Purpose: To evaluate differences in vision loss and blindness by disease category between men and women in the the United States (US). Design: Retrospective observational study. Participants: Patients (14 549 105) >50 years old with eye examination data recorded in the American Academy of Ophthalmology IRIS (R) Registry (Intelligent Research in Sight) between January 1, 2018, and December 31, 2018. Methods: Patients were assigned to the vision loss cohort and categorized (mild, moderate, severe, blindness) based on the best-corrected visual acuity in the better-seeing eye. The cause of vision loss was assumed using the International Classification of Diseases, 10th Revision codes for cataract, diabetic retinopathy, age-related macular degeneration (AMD), glaucoma, retinal detachment, retinal vein occlusion, corneal opacity, or amblyopia documented in the electronic health record. The no vision loss cohort was created by subtracting the vision loss cohort from the 2018 total IRIS Registry database. Main Outcome Measures: Primary analyses provided age-adjusted prevalence ratios (PRs) for vision loss conditions for women and men within the vision loss cohort relative to the 2018 US census. Secondary analyses computed age-adjusted PRs for women and men for the same conditions relative to the IRIS Registry. Results: The age-adjusted PR of vision loss in women versus men when comparing our vision loss cohort relative to the US census was 1.28 (95% confidence interval, 1.27, 1.29) for mild vision loss, 1.29 (1.28, 1.30) for moderate vision loss, 1.35 (1.32, 1.38) for severe vision loss, and 1.54 (1.49, 1.59) for blindness. However, these differences were attenuated when age-adjusted prevalences were computed relative to those who were seen in 2018 in the IRIS Registry database. In women, the prevalence of vision loss associated with cataract and AMD was increased in both analyses, while men had a higher prevalence of vision loss associated with retinal detachment in both analyses. Conclusions: Women in the US are more likely to be diagnosed with vision loss at an IRIS Registry practice compared with men, based on clinical presentations relative to the US census. However, this finding is partly driven by the higher rates at which women presented to ophthalmic practices in both the vision loss cohort and no vision loss cohort. The age-adjusted prevalence for vision loss associated with cataract and AMD was higher in women when utilizing both the US census and the 2018 IRIS Registry database as the denominator, which suggests that a true difference in prevalence is present. The same is true for an increase in the age-adjusted relative risk for vision loss associated with retinal detachment in men. These findings warrant further study. (c) 2025 by the American Academy of Ophthalmology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

BACKGROUND: Comanagement of orthopedic surgery patients by internal medicine hospitalists is associated with improvements in clinical outcomes including complications, length of stay, and cost. Clinical outcomes of orthopedic comanagement performed solely by internal medicine advanced practice clinicians have not been reported. Our objecyive was to compare clinical outcomes between advanced practice clinician-based comanagement and usual orthopedic care. METHODS: This is a retrospective cohort study in patients 18 years or older, hospitalized for orthopedic joint or spine surgery between May 1, 2014 and January 1, 2022. Outcomes assessed were length of stay, intensive care unit (ICU) transfer, return to operating room, in-hospital and 30-day mortality, 30-day readmission, and total direct cost, excluding surgical implants. Generalized boosted regression and propensity score weighting was used to compare clinical outcomes and health care cost between usual care and advanced practice clinician comanagement. RESULTS: Advanced practice clinician comanagement was associated with a 5% reduction in mean length of stay (rate ratio = 0.95, P = .009), decreased odds of returning to the operating room (odds ratio [OR] 0.51, P = .002), and a significant reduction in 30-day mortality (OR 0.32, P = .037) compared with usual orthopedic care in a weighted analysis. Need for ICU transfer was higher with advanced practice clinician comanagement (OR 1.54, P = .009), without significant differences in 30-day readmission or in-hospital mortality. CONCLUSIONS: We observed reductions in length of stay, health care costs, return to the operating room, and 30-day mortality with advanced practice clinician comanagement compared with usual orthopedic care. Our findings suggest that advanced practice clinician-based comanagement may represent a safe and cost-effective model for orthopedic comanagement. (c) 2024 Published by Elsevier Inc. center dot The American Journal of Medicine (2024) 137:1097-1103

