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Outcomes of a Team-Based Chronic Care Management Service in a Dual-Eligible Medicare and Medicaid Population with Diabetes Mellitus
No full textResearch Appreciation Day Award Winner - Texas College of Osteopathic Medicine - 2023 University of North Texas Health Science Center Interprofessionalism AwardTitle: Outcomes of a Team-Based Chronic Care Management Service in a Dual-Eligible Medicare and Medicaid Population with Diabetes Mellitus
Purpose: Patients receiving Medicare and Medicaid benefits (dual-eligible) have a higher prevalence of multiple comorbidities, including diabetes mellitus. This same population is less likely to have routine preventative measures completed and a higher incidence of disease-related complications. The purpose of this study is to evaluate the effectiveness of a team-based Chronic Care Management (CCM) program in achieving health outcomes in dual-eligible patients with type 2 diabetes (T2D) and the financial sustainability of a CCM program.
Methods: Dual-eligible patients with T2D meeting CCM enrollment criteria were evaluated in a retrospective, pre-/post- intervention, observational chart review study from March 2019 to August 2021. Statistical analyses using non-parametric tests evaluated clinical outcomes (e.g., hemoglobin A1c), preventative measures and clinical staff encounters. Preliminary financials are reported descriptively.
Results: Twenty-six patients were included in the analysis. There was a significant reduction in mean A1c levels (8.15% to 7.34%, p = 0.035). Changes in preventative metrics included a statically significant increase in statin prescriptions (p=0.039) while a non-significant increase in pneumococcal and influenza vaccine rates and depression screenings is noted. $14,721.00 was billed to insurers for the service with a reimbursement rate of 39.6%.
Conclusion: This study shows that team-based patient care in a CCM program improves A1c levels and supports achievement of preventative measures. Full realization of intervention impact limited by the lack of in-person access to healthcare services due to shutdowns in response to the global pandemic
Pediatric Rhabdomyolysis and Plasmapheresis - A Review of Two Cases
No full textResearch Appreciation Day Award Winner - Texas College of Osteopathic Medicine, 2023 Pediatric Case Study AwardBackground: Rhabdomyolysis is the breakdown of skeletal muscles causing leakage of cellular components like creatine kinase (CK) into the bloodstream. Clear guidelines for managing pediatric rhabdomyolysis currently do not exist. Traditional treatment involves prompt administration of intravenous (IV) fluids to counteract dehydration and prevent acute kidney injury (AKI). However, there have been limited case studies involving plasma exchange to treat severe cases of rhabdomyolysis in pediatrics.
Case Information:
Case 1: A 14-year-old female presented with muscle pain, headache, decreased urine output, and tea-colored urine. Her history included lifting weights and dehydration. Her presenting CK was 281,483 U/L and creatinine was 2.88 mg/dL. She was diagnosed with rhabdomyolysis, AKI, and transaminitis. CK levels rose to 410,000 U/L. On the second day, plasmapheresis was performed, and CK levels decreased after two more treatments. However, creatinine levels continued to increase. Renal biopsy showed acute tubular injury secondary to rhabdomyolysis. Hemodialysis was performed. Upon discharge, creatinine was 2.43 mg/dL, and she no longer required dialysis.
Case 2: An 11-year-old female presented with a respiratory illness for two days. Her CK was 41,671 U/L. She was diagnosed with AKI and rhabdomyolysis induced by COVID-19. Standardized treatments were initiated with no improvement. CK levels reached over 410,000 U/L. Plasmapheresis was then initiated for three days, which lowered the CK levels significantly. Upon completion of plasmapheresis, her CK level dropped down to 40,000 U/L. Her CK levels normalized and her AKI became stable.
