Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions.

A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.

Scratch Descriptive epidemiologic study of billiards-related injuries.

The purpose of this descriptive epidemiological study is to identify billiards-related injuries that presented to the United States emergency departments from 2000 to 2020. This is a study using secondary data from emergency departments from 2000 to 2020 and presented with billiards-related injuries. No applicable intervention, but the main outcome measure was a description of injuries sustained due to participation in billiards. Billiards-related injury was captured by the National Electronic Injury Surveillance System - All Injury Program database. We extracted information on age, gender, injury, and disposition. A collective total of 78,524 (n = 1214) estimated patients, had emergency department visits after incurring billiards-related injuries as a sample. The mean age was 24.9 years. Most injuries occurred in males, 54,915 (n = 851, 69.9%). More injuries appeared to be soft-tissue contusions and abrasions, 19,000 (24.2%, n = 280), followed by lacerations, 17,520 (22.3%, n = 269). The most common cause of injury was being struck by a ball or cue, 39,705 (51.1%, n = 643). While the majority of injured patients were discharged home after evaluation, 2527 (3.2%, n = 45) of them required hospitalization. While a small number of billiards-related injuries presented to the emergency department in comparison to other sports-related injuries, some required more intensive treatment or hospitalization.

Failure to Participate in Sports: An Evaluation of Preparticipation Physicals in a Local School District.

PURPOSE: To determine the incidence of the documentation of athlete failure of preparticipation sports physicals. METHODS: This was a retrospective observational study that involved review of preparticipation examination physical form documentation from multiple clinicians for all student athletes who participated in athletics during the 2018 to 2019 academic year at Galveston Independent School District (GISD). We collected the reasons for failure to pass the preparticipation physical examination. RESULTS: Of the approximately 800 student athlete forms reviewed, 183 forms indicated individual athletes failed the visual acuity or cardiovascular portions of the preparticipation physical examination. DISCUSSION: Athlete failures of the preparticipation physical examination may cause delays in sports participation, and time and monetary costs to students and their parents. Inconsistences in guidelines used to clear athletes as well as variation in form completion impacts whether athletes reportedly failed or passed the examination. Mass participation screening becomes a safety net for communities for athletes who may not have primary care providers to encourage follow-up with a regular clinician for previously undiagnosed medical issues and standardizing guideline use and form completion across clinicians who do these exams may improve numbers of athletes who are cleared to play sports. CONCLUSION: Focusing on preventable and addressable preparticipation examination failures may help clinicians who perform these exams, while also establishing a safety net for previously undiagnosed medical conditions. Instituting yearly vision checks, addressing cardiovascular issues, and encouraging yearly follow-up with primary care clinicians can more readily address physical and mental health issues and will provide more comprehensive care to student athletes.

Text messaging intervention for Pap smear uptake: a single-institution study.

Cervical cancer continues to be one of the leading causes of death among women in many parts of the world. With the increasing proliferation of mobile technology, text messaging interventions have been effective in improving Pap smear uptake in non-United States populations. This study evaluated whether text message reminders from a health system in Galveston, Texas, USA increased uptake of cervical cancer screening as compared to usual care. A single text message reminder was sent to 16,002 unique patient phone numbers using the Televox Communication Program from February 20, 2019, to April 4, 2019. The institution's population health database was subsequently used to determine if patients received cervical cancer screening (Pap smear) following the text message transmission. Patient demographics within text message and control groups were compared using Chi-square tests. Our text messaging intervention to improve Pap smear rates did not show a statistically significant difference between the intervention group receiving a text message and the control. However, there were significant interactions between text messages and age, financial class, and county (P=0.0023, 0.0299, and <0.0001, respectively). Text messaging did have a positive impact on our most vulnerable patient populations given that the text messaging intervention showed a marginally higher rate of Pap smear among Medicaid and low-income/uninsured (MLIU) patients. Text messaging interventions do have effectiveness in increasing Pap smear uptake in populations which are most impacted by health disparities.

The outcome of frailty in older people with diabetes as a function of glycaemic control and hypoglycaemic therapy: a review.

