Design of a pragmatic randomized implementation effectiveness trial testing a health system wide hypertension program for older adults.

Hypertension control remains poor. Multiple barriers at the level of patients, providers, and health systems interfere with implementation of hypertension guidelines and effective lowering of BP. Some strategies such as self-measured blood pressure (SMBP) and remote management by pharmacists are safe and effectively lower BP but have not been effectively implemented. In this study, we combine such evidence-based strategies to build a remote hypertension program and test its effectiveness and implementation in large health systems. This randomized, controlled, pragmatic type I hybrid implementation effectiveness trial will examine the virtual collaborative care clinic (vCCC), a hypertension program that integrates automated patient identification, SMBP, remote BP monitoring by trained health system pharmacists, and frequent patient-provider communication. We will randomize 1000 patients with uncontrolled hypertension from two large health systems in a 1:1 ratio to either vCCC or control (usual care with education) groups for a 2-year intervention. Outcome measures including BP measurements, cognitive function, and a symptom checklist will be completed during study visits. Other outcome measures of cardiovascular events, mortality, and health care utilization will be assessed using Medicare data. For the primary outcome of proportion achieving BP control (defined as systolic BP < 130 mmHg) in the two groups, we will use a generalized linear mixed model analysis. Implementation outcomes include acceptability and feasibility of the program. This study will guide implementation of a hypertension program within large health systems to effectively lower BP.

Primary Retrograde Tibiotalocalcaneal Nailing in an Elderly Osteoporotic Patient With Ankle Fracture: A Case Report.

Introduction: Ankle fractures are a common orthopedic injury traditionally treated with open reduction and internal fixation or conservative management. One complication introduced with open reduction and internal fixation is the requirement for non or partial weight bearing in the post-operative period. This requirement poses a unique challenge for patients who may not comply with these weight-bearing restrictions. This case is the first known article that specifically illustrates the validity and effectiveness of retrograde tibiotalocalcaneal (TTC) nailing for patients who are unlikely to follow weight-bearing restrictions. Case Report: An 83-year-old Caucasian female with idiopathic mild mental retardation and Alzheimer's presented with a minimally displaced trimalleolar ankle fracture and was treated at a single urban hospital with a retrograde TTC nail secondary to her inability to adhere to weight-bearing restrictions post-operatively. Pertinent demographic, clinical, radiographic, and surgical data were collected. The patient had minimal post-operative pain, was able to bear weight on the day of surgery, and had no post-operative complications. Conclusion: This case report demonstrates that the use of a TTC nail is a safe and effective mode of fixation for ankle fractures in patient populations who may not adhere to weight-bearing restrictions post-operatively. The main benefits of fixation with a TTC nail are the ability to weight bear as tolerated post-operatively and decreased wound complications while having similar functional outcomes to open reduction and internal fixation. We suggest the use of TTC nails for ankle fractures in select patients who may not adhere to weight-bearing restrictions post-operatively.

Association Between Pronation External Rotation IV Fracture Pattern and Regional Bone Density.

INTRODUCTION: Throughout the musculoskeletal system, fracture patterns and subsequent healing rely partly on bone density. In the foot and ankle, bone density has been shown to play a role in supination and external rotation fracture patterns. Adding to previous research, this investigation examines the association between bone density and trimalleolar versus trimalleolar equivalent fracture patterns following pronation and external rotation injuries using computed tomography (CT)-derived Hounsfield units (HU). METHODS: A retrospective chart review was conducted among patients without a history of fracture or osteoporosis who sustained a PER IV fracture. Demographic data were collected. Fractures were separated between PER IV equivalent and fracture groups. CT-derived HU was assessed at the distal tibia and fibula. Density was compared between PER IV equivalent and fracture groups and among posterior malleolar fracture patterns. RESULTS: Seventy-five patients met the selection criteria, with 17 comprising the equivalent group and 58 in the fracture group. There were 38 type 1, 9 type 2, and 11 type 3 posterior malleolus fractures. The ankle bone density of the PER fracture equivalent group (331.98 ± 65.71HU) was greater than the PER fracture group (281.61 ± 76.99HU; P = .008). A statistically significant difference in tibial bone densities among equivalent and all PER fracture types (P = .01) with the equivalent group (331.98 ± 65.71HU) maintaining a greater tibial bone density than the type 2 posterior malleolus fracture group (252.35 ± 57.33HU; P = .009). CONCLUSION: Higher bone density was associated with PER IV equivalent fractures; however, there was no density difference among posterior malleolus fracture types. When presented with PER IV fractures, consider fixation that addresses a lower bone density. LEVEL OF EVIDENCE: III.

