A system approach to improving guideline-directed therapy for cardio-renal-metabolic conditions: The "beyond diabetes" initiative.

Objective: Despite demonstrating improvements in cardiovascular disease, kidney disease, and survival outcomes, guideline-directed antihyperglycemic medications such as sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like-peptide-1 receptor agonists (GLP1-RA), are underutilized. Many obstacles constrain their use including lack of systematic provider and patient education, concern for medication side effects, and patient affordability. Methods: We designed a multimodality, systems-based approach to address these challenges with the goal of increasing medication utilization across the largest healthcare system in New York State. This multispecialty collaborative included provider and patient education, an electronic health record-enabled platform to identify eligible patients, and access to pharmacists for medication guidance and addressing insurance coverage barriers. Surveys were administered following grand rounds lectures and knowledge-based questionnaires were given before and after case-based sessions for housestaff, with results analyzed using a two-sided Student's t-test. Rates of first prescriptions of SGLT2i/GLP1-RA in combined and individual analyses were compared between the pre- and post-education periods (6 months prior to 3/31/2021 and 6 months post 8/19/2021), and the change in prescriptions per 100 eligible-visits was assessed using the incidence density approach. Results: Among grand rounds participants, 69.3% of respondents said they would make changes to their clinical practice. Knowledge increased by 14.7% (p-value <0.001) among housestaff following case-based sessions. An increase in SGLT2i/GLP1-RA prescribing was noted for eligible patients among internal medicine, cardiology, nephrology, and endocrinology providers, from 11.9 per 100 eligible visits in the pre-education period to 14.8 in the post-education period (absolute increase 2.9 [24.4%], incidence risk ratio 1.24 [95% CI 1.18-1.31]; p-value <0.001). Increases in prescribing rates were also seen among individual medical specialties. Conclusions: Our "Beyond Diabetes" initiative showed an improvement in provider knowledge-base and was associated with a modest, but statistically significant increase in the use of SGLT2i and GLP1-RA throughout our healthcare system.

Evaluation of the Impact and Outcomes of a Rapid Transition to Telehealth PrEP Delivery at a Sexual Health Clinic During the COVID-19 Pandemic.

BACKGROUND: Increasing human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) use is a critical part of ending the HIV epidemic. In response to the COVID-19 pandemic, many PrEP services transitioned to a telehealth model (telePrEP). This report evaluates the effect of COVID-19 and the addition of telePrEP on delivery of PrEP services at the Denver Sexual Health Clinic (DSHC), a regional sexual health clinic in Denver, CO. METHODS: Before COVID-19, DSHC PrEP services were offered exclusively in-clinic. In response to the pandemic, after March 15, 2020, most PrEP initiation and follow-up visits were converted to telePrEP. A retrospective analysis of DSHC PrEP visits compared pre-COVID-19 (September 1, 2019 to March 15, 2020) to post-COVID-19 (March 16, 2020 to September 30, 2020) visit volume, demographics, and outcomes. RESULTS: The DSHC completed 689 PrEP visits pre-COVID-19 and maintained 96.8% (n = 667) of this volume post-COVID-19. There were no differences in client demographics between pre-COVID-19 (n = 341) and post-COVID-19 PrEP start visits (n = 283) or between post-COVID-19 in-clinic (n = 140) vs telePrEP start visits (n = 143). There were no differences in 3- to 4-month retention rates pre-COVID-19 (n = 17/43) and post-COVID-19 (n = 21/43) ( P = 0.52) or between in-clinic (n = 12/21) and telePrEP clients (n = 9/22) in the post-COVID-19 window ( P = 0.37). Also, there were no significant differences in lab completion rates between in-clinic (n = 140/140) and telePrEP clients (n = 138/143) ( P = 0.06) and prescription fill rates between in-clinic (n = 115/136) and telePrEP clients (n = 116/135) in the post-COVID-19 window ( P = 0.86). CONCLUSIONS: Implementation of TelePrEP enabled the DSHC to sustain PrEP services during the COVID-19 pandemic without significant differences in demographics, engagement, or retention in PrEP services.

Predictors of Participation in Clinical Research.