Conclusions: Given the risks associated with high CK levels resistant to traditional IV hydration, it is crucial that the levels are brought down quickly to prevent long-term complications such as AKI. Therefore, plasmapheresis may be considered in severe, life-threatening rhabdomyolysis in pediatrics
Assessment of Patient Engagement in Pediatric Mental Health Calls in Mothers of Young Children Since COVID-19 with Improvement Solutions
No full textPurpose: COVID-19 restrictions led to a rise in telehealth visits. To combat the issue of limited in-person visits, Pediatric Mental Health Calls (PMHC) were created to bridge the gap and provide continued mental health support to UNTHSC Pediatric patients and their caregivers during the pandemic and beyond. Patient engagement was analyzed to gain a better understanding of the impact of PMHC during COVID-19 in 2020 and 2021-22 and to provide improvement for future calls.
Methods: PMHC was completed by HSC student volunteers. Quantitative analysis of patient involvement was made in mothers whose children were infants in 2020 and toddlers in 2021-2022. Patients no longer with UNTHSC clinic or phone numbers no longer in service were omitted from the count. Participation of these mothers (n=292) was assessed using the percentage of the total number of responses in open or close-ended questions (<5, ≧5, or no response at all) and the number of word sentences in open-ended questions (<5 in any category, ≧5 in 1 category, ≧5 in 3 categories). Analysis used chi-square test of independence. Statistical significance was set at p < 0.05. Additionally, Edinburg Postnatal Depression Scale (EPDS) phone screenings and referrals in mothers of infants were compared with early COVID-19 in 2020 to follow-ups in 2021-2022. In 2020, 199 out of 543 infant mothers who agreed to complete the EPDS screenings over the phone were compared to 229 out of 473 mothers of infants in 2021-2022. A comparison was also evaluated for 2020 (n=165) and 2021-2022 (n=190) postnatal mothers with an EPDS score of ≧10 indicating an increased risk for depression, thereby given referrals based on volunteer judgment.
Results: There was a positive response in patient engagement in early 2020 compared to 2021-2022. Chi square test showed a statistically significant decline in both the number of responses in open or closed-ended questions (<5, ≧5, with an increase in no response at all category) and in the number of word sentences in open-ended questions (<5 in any category, ≧5 in 1 category, ≧5 in 3 categories) in 2021-2022. In 2020, from the 199 infant mothers willing to complete the EPDS screening over the phone, 127 answered yes and 72 answered no. In 2021-2022, from the 229 infant mothers, 147 answered yes and 82 answered no. There was a drop in percentage in the number of referrals made for mothers of infants with an EPDS score of ≧10 in 2021-2022 when compared to 2020.
Discussion: Modifications of the PMHC are recommended to increase patient participation beyond the pandemic. Volunteers are encouraged to connect with patients using motivation and interpersonal interaction. Demographic data must be considered to assess patterns of patient engagement. Mothers should be educated on the data and the importance of completing EPDS screenings. Specific questions relevant to current concerns in the country affecting maternal and pediatric health should be focused upon. Alternatives should be suggested to patients who are less likely to respond
Effects of the thromboxane receptor antagonist S18886 in the porcine coronary circulation
No full textThromboxane A2 (TxA2) is a potent coronary vasoconstrictor that has been implicated in promoting decreases in myocardial perfusion in a variety of (patho)-physiologic conditions. S18886 is a promising orally-active TxA2 receptor antagonist currently approved for investigational clinical use. However, the coronary vascular effects of S18886 are unknown and its specificity and affinity for the thromboxane receptor in the coronary circulation remain unclear. We tested the hypothesis that administration of S18886 dose-dependently attenuates coronary vasoconstriction to the TxA2 mimetic U46619 without influencing coronary responses to prostaglandin F2α, acetylcholine, or smooth muscle depolarization (K+).
Experiments to test this hypothesis were performed in male (n = 5) and female (n = 6) domestic swine. Hearts were excised and the left circumflex coronary artery isolated, cleaned of periadventitial fat, and cut into 3 mm rings. Isometric tension of coronary artery rings was measured in response to log order increments of U46619 (1 nM to 1 µM) with and without S18886 (0.1-100 nM). Similar isometric studies were conducted with prostaglandin F2α (10 nM-10 µM), acetylcholine (0.1-10 µM), and KCl (5-90 mM).
