Rural Clinical Settings Research Articles

Engagement in a pilot produce prescription program in rural and urban counties in the Southeast United States.

In the United States, over one in every ten households experiences food insecurity. Food insecurity is associated with often co-occurring adverse health consequences, including risk for obesity, type 2 diabetes, and hypertension. Within the "Food is Medicine" intervention space, Produce Prescription Programs (PRx) seek to alleviate food insecurity and improve diet and health outcomes by leveraging access to produce through healthcare organizations. Though these programs are burgeoning across the United States, research surrounding their implementation and outreach is limited. This study evaluates the implementation, reach, engagement, and retention of a PRx program piloted in two regions of Georgia (US) from 2020 to 2022. The study included 170 people living with one or more cardiometabolic conditions recruited from clinical sites in metropolitan and rural areas. The program provided pre-packaged produce boxes and nutrition education over six months. We examine participants' baseline demographics, food security status, dietary patterns, and loss to follow-up across contexts (metropolitan and rural). We employ regression analyses and model comparison approaches to identify the strongest predictors of loss to follow-up during the pilot period. In the pilot period of this program, 170 participants enrolled across rural and metropolitan sites. Of these, 100 individuals (59%) remained engaged for the six-month program. While many individuals met the target criteria of living with or at-risk of food insecurity, not all lived with low or very low food security. Metropolitan participants, males, and those with children in the household had significantly higher odds of loss to follow-up compared to rural participants, females, and those without children in the household. No other significant demographic or household differences were observed. This study demonstrates the potential of PRx programs to enhance food and nutrition security and cardiometabolic health in metropolitan and rural clinical settings. Future research should focus on addressing barriers to engagement and expanding the reach, impact, and sustainability of PRx programs across diverse contexts.

Effectiveness of self-check-in kiosk use in a community-based clinic setting

With current and projected staffing shortages, healthcare settings must find innovative ways to address workload problems. One possible solution in the outpatient setting is the use of patient self-check-in kiosks. This paper aimed to understand the effectiveness of the use of self-check-in kiosks in a rural community-based clinic setting. Data was gathered retrospectively on patients seen in our clinic during 2022. Two-sample z-tests were used to compare the use of kiosks before and after the implementation of intentional interventions to help motivate patients to check in using kiosks. Binomial logistic regression was used to determine factors that influence use of kiosks. We then analysed patient satisfaction surveys to determine whether the interventions affected patient satisfaction. A total of 143,208 patients were included in the study. Significantly more patients used the self-check-in kiosks during the post-intervention period (24.9 per cent) than during the pre-intervention period (6.5 per cent) ( z = −102.79, P < 0.001). The outcome of the binomial logistic regression in the form of a model was significant ( χ2(9) = 2,274, P < 0.001) and showed that gender, age, financial (insurance) class and time of check-in significantly affect the likelihood of patients using the self-check-in kiosks. Patient satisfaction was not affected by the interventions. The study findings suggest that it is possible to increase the use of self-check-in kiosks with intentional interventions in a community-based clinic setting without negatively affecting patient satisfaction. Expecting that patients will use technology just because it is there may not be feasible, as evidenced by this case. Non-use of the technology by patients could lead to negative consequences, such as longer wait times and effects on overall patient flow.

A Scoping Review of Nurse-Led Medical-Surgical Knowledge Translation Interventions to Improve In-Hospital Clinical Practice in the WHO Afro Region

