PURPOSE Rural low-income African American patients with diabetes have traditionally poorer clinical outcomes and limited access to state-of-the-art diabetes care. We determined the effectiveness of a redesigned primary care model on patients' glycemic, blood pressure, and lipid level control. METHODSIn 3 purposively selected, rural, fee-for-service, primary care practices, African American patients with type 2 diabetes received point-of-care education, coaching, and medication intensifi cation from a diabetes care management team made up of a nurse, pharmacist, and dietitian. In 5 randomly selected control practices matched for practice and patient characteristics, African American patients received usual care. Using univariate and multivariate adjusted models, we evaluated the effects of the intervention on intermediate (median 18 months) and long-term (median 36 months) changes in glycated hemoglobin (hemoglobin A 1c ) levels, blood pressure, and lipid levels, as well as the proportion of patients meeting target values.RESULTS Among 727 randomly selected rural African American diabetic patients (368 intervention, 359 control), intervention patients had a signifi cantly greater reduction in mean hemoglobin A 1c levels at intermediate (-0.5 % vs -0.2%; P <.05) and long-term (-0.5% vs -0.10%; P <.005) follow-up in univariate and multivariate models. The proportion of patients achieving a hemoglobin A 1c level of less than 7.5% (68% vs 59%, P <.01) and/or a systolic blood pressure of less than 140 mm Hg (69% vs 57%, P <.01) was also signifi cantly greater in intervention practices in multivariate models.CONCLUSION Redesigning care strategies in rural fee-for-service primary care practices for African American patients with established diabetes results in significantly improved glycemic control relative to usual care.

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BACKGROUND Duodenal-jejunal bypass (DJB) has been shown to reverse type 2 diabetes (T2DM) in Goto-Kakazaki (GK) rats, a rodent model of non-obese T2DM. Skeletal muscle insulin resistance is a hallmark decrement in T2DM. The aim of the current work was to investigate the effects of DJB on skeletal muscle insulin signal transduction and glucose disposal. It was hypothesized that DJB would increase skeletal muscle insulin signal transduction and glucose disposal in GK rats. METHODS DJB was performed in GK rats. Sham operations were performed in GK and non-diabetic Wistar-Kyoto (WKY) rats. At two weeks post-DJB, oral glucose tolerance (OGTT) was measured. At three weeks post-DJB, insulin-induced signal transduction and glucose disposal were measured in skeletal muscle. RESULTS In GK rats and compared to Sham operation, DJB did not: 1) improve fasting glucose or insulin; 2) improve OGTT; or 3) increase skeletal muscle insulin signal transduction or glucose disposal. Interestingly, skeletal muscle glucose disposal was similar between WKY-Sham, GK-Sham, and GK-DJB. CONCLUSIONS Bypassing of the proximal small intestine does not increase skeletal muscle glucose disposal. The lack of skeletal muscle insulin resistance in GK rats questions whether this animal model is adequate to investigate the etiology and treatments for T2DM. Additionally, bypassing of the foregut may lead to different findings in other animal models of T2DM as well as in T2DM patients.

Fractures of the proximal fifth metatarsal are relatively common and can be treated with a variety of treatment modalities. The goals of the current study were to answer the following questions: (1) Is there a difference in functional outcomes with different nonoperative treatment modalities for avulsion and Jones fractures? (2) What is the long-term functional impairment? This study included 53 patients who were treated for proximal fifth metatarsal fracture at 1 university health care system between 2004 and 2013. Treatment methods included shoe modification, cast, and boot. Patients completed a telephone questionnaire that included selected questions from the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS). Treatment groups were stratified as shoe modification or immobilization, and the results of the MODEMS survey were compared. At most recent follow-up, no significant difference was found between the 2 patient groups (P=.062) for self-reported effects of the injury on work and quality of life. No significant difference was found for frequency of use of pain medication (P=.157), patient satisfaction with current symptoms (P=.633), ambulatory status (P=.281), or pain level with strenuous activity (P=.772). Obese patients were more likely to have severe pain with strenuous activity (P=.015). Most (87%) patients were able to ambulate without the need for assistive devices. Of the study patients, 79% could wear dress shoes, excluding high heels, comfortably. The findings showed that patients who were treated with a variety of nonoperative methods for closed proximal fifth metatarsal fracture had acceptable functional outcomes, regardless of treatment method. [Orthopedics. 2017; 40(6):e1030-e1035.].

Objectives:Patella fracture is a rare complication after medial patellofemoral ligament (MPFL) reconstruction. Though many of the cases in the literature have been precipitated by trauma, the surgical factors that may lead to a higher risk of fracture are not well understood. The purpose of our study was to determine if transosseous tunnels that exit through the anterior cortex of the patella, and transverse bone tunnels have lower tensile load to failure as compared to control, and may predispose to post-operative patellar fracture.Methods:Fresh-frozen cadaveric human patellas were randomized to one of three groups: a control group with unmodified intact patellas, a group with two transverse tunnels (TT) drilled in the superior third of the patella that did not violate the anterior cortex, and a group with two transversetunnels that breach anterior cortex of the patella (PA). Patellas were connected to a freeze clamp mechanism via the remaining quadriceps and patellar tendons. A load cell was connected in series with the quadriceps clamp to measure maximum load to failure with a maximum load of 9000N. The angle of pull was fixed at 45 degrees, with the patella set in the trochlear groove of a composite synthetic femur. Patellas were cyclically loaded to 500 N for a total of 100 cycles. Specimens that did not fail during cyclic loading were then loaded to failure defined as fracture or tendon rupture. At failure, fluoroscopy was used to confirm a fracture if present and maximum load was recorded. The mean and standard deviation (STD) for each group were recorded. ANOVA and Student-T tests were used to identify significant differences between groups.Results:A total of 26 patellas were randomized and tested in this study. There were 12 male and 14 female patellas ranging in age from 37-95 years. There was no significant difference in the average age among the groups (Mean = 71.4 years, STD = 11.5 years, P =0.96). None of the patellas failed during cyclic loading alone. Control, TT and PA groups failed at 1915 N (STD= 508N), 1901 N (STD= 884N), and 1640 N (STD= 625N) respectively. This represents a 14% difference in means between Control and PA and Control and TT tunnels. There was no statistically significant difference between control and TT (p=.969), control and PA (p=.321), and TT and PA (p=.488). Subset analysis of fractures only through bone tunnels did not affect the significance.Conclusion:Our results show that breeching of the anterior cortex and transosseous tunnels that do not breach the anterior cortex during MPFL reconstruction do not significantly decrease the load to failure when compared to native patellas and, thus, may not pose an increased risk for patellar fracture. Further research is needed to analyze if other surgical factors may predispose to this complication.