U46619 induced concentration dependent increases in tension development of isolated coronary artery rings (average EC50 of 42 ± 19 nM). Incubation of coronary arteries with S18886 (1 nM) significantly attenuated coronary vasoconstriction to U46619 resulting in a rightward shift of the EC50 to 187 ± 38 nM (P < 0.02). Vehicle had no effect on U46619-induced contractions. Higher concentrations of S18886 dose-dependently reduced U46619-induced contractions. S18886 (1 nM) antagonized coronary vasoconstriction of prostaglandin F2α (10 µM) by 68% ± 5 (P < 0.0001) but had no effect on either acetylcholine or KCl-induced contraction.
Data from this investigation indicate that S18886 is an effective antagonist of U46619-induced vasoconstriction in the porcine coronary circulation. While S18886 does not influence coronary smooth muscle response to either acetylcholine or activation of L-type Ca2+ channels, attenuation of prostaglandin F2α suggests antagonists specificity may extend beyond TxA2 receptor signaling.NIH R25GM12558
Oral health during pregnancy: an analysis of interprofessional guideline awareness and practice behaviors among prenatal and oral health providers
Get PDFBACKGROUND: Poor oral health during pregnancy has significant implications across the life course, including increased risk for adverse pregnancy, birth outcomes, and the development of early childhood caries. In efforts to improve perinatal oral health in the United States, a set of national interprofessional guidelines were developed that include recommended practice behaviors for both oral health providers and prenatal providers. The purpose of this study was to examine guideline awareness, familiarity, beliefs, and practice behaviors among both provider types. METHODS: Prenatal providers and oral health providers in Florida were recruited via random and convenience sampling to complete an online survey guided by the Consolidated Framework for Implementation Research (CFIR) and the Cabana Framework. The present analysis focused on the Individuals Involved domain (CFIR), awareness and familiarity with the guidelines (Cabana Framework), confidence, and practice behaviors as recommended by prenatal oral health guidelines (assess, advise, refer, share/coordinate). Data were analyzed using chi-square tests, independent samples t-tests, Pearson correlation coefficients, and one-way analysis of variance (ANOVA) and analyses were conducted in SPSS. RESULTS: Prenatal and oral health providers did not differ significantly in their awareness of the guidelines, but awareness was significantly associated with three of the four practice behaviors for prenatal providers. Familiarity with the guidelines was significantly higher among oral health providers and was associated with all four practice behaviors for both provider types. Five out of ten oral health belief items were significantly associated with practicing the guidelines among prenatal providers, but only two among oral health providers. Confidence in performing the practice behaviors was significantly associated with guideline implementation among both groups. Years in practice was significantly associated with performing practice behaviors for prenatal providers, but not for oral health providers. CONCLUSIONS: Our findings highlight the importance of professional organizations and the role of clinical guidelines on practice behaviors. Although provider education is a key implementation strategy, organizational and policy-level system changes could also be critical in supporting practice behaviors.This research was funded by the National Institute of Dental & Craniofacial Research of the National Institutes of Health under Award Number R03DE02463
Effect of Composition and Size on Surface Properties of Anti-Cancer Nanoparticles
Get PDFLiposomal formulations offer significant advantages as anticancer drug carriers for targeted drug delivery; however, due to their complexity, clinical translation has been challenging. In addition, liposomal product manufacturing has been interrupted in the past, as was the case for Doxil((R)) (doxorubicin hydrochloride liposome injection). Here, interfacial tension (IFT) measurements were investigated as a potential physicochemical characterization tool to aid in liposomal product characterization during development and manufacturing. A pendant drop method using an optical tensiometer was used to measure the interfacial tension of various analogues of Doxil((R)) liposomal