Baseline Characteristics of PATHWEIGH: A Stepped-Wedge Cluster Randomized Study for Weight Management in Primary Care.

Context: Despite the fact that obesity is both treatable and preventable, treating the comorbidities, rather than obesity per se remains the mainstay of therapy. Objective: To evaluate the efficacy and implementation of a pragmatic approach to weight management in primary care that prioritizes treatment of weight rather than weight-related diseases (PATHWEIGH). Study Design and Analysis: PATHWEIGH is a hybrid type 1 cluster randomized stepped wedge clinical trial. Clinics were enrolled and randomized to three sequences using covariate constrained randomization. Descriptive statistics were used to summarize clinic and patient characteristics with t-tests, Wilcoxon rank sums or Fisher's exact tests used to compare groups. Setting: Fifty-seven primary care clinics in rural, suburban and urban Colorado in a single healthcare system were utilized. Population Studied: Patients age >18 years and body mass index (BMI) >25 kg/m2 who had a weight-prioritized visit (WPV) in the prior year were enrolled. A WPV was defined as a chief complaint or reason for visit that included "weight", ICD-10 codes for weight or use of an intake questionnaire for weight. Intervention: None. This abstract describes the baseline (pre-intervention) characteristics of the clinics and patients treated with standard-of-care (SOC) for weight management. Outcome Measures: Baseline characteristics of the clinics and patients undergoing a WPV from March 17, 2020 - March 16, 2021. Results: 20,410 patients met these eligibility requirements representing 12% of patients >18 years and body mass index (BMI) >25 kg/m2 seen at the clinic during this baseline period. The three randomization sequences of 20, 18, and 19 sites were similar with an overall median age of 53 years (IQR: 39-65), 58% women, 76% non-Hispanic whites, 64% commercial insurance, and median BMI of 36 kg/m2 (IQR: 32-41). No sequence differences were seen for vital signs, relevant laboratory values, or numbers of comorbidities or medications that cause weight loss or weight gain. Referral for anything weight-related was low (<6%) and only 334 prescriptions of an anti-obesity medication were noted. Conclusions: Of patients >18 years and body mass index (BMI) >25 kg/m2 seen in the 57 primary care clinics, 12% had a weight-prioritized visit during the baseline period. Despite most being commercially insured, referral to any weight-related service or prescription of anti-obesity medication was uncommon.

Prelude to PATHWEIGH: pragmatic weight management in primary care.

OBJECTIVE: Treatment of obesity-related diseases, rather than obesity itself, remains the mainstay of medical care. The current study examined a novel approach that prioritizes weight management in primary care to shift this paradigm. METHODS: PATHWEIGH is a weight management approach consisting of staff team training, workflow system management, and data capture from tools built into the electronic medical record (EPIC). PATHWEIGH was compared to standard of care (SOC) using two family medicine clinics in the same US healthcare system. Descriptive statistics compared patient-, provider-, and clinic-level factors between the groups among those with at least one weight-prioritized visit (WPV) and one follow-up weight over 14 months. RESULTS: Groups were similar in terms of total patient visits (7,353 vs. 7,984) and patients eligible for a WPV (i.e. >18 years + body mass index >25 kg/m2; 3,746 vs. 3,008, PATHWEIGH vs. SOC, respectively). However, more PATHWEIGH clinic patients (15.9% vs. 8.4%; P < 0.001) received at least one WPV. Although no difference was observed for average patient weight loss over 14 months (P = 0.991), the number of WPVs per patient was higher in PATHWEIGH (P < 0.001) and significantly associated with weight loss (P = 0.001), with an average decrease in weight of 0.55 kg per additional visit. CONCLUSIONS: Results from the current study demonstrate early success in changing the paradigm from treating weight-related comorbidities to treating weight in primary care.

Comparing Ultrasound-Guided Needling Combined With a Subacromial Corticosteroid Injection Versus High-Energy Extracorporeal Shockwave Therapy for Calcific Tendinitis of the Rotator Cuff: A Randomized Controlled Trial.