The process of placing research knowledge into action and thereby ensuring its dissemination is very important in healthcare currently. Although nurse-led knowledge translation interventions have become an important focus in the high-income countries, the extent of such interventions in the World Health Organization (WHO) Afro Region is not well established. This scoping review aimed to map the evidence of nurse-led knowledge translation interventions in the countries in the WHO Afro Region using the Joanna Briggs Institute (JBI) Scoping Review Methodology. A systematic electronic search of articles was carried out in selected electronic data bases using various search engines. All 688 eligible identified articles were imported into the Systematic Reviews Web App (Beta) Rayyan. The selection process included title and abstract screening, and full text article screening. A Prisma flow diagram detailing the procedure was developed. The review process resulted in 21 selected articles. The results showed minimal publications between 2013 and 2019 with a sudden increase in 2020 (n = 5) and 2021 (n = 4). The Eastern WHO Afro Region contributed 48% of the studies, followed by the Western WHO Afro Region with 43%. Ten countries were selected through the process of screening according to where nurse-led medical-surgical knowledge translation interventions were found. Nigeria contributed 33%, followed by Uganda with 19%. The scoping review concluded that studies be appraised for their ability to promote evidence-based knowledge, skills and behaviour in both rural and urban clinical settings. More of these studies need to be conducted in the WHO Afro Region. More focused systematic reviews should be conducted to sum up the best available research on these specific questions, supported by findings by clinical setting, type of intervention, and outcomes.

Knowledge and Behavior of Primary Care Physicians Regarding Utilization of Standardized Tools in Screening and Assessment of Anxiety, Depression, and Mood Disorders at a Large Integrated Health System.

Standardized screening, objective evaluation, and management of behavioral health conditions are major challenges in primary care. The Generalized Anxiety Disorder Scale (GAD-7), Patient Health Questionnaire (PHQ-9), and Mood Disorder Questionnaire (MDQ) provide standardized screening and symptom management tools for generalized anxiety disorder (GAD), major depressive disorder (MDD), and Mood Disorders (MD), respectively. This study explores family physicians' knowledge, attitudes, and practices regarding the utilization of GAD-7, PHQ-9, and MDQ in outpatient primary care offices. The study method was a cross-sectional electronic and paper survey utilizing a self-administered questionnaire that assessed primary care physicians' demographics, knowledge, attitudes, and practices in rural and urban outpatient clinical settings regarding GAD-7, PHQ-9, and MDQ. Statistical software SAS 9.4 was used for descriptive and Chi-Square statistics. Out of 320 total participants,145 responded (45.3%). Responding family physicians demonstrated a high level of familiarity with the GAD-7 (97.9%), PHQ-9 (97.9%), and MDQ (81.3%) assessment tools. However, the reported utilization rates were relatively lower than knowledge, with 62.7%, 73.1%, and 31.9% extremely likely or likely to utilize the GAD-7, PHQ-9, and MDQ as screening and monitoring tools, respectively. Less than a quarter of the total respondents use the objective score for the future management of GAD, with significantly more residents utilizing the score for GAD-7 compared to attendings (P < .05). There was no statistical significance difference between residents and attendings for the objective evaluation of Major Depressive Disorder (P = .26) and Mood Disorders (P = .05). Despite being knowledgeable of the utility of GAD-7, PHQ-9, and MDQ, the primary care physicians in a large integrated health system in Central Pennsylvania and Northern Maryland report inconsistent utilization in their practice. Further studies are needed to determine the underlying factors contributing to the suboptimal usage of these screening tools and ways to increase it.

Mending Hearts in Northland: It's Not Rocket Science

Applying heart failure (HF) guidelines in a rural hospital clinic setting can result in significant improvements in patient outcomes. We describe the early days of a rural HF service. Northland has one of the highest cardiovascular disease and death rates in the country; in addition, access to primary care is suboptimal for a variety of reasons. In late 2019, a cardiologist with an HF interest took over the responsibility of cardiology clinics in the mid and far North. The data below relate to 86 consecutive cardiology clinic patients with a diagnosis of HF reduced ejection fraction (rEF), attending either Kaitaia or Bay Of Islands hospitals between October 2019 and March 2020. Of the patients, 85% were male and 71% Māori. The average age was 62.2 years, ranging 25–84 years with a median of 63 years. In addition, 38% were diabetic, almost all type 2. Causative and contributing factors for HF included ischaemic heart disease in 24% and alcohol in 41%. Methamphetamine and familial/genetic causes were involved in 7% each. Usual guideline recommended HF therapy was utilised and patients followed up with ejection fraction (EF) results are shown below.Tabled 1Year20182019202020212022Average EF%29.729.930.435.338.8 Open table in a new tab Four of 86 patients died, five relocated, and there were issues with adherence that likely contributed to delayed and/or poorer outcomes in 15%. Contributors to EF improvement will be described elsewhere. This real-life data highlight the complex burden of HF in rural Northland, but how relatively successful a guideline-focused management strategy can be.

