Neuroimaging assessment of facility-bound severely-affected MS reveals the critical role of cortical gray matter pathology: results from the CASA-MS case-controlled study.

BACKGROUND: A subgroup of people with multiple sclerosis (pwMS) will develop severe disability. The pathophysiology underlying severe MS is unknown. The comprehensive assessment of severely affected MS (CASA-MS) was a case-controlled study that compared severely disabled in skilled nursing (SD/SN) (EDSS ≥ 7.0) to less-disabled (EDSS 3.0-6.5) community dwelling (CD) progressive pwMS, matched on age-, sex- and disease-duration (DDM). OBJECTIVES: To identify neuroimaging and molecular biomarker characteristics that distinguish SD/SN from DDM-CD progressive pwMS. METHODS: This study was carried at SN facility and at a tertiary MS center. The study collected clinical, molecular (serum neurofilament light chain, sNfL and glial acidic fibrillary protein, sGFAP) and MRI quantitative lesion-, brain volume-, and tissue integrity-derived measures. Statistical analyses were controlled for multiple comparisons. RESULTS: 42 SD/SN and 42 DDM-CD were enrolled. SD/SN pwMS showed significantly lower cortical volume (CV) (p < 0.001, d = 1.375) and thalamic volume (p < 0.001, d = 0.972) compared to DDM-CD pwMS. In a logistic stepwise regression model, the SD/SN pwMS were best differentiated from the DDM-CD pwMS by lower CV (p < 0.001) as the only significant predictor, with the accuracy of 82.3%. No significant differences between the two groups were observed for medulla oblongata volume, a proxy for spinal cord atrophy and white matter lesion burden, while there was a statistical trend for numerically higher sGFAP in SD/SN pwMS. CONCLUSIONS: The CASA-MS study showed significantly more gray matter atrophy in severe compared to less-severe progressive MS.

Identifying incarceration status in the electronic health record using large language models in emergency department settings.

Background: Incarceration is a significant social determinant of health, contributing to high morbidity, mortality, and racialized health inequities. However, incarceration status is largely invisible to health services research due to inadequate clinical electronic health record (EHR) capture. This study aims to develop, train, and validate natural language processing (NLP) techniques to more effectively identify incarceration status in the EHR. Methods: The study population consisted of adult patients (≥ 18 y.o.) who presented to the emergency department between June 2013 and August 2021. The EHR database was filtered for notes for specific incarceration-related terms, and then a random selection of 1,000 notes was annotated for incarceration and further stratified into specific statuses of prior history, recent, and current incarceration. For NLP model development, 80% of the notes were used to train the Longformer-based and RoBERTa algorithms. The remaining 20% of the notes underwent analysis with GPT-4. Results: There were 849 unique patients across 989 visits in the 1000 annotated notes. Manual annotation revealed that 559 of 1000 notes (55.9%) contained evidence of incarceration history. ICD-10 code (sensitivity: 4.8%, specificity: 99.1%, F1-score: 0.09) demonstrated inferior performance to RoBERTa NLP (sensitivity: 78.6%, specificity: 73.3%, F1-score: 0.79), Longformer NLP (sensitivity: 94.6%, specificity: 87.5%, F1-score: 0.93), and GPT-4 (sensitivity: 100%, specificity: 61.1%, F1-score: 0.86). Conclusions: Our advanced NLP models demonstrate a high degree of accuracy in identifying incarceration status from clinical notes. Further research is needed to explore their scaled implementation in population health initiatives and assess their potential to mitigate health disparities through tailored system interventions.

Disparities Associated With Electronic Behavioral Alerts for Safety and Violence Concerns in the Emergency Department.

