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Objective: To assess for differences in patient care outcomes in the primary care setting for patients assigned to an independent practice panel (IPP) or a shared practice panel (SPP). Patients and Methods: We retrospectively reviewed the electronic health records of patients of 2 Mayo Clinic family medicine primary care clinics from January 1, 2019 to December 31, 2019. Patients were assigned to either an IPP (physician or advanced practice provider [APP]) or an SPP (physician and ≥1 APP). We assessed 6 measures of quality care and compared them between IPP and SPP groups: diabetes optimal care, hypertension control, depression remission at 6 months, breast cancer screening, cervical cancer screening, and colon cancer screening. Results: The study included 114,438 patients assigned to 140 family medicine panels during the study period: 87 IPPs and 53 SPPs. The IPP clinicians showed improved quality metrics compared with the SPP clinicians for the percentage of assigned patients achieving depression remission (16.6% vs 11.1%; P

Abstract Background Estimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as ‘accidents,’ and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia. Methods Cost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention’s (CDC’s) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019. Results 40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%—from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and − 1%, respectively. Conclusion The scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs—fiscal, social, and personal—incurred by deaths due to self-injurious behaviors.

Intraosseous schwannomas are rare benign tumors that most often occur at the mandible or sacrum. We present an unusual case of a bilobed schwannoma of the distal humerus with both intraosseous and extraosseous components. The extraosseous component was non-enhancing on initial MRI and enhanced on a subsequent MRI obtained after biopsy. We hypothesize that this change was attributable to decreased intra-tumoral pressure secondary to biopsy-related disruption of the tumor capsule.

Abstract Background Dental implants are considered the gold standard replacement for missing natural teeth. The successful clinical performance of dental implants is due to their ability to osseointegrate with the surrounding bone. Most dental implants are manufactured from Titanium and it alloys. Titanium does however have some shortcomings so alternative materials are frequently being investigated. Effective preclinical studies are essential to transfer the innovations from the benchtop to the patients. Many preclinical studies are carried out in the extra-oral bones of small animal models to assess the osseointegration of the newly developed materials. This does not simulate the oral environment where the dental implants are subjected to several factors that influence osseointegration; therefore, they can have limited clinical value. Aim This study aimed to develop an appropriate in-vivo model for dental implant research that mimic the clinical setting. The study evaluated the applicability of the new model and investigated the impact of the surgical procedure on animal welfare. Materials and methods The model was developed in male New Zealand white rabbits. The implants were inserted in the extraction sockets of the secondary incisors in the maxilla. The model allows a split-mouth comparative analysis. The implants’ osseointegration was assessed clinically, radiographically using micro-computed tomography (µ-CT), and histologically. A randomised, controlled split-mouth design was conducted in 6 rabbits. A total of twelve implants were inserted. In each rabbit, two implants; one experimental implant on one side, and one control implant on the other side were applied. Screw-shaped implants were used with a length of 8 mm and a diameter of 2 mm. Results All the rabbits tolerated the surgical procedure well. The osseointegration was confirmed clinically, histologically and radiographically. Quantitative assessment of bone volume and mineral density was measured in the peri-implant bone tissues. The findings suggest that the new preclinical model is excellent, facilitating a comprehensive evaluation of osseointegration of dental implants in translational research pertaining to the human application. Conclusion The presented model proved to be safe, reproducible and required basic surgical skills to perform.

Abstract Background Interpersonal and Communication Skills (ICS) and Professionalism milestones are challenging to evaluate during medical training. Paucity in proficiency, direction and validity evidence of assessment tools of these milestones warrants further research. We validated the reliability of the previously-piloted Instrument for Communication skills and Professionalism Assessment (InCoPrA) in medical learners. Methods This validity approach was guided by the rigorous Kane’s Framework. Faculty-raters and standardized patients (SPs) used their respective InCoPrA sub-component to assess distinctive domains pertinent to ICS and Professionalism through multiple expert-built simulated-scenarios comparable to usual care. Evaluations included; inter-rater reliability of the faculty total score; the correlation between the total score by the SPs; and the average of the total score by two-faculty members. Participants were surveyed regarding acceptability, realism, and applicability of this experience. Results Eighty trainees and 25 faculty-raters from five medical residency training sites participated. ICC of the total score between faculty-raters was generally moderate (ICC range 0.44–0.58). There was on average a moderate linear relationship between the SPs and faculty total scores (Pearson correlations range 0.23–0.44). Majority of participants ascertained receiving a meaningful, immediate, and comprehensive patient-faculty feedback. Conclusions This work substantiated that InCoPrA was a reliable, standardized, evidence-based, and user-friendly assessment tool for ICS and Professionalism milestones. Validating InCoPrA showed generally-moderate agreeability and high acceptability. Using InCoPrA also promoted engaging all stakeholders in medical education and training–faculty, learners, and SPs—using simulation-media as pathway for comprehensive feedback of milestones growth.