The Bergen 4-day treatment for panic disorder: implementation in a rural clinical setting

IntroductionThe Bergen 4-Day Treatment (B4DT) is a concentrated treatment with individually tailored exposure exercises. The format has shown promising results in the treatment of panic disorder.AimThe aim of the current study was to investigate the effectiveness of the B4DT in a large sample in a rural clinical setting.MethodFifty-eight patients with panic disorder were consecutively included using an open trial design. The primary outcome measure was the Panic Disorder Severity Scale. The Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-9 were used as secondary outcome measures. Assessments were conducted at pretreatment, posttreatment, and 3-month follow-up. Treatment satisfaction was measured at posttreatment using the Client Satisfaction Questionnaire-8.ResultsThere was a significant reduction in symptoms of panic disorder from pre- to posttreatment (d = 3.36) and from pretreatment to follow-up (d = 3.63). At posttreatment and follow-up, 72.4% and 81.0% of patients, respectively, were classified as in remission. Patients reported high treatment satisfaction, and there were significant reductions in symptoms of generalized anxiety and depression.ConclusionThe results from the current study replicated the findings from previous studies using a larger sample size. The findings indicate that the B4DT is a promising treatment format for panic disorder. The study also demonstrated that the treatment format can be successfully implemented in new rural clinics.

Smartphone intervention to optimize medication-assisted treatment outcomes for opioid use disorder: study protocol for a randomized controlled trial

BackgroundOpioids accounted for 75% of drug overdoses in the USA in 2020, with rural states particularly impacted by the opioid crisis. While medication-assisted treatment (MAT) with Suboxone remains one of the more efficacious treatments for opioid use disorder (OUD), approximately 40% of people receiving Suboxone for outpatient MAT for OUD (MOUD) relapse within the first 6 months of treatment. We developed the smartphone app-based intervention OptiMAT as an adjunctive intervention to improve MOUD outcomes. The aims of this study are to (1) evaluate the efficacy of adjunctive OptiMAT use in reducing opioid misuse among people receiving MOUD and (2) evaluate the role of specific OptiMAT features in reducing opioid misuse, including the use of GPS-driven just-in-time intervention.MethodsWe will conduct a two-arm, single-blind, randomized controlled trial of adults receiving outpatient MOUD in the greater Little Rock AR area. Participants are English-speaking adults ages 18 or older recently enrolled in outpatient MOUD at one of our participating study clinics. Participants will be allocated via 1:1 randomized block design to (1) MOUD with adjunctive use of OptiMAT (MOUD+OptiMAT) or (2) MOUD without OptiMAT (MOUD-only). Our blinded research statistician will evaluate differences between the two groups in opioid misuse (as determined by quantitative urinalysis conducted by clinical lab staff blinded to group membership) during the 6-months following study enrolment. Secondary analyses will evaluate if OptiMAT-usage patterns within the MOUD+OptiMAT group predict opioid misuse or continued abstinence.DiscussionThis study will test if adjunctive use of OptiMAT improve MOUD outcomes. Study findings could lead to expansion of OptiMAT into rural clinical settings, and the identification of OptiMAT features which best predict positive clinical outcome could lead to refinement of this and similar smartphone app-based interventions.Trial registrationClinicalTrials.govidentifier: NCT05336188, registered March 21, 2022.

The Effectiveness of Antibiotics in Managing Bacterial Infections on Bite Sites following Snakebite Envenomation.

