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Family physicians' suggestions to improve the documentation, coding, and billing system: a study from the residency research network of Texas

Richard Young, MD - Tue, 06/10/2014 - 05:00

Fam Med. 2014 Jun;46(6):470-2.

ABSTRACT

BACKGROUND AND OBJECTIVES: The study's aim was to ascertain family physicians' suggestions on how to improve the commonly used US evaluation and management (E/M) rules for primary care.

METHODS: A companion paper published in Family Medicine's May 2014 journal describes our study methods (Fam Med 2014;46(5):378-84).

RESULTS: Study subjects supported preserving the overall SOAP note structure. They especially suggested eliminating bullet counting in the E/M rules. For payment reform, respondents stated that brief or simple work should be paid less than long or complex work, and that family physicians should be paid for important tasks they currently are not, such as spending extra time with patients, phone and email clinical encounters, and extra paperwork. Subjects wanted shared savings when their decisions and actions created system efficiencies and savings. Some supported recent payment reforms such as monthly retainer fees and pay-for-performance bonuses. Others expressed skepticism about the negative consequences of each. Aligned incentives among all stakeholders was another common theme.

CONCLUSIONS: Family physicians wanted less burdensome documentation requirements. They wanted to be paid more for complex work and work that does not include traditional face-to-face clinic visits, and they wanted the incentives of other stakeholders in the health care systems to be aligned with their priorities.

PMID:24911305

Quadriceps and patellar tendon pie-crusting as a treatment for limited flexion in total knee arthroplasty

Hugo Sanchez, MD - Tue, 04/15/2014 - 05:00

Am J Orthop (Belle Mead NJ). 2014 Apr;43(4):E83-8.

ABSTRACT

The pie-crusting method of ligament and tendon lengthening has been used successfully in various tissues but is not reported in the literature as an option for patellar or quadriceps tendons to address flexion limitation. Our case report discusses a patient with longstanding flexion limitation who underwent primary total knee arthroplasty. The report reviews the literature on intraoperative treatments, which primarily pertains to the condition of patella baja, and demonstrates that the pie-crusting technique should be included as a treatment option for a tight extensor mechanism while having some advantages over tibial tubercle osteotomy or Z-plasty.

PMID:24730010

The accuracy of interqual criteria in determining the need for observation versus hospitalization in emergency department patients with chronic heart failure

Richard Robinson, MD - Tue, 11/19/2013 - 05:00

Crit Pathw Cardiol. 2013 Dec;12(4):192-6. doi: 10.1097/HPC.0b013e3182a313e1.

ABSTRACT

McKesson's Interqual criteria are one of the medical screening criteria that are widely used in emergency departments (EDs) to determine if patients qualify for observation or inpatient admission. Chronic heart failure (CHF) is one of the most common yet severe cardiovascular diseases seen in the ED with a relatively higher admission rate. This study is to evaluate the accuracy of Interqual criteria in determining observation versus hospitalization need in CHF patients. From January 2009 till December 2010, data from 503 CHF patients were reviewed. One hundred twenty-two patients were observed and 381 patients were admitted. Only one variable (blood urea nitrogen, ≥30 mg/dL; odds ratio, 2.44) from Interqual criteria had reached statistical significant difference between observation and hospitalization groups. Our results showed that based on the initial review at ED, clinical variables from Interqual criteria did not appear to help accurately predict the level of care in CHF patient in our patient population. Other clinical variables may need to be added in the criteria for better prediction.

PMID:24240548 | DOI:10.1097/HPC.0b013e3182a313e1

The accuracy of interqual criteria in determining the need for observation versus hospitalization in emergency department patients with chronic heart failure

Hao Wang, MD - Tue, 11/19/2013 - 05:00

Crit Pathw Cardiol. 2013 Dec;12(4):192-6. doi: 10.1097/HPC.0b013e3182a313e1.

ABSTRACT

McKesson's Interqual criteria are one of the medical screening criteria that are widely used in emergency departments (EDs) to determine if patients qualify for observation or inpatient admission. Chronic heart failure (CHF) is one of the most common yet severe cardiovascular diseases seen in the ED with a relatively higher admission rate. This study is to evaluate the accuracy of Interqual criteria in determining observation versus hospitalization need in CHF patients. From January 2009 till December 2010, data from 503 CHF patients were reviewed. One hundred twenty-two patients were observed and 381 patients were admitted. Only one variable (blood urea nitrogen, ≥30 mg/dL; odds ratio, 2.44) from Interqual criteria had reached statistical significant difference between observation and hospitalization groups. Our results showed that based on the initial review at ED, clinical variables from Interqual criteria did not appear to help accurately predict the level of care in CHF patient in our patient population. Other clinical variables may need to be added in the criteria for better prediction.