BACKGROUND:Social risk screening during inpatient care is required in new CMS regulations, yet its impact on inpatient care and patient outcomes is unknown. OBJECTIVES:To evaluate whether implementing a social risk screening protocol improves discharge processes, patient-reported outcomes, and 30-day service use. RESEARCH DESIGN:Pragmatic mixed-methods clinical trial. SUBJECTS:Overall, 4130 patient discharges (2383 preimplementation and 1747 postimplementation) from general medicine and surgical services at a 528-bed academic medical center in the Intermountain United States and 15 attending physicians. MEASURES:Documented family interaction, late discharge, patient-reported readiness for hospital discharge and postdischarge coping difficulties, readmission and emergency department visits within 30 days postdischarge, and coded interviews with inpatient physicians. RESULTS:A multivariable segmented regression model indicated a 19% decrease per month in odds of family interaction following intervention implementation (OR=0.81, 95% CI=0.76-0.86, P<0.001), and an additional model found a 32% decrease in odds of being discharged after 2 pm (OR=0.68, 95% CI=0.53-0.87, P=0.003). There were no postimplementation changes in patient-reported discharge readiness, postdischarge coping difficulties, or 30-day hospital readmissions, or ED visits. Physicians expressed concerns about the appropriateness, acceptability, and feasibility of the structured social risk assessment. CONCLUSIONS:Conducted in the immediate post-COVID timeframe, reduction in family interaction, earlier discharge, and provider concerns with structured social risk assessments likely contributed to the lack of intervention impact on patient outcomes. To be effective, social risk screening will require patient/family and care team codesign its structure and processes, and allocation of resources to assist in addressing identified social risk needs.

Background: Social risk screening during inpatient care is required in new CMS regulations, yet its impact on inpatient care and patient outcomes is unknown. Objectives: To evaluate whether implementing a social risk screening protocol improves discharge processes, patient-reported outcomes, and 30-day service use. Research Design: Pragmatic mixed-methods clinical trial. Subjects: Overall, 4130 patient discharges (2383 preimplementation and 1747 postimplementation) from general medicine and surgical services at a 528-bed academic medical center in the Intermountain United States and 15 attending physicians. Measures: Documented family interaction, late discharge, patient-reported readiness for hospital discharge and postdischarge coping difficulties, readmission and emergency department visits within 30 days postdischarge, and coded interviews with inpatient physicians. Results: A multivariable segmented regression model indicated a 19% decrease per month in odds of family interaction following intervention implementation (OR=0.81, 95% CI=0.76–0.86, P<0.001), and an additional model found a 32% decrease in odds of being discharged after 2 pm (OR=0.68, 95% CI=0.53–0.87, P=0.003). There were no postimplementation changes in patient-reported discharge readiness, postdischarge coping difficulties, or 30-day hospital readmissions, or ED visits. Physicians expressed concerns about the appropriateness, acceptability, and feasibility of the structured social risk assessment. Conclusions: Conducted in the immediate post-COVID timeframe, reduction in family interaction, earlier discharge, and provider concerns with structured social risk assessments likely contributed to the lack of intervention impact on patient outcomes. To be effective, social risk screening will require patient/family and care team codesign its structure and processes, and allocation of resources to assist in addressing identified social risk needs.

