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BACKGROUND: Cervical cancer is the third most common malignancy affecting women. Screening with Papanicolaou (Pap) tests effectively identifies precancerous lesions and early-stage cervical cancer. While the nationwide rate of cervical cancer screening (CCS) is 84%, our urban general internal medicine (GIM) clinic population had a CCS rate of 70% in 2016. OBJECTIVE: To improve our clinic’s CCS rate to match or exceed the national average within 18 months by identifying barriers and testing solutions. DESIGN: A quality improvement project led by a multidisciplinary group of healthcare providers. PARTICIPANTS: Our GIM clinic includes 16 attending physicians, 116 resident physicians, and 20 medical assistants (MAs) with an insured and underserved patient population. INTERVENTION: Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period. MAIN MEASURES: Our primary outcome was the number of Pap tests completed per month during the 2 study phases. Our secondary outcome was the clinic population’s CCS rate for all eligible clinic patients. KEY RESULTS: After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64–2.10; P < 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40–3.02; P < 0.001). Our clinic’s CCS rate improved from 70% to 75% after the 18-month intervention. CONCLUSIONS: The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS.

Highlights • Community health worker (CHW) care benefits diabetes management. • Propensity score weighting was used to assess diabetes intervention effectiveness. • CHW coaching reduced hemoglobin A1c by at least 1.0% for most participants. • Most participants with diabetes working with the CHW met glycemic control., The burden of diabetes is higher in urban areas and among racial and ethnic minorities. The purpose of this research was to evaluate the effectiveness of extending a diabetes intervention program (DIP) by engaging a team, including a community health worker (CHW), to provide care for patients to meet glycemic control, specifically in a predominantly urban, minority patient population. The DIP enrolled diabetic patients from an internal medicine clinic. A CHW facilitated the collection of glucose meter readings. The CHW coached patients on glycemic control while the CHW’s registered nurse partner titrated the patient’s recommended insulin dose. Subsequent HbA1c values for participants were compared to those seen at the same clinic who were not enrolled. The DIP was deployed for nine months. One hundred forty-four patients were enrolled in the DIP and 348 patients constituted the comparator group. Ninety-three DIP participants had pre- and post-intervention HbA1c values and were compared to 348 non-DIP participants. Propensity score weighted adjusted analyses suggest that participants were more likely to reduce their HbA1c values by at least 1.0% and have HbA1c values of less than 8.0% (64 mmol/mol) than non-participants (adjusted odds ratio = aOR = 1.47, 95% CI 1.26–1.71, and aOR = 1.23, 95% CI 1.06–1.43, respectively). CHW coaches as part of a team in a clinical setting improved glycemic control in a predominantly urban, minority patient population.

Pancreatic adenocarcinoma has an incidence rate nearly equal to the mortality rate and is the fourth leading cause of cancer-related death in the USA. This is largely due to late symptom onset and diagnosis. Evidence has emerged that new-onset diabetes may be a symptom caused by occult pancreatic cancer. We report the case of a middle-aged African American female who presented with hyperglycemia and persistent scapular tenderness. She was subsequently diagnosed with new-onset diabetes and metastatic pancreatic cancer confirmed by liver biopsy. She did not have diabetes or pre-diabetes in the 6 months prior to presentation. The following report will serve to emphasize the role of new-onset diabetes in certain patients as a warning sign necessitating further investigation for pancreatic cancer. New-onset diabetes associated with specific risk factors may prompt for early testing, detection and treatment of pancreatic cancer.

IN BRIEF Most diabetic patients are managed by primary care physicians, but clinical inertia and limited time with patients hamper efforts to meet treatment goals. Successfully caring for the medical and psychosocial needs of the expanding diabetic population seen in primary care will require new strategies. This article reviews interdisciplinary efforts by primary care physicians, advanced practice nurses, and clinical pharmacists that can achieve improvements in clinical processes and outcomes at reasonable costs.