PMID:24240548 | DOI:10.1097/HPC.0b013e3182a313e1

Preventable acute care spending for medicare patients

Richard Young, MD - Thu, 11/14/2013 - 05:00

JAMA. 2013 Nov 13;310(18):1984. doi: 10.1001/jama.2013.278604.

NO ABSTRACT

PMID:24219956 | DOI:10.1001/jama.2013.278604

Family physicians' perceptions on how they deliver cost-effective care: a qualitative study from the Residency Research Network of Texas (RRNeT)

Richard Young, MD - Sat, 05/18/2013 - 05:00

Fam Med. 2013 May;45(5):311-8.

ABSTRACT

BACKGROUND AND OBJECTIVES: The aim of our study was to deepen our understanding of the factors that may explain the observational literature that more primary care physicians in an area contribute to better population health outcomes and lower health care costs.

METHODS: This study used in-depth, qualitative interviewing of family physicians in both urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking subjects to give examples and personal narratives demonstrating cost-effectiveness and cost inefficiencies in their own practices. An iterative open-coding approach was used to analyze transcripts to search for unifying themes and sub-themes until consensus among investigators was achieved.

RESULTS: Thirty-eight respondents gave examples of how their decision-making approaches resulted in improved patient outcomes and lower costs. Family physicians' cost-effective care was founded on two themes-characteristic attitudes and skills of the physicians themselves and a thorough knowledge of the whole patient. Family physicians also felt their approaches to gathering information and then making diagnostic and treatment decisions resulted in fewer tests and fewer treatments ordered overall. Family physicians also delivered care in less expensive facilities and generated lower overall charges for physician fees.

CONCLUSIONS: Family physicians perceived that their approaches to patient care result in medical decision making priorities and care delivery processes that contribute to more cost-effective health care. These outcomes were achieved less by providing preventive services and strictly adhering to guidelines but rather by how they individualized the management of new symptoms and chronic conditions.

PMID:23681681

Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center

Richard Robinson, MD - Sat, 03/23/2013 - 05:00

J Clin Med Res. 2013 Apr;5(2):75-83. doi: 10.4021/jocmr1227w. Epub 2013 Feb 25.

ABSTRACT

BACKGROUND: It has been found that significantly different clinical outcomes occur in trauma patients with different mechanisms of injury. Ground level falls (GLF) are usually considered "minor trauma" with less injury occurred in general. However, it is not uncommon that geriatric trauma patients sustain cervical spine (C-spine) fractures with other associated injuries due to GLF or less. The aim of this study is to determine the injury patterns and the roles of clinical risk factors in these geriatric trauma patients.

METHODS: Data were reviewed from the institutional trauma registry of our local level 1 trauma center. All patients had sustained C-spine fracture(s). Basic clinical characteristics, the distribution of C-spine fracture(s), and mechanism of injury in geriatric patients (65 years or older) were compared with those less than 65 years old. Furthermore, different clinical variables including age, gender, Glasgow coma scale (GCS), blood alcohol level, and co-existing injuries were analyzed by multivariate logistic regression in geriatric trauma patients due to GLF and internally validated by random bootstrapping technique.

RESULTS: From 2006 - 2010, a total of 12,805 trauma patients were included in trauma registry, of which 726 (5.67%) had sustained C-spine fracture(s). Among all C-spine fracture patients, 19.15% (139/726) were geriatric patients. Of these geriatric patients 27.34% (38/139) and 53.96% (75/139) had C1 and C2 fractures compared with 13.63% (80/587) and 21.98% (129/587) in young trauma patients (P < 0.001). Of geriatric trauma patients 13.67% (19/139) and 18.71% (26/139) had C6 and C7 fractures compared with 32.03% (188/587) and 41.40% (243/587) in younger ones separately (P < 0.001). Furthermore, 53.96% (75/139) geriatric patients had sustained C-spine fractures due to GLF with more upper C-spine fractures (C1 and C2). Only 3.2% of those had positive blood alcohol levels compared with 52.9% of younger patients (P < 0.001). In addition, 6.34% of geriatric patients due to GLF had intracranial pathology (ICP) which was one of the most common co-injuries with C-spine fractures. Logistic regression analysis showed the adjusted odds ratios of 1.17 (age) and 91.57 (male) in geriatric GLF patients to predict this co-injury pattern of C-spine fracture and ICP.