Introduction:Many people experience trauma, and its cumulative effects throughout the life span can alter health, development, and well-being. Despite this, few publications focusing on interpersonal trauma include a holistic understanding of the nature and widespread exposure of trauma experiences for patients. We developed an educational resource to teach residents about identifying and intervening with patients who experience trauma across the life span using a trauma-informed care (TIC) perspective.Methods:We created a 4-hour educational session for residents that included didactics, a virtual visit with a domestic violence shelter, a discussion with a person who had experienced trauma, and role-playing. A pretest/posttest retrospective survey assessed resident confidence level in identifying and intervening with patients who may have experienced trauma. We used the Wilcoxon signed rank test to compare pretest and posttest scores and the Kruskal-Wallis test to compare responses by residency type and year. Free-text questions were analyzed for thematic content.Results:During the 2021-2022 academic year, 72 of 90 residents (80%) from four residency programs attended and evaluated the session. More than 90% of respondents reported the session met their educational needs and provided them with new ideas, information, and practical suggestions to use in their clinical endeavors. The results demonstrated significantly increased confidence on most of the metrics measured.Discussion:This session significantly improved residents' confidence in identifying and intervening with patients who have had trauma experiences using a TIC perspective, which may lead them to provide improved patient care to those who have experienced trauma.

Objective: Medial epicondyle fractures are a common pediatric injury. When operative, cannulated partially threaded screws, with or without a washer, are commonly utilized. These implants may need to be removed after full healing if symptomatic. There is mixed evidence regarding the influence of a washer on rates of implant removal, and the influence of screw size has not been studied. We aim to determine the rate of symptomatic deep implant removal for each fixation type and identify factors associated with the need for removal. Methods: This was an IRB-reviewed, retrospective, case-cohort study. Patients treated at our institution between January 1, 2004 and December 31, 2019, age 18 years old or younger, with a medial epicondyle fracture managed operatively with 4.0 or 4.5 mm cannulated screws with or without washers were included. Patients with multiple operative ipsilateral elbow fractures and those who underwent implant removal for reasons other than pain or irritation were excluded. Removal rates were compared between screw sizes (4.0 vs 4.5 mm), as well as with and without a washer using a Cox proportional hazards model. Results: In total, 151 patients met the inclusion criteria, 54 with symptomatic hardware removed and 97 without symptomatic hardware removed. A significantly higher number of patients treated with 4.5 mm screws compared with 4.0 mm screws underwent removal of symptomatic deep implants (50% vs 30%, P = 0.033). In a multivariable Cox regression model adjusting for age and ulnar nerve status, when no washer was used, the hazard ratio (HR) for symptomatic hardware removal for 4.5 mm screws was 2.92 times the HR for 4.0 mm screws (95% CI: 1.35-6.29). When a 4.0 mm screw was used, the HR for symptomatic hardware removal for a washer was 3.24 times the HR without a washer (95% CI: 1.53-6.84). Conclusion: Implant removal rates are influenced by screw size and the use of a washer. These results may help guide implant choice and counsel families regarding the rate of symptomatic implant removal. Level of Evidence: Level III—therapeutic level, case-control study.

BackgroundHeadache (HA) is a common persistent complaint following mild traumatic brain injury (mTBI), but the association with remote mTBI is not well established, and risk factors are understudied.ObjectiveDetermine the relationship of mTBI history and other factors with HA prevalence and impact among combat-exposed current and former service members (SMs).DesignSecondary cross-sectional data analysis from the Long-Term Impact of Military-Relevant Brain Injury Consortium—Chronic Effects of Neurotrauma Consortium prospective longitudinal study.MethodsWe examined the association of lifetime mTBI history, demographic, military, medical and psychosocial factors with (1) HA prevalence (“lately, have you experienced headaches?”) using logistic regression and (2) HA burden via the Headache Impact Test-6 (HIT-6) using linear regression. Each lifetime mTBI was categorized by mechanism (blast-related or not) and setting (combat deployed or not). Participants with non-credible symptom reporting were excluded, leaving N = 1,685 of whom 81% had positive mTBI histories.ResultsAt a median 10 years since last mTBI, mTBI positive participants had higher HA prevalence (69% overall, 78% if 3 or more mTBIs) and greater HA burden (67% substantial/severe impact) than non-TBI controls (46% prevalence, 54% substantial/severe impact). In covariate-adjusted analysis, HA prevalence was higher with greater number of blast-related mTBIs (OR 1.81; 95% CI 1.48, 2.23), non-blast mTBIs while deployed (OR 1.42; 95% CI 1.14, 1.79), or non-blast mTBIs when not deployed (OR 1.23; 95% CI 1.02, 1.49). HA impact was only higher with blast-related mTBIs. Female identity, younger age, PTSD symptoms, and subjective sleep quality showed effects in both prevalence and impact models, with the largest mean HIT-6 elevation for PTSD symptoms. Additionally, combat deployment duration and depression symptoms were factors for HA prevalence, and Black race and Hispanic/Latino ethnicity were factors for HA impact. In sensitivity analyses, time since last mTBI and early HA onset were both non-significant.ConclusionThe prevalence of HA symptoms among formerly combat-deployed veterans and SMs is higher with more lifetime mTBIs regardless of how remote. Blast-related mTBI raises the risk the most and is uniquely associated with elevated HA burden. Other demographic and potentially modifiable risk factors were identified that may inform clinical care.

