Effect of Visit Frequency of Pharmacist-Led Diabetes Medication Management Program.

BACKGROUND: Pharmacists have a positive effect on clinical outcomes in chronic disease state management, however, few studies have evaluated the effect that frequency of visits may have on diabetes biomarkers such as hemoglobin A1c and blood pressure readings. METHODS: Under the medication management program (MMP), patients with diabetes were seen monthly by pharmacists until early 2015, when time between visits was increased to every 3 months. A retrospective chart review was conducted to evaluate the primary outcome of the percent change in hemoglobin A1c and blood pressure after the change in visit frequency. RESULTS: In the 303 patients enrolled, no statistical difference existed between the pre and post average A1c (p-value = 0.10). The intermediate average A1c was statistically lower from the preintervention mean A1c (p-value = 0.001) but not from the postintervention mean A1c (p-value = 0.30). No statistical differences were seen between systolic blood pressure and diastolic blood pressure. CONCLUSION: Patients who have been seen by a clinical pharmacist more frequently (every month or every other month) for several years may be able to maintain their reduction in A1c with less-frequent visits (every 3 to 6 months).

Rate of contralateral hip fracture after dynamic hip screw vs intramedullary nail for treatment of pertrochanteric hip fractures.

A retrospective, comparative study was performed reviewing the electronic medical records and digital radiographs of patients who underwent treatment for intertrochanteric and pertrochanteric hip fractures with either a hip screw and side plate (HSSP) or intramedullary nail. A total of 430 patients were treated with HSSP, and 725 were managed with a cephalomedullary nail (CMN). Of these, 103 sustained a contralateral hip fracture. Fixation technique was not associated with a significant difference in the rate of contralateral fracture. Among the patients with a contralateral fracture, the median time to contralateral fracture was 119.28 months following HSSP and 81.97 months following CMN. Bisphosphonate use was found to be a significant predictor of contralateral fracture for all patients, but when matching using propensity scores, its use was found to be insignificant. In conclusion, there was no difference in the rate of subsequent contralateral hip fracture when comparing HSSP with CMN. Additionally, the time to second surgery between the two treatment modalities was found to be statistically insignificant. It is unclear if bisphosphonate use increased the odds of having a contralateral fracture, regardless of the surgical intervention. The difference in the bisphosphonate effect using propensity score matching suggests that the results may be due to confounding variables and bias.

Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial.

Study Design Prospective, randomized, partially blinded. Background Greater trochanteric pain syndrome (GTPS) is the current terminology for what was once called greater trochanteric or subgluteal bursitis. Cortisone (corticosteroid) injection into the lateral hip has traditionally been the accepted treatment for this condition; however, the effectiveness of injecting the bursa with steroids is increasingly being questioned. An equally effective treatment with fewer adverse side effects would be beneficial. Objective To investigate whether administration of dry needling (DN) is noninferior to cortisone injection in reducing lateral hip pain and improving function in patients with GTPS. Methods Forty-three participants (50 hips observed), all with GTPS, were randomly assigned to a group receiving cortisone injection or DN. Treatments were administered over 6 weeks, and clinical outcomes were collected at baseline and at 1, 3, and 6 weeks. The primary outcome measure was the numeric pain-rating scale (0-10). The secondary outcome measure was the Patient-Specific Functional Scale (0-10). Medication intake for pain was collected as a tertiary outcome. Results Baseline characteristics were similar between groups. A noninferiority test for a repeated-measures design for pain and averaged function scores at 6 weeks (with a noninferiority margin of 1.5 for both outcomes) indicated noninferiority of DN versus cortisone injection (both, P<.01). Medication usage (P = .74) was not different between groups at the same time point. No adverse side effects were reported. Conclusion Cortisone injections for GTPS did not provide greater pain relief or reduction in functional limitations than DN. Our data suggest that DN is a noninferior treatment alternative to cortisone injections in this patient population. Level of Evidence Therapy, level 1b. Registered December 2, 2015 at www.clinicaltrials.gov (NCT02639039). J Orthop Sports Phys Ther 2017;47(4):232-239. Epub 3 Mar 2017. doi:10.2519/jospt.2017.6994.

Effect of Obesity on Bone Healing After Foot and Ankle Long Bone Fractures.