CONCLUSION: Geriatric patients tend to sustain more upper C-spine fractures than non-geriatric patients regardless of the mechanisms. GLF or less not only can cause isolated C-spines fracture(s) but also lead to other significant injuries with ICP as the most common one in geriatric patients. Advanced age and male are two risk factors that can predict this co-injury pattern. In addition, it seems that alcohol plays no role in the cause of GLF in geriatric trauma patients.

PMID:23519239 | PMC:PMC3601504 | DOI:10.4021/jocmr1227w

Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center

Hao Wang, MD - Sat, 03/23/2013 - 05:00

J Clin Med Res. 2013 Apr;5(2):75-83. doi: 10.4021/jocmr1227w. Epub 2013 Feb 25.

ABSTRACT

BACKGROUND: It has been found that significantly different clinical outcomes occur in trauma patients with different mechanisms of injury. Ground level falls (GLF) are usually considered "minor trauma" with less injury occurred in general. However, it is not uncommon that geriatric trauma patients sustain cervical spine (C-spine) fractures with other associated injuries due to GLF or less. The aim of this study is to determine the injury patterns and the roles of clinical risk factors in these geriatric trauma patients.

METHODS: Data were reviewed from the institutional trauma registry of our local level 1 trauma center. All patients had sustained C-spine fracture(s). Basic clinical characteristics, the distribution of C-spine fracture(s), and mechanism of injury in geriatric patients (65 years or older) were compared with those less than 65 years old. Furthermore, different clinical variables including age, gender, Glasgow coma scale (GCS), blood alcohol level, and co-existing injuries were analyzed by multivariate logistic regression in geriatric trauma patients due to GLF and internally validated by random bootstrapping technique.

RESULTS: From 2006 - 2010, a total of 12,805 trauma patients were included in trauma registry, of which 726 (5.67%) had sustained C-spine fracture(s). Among all C-spine fracture patients, 19.15% (139/726) were geriatric patients. Of these geriatric patients 27.34% (38/139) and 53.96% (75/139) had C1 and C2 fractures compared with 13.63% (80/587) and 21.98% (129/587) in young trauma patients (P < 0.001). Of geriatric trauma patients 13.67% (19/139) and 18.71% (26/139) had C6 and C7 fractures compared with 32.03% (188/587) and 41.40% (243/587) in younger ones separately (P < 0.001). Furthermore, 53.96% (75/139) geriatric patients had sustained C-spine fractures due to GLF with more upper C-spine fractures (C1 and C2). Only 3.2% of those had positive blood alcohol levels compared with 52.9% of younger patients (P < 0.001). In addition, 6.34% of geriatric patients due to GLF had intracranial pathology (ICP) which was one of the most common co-injuries with C-spine fractures. Logistic regression analysis showed the adjusted odds ratios of 1.17 (age) and 91.57 (male) in geriatric GLF patients to predict this co-injury pattern of C-spine fracture and ICP.

CONCLUSION: Geriatric patients tend to sustain more upper C-spine fractures than non-geriatric patients regardless of the mechanisms. GLF or less not only can cause isolated C-spines fracture(s) but also lead to other significant injuries with ICP as the most common one in geriatric patients. Advanced age and male are two risk factors that can predict this co-injury pattern. In addition, it seems that alcohol plays no role in the cause of GLF in geriatric trauma patients.

PMID:23519239 | PMC:PMC3601504 | DOI:10.4021/jocmr1227w

What could family income be if health insurance were more affordable?

Richard Young, MD - Wed, 10/03/2012 - 05:00

Fam Med. 2012 Oct;44(9):633-6.

ABSTRACT

BACKGROUND AND OBJECTIVES: Adjusted for inflation, household income has been relatively flat since the mid-1990s, but the inflation rate of employer-sponsored health insurance has been greater than both household income growth and general inflation for 50 years. We estimated the effect on average family income if health insurance inflation matched the general inflation rate since 1996, and those savings were given to employees as income.