STUDY OBJECTIVE: Although electronic behavioral alerts are placed as an alert flag in the electronic health record to notify staff of previous behavioral and/or violent incidents in emergency departments (EDs), they have the potential to reinforce negative perceptions of patients and contribute to bias. We provide characterization of ED electronic behavioral alerts using electronic health record data across a large, regional health care system. METHODS: We conducted a retrospective cross-sectional study of adult patients presenting to 10 adult EDs within a Northeastern United States health care system from 2013 to 2022. Electronic behavioral alerts were manually screened for safety concerns and then categorized by the type of concern. In our patient-level analyses, we included patient data at the time of the first ED visit where an electronic behavioral alert was triggered or, if a patient had no electronic behavioral alerts, the earliest visit in the study period. We performed a mixed-effects regression analysis to identify patient-level risk factors associated with safety-related electronic behavioral alert deployment. RESULTS: Of the 2,932,870 ED visits, 6,775 (0.2%) had associated electronic behavioral alerts across 789 unique patients and 1,364 unique electronic behavioral alerts. Of the encounters with electronic behavioral alerts, 5,945 (88%) were adjudicated as having a safety concern involving 653 patients. In our patient-level analysis, the median age for patients with safety-related electronic behavioral alerts was 44 years (interquartile range 33 to 55 years), 66% were men, and 37% were Black. Visits with safety-related electronic behavioral alerts had higher rates of discontinuance of care (7.8% vs 1.5% with no alert; P<.001) as defined by the patient-directed discharge, left-without-being-seen, or elopement-type dispositions. The most common topics in the electronic behavioral alerts were physical (41%) or verbal (36%) incidents with staff or other patients. In the mixed-effects logistic analysis, Black non-Hispanic patients (vs White non-Hispanic patients: adjusted odds ratio 2.60; 95% confidence interval [CI] 2.13 to 3.17), aged younger than 45 (vs aged 45-64 years: adjusted odds ratio 1.41; 95% CI 1.17 to 1.70), male (vs female: adjusted odds ratio 2.09; 95% CI 1.76 to 2.49), and publicly insured patients (Medicaid: adjusted odds ratio 6.18; 95% CI 4.58 to 8.36; Medicare: adjusted odds ratio 5.63; 95% CI 3.96 to 8.00 vs commercial) were associated with a higher risk of a patient having at least 1 safety-related electronic behavioral alert deployment during the study period. CONCLUSION: In our analysis, younger, Black non-Hispanic, publicly insured, and male patients were at a higher risk of having an ED electronic behavioral alert. Although our study is not designed to reflect causality, electronic behavioral alerts may disproportionately affect care delivery and medical decisions for historically marginalized populations presenting to the ED, contribute to structural racism, and perpetuate systemic inequities.

Deployment of a Digital Advance Care Planning Platform at an Accountable Care Organization.

BACKGROUND: Advance care planning (ACP), a process of sharing one's values and preferences for future medical treatments, can improve quality of life, reduce loved ones' anxiety, and decrease unwanted medical utilization and costs. Despite benefits to patients and health care systems, ACP uptake often remains low, due partially to lack of knowledge and difficulty initiating discussions. Digital tools may help reduce these barriers to entry. METHODS: We retrospectively examined data from pilot deployment of Koda Health patient-facing ACP among Houston Methodist Coordinated Care patients, for quality improvement (QI) purposes. Patients referred by nurse navigators could access Koda's digital platform, complete ACP, and share the legal documentation generated. Analyzed measures include usage rates and ACP-related decisions within the platform. RESULTS: Of eligible patients (n = 203), 52.7% voluntarily completed their plan. Engagement and completion rates were similar across demographics. Patients indicated majority preference (66.4%) toward spending the last days of life at home. Most patients indicated wanting no life-support intervention if quality of life became unacceptable (51 to 71% across 4 treatments). Life-support decisions were similar between demographic categories, excepting CPR and dialysis, wherein a greater portion of Black patients than White patients preferred at least trial intervention, rather than none. CONCLUSIONS: As an observational QI analysis, limitations include bounded geographical reach and lack of data on ACP impacts to subsequent health care utilization, which future studies will address. Findings suggest that digital health tools like Koda can effectively facilitate equitable ACP access and may help support health systems and providers in offering comprehensive ACP.

Ohio Coronavirus Wastewater Monitoring Network: Implementation of Statewide Monitoring for Protecting Public Health.