PURPOSE: To compare clinical and radiographic outcomes after treatment with standardized high-energy extracorporeal shock wave therapy (ESWT) and ultrasound-guided needling (UGN) in patients with symptomatic calcific tendinitis of the rotator cuff who were nonresponsive to conservative treatment. METHODS: The study was designed as a randomized controlled trial. The ESWT group received ESWT (2000 pulses, energy flux density 0.35 mJ/mm2) in 4 sessions with 1-week intervals. UGN was combined with a corticosteroid ultrasound-guided subacromial bursa injection. Shoulder function was assessed at standardized follow-up intervals (6 weeks and 3, 6, and 12 months) using the Constant Murley Score (CMS), the Disabilities of the Arm, Shoulder, and Hand questionnaire, and visual analog scale for pain and satisfaction. The size, location, and morphology of the deposits were evaluated on radiographs. The a priori sample size calculation computed that 44 participants randomized in each treatment group was required to achieve a power of 80%. RESULTS: Eighty-two patients were treated (56 female, 65%; mean age 52.1 ± 9 years) with a mean baseline CMS of 66.8 ± 12 and mean calcification size of 15.1 ± 4.7 mm. One patient was lost to follow-up. At 1-year follow-up, the UGN group showed similar results as the ESWT group with regard to the change from baseline CMS (20.9 vs 15.7; P = .23), Disabilities of the Arm, Shoulder, and Hand questionnaire (-20.1 vs -20.7; P = .78), and visual analog scale for pain (-3.9 and -2.6; P = .12). The mean calcification size decreased by 13 ± 3.9 mm in the UGN group and 6.7 ± 8.2 mm in the ESWT group (

Violent reinjury risk assessment instrument (VRRAI) for hospital-based violence intervention programs.

BACKGROUND: Violent injury is the second most common cause of death among 15- to 24-year olds in the US. Up to 58% of violently injured youth return to the hospital with a second violent injury. Hospital-based violence intervention programs (HVIPs) have been shown to reduce injury recidivism through intensive case management. However, no validated guidelines for risk assessment strategies in the HVIP setting have been reported. We aimed to use qualitative methods to investigate the key components of risk assessments employed by HVIP case managers and to propose a risk assessment model based on this qualitative analysis. MATERIALS AND METHODS: An established academic hospital-affiliated HVIP served as the nexus for this research. Thematic saturation was reached with 11 semi-structured interviews and two focus groups conducted with HVIP case managers and key informants identified through snowball sampling. Interactions were analyzed by a four-member team using Nvivo 10, employing the constant comparison method. Risk factors identified were used to create a set of models presented in two follow-up HVIP case managers and leadership focus groups. RESULTS: Eighteen key themes within seven domains (environment, identity, mental health, behavior, conflict, indicators of lower risk, and case management) and 141 potential risk factors for use in the risk assessment framework were identified. The most salient factors were incorporated into eight models that were presented to the HVIP case managers. A 29-item algorithmic structured professional judgment model was chosen. CONCLUSIONS: We identified four tiers of risk factors for violent reinjury that were incorporated into a proposed risk assessment instrument, VRRAI.

The Cost of Intramedullary Nailing for Femoral Shaft Fractures in Dar es Salaam, Tanzania.

BACKGROUND: Femoral shaft fractures are one of the most common injuries seen by surgeons in low- and middle-income countries (LMICs). Surgical repair in LMICs is often dismissed as not being cost-effective or unsafe, though little evidence exists to support this notion. Therefore, the goal of this study is to determine the cost of intramedullary nailing of femoral shaft fractures in Tanzania. METHODS: We used micro-costing methods to estimate the fixed and variable costs of intramedullary nailing of femoral shaft fractures. Variable costs assessed included medical personnel costs, ward personnel costs, implants, medications, and single-use supplies. Fixed costs included costs for surgical instruments and administrative and ancillary staff. RESULTS: 46 adult femoral shaft fracture patients admitted to Muhimbili Orthopaedic Institute between June and September 2014 were enrolled and treated with intramedullary fixation. The total cost per patient was $530.87 (SD $129.99). The mean variable cost per patient was $419.87 (SD $129.99), the largest portion coming from ward personnel $144.47 (SD $123.30), followed by implant $134.10 (SD $15.00) medical personnel $106.86 (SD $28.18), and medications/supplies $30.05 (SD $12.28). The mean fixed cost per patient was $111.00, consisting of support staff, $103.50, and surgical instruments, $7.50. CONCLUSIONS: Our study provides empirical information on the variable and fixed costs of intramedullary nailing of femoral shaft fractures in LMICs. Importantly, the lack of surgical capacity was the primary driver of the largest cost for this procedure, preoperative ward personnel time. Our results provide the cost data for a formal cost-effectiveness analysis on this intervention.