BACKGROUND: Despite numerous efforts to create more equitable healthcare systems, minority populations face long-standing health disparities compared to White populations. Healthcare research is the necessary foundation for creating equitable health systems and providing patient-centered care. Significant challenges exist, however, with recruiting and engaging underrepresented populations in clinical research. OBJECTIVES: The purpose of this analysis was to determine how research participants' race, trust, and level of education influence participation barriers in clinical research. METHODS: The study used secondary, cross-sectional survey data that were collected between 2014 and 2016 through the former Mid-South Clinical Data Research Network, currently known as the Stakeholders, Technology, and Research Clinical Research Network. Descriptive statistics and Spearman rank correlations were performed between level of education, level of trust, and each attitude statement for each racial category. RESULTS: A total of 2,190 survey responses were used in the data analysis. The mean age of respondents was 52 years, with majority being women, White, insured, and working full time. Overall, the respondents had favorable attitudes toward research participation. Trust was correlated with agreement in many attitude statements for both White and African American respondents, whereas correlations with education level were more variable depending on racial grouping. Trust level was negatively associated with agreement toward the statement "researchers do not care about me" in White and Native American respondents. DISCUSSION: The results support the importance of trust to research participation. Generally, education level was not strongly predictive of research participation, although prediction was influenced by race and attitude.

Staircase sign: a newly described uterine contraction pattern seen in rupture of unscarred gravid uterus.

Although extremely rare, rupture of an unscarred gravid uterus poses significant morbidity and mortality to both fetus and mother. In the past, loss of uterine contraction was thought to be characteristic of uterine rupture, while recent evidence shows that uterine contraction pattern is not associated with uterine rupture. We report two cases of rupture in the unscarred term uterus. Both patients were multiparous and denied any past medical complications, previous cesarean delivery or myomectomy. Uterine rupture occurred in the latent phase of labor at 1 cm dilation (Case 1) and during an intravenous oxytocin infusion after three doses of intravaginal misoprostol (Case 2). Case 2 required cesarean hysterectomy and blood transfusion. Case 1 was monitored with an external tocodynamometer, while Case 2 was monitored with an internal pressure transducer. External monitoring demonstrated the classic sign of complete loss of uterine tone. In contrast, internal monitoring demonstrated an increase in uterine resting tone. Both techniques revealed a stepwise gradual decrease in contraction amplitude followed by sudden onset of profound and prolonged fetal bradycardia (staircase sign). In cases of uterine rupture, differing baseline characteristics between contraction patterns were dependent on uterine monitoring technique. In both techniques a stepwise gradual decrease in contraction amplitude was followed by prolonged fetal bradycardia.

Four-year review of burns as an etiologic factor in the development of long bone fractures in pediatric patients.

Reduced bone density has been documented in children after burns. This loss of bone may place children at heightened risk for fractures. The medical records of all acutely injured patients with burns in excess of 40% TBSA burn admitted to our institution between January 1, 1997, through December 31, 2000, were reviewed for fracture incidence. Patients with fractures sustained during the course of initial trauma were not included in the review. One hundred four records were reviewed. These patients had a mean age of 6.7 +/- 0.51 years, (range, 0.2 to 18.0) and a mean %TBSA burn of 59.9 +/- 1.60 (range, 40 to 98) with a mean full-thickness %burn of 51.7 +/- 2.16 (range, 0 to 95). Fifteen long bone fractures were documented in six patients during the review time frame. All fractures were initially suspected by physical therapy personnel upon regularly scheduled therapy sessions and subsequently verified by x-ray. All fractures identified by this review occurred in children less than 3 years of age. Most fractures were noted during the rehabilitation phase of injury (range, 73 to 283 days after burn) once wounds were more than 95% healed, except for one child, who sustained multiple fractures during the acute recovery phase at a referring hospital. A 5.8% incidence of fractures was noted in patients with burns in excess of 40% (6 of 104 admissions). The etiology of the fractures is unknown, although the hormonal milieu postburn, depressed vitamin D status, inadequate protein intake, and decreased weight-bearing activity are potential contributory factors. In addition, infants and toddlers tend to provide more resistance to therapy because of an inherent lack of cognition. This may account for the increased breaks in this population.