Snakebite envenomation (SBE) is a life-threatening medical emergency with a high mortality rate. Common secondary complications following SBE, such as wound infections, are significant due to their impact on worsening local tissue damage and causing systemic infection. Antivenoms are not effective to treat wound infections following SBE. Moreover, in several rural clinical settings, broad-spectrum antibiotics are often used without clear guidelines or based on limited laboratory data, resulting in undesirable side effects and exacerbated treatment costs. Therefore, robust antibiotic strategies should be developed to tackle this critical issue. Currently, there is limited information available on the bacterial profiles of SBE-induced infections and antibiotic susceptibility. Hence, it is essential to improve the knowledge of bacterial profiles and their antibiotic sensitivity in SBE victims to develop better treatment strategies. This study aimed to address this issue by examining the bacterial profiles of SBE victims with a specific focus on Russell's viper envenomation. The most frequently found bacteria in the bites of SBE victims were Staphylococcus aureus, Klebsiella sp., Escherichia coli, and Pseudomonas aeruginosa. Linezolid, clindamycin, colistin, meropenem, and amikacin were some of the most effective antibiotics for commonly grown bacteria in SBE victims. Similarly, ciprofloxacin, ampicillin, amoxiclave, cefixime, and tetracyclin were the least effective antibiotics for common bacteria found in the wound swabs of SBE victims. These data provide robust guidance for infection management following SBE and offer useful insights to aid in designing effective treatment protocols for SBE with serious wound infections in rural areas where laboratory facilities may not be readily available.

ROLE OF FAMILY MEDICINE IN CANCER PATIENT CARE: A REVIEW

According to one definition, Family Medicine is a specialty that provides the provision of ongoing, comprehensive medical treatment to patients within the setting of their families and communities. Acute and chronic care, identification of family and social needs, long-term support, epidemiologic awareness, and treatment of unexplained illness are all included in continuing whole-patient care. This review aimed to summarize the updated evidence considering the role of Family Medicine in the care and management of cancer patients. PubMed, Web of Science, Science Direct, EBSCO, SCOPUS, Wiley, and Cochrane Library were searched. Study articles were screened by title and abstract then a full-text assessment was implemented. Family Physician (FP) plays a crucial part in providing care for a patient with cancer. There have been many different roles for doctors identified, and these responsibilities differ greatly depending on whether the practice takes place in an urban or rural clinical setting. Alongside surgical, medical, and radiation oncology specialists, FPs commonly provide care for patients with breast and gastrointestinal cancer. They also work with gynecologic, hematologic, and paediatric cancer patient populations. The management of treatment-related physical and psychosocial side effects, the provision of follow-up care for cancer survivors, and palliative medicine are examples of typical tasks and responsibilities. In addition, the FP support clinical trials, research focused on genetics, and high-risk population cancers.

Support for Trauma-informed Care Implementation Among Ryan White HIV Clinics in the Southeastern United States.

Trauma histories are common among people with HIV and associated with poor HIV outcomes, underscoring the importance of integrating trauma-informed care (TIC) into HIV services. As part of the quantitative phase of an explanatory sequential mixed-methods study, we assessed individual and clinic-wide support (using the Attitudes Related to Trauma-informed Care-45 (ARTIC-45)) and factors influencing TIC support through surveys with 152 administrators, providers, and staff from 38 Ryan White Clinics (RWCs) in the Southeastern US. Mean responses to the ARTIC-45 Personal and System Support Subscales were 5.18 (SE = 0.09; range 1-7) and 4.45 (SE = 0.16; range 1-7), respectively. In bivariate analysis, higher personal and system support were associated with strong clinic leadership culture (personal support: β = 0.08, t-value = 2.66, p = 0.009; system support: β = 0.16, t-value = 4.71, p < 0.001) and lower staff burnout (personal support: β=-0.05, t-value=-3.10, p = 0.002; system support: β=-0.07, t-value=-3.63, p < 0.001). System support was also associated with rural clinic setting (β = 0.61, t-value = 2.34, p = 0.021), strong staff culture (β = 0.14, t-value = 4.70, p = < 0.001), and resource availability (β = 0.16, t-value = 5.76, p < 0.001), and negatively associated with academic clinic setting (β=-0.52, t-value=-2.25, p = 0.026). Thus, while there is encouraging individual support for TIC, RWCs need tools (training and/or resources) to foster leadership and staff culture and trauma support to enable their transition to trauma-informed HIV care.