Objective: To determine the relationship of the emotional exhaustion domain of burnout with care team composition in a Midwestern primary care practice network. Participants and Methods: We studied 420 family medicine clinicians (253 physicians and 167 nurse practitioners/physician assistants [NP/PAs]) within a large integrated health system throughout 59 Midwestern communities. The observational cross-sectional study utilized a single-question clinician self-assessment of the emotional exhaustion domain of burnout on a scale of 0 (never) to 6 (daily) conducted between March 1 and April 2, 2018, and administrative data collected between January 1, 2017, and December 31, 2017. We used a multivariable linear mixed model for data analysis, adjusted for clinical- and team-level factors, including clinician sex, panel size and complexity, clinician type (physician or NP/PA), clinician full-time equivalent (FTE), total care team panel size, and number of clinicians on the care team. Results: Among 217 survey respondents (51.7%), the median frequency of the emotional exhaustion domain of burnout was once per week. Adjusted analyses revealed that a greater proportion of physician FTE on the care team was associated with a lower emotional exhaustion domain of burnout among individual clinicians (P=.05). Female clinicians had a higher emotional exhaustion domain of burnout than male clinicians (P=.05). None of the other variables in the model were associated with emotional exhaustion. Conclusion: Primary care teams containing both physicians and NP/PAs had lower levels of emotional exhaustion with increasing proportion of physician FTE. More work is needed to explore what other variables may be associated with burnout in primary care team-based practices.

Abstract Objective: To identify important risk factors for carbapenem-resistant Enterobacterales (CRE) infections among hospitalized patients. Design: We utilized a case–case–control design that compared patients with CRE infections to patients with carbapenem-susceptible Enterobacterales (CSE) infections and randomly selected controls during the period from January 2011 through December 2016. Setting: The study population was selected from patients at a large metropolitan tertiary-care and instructional medical center. Patients: Cases of CRE were defined as initial admission of adults diagnosed with a bacterial infection of an Enterobacterales species resistant clinically or through sensitivity testing to carbapenems 48 hours or more after admission. Cases of CSE were selected from the same patient population as the CRE cases within a 30-day window for admission, with diagnostic pathogens identified as susceptible to carbapenems. Controls were defined as adult patients admitted to any service within a 30-day window from a CRE case for >48 hours who did not meet either of the above case definitions during that admission. Results: Antibiotic exposure within 90 days prior to admission and length of hospital stay were both associated with increased odds of CRE and CSE infections compared to controls. Patients with CRE infections had >18 times greater odds of prior antibiotic exposure compared to patients with CSE infections. Conclusions: Antibiotic exposure and increased length of hospital stay may result in increased patient risk of developing an infection resistant to carbapenems and other β-lactams.

Background The number of pre-anesthetic medical evaluations (PAMEs) being conducted in primary care is increasing. Due to the COVID-19 pandemic, the use of telemedicine has surged, providing a feasible way to conduct some of these visits. This study aimed to identify patient-related factors where a face to face (FTF) evaluation is indicated, measured by the need for pre-operative testing. Methods A retrospective chart review was conducted on patients age ≥ 18 years who had a PAME between January 2019–June 2020 at a rural primary care clinic in Southeast Minnesota. Data collected included age, gender, Charlson Comorbidity Index Score, medications, revised cardiac risk index (RCRI), smoking status, exercise capacity, body mass index, and pre-operative testing. Logistical regression modeling for odds ratios of outcomes was performed. Results 254 patients were included, with an average age of 64.1 years; 43.7% were female. Most were obese (mean BMI 31.6), non-smoking (93.7%) with excellent functional capacity (87.8% ≥ 5 METs). 76.8% of the planned surgeries were intermediate or high risk. 35.0% ( n = 89) of visits resulted in medication adjustments and 76.7% ( n = 195) in pre-operative testing. Age ≥ 65 years, ≥7 current medications, and diabetes all significantly increased the odds of requiring pre-operative testing ( P