METHODS: We used data from the Medical Expenditure Panel Survey, the Milliman Medical Index, and other federal sources to model the relationship between private health insurance costs and household income over the last 15 years.

RESULTS: If the cost of family health care costs had kept pace with the Consumer Price Index (CPI) rate since 1996, the average family income could have been $8,410 higher in 2010 ($68,805 versus $60,395), 13.9% more than actual earnings.

CONCLUSIONS: If health care costs had not exceeded the CPI rate since 1996 and if all the excess costs were converted into employee wages, median family income could be substantially higher today.

PMID:23027155

Who will have health insurance in the future? An updated projection

Richard Young, MD - Wed, 03/14/2012 - 05:00

Ann Fam Med. 2012 Mar-Apr;10(2):156-62. doi: 10.1370/afm.1348.

ABSTRACT

The passage of the 2010 Patient Protection and Affordable Care Act (PPACA) in the United States put the issues of health care reform and health care costs back in the national spotlight. DeVoe and colleagues previously estimated that the cost of a family health insurance premium would equal the median household income by the year 2025. A slowdown in health care spending tied to the recent economic downturn and the passage of the PPACA occurred after this model was published. In this updated model, we estimate that this threshold will be crossed in 2033, and under favorable assumptions the PPACA may extend this date only to 2037. Continuing to make incremental changes in US health policy will likely not bend the cost curve, which has eluded policy makers for the past 50 years. Private health insurance will become increasingly unaffordable to low-to-middle-income Americans unless major changes are made in the US health care system.

PMID:22412008 | PMC:PMC3315130 | DOI:10.1370/afm.1348

Vascular pedicle width on chest radiograph as a measure of volume overload: meta-analysis

James d'Etienne, MD - Sat, 01/07/2012 - 05:00

West J Emerg Med. 2011 Nov;12(4):426-32. doi: 10.5811/westjem.2011.3.2023.

ABSTRACT

INTRODUCTION: Vascular pedicle width (VPW), a measurement obtained from a chest radiograph (CR), is thought to be an indicator of circulating blood volume. To date there are only a handful of studies that demonstrate a correlation between high VPW and volume overload, each utilizing different VPW values and CR techniques. Our objective was to determine a mean VPW measurement from erect and supine CRs and to determine whether VPW correlates with volume overload.

METHODS: MEDLINE database, Web of Science, and the Cochrane Central Register of Controlled Trials were searched electronically for relevant articles. References from the original and review publications selected electronically were manually searched for additional relevant articles. Two investigators independently reviewed relevant articles for inclusion criteria and data extraction. Mean VPW measurements from both supine and erect CRs and their correlation with volume overload were calculated.

RESULTS: Data from 8 studies with a total of 363 subjects were included, resulting in mean VPW measurements of 71 mm (95% confidence interval [CI] 64.9-77.3) and 62 mm (95% CI 49.3-75.1) for supine and erect CRs, respectively. The correlation coefficients for volume overload and VPW were 0.81 (95% CI 0.74-0.86) for both CR techniques and 0.81 (95% CI 0.72-0.87) for supine CR and 0.80 (95% CI 0.69-0.87) for erect CR, respectively.

CONCLUSION: There is a clinical and statistical correlation between VPW and volume overload. VPW may be used to evaluate the volume status of a patient regardless of the CR technique used.

PMID:22224132 | PMC:PMC3236159 | DOI:10.5811/westjem.2011.3.2023

Vascular pedicle width on chest radiograph as a measure of volume overload: meta-analysis

Hao Wang, MD - Sat, 01/07/2012 - 05:00

West J Emerg Med. 2011 Nov;12(4):426-32. doi: 10.5811/westjem.2011.3.2023.

ABSTRACT

INTRODUCTION: Vascular pedicle width (VPW), a measurement obtained from a chest radiograph (CR), is thought to be an indicator of circulating blood volume. To date there are only a handful of studies that demonstrate a correlation between high VPW and volume overload, each utilizing different VPW values and CR techniques. Our objective was to determine a mean VPW measurement from erect and supine CRs and to determine whether VPW correlates with volume overload.