The use of traction for treating femoral shaft fractures in low- and middle-income countries: a systematic review.

PURPOSE: The use of traction for treatment of femoral shaft fractures remains common in low- and middle-income countries (LMICs). The objective of this study is to systematically review the literature on outcomes of traction as definitive treatment for adult femoral shaft fractures in LMICs. METHODS: Using the recommended PRISMA methods for systematic reviews, MEDLINE, EMBASE, LILACS, and AJOL were searched for relevant publications. Results were limited to studies occurring in LMICs as defined by the World Bank. Data on time spent in traction (TT), length of stay (LOS), time to partial weight bearing (PWB), complication incidences, and a total complication incidence were recorded. RESULTS: Of the 693 initial results, nine were eligible for analysis giving a total of 455 unique patients with a mean age of 32.9 years (range: 0 to 96). The average time spent in traction was 52.8 days (range: 19.8 to 122.5), the average length of stay was 55.4 days (range: 45 to 140), and the average time to partial weight bearing was 52.2 days (range: 42 to 60 days). There were a total of 91 malunions, 25 un-united fractures, 60 infections, 45 other complications, giving a total of 221 complications in 455 patients. CONCLUSIONS: The use of traction in treating femoral shaft fractures is associated with a high incidence of complications and prolonged course of treatment. Although operative stabilization may be a better alternative, comparative studies are needed to assess whether this can be achieved in a safe and cost-effective manner for widespread application in LMICs.

Evaluation of cartilage degeneration in a rat model of rotator cuff tear arthropathy.

BACKGROUND AND HYPOTHESIS: Rotator cuff tears are the most common injury seen by shoulder surgeons. Glenohumeral osteoarthritis develops in many late-stage rotator cuff tear patients as a result of torn cuff tendons, termed "cuff tear arthropathy." However, the mechanisms of cuff tear arthropathy have not been fully established. It has been hypothesized that a combination of synovial and mechanical factors contribute equally to the development of cuff tear arthropathy. The goal of this study was to assess the utility of this model in investigating cuff tear arthropathy. MATERIALS AND METHODS: We used a rat model that accurately reflects rotator cuff muscle degradation after massive rotator cuff tears through either infraspinatus and supraspinatus tenotomy or suprascapular nerve transection. Using a modified Mankin scoring system, we found significant glenohumeral cartilage damage after both rotator cuff tenotomy and suprascapular nerve transection after only 12 weeks. RESULTS: Cartilage degeneration was similar between groups and was present on both the humeral head and the glenoid. Denervation of the supraspinatus and infraspinatus muscles without opening the joint capsule caused cartilage degeneration similar to that found in the tendon transection group. CONCLUSIONS: Our results suggest that altered mechanical loading after rotator cuff tears is the primary factor in cartilage degeneration after rotator cuff tears. Clinically, understanding the process of cartilage degeneration after rotator cuff injury will help guide treatment decisions in the setting of rotator cuff tears. LEVEL OF EVIDENCE: Basic science study, animal model.

Refugee and Migrant Health Literacy Interventions in High-Income Countries: A Systematic Review.