INTRODUCTION: Frailty is an emerging and newly recognized complication of diabetes in older people. However, frailty is not thoroughly investigated in diabetes outcome studies. AREAS COVERED: This manuscript reviews the effect of glycemic control and hypoglycemic therapy on the incidence of frailty in older people with diabetes. EXPERT OPINION: Current studies show that both low glycemia and high glycemia are associated with frailty. However, most of the studies, especially low glycemia studies, are cross-sectional or retrospective, suggesting association, rather than causation, of frailty. In addition, frail patients in the low glycemia studies are characterized by lower body weight or lower body mass index (BMI), contrary to those in the high glycemia studies, who are either overweight or obese. This may suggest that frailty has a heterogeneous metabolic spectrum, starting with an anorexic malnourished (AM) phenotype at one end, which is associated with low glycemia and a sarcopenic obese (SO) phenotype on the other end, which is associated with high glycemia. The current little evidence suggests that poor glycemic control increases the risk of frailty, but there is a paucity of evidence to suggest that tight glycemic control would reduce the risk of incident frailty. Metformin is the only well-studied hypoglycemic agent, so far, to have a protective effect against frailty independent of glycemic control in the non-frail older people with diabetes. However, once frailty is developed, the choice of the best hypoglycemic agent for these patients will be affected by the metabolic phenotype of frailty. For example, sodium glucose transporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) are appropriate in the SO phenotype due to their weight losing properties, while insulin therapy may be considered early in the AM phenotype due to its anabolic and weight gaining benefits. Future studies are still required to further investigate the metabolic effects of frailty on older people with diabetes, determine the most appropriate HbA1c target, and explore the most suitable hypoglycemic agent in each metabolic phenotype of frailty.

Resident Self-assessment and Clinical Competency Committee Evaluations in Family Medicine: A Single-Institution Study.

BACKGROUND AND OBJECTIVES: We sought to describe the process of integrating resident self-assessments into milestone assessments at the University of Texas Medical Branch Family Medicine Residency Program in Galveston, Texas. We compared resident self-assessments across milestones to Clinical Competency Committee (CCC) assessments across terms (fall versus spring) and by postgraduate year (PGY). METHODS: In fall 2020, the milestone assessment process was updated to include a resident milestone self-assessment, which was used as the starting point for CCC assessment. We calculated mean and standard deviation of average milestone scores for both self-assessment and CCC for each PGY. We used repeated measure analysis of variance to examine within- and between-subject effects. RESULTS: Self-assessment and CCC assessments were completed for 30 postgraduate trainees for spring 2020 and fall 2021 terms, for a total of 60 self- and 60 CCC assessments. CCC score was similar to self-assessment. There were larger variations in the resident self-assessment scores than CCC scores. Self-assessment scores increased by PGY, but were not different between fall and spring terms. We found a significant three-way interaction of assessors, terms, and PGYs. CONCLUSIONS: Resident milestone self-assessment enables residents to participate in the assessment process, and when differences exist between self- and CCC assessments, specific feedback can be given based on individual milestone skills. Our study showed progression between PGY regardless of the assessor, but only CCC assessment showed significant differences between terms.

Current Trends in Intra-articular Knee Injections Among Family Physicians.

Introduction: Family physicians use a variety of medications and techniques to perform intra-articular knee injections in the treatment of knee osteoarthritis. Currently, there is no consensus in the literature among the various specialties that perform joint injections for osteoarthritis of the knee regarding frequency of injections and injectate. The purpose of this study is to examine (1) the types of intra-articular knee injections used by family physicians for arthritis, (2) the most commonly used injectate, (3) the procedural approach, and (4) the maximum number of times the majority of family physicians would inject a single knee. Our study provides a descriptive epidemiology of current knee injection practices in the United States among family physicians. Methods: Surveys were emailed to family physicians. We evaluated and analyzed responses. Results: We received 360 responses, of which 317 family physicians indicated using intra-articular knee injections for pain. The majority (99%) used intra-articular injection steroid therapy in the treatment of knee osteoarthritis. About half (57.4%) of the family physicians would inject the same knee between one to five times. Conclusion: This study provides an overview of current practices in intra-articular injections among family physicians in the United States and provides important information regarding injection practices. Given the lack of consensus and that current practice contradicts evidence in the literature, consideration should be given among all specialties who perform joint injections to create evidence-based clinical practice guidelines to optimize patient care.