suspensions in air and in dodecane. The effect of liposome concentration, formulation (PEG and cholesterol content), presence of encapsulated drug, as well as average particle size was analyzed. It was observed that Doxil((R)) analog liposomes demonstrate surfactant-like behavior with a sigmoidal-shape interfacial tension vs. concentration curve. This behavior was heavily dependent on PEG content, with a complete loss of surfactant-like behavior when PEG was removed from the formulation. In addition to interfacial tension, three data analyses were identified as able to distinguish between formulations with variations in PEG, cholesterol, and particle size: (i) polar and non-polar contribution to interfacial tension, (ii) liposomal concentration at which the polar and non-polar components were equal, and (iii) rate of interfacial tension decay after droplet formation, which is indicative of how quickly liposomes migrate from the bulk of the solution to the surface. We demonstrate for the first time that interfacial tension can be used to detect certain liposomal formulation changes, such as PEG content, encapsulated drug presence, and size variability, and may make a useful addition to physicochemical characterization during development and manufacturing of liposomal products.This research was supported by the Pharmaceutical Research and Manufacturers of America, 2019 Research Starter Grant, and the National Institute on Minority Health and Health Disparities, grant number 2U54MD006882-06
Mitochondria-associated endoplasmic reticulum membranes (MAMs) and their role in glaucomatous retinal ganglion cell degeneration-a mini review
Get PDFGlaucoma is a leading cause of blindness worldwide, commonly associated with elevated intraocular pressure (IOP), leading to degeneration of the optic nerve and death of retinal ganglion cells, the output neurons in the eye. In recent years, many studies have implicated mitochondrial dysfunction as a crucial player in glaucomatous neurodegeneration. Mitochondrial function has been an increasingly researched topic in glaucoma, given its vital role in bioenergetics and propagation of action potentials. One of the most metabolically active tissues in the body characterized by high oxygen consumption is the retina, particularly the retinal ganglion cells (RGCs). RGCs, which have long axons that extend from the eyes to the brain, rely heavily on the energy generated by oxidative phosphorylation for signal transduction, rendering them more vulnerable to oxidative damage. In various glaucoma models, mitochondrial dysfunction and stress from protein aggregates in the endoplasmic reticulum (ER) have been observed in the RGCs. However, it has been shown that the two organelles are connected through a network called mitochondria-associated ER membranes (MAMs); hence this crosstalk in a pathophysiological condition such as glaucoma should be evaluated. Here, we review the current literature suggestive of mitochondrial and ER stress related to glaucoma, indicating potential cross-signaling and the potential roles of MAMs.This research was funded by National Eye Institute (EY029823)
Attractiveness of Anthropometrically Average Facial Anatomy: Is the Whole a Sum of Its Parts?
No full textGoals/Purpose: Literature suggests that faces that possess average anatomy for the population are considered more attractive. When patients seek facial cosmetic surgery, they often have a certain feature or features that they desire improvement on. With the subjective and evolving nature of beauty, it can be difficult for plastic surgeons to differentiate between relative change and definite improvement. Thus, identifying ideal dimensions of facial features would provide evidence-based guidance for aesthetic surgery. This study aims to investigate the independent relationship between measurements of anthropometrically average facial features and perceived beauty, as well as their relative importance to each other and the overall perception.
Methods/Technique:
Ratings: To assess perceived attractiveness, crowdsourcing, a well-founded online method of studying aesthetic and reconstructive outcomes, was utilized. The photographs were uploaded to Google Forms with multiple-choice responses ranging from 1-7, with 1 and 7 being the least and most attractive, respectively. The images were presented in a random order to each respondent. Monochrome photos were used to negate the biases of hair, skin, and eye color.