ABSTRACT Rapid synovial fluid-induced aggregation of Staphylococcus aureus is currently being investigated as an important factor in the establishment of periprosthetic joint infections (PJIs). Pathogenic advantages of aggregate formation have been well documented in vitro, including recalcitrance to antibiotics and protection from host immune defenses. The objective of the present work was to determine the strain dependency of synovial fluid-induced aggregation by measuring the degree of aggregation of 21 clinical S. aureus isolates cultured from either PJI or bloodstream infections using imaging and flow cytometry. Furthermore, by measuring attached bacterial biomass using a conventional crystal violet assay, we assessed whether there is a correlation between the aggregative phenotype and surface-associated biofilm formation. While all of the isolates were stimulated to aggregate upon exposure to bovine synovial fluid (BSF) and human serum (HS), the extent of aggregation was highly variable between individual strains. Interestingly, the PJI isolates aggregated significantly more upon BSF exposure than those isolated from bloodstream infections. While we were able to stimulate biofilm formation with all of the isolates in growth medium, supplementation with either synovial fluid or human serum inhibited bacterial surface attachment over a 24 h incubation. Surprisingly, there was no correlation between the degree of synovial fluid-induced aggregation and quantity of surface-associated biofilm as measured by a conventional biofilm assay without host fluid supplementation. Taken together, our findings suggest that synovial fluid-induced aggregation appears to be widespread among S. aureus strains and mechanistically independent of biofilm formation. IMPORTANCE Bacterial infections of hip and knee implants are rare but devastating complications of orthopedic surgery. Despite a widespread appreciation of the considerable financial, physical, and emotional burden associated with the development of a prosthetic joint infection, the establishment of bacteria in the synovial joint remains poorly understood. It has been shown that immediately upon exposure to synovial fluid, the viscous fluid in the joint, Staphylococcus aureus rapidly forms aggregates which are resistant to antibiotics and host immune cell clearance. The bacterial virulence associated with aggregate formation is likely a step in the establishment of prosthetic joint infection, and as such, it has the potential to be a potent target of prevention. We hope that this work contributes to the future development of therapeutics targeting synovial fluid-induced aggregation to better prevent and treat these infections.

Background. In kidney transplantation, long-term allograft acceptance in cynomolgus macaques was achieved using a mixed-chimerism protocol based on the clinically available reagents, rabbit anti-thymocyte globulin (ATG), and belatacept. Here, we have tested the same protocol in cynomolgus macaques transplanted with fully allogeneic lung grafts. Methods. Five cynomolgus macaques underwent left orthotopic lung transplantation. Initial immunosuppression included equine ATG and anti-IL6RmAb induction, followed by triple-drug immunosuppression for 4 mo. Post-transplant, a nonmyeloablative conditioning regimen was applied, including total body and thymic irradiation. Rabbit ATG, belatacept, anti-IL6RmAb, and donor bone marrow transplantation (DBMT) were given, in addition to a 28-d course of cyclosporine. All immunosuppressant drugs were stopped on day 29 after DBMT. Results. One monkey rejected its lung before DBMT due to AMR, after developing donor-specific antibodies. Two monkeys developed fatal post-transplant lymphoproliferative disorder, and both monkeys had signs of cellular rejection in their allografts upon autopsy. The remaining 2 monkeys showed severe cellular rejection on days 42 and 70 post-DBMT. Cytokine analysis suggested higher levels of pro-inflammatory markers in the lung transplant cohort, as compared to kidney recipients. Conclusion. Although the clinically applicable protocol showed success in kidney transplantation, the study did not show long-term survival in a lung transplant model, highlighting the organ-specific differences in tolerance induction.

Abstract Background Depression is the second leading cause of death among young adults and a major cause of disability worldwide. Some studies suggest a disparity between rural and urban outcomes for depression. Collaborative Care Management (CCM) is effective in improving recovery from depression, but its effect within rural and urban populations has not been studied. Methods A retrospective cohort study of 3870 patients diagnosed with depression in a multi-site primary care practice that provided optional, free CCM was conducted. US Census data classified patients as living in an Urban Area, Urban Cluster, or Rural area and the distance they resided from their primary care clinic was calculated. Baseline demographics, clinical data, and standardized psychiatric assessments were collected. Six month Patient Health Questionnaire (PHQ 9) scores were used to judge remission (PHQ9

