Photo-control of nanointeractions.

The manipulation of physical interactions between structural moieties on the molecular scale is a fundamental hurdle in the realization and operation of nanostructured materials and high surface area microsystem architectures. These include such nano-interaction-based phenomena as self-assembly, fluid flow, and interfacial tribology. The proposed research utilizes photosensitive molecular structures to tune such interactions reversibly. This new material strategy provides optical actuation of nano-interactions impacting behavior on both the nano- and macroscales and with potential to impact directed nanostructure formation, microfluidic rheology, and tribological control

An Unusual Case of A Blue Finger

Introduction:Acute discoloration and paresthesia of a distal extremity is concerning for an ischemic event or a manifestation of underlying systemic disease. Achenbach syndrome is an infrequent, but benign etiology of an acute blue finger that needs to be recognized clinically. We present a case to increase awareness. Case:A 57-year-old Caucasian female presented to rheumatology clinic for bruising digits.” She described four episodes of spontaneous segmental, blue discoloration of varying digits over the past two years. Each episode was isolated to a single digit and preceded by 10-15 minutes of throbbing with the digit then turning white and numb. These prodromes were followed by a feeling of “blood vessel popping” with subsequent bruising and mild swelling. Resolution of discoloration ranged from several hours to several days. There was no association with exposure to cold temperatures and warming the fingers would not alleviate the symptoms, nor abort the course. Past medical history includes Raynaud’s disease diagnosed in her twenties. Her current symptoms feel distinctly different from usual Raynaud’s episodes. She is a non-smoker and takes no medications. Family history is non-contributory. Physical exam was unremarkable at presentation and follow up. Photos from the recent episode were available, revealing blue discoloration involving the volar surface of the right 3rd digit at the PIP extending 1cm on either side of the joint with mild swelling, sparing of the distal phalange and no abnormalities of the surrounding digits. Work-up for Raynaud’s included anti-nuclear antibodies and its sub-serologies, anti-phospholipid serologies, complements, complete blood count and complete metabolic panel. These studies were unremarkable and no autoimmune process was identified. The patient also underwent MRA of the right upper extremity, which was non-revealing. Based on the clinical presentation, a diagnosis of Achenbach syndrome was made and the patient was reassured. Discussion:Achenbach syndrome is a benign, self-limiting cause of spontaneous blue finger discoloration that is commonly misdiagnosed as vascular problems, including Raynaud’s. Unlike Achenbach syndrome, Raynaud’s episodes may involve multiple fingers simultaneously, is temperature related and warrants further work-up. In contrast, case studies and case series of Achenbach syndrome suggest futility of angiography and extensive rheumatologic work-up and have not demonstrated any significant disease associations over time. Despite the concerns raised by acuity and appearance, knowledge of Achenbach syndrome along with careful history taking will direct the physician to the correct diagnosis and avoid unnecessary, costly testing

Osteoporosis and fracture reduction in the primary care setting at GW MFA

Osteoporosis is a disorder characterized by deterioration in bone mass and bone architecture, leading to bone fragility and a predisposition to fracture. Among older patients, hip osteoporotic fractures are a major cause of morbidity, mortality, and health care costs. Currently, osteoporosis results in over 1.5 million fractures per year in the United States. With the aging of the population, the rate of fracture is expected to increase by 48% in the next 25 years, making the current fracture rate rise from 1.5 million to greater than 3 million fractures in the United States. Most osteoporotic fractures occur in women, primarily due to postmenopausal estrogen deficiency, leading to increased trabecular bone resorption. With osteoporosis becoming an increasingly significant public health burden, it is critically important to identify and treat at-risk patients. The focus of our QI project is to improve the rate of osteoporosis screening in the primary care setting for women equal to or greater than the age of 65, in accordance with the United States Preventive Services Task Force (USPSTF) recommendations. Specifically, we aim to increase the percentage of screening dual-energy x-ray absorptiometry (DXA) scan orders by a total of 10% for female patients age 65 or greater in the primary care setting through the use of education. Our initial PDSA cycles focused on collecting baseline data for two cohorts of residents to determine the percentage of patients in our study population who have existing or new DXA scan orders. Among the two cohorts of residents, we found a significant variability in the percentage of DXA scan orders (53% and 82.5%, respectively). Interventions included providing verbal reminders as well as email reminders and educational material regarding screening guidelines. In one of the resident cohorts, we see a 3% increase in percentage of new or existing DXA scan orders for a given week compared to baseline. With future PDSA cycles, we intend to incorporate education in the form of oral presentations, reminders, and encourage the use of documentation templates among resident cohorts with a low percentage of DXA scan orders

Youth Has its Disadvantages -- Younger Consumers are Less Likely to Understand Their Health Insurance