CONTEXT: Prior to the COVID-19 pandemic, wastewater influent monitoring for tracking disease burden in sewered communities was not performed in Ohio, and this field was only on the periphery of the state academic research community. PROGRAM: Because of the urgency of the pandemic and extensive state-level support for this new technology to detect levels of community infection to aid in public health response, the Ohio Water Resources Center established relationships and support of various stakeholders. This enabled Ohio to develop a statewide wastewater SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) monitoring network in 2 months starting in July 2020. IMPLEMENTATION: The current Ohio Coronavirus Wastewater Monitoring Network (OCWMN) monitors more than 70 unique locations twice per week, and publicly available data are updated weekly on the public dashboard. EVALUATION: This article describes the process and decisions that were made during network initiation, the network progression, and data applications, which can inform ongoing and future pandemic response and wastewater monitoring. DISCUSSION: Overall, the OCWMN established wastewater monitoring infrastructure and provided a useful tool for public health professionals responding to the pandemic.

Effectiveness of out-patient based acute heart failure care: a pilot randomised controlled trial.

OBJECTIVES: Acute heart failure (AHF) hospitalisation is associated with 10% mortality. Outpatient based management (OPM) of AHF appeared effective in observational studies. We conducted a pilot randomised controlled trial (RCT) comparing OPM with standard inpatient care (IPM). METHODS: We randomised patients with AHF, considered to need IV diuretic treatment for ≥2 days, to IPM or OPM. We recorded all-cause mortality, and the number of days alive and out-of-hospital (DAOH). Quality of life, mental well-being and Hope scores were assessed. Mean NHS cost savings and 95% central range (CR) were calculated from bootstrap analysis. Follow-up: 60 days. RESULTS: Eleven patients were randomised to IPM and 13 to OPM. There was no statistically significant difference in all-cause mortality during the index episode (1/11 vs 0/13) and up to 60 days follow-up (2/11 vs 2/13) [p = .86]. The OPM group accrued more DAOH {47 [36,51] vs 59 [41,60], p = .13}. Two patients randomised to IPM (vs 6 OPM) were readmitted [p = .31]. Hope scores increased more with OPM within 30 days but dropped to lower levels than IPM by 60 days. More out-patients had increased total well-being scores by 60 days (p = .04). OPM was associated with mean cost savings of £2658 (95% CR 460-4857) per patient. CONCLUSIONS: Patients with acute HF randomised to OPM accrued more days alive out of hospital (albeit not statistically significantly in this small pilot study). OPM is favoured by patients and carers and is associated with improved mental well-being and cost savings.

Association Between Head Impact Exposure, Psychological Needs, and Indicators of Mental Health Among U.S. High School Tackle Football Players.

PURPOSE: Age of first exposure to tackle football and head impact kinematics have been used to examine the effect of head impacts on mental health outcomes. These measures coupled with retrospective and cross-sectional designs have contributed to conflicting results. The purpose of this study was to identify the effect of one season of head impact exposure, age of first exposure to football, and psychological need satisfaction on acute mental health outcomes in adolescent football players. METHODS: This prospective single-season cohort study used sensor-installed mouthguards to collect head impact exposure along with surveys to assess age of first exposure to football, psychological satisfaction, depressive symptoms, anxiety symptoms, and thriving from football players at four high schools (n = 91). Linear regression was used to test the association of head impact exposure, age of first exposure, and psychological satisfaction with acute mental health outcomes. RESULTS: A total of 9,428 impacts were recorded with a mean of 102 ± 113 impacts/player. Cumulative head impact exposure and age of first exposure were not associated with acute mental health outcomes at postseason or change scores from preseason to postseason. Greater psychological satisfaction was associated with fewer depressive symptoms (ß = -0.035, SE = 0.008, p = < .001), fewer anxiety symptoms (ß = -0.021, SE = 0.008, p = .010), and greater thriving scores (ß = 0.278, SE = 0.040, p = < .001) at postseason. DISCUSSION: This study does not support the premise that greater single-season head impact exposure or earlier age of first exposure to tackle football is associated with worse acute mental health indicators over the course of a single season in adolescent football players.