Background: Suicides by any method, plus ‘nonsuicide’ fatalities from drug self-intoxication (estimated from selected forensically undetermined and ‘accidental’ deaths), together represent self-injury mortality (SIM)—fatalities due to mental disorders or distress. SIM is especially important to examine given frequent undercounting of suicides amongst drug overdose deaths. We report suicide and SIM trends in the United States of America (US) during 1999–2018, portray interstate rate trends, and examine spatiotemporal (spacetime) diffusion or spread of the drug self-intoxication component of SIM, with attention to potential for differential suicide misclassification. Methods: For this state-based, cross-sectional, panel time series, we used de-identified manner and underlying cause-of-death data for the 50 states and District of Columbia (DC) from CDC's Wide-ranging Online Data for Epidemiologic Research. Procedures comprised joinpoint regression to describe national trends; Spearman's rank-order correlation coefficient to assess interstate SIM and suicide rate congruence; and spacetime hierarchical modelling of the ‘nonsuicide’ SIM component. Findings: The national annual average percentage change over the observation period in the SIM rate was 4.3% (95% CI: 3.3%, 5.4%; p6.0% increase (p

Objective: To determine whether a pharmacist visit after hospital dismissal for patients taking at least 1 medication that places patients at high risk for emergent hospital admissions (termed high-risk medication) would decrease the risk of hospital readmission at 30 days compared with usual care. Patients and Methods: This was a retrospective study at a tertiary care center conducted from July 26, 2013, through April 1, 2016. We reviewed outcomes among patients who did or did not have a post–hospital dismissal pharmacist visit immediately before a clinician visit. We included patients who were at least 18 years old and were taking at least 10 total medications at hospital dismissal, 1 or more of which were high-risk medications. A Cox proportional hazards model was used to compare the risk of 30-day readmission between the groups. Results: The study cohort included 502 patients in each group (pharmacist + clinician group and clinician-only group). After adjusting for differences in background demographic characteristics, patients in the pharmacist + clinician group were significantly less likely to be readmitted to the hospital within 30 days postdismissal compared with the clinician-only group (hazard ratio, 0.49; 95% CI, 0.35-0.69; P

The detailed study of prehospital injury death is critical to advancing trauma and emergency care, as circumstance and causality have significant implications for the development of mitigation strategies. Though there is no true ‘Golden Hour,’ the time from injury to care is a critical element in the analysis matrix, particularly in patients with severe injury. Currently, there is no standard method for the assessment of time to definitive care after injury among prehospital deaths. This article describes a methodology to estimate total prehospital time and distance for trauma patients transported via ground emergency medical services and helicopter emergency medical services using a geographic information system. Data generated using this method, along with medical examiner and field investigation reports, will be used to estimate the potential survivability of prehospital trauma deaths occurring in five US states and the District of Columbia as part of the Multi-Institutional Multidisciplinary Injury Mortality Investigation in the Civilian Pre-Hospital Environment study. One goal of this work is to develop standard metrics for the assessment of total prehospital time and distance, which can be used in the future for more complex spatial analyses to gain a deeper understanding of trauma center access. Results will be used to identify high priority areas for research and development in injury prevention, trauma system performance improvement, and public health.

Background: Depression is common in the primary care setting and tobacco use is more prevalent among individuals with depression. Recent research has linked smoking to poorer outcomes of depression treatment. We hypothesized that in adult primary care patients with the diagnosis of depression, current smoking would have a negative impact on clinical outcomes, regardless of treatment type (usual primary care [UC] vs collaborative care management [CCM]). Methods: A retrospective chart review study of 5155 adult primary care patients with depression in a primary care practice in southeast Minnesota was completed. Variables obtained included age, gender, marital status, race, smoking status, initial Patient Health Questionnaire–9 (PHQ-9), and 6-month PHQ-9. Clinical remission (CR) was defined as 6-month PHQ-9

* Context.--A prior study in this journal, 'Clinicians Are from Mars and Pathologists Are From Venus,' demonstrated that clinicians can erroneously interpret pathology reports up to 30% of the time. After noticing reporting heterogeneity in the setting of inflammatory bowel disease (IBD), we speculated that a standardized synoptic report could improve gastroenterologist comprehension. Objective.--To investigate the effect of a synoptic table on gastroenterologist comprehension of IBD pathology reports. Design.--We recruited gastroenterology fellows and faculty to participate in this study. All participants were given 6 pathology reports and asked if the following were present: active inflammation, chronic inflammation, IBD, and dysplasia. Participants were also asked to rate their confidence. After a 6-week washout period, the same questionnaire was distributed with a synoptic report. We performed paired t-tests to compare the mean accuracy and confidence scores between the preintervention and postintervention responses. Results.--A total of 39 physicians participated: 9 fellows and 30 faculty. Mean accuracy scores were higher after the intervention (0.81 versus 0.86; P < .001). Mean confidence was also higher after intervention, but this was not statistically significant (3.91 versus 3.98; P = .24). Conclusions.--The improvement in accuracy scores after intervention confirms that clinician comprehension improved with the synoptic table. A synoptic report may provide a standardized way of communicating diagnostic information to clinicians in the setting of IBD and potentially other inflammatory conditions. doi: 10.5858/arpa.2023-0068-0A), No matter how much time a pathologist spends painstakingly detailing their findings in a report, the fact remains that their report does not directly help the patient. Instead, it informs [...]