METHODS: MEDLINE database, Web of Science, and the Cochrane Central Register of Controlled Trials were searched electronically for relevant articles. References from the original and review publications selected electronically were manually searched for additional relevant articles. Two investigators independently reviewed relevant articles for inclusion criteria and data extraction. Mean VPW measurements from both supine and erect CRs and their correlation with volume overload were calculated.

RESULTS: Data from 8 studies with a total of 363 subjects were included, resulting in mean VPW measurements of 71 mm (95% confidence interval [CI] 64.9-77.3) and 62 mm (95% CI 49.3-75.1) for supine and erect CRs, respectively. The correlation coefficients for volume overload and VPW were 0.81 (95% CI 0.74-0.86) for both CR techniques and 0.81 (95% CI 0.72-0.87) for supine CR and 0.80 (95% CI 0.69-0.87) for erect CR, respectively.

CONCLUSION: There is a clinical and statistical correlation between VPW and volume overload. VPW may be used to evaluate the volume status of a patient regardless of the CR technique used.

PMID:22224132 | PMC:PMC3236159 | DOI:10.5811/westjem.2011.3.2023

The influence of research compensation options on Practice-based Research Network (PBRN) physician participation: a North Texas (NorTex) PBRN study

Richard Young, MD - Fri, 09/09/2011 - 05:00

J Am Board Fam Med. 2011 Sep-Oct;24(5):562-8. doi: 10.3122/jabfm.2011.05.100291.

ABSTRACT

OBJECTIVE: To study the effect of two compensation approaches, continuing medical education (CME) credits (5 hours) or monetary ($150), on the participation rate of a physician needs assessment study.

METHODS: Physicians representing family medicine, internal medicine, pediatric, and geriatrics specialties, and practicing in ambulatory primary care clinics affiliated with the North Texas Primary Care (NorTex) PBRN clinics, were recruited to complete a survey relevant to their subspecialty and to conduct a self-audit/abstraction of five medical records. Physicians were recruited from four health care systems, and the recruiting methods varied by system. Study outcome was the rate of study completion by type of incentive.

RESULTS: One hundred five of 211 (49.8%) physicians approached to participate gave consent and 84 (39.8%) completed the study. There was no difference in the number of physicians randomly assigned to monetary compared with CME compensation for giving consent to participate (adjusted odds ratio = 1.42, confidence interval = 0.69, 2.93). However, physicians in the monetary compensation group were more likely to complete the study after giving consent (adjusted odds ratio = 4.70, confidence interval = 1.25, 17.58). This monetary effect was also significant from the perspective of all physicians approached initially (adjusted odds ratio = 2.78, confidence interval = 1.16, 6.67).

DISCUSSION: This study suggests that future PBRN investigators should receive monetary compensation for the opportunity cost of adding research activities to their already busy practices. This compensation may be especially vital for PBRNs to complete more ambitious projects requiring a significant time commitment from the participating physicians.

PMID:21900439 | DOI:10.3122/jabfm.2011.05.100291

Factors influencing work interference in patients with chronic low back pain: a Residency Research Network of Texas (RRNeT) study

Richard Young, MD - Fri, 09/09/2011 - 05:00

J Am Board Fam Med. 2011 Sep-Oct;24(5):503-10. doi: 10.3122/jabfm.2011.05.100298.

ABSTRACT

INTRODUCTION: Chronic low back pain (CLBP) is a disabling and expensive condition commonly seen in family physicians' offices. A complete understanding of factors contributing to patients' return to work remains elusive.

OBJECTIVE: To describe patients with CLBP seen in family physicians' offices and to explore factors interfering with return to work.

SUBJECTS: Three hundred sixty outpatients with CLBP for more than 3 months.

SETTING: Ten participating family physicians' offices of the Residency Research Network of Texas.

PRIMARY OUTCOME: The effect of pain on work effect as measured by a Likert scale.

RESULTS: Patients were typically female (72%), overweight or obese (mean body mass index, 33.4), had pain for many years (mean, 13.6 years), and screened positive for recent depressive symptoms (83%). The majority of patients took at least some opioid medication for their pain (59%). Multivariate linear regression analysis found that the largest single contributor to effect on work was the subjects' score on the SF-36 physical function scale (β = -0.382). Other contributors included average daily pain (β = 0.189), the frequency of flare-ups of pain (β = 0.108), the effect of the painful flare-ups (β = 0.170), and current depressive symptoms (β = 0.131) (adjusted R(2) for model = 0.535). Age, sex, race/ethnicity, total time the patient has had CLBP, other comorbidities (including a diagnosis of depression), disability status, use of opioids, history of intimate partner violence, social support, and procedures attempted were not predictive.