ANEW Project to Develop and Support Rural Primary Practice

South Dakota is one of the nation’s most rural and frontier states and has the highest proportion of rural dwellers in the Midwest. Many of the state’s counties suffer from provider shortages, with nurse practitioners increasingly being called upon to fill the role of the primary care provider in clinics and critical access hospitals. However, family nurse practitioner (FNP) education programs are not required to provide the training and skills necessary to meet the unique challenges of rural practice.&#x0D; An Upper Midwest land grant university prepares both masters and doctoral FNP students to fill primary care provider needs in South Dakota and the surrounding region. The purpose and scope of this two-year Advanced Nursing Education Workforce (ANEW) project was to enhance an existing academic/practice partnership to prepare primary care advanced practice registered nursing (APRN) students for practice in rural and/or underserved settings in the state and region. The ANEW project provided FNP students with a longitudinal primary care clinical traineeship experience in rural clinical settings.&#x0D; Trainees benefited from traineeship funds, learning advanced procedures and skill concepts through attendance at a series of educational workshops, and job placement efforts postgraduation. The ANEW project also provided for a comprehensive preceptor development collaborative designed to enhance competence and confidence for independent rural practice and facilitate job placement in rural communities after graduation.&#x0D; This project strengthened the quality of FNP education through an academic/practice partnership which resulted in a symbiotic, synergistic relationship to address rural work force supply and the identification of the knowledge and skills needed for current and future rural healthcare providers.&#x0D; Keywords: family nurse practitioner, education, preceptor, academic, practice partnership, rural primary healthcare, healthcare provider shortage&#x0D; DOI: https://doi.org/10.14574/ojrnhc.v21i1.649

Foldscope: A smartphone based diagnostic tool for fungal keratitis.

Purpose:Smartphone-based microscopy tool like foldscope (FS) may serve the purpose of a low-cost diagnostic alternative to the compound light microscope especially in areas with limited resources. The purpose of this study was to detect fungal pathogens causing keratitis on direct smear by smartphone-mounted FS and to evaluate the efficacy of FS against routine compound light microscope (CLM).Methods:The prospective study was conducted at a tertiary eye care center from September 2019 to March 2020. The study included 60 smear examinations (Gram stain [GM] n = 30, Lactophenol Cotton Blue [LCB] n = 30) to detect fungal pathogens from corneal scraping material of clinically suspected fungal keratitis (FK) cases. The diagnostic utility of FS was compared with CLM for both GM and LCB wet mount. Data collected were used to quantify the agreement using Cohen’s kappa between CLM and FS imaging.Results:Forty-six samples out of 60 were positive for fungi using CLM. GM stain and LCB showed 22/30 (73.33%) and 24/30 (80%) positive results with CLM, respectively. Moderate agreement (0.49) was observed between CLM and FS with the smartphone method. LCB mount showed high specificity of 1.00 over 0.87 of GM stain for FS with the smartphone.Conclusion:Direct smear can be an early and sensitive measure to diagnose FK other than clinical suspicion. The smartphone-mounted FS has limited sensitivity as an alternative to CLM, but excellent specificity in the present study for FK. The FS as a smartphone-based diagnostic tool is simple, portable, and inexpensive in resource-constrained rural or remote clinical and public health settings in the absence of CLM and other higher diagnostic modalities.

Evaluation of a clinical pharmacist team-based telehealth intervention in a rural clinic setting: a pilot study of feasibility, organizational perceptions, and return on investment

