An Advanced Clinician Practitioner in Arthritis Care (ACPAC) Maintains a Positive Patient Experience While Increasing Capacity in Rheumatology Community Care.

PURPOSE: This study describes patient care experiences of solo-rheumatologist and co-managed care models utilizing an Advanced Clinician Practitioner in Arthritis Care-trained Extended Role Practitioner (ACPAC-ERP) in three community rheumatology practices. MATERIALS AND METHODS: Patients with inflammatory arthritis (IA) were assigned to care provided by one of three (2 senior, 1 early-career) community-based rheumatologists (usual care), or an ACPAC-ERP (co-managed care) for the 6-months following diagnosis. Patient experiences were surveyed using validated measures of patient satisfaction (Patient Doctor Interaction Scale-PDIS), global ratings of confidence and satisfaction, referral patterns, disease activity (RADAI) and self-perceived disability (HAQ-Disability) as well as demographic information. Practice capacity was evaluated 18-months prior to, and across, the study period. RESULTS: Of 55 participants (mean age 56.6 years, 61.8% female), 33 received co-managed care. Most participants were diagnosed with rheumatoid arthritis (65.5%) with a median symptom duration of 1.1 years. At 6-months, patients from both models of care were equally satisfied in terms of the information provided (usual care 4.6 vs co-managed care 4.7/5=greater satisfaction), rapport with health-care provider (4.6 vs 4.6/5) and having needs met (4.7 vs 4.5/5). Overall satisfaction was high (87.2 vs 85.3/100=completely satisfied) as was confidence in the system by which care was received (85.0 vs 82.1/100=completely confident). Usual care patients reported higher perceived disability than co-managed patients (HAQ-Disability 0.5 vs 0.2/3=unable to do). Significant differences in overall RADAI score (p=0.014) were found between the two models. The senior rheumatologist, with a previously saturated practice, attained a 37% capacity increase for new patients utilizing the co-managed care model. CONCLUSION: The ACPAC-ERP model was equivalent to the solo-rheumatologist model with regard to patient experience and satisfaction. A co-management model utilizing a highly trained ACPAC-ERP can increase capacity in community rheumatology clinics for patients newly diagnosed with IA while maintaining confidence and satisfaction with their care.

Characterization and treatment response of anxious children with asthma.

OBJECTIVES: To compare children with Axis I anxiety disorders and asthma with a matched group of anxious children without asthma on questionnaire measures and response to cognitive-behavioural treatment (CBT) for anxiety. METHOD: A sample of 36 children with comorbid anxiety and asthma, aged 8 to 12 years, were matched for age, sex, and specific anxiety disorder with 36 children with an Axis I anxiety disorder but no asthma. Parents and children completed standardized questionnaires. RESULTS: Children with comorbid anxiety and asthma had significantly more perinatal complications (P = 0.001), and higher total (P = 0.000) and psychological stressors (P = 0.02), especially parent-child problems (P = 0.01), but lower levels of depression (P = 0.03) and anxiety (P = 0.05), compared with anxious, nonasthmatic children. All children reported decreased anxiety (P = 0.001) and depression (P = 0.000) posttreatment, with a trend toward less improvement in anxiety in anxious children with asthma. CONCLUSIONS: Although replication is needed, addressing psychosocial stress and parent-child problems may increase CBT efficacy in children with comorbid anxiety and asthma.

Increased angiopoietin2 expression is associated with endothelial apoptosis and blood-brain barrier breakdown.

Normal intracerebral and pial vessels show constitutive expression of angiopoietin (Ang) 1 in endothelium while weak Ang2 immunoreactivity is present in occasional vessels. In the early phase postinjury, blood-brain barrier (BBB) breakdown at the lesion site is associated with decreased endothelial Ang1 and increased Ang2 expression, raising the possibility that Ang2 may have a role in early BBB breakdown. In order to determine whether Ang2 can cause BBB breakdown, the effect of recombinant Ang2 on cerebrovascular permeability to horseradish peroxidase (HRP) was studied in normal rat cortex. As hypothesized, Ang2 produced significant BBB breakdown to HRP as compared with vehicle-injected control rats. Since Ang2 is reported to have proapoptotic activity, the possibility that Ang2 may be associated with endothelial apoptosis was investigated in the rat cortical cold injury model over a period of 6 h to 6 days postinjury. Perilesion and pial vessels showed evidence of endothelial apoptosis as demonstrated by active Caspase-3 localization and TUNEL staining. Dual labeling for Ang proteins and active Caspase-3 demonstrated endothelial colocalization of Ang2 with active caspase-3. These data suggest that following injury, Ang2 may play a role in BBB breakdown of perilesional vessels, and it may also be a factor in endothelial cell apoptosis that occurs at days 1 and 2 following the injury.