Health literacy is a key determinant of health in refugee and migrant populations living in in high-income countries (HICs). We conducted a systematic review of randomized-controlled trials (RCTs) to characterize the scope, methodology, and outcomes of research on interventions aimed at improving health literacy among these vulnerable populations. We searched EMBASE, MEDLINE, PsycINFO, CINAHL, and Web of Science databases to identify RCTs of health literacy intervenions in our target population published between 1997 and 2018. The search yielded 23 RCTs (n = 5625 participants). Study demographics, health literacy topics, interventions, and outcome measures were heterogeneous but demonstrated overall positive results. Only two studies used a common health literacy measure. Few RCTs have been conducted to investigate interventions for improving the health literacy of refugees and migrants in HICs. The heterogeniety of health literacy outcome measures used impeded a robust comparison of intervention efficacy.

Telehealth and Diabetes Management.

The care of patients with diabetes is complex and longitudinal. Improved management of diabetic risk factors can decrease long-term complications such as cardiovascular disease, renal failure, vision impairment, and amputation. A variety of telehealth options are available which may improve patient access to needed care as well as a provider understanding of the challenges for an individual patient. Health care teams must be thoughtful about how best to incorporate telehealth into the care of patients with diabetes.

Intramedullary nailing versus external fixation for open tibia fractures in Tanzania: a cost analysis.

OBJECTIVES: Open tibia fractures pose a clinical and economic burden that is disproportionately borne by low-income countries. A randomized trial conducted by our group showed no difference in infection and nonunion comparing 2 treatments: external fixation (EF) and intramedullary nailing (IMN). Secondary outcomes favored IMN. In the absence of clear clinical superiority, we sought to compare costs between EF and IMN. DESIGN: Secondary cost analysis. SETTING: Single institution in Tanzania. PATIENTS/PARTICIPANTS: Adult patients with acute diaphyseal open tibia fractures who participated in a previous randomized controlled trial. INTERVENTION: SIGN IMN versus monoplanar EF. MAIN OUTCOME MEASUREMENTS: Direct costs of initial surgery and hospitalization and subsequent reoperation: implant, instrumentation, medications, disposable supplies, and personnel costs.Indirect costs from lost productivity of patient and caregiver.Societal (total) costs: sum of direct and indirect costs.All costs were reported in 2018 USD. RESULTS: Two hundred eighteen patients were included (110 IMN, 108 EF). From a payer perspective, costs were $365.83 (95% CI: $332.75-405.76) for IMN compared with $331.25 ($301.01-363.14) for EF, whereas from a societal perspective, costs were $2664.59 ($1711.22-3955.25) for IMN and $2560.81 ($1700.54-3715.09) for EF. The largest drivers of cost were reoperation and lost productivity. Accounting for uncertainty in multiple variables, probabilistic sensitivity analysis demonstrated that EF was less costly than IMN from the societal perspective in only 55% of simulations. CONCLUSIONS: Intramedullary nail fixation compared with external fixation of open tibia fractures in a resource-constrained setting is not associated with increased cost from a societal perspective.

The Initial Economic Burden of Femur Fractures on Informal Caregivers in Dar es Salaam, Tanzania.

Background: Femur fracture patients require significant in-hospital care. The burden incurred by caregivers of such patients amplifies the direct costs of these injuries and remains unquantified. Aim: Here we aim to establish the in-hospital economic burden faced by informal caregivers of femur fracture patients. Methods: 70 unique caregivers for 46 femoral shaft fracture patients were interviewed. Incurred economic burden was determined by the Human Capital Approach, using standardized income data to quantify productivity loss (in $USD). Linear regression assessed the relationship between caregiver burden and patient time-in-hospital. Results: The average economic burden incurred was $149, 9% of a caregiver's annual income and positively correlated with patient time in hospital (p<0.01). Conclusion: Caregivers of patients treated operatively for femur fractures lost a large portion of their annual income, and this loss increased with patient time in hospital. These indirect costs of femur fracture treatment constitute an important component of the total injury burden.

Lessons Learned During COVID-19 That Can Move Telehealth in Primary Care Forward.