Abstract Caregiver support services may improve experiences among caregivers of people with dementia, but racial/ethnic disparities exist in service use. Using data from the 2021 National Study of Caregiving, we measured caregiver service use and caregiving impacts among 470 Black (n=187), Hispanic (n=37), and White (n=246) caregivers of older adults with possible/probable dementia from the National Health and Aging Trends Study. We classified caregivers as using at least one or none of the following services in the past year: caregiver support group, training, or respite care. We calculated the weighted proportion of caregivers reporting caregiver burden (at least one: physical, emotional or financial difficulty), exhaustion, and feeling overwhelmed within each racial/ethnic group. Caregiver service use varied by race/ethnicity (47% of Hispanic, 29% of Black, and 32% of White caregivers). Black and White caregiver service-users were significantly more likely to report a burden than their peers using no service (59% versus 36% of Black, p=0.04, and 90% versus 41% of White, p<0.001, caregivers). There was no significant difference in burden among Hispanic caregivers (59% versus 69%, p=0.65). In each racial/ethnic category, caregivers reported similar prevalence of exhaustion and feeling overwhelmed from caregiving whether they used a service or not. Based on these cross-sectional data, we hypothesize that Black and White caregivers who feel burdened use services more often, and that service use mitigates caregivers’ feelings of being exhausted or overwhelmed by caregiving, despite burden. Racial/ethnic differences highlight the need to understand contextual factors that influence caregiver burden and service use.

Introduction: Children in food insecure households or living in poverty use health care services more often, and have poorer health outcomes, including critical illness. However, the prevalence of resource insecurities in patients admitted to the pediatric ICU (PICU) is unknown. Understanding the prevalence of resource insecurities and associated factors can improve patient care and long-term health outcomes. Methods: This is a prospective single center observational cohort study conducted between December 2021 and July 2022. English- or Spanish-speaking caretakers of children admitted to a large academic PICU were eligible. Caretakers of children in state custody, unlikely to survive, or NICU transfers were excluded. Caretakers were approached to self-complete a tablet-based survey that included questions on demographics, resource insecurities, unmet healthcare needs, caretaker social support, and special healthcare needs of the child using validated or previously developed measures. We described resources insecurities related to food, housing, energy and employment. We used chi-squared tests to examine factors that were significantly associated with food insecurity. Results: We enrolled 260 families. Fifty percent of the children were below 5 years old and 70% had a special healthcare need prior to admission. Most families were white (82%), and 46% fell at or below 200% of the federal poverty limit. Families reported food insecurity (29%), housing insecurity (32%), energy insecurity (11%), and employment insecurity (26%). Food insecurity was significantly associated with lower income (p<.001), lower levels of caregiver social support (p<.001), housing insecurity (p<.001), employment insecurity (p<.001), energy insecurity (p<.001), unmet healthcare needs (p=.01), government insurance (p<.001), and special healthcare needs (p=.05). Conclusions: Among a cohort of families whose children were admitted to the PICU, nearly one third reported food insecurity, which is double the national prevalence. Given that children frequently accrue additional medical complexity and families often struggle with healthcare burden after an ICU stay, asking about resources during a PICU stay can help connect families to resources prior to discharge and optimize outcomes for children.