Probability of Occult Ankle Fracture Based on Radiograph-Measured Swelling.

INTRODUCTION: Pediatric ankle injuries are a common presentation in the emergency department (ED). A quarter of pediatric ankle fractures show no radiographic evidence of a fracture. Physicians often correlate non-weight bearing and tenderness with an occult fracture. We present this study to predict the probability of an occult fracture using radiographic soft-tissue swelling on initial ED radiographs. METHODS: This is a retrospective study at a Level 1 pediatric trauma center from 2021 to 22. Soft-tissue swelling between the lateral malleolus and skin was measured on radiographs, and weight-bearing status was documented. Statistical analysis was conducted using Stata software. DISCUSSION: The study period involved 32 patients with an occult fracture, with 8 (25%) diagnosed with a fracture on follow-up radiographs. The probability of an occult fracture was calculated as a function of the ankle swelling in millimeters (mm) using a computer-generated predictive model. False-negative and false-positive rates were plotted as a function of the degree of ankle swelling. CONCLUSION: Magnitude of ankle soft-tissue swelling as measured on initial ED radiographs is predictive of an occult fracture. Although weight-bearing status was not a sign of occult fracture, it improves the predictive accuracy of soft-tissue swelling.

Association of Obesity and Diabetes With the Incidence of Breast Cancer in Louisiana.

INTRODUCTION: Breast cancer is a heterogeneous disease, consisting of multiple molecular subtypes. Obesity has been associated with an increased risk for postmenopausal breast cancer, but few studies have examined breast cancer subtypes separately. Obesity is often complicated by type 2 diabetes, but the possible association of diabetes with specific breast cancer subtypes remains poorly understood. METHODS: In this retrospective case-control study, Louisiana Tumor Registry records of primary invasive breast cancer diagnosed in 2010-2015 were linked to electronic health records in the Louisiana Public Health Institute's Research Action for Health Network. Controls were selected from Research Action for Health Network and matched to cases by age and race. Conditional logistic regression was used to identify metabolic risk factors. Data analysis was conducted in 2020‒2021. RESULTS: There was a significant association between diabetes and breast cancer for Luminal A, Triple-Negative Breast Cancer, and human epidermal growth factor 2‒positive subtypes. In multiple logistic regression, including both obesity status and diabetes as independent risk factors, Luminal A breast cancer was also associated with overweight status. Diabetes was associated with increased risk for Luminal A and Triple-Negative Breast Cancer in subgroup analyses, including women aged ≥50 years, Black women, and White women. CONCLUSIONS: Although research has identified obesity and diabetes as risk factors for breast cancer, these results underscore that comorbid risk is complex and may differ by molecular subtype. There was a significant association between diabetes and the incidence of Luminal A, Triple-Negative Breast Cancer, and human epidermal growth factor 2‒positive breast cancer in Louisiana.

Factors influencing acceptance of influenza vaccination given in an ED.

Factors correlating with successful administration of flu vaccine in an emergency department (ED) were examined. Patients 18 years and older were screened for indications for flu immunization. Vaccine was offered to those with indications. Of 3425 patients screened, 1311 had indications, 705 of 1311 agreed to immunization, and 513 of 705 were immunized. Factors related to immunization agreement were comorbidity, interviewer, and being 50 to 64 years old with prior immunization. Immunization factors were month, comorbidity, and not being pregnant. Factors associated with suboptimal acceptance and receipt should be addressed in future efforts.

Weight loss maintenance following a primary care intervention for low-income minority women.

Although the primary care setting offers an innovative option for weight loss interventions, there is minimal research examining this type of intervention with low-income minority women. Further, there is a lack of research on the long-term effects of these programs. The purpose of this investigation was to examine the weight loss maintenance of low-income African-American women participating in a primary care weight management intervention. A randomized controlled trial was conducted with overweight and obese women (N = 144) enrolled at two primary care clinics. Women received a 6-month tailored weight loss intervention delivered by their primary care physician and completed follow-up assessments 9, 12, and 18 months following randomization. The weight loss maintenance of the tailored intervention was compared to a standard care comparison group. The weight loss of intervention participants (-1.52 +/- 3.72 kg) was significantly greater than that of standard care participants (0.61 +/- 3.37 kg) at month 9 (P = 0.01). However, there was no difference between the groups at the 12-month or 18-month follow-ups. Participants receiving a tailored weight loss intervention from their physician were able to maintain their modest weight loss up to 3-6 months following treatment. Women demonstrated weight regain at the 18-month follow-up assessment, suggesting that more intensive follow-up in the primary care setting may be needed to obtain successful long-term weight loss maintenance.

Diabetes mellitus medication assistance program: relationship of effectiveness to adherence.

This retrospective study examines the effect of a medication assistance program (MAP) on HbA1c levels in an uninsured, low-income, type 2 diabetes population. It also examines the degree to which improvement in HbA1c level varied with adherence to medication regimens among those patients using the MAP. The MAP was found to have a mean effect of -0.60% on HbA1c levels. However, MAP users differed in how strictly they adhered to medication regimens, as measured by number of refill opportunities taken. The MAP's effect on HbA1c varied monotonically with adherence level, with greater adherence leading to greater HbA1c improvement. Never refilling the prescription (complete nonadherence) led to no change in HbA1c, while complete adherence led to an estimated -0.88% improvement in HbA1c. Further study is needed to investigate factors related to non-adherence within medication assistance programs and the effect of such programs on other patient outcomes.