Introduction There are benefits of integrating a behavioral health specialist in primary care; however, little is known about the physicians' perspectives. The purpose of this study was to explore primary care physicians' beliefs regarding the benefits of integrated care for both patients and themselves. Method Fifteen senior staff physicians and 78 residents completed surveys regarding their opinions of referring to a psychologist in a patient-centered medical home. Results The top reasons that physicians believed their patients followed through with a visit with an integrated psychologist included that they recommended it (79.5%) and that patients can be seen in the same primary care clinic (76.9%). The overwhelming majority of physicians were satisfied with having access to an integrated psychologist (97.4%). Physicians believed that integrated care directly improves patient care (93.8%), is a needed service (90.3%), and helps provide better care to patients (80.9%). In addition, physicians reported that having an integrated psychologist reduces their personal stress level (90.1%). Conclusion Primary care physicians may be motivated to integrate behavioral health services into their clinics knowing that other physicians believe that it directly and indirectly improves patient care and physician stress.

Multiple variables are related to missed clinic appointments. However, the prevalence of missed appointments is still high suggesting other factors may play a role. The purpose of this study was to investigate the relationship between missed appointments and multiple variables simultaneously across a health care system, including patient demographics, psychiatric symptoms, cognitive functioning and literacy status. Chart reviews were conducted on 147 consecutive patients who were seen by a primary care psychologist over a six month period and completed measures to determine levels of depression, anxiety, sleep, cognitive functioning and health literacy. Demographic information and rates of missed appointments were also collected from charts. The average rate of missed appointments was 15.38%. In univariate analyses, factors related to higher rates of missed appointments included younger age (p = .03), lower income (p = .05), probable depression (p = .05), sleep difficulty (p = .05) and limited reading ability (p = .003). There were trends for a higher rate of missed appointments for patients identifying as black (p = .06), government insurance (p = .06) and limited math ability (p = .06). In a multivariate model, probable depression (p = .02) and limited reading ability (p = .003) were the only independent predictors. Depression and literacy status may be the most important factors associated with missed appointments. Implications are discussed including regular screening for depression and literacy status as well as interventions that can be utilized to help improve the rate of missed appointments.

The antithrombotic effect of the glycoprotein IIb/IIIa receptor antagonist, CRL42796, was examined in canine models of carotid and coronary artery thrombosis. In the carotid artery thrombosis model, occlusion occurred in all control vessels (time to thrombosis 47.6±8.9 min). After treatment with low dose CRL42796 (15 μg kg−1 loading dose +0.31 μg kg−1 min−1 i.v.), two of five vessels occluded. Time to thrombosis increased significantly to 155.2±23.1 min. When the drug infusion was increased (0.69 μg kg−1 min−1), each of five vessels remained patent. Ex vivo platelet aggregation in response to arachidonic acid (AA) and ADP was examined in platelet rich plasma (PRP) prepared from citrate or heparin anticoagulated blood. CRL42796 reduced platelet reactivity at low and high doses in PRP from citrate anticoagulated blood. However, in PRP from heparin anticoagulated blood, only the higher infusion dose produced a significant reduction in ex vivo platelet responses. A combination of oral aspirin (4.6 mg kg−1 −41, −17 h) and the low infusion dose of CRL42796 did not produce an additional benefit beyond that provided by CRL42796 alone. Coronary artery thrombosis was inhibited in four of five vessels treated with the lower infusion dose of CRL42796 and in five of five vessels treated with the higher infusion. Time to thrombosis increased with both doses (Control, 90.8±10.4 min; low dose, 165.8±14.2 min; high dose, >180.0±0 min). The results indicate that CRL42796 is an effective in vivo antithrombotic agent against experimentally-induced carotid and coronary artery thrombosis. British Journal of Pharmacology (2002) 136, 927–937. doi:10.1038/sj.bjp.0704744

A middle aged African-American woman with a stable history of carnitine palmitoyl transferase II (CPT II) deficiency presented with myalgias for 1 week. Physical examination and laboratory findings were consistent with severe sepsis secondary to pyelonephritis leading to rhabdomyolysis. Subsequent CT of the abdomen revealed bilateral supernumerary kidneys with non-obstructive calculi within the supernumerary kidneys. Abnormal ureteral development of the supernumerary kidneys likely led to an increased risk for urinary tract infections (UTIs) and renal calculi resulting in pyelonephritis. The stress of this infection overwhelmed the muscle CPT II enzyme load, putting her in a state of rhabdomyolysis. In addition to fluids and antibiotics, she was provided a diet rich in carbohydrates and low in fats so as to limit long-chain fatty acid oxidation. Supernumerary nephrectomy was not considered during this admission. During follow-up, she developed obstructive ureteral calculi requiring placement of a right-sided ureteral stent.