In situations of uncertainty, people often make decisions with heuristic shortcuts or decision rules, rather than using computational or logical methods such as optimizing their behavior based on specific goals. The high level of uncertainty and complexity involved in adapting to climate change suggests that heuristics would be commonly used in this context rather than more structured decision methods. Through a systematic review of 137 articles, from 2007–2017 we explore the behavioral and cognitive assumptions used to examine agricultural decision-making related to climate change among farmers in developing countries. We find a strong orientation toward modeling behavior and decision making as a rational utility-maximizing process, despite decades of research demonstrating the prevalence of simpler heuristic choice when facing uncertainty and real-world constraints. Behavioral and cognitive approaches can increase our ability to predict or explain decisions being made in this realm, particularly in terms of how we understand decision making around information processing and risk assessment. In the following review, we highlight articles that have contributed to developing a more realistic decision-making framework for studying this problem on the ground. While there is a burgeoning literature using psychological insights to examine decision making under climate uncertainty, few studies consider the prevalence of simple heuristics, the presence of cognitive biases, and the salience of climate relative to other risk factors.

Sin Nombre virus (SNV) causes hantavirus cardiopulmonary pulmonary syndrome (HCPS) with the loss of pulmonary vascular endothelial integrity, and pulmonary edema without causing cytopathic effects on the vascular endothelium. HCPS is associated primarily with a dysregulated immune response. We previously found occult signs of hemostatic imbalance in the form of a sharp >30–100 fold increase in the expression of plasminogen activator inhibitor type 1 (PAI-1), in serial blood plasma draws of terminal stage-patients. However, the mechanism of the increase in PAI-1 remains unclear. PAI-1 is a primary inhibitor of fibrinolysis caused by tissue plasminogen activator (tPA) and urokinase plasminogen activator plasma (uPA). Here, we investigate factors that contribute to PAI-1 upregulation during HCPS. Using zymography, we found evidence of PAI-1-refractory uPA activity and no tPA activity in plasma samples drawn from HCPS patients. The sole prevalence of uPA activity suggested that severe inflammation drove PAI-1 activity. We have recently reported that the P2Y2 receptor (P2Y2R) mediates SNV infectivity by interacting in cis with β3 integrins, which activates the latter during infection. P2Y2R is a known effector for several biological processes relevant to HCPS pathogenesis, such as upregulation of tissue factor (TF), a primary initiator of the coagulation cascade, stimulating vascular permeability and leukocyte homing to sites of infection. As P2Y2R is prone to upregulation under conditions of inflammation, we compared the expression level of P2Y2R in formalin fixed tissues of HCPS decedents using a TaqMan assay and immunohistochemistry. Our TaqMan results show that the expression of P2Y2R is upregulated significantly in HCPS cases compared to non- HCPS controls (P < 0.001). Immunohistochemistry showed that lung macrophages were the primary reservoir of high and coincident localization of P2Y2R, uPA, PAI-1, and TF antigens. We also observed increased staining for SNV antigens in the same tissue segments where P2Y2R expression was upregulated. Conversely, sections of low P2Y2R expression showed weak manifestations of macrophages, SNV, PAI-1, and TF. Coincident localization of P2Y2R and PAI-1 on macrophage deposits suggests an inflammation-dependent mechanism of increasing pro-coagulant activity in HCPS in the absence of tissue injury.