Aminoacid Profiling of Children with Severe Acute Malnutrition Pre and Post Nutritional Rehabilitation.

Malnutrition is a significant comorbidity in nearly one-third of the 8 million deaths in children under five years of age worldwide. Children with severe acute malnutrition have severely disturbed physiology and metabolism. Considering the vital importance of amino acids and the likely changes with the therapeutic diet, we aimed at evaluating these changes in children with SAM at baseline and after rehabilitation with a therapeutic diet at 14 days. Severe acute malnutrition defined as per WHO, for children between 6 months and 5 years with weight for height/length < -3SD of WHO charts, bilateral pitting edema, and mid-upper arm circumference (MUAC) < 1.5 cm. A total of 38 children were enrolled as cases, whereas the control group comprised of 37 children. Anthropometric measurement and estimation of amino acids in the blood were done at the baseline and after dietary rehabilitation. The individual levels of the essential and non-essential amino acids were significantly lower in the cases as compared to the controls, except for Aspartate and Threonine. The levels of amino acids increased significantly after dietary rehabilitation except for arginine, however not to the levels of those in controls. Most of the metabolites were reflective of maladaptation in SAM. Though nutritional rehabilitation of children with SAM improved the levels of amino acids, these levels were still low when compared to the controls, stipulating that complete metabolic recovery may take a longer duration of time. This necessitates the continuation of nutritional rehabilitation for a longer time and regular follow up of these children to ensure better compliance.

Atopic Dermatitis: Diagnosis and Treatment.

Atopic dermatitis (atopic eczema) is a chronic relapsing and remitting inflammatory skin disease affecting one in 10 people in their lifetime. Atopic dermatitis is caused by a complex interaction of immune dysregulation, epidermal gene mutations, and environmental factors that disrupts the epidermis causing intensely pruritic skin lesions. Repeated scratching triggers a self-perpetuating itch-scratch cycle, which can have a significant impact on the patient's quality of life. The American Academy of Dermatology has created simple diagnostic criteria based on symptoms and physical examination findings. Maintenance therapy consists of liberal use of emollients and daily bathing with soap-free cleansers. Use of topical corticosteroids is the first-line treatment for atopic dermatitis flare-ups. Pimecrolimus and tacrolimus are topical calcineurin inhibitors that can be used in conjunction with topical corticosteroids as first-line treatment. Ultraviolet phototherapy is a safe and effective treatment for moderate to severe atopic dermatitis when first-line treatments are not adequate. Antistaphylococcal antibiotics are effective in treating secondary skin infections. Oral antihistamines are not recommended because they do not reduce pruritus. Evidence is lacking to support the use of integrative medicine in the treatment of atopic dermatitis. Newer medications approved by the U.S Food and Drug Administration, such as crisaborole and dupilumab, are effective in treating atopic dermatitis but are currently cost prohibitive for most patients.

Cataracts induced by neodymium-yttrium-aluminium-garnet laser lysis of vitreous floaters.

BACKGROUND: Neodymium-yttrium-aluminium-garnet (Nd:YAG) laser vitreolysis has been proposed as a treatment modality for symptomatic vitreous floaters. The purpose of this paper is to report two cases of cataracts associated with posterior capsular compromise, induced by Nd:YAG laser vitreolysis for symptomatic vitreous floaters. METHOD: Case series. RESULTS: Two patients who underwent ND:YAG laser vitreolysis for symptomatic floaters, presented with decline in visual acuity in the treated eye after the laser procedure. At the slit-lamp biomicroscope, each patient was found to have a posterior subcapsular cataract in the treated eye, with obvious loss of integrity of the posterior capsule. These two patients underwent cataract extraction by the same surgeon via phacoemulsification. Both eyes were found to have a defect in the posterior capsule intraoperatively. In both cases, a three-piece acrylic intraocular lens implant was placed in the sulcus, achieving optic capture. The best-corrected visual acuity (BCVA) was 20/20 in both patients, at 1 month following the surgery. At 2 months, one patient had a BCVA of 20/15. The second patient maintained a BCVA of 20/20 at 3 months. CONCLUSIONS: Secondary cataract formation accompanied by loss of integrity of the posterior capsule is a potential complication of Nd:YAG laser vitreolysis for symptomatic floaters.