A wound care and immunization needs assessment for participants of a mobile syringe services program in Austin, TX.

BACKGROUND: People who inject drugs (PWID) are subject to injection-related harm, including skin and soft tissue infections. Syringe services programs (SSPs) provide sterile syringes, disposal of used syringes, and other supportive services. Given their contact and credibility with PWID, SSPs could facilitate triage and treatment of wounds and access to immunizations for communicable diseases. OBJECTIVE: This work aimed to assess wound care and immunization needs among participants accessing mobile SSP services in Austin, TX. METHODS: A 21-item mixed-methods survey was created to assess frequency and severity of wounds, wound care approaches, and vaccination status. Participants were included if they reported injection drug use and experienced a related wound in the previous 6 months. Interview sections included screening, demographics, wound care, and immunization status. RESULTS: A total of 21 participants completed the semistructured interview. A majority identified as male (n = 13, 61.9%), white (n = 12, 57.1%), and were unhoused (n = 12, 57.1%). The primary drug of injection was heroin alone (n = 14, 66.7%). Many avoided seeking wound care from health care providers (n = 16, 76.2%) owing to stigmatization (n = 13, 61.9%) and previous negative experiences (n = 7, 33.3%). Self-treatment of wounds included over-the-counter medications (n = 10, 47.6%), over-the-counter supplies (n = 10, 47.6%), and antibiotics (n = 9, 42.8%). In the past 5 years, few had received vaccination for hepatitis A and B (n = 3, 14.3%) or tetanus (n = 7, 33.3%), and many expressed interest in receiving vaccinations through the SSP. Interest for other expanded services included access to antibiotics, an on-site provider, wound care supplies, and education. CONCLUSIONS: PWID may avoid professional health care for wound care or immunizations owing to perceived stigma. Expanding availability of wound care services and immunizations directly through mobile SSPs is desired by participants and could positively affect public health.

U.S. Women Faculty in the Social Sciences Also Face Gender Inequalities.

There is a national interest in United States women's underrepresentation in science, technology, engineering, and mathematics (STEM); however, gender inequality in the social sciences has not received similar attention. Although women increasingly earn postgraduate degrees in the social sciences, women faculty still experience gender inequities. Consistent gender inequities include slower career advancement, blunted salaries, unequal workloads, work-life conflict, systemic gender biases, underrepresentation in positions of power, and hostile work environments. Cultural biases suggest that once women have achieved parity, gender bias no longer exists. This review challenges that notion by providing evidence from social science domains in which women are well-represented but continue to face systemic gender biases. We examine cultural influences on gender representation and career advancement in psychology, economics, political science, sociology, and anthropology. We make interdisciplinary comparisons of career trajectories and salaries using national data, documenting patterns across the social sciences. For example, women economists face gendered standards in publishing, and women political scientists are less likely to have their work cited than men. Furthermore, data show that salaries become stagnant as the representation of women in these fields increases. These disparities reflect cultural biases in perceptions of women's competence stemming from social role theory. We discuss best practices to address these problems, focusing on the ADVANCE organizational change programs funded by the National Science Foundation that target (a) improving academic climate, (b) providing professional development, and (c) fostering social networking. Federally supported interventions can reveal systemic gender biases in academia and reduce gender disparities for women academics in the social sciences.

Assessment of Biomarker Heterogeneity in Sinus Versus Inferior Turbinate Tissue in Patients Without Chronic Rhinosinusitis.