Background Prostanoid synthesis via the action of cyclooxygenase-2 (COX-2) is a component of the inflammatory response. Prostacyclin, a product of COX-2 in vascular endothelium, has important physiological roles, such as increasing blood flow to injured tissues, reducing leukocyte adherence, and inhibiting platelet aggregation. We examined the possibility that selective COX-2 inhibition could suppress the protective effects of prostacyclin, resulting in an alteration of the hemostatic balance and vascular tone. Methods and Results Circumflex coronary artery thrombosis was induced in dogs by vascular electrolytic injury. Orally administered celecoxib (COX-2 inhibition) or high-dose aspirin (HDA) (COX-1 and COX-2 inhibition) did not alter time to occlusive thrombus formation compared with controls (celecoxib 77.7±7.2 minutes, HDA 72.0±18.5 minutes, control 93.0±21.8 minutes). Oral HDA with an endothelial recovery period (HDA-ER) (COX-1 inhibition) produced a significant increase in time to vessel occlusion (257.0±41.6 minutes). The observed increase in time to occlusion was abolished when celecoxib was administered to animals dosed with HDA-ER (80.7±20.6 minutes). The vasomotor effect of endothelium-derived prostacyclin was examined by monitoring coronary flow during intracoronary administration of arachidonic acid or acetylcholine. In celecoxib-treated animals, vasodilation in response to arachidonic acid was reduced significantly compared with controls. Conclusions The results indicate important physiological roles for COX-2–derived prostacyclin and raise concerns regarding an increased risk of acute vascular events in patients receiving COX-2 inhibitors. The risk may be increased in individuals with underlying inflammatory disorders, including coronary artery disease.

Health literacy impacts health outcomes. However, the relationship to blood pressure is inconsistent. This study aimed to determine whether health literacy, assessed by clinic staff, is associated with blood pressure among patients with hypertension. The design was a cross-sectional study of a large sample of primary care patient encounters in 3 academic medical center clinics in Nashville, Tennessee. Health literacy was assessed using the Brief Health Literacy Screen, with higher scores indicating higher health literacy. Blood pressure was extracted from the electronic health record. Using 23,483 encounters in 10,644 patients, the authors examined the association of health literacy with blood pressure in multivariable analyses, adjusting for age, gender, race, education, and clinic location. Independent of educational attainment, 3-point increases in health literacy scores were associated with 0.74 mmHg higher systolic blood pressure (95% CI [0.38, 1.09]) and 0.30 mmHg higher diastolic blood pressure (95% CI [0.08, 0.51]). No interaction between education and health literacy was observed (p = .91). In this large primary care population of patients with hypertension, higher health literacy, as screened in clinical practice, was associated with a small increase in blood pressures. Future research is needed to explore this unexpected finding.