Measurements: Our female and male cohorts each consisted of standardized frontal-view photos of 41 individuals, with 1 composite derived from the other 40. Composite images were generated using Webmorph.org, which is a web-based software that specializes in averaging and transforming faces. Each face had the same number of standardized points placed manually to delineate the position of facial landmarks. The corresponding points allowed for averaging each facial landmark across all the faces to develop the composite. All photos were calibrated by interpupillary distance. Next, linear facial features (including measurements of the upper face, middle face, lower face, and facial height and width) were measured by pixels with WebMorph.org. Lastly, angular facial features were measured in degrees using Mirror software.
Statistical Analysis: A t-test was used to verify that the composite with average facial features was the most attractive in each cohort. After verifying that the average faces were most attractive, a Spearman correlation test calculated correlation coefficients between facial measurements and perceived attractiveness. A larger correlation coefficient indicates a stronger association between average facial measurements and perceived attractiveness. p<0.05 was considered significant.
Results:
For the male and female cohorts, the respondents (n=870 and 876, respectively) found the composites (derived from average facial anatomy) significantly more attractive than the rest of the cohort (both p<0.0001).
For the male cohort, only anthropometrically average upper lip height had a statistically significant correlation with attractiveness (Table 1) (R=0.376; p=0.017).
For the female cohort, only anthropometrically average bigonial width had a statistically significant correlation with attractiveness (R= 0.352; p=0.026).
Conclusion: Our study identifies average male lip height and average female bigonial features significantly correlated with perceived beauty. Though overall average faces were found to be significantly more attractive, the majority of facial features when independently analyzed for their correlation with beauty were not found to be significantly associated. Our findings suggest that the attractiveness of the average face is not largely due to the summative attractiveness of its individual facial components
Opioid Crisis Breakdown in Tarrant County
No full textPurpose: It is undisputed that opioids, while they have inherent medicinal value, can be abused recreationally leading to devastating effects. According to the CDC, Texas had the 6th most related deaths from opioids in 2019[1]. There were 3136 opioid related deaths in 2019 in the state of Texas [1]. It has been noted by physicians that Tarrant County in particular has seen a high incidence. The purpose of this research was to quantify the data surrounding opioid use in Tarrant County. Data from the National Institute on Drug Abuse shows that overdose deaths from opioids have risen steadily across the country in the last decade with a sharper increase in the last few years [2].
Methods: Using a database from the Texas Department of State Health Services we identified all calls, visits, and deaths related to opioid use [3]. The following metrics were used: Total opioid related deaths in Tarrant County and opioid deaths filtered by age, sex, race, education status, and marital status in Tarrant County. Total emergency department (ED) visits and ED visits per 100,000 population and per 100,000 ED visits in Tarrant County. The type of opioid related to each ED visit in Tarrant County was quantified as well. Finally, poison center opioid-related calls were totalled in Tarrant County.
Results: Out of 254 counties in the state of Texas, Tarrant County recorded the 5th highest number of opioid related deaths in 2019, with 75 total deaths and a rate of 8 per 100,000 population. These opioid related deaths were most focal in the age range of 18-44 (72%). Of the total deaths, 65% of them were white and 68% were male. Of note, 70% of the users who died were not married, while 30% were married. Of these deaths, the most significant portion were by non-heroin opioids (34%), followed by heroin users (15%). In addition, in 2019 there were 244 poison center calls related to opioids. Finally, in 2019 there were a total of 774 ED visits related to opioids, with a rate of 87.5 visits per 100,000 ED visits.
Conclusions: As indicated in the results, both the state of Texas and Tarrant County have been negatively impacted by the epidemic rise in opioids. Texas has sought to alleviate some of the disparities, and funding was received by the U.S. government. Beginning in May 2017, under the Texas targeted Opioid Response Program, Texas has received over $280 million in federal funding to address the opioid crisis [4]. However, the data presented in the case report (objective opioid related outcomes in 2019) demonstrates that more needs to be done. In response to the high prevalence of deaths, emergency room visits, and opioid related calls, it is critical that Texas mounts a proportional response. This response may be both systemic and individualistic as people are educated on the effects of opioids and what they can do to prevent negative outcomes