilated examinations yielded the greatest sensitivity for detecting SVPs, with 91.5% of subjects having SVPs. However, in subjects with IOPP of 1.2 mm Hg or more in at least one eye, the incidence of SVPs was 100%. CONCLUSIONS: A significant correlation exists between the amplitude of IOPP and the presence of SVPs, with SVPs detected in one or both eyes of all patients with IOPP of 1.2 mm Hg or more. When IOPP is 1.2 mm Hg or more, absent SVPs may be more predictive of elevated intracranial pressure than previously recognized.

The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors.

OBJECTIVES: To explore changes in mortality and hospital usage for chronically ill seniors enrolled in a multidisease care management program, Care Management Plus (CMP). DESIGN: Controlled clinical trial with seven intervention and six control clinics with additional patient-level matching. SETTING: Intermountain Health Care, a large health system in Utah; seven intervention and six control clinics. PARTICIPANTS: Three thousand four hundred thirty-two senior patients (>or=65) enrolled in Medicare. INTERVENTION: The intervention employed nurse care managers supported by specialized information technology in primary care to manage chronically ill patients (2002-2005). MEASUREMENTS: Mortality and hospitalization data were collected from clinical records and Medicare billing. RESULTS: One thousand one hundred forty-four intervention patients were matched to 2,288 controls. Average age was 76.2; average comorbidity score was 2.3+/-1.1; 75% of patients had two or more chronic diseases. Survival analyses showed lower mortality and slightly more emergency department visits for care managed patients than for controls. In patients with diabetes mellitus, the intervention resulted in significantly lower mortality at 1 year (6.2%, vs 10.6% for controls) and at 2 years (12.9% vs 18.2%). Hospitalization rate was lower (21.0%, vs. 24.2% for controls) at 1 year and substantially more so at the 2-year follow-up. CONCLUSION: CMP was successful in reducing death for all patients. For complex patients with diabetes mellitus in the intervention group, death and hospital usage were lower. Per clinic, hypothesized savings from decreased hospitalizations was $17,384 to $70,349.

Ocular diseases and nonbattle injuries seen at a tertiary care medical center during the Global War on Terrorism.

We retrospectively reviewed the records of 107 U.S. military personnel referred to the Walter Reed Army Medical Center ophthalmology service with eye diseases and nonbattle injuries diagnosed during Operation Enduring Freedom and Operation Iraqi Freedom. Ocular diseases and nonbattle injuries ranged from minor to vision-threatening, represented a broad variety of conditions, and required the expertise of a number of ophthalmic subspecialists. The most common diagnoses were uveitis (13.1%), retinal detachment (11.2%), infectious keratitis (4.7%), and choroidal neovascularization (4.7%). Eighty-four patients (78.5%) met Army retention standards and were returned to duty. Twenty patients (18.7%) were referred to a medical evaluation board, seven (6.5%) of whom failed to meet retention standards for eye and vision; the retention status of three patients (2.8%) remains to be determined.

Care management dosage.

BACKGROUND: The care of patients with complex illnesses requires careful management, but systems of care management (CM) vary in their structure and effectiveness. OBJECTIVE: To create a framework identifying components of broad-based CM interventions and validate the framework, including using this framework to evaluate the contribution of varying components on outcomes of patients with chronic illness. DESIGN: We create the framework using retrospective information about CM activities and services over 12 months and categorize it using cluster and factor analysis. We then validate this framework through content and criterion techniques. Content validity is assessed through a Delphi study and criterion validity through relationship of the dosage measures and patterns of care to process and outcomes measures. PARTICIPANTS: Patients with diabetes and/or cardiovascular disease receiving CM services in a model known as Care Management Plus implemented in primary care. RESULTS: Six factors of CM activity were identified, including a single dosage summary measure and 5 separate patterns of care. Of these, the overall dosage summary measure, face-to-face time, duration of follow-up, and breadth of services were all related to improved processes for hemoglobin A1c and LDL testing and control. Brief intense patterns of care and high face-to-face care manager time were also related to improved outcomes. CONCLUSIONS: Using this framework, we isolate components of a CM intervention directly related to improved process of care or patient outcomes. Current efforts to structure CM to include face-to-face time and multiple diseases are discussed.

