Critical Race Theory as a Lens for Examining Primary Care Provider Responses to Persistently-Elevated HbA1c

IntroductionClinical inertia remains a persistent problem in the treatment of diabetes in clinical care. Primary care provider behavior is thought to be a significant contributor to diabetes clinical inertia. This study used the lens of Critical Race Theory to examine whether provider's diabetes management activities differ by patient race and frame implications for future research.MethodsChart abstractors retrospectively reviewed a random sample of charts from primary care patients with persistently-elevated HbA1c to assess providers' diabetes management activities in the subsequent year. Provider activities aligned with the American Diabetes Association's standards of medical care and included HbA1c test ordering, documentation of patient medication adherence, counseling on lifestyle modification, lifestyle modification referral, endocrinologist participation in care, and medication titration. Differences in provider actions by patient race (Black, white, or other) were examined using chi-square tests.ResultsA total of 188 patient charts were reviewed. For all provider actions, there were statistically-significant differences by patient race. Black patients were least likely to be counseled on dietary changes (72.0%) or physical activity (57.7%) by their primary care provider, but most likely to be referred to an outside specialist for this counseling (46.2%). Black patients were also least likely to have medication adjustments made (72%).DiscussionStudy findings showed an association between provider diabetes management behaviors and patient race, Future studies showed explore providers' racial beliefs, attitudes and clinical decision-making, and patients’ experiences with historical exclusion from medical care and racism in healthcare encounters In addition, more research is needed to explore the role of structural racism in clinical inertia.     

18FDG‐PET/CT: 21st century approach to leukemic tumors in 124 cases

Extramedullary tumors remain an obstacle to curing more acute leukemia patients. Their incidence is unknown because the presence of occult tumors that contribute to relapse is not routinely sought as in other cancers. No standard approach exists for treating tumors at most sites, apparent clinical response is typically followed by further tumors, and achievement of lengthy remission is uncommon. Body scanning with ¹⁸FDG PET/CT now provides a means to identify the extent of occult tumors that enables directed tumor eradication and a way to evaluate tumor response. To evaluate its potential benefits, analysis was undertaken of 124 published cases scanned after apparent tumors were diagnosed. Clinical and radiologic exams underestimated extent of disease in over half of 100 cases. Among 70 cases that reported scans after various treatments, 70% achieved negative scans. Half relapsed subsequently but disease‐free survivals up to 6 years were documented. These reported cases add to our knowledge of extramedullary leukemia in showing that further tumors are more likely than marrow relapse, clinical and radiologic evaluation of response is inadequate, intensive chemotherapy alone generally does not prevent progression and is associated with significant mortality, and tumor‐directed plus systemic therapies appears the most effective approach, particularly to AML tumors. This analysis suggests this technology could increase our ability to eradicate all foci of leukemia, and identify tumors responsible for refractory, residual, and relapsed disease. Am. J. Hematol. 91:379–384, 2016. © 2015 Wiley Periodicals, Inc.     

An anatomic study of local infiltration analgesia in total knee arthroplasty

BackgroundLocal infiltration analgesia (LIA) is a relatively novel technique developed for effective pain control following total knee arthroplasty (TKA), reducing requirements for epidural or parenteral postoperative analgesia. This study investigated the anatomical spread of an LIA used in TKA to identify the nerve structures reached by the injected fluid.MethodsSix fresh-frozen cadaveric lower limbs were injected according to a standardised LIA technique with a solution of latex and India ink to enable visualisation. Wounds were closed and limbs placed flat in a freezer at ? 20 °C for two weeks. Limbs were then either sliced or dissected to identify solution locations.ResultsSolution was found from the proximal thigh to the middle of the lower leg. The main areas of concentration were the popliteal fossa, the anterior aspect of the femur and the subcutaneous tissue of the anterior aspect of the knee. There was less solution in the lower popliteal fossa. The solution was found to reach the majority of nerves, with good infiltration of nerves supplying the knee.ConclusionsThese results support the positive clinical outcomes with this LIA technique. However, the lack of infiltration into the lower popliteal fossa suggests more fluid or a different injection point could be used. The solution reaching the extensor muscles of the lower leg is likely to have no beneficial analgesic effect for a TKA patient. The LIA technique is already used in clinical practice following total knee arthroplasty. Results from this study show there may be scope to optimise the injection sites in LIA technique.     

Evaluating training methods for transporting contingency management to therapists

The effects of three increasingly intensive training methods on therapist use, knowledge, and implementation adherence of contingency management (CM) with substance abusing adolescents were evaluated. Ten public sector substance abuse or mental health provider organizations were randomized to one of three training conditions: workshop and resources (WS +), WS + and computer assisted training (WS +/CAT), or WS +/CAT and supervisory support (WS +/CAT/SS). Across conditions, 161 therapists participated in the training experiences, and measures were obtained at baseline and 2-month intervals for 12 months following workshop participation. Across training conditions, therapists reported increased CM use, knowledge, and implementation adherence through the 12-month follow-up. The findings show that community-based practitioners are amenable to the adoption of evidence-based treatments when provided access to useful resources. Moreover, high quality workshops in combination with resource access can increase knowledge of the evidence-based treatment and might enhance intervention adherence to a level needed to improve youth outcomes.     

Differential Effects of Normal Aging on Memory for Odor-Place and Object-Place Associations

Asking other people for help is a compensatory behavior that may be useful across the life span to enhance functioning. Seventy-two older and younger men and women were either allowed to ask for help or were not allowed to ask for help while solving reasoning problems. Although the older adults answered fewer problems correctly, they did not seek additional help to compensate for their lower levels of performance. Younger adults sought more help. There were no age differences, however, in the types of help sought: indirect help (e.g., hints) was sought more often than direct help (e.g., asking for the answer). Exploratory analyses revealed that one's ability level was a better indicator than age of the utility of help-seeking. Findings are interpreted in the context of social and task-related influences on the use of help-seeking as a compensatory behavior across the life span.     

Patient Preferences of a Low-Income Hispanic Population for Mental Health Services in Primary Care

We used a discrete-choice conjoint experiment to model the mental health services preferences of patients of a federally-qualified health center serving a primarily low-income, Hispanic farmworker population in southwestern Arizona. The two attributes that had the largest influence on patient choices (i.e., received the highest importance scores) were where patients receive these services and the language and cultural awareness of the provider who prescribed their treatment. Simulations indicated that the clinic could substantially improve its patients’ welfare with even a single change. The single most effective change in terms of patient preferences would be to offer behavioral health services onsite.     

Adulthood Relocation: Implications for Personality,Future Orientation,and Social Partner Choices

The purpose of this study was to learn the reasons why individuals relocate and whether relocaters differ from nonrelocaters on demographic, social, and personality factors. One hundred participants from three age groups, 34 to 46 (young/middle-aged), 54 to 66 (young-old), and 69 to 93 (older) years, were designated as relocaters or residents as a function of months of residence. Relocaters did not differ from residents in age, income, health, or marital status. Reasons provided for relocating revealed the following differences: young/middle-aged moved for employ ment reasons, young-old moved for reasons of retirement, and older adults relocated to be closer to family members. No differences in network size occurred and older relocaters selected more cards in a social partner selection task. Most interesting was the finding that relocaters scored higher on Openness to Experience and future orientation. These data suggest personality may be an important trait that explains why some individuals are more likely to relocate.