Mortality benefit of a comprehensive heart failure disease management program in indigent patients.

BACKGROUND: Heart failure (HF) produces significant morbidity and mortality. Although HF disease management (HFDM) programs have been shown to decrease this morbidity, there is still a paucity of data on their effect on mortality. The objective of this study was to determine whether participation in an HFDM program would reduce mortality in an indigent population from rural Louisiana. METHODS: Proportional hazards modeling was used to determine whether patients participating in the HFDM program had improved survival compared with patients receiving traditional outpatient care at the same institution. Inclusion criteria consisted of an index hospitalization with discharge occurring between July 1, 1997, and May 30, 2002, hospital discharge diagnosis of HF, left ventricular systolic dysfunction documented during hospitalization, and at least 1 subsequent outpatient visit. Data from patients having participated in the HFDM program before their index hospitalization were excluded. RESULTS: Compared with patients who were given traditional care (n = 100), HFDM patients (n = 156) were younger (56.7 vs 60 years, P = .031), more likely to be African American (48.7% vs 33.0%, P = .014), more likely to be uninsured (47.4% vs 27%, P = .001), and more likely to have an ejection fraction of < or = 25% (73.1% vs 36%, P < .001). Overall comorbidity did not differ significantly between the groups. After controlling for differences in demographics, ejection fraction, and comorbidities, participation in the HFDM program was associated with a significant reduction in mortality compared with traditional care (adjusted hazard ratio .33, P < .001). CONCLUSION: In this indigent population, participation in an HFDM program was associated with decreased mortality compared with traditional follow-up care.

Perceived barriers to diabetic eye care: qualitative study of patients and physicians.

OBJECTIVES: To address inadequate retinopathy screening at a largely indigent clinic and to explore perceived barriers, using qualitative techniques. METHODS: Responses were analyzed from structured focus groups of patients and key informant interviews of primary diabetic physicians and ophthalmologists at the Medical Center of Louisiana in New Orleans. The number of diabetic patients screened at the center from 2000 to 2002 was obtained by quantitative analysis of an administrative database. RESULTS: Participants cited finances as the major barrier, while physicians cited inadequate patient education. Patients largely believed that diabetic education was adequate, yet there was a gap between patient education provided and their understanding. All sources agreed that poor access to care, particularly the 1-year wait for an appointment, was a barrier. No respondent mentioned constraints of the system to provide eye care to the number of diabetic patients as a possible barrier, despite the 1-year wait for an eye appointment and a 29% increase in eye examinations within 2 years. CONCLUSIONS: Perceptions of barriers to diabetic eye care differed among physicians and patients, although both groups agreed that access to care was a barrier. A gap exists between educational material provided to patients and what patients understand. A large unrecognized workload stresses the capacity of the current system.

A staged management diabetes foot program versus standard care: a 1-year cost and utilization comparison in a state public hospital system.

OBJECTIVE: To determine whether staged management of foot ulcers reduces health care costs and utilization. DESIGN: Nonrandomized retrospective study using data from 1998-1999 in the Louisiana public hospital system. SETTING: Louisiana public hospital system. PARTICIPANTS: Forty-five patients with diabetes foot ulcer who received staged management foot care and 169 patients with diabetes foot ulcer who received standard foot care. INTERVENTIONS: Staged management of foot ulcers consisting of devices to offload pressure; self-care education; and, after healing, custom-fabricated orthoses and footwear, and monitored progressive ambulation. MAIN OUTCOME MEASURES: One-year levels of the number of foot-related inpatient hospitalizations, number of amputation-related hospitalizations, total number of foot-related inpatient days, total charges for foot-related inpatient hospitalizations, all-cause outpatient visits, total charges for all-cause outpatient visits, and combined outpatient and foot-related inpatient charges. RESULTS: Over the 12-month study period, the staged management group had a lower foot-related hospitalization rate than did the comparison group (.09 admissions per person vs.50 admissions per person, P=.0002); lower foot-related inpatient days (.91d per person vs 3.97d per person, P=.0289); lower foot-related inpatient charges ($1321 per person vs $5411 per person, P=.0151); fewer amputation-related hospitalizations (.04 per person vs.19 per person, P=.0351); fewer emergency department visits (.60 visits per person vs 1.22 visits per person, P=.0043); lower emergency department charges ($104 per person vs $208 per person, P=.0057); and lower total charges ($4776 per person vs $9402 per person, P=.0141). The staged management group had a higher number of outpatient visits (24.91 per person vs 8.04 per person, P<.0001) and higher outpatient charges ($2169 per person vs $1471 per person, P<.0001). CONCLUSIONS: A staged management diabetes foot program significantly reduced emergency department and hospital utilization and charges in a statewide public hospital system.