BACKGROUND: Currently, no consensus exists on the appropriate control specimen site to utilize in studies evaluating for biomarkers in chronic rhinosinusitis (CRS). Studies thus far have utilized tissue from various anatomic sites despite regional heterogeneity. OBJECTIVE: We set out to quantify the differences in biomarker levels present in inferior turbinate versus sphenoid sinus mucosa in paired healthy control patients. We hypothesize that statistically significant differences in cytokine/chemokine expression exist between these two distinct sites. METHODS: A 38-plex commercially available cytokine/chemokine Luminex Assay was performed on 54 specimens encompassing paired inferior turbinate and sphenoid sinus mucosa samples from 27 patients undergoing endoscopic anterior skull base surgery. Patients with a history of CRS were excluded. Paired sample t-tests and Fisher's exact tests were performed. RESULTS: Twenty-seven patients were included in the study, including 10 male and 17 female patients with an average age of 48 years. The following 8 biomarkers had statistically significant concentration differences between inferior turbinate mucosa and sphenoid mucosa sites: Flt-3L, Fractalkine, IL-12p40, IL-1Ra, IP-10, MCP-1, MIP-1ß, and VEGF, with all P-values <0.01. CONCLUSION: No consensus exists regarding the optimal choice of control specimen for CRS research. We present statistically significant quantitative differences in biomarker levels between paired inferior turbinate and sphenoid mucosa samples. This confirms the presence of heterogeneity between different subsites of sinonasal mucosa and highlights the need for standardization in future CRS research.

UK psychodermatology services in 2019: service provision has improved but is still very poor nationally.

BACKGROUND: Psychodermatology is an emerging subspeciality of dermatology. Psychodermatology clinics use a multidisciplinary approach to deal with psychological or psychiatric elements related to skin disease. Two previous studies in 2004 and 2012 highlighted the deficiency of psychodermatology services in the UK, despite the evidence that these services have high demand and are cost-effective. AIMS: To reassess psychodermatology service provision in the UK and outline the developments that have been made. METHODS: In conjunction with BBC Radio 5 Live, a survey questionnaire was distributed via email to the UK membership of the British Association of Dermatologists (BAD) and Psychodermatology UK. The survey consisted of 13 questions asking about the availability of psychodermatology services. RESULTS: Basic percentages were used to analyse quantitative data, and content analysis was used for qualitative data. Our results showed that less than a quarter of the respondents (24%) have access to a nearby dedicated psychodermatology service. Additionally, the psychodermatology units do not have a unified configuration and clinical provision model differs nationally. Only around 5% of the clinicians have access to a clinic that provides psychology-dermatology-oncology service, and even fewer have access to a paediatric psychodermatology (4.8%). Engagement in psychodermatology research was reported by around 12% of the participants. CONCLUSIONS: The psychocutaneous services in the UK have improved to some extent over the past decade; the service has become more widely available nationally, and the investment in research is promising. However, it is still insufficient and unable to fulfil patient demand, especially for vulnerable individuals such as children and dermato-oncology patients.

Personality Assessment and Psychotherapy Preferences: Congruence between Client Personality and Therapist Personality Preferences.

Consideration of client preferences has been emphasized as important to therapeutic outcomes, such as treatment engagement and retention. Although studies have investigated several client and therapist characteristics associated with client preferences, few have considered whether people have preferences regarding a potential therapist's personality. The current study extended prior research on client preferences by examining the influence of participants' Big Five personality traits on preferences for therapist personality characteristics utilizing latent profile analysis. We expected congruence between client personality traits and preferred psychotherapist personality traits. In both undergraduate and community samples, results indicated that participants generally prefer a psychotherapist with personality characteristics similar to their own. Our findings establish the presence of preferences based on personality factors and have implications for future research directions and the role of personality assessment in routine clinical practice.

Hardly Silent: Exploring Civic Engagement and Participation among a Panel of Adults Ages 85.

The past twenty years have seen a surge of resources for and public attention devoted to civic participation opportunities for older adults in the United States. At the same time, technology has transformed the way information related to political and social issues is spread and shared. As more older adults migrate to using a wider range of communication tools and the internet, technology-mediated forms of engagement represent a new way for the oldest old to participate in society. In this study, a panel of adults ages 85 and older was surveyed to understand their experiences engaging with political and social issues. Responses to a questionnaire (N = 24) and focus groups (n = 22) indicate the oldest old are interested in social and political issues, and there are opportunities for technology to facilitate the oldest olds' civic and political action. This study identifies roles social workers may play in helping the oldest old engage with social and political issues in their communities.