Introduction: Implementation of the Affordable Care Act provided Approximately 23 million people acquired health insurance as a result of Affordable Care Act. While access to insurance may have increased, applicants have been faced with a wide variety of choices of insurance products, in some cases more than they would have had with employer-based plans. Consumers faced with acronyms such as HMO, PPO, HDHPs, and POS are asked to choose coverage while they may have little understanding of what these terms mean and how they differ. Young people typically have had little exposure to insurance plans in the past and may be at a greater disadvantage in choosing a policy. This study examined understanding of one’s health insurance plan as a function of age. Methods: Individuals attending a Washington, DC health exposition sponsored by the Rodham Institute completed an anonymous survey in August 2015. The exposition was hosted in an urban, medically underserved setting where the population has historically been predominantly African American; currently 92% of residents identify as such. The survey included questions on demographic information, insurance status, as well as questions related to obtaining insurance. Responses were excluded if questions regarding age or insurance knowledge were unanswered. The university institutional review board approved the study. Statistical analysis was performed using Fisher’s exact test, with significance set at p\u3c0.05. Results: There were 96 responses analyzed. Twenty eight (29.2%) individuals were over the age of 50 and 68 (70.8%) were younger. Twenty (29.4%) of the younger respondents reported understanding how their insurance worked. In the older age group, 26 (92.8%) understood their health insurance. Those over the age of 50 were more likely to have a firm understanding of their medical insurance plan compared to those under the age of 50 (p=0.0001). Among 28 college educated respondents, 23 (82.1%) understood their insurance. Fifty one (76.1%) of 67 respondents with less education had such an understanding. There was no difference with respect to education level (p=0.5973). Discussion: Our study revealed that younger customers are three times less likely to endorse an understanding of how their health insurance works. While the Affordable Care Act has expanded access to health insurance, many face a wider variety of options than they may have had prior to the passage of reforms. Because younger people have had less experience (or no experience) with health insurance in the past, they would benefit from educational resources to inform their choices. A disadvantageous selection of plan, deductible, and coinsurance may make financial concerns a greater component of medical decision making

Missed opportunities for attempts at de-escalation of proton pump inhibitor therapy

Introduction: Proton pump inhibitors (PPI) are amongst some of the most widely prescribed classes of medication in the United States. While long term treatment is appropriate in certain situations, attempts to should be made to reduce, or discontinue their use in many patients. Methods: A retrospective chart review of patients with a PPI listed as a current medication seen by a faculty gastroenterologist at an urban university medical center over a 12-month period was conducted. Data was collected to determine the indication for PPI use, reason for clinic visit, and whether or not there was a documented discussion of de-escalation of PPI therapy. De-escalation was defined as attempts at reduction in dose, reduction in frequency, or complete discontinuation, of the PPI. Patients prescribed PPI’s for Barrett’s esophagus, Helicobacter pylori infection, and gastrointestinal bleeding were excluded. A Microsoft Excel database maintaining subject confidentiality was used. Statistical analysis performed via two-tailed Fisher’s Exact Test, p\u3c0.05. Results: A total of 600 charts were initially reviewed, of which, 324 were included in the analysis. Of the 324 patients , 141 patients were prescribed a PPI by a gastroenterologist. 72 out of 141 were seen for GERD, and 69 seen for non-GERD reasons. 29 patients (40%) seen for GERD had documented discussions of de-escalation, compared to 12 (17%) of patients being seen for non-GERD reasons. A missed opportunity exists for attempts at de-escalation in patients who are prescribed a PPI by a gastroenterologist, yet being seen for a chief complaint unrelated to GERD (p = 0.0031). Discussion: Proton pump inhibitors are amongst the most commonly prescribed medications in the United States. There is evidence to suggest that patients with uncomplicated GERD who have obtained symptomatic relief with PPIs, should be able to successfully de-escalate their therapy. Our data show that when a gastroenterologist is the prescriber of a patient’s PPI, and the patient is being seen for a GERD related chief complaint, the likelihood of a documented de-escalation discussion is much greater than compared to when a patient is presenting for a non-GERD related chief complaint (40% vs 17%, p = 0.0031). While PPI’s are quite safe, and overall, well tolerated, nevertheless, their continued use in a patient should be re-evaluated periodically. There appear to be missed opportunities to for attempts at de-escalation of PPI during non-GERD related visits

Metabolic syndrome is associated with similar long-term prognosis in non-obese and obese patients. An analysis of 45 615 patients from the nationwide LIPIDOGRAM 2004-2015 cohort studies

Aims We aimed to evaluate the association between metabolic syndrome (MetS) and long-term all-cause mortality. Methods The LIPIDOGRAM studies were carried out in the primary care in Poland in 2004, 2006 and 2015. MetS was diagnosed based on the National Cholesterol Education Program, Adult Treatment Panel III (NCEP/ATP III) and Joint Interim Statement (JIS) criteria. The cohort was divided into four groups: non-obese patients without MetS, obese patients without MetS, non-obese patients with MetS and obese patients with MetS. Differences in all-cause mortality was analyzed using Kaplan-Meier and Cox regression analyses. Results 45,615 participants were enrolled (mean age 56.3, standard deviation: 11.8 years; 61.7% female). MetS was diagnosed in 14,202 (31%) by NCEP/ATP III criteria, and 17,216 (37.7%) by JIS criteria. Follow-up was available for 44,620 (97.8%, median duration 15.3 years) patients. MetS was associated with increased mortality risk among the obese (hazard ratio, HR: 1.88 [95% CI, 1.79-1.99] and HR: 1.93 [95% CI 1.82-2.04], according to NCEP/ATP III and JIS criteria, respectively) and non-obese individuals (HR: 2.11 [95% CI 1.85-2.40] and 1.7 [95% CI, 1.56-1.85] according to NCEP/ATP III and JIS criteria respectively). Obese patients without MetS had a higher mortality risk than non-obese patients without MetS (HR: 1.16 [95% CI 1.10-1.23] and HR: 1.22 [95%CI 1.15-1.30], respectively in subgroups with NCEP/ATP III and JIS criteria applied). Conclusions MetS is associated with increased all-cause mortality risk in non-obese and obese patients. In patients without MetS obesity remains significantly associated with mortality. The concept of metabolically healthy obesity should be revised