Evaluation of a chronic disease management system for the treatment and management of diabetes in primary health care practices in Ontario: an observational study.

BACKGROUND: Computerized chronic disease management systems (CDMSs), when aligned with clinical practice guidelines, have the potential to effectively impact diabetes care. OBJECTIVE: The objective was to measure the difference between optimal diabetes care and actual diabetes care before and after the introduction of a computerized CDMS. METHODS: This 1-year, prospective, observational, pre/post study evaluated the use of a CDMS with a diabetes patient registry and tracker in family practices using patient enrolment models. Aggregate practice-level data from all rostered diabetes patients were analyzed. The primary outcome measure was the change in proportion of patients with up-to-date "ABC" monitoring frequency (i.e., hemoglobin A1c, blood pressure, and cholesterol). Changes in the frequency of other practice care and treatment elements (e.g., retinopathy screening) were also determined. Usability and satisfaction with the CDMS were measured. RESULTS: Nine sites, 38 health care providers, and 2,320 diabetes patients were included. The proportion of patients with up-to-date ABC (12%), hemoglobin A1c (45%), and cholesterol (38%) monitoring did not change over the duration of the study. The proportion of patients with up-to-date blood pressure monitoring improved, from 16% to 20%. Data on foot examinations, retinopathy screening, use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and documentation of self-management goals were not available or not up to date at baseline for 98% of patients. By the end of the study, attitudes of health care providers were more negative on the Training, Usefulness, Daily Practice, and Support from the Service Provider domains of the CDMS, but more positive on the Learning, Using, Practice Planning, CDMS, and Satisfaction domains. LIMITATIONS: Few practitioners used the CDMS, so it was difficult to draw conclusions about its efficacy. Simply giving health care providers a potentially useful technology will not ensure its use. CONCLUSIONS: This real-world evaluation of a web-based CDMS for diabetes failed to impact physician practice due to limited use of the system. PLAIN LANGUAGE SUMMARY: Patients and health care providers need timely access to information to ensure proper diabetes care. This study looked at whether a computer-based system at the doctor's office could improve diabetes management. However, few clinics and health care providers used the system, so no improvement in diabetes care was seen.

Dental health in Iron Age Cambodia: Temporal variations with rice agriculture.

The dental health of two Cambodian Iron Age (500 BC to 500 AD) communities is interpreted through an analysis of advanced wear, caries, periapical lesions, and antemortem tooth loss (AMTL). The two communities, Phum Snay and Phum Sophy, just 40km apart, are temporally situated at a time of significant socio-political change prior to the establishment of Angkorian state rule. Dental pathology frequencies are compared between the two communities and with other prehistoric sites throughout Southeast Asia to determine whether dental health was affected by socio-political changes and the intensification of rice agriculture that also occurred at this time. The people of Snay and Sophy, despite their proximity, were found to exhibit significant differences in dental health. When subdivided by age and sex, Sophy older age class teeth had significantly more advanced wear, and older females had more periapical lesions, while the Phum Snay older age dentitions had significantly more AMTL. Caries rates were similar between the samples. When compared in the broader context of the Iron Age in prehistoric Southeast Asia, both Phum Snay and Phum Sophy suggest a trend of declining dental health during the period prior to the rise of the Angkorian state.

Proceedings of the DMS medical ethics symposium.

This article presents the proceedings of a symposium on medical ethics held at the Royal Centre for Defence Medicine in October 2010. The nature of current operations continually generates challenging ethical problems, many of which are unique to the military environment. This article is intended to generate a debate on these difficult issues and readers are encouraged to contribute to this debate by emailing the Editor.

Analysis of the initial 100 scans from the first CT scanner deployed by the British armed forces in a land environment.

AIMS: To examine usage of the first CT scanner installed in a UK field hospital, BMH Shaibah, over a 13 month period. METHODS: All request forms and reports for the first 100 studies were analysed retrospectively. RESULTS: An average of 7.7 scans per month was performed. Trauma was the most common indication followed by urinary symptoms and headache. Significant pathology was diagnosed in many cases. CONCLUSION: A deployed CT scanner can make a significant contribution to the capability of a field hospital, shaping both the management and disposal of patients. A more easily deployable scanner will be needed in future.