Statewide identification of adverse events using retrospective nurse review: methods and outcomes.

This study was conducted as part of a two-state study of the validity of hospital discharge data for adverse event (AE) surveillance. Reliability of nurse identification of AEs was assessed through comparison with physician review. Nurses reviewed 6,296 medical records selected from two sampling frames. All were patients in 41 Utah acute care hospitals and surgery patients in 36 Missouri hospitals. A total of 1,035 records were independently reviewed by physicians using the same methods. Overall agreement between nurse and physician findings in Utah and Missouri, at the case level, was 78.5% (238/303) and 68.2% (499/732), respectively. Nurse review of medical records to identify AEs represents a cost-effective alternative to physician review for large-scale and ongoing patient safety improvements and surveillance purposes.

Acanthamoeba keratitis in a U.S. Army soldier after unauthorized use of contact lenses in the combat theater.

A 25-year-old active duty Army E-5 developed severe infectious keratitis in his left eye secondary to soft contact lens (CL) wear while deployed in Iraq, necessitating evacuation to Walter Reed Army Medical Center for further evaluation and treatment. Initial clinical examination at Walter Reed Army Medical Center was suggestive of Acanthamoeba keratitis, a serious corneal pathogen associated with CL wear. In vivo confocal microscopy demonstrated Acanthamoeba cysts in the epithelium and anterior stroma, and smears and cultures from an epithelial biopsy specimen confirmed the diagnosis of Acanthamoeba keratitis. To our knowledge this is the first reported case of Acanthamoeba keratitis in a soldier wearing CLs in the combat theater. Because of the inability to maintain proper lens hygiene in a combat or field environment, the risk of developing a potentially sight-threatening corneal infection is significant. This unfortunate case of a devastating eye infection serves as a reminder of the current Army policy, which prohibits the use of CLs during gas chamber exercises, field training, and combat.

Improved clinical outcomes with utilization of a community-acquired pneumonia guideline.

BACKGROUND: We previously reported decreased mortality following implementation of a community-acquired pneumonia guideline derived from specialty society recommendations. However, patients with respiratory failure and sepsis from pneumonia were not included, adjustment for comorbidities was limited, and no guideline compliance data were available. We also questioned whether decreased mortality continued after 1997. METHODS: We utilized Utah data from the Centers for Medicare and Medicaid from 1993 to 2003 to determine if pneumonia guideline implementation was associated with 30-day all-cause mortality, length of hospital stay, and readmission rate. We adjusted outcomes by age, gender, Deyo comorbidity score, prior hospitalizations, and race. Guideline compliance was measured by initial default guideline antibiotic administration. We included patients > or = 66 years old with primary International Classification of Diseases, Ninth Revision, Clinical Modification codes 480.0-483.9, 485.0-486.9, 487.0, 507.0 or 518.81, and 038.x with secondary code pneumonia. We excluded patients with prior hospitalization within 10 days, patients with HIV infection or transplant recipients, and patients not treated by physicians closely affiliated with study hospitals. RESULTS: Mean (+/- SD) age of 17,728 pneumonia patients admitted to the hospital was 72.3 +/- 12.0 years, 55.2% were female, and 96.0% were white. Within Intermountain Healthcare hospitals, a 1-SD increase (10%) in guideline compliance (range, 61 to 100%) was associated with mortality odds ratio (OR) of 0.92 (95% confidence interval[CI], 0.87 to 0.98; p = 0.007). Mortality OR at 16 Intermountain Healthcare hospitals was 0.89 (95% CI, 0.82 to 0.97; p = 0.007) compared with 19 other Utah hospitals. This mortality difference corresponds to approximately 20 lives saved yearly. The readmission rate was also lower. CONCLUSION: Improved clinical outcomes were associated with pneumonia guideline utilization.

