Ultrasound visualization of the thumb annular pulleys: A cadaveric validation study.

BACKGROUND: The thumb annular pulley system is unique from the other digits and is integral to normal thumb function. Injuries to this pulley system can present a diagnostic challenge. No prior study has evaluated the ability of ultrasound (US) to evaluate all four thumb pulleys. OBJECTIVE: To validate the sonographic visualization of all four thumb pulleys. DESIGN: Prospective cadaveric laboratory investigation. SETTING: Academic center procedural skills laboratory. PARTICIPANTS: Twelve unembalmed cadaveric hands from seven adult male donors ages 78-89 years with body mass index 21.9-26.6 kg/m2 . INTERVENTIONS: Based on anatomic descriptions, a single examiner used a standardized protocol and high-frequency linear transducers to identify the A1, variable (Av), oblique (Ao), and A2 pulleys of the thumb in 10 cadaveric hands. As part of the validation process, the presumed Ao pulley was injected with diluted colored latex using US guidance. Two additional cadaveric specimens were dissected for detailed study of the thumb pulley system. MAIN OUTCOME MEASURES: Correlation between the four anatomic pulleys as revealed by dissection and the US findings, including identification of latex location with respect to the Ao pulley. RESULTS: US correctly identified all four thumb pulleys as distinct anatomic structures and the sonographic appearance of the pulleys correlated with the dissection in all 10 specimens. Latex was observed in the Ao pulley in 100% of the cadavers. CONCLUSIONS: Ultrasound can be used to accurately identify all four thumb pulleys, including distinct Ao and Av pulleys, and should be considered in the evaluation of thumb pulley injuries. This is the first study to validate the US visualization of the annular pulley system of the thumb.

Patient Perspectives: Valuable Food Insecurity Interventions.

INTRODUCTION: Food insecurity (FI), defined as "limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire acceptable foods in socially acceptable ways," affects over 12% of US households. Embarrassment persists for patients with FI, and due to the potential consequences of FI, including increased utilization of the health care system, it is important to find causes and potential interventions for FI. The purpose of this project was to better understand FI from the patient perspective, including contributing factors, perceived health effects, and helpful interventions. METHODS: Interviews (N=21) were conducted with suburban community residency clinic patients who screened positive for FI in the last 12 months. Six open-ended questions and a ranking question examined contributors to FI, effects of FI, perceptions of clinic intervention helpfulness, and ideas for novel interventions. RESULTS: Patients identified lack of income (85.7%) as the primary issue they faced. Secondary identified issues were lack of transportation (38.1%), too much debt (33.3%), and food assistance programs not providing for all needs (33.3%). FI effects on patients' health included difficulty adhering to specialized diets and the need to modify eating patterns due to lack of food. Surprisingly, 28.6% perceived no FI related-health effects. Patients felt that the most valuable clinic intervention was provision of urgent need food boxes, followed by FI screening and referrals to community food resources. CONCLUSIONS: Frequent FI screening is in itself useful to patients. Screening paired with community food resource referrals and urgent-need food boxes are the most helpful interventions according to patients.

Improving Identification of Food-Insecure Patients in an Outpatient Clinic Setting.

INTRODUCTION: Food insecurity (FI) is defined as limited or uncertain access to enough nutritious food for all household members to lead an active and healthy life. In 2017, roughly 12% of US households reported FI. FI screening is not standard practice despite FI's association with poor health outcomes. This study compared FI screening strategies in a community-based family medicine residency clinic to determine which strategies identified the largest number of FI patients. METHODS: We conducted this study using a validated two-question screening tool with high sensitivity and specificity for identifying FI. Three implementation strategies of the screening tool were tested: two clinician-initiated and one staff-initiated. Data measured included opportunities to screen, patients actually screened, and the number of positive (disclosure) responses. RESULTS: Clinician-initiated screening rates increased when clinicians followed a standard note template with embedded FI questionnaire vs no template (58.6% vs 7.1%). Despite this improvement, staff-initiated screening returned an even higher screening rate (95.2%). The disclosure of FI determined by staff-initiated screening was also higher (12.2%, similar to previously published data) than clinician-initiated screening (2.3%). CONCLUSIONS: Staff-initiated screening for FI was the best way of identifying FI patients and yielded results consistent with local and national estimates. Clinicians did not screen patients for FI often enough for this approach to be effective, but embedding FI screening into templated notes improved clinician screening rates. Disclosure of FI when staff conducted screening far exceeded disclosure when screening was initiated by clinicians.