This study investigates the effect of the glycoprotein IIb/IIIa receptor antagonist CRL42796 in a canine model of carotid artery thrombosis. Both carotid arteries developed occlusive thrombosis in each of the five control animals (time to occlusion: right carotid artery, 92.6 minutes; left carotid artery, 89.0 minutes). A single oral dose of CRL42796 (3 mg/kg) prevented occlusive thrombosis in 4 of 6 vessels and increased time to thrombosis, albeit not significantly (right carotid artery, 134.1 minutes; left carotid artery, 145.0 minutes). When the initial dose of CRL42796 was followed by a second oral dose (3 mg/kg) 2 hours later, 10 of 10 carotid arteries remained patent throughout the period of electrolytic injury. CRL42796 reduced thrombus weight in both treatment protocols. Ex vivo platelet aggregation with arachidonic acid (AA) or adenosine diphosphate (ADP) was reduced at 120, 240, and 360 minutes after two doses of CRL42796. A single oral dose reduced ADP-induced responses at 240 and 360 minutes, but significant effects were not observed with AA. Bleeding time increased 360 minutes after two oral doses of CRL42796, but not at 120 minutes. Bleeding time was unchanged with the single dose of CRL42796. The results demonstrate that oral administration of CRL42796 prevents carotid artery thrombosis in response to deep vessel wall injury and may have potential value to be characterized in extended preclinical and clinical study.

1. The antithrombotic effect of the glycoprotein IIb/IIIa receptor antagonist, CRL42796, was examined in canine models of carotid and coronary artery thrombosis. 2. In the carotid artery thrombosis model, occlusion occurred in all control vessels (time to thrombosis 47.6+/-8.9 min). After treatment with low dose CRL42796 (15 microg kg(-1) loading dose +0.31 microg kg(-1) min(-1) i.v.), two of five vessels occluded. Time to thrombosis increased significantly to 155.2+/-23.1 min. When the drug infusion was increased (0.69 microg kg(-1) min(-1)), each of five vessels remained patent. 3. Ex vivo platelet aggregation in response to arachidonic acid (AA) and ADP was examined in platelet rich plasma (PRP) prepared from citrate or heparin anticoagulated blood. CRL42796 reduced platelet reactivity at low and high doses in PRP from citrate anticoagulated blood. However, in PRP from heparin anticoagulated blood, only the higher infusion dose produced a significant reduction in ex vivo platelet responses. 4. A combination of oral aspirin (4.6 mg kg(-1) -41, -17 h) and the low infusion dose of CRL42796 did not produce an additional benefit beyond that provided by CRL42796 alone. 5. Coronary artery thrombosis was inhibited in four of five vessels treated with the lower infusion dose of CRL42796 and in five of five vessels treated with the higher infusion. Time to thrombosis increased with both doses (Control, 90.8+/-10.4 min; low dose, 165.8+/-14.2 min; high dose,180.0+/-0 min). 6. The results indicate that CRL42796 is an effective in vivo antithrombotic agent against experimentally-induced carotid and coronary artery thrombosis.

Article-at-a-Glance Background Patients with inadequate health literacy often have poorer health outcomes and increased utilization and costs. The Institute of Medicine has recommended that health literacy assessment be incorporated into health care information systems, which would facilitate large-scale studies of the effects of health literacy, as well as evaluation of system interventions to improve care by addressing health literacy. As part of the Health Literacy Screening (HEALS) study, a Brief Health Literacy Screen (BHLS) was incorporated into the electronic health record (EHR) at a large academic medical center. Methods Changes were implemented to the nursing intake documentation across all adult hospital units, the emergency department, and three primary care practices. The change involved replacing previous education screening items with the BHLS. Implementation was based on a quality improvement framework, with a focus on acceptability, adoption, appropriateness, feasibility, fidelity and sustainability. Support was gained from nursing leadership, education and training was provided, a documentation change was rolled out, feedback was obtained, and uptake of the new health literacy screening items was monitored. Results Between November 2010 and April 2012, there were 55,611 adult inpatient admissions, and from November 2010 to September 2011, 23,186 adult patients made 39,595 clinic visits to the three primary care practices. The completion (uptake) rate was 91.8% for the hospital and 66.6% for the outpatient clinics. Conclusions Although challenges exist, it is feasible to incorporate health literacy screening into clinical assessment and EHR documentation. Next steps are to evaluate the association of health literacy with processes and outcomes of care across inpatient and outpatient populations.

Presentation This article summarizes the three types of hybrid effectiveness-implementation designs and associated evaluation methods. It includes a discussion of how hybrid designs have the potential to enhance knowledge development and application of clinical interventions and implementation strategies in “real world” settings. The authors propose implications of hybrid designs for qual