Use of health-related, quality-of-life metrics to predict mortality and hospitalizations in community-dwelling seniors.

OBJECTIVES: To investigate whether health-related quality-of-life (HRQoL) scores in a primary care population can be used as a predictor of future hospital utilization and mortality. DESIGN: Prospective cohort study measuring Short Form 12 (SF-12) scores obtained using a mailed survey. SF-12 scores, age, and a comorbidity score were used to predict hospitalization and mortality rate using multivariable logistic regression and Cox proportional hazards during the ensuing 28-month period for elderly patients. SETTING: Intermountain Health Care, a large integrated-delivery network serving a population of more than 150,000 seniors. PARTICIPANTS: Participants were senior patients who had one or more chronic diseases, were community dwelling, and were initially treated in primary care clinics. MEASUREMENTS: SF-12 survey Version 1. RESULTS: Seven thousand seventy-six surveys were sent to eligible participants; 3,042 (43%) were returned. Of the returned surveys, 2,166 (71%) were complete and scoreable. For the respondent group, a multivariable analysis demonstrated that older age, male sex, higher comorbidity score, and lower mental and physical summary measures of SF-12 predicted higher mortality and hospitalization. On average, nonresponders were older and had higher comorbidity scores and mortality rates than responders. CONCLUSION: The SF-12 survey provided additional predictive ability for future hospitalizations and mortality. Such predictive ability might facilitate preemptive interventions that would change the course of disease in this segment of the population. However, nonresponder bias may limit the utility of mailed SF-12 surveys in certain populations.

Impact of generalist care managers on patients with diabetes.

OBJECTIVE: To determine how the addition of generalist care managers and collaborative information technology to an ambulatory team affects the care of patients with diabetes. STUDY SETTING: Multiple ambulatory clinics within Intermountain Health Care (IHC), a large integrated delivery network. STUDY DESIGN: A retrospective cohort study comparing diabetic patients treated by generalist care managers with matched controls was completed. Exposure patients had one or more contacts with a care manager; controls were matched on utilization, demographics, testing, and baseline glucose control. Using role-specific information technology to support their efforts, care managers assessed patients' readiness for change, followed guidelines, and educated and motivated patients. DATA COLLECTION: Patient data collected as part of an electronic patient record were combined with care manager-created databases to assess timely testing of glycosylated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels and changes in LDL and HbA1c levels. PRINCIPAL FINDINGS: In a multivariable model, the odds of being overdue for testing for HbA1c decreased by 21 percent in the exposure group (n=1,185) versus the control group (n=4,740). The odds of being tested when overdue for HbA1c or LDL increased by 49 and 26 percent, respectively, and the odds of HbA1c <7.0 percent also increased by 19 percent in the exposure group. The average HbA1c levels decreased more in the exposure group than in the controls. The effect on LDL was not significant. CONCLUSIONS: Generalist care managers using computer-supported diabetes management helped increase adherence to guidelines for testing and control of HbA1c levels, leading to improved health status of patients with diabetes.

Corneal iron line following LASIK with epithelial ingrowth.

PURPOSE: To report a new corneal iron line following keratorefractive surgery. METHODS: Case report and review of the literature. A 51-year-old man developed epithelial ingrowth after otherwise uneventful LASIK surgery. The patient, satisfied with an uncorrected visual acuity of 20/25 and otherwise asymptomatic, declined to have his flap relifted to treat the ingrowth. RESULTS: Six months postoperatively a corneal iron line was noted at the leading edge of the epithelial ingrowth. Vision remained stable. CONCLUSIONS: : Epithelial iron lines have been reported with a number of conditions, including post-refractive procedures. This is the first report of an iron line associated with epithelial ingrowth following LASIK.