The cost of baby-led vs. parent-led approaches to introducing complementary foods in New Zealand.

Baby-led approaches to complementary feeding promote intake of family foods rather than infant specific foods, from the start of the complementary feeding period, which advocates suggest should be less expensive. However, this has never been formally examined. We recently completed a 2-year randomised controlled trial comparing baby-led (BLISS) and traditional spoon-feeding (Control) approaches to complementary feeding in 206 infants. Perceived expense was assessed at infant 7, 8, 9 and 12 months of age. The actual cost of intake (food offered, consumed and left over) was calculated from 3-day weighed diet records at 7 and 12 months of age. BLISS was perceived as less expensive than traditional feeding (P = 0.002), but comparisons of actual costs showed only small differences in total daily cost for food offered (NZ$0.20 and NZ$0.10 at 7 and 12 months, respectively), consumed (NZ$0.30, NZ$0.20) or left over (NZ$0.10, NZ$0.20). Baby-led approaches are not cheaper for families than traditional spoon-feeding.

Risk assessment for recrudescence of avian influenza in caged layer houses following depopulation: the effect of cleansing, disinfection and dismantling of equipment.

Following an outbreak of highly pathogenic avian influenza virus (HPAIV) in a poultry house, control measures are put in place to prevent further spread. An essential part of the control measures based on the European Commission Avian Influenza Directive 2005/94/EC is the cleansing and disinfection (C&D) of infected premises. Cleansing and disinfection includes both preliminary and secondary C&D, and the dismantling of complex equipment during secondary C&D is also required, which is costly to the owner and also delays the secondary cleansing process, hence increasing the risk for onward spread. In this study, a quantitative risk assessment is presented to assess the risk of re-infection (recrudescence) occurring in an enriched colony-caged layer poultry house on restocking with chickens after different C&D scenarios. The risk is expressed as the number of restocked poultry houses expected before recrudescence occurs. Three C&D scenarios were considered, namely (i) preliminary C&D alone, (ii) preliminary C&D plus secondary C&D without dismantling and (iii) preliminary C&D plus secondary C&D with dismantling. The source-pathway-receptor framework was used to construct the model, and parameterisation was based on the three C&D scenarios. Two key operational variables in the model are (i) the time between depopulation of infected birds and restocking with new birds (TbDR) and (ii) the proportion of infected material that bypasses C&D, enabling virus to survive the process. Probability distributions were used to describe these two parameters for which there was recognised variability between premises in TbDR or uncertainty due to lack of information in the fraction of bypass. The risk assessment estimates that the median (95% credible intervals) number of repopulated poultry houses before recrudescence are 1.2 × 104 (50 to 2.8 × 106), 1.9 × 105 (780 to 5.7 × 107) and 1.1 × 106 (4.2 × 103 to 2.9 × 108) under C&D scenarios (i), (ii) and (iii), respectively. Thus for HPAIV in caged layers, undertaking secondary C&D without dismantling reduces the risk by 16-fold compared to preliminary C&D alone. Dismantling has an additional, although smaller, impact, reducing the risk by a further 6-fold and thus around 90-fold compared to preliminary C&D alone. On the basis of the 95% credible intervals, the model demonstrates the importance of secondary C&D (with or without dismantling) over preliminary C&D alone. However, the extra protection afforded by dismantling may not be cost beneficial in the context of reduced risk of onward spread.

Prioritizing Health Equity: Patient Perspectives from a Clinic-Based PhotoVoice Qualitative Study.

Purpose: This article explores the results of community-engaged PhotoVoice research with the Family Tree Clinic (FTC) in St. Paul, MN. FTC has >45 years of experience providing sexual, reproductive, and primary health care, with a central mission of overcoming issues for their patients including those of poverty, oppression, lack of access, and discrimination in meeting health care needs. Methods: This research presents the findings of social justice-inspired PhotoVoice focus groups with patients of the clinic that asked two central questions: "Why do you choose Family Tree Clinic" and "What stands in the way of achieving your goals for your health?" Results: When health equity is a central priority and evident in clinic culture, practices, and policies, patients articulate positive experiences despite real structural and systemic barriers outside the clinic. Conclusion: We offer suggestions for a health equity-oriented approach to clinic care.