Differences Between Patients With Diabetes Mellitus and Those Without in Cases of Necrotizing Fasciitis.

Purposes This study aims to evaluate further differences between patients with diabetes and those without who have been diagnosed with necrotizing fasciitis (NF) to assist clinicians in improving morbidity and mortality. Methods All patients diagnosed with NF of an extremity were retrospectively reviewed and divided into two groups based on a diagnosis of diabetes. Patient charts were reviewed to obtain multiple variables, which were compared between groups. Results From 2015 to 2021, 115 patients underwent surgical intervention due to concern for NF of an extremity with 92 patients included for data computation. Patients with diabetes had an average Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score of 9.02 compared to 7.24 (p=0.02). Patients with diabetes had a significantly higher rate of undergoing amputation when diagnosed with NF (p<0.0001). The mortality rate for diabetes and non-diabetes cohorts were 30.9% and 18.9%, respectively (p=0.2). Conclusion This study demonstrated that patients with diabetes with confirmed NF of an extremity had a significantly higher LRINEC score were more likely to undergo an amputation primarily, and were more likely to have a polymicrobial infection compared to those without. The overall mortality rate of NF was 26.1%.

Outpatient Surgery for Rib Fracture Fixation: A Report of Three Cases.

Rib fractures are common injuries observed in trauma patients that will often heal without operative intervention. However, patients can infrequently have continued pain. Operative fixation of these symptomatic rib fractures has traditionally led to the patient requiring hospital admission for observation and pain control. The purpose of this study was to review three cases of outpatient rib fracture, open reduction and internal fixation (ORIF) surgery. Three patients with symptomatic rib fractures treated with ORIF at a single urban level one trauma center underwent outpatient same-day surgery. Pertinent demographic, clinical, radiographic, and surgical data were collected. All patients had decreased preoperative pain and no complications. This case series demonstrates that outpatient surgery for rib fracture ORIF can be performed safely in a select patient population. Additionally, it has similar efficacy as inpatient operative fixation with the main added benefit being decreased costs to both the patient and the healthcare system. We suggest that outpatient operative fixation of rib fractures should be considered for select patients.

Loss of UHRF2 expression is associated with human neoplasia, promoter hypermethylation, decreased 5-hydroxymethylcytosine, and high proliferative activity.

Ubiquitin-like with PHD and ring finger domains 2 (UHRF2) binds to 5-hydroxymethylcytosine (5hmC), a DNA base involved in tissue development, but it is unknown how their distribution compares with each other in normal and malignant human tissues. We used IHC on human tumor specimens (160 from 19 tumor types) or normal tissue to determine the expression and distribution of UHRF2, Ki-67, and 5hmC. We also examined UHRF2 expression in cord blood progenitors and compared its expression to methylation status in 6 leukemia cell lines and 15 primary human leukemias. UHRF2 is highly expressed, paralleling that of 5hmC, in most non-neoplastic, differentiated tissue with low Ki-67 defined proliferative activity. UHRF2 is expressed in common lymphoid progenitors and mature lymphocytes but not common myeloid progenitors or monocytes. In contrast, UHRF2 immunostaining in human cancer tissues revealed widespread reduction or abnormal cytoplasmic localization which correlated with a higher Ki-67 and reduced 5hmC. UHRF2 expression is reduced in some leukemia cell lines, this correlates with promoter hypermethylation, and similar UHRF2 methylation profiles are seen in primary human leukemia samples. Thus, UHRF2 and 5hmC are widely present in differentiated human tissues, and UHRF2 protein is poorly expressed or mislocalized in diverse human cancers.