Effectiveness of prediabetes nutrition shared medical appointments: prevention of diabetes.

PURPOSE: The purpose of this study is to evaluate the effectiveness of a nutrition-based shared medical appointment (SMA) intervention in the treatment of prediabetes compared to the individualized counseling standard of care. METHODS: A randomized controlled trial design comparing health outcomes in patients with prediabetes attending either an individualized counseling (control group) or three 90-minute nutrition SMA (intervention group) sessions. Demographic, anthropometric (weight and body mass index), clinical (blood pressure), and biochemical (lipid profile, fasting blood sugar, glycated hemoglobin, albumin-to-creatinine ratio) measures were obtained from all participants at baseline, at 3 months, and at 1 year. RESULTS: Ninety-four participants were randomized into the 2 study groups with a 69% completion rate at 1 year (n = 34 SMA, n = 31 control). The average participant was Caucasian (64%), male (54%), 58.3 ± 9.6 years, had a BMI of 30.8 ± 4.9 kg/m(2) (obese), and fasting blood glucose of 109 ± 9.5 mg/dL. The SMA and control participants lost a mean of 6.6 pounds and 3.6 pound, respectively; neither group met the 5% modest weight loss expected. The SMA and control group experienced a mean drop in fasting blood glucose of 6 mg/dL. CONCLUSIONS: As demands on health care providers continue to rise, finding innovative ways to manage the patient load while providing quality health care is increasingly important. SMA health outcomes were equivalent to individual counseling outcomes, while increasing the provider's productivity by treating 6 to 8 people with prediabetes in 90 minutes compared to 1 patient in 60 minutes.

Limited-sampling strategies for anti-infective agents: systematic review.

BACKGROUND: Area under the concentration-time curve (AUC) is a pharmacokinetic parameter that represents overall exposure to a drug. For selected anti-infective agents, pharmacokinetic-pharmacodynamic parameters, such as AUC/MIC (where MIC is the minimal inhibitory concentration), have been correlated with outcome in a few studies. A limited-sampling strategy may be used to estimate pharmacokinetic parameters such as AUC, without the frequent, costly, and inconvenient blood sampling that would be required to directly calculate the AUC. OBJECTIVE: To discuss, by means of a systematic review, the strengths, limitations, and clinical implications of published studies involving a limited-sampling strategy for anti-infective agents and to propose improvements in methodology for future studies. METHODS: The PubMed and EMBASE databases were searched using the terms "anti-infective agents", "limited sampling", "optimal sampling", "sparse sampling", "AUC monitoring", "abbreviated AUC", "abbreviated sampling", and "Bayesian". The reference lists of retrieved articles were searched manually. Included studies were classified according to modified criteria from the US Preventive Services Task Force. RESULTS: Twenty studies met the inclusion criteria. Six of the studies (involving didanosine, zidovudine, nevirapine, ciprofloxacin, efavirenz, and nelfinavir) were classified as providing level I evidence, 4 studies (involving vancomycin, didanosine, lamivudine, and lopinavir-ritonavir) provided level II-1 evidence, 2 studies (involving saquinavir and ceftazidime) provided level II-2 evidence, and 8 studies (involving ciprofloxacin, nelfinavir, vancomycin, ceftazidime, ganciclovir, pyrazinamide, meropenem, and alpha interferon) provided level III evidence. All of the studies providing level I evidence used prospectively collected data and proper validation procedures with separate, randomly selected index and validation groups. However, most of the included studies did not provide an adequate description of the methods or the characteristics of included patients, which limited their generalizability. CONCLUSIONS: Many limited-sampling strategies have been developed for anti-infective agents that do not have a clearly established link between AUC and clinical outcomes in humans. Future studies should first determine if there is an association between AUC monitoring and clinical outcomes. Thereafter, it may be worthwhile to prospectively develop and validate a limited-sampling strategy for the particular anti-infective agent in a similar population.

Disease management in Canada: surmounting barriers to adoption.

Disease Management (DM) programs are used to optimize economic outcomes and improve patient outcomes. Despite this, relative to the United States, Canadian health care organizations have been slow to adopt them. The objective of this article is to examine the concept of DM programs, the existing evidence to support their use and the barriers to their adoption in Canada. Several solutions aimed at overcoming the barriers to DM in Canada are proposed.

Selection of atypical antipsychotics for the management of schizophrenia.

OBJECTIVE: To review the evidence for selecting one atypical antipsychotic agent over another for management of schizophrenia. DATA SOURCES: A literature search of MEDLINE (1966-June 2003), EMBASE (1998-June 2003), and the Cochrane Library was conducted using the following terms: schizophrenia, quetiapine, ziprasidone, olanzapine, aripiprazole, and risperidone. Bibliographies of relevant articles were hand-searched for additional references. STUDY SELECTION AND DATA EXTRACTION: Prospective, randomized, blinded trials and meta-analyses that directly or indirectly compared > or =2 atypical antipsychotic agents in the management of schizophrenia are included in this review. Studies comparing an atypical agent with clozapine are not included. DATA SYNTHESIS: A small number of prospective, randomized, blinded trials that compare efficacy and tolerability of olanzapine and risperidone have been published. These trials did not reveal clinically meaningful differences in efficacy but did confirm that their adverse effect profiles are slightly different (more weight gain with olanzapine and more extrapyramidal reactions with risperidone). Direct comparisons between other atypical antipsychotics are not available. Systematic reviews (indirect comparisons) of placebo-controlled or traditional antipsychotic-controlled trials suggest similar efficacy for quetiapine, olanzapine, and risperidone when placebo is the comparator and inferior efficacy of quetiapine compared to olanzapine and risperidone when haloperidol is the comparator. The few available economic analyses are difficult to interpret in light of current practice. CONCLUSIONS: Additional randomized, blinded clinical trials directly comparing efficacy, tolerability, and cost-effectiveness are needed to confirm the proposed differences among atypical antipsychotic agents before recommendations can be made with confidence.