Impact of Insurance Status on Time to Evaluation and Treatment of Meniscal Tears in Children, Adolescents, and College-Aged Patients in the United States.

BACKGROUND: The meniscus is vital for load bearing, knee stabilization, and shock absorption, making a meniscal tear a well-recognized sport-related injury in children and young adults. An inverse relationship between the quality and value of orthopaedic care provided and the overall treatment cycle exists in which delayed meniscal tear treatment increases the likelihood of unfavorable outcomes. Although a majority of children and young adults have health insurance, many athletes within this demographic still face significant barriers in accessing orthopaedic services because of insurance type and household income. PURPOSE: To determine the impact of insurance status and socioeconomic markers on the time to orthopaedic evaluation and treatment as well as the rate of surgical interventions for meniscal tears in children and young adult athletes in the United States. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We conducted a retrospective review of all patients ≤22 years of age who presented to our institution between 2008 and 2016 and who were diagnosed with meniscal tears. Patients were categorized based on insurance and socioeconomic status. Dates of injury, referral, evaluation by an orthopaedic surgeon, and surgery were also recorded. Chi-square and regression analyses were utilized to determine the significance and correlation between the influencing factors and time to referral, evaluation, and surgery. RESULTS: Publicly insured, commercially insured, and uninsured patients comprised 49.4%, 26.6%, and 24.1%, respectively, of the 237 patients included in this study. Insurance status was predictive of time to orthopaedic referral, initial evaluation, and surgery (P < .01). Uninsured and publicly insured patients experienced significant delays during their orthopaedic care compared with commercially insured patients. However, no correlation was found between insurance status or household income and the rate of surgical interventions. CONCLUSION: Publicly insured and uninsured pediatric and college-aged patients faced significant barriers in accessing orthopaedic services, as demonstrated by substantially longer times between the initial injury and referral to an orthopaedic evaluation and surgery; however, these socioeconomic factors did not affect the rate of surgical management. Clinical competency regarding the effects of socioeconomic factors on the time to orthopaedic care and efforts to expedite care among underinsured and underserved children are vital for improving patient outcomes.

Type 2 diabetes remission: economic evaluation of the DiRECT/Counterweight-Plus weight management programme within a primary care randomized controlled trial.

AIM: The Counterweight-Plus weight management programme achieved 46% remission of Type 2 diabetes at 1 year in the DiRECT trial. We estimated the implementation costs of the Counterweight-Plus programme and its 1-year cost-effectiveness in terms of diabetes remission, compared with usual care, from the UK National Health Service (NHS) perspective. METHODS: Within-trial total costs included programme set-up and running costs (practitioner appointment visits, low-energy formula diet sachets and training), oral anti-diabetes and anti-hypertensive medications, and healthcare contacts. Total costs were calculated for aggregated resource use for each participant and 95% confidence intervals (CI) were based on 1000 non-parametric bootstrap iterations. RESULTS: One-year programme costs under trial conditions were estimated at £1137 per participant (95% CI £1071, £1205). The intervention led to a significant cost-saving of £120 (95% CI £78, £163) for the oral anti-diabetes drugs and £14 (95% CI £7.9, £22) for anti-hypertensive medications compared with the control. Deducting the cost-savings of all healthcare contacts from the intervention cost resulted an incremental cost of £982 (95% CI £732, £1258). Cost per 1 year of diabetes remission was £2359 (95% CI £1668, £3250). CONCLUSIONS: Remission of Type 2 diabetes within 1-year can be achieved at a cost below the annual cost of diabetes (including complications). Providing a reasonable proportion of remissions can be maintained over time, with multiple medical gains expected, as well as immediate social benefits, there is a case for shifting resources within diabetes care budgets to offer support for people with Type 2 diabetes to attempt remission. (Clinical Trial Registry No.: ISRCTN03267836).