As obesity has become more common, fractures in the obese population have become more frequent. Concern exists regarding alterations in bone health and healing in obese patients. A matched case-control study was performed at 1 institution to evaluate whether an association exists between nonunion and a high body mass index in metatarsal and ankle fractures. A total of 48 patients with nonunion were identified, and control patients matched 2 to 1 (n = 96) were selected. The control patients were matched for age, sex, and fracture type. No association was identified between nonunion and the continuous body mass index (p = .23) or morbid obesity, with a body mass index of ≥40 kg/m2 (p = .51). However, the results from both univariate and multivariate analysis suggested that patients with a current alcohol problem or a history of an alcohol problem might have a greater risk of nonunion. The odds ratio of a patient with a history of alcohol use experiencing nonunion was 2.7 (95% confidence interval 1.2 to 6.2). Further studies are warranted to confirm these findings.

Routine central lymph node dissection with total thyroidectomy for papillary thyroid cancer potentially minimizes level VI recurrence.

BACKGROUND: Treatment strategies for papillary thyroid cancer remain controversial due to the lack of large, randomized controlled trials. The purpose of this study was to review the benefit of routine bilateral central lymph node dissection (CLND) by analyzing local recurrence and complication rates from a single institution over a 15-year period. METHODS: A retrospective, institutional review board-approved review of the Baylor Scott & White Tumor Registry was performed on all patients who underwent operation for papillary thyroid cancer between 2000 and 2015. Patients were evaluated by age, sex, tumor size, operation performed, pathologic findings, adjuvant therapy, and date of recurrence. Primary outcomes were cancer recurrence, recurrent laryngeal nerve injury, and hypoparathyroidism. RESULTS: Total thyroidectomy with CLND was performed in 266 patients. Metastases to level VI lymph nodes were present in 106/266 (39.8%) patients. Average follow-up after thyroidectomy was 46 months (range 1-125 months). Papillary thyroid cancer recurred in 4 patients after thyroidectomy with CLND for primary tumors with mean size of 1.6 cm (range 1.0-2.0 cm). Two patients with T4 tumors had local recurrence in the paratracheal soft tissues, and 2 patients presented with recurrence in the lateral neck. Temporary nerve injuries occurred in 9/266 (3.4%) and permanent nerve injuries in 1/266 (0.4%) of CLND. Permanent hypoparathyroidism occurred in 4/266 (1.5%) patients. CONCLUSION: Total thyroidectomy with CLND can safely be performed routinely for treatment of papillary thyroid cancer in the hands of experienced endocrine surgeons. Dissection of level VI lymph nodes does not increase the risk of recurrent laryngeal nerve injury when performed routinely. Bilateral CLND with total thyroidectomy for papillary thyroid cancer potentially minimizes recurrence in the level VI compartment.

Mortality by treatment in patients ≥80 years of age with gastroesophageal cancer seen in a 20-year period at a single medical center.

The treatment approach to patients 80 years of age and older with gastroesophageal cancer at Baylor Scott and White in Temple, Texas, has historically favored conservative measures in the form of palliation and observation. To evaluate this trend in practice, the administered treatments and subsequent patient outcomes of this group were retrospectively reviewed. The study group included all patients 80 years of age and older with a diagnosis of gastroesophageal cancer seen at our facility between 1991 and 2010. Of the 117 cases, 49% received none of the available treatment modalities. The median overall survival (OS) of patients who received treatment, however, was significantly longer than the OS of those who did not, regardless of modality. Specifically, surgical intervention offered an almost double median OS compared with no therapy (6.8 vs. 3.9 months, respectively; P = 0.02); chemotherapy, an almost 4-fold OS benefit (14.8 vs. 3.9 months; P = 0.03); and radiation therapy, a >3-fold OS benefit (11.1 vs. 3.5 months; P = 0.04). These results further substantiate chronological age as an inaccurate predictor of treatment benefit, and age alone should not dictate the administration or withholding of available treatment options.

Functional Data Analysis of Tree Data Objects.

Data analysis on non-Euclidean spaces, such as tree spaces, can be challenging. The main contribution of this paper is establishment of a connection between tree data spaces and the well developed area of Functional Data Analysis (FDA), where the data objects are curves. This connection comes through two tree representation approaches, the Dyck path representation and the branch length representation. These representations of trees in Euclidean spaces enable us to exploit the power of FDA to explore statistical properties of tree data objects. A major challenge in the analysis is the sparsity of tree branches in a sample of trees. We overcome this issue by using a tree pruning technique that focuses the analysis on important underlying population structures. This method parallels scale-space analysis in the sense that it reveals statistical properties of tree structured data over a range of scales. The effectiveness of these new approaches is demonstrated by some novel results obtained in the analysis of brain artery trees. The scale space analysis reveals a deeper relationship between structure and age. These methods are the first to find a statistically significant gender difference.

Alcohol septal ablation for the treatment of hypertrophic obstructive cardiomyopathy. A multicenter North American registry.