DISCUSSION: Future studies attempting to demonstrate the effectiveness of interventions in CLBP should measure depressive symptoms and the magnitude and effect of painful flare-ups, not just the overall pain score. The majority of CLBP patients seen in these practices take opioids for their pain. Screening and treating for depression may be reasonable for some patients, though evidence of its effectiveness is lacking.

PMID:21900433 | DOI:10.3122/jabfm.2011.05.100298

Echocardiographic indices do not reliably track changes in left-sided filling pressure in healthy subjects or patients with heart failure with preserved ejection fraction

Paul Bhella - Wed, 07/27/2011 - 05:00

Circ Cardiovasc Imaging. 2011 Sep;4(5):482-9. doi: 10.1161/CIRCIMAGING.110.960575. Epub 2011 Jul 25.

ABSTRACT

BACKGROUND: In select patient populations, Doppler echocardiographic indices may be used to estimate left-sided filling pressures. It is not known, however, whether changes in these indices track changes in left-sided filling pressures within individual healthy subjects or patients with heart failure with preserved ejection fraction (HFpEF). This knowledge is important because it would support, or refute, the serial use of these indices to estimate changes in filling pressures associated with the titration of medical therapy in patients with heart failure.

METHODS AND RESULTS: Forty-seven volunteers were enrolled: 11 highly screened elderly outpatients with a clear diagnosis of HFpEF, 24 healthy elderly subjects, and 12 healthy young subjects. Each patient underwent right heart catheterization with simultaneous transthoracic echo. Pulmonary capillary wedge pressure (PCWP) and key echo indices (E/e' and E/Vp) were measured at two baselines and during 4 preload altering maneuvers: lower body negative pressure -15 mm Hg; lower body negative pressure -30 mm Hg; rapid saline infusion of 10 to 15 mL/kg; and rapid saline infusion of 20 to 30 mL/kg. A random coefficient mixed model regression of PCWP versus E/e' and PCWP versus E/Vp was performed for (1) a composite of all data points and (2) a composite of all data points within each of the 3 groups. Linear regression analysis was performed for individual subjects. With this protocol, PCWP was manipulated from 0.8 to 28.8 mm Hg. For E/e', the composite random effects mixed model regression was PCWP=0.58×E/e'+7.02 (P<0.001), confirming the weak but significant relationship between these 2 variables. Individual subject linear regression slopes (range, -6.76 to 11.03) and r(2) (0.00 to 0.94) were highly variable and often very different than those derived for the composite and group regressions. For E/Vp, the composite random coefficient mixed model regression was PCWP=1.95×E/Vp+7.48 (P=0.005); once again, individual subject linear regression slopes (range, -16.42 to 25.39) and r(2) (range, 0.02 to 0.94) were highly variable and often very different than those derived for the composite and group regressions.

CONCLUSIONS: Within individual subjects the noninvasive indices E/e' and E/Vp do not reliably track changes in left-sided filling pressures as these pressures vary, precluding the use of these techniques in research studies with healthy volunteers or the titration of medical therapy in patients with HFpEF.

PMID:21788358 | PMC:PMC3205913 | DOI:10.1161/CIRCIMAGING.110.960575

Levels of acculturation and effect on glycemic control in Mexicans and Mexican Americans with type 2 diabetes

Richard Young, MD - Sat, 02/05/2011 - 05:00

Postgrad Med. 2011 Jan;123(1):66-72. doi: 10.3810/pgm.2011.01.2246.

ABSTRACT

BACKGROUND: Acculturation of Mexican Americans toward the predominant American culture has been shown to influence health outcomes. Little is known about the role of acculturation in diabetes control.

OBJECTIVE: To measure the association between acculturation and diabetes control in Mexicans and Mexican Americans with type 2 diabetes mellitus (T2DM).

DESIGN: Cross-sectional survey and chart review.

SETTING: Ambulatory family medicine clinics.