INTRODUCTION: Our university hospital-based primary care practices transitioned a budding interest in telehealth to a largely telehealth-based approach in the face of the COVID-19 pandemic. INITIAL WORK: Implementation of telehealth began in 2017. Health system barriers, provider and patient reluctance, and inadequate reimbursement prevented widespread adoption at the time. COVID-19 served as the catalyst to accelerate telehealth efforts. IMPLEMENTATION: COVID-19 resulted in the need for patient care with "social distancing." In addition, due to the pandemic, the Centers for Medicare and Medicaid Services and other insurers began expanded reimbursement for telehealth. More than 2000 providers received virtual health training in less than 2 weeks. In March 2020, we provided 2376 virtual visits, and in April 5293, which was more than 75 times the number provided in February; 73% of all visits in April were virtual (up from 0.5% in October 2019). As COVID-19 cases receded in May, June, and July, patient demand for virtual visits decreased, but 28% of visits in July were still virtual. LESSONS LEARNED: Several key lessons are important for future efforts regarding clinical implementation: (1) prepare for innovation, (2) cultivate an innovation mindset, (3) standardize (but not too much), (4) technological innovation is necessary but not sufficient, and (5) communicate widely and often.

Response to hepatitis A and B vaccine alone or in combination in patients with chronic hepatitis C virus and advanced fibrosis.

Patients with advanced fibrosis are at increased risk of severe outcomes if they develop acute infection with hepatitis A (HAV) or hepatitis B (HBV) viruses. There are no data on the efficacy of combined HAV/HBV vaccination in patients with advanced fibrosis. Our aim was to evaluate the response to the HAV and HBV vaccine alone or in combination for patients with chronic hepatitis C (HCV) and advanced fibrosis and to evaluate the impact of administering the vaccine while patients were receiving peginterferon for treatment of chronic HCV. In this prospective study of patients with advanced fibrosis (Ishak 3-6), those without serologic evidence of prior exposure were vaccinated with either Havrix HAV, Engerix( HBV, or the TWINRIX HAV/HBV combination vaccine as appropriate, and response was defined as the development of anti-HAV or anti-HBV surface antibodies. Of the 162 eligible patients, the prevalence of prior exposure to HAV and HBV was 30 and 18%, respectively. Of the 84 patients vaccinated, 38% received Havrix, 14% Engerix, and 48% TWINRIX. The response to the HAV vaccine was 75% in those receiving Havrix compared to 78% receiving TWINRIX. In contrast, the response to HBV vaccination was 42% in patients receiving Engerix compared to 60% in those vaccinated with TWINRIX (difference 18.3%; OR 0.29; 95% CI: 0.57-7.79). The presence of diabetes was the only risk factor identified for reduced HBV response (P = 0.01). Responses to both HAV and HBV vaccines when administered alone or in combination were lower than expected in patients with HCV and advanced fibrosis, especially in those with diabetes. The observation that the decline in HBV vaccine response was somewhat lower when this was administered alone as opposed to the combination A/B vaccine suggests that the administration of a combination vaccine may enhance the vaccination response to HBV.

MRI quantification of fatty infiltration and muscle atrophy in a mouse model of rotator cuff tears.

Rotator cuff pathology is the most common shoulder problem seen by orthopedic surgeons. Rotator cuff muscle fatty infiltration and muscle atrophy are common in larger tears and are considered predicting factors for the prognosis of cuff repair. Clinically, MRI is the gold standard in determining fatty infiltration and muscle atrophy; however, analysis for MRI imaging is primarily qualitative in nature with the results lacking further validation. We have recently developed a mouse model of rotator cuff tears. The goal of this study is to quantify and verify rotator cuff muscle atrophy and fatty infiltration using high-resolution MRI in our mouse model. The rotator cuff muscles were analyzed for fat using a triglyceride quantification assay (TQA), muscle volume was measured through water displacement (WD), and histology. The study revealed that MRI had a high correlation with fat as measured with histology and TQA (R(2) =098). MRI also correlated well with atrophy measured with WD and wet weight. This suggests that MRI is a reliable modality in evaluating the progression of fatty infiltration and muscle atrophy following rotator cuff tears in a small animal model.