BackgroundRemote, centralized clinical pharmacist services provided by board-certified clinical pharmacists have been shown to effectively assist in chronic disease management. We assess the feasibility of implementing a pharmacist-led, remote, centralized pharmacy service to improve A1c levels in patient with diabetes in a rural clinic setting.MethodsThis was a non-randomized pilot and feasibility study. Participants were enrolled in a pharmacist-led telehealth intervention service, with data prior to enrollment used as baseline data for control. To be included, patients needed to have A1c readings of greater than 7% to be considered uncontrolled. A1c changes were reported for two groups based on A1c ranges: between 7 and 10% and ≥ 10%. Clinical pharmacists and clinical pharmacy interns initiated contact with patients via telephone communication and managed the patients remotely. The following outcomes were evaluated: organization perceptions (patients, providers, and clinic staff), changes in A1c, medication discrepancies, impact of an internally operated Patient Assistance Program, and potential return on investment (ROI).ResultsFifty-two patients were initially identified and referred to the service with 43 patients consenting to participate in the intervention. Patient and provider survey responses were recorded. In the initial analysis occurring during the first 3 to 5 months of the program, there was considerable improvement in diabetes control as measured by A1c. For patients with uncontrolled diabetes with a baseline A1c > 7% but less than < 10% and ≥ 10%, the intervention resulted in an A1c decrease of 0.57% and 2.55%, respectively. Clinical pharmacists and clinical pharmacy interns identified at least one medication discrepancy in 44% of patients, with number of discrepancies ranging from 1 to 5 per patient. At the conclusion of the study window, 42 potentially billable encounters were documented, which would have generated a net profit of $1140 USD, had they been submitted for reimbursement. Given the potential revenue generation, the service theoretically yields a ROI of 1.4 to 1.ConclusionsInitial results suggest that a pharmacist-led telehealth intervention has potential to decrease A1c levels in patients with diabetes, assist in identification of medication discrepancies, provide a positive return on investment for rural clinics, and potentially increase reimbursement for providers and clinics tasked with managing patients with uncontrolled diabetes.

Retaining graduates of non-metropolitan medical schools for practice in the local area: the importance of locally based postgraduate training pathways in Australia and Canada.

The objective of this study was to identify commonalities between one regionally based medical school in Australia and one in Canada regarding the association between postgraduate training location and a doctor's practice location once fully qualified in a medical specialty. Data were obtained using a cross-sectional survey of graduates of the James Cook University (JCU) medical school, Queensland, Australia, who had completed advanced training to become a specialist (a 'Fellow') in that field (response rate = 60%, 197 of 326). Medical education, postgraduate training and practice data were obtained for 400 of 409 (98%) fully licensed doctors who completed undergraduate medical education or postgraduate training or both at the Northern Ontario School of Medicine (NOSM), Ontario, Canada. Binary logistic regression used postgraduate training location to predict practice in the school's service region (northern Australia or northern Ontario). Separate analyses were conducted for medical discipline groupings of general/family practitioner, general specialist and subspecialist (JCU only). For JCU graduates, significant associations were found between training in a northern Australian hospital at least once during postgraduate training and current (2018) northern Australian practice for all three discipline subgroups: family practitioner (p<0.001; prevalence odds ratio (POR)=30.0; 95% confidence interval (CI): 6.7-135.0), general specialist (p=0.002; POR=30.3; 95%CI: 3.3-273.4) and subspecialist (p=0.027; POR=6.5; 95%CI: 1.2-34.0). Overall, 38% (56/149) of JCU graduates who had completed a Fellowship were currently practising in northern Australia. For NOSM-trained doctors, a significant positive effect of training location on practice location was detected for family practice doctors but not for general specialist doctors. Family practitioners who completed their undergraduate medical education at NOSM and their postgraduate training in northern Ontario had a statistically significant (p<0.001) POR of 36.6 (95%CI: 16.9-79.2) of practising in northern Ontario (115/125) versus other regions, whereas those who completed only their postgraduate training in northern Ontario (46/85) had a statistically significant (p<0.001) POR of 3.7 (95%CI: 2.1-6.8) relative to doctors who only completed their undergraduate medical education at NOSM (28/117). Overall, 30% (22/73) of NOSM's general speciality graduates currently practise in northern Ontario. The findings support increasing medical graduate training numbers in rural underserved regions, specifically locating full specialty training programs in regional and rural centres in a 'flipped training' model, whereby specialty trainees are based in rural or regional clinical settings with some rotations to the cities. In these circumstances, the doctors would see their regional or rural centre as 'home base' with the city rotations as necessary to complete their training requirements while preparing to practise near where they train.

