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Prescription opioids can treat acute pain in primary care but have potential for unsafe use and progression to prolonged opioid prescribing.To compare clinician-facing interventions to prevent unsafe opioid prescribing in opioid-naive primary care patients with acute noncancer pain.We conducted a multisite, cluster-randomized, 2 × 2 factorial, clinical trial in 3 health care systems that comprised 48 primary care practices and 525 participating clinicians from September 2018 through January 2021. Patient participants were opioid-naive outpatients, 18 years or older, who presented for a qualifying clinic visit with acute noncancer musculoskeletal pain or nonmigraine headache.Practices randomized to: (1) control; (2) opioid justification; (3) monthly clinician comparison emails; or (4) opioid justification and clinician comparison. All groups received opioid prescribing guidelines via the electronic health record at the time of a new opioid prescription.Primary outcome measures were receipt of an initial opioid prescription at the qualifying clinic visit. Other outcomes were opioid prescribing for more than 3 months and a concurrent opioid/benzodiazepine prescription over 12-month follow-up.Among 22 616 enrolled patient participants (9740 women [43.1%]; 64 American Indian/Alaska Native [0.3%]; 590 Asian [2.6%], 1120 Black/African American [5.0%], 1777 Hispanic [7.9%], 225 Native Hawaiian/Pacific Islander [1.0%], and 18 981 White [83.9%] individuals), the initial opioid prescribing rates at the qualifying clinic visit were 3.1% in the total sample, 4.2% in control, 3.6% in opioid justification, 2.6% in clinician comparison, and 1.9% in opioid justification and clinician comparison. Compared with control, the adjusted odds ratio (aOR) for a new opioid prescription was 0.74 (95% CI, 0.46-1.18;In this cluster randomized clinical trial, comparison emails decreased the proportion of opioid-naive patients with acute noncancer pain who received an opioid prescription, progressed to treatment with long-term opioid therapy, or were exposed to concurrent opioid and benzodiazepine therapy. Health care systems can consider adding clinician-targeted nudges to other initiatives as an efficient, scalable approach to further decrease potentially unsafe opioid prescribing.ClinicalTrials.gov Identifier: NCT03537573.

Background: Implantable cardioverter-defibrillators (ICDs) are indicated in patients with left ventricular ejection fraction ≤35%, but many eligible patients do not receive this therapy. In this cluster randomized trial, we investigated the impact of a best practice alert (BPA) through the electronic health records on the rates of electrophysiology referrals, ICD implantations, and all-cause mortality in severe cardiomyopathy patients. Methods and Results: Providers in the Heart and Vascular Institute (n=106) and in General Internal Medicine (n=89) were randomized to receive or not receive a BPA recommending consideration for ICD implantation. Patients belonging to the BPA and no BPA groups of providers were followed to the end points of electrophysiology referrals, ICD implantations, and all-cause mortality. Between 2013 and 2015, patients with reduced left ventricular ejection fraction were managed by 93 providers in the BPA (n=997 patients) and 102 providers in the no BPA (n=909 patients) groups. Patients in the 2 groups had comparable baseline characteristics. After a median follow-up of 36 months, 638 (33%) patients were referred to electrophysiology, 536 (27%) received an ICD, and 445 (23%) died. Patients in the BPA group were more likely to be referred to electrophysiology (hazard ratio=1.23; P =0.026), to receive ICD therapy (hazard ratio=1.35; P =0.006), and exhibited a trend towards slightly lower mortality (hazard ratio=0.85; P =0.091). Conclusions: Delivering a BPA through the electronic health record recommending to providers consideration of ICD implantation when the left ventricular ejection fraction is ≤35% improves the rates of electrophysiology referrals and ICD therapy in patients with severe left ventricular dysfunction.

BACKGROUND Online tools are a convenient and effective method of delivering lifestyle interventions to obese adult primary care patients. A referral model allows physicians to efficiently direct their patients to the intervention during a primary care visit. However, little is known of physicians’ perspectives and utilization of the referral model for an online lifestyle modification intervention. OBJECTIVE The aim was to evaluate the response of primary care providers (PCPs) to a referral model for implementing a year-long online intervention for weight loss to obese adult patients. METHODS The PCPs at six primary care clinics were asked to refer adult obese patients to a year-long online lifestyle intervention providing self-management support for weight loss. Following the 1-year intervention, all providers at the participating practices were surveyed regarding their views of the program. Respondents completed survey items assessing their attitudes regarding the 1-year intensive weight loss intervention and identifying resources they would find helpful for assisting patients with weight loss. Referring physicians were asked about their level of satisfaction with implementing the counseling services using standard electronic health record referral processes. Attitudes toward obesity counseling among referring and nonreferring providers were compared. Impressions of how smoothly the referral model of obesity treatment integrated with the clinical workflow were also quantified. RESULTS Of the 67 providers who completed the surveys, nonreferring providers (n=17) were more likely to prefer counseling themselves (P=.04) and to report having sufficient time to do so (P=.03) than referring providers (n=50) were. Nonreferring providers were more likely to report that their patients lacked computer skills (76%, 13/17 vs 34%, 17/50) or had less access to the Internet (65%, 11/17 vs 32%, 16/50). CONCLUSIONS Understanding providers’ views and barriers regarding the integration of online tools will facilitate widespread implementation of an online lifestyle modification intervention.