OBJECTIVES: The purpose of the study is to identify the predictors of clinical outcome (mortality and survival without repeat septal reduction procedures) of alcohol septal ablation for the treatment of patients with hypertrophic obstructive cardiomyopathy. BACKGROUND: Alcohol septal ablation is used for treatment of medically refractory hypertrophic obstructive cardiomyopathy patients with severe outflow tract obstruction. The existing literature is limited to single-center results, and predictors of clinical outcome after ablation have not been determined. Registry results can add important data. METHODS: Hypertrophic obstructive cardiomyopathy patients (N = 874) who underwent alcohol septal ablation were enrolled. The majority (64%) had severe obstruction at rest, and the remaining had provocable obstruction. Before ablation, patients had severe dyspnea (New York Heart Association [NYHA] functional class III or IV: 78%) and/or severe angina (Canadian Cardiovascular Society angina class III or IV: 43%). RESULTS: Significant improvement (p < 0.01) occurred after ablation (~5% in NYHA functional classes III and IV, and 8 patients in Canadian Cardiovascular Society angina class III). There were 81 deaths, and survival estimates at 1, 5, and 9 years were 97%, 86%, and 74%, respectively. Left anterior descending artery dissections occurred in 8 patients and arrhythmias in 133 patients. A lower ejection fraction at baseline, a smaller number of septal arteries injected with ethanol, a larger number of ablation procedures per patient, a higher septal thickness post-ablation, and the use beta-blockers post-ablation predicted mortality. CONCLUSIONS: Variables that predict mortality after ablation, include baseline ejection fraction and NYHA functional class, the number of septal arteries injected with ethanol, post-ablation septal thickness, beta-blocker use, and the number of ablation procedures.

Initiating BMI prevalence studies in Vietnamese children: changes in a transitional economy.

BACKGROUND: Rapid changes in dietary patterns and lifestyles in Vietnam warrant monitoring trends of weight, height and body mass index (BMI) among children. OBJECTIVE: To determine the trends of weight, height and BMI classification of Vietnamese children, 6-15 years of age, from 1992 to 2000 with reference to socioeconomic, urban and rural differences. METHODS: Data in the Vietnam Living Standard Survey (1992-1993) and the General Nutrition Survey (2000) were collected from representative samples of children. Body mass index classification was determined using the International Obesity Task Force criteria to calculate the prevalence and trends in each survey, and in a pooled survey analysis. RESULTS: Statistically significant increases were seen in children's mean weight, height and BMI between the two surveys: 2.1 kg for weight, 4 cm for height, and 0.28 kg/m2 for BMI. Increases in height were greater in rural than urban areas, and BMI increases were smaller in rural than urban areas. CONCLUSIONS: The rising prevalence of children at risk of overweight in urban Vietnam is a concern that must be monitored to guide policy changes. The unchanging prevalence of rural underweight boys requires attention. A national nutrition program to address under- and overweight for children throughout primary school is needed.

Temporal analysis of airborne particulate matter reveals a dose-rate effect on mortality in El Paso: indications of differential toxicity for different particle mixtures.

One of two topics explored is the limitations of the daily average in summarizing pollutant hourly profiles. The daily average of hourly measurements of air pollutant constituents provides continuity with previous studies using monitoring technology that only provided the daily average. However, other summary statistics are needed that make better use of all available information in 24-hr profiles. The daily average reflects the total daily dose, obscuring hourly resolution of the dose rate. Air pollutant exposures with comparable total daily doses may have very different effects when occurring at high levels over a few hours as opposed to low levels over a longer time. Alternative data-based choices for summary statistics are provided using principal component analysis to capture the exposure dose rate, while preserving ease of interpretation. This is demonstrated using the earliest hourly particle concentration data available for El Paso from archived records of particulate matter (PM)10. In this way, a significant association between evening PM10 exposures and nonaccidental daily mortality is found in El Paso from 1992 to 1995, otherwise missed using the daily average. Secondly, the nature and, hence, effects of particles in the ambient aerosol during El Paso sandstorms is believed different from that of particles present during still-air conditions resulting from atmospheric temperature inversions. To investigate this, wind speed (ws) is used as a surrogate variable to label PM10 exposures as Low-ws (primarily fine particles), High-ws (primarily coarse particles), or Mid-ws (a mixture of fine and coarse particles). A High-ws evening is significantly associated with a 10% lower risk of mortality on the succeeding third day, as compared with comparable exposures at Low- or Mid-ws. Although this analysis cannot be used to form firm conclusions because it uses a very small data set, it demonstrates the limitations of the daily average and suggests differential toxicity for different particle compositions.