Improving Discussion on Nutrition Topics in a Rural Clinic Setting Between Primary Care Physicians and Pediatric Patients

Abstract Objectives This research, conducted in rural under served southwest Virginia, determined outcomes for the Healthy People 2020 Nutrition and Weight Status Objective to assess implementation of provider nutrition education in office visits to promote nutrition as a component of routine preventive medicine. Methods The authors' prior research, clinical experiences, familiarity with the region, along with agency reports identified the collaborating clinic as representative of the health disparity region characterized by high childhood obesity rates. Researchers distributed a 14 item survey to participants consenting to an IRB approved protocol, responding anonymously to the paper survey by depositing their completed form in a locked box. Results Participants (n = 384; 80% providing valid responses) were parents or guardians of children 2 to 18 years of age visiting a local pediatrician's office. All responded to have medical insurance, 98% were the primary caregiver of the child and 74% received government aid. Most (77%) caregivers “find fun and interesting way to introduce new foods”. Most (79%) caregivers agreed their child “likes to eat fruits and vegetables”. Caregivers disagreed (84%) to, “A healthy child is a fat child.” Responses by caregivers to, “How often does your provider discuss nutrition topics with you?” were very often (25%); sometimes (32%); occasionally (33%); and never (11%). Responses to, ‘How often would you like your provider to discuss these topics with you?’ were very often (19%); sometimes (30%); occasionally (43%); and never (7%). There was little to no correlation to age of the child on how caregivers responded to “…does your provider discuss nutrition topics with you”? (r = 0.14) and “…would you like your provider to discuss these topics with you?” (r = 0.12). Correlations indicated little to no relationship to children's ages. Conclusions Caregivers in a southwest Virginia clinic reported receiving nutrition education services at a rate exceeding Healthy People 2020 goals and recognized healthy nutrition guidelines. Our findings are consistent with our previous studies, confirming future interventions should target translation of caregivers’ knowledge to children's behaviors to ultimately improve healthy childhood development. This study was sponsored by a Paul Scholarship Program Award, Rachel Horn Mullins OMSIV. Funding Sources N/A.

Combination of Simple Diagnostic Tests to Detect Primary Angle Closure Disease in a Resource-constrained Region

ABSTRACTPurpose: To report on diagnostic accuracy of van Herick (vH) technique performed by a vision technician (VT) as well as on efficacy of a combination of vH technique and central anterior chamber depth (ACD) in detection of primary angle closure disease.Methods: Data was obtained from two cohorts; rural clinic setting (n = 111), and rural population-based research setting (n = 888). Van Herick grading was performed by a VT in first cohort and a glaucoma specialist in second cohort. A reference standard four-mirror gonioscopy was performed by a glaucoma specialist in both cohorts. We did preferential sampling. Cut-off levels for vH technique and central ACD were grade 2 and 25th percentile value, respectively. Data from one eye per participant was analyzed.Results: Three hundred and forty (34%) eyes were gonioscopically occludable. Area under receiver operating characteristic curve (95% confidence interval) for vH test was 0.83 (0.76, 0.9) and 0.81 (0.78, 0.84) in first and second cohorts, respectively. Simultaneous testing achieved sensitivity of 87.8% while sequential testing achieved specificity of 99.3%. Negative predictive value* of simultaneous testing was 98.3% compared to 96.6% of vH technique while positive predictive value* of sequential testing was 86% compared to 49.3% of vH technique. (*at 10% prevalence of gonioscopically occludable angle)Conclusions: Diagnostic accuracy of vH grading was similar when performed by a VT and a glaucoma specialist. While test combination was effective to rule in, vH technique may suffice to rule out the disease. Implications of these findings for resource-constrained regions are discussed.

Early and Late Virologic Failure After Virologic Suppression in HIV-Infected Asian Children and Adolescents.