PATIENTS: Sixty-six Mexican and Mexican American adults with T2DM for ≥ 1 year. INSTRUMENT AND OUTCOMES: A survey tool was developed that included the General Acculturation Index developed by Balcazar et al to measure acculturation. Basic demographics, psychosocial factors, patient satisfaction, and patients' most recent hemoglobin A(1c) (HbA(1c)) levels were also obtained.

RESULTS: There was no significant correlation between acculturation score and HbA(1c) levels. On binary logistic regression, HbA(1c) levels were associated with patient satisfaction in having their questions answered (odds ratio [OR], 0.44; P < 0.05), interference of diabetes with daily life (OR, 1.4; P < 0.05), male gender (OR, 3.93; P < 0.01), and number of diabetes complications (OR, 1.81; P < 0.05). In the multivariate linear regression model, age (beta, -0.348; P < 0.05) and frequency of physician visits (beta, -0.403; P < 0.05) were the only variables significantly associated with glycemic control. Variables included in the model that were not associated with glycemic control include family history of diabetes and confidence in diabetes treatment efficacy.

CONCLUSIONS: Acculturation was not associated with glycemic control in this population. Family physicians should not assume that acculturation difficulties explain poor glycemic control in their Mexican American patients with T2DM.

PMID:21293085 | DOI:10.3810/pgm.2011.01.2246

Alcohol affects the late differentiation of progenitor B cells

Hao Wang, MD - Thu, 11/25/2010 - 05:00

Alcohol Alcohol. 2011 Jan-Feb;46(1):26-32. doi: 10.1093/alcalc/agq076. Epub 2010 Nov 22.

ABSTRACT

AIMS: Previous studies show that alcohol exposure can affect the differentiation of progenitor B cells. Before final commitment to a B lineage, progenitor B cells usually undergo several important stages. However, it is still unclear whether alcohol alters B cell differentiation at which stages. The aim of this study was to determine which stage(s) of progenitor cell differentiation are affected by alcohol and to elucidate the mechanism(s) responsible for the effect of alcohol on B cell differentiation.

METHODS: Oligoclonal-neonatal-progenitor (ONP) cells from bone marrow cells of 2-week-old mice were cultured under different conditions in vitro with or without the exposure of 100 mM alcohol. Phenotype analysis was performed at different time points and expression levels of transcription factors (TFs) and cytokine receptors were measured quantitatively and kinetically.

RESULTS: After 3 days in vitro culture, ONP cells differentiated into two populations: B220(-)CD11b(-) and B220(-)CD11b(+) cells. B220(-)CD11b(-) cells can further differentiate into B lineage cells only with the support of B220(-)CD11b(+) cells. Cells exposed to 100 mM of alcohol during the first 3 days of culture showed no statistically significant difference in B cell formation after 12 days compared with the control group. However, cells exposed to alcohol from Day 4 till the end of culture yield very few B cells. Expression levels of TFs and cytokine receptors were down-regulated kinetically among ONP cells co-cultured with the addition of 100 mM alcohol.

CONCLUSIONS: Alcohol affects the ONP cell differentiation into B lineage at a late stage. Alcohol also down-regulates the expression level of TFs and cytokine receptors resulting in the impairment of B cell differentiation.

PMID:21098503 | PMC:PMC3002845 | DOI:10.1093/alcalc/agq076

Referrals from a primary care-based sports medicine department to an orthopaedic department: a retrospective cohort study

Richard Young, MD - Fri, 10/22/2010 - 05:00

Br J Sports Med. 2011 Oct;45(13):1064-7. doi: 10.1136/bjsm.2010.072736. Epub 2010 Oct 19.

ABSTRACT

OBJECTIVE: To describe the impact of an expanded primary care-based sports medicine clinic on referrals to an orthopaedics clinic and to describe the patients seen and procedures performed.

DESIGN: Retrospective cohort study.

SETTING: Primary care-based sports medicine clinic and orthopaedics clinic at a tax-supported American safety net healthcare system.

PARTICIPANTS: All patients referred to the sports medicine clinic by other primary care physicians over a 1-year time period of July 2006-June 2007.

MAIN OUTCOME MEASURES: The referral rate from sports medicine clinic to orthopaedics clinic, the percentage of referred patients who were recommended surgery by the orthopaedists, the change in average waiting time to be seen in orthopaedics clinic and the most common conditions and procedures.

