Background Studies have demonstrated that blood pressure (BP) control can be improved when clinical pharmacists assist with patient management. The purpose of this study was to evaluate the effectiveness of a physician/pharmacist intervention to improve BP control. Methods This was a prospective, cluster-randomized controlled clinical trial with clinics randomized to control (n=3) or intervention (n=3) groups. The study enrolled 402 patients with uncontrolled hypertension (mean age 58.3 years). Clinical pharmacists made drug-therapy recommendations to physicians based on national guidelines. Research nurses performed BP measurements and 24-hour BP monitoring. Results Guideline adherence scores increased from 49.4 ± 19.3 at baseline to 53.4 ± 18.1 at 6 months (9% increase) in the control group and from 40.4 ± 22.6 to 62.8 ± 13.5 (57% increase) in the intervention group (p=0.089 adjusted comparison between groups). Mean BP decreased 6.8/4.5 and 20.7/9.7 mm Hg in the control and intervention groups, respectively, (p<0.05 for between-group systolic BP (SBP) comparison). The adjusted difference in SBP was −12.0 (95% CI: −24.0, 0.0) mm Hg, while the difference in diastolic BP (DBP) was −1.8 (CI: −11.9, 8.3). The 24-hour BP levels showed similar effect sizes. BP was controlled in 29.9% of patients in the control group and 63.9% in the intervention group (adjusted odds ratio 3.2; CI: 2.0, 5.1; p<0.001). Conclusions A physician/pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates when compared to a control group. Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management.

Microbial burden of chronic wounds is believed to play an important role in impaired healing and development of infection-related complications. However, clinical cultures have little predictive value of wound outcomes, and culture-independent studies have been limited by cross-sectional design and small cohort size. We systematically evaluated the temporal dynamics of the microbiota colonizing diabetic foot ulcers (DFU), a common and costly complication of diabetes, and its association with healing and clinical complications. Dirichlet multinomial mixture modeling, Markov chain analysis, and mixed-effect models were used to investigate shifts in the microbiota over time and its associations with healing. Here we show to our knowledge previously unreported temporal dynamics of the chronic wound microbiome. Microbiota community instability was associated with faster healing and improved outcomes. DFU microbiota were found to exist in one of four community types that experienced frequent and non-random transitions. Transition patterns and frequencies associated with healing time. Exposure to systemic antibiotics destabilized the wound microbiota, rather than altering overall diversity or relative abundance of specific taxa. This study provides to our knowledge previously unreported evidence that the dynamic wound microbiome is indicative of clinical outcomes and may be a valuable guide for personalized management and treatment of chronic wounds.

Study Objective-To evaluate blood pressure (BP) control following discontinuation of a physician\pharmacist collaborative intervention.Design-BP was previously measured at baseline and at the end of a 9-month clusterrandomized intervention trial. This study abstracted medical record data for mean BP and BP control at 18 months (9 months after the discontinuation of the intervention) and at 27 months (18 months after discontinuation of the intervention).Setting-Five primary care medical offices operated by a university health system.Patients-Subjects with hypertension who were enrolled in a previous controlled trial and who consented to have data abstracted for an additional 18 months following the end of that study.Intervention-A physician\pharmacist collaborative intervention to improve BP control was withdrawn after 9 months and BP and the change in BPs following withdrawal of the intervention were evaluated.Measurements-A research nurse measured BP during the 9-month interventional study. BP values were then abstracted from the medical record for the 18 month period after the end of that study.Main Results-104 patients had BP values at all 4 time periods. At baseline, systolic BP (SBP) was 152.5 ± 9.5 and 150.1 ± 9.6 mm Hg in the intervention and control groups, respectively Conclusions-This study found a sustained effect on BP control up to 18 months following discontinuation of a pharmacist intervention. However, BP control deteriorated at a similar rate in both the intervention and control group but remained significantly higher in the intervention group. This study suggests that continued interventions by pharmacists may be necessary to maintain high rates of BP control, especially in those patients who lose BP control.

OBJECTIVEWe examined associations between ulcer bioburden and ulcer outcomes in neuropathic diabetic foot ulcers (DFUs) that lacked clinical signs of infection.RESEARCH DESIGN AND METHODSThree dimensions of bioburden (i.e., microbial load, microbial diversity, and the presence of likely pathogens) were measured at baseline using swab cultures obtained by Levine’s technique. Subjects were assessed every 2 weeks for 26 weeks to determine the rate of healing and development of infection-related complications. Foot ulcers were off-loaded using total-contact casts and routinely debrided. To establish associations between bioburden and rate of healing, Cox proportional hazards and least squares regression were used after adjusting for ulcer depth, surface area, and duration.RESULTSA total of 77 subjects completed the study. Sixty-five (84.4%) had ulcers that healed during follow-up; weeks-to-closure ranged from 2 to 26 (median 4.0). Mean (± SD) percent reduction in surface area/week was 25.0% (± 23.33). Five (6.5%) of the DFUs developed an infection-related complication. None of the bioburden dimensions (i.e., microbial load, microbial diversity, or presence of likely pathogens) was significantly associated with weeks-to-closure or percent reduction in surface area per week. Weeks-to-closure was best predicted by ulcer duration, depth, and surface area (c-statistic = 0.75).CONCLUSIONSCulturing DFUs that showed no clinical signs of infection had no predictive value for outcomes of DFUs managed with total-contact casts and routine debridement. These findings support recommendations of the Infectious Disease Society of America that culturing and antibiotics should be avoided in treating DFUs that show no clinical signs of infection.

1 Despite the publication by the National Heart, Lung, and Blood Institute of 7 sets of guidelines for the management of hypertension, blood pressure (BP) is controlled to recommended levels for only about 34% of persons with hypertension.2 One possible explanation for low control rates is poor physician adherence to guidelines. Several studies have examined physician adherence and arrived at differing conclusions. 3-16These studies, however, failed to evaluate multiple aspects of care, describe adherence of patients with specific comorbid conditions, use both explicit and implicit reviews, or consider factors that might explain instances of nonadherence. 17The goals of this study were to: (1) describe physician adherence to the guidelines of the Seventh Report of the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) 2 for patients with uncontrolled hypertension using a set of explicit criteria; (2) evaluate adherence in subpopulations with specific comorbid conditions; (3) detect any trend in adherence following release of the guidelines; (4) evaluate the degree to which nonadherence is justified; and (5) identify barriers that might contribute to poor adherence. Unique features of this evaluation include a comprehensive review of medical records and the inclusion of community-based primary care practices. MATERIALS AND METHODSThe study was conducted at 6 family medicine community-based residency training offices in Iowa and approved by each site's institutional review board and by the University of Iowa institutional review board. All subjects gave informed consent,