Virologic failure is a major threat to maintaining effective combination antiretroviral therapy, especially for children in need of lifelong treatment. With efforts to expand access to HIV viral load testing, our understanding of pediatric virologic failure is evolving. An Asian cohort in 16 pediatric HIV services across 6 countries. From 2005 to 2014, patients younger than 20 years who achieved virologic suppression and had subsequent viral load testing were included. Early virologic failure was defined as a HIV RNA ≥1000 copies per milliliter within 12 months of virologic suppression, and late virologic as a HIV RNA ≥1000 copies per milliliter after 12 months following virologic suppression. Characteristics at combination antiretroviral therapy initiation and virologic suppression were described, and a competing risk time-to-event analysis was used to determine cumulative incidence of virologic failure and factors at virologic suppression associated with early and late virologic failure. Of 1105 included in the analysis, 182 (17.9%) experienced virologic failure. The median age at virologic suppression was 6.9 years, and the median time to virologic failure was 24.6 months after virologic suppression. The incidence rate for a first virologic failure event was 3.3 per 100 person-years. Factors at virologic suppression associated with late virologic failure included older age, mostly rural clinic setting, tuberculosis, protease inhibitor-based regimens, and early virologic failure. No risk factors were identified for early virologic failure. Around 1 in 5 experienced virologic failure in our cohort after achieving virologic suppression. Targeted interventions to manage complex treatment scenarios, including adolescents, tuberculosis coinfection, and those with poor virologic control are required.

A case of Gitelman syndrome: our experience with a patient treated in clinical practice on a local island.

Background: Gitelman syndrome (GS) is an autosomal recessive salt-losing renal tubulopathy resulting from mutations in the thiazide-sensitive Na-Cl cotransporter (NCC) gene. Notably, lack of awareness regarding GS and difficulty with prompt diagnosis are observed in clinical practice, particularly in rural settings.Case presentation: We report a case of a 48-year-old man with GS who presented to a local clinic on a remote island. Occasional laboratory investigations incidentally revealed a reduced serum potassium level of 2.6 mmol/L. A careful medical interview revealed episodes of intermittent paralysis of the lower extremities and muscular weakness for >30 years. Subsequent laboratory investigations revealed hypomagnesemia, hypocalciuria, and hypokalemic metabolic alkalosis. Based on the patient’s history, clinical presentation, and laboratory investigations, we suspected GS. Genetic testing revealed a rare homozygous in-frame 18 base insertion in the NCC gene that might have resulted from the founder effect, consequent to his topographically isolated circumstances.Conclusion: More case studies similar to our study need to be added to the literature to gain a deeper understanding of the functional consequences of this mutation and to establish optimal management strategies for this condition, particularly in rural clinical settings.

Smartphone Use and Professional Communication Among Medical Residents in Primary Care.

The rapid integration and evolution of technology has impacted remote data access, dissemination of medical information, and use of applications (apps) for patient care and treatment. The aims of this study were to (1) describe patterns of smartphone use by residents in a rural clinical setting (both clinical and communicative patterns), (2) examine residents' perceptions of benefits of smartphone use, and (3) determine whether there is an association between smartphone use and organizational attributes. Self-report surveys were administered to family medicine and internal medicine residents (N=39). Descriptive analyses indicated that primary care residents used their pagers more often for communication, but also believed smartphones were more efficient, and increased accessibility and timeliness of attending physicians. Additional analyses suggested that smartphone use was not associated with chaos, and was negatively correlated with history of culture change within the organization. Overall, use of smartphones among medical residents is relatively common, and residents believe there are numerous benefits of use. Future research might consider causal reasons why there is reduced communication among primary care practices with a history of change.

Practical experience implementing supervised exercise therapy for peripheral artery disease in urban and rural Minnesota

Although numerous studies have demonstrated the effectiveness of treadmill-based supervised exercise therapy (SET) in improving pain-free and total walking distance and quality of life in individuals with peripheral artery disease (PAD), historically this treatment has not been widely available outside of research settings. Last year’s decision by Centers for Medicare and Medicaid Services (CMS) to cover up to 36 sessions of SET over a 12-week period for beneficiaries with symptomatic PAD (1) has enabled greater implementation of this effective treatment in clinical settings. An additional 36 sessions are available over an extended period with a new referral from a health care provider. At the University of Minnesota, we have been implementing SET in both urban and rural clinical settings since 2015. In this column, we provide examples of two patients who have participated in SET through these programs, highlighting their experiences and tips for those considering implementing SET for individuals with PAD at their own institutions.