Introduction: Primary care physicians are uniquely positioned to provide counselling for weight loss, yet lifestyle habits of primary care patients with recent, intentional weight loss are unclear. Our objective was to characterize diet and exercise habits in primary care patients with recent, intentional weight loss, comparing those with greater (≥10%) to those with lesser (5 to Methods: This cross-sectional analysis of baseline data from a weight loss maintenance clinical trial in a primary care setting included patients,18-75 years old, with ≥5% intentional weight loss via lifestyle change in the past 2 years. Recent weight loss was confirmed with medical records. Dietary habits were measured by the Connor Diet Habits Survey. Results: Participants (n=192, 74% female, 87% white) had mean (SD) age 53 (12) years, body mass index 30.4 (5.9) kg/m 2 , and recent weight loss of 11 (8) %. Participants had a high burden of comorbidities: high blood pressure (50%), dyslipidemia (43%), diabetes (14%), and cardiovascular disease (10%). Participants reported high median intake of fruits and vegetables (5 servings/day), and low intake of fried foods (1 servings/wk), desserts (1 serving/wk) and sugar-sweetened beverages (0 serving/wk) (see Table) . Participants ate at restaurants on average twice/wk and most drank skim milk. Those with greater weight loss had higher intakes of fruits and vegetables (p=0.04) and low fat foods/recipes (p=0.02); other dietary habits were not related to amount of recent weight loss (see Table ). Conclusions: Despite the plethora of studies that support and refute a variety of dietary recommendations to promote weight loss, dietary habits in primary care patients with a high burden of comorbidities and recent, intentional weight loss were consistent with conventional wisdom including: more fruits and vegetables, limited added sugars, and more low fat foods and recipes. Future research should test the effects of this eating pattern in a primary care setting for weight loss and maintenance.

With the increasing demand on the world’s power grids, now more then ever it is important to keep power plant condensers, feedwater heaters and balance of plant heat exchangers running at peak efficiency. While it is well known that keeping these units clean is important for maximizing power output, so too is monitoring each unit’s tube integrity and taking corrective action to prevent tube failure. The best way to monitor a unit’s tube integrity, detect patterns of tube wear and damage, and determine the specific wear and damage to a particular tube is through Non-Destructive Testing. Depending on the tube material, the best Non-Destructive Testing method to employ would be either Eddy Current Testing, Remote Field Testing or other variations of these electromagnetic techniques. This paper will discuss the science behind Eddy Current and Remote Field Testing, how they differ and which one to select depending on the situation. It will look at the construction of the probes and how they work. It will explain the difference between use of a single frequency or multiple frequencies and the advantages of multi-frequency testing. The paper will also identify the necessary procedure for a successful Non-Destructive Test, including the types of tubes that can be tested and tube preparation.

Whether a power plant chooses an air-cooled condenser (ACC) because of siting issues, or because of changing environmental laws, the utilization of this dry cooling option has seen a dramatic level of growth over the past decade around the world. Like the steam surface condenser, the ACC is prone to tube fouling, albeit to the external finned tube surfaces instead of internal surfaces. This tube fouling can dramatically impact the performance of the ACC causing plant heat rate to suffer, increasing the consumption of fuel, increasing CO2 emissions and reducing megawatt output. In addition to fouling, ACC units are exposed to dramatic swings in ambient temperature. Units exposed to multiple freeze-thaw cycles each year often develop numerous points of inleakage into the vacuum boundary, also causing unit efficiency to suffer. Unlike the steam surface condenser, the ACC can be elevated at 60–75 feet in the air which poses considerable challenges to locating and repairing the sources of leaks. This paper will examine the performance improvements realized by the Yellowstone Power Plant, located in Billings, Montana on their ACC unit after utilizing an innovative cleaning technology as well as the use of a new finned tube “sleeve” to repair leaking tubes.

Generating companies lose hundreds of millions of dollars annually to problems related to condenser and heat exchanger fouling, corrosion and tube leaks. In fact, the Condenser Tube Failure Control Program of Electric Power Research Institute (EPRI, Matthews, J.) disclosed that condenser tube failures contributed to almost 25,000 outages nationwide during a recent four year period and continue to be one of the most pressing issues related to plant output and availability. To adequately prevent condenser tube failures, effective condenser tube cleaning and nondestructive testing must be performed. Effective tube cleaning should ideally remove all deposits, leaving only the cleanest metal surface. Once tubes are free of fouling deposits, multi-frequency eddy current testing should be used to establish the overall integrity of condenser tubes. Plugging is recommended for the tubes with poor integrity that put condenser reliability at risk. If tube failures do occur, advances in tracer gas leak detection, specifically those using sulfur hexafluoride and helium, can be used to quickly locate sources of circulating water tube leakage and return the unit to reliable operation. This paper will examine implications of condenser tube fouling and failure, and the available nondestructive technologies for their prevention and correction.Copyright © 2009 by ASME

The purpose of this qualitative study was to explore perceptions of people with diabetes about their experience of living with and managing their diabetes.This study was part of a larger study of patients with diabetes who used a novel computer portal system for access to information about diabetes and to their health care providers for enhanced communication. The research method used for this portion of the study was grounded theory methodology, a particular kind of qualitative research method.A central theme generated from the data was "normalizing an identity as a person with diabetes." The participants described themselves as diabetic; they took on an identity in which having diabetes was central. They struggled with how to become "a person with diabetes" rather than a "diabetic person."For people who are diagnosed with diabetes, there is a struggle to become a person with diabetes rather than a diabetic person and to manage the lifestyle changes that are mandated by this role/identity. One way of dealing or coping with this new identity is to begin to "normalize" these lifestyle changes-to view them as healthy living for all people, those with and without diabetes. This will then have implications for interventions-encouraging healthy lifestyles among people with diabetes rather than emphasizing that people with diabetes are "different from" the general population.