Surgical outcomes of inflammatory glaucoma: a comparison of trabeculectomy and glaucoma-drainage-device implantation.

PURPOSE: Our aim was to compare surgical outcomes of trabeculectomy and nonvalved glaucoma-drainage-device (GDD) implantation in eyes with chronic inflammatory glaucoma and uncontrolled intraocular pressure (IOP). METHODS: A retrospective chart review was conducted on patients with glaucomatous optic neuropathy, chronic anterior or posterior segment inflammation, and ≥6 months postoperative follow-up. All eyes underwent trabeculectomy with either antifibrotic therapy or implantation of a Baerveldt GDD (Abbott Laboratories Inc., Abbott Park, IL, USA). Failure was defined as IOP >21 mmHg, <20 % reduction below baseline or IOP <5 mmHg on two consecutive follow-up visits after 3 months, reoperation for glaucoma, or loss of light-perception vision. Statistical methods consisted of Student's t tests, χ(2) test, and Kaplan-Meier time to failure analysis. RESULTS: Nineteen trabeculectomies of 42 patients were followed for a mean of 31 ± 23 and 23 GDD eyes for a mean of 39 ± 19 months (P = 0.22). At last follow-up, mean IOP (11.83 ± 4.59 and 13.15 ± 6.11 mmHg, P = 0.45) and number of glaucoma medications (1.28 ± 1.56 and 1.26 ± 1.25, P = 0.97) were similar between the trabeculectomy and GDD groups. The frequency and types of postoperative complications in both groups were similar. The cumulative probability of failure after 5 years of follow-up was significantly greater in trabeculectomy eyes (62 %) compared with GDD eyes (25 %) (P = 0.006). CONCLUSIONS: Nonvalved tube-shunt surgery was more likely to maintain IOP control and avoid reoperation than trabeculectomy with antifibrotic therapy in eyes with chronic inflammatory glaucoma.

The impact of surgical intraocular pressure reduction on visual function using various criteria to define visual field progression.

PURPOSE: To examine the impact of surgical intraocular pressure (IOP) reduction on visual function using various methods to define visual field (VF) progression. METHODS: A retrospective chart review was conducted on consecutive glaucoma patients who underwent surgical IOP reduction between January 1, 2002 and December 31, 2007. All subjects had glaucomatous optic neuropathy, a minimum of 5 preoperative and 5 postoperative VFs, and were followed for a minimum of 2 years both before and after surgery. VF progression was determined using guided progression analysis, linear regression analysis of the visual field index, and individual sensitivity values using Progressor software. RESULTS: Seventeen eyes of 17 patients (mean age 77.9±9.9 y) were enrolled. Subjects were followed for a mean 5.8±2.4 years before surgery and 4.5±1.5 years after surgery. The mean postoperative IOP (11.3±4.2 mm Hg) and medications (1.3±1.3) were significantly (P<0.001 and P=0.01) reduced compared with before surgery (18.0±3.9 mm Hg, 2.4±0.9, respectively). The number of eyes judged to have VF progression using any method during the postoperative period (3 of 17, 17.6%) was significantly (P=0.03) reduced compared with the preoperative period (9 of 17 eyes, 52.9%). Using visual field index criteria, 8 eyes were judged to have preoperative VF progression and 1 eye had persistent VF progression during the postoperative period. None of the eyes judged to have preoperative VF progression using Early Manifest Glaucoma Trial (n=4) and Progressor criteria (n=1) demonstrated persistent VF progression during the postoperative period. Among eyes with preoperative VF progression, the postoperative slope of mean deviation (-0.21±0.23 dB/y) was significantly (P=0.03) reduced compared with before surgery (-1.01±0.23 dB/y). CONCLUSIONS: Despite differences in the criteria used to define VF progression, glaucoma surgical IOP reduction significantly reduces the incidence and rate of VF progression.

Optic Neuropathy from Cobalt Toxicity in a Patient who Ingested Cattle Magnets.

Cobalt is a widely used in the industrial production of hard metals. Cobalt ingestion has been reported to cause widespread systemic toxicity, but its effects on vision have been sparsely reported. The authors report the case of a patient who ingested cattle magnets, which remained in his stomach for an unknown duration of time. These magnets largely consist of cobalt that gradually leached into his blood stream, resulting in protean systemic manifestations, which included optic atrophy.