RESULTS: 4925 patients were seen by the sports medicine department; 118 (2.4%) of those patients were referred to the orthopaedic department. Of the referred patients, surgery was offered by orthopaedists to 80 (68%) patients. The average wait for initial consultation by the orthopaedic spine clinic decreased from 199 to 70 days; the wait for general orthopaedic clinic decreased from 97 to 19 days. No single patient complaint or musculoskeletal pathology predominated: knee degenerative joint disease (25.3%), mechanical low back pain (21.6%) and lumbar disc disease (19.9%). Knee injections and epidural steroid injections were the most common procedures performed.

CONCLUSIONS: Very few patients with musculoskeletal pathology were referred by a primary care-based sports medicine clinic to an orthopaedics clinic. Of the referred patients, sports medicine physicians and orthopaedists frequently agreed on the need for surgery. Expansion of a primary care-based sports medicine service could help relieve overburdened orthopaedics departments of patients with conditions not requiring surgery.

PMID:20961919 | DOI:10.1136/bjsm.2010.072736

Surgical treatment of hallux rigidus using a metatarsal head resurfacing implant: mid-term follow-up

Travis Motley, DPM - Fri, 07/09/2010 - 05:00

J Foot Ankle Surg. 2010 Jul-Aug;49(4):321-5. doi: 10.1053/j.jfas.2010.04.007.

ABSTRACT

The treatment of advanced hallux rigidus remains controversial, with many authors discussing arthrodesis versus arthroplasty. The purpose of this study is to report mid-term outcomes after implantation of a motion-preserving metatarsal head-resurfacing prosthetic and to present our technical considerations and modifications to the published technique to further enhance the clinical benefit of the procedure. Thirty-two implantations were performed in 30 patients. Twenty-three patients were women, 9 men. The average age was 62.8 years (range, 39-86 years). Patients were graded at baseline according to Hattrup and Johnson and completed the American Orthopaedic Foot & Ankle Surgery metatarsophalangeal clinical rating system preoperatively and postoperatively and a patient satisfaction question at final follow-up. Seventy-two percent of implantations were grade III hallux rigidus and 28% were grade II. The average follow-up was 27.3 months (range, 12-43 months). The mean change score for the overall American Orthopaedic Foot & Ankle Surgery scale was 236.8% (SD = 146.62, confidence interval [CI] = 186-287.6). A similar result was achieved between grade II (250.9%, SD = 240.3, CI = 93.9-407.9) and grade III (231.3%, SD = 95.83, CI = 195.14-270.46). No implants were revised or removed, and all patients stated that they were happy with their outcome and would repeat the procedure again if needed. In conclusion, metatarsal head resurfacing in combination with joint decompression, soft tissue mobilization, and debridement can achieve excellent results in grade II and III hallux rigidus. Salvage arthrodesis remains an option if future revisions are indicated.

PMID:20610200 | DOI:10.1053/j.jfas.2010.04.007

Long-term outcome of adults who undergo transplantation with single pediatric kidneys: how young is too young?

Saravanan Balamuthusamy, MD - Sat, 08/22/2009 - 05:00

Clin J Am Soc Nephrol. 2009 Sep;4(9):1500-6. doi: 10.2215/CJN.04610908. Epub 2009 Aug 20.

ABSTRACT

BACKGROUND AND OBJECTIVES: The optimal donor age for transplanting a single pediatric kidney in an adult recipient remains unknown. En block kidney transplantation is usually performed when the donor age is <5 yr.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We compared the outcomes of adult patients who underwent transplantation with single pediatric kidneys from donors who were younger than 5 yr (group 1, n = 40) and from donors who were aged 5 to 10 yr of age (group 2, n = 39) in our center.

RESULTS: The donor kidney sizes were significantly smaller in group 1 than in group 2 (P < 0.001), and group 1 required more ureteral stents than group 2 (73 versus 38%). The surgical complications, delayed graft function, and development of proteinuria were similar in both groups. Group 1 had slightly higher rejection episodes than group 2 (25 versus 18%; P = 0.67), and graft function was comparable in both groups. There were no statistical differences between the two groups in patient (P = 0.73) or death-censored graft (P = 0.68) survivals over 5 yr.

CONCLUSIONS: Single pediatric kidney transplants from donors who are younger than 5 yr can be used with acceptable complications and long-term outcomes as those from older donors.

PMID:19696216 | PMC:PMC2736693 | DOI:10.2215/CJN.04610908

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