Clinical significance of concurrent hepatitis B surface antigen and antibody positivity.

Over a period of 30 months, 64 patients with concurrently positive hepatitis B surface antigen (HBsAg) and antibody (anti-HBs) were identified at two institutions. When all assays were considered, 23.9% of HBsAg-positive individuals exhibited anti-HBs. Both persistent HBsAg/anti-HBs positivity and variable changes in antigen or antibody status were observed among the 36 patients with follow-up beyond six months. When compared to a control group, these patients did not exhibit differences in risk factors for acquiring hepatitis B or in clinical and histological diagnoses. Concurrent HBsAg and anti-HBs was present at detection in 25 patients, while antibody appeared in the remaining 11 subjects. Subsequently, it was undetectable in seven of these 36 patients; no clinical changes occurred at the time of acquisition or loss of the antibody. The titer of the antibody was below 10 mIU/ml in 75% of these individuals. In 10 patients, the subtype of HBsAg was ad, while the anti-HBs was anti-y. Concurrent HBsAg and anti-HBs is a pattern frequently observed throughout the spectrum of hepatitis B-related events. The heterotypic antibody in these patients is of a low titer, and its appearance or disappearance is not associated with changes in the clinical course; simultaneous HBsAg/anti-HBs positivity does not appear to reflect a distinct clinical entity.

Distribution of portal blood flow in the liver of the rat: a microsphere study.

We sought to determine whether streamlining of portal venous blood occurs in normal anaesthetized rats under basal conditions and with variations in hepatic blood flow. We catheterized the ileocolic vein and injected 15 micron microspheres labeled with 85Sr and 141Ce into this vein and into the spleen, respectively. The hepatic lobar distribution of microspheres was studied in a group under basal conditions and after hepatic blood flow was increased (infusions of nitroglycerin or glucagon) or decreased (infusion of vasopressin or ligation of the superior mesenteric artery); this blood flow was measured with a constant infusion of indocyanine green. Measured results (expressed as proportion of total liver counts per minute) were compared with a reference group in which the portal vein of rats had been partially ligated 10 days prior to study and in which similarly injected microspheres that lodged in the liver were assumed to be completely mixed with portal blood. No differences were seen within groups and between the reference and experimental groups. We conclude that under these experimental conditions, portal venous blood flow appears to be distributed homogeneously between hepatic lobes.

Portal-systemic shunting and the hemodynamic effects of nitroglycerin in the rat.

A hemodynamic response to oral nitroglycerin has been used recently to estimate the extent of portal systemic shunts in humans. We studied the hemodynamic effects of this drug in the rat with partial portal vein ligation, a model in which portal hypertension develops and the extent of portal-systemic collaterals can be measured. Two to ten days after the initial procedure, shunted and sham-operated controls received a continuous infusion of nitroglycerin into a jugular vein, the ileocolic vein, or intrajejunally. The response of systolic arterial pressure to intravenous nitroglycerin was similar in shunted and sham animals. The cumulative dose-response curve showed an earlier and more pronounced response in shunted rats receiving nitroglycerin intraportally, suggesting a marked increase in bioavailability. When the arterial response to nitroglycerin, infused intraportally at 1 microgram/kg X min, was compared to the extent of ileocolic shunting, measured with radioactive microspheres, a close correlation (r = 0.84) was seen; shunting values ranged from 0% (sham) to 97%. Additionally, in shunted rats a more pronounced response to intraportal, compared to intrajejunal, infusion suggested a contribution of the intestine to the first-pass elimination of the drug. The bioavailability of intraportal and intrajejunal nitroglycerin is influenced by the extent of portal systemic collaterals. A significant reduction in portal vein pressure in response to nitroglycerin seen in this animal model supports its testing as a therapeutic agent in portal hypertension.

Heterotopic pancreas mimicking carcinoma of the head of the pancreas: a rare cause of obstructive jaundice.

A 61-year-old man developed obstructive jaundice and had ultrasonographic and cholangiopancreatographic findings consistent with carcinoma of the pancreas. However, pathologically the obstruction proved to be from heterotopic pancreatic tissue compressing the common bile duct. This patient and eight previously reported patients with a similar problem are the subjects of this report.