Background: The use of a collaborative care management (CCM) model can dramatically improve short- and long-term treatment outcomes for patients with major depressive disorder (MDD). Patients with comorbid personality disorder (PD) may experience poorer treatment outcomes for MDD. Our study seeks to examine the differences in MDD treatment outcomes for patients with comorbid PD when using a CCM approach rather than usual care (UC). Methods: In our retrospective cohort study, we reviewed the records of 9614 adult patients enrolled in our depression registry with the clinical diagnosis MDD and the diagnosis of PD (Yes/No). Clinical outcomes for depression were measured with Patient Health Questionnaire–9 (PHQ-9) scores at 6 months. Results: In our study cohort, 59.4% of patients (7.1% of which had comorbid PD) were treated with CCM, as compared with 40.6% (6.8% with PD) treated with UC. We found that the presence of a PD adversely affected clinical outcomes of remission within both groups, however, at 6 months patients with PD had significantly lower MDD remission rates when treated with UC as compared with those treated with CCM (11.5% vs 25.2%, P = .002). Patients with PD in the UC group were also noted to have an increased rate of persistent depressive symptoms (PHQ-9 score ≥10) at 6 months as compared with those in the CCM group (67.7% vs 51.7%, P = .004). Conclusions: In patients with comorbid MDD and PD, clinical outcomes at 6 months were significantly improved when treated with CCM compared with UC. This finding is encouraging and supports the idea that CCM is an effective model for caring for patients with behavioral concerns, and it may be of even greater benefit for those patients being treated for comorbid behavioral health conditions.

Background: Previous studies have suggested that having a comorbid personality disorder (PD) along with major depression is associated with poorer depression outcomes relative to those without comorbid PD. However, few studies have examined the influence of specific PD cluster types. The purpose of the current study is to compare depression outcomes between cluster A, cluster B, and cluster C PD patients treated within a collaborative care management (CCM), relative to CCM patients without a PD diagnosis. The overarching goal was to identify cluster types that might confer a worse clinical prognosis. Methods: This retrospective chart review study examined 2826 adult patients with depression enrolled in CCM. The cohort was divided into 4 groups based on the presence of a comorbid PD diagnosis (cluster A/nonspecified, cluster B, cluster C, or no PD). Baseline clinical and demographic variables, along with 6-month follow-up Patient Health Questionnaire–9 (PHQ-9) scores were obtained for all groups. Depression remission was defined as a PHQ-9 score

OBJECTIVE:A paucity of corroborative psychological and psychiatric evidence may be inhibiting detection of drug intoxication suicides in the United States. We evaluated the relative importance of suicide notes and psychiatric history in the classification of suicide by drug intoxication versus firearm (gunshot wound) plus hanging/suffocation-the other two major, but overtly violent methods. METHODS:This observational multilevel (individual/county), multivariable study employed a generalized linear mixed model (GLMM) to analyze pooled suicides and undetermined intent deaths, as possible suicides, among the population aged 15 years and older in the 17 states participating in the National Violent Death Reporting System throughout 2011-2013. The outcome measure was relative odds of suicide versus undetermined classification, adjusted for demographics, precipitating circumstances, and investigation characteristics. RESULTS:A suicide note, prior suicide attempt, or affective disorder was documented in less than one-third of suicides and one-quarter of undetermined deaths. The prevalence gaps were larger among drug intoxication cases than gunshot/hanging cases. The latter were more likely than intoxication cases to be classified as suicide versus undetermined manner of death (adjusted odds ratio [OR], 41.14; 95% CI, 34.43-49.15), as were cases documenting a suicide note (OR, 33.90; 95% CI, 26.11-44.05), prior suicide attempt (OR, 2.42; 95% CI, 2.11-2.77), or depression (OR, 1.61; 95% CI, 1.38 to 1.88), or bipolar disorder (OR, 1.41; 95% CI, 1.10-1.81). Stratification by mechanism/cause intensified the association between a note and suicide classification for intoxication cases (OR, 45.43; 95% CI, 31.06-66.58). Prior suicide attempt (OR, 2.64; 95% CI, 2.19-3.18) and depression (OR, 1.48; 95% CI, 1.17-1.87) were associated with suicide classification in intoxication but not gunshot/hanging cases. CONCLUSIONS:Without psychological/psychiatric evidence contributing to manner of death classification, suicide by drug intoxication in the US is likely profoundly under-reported. Findings harbor adverse implications for surveillance, etiologic understanding, and prevention of suicides and drug deaths.

OBJECTIVE:Higher prevalence of suicide notes could signify more conservatism in accounting and greater proneness to undercounting of suicide by method. We tested two hypotheses: (1) an evidentiary suicide note is more likely to accompany suicides by drug-intoxication and by other poisoning, as less violent and less forensically overt methods, than suicides by firearm and hanging/suffocation; and (2) performance of a forensic autopsy attenuates any observed association between overtness of method and the reported presence of a note. METHODS:This multilevel (individual/county), multivariable analysis employed a generalized linear mixed model (GLMM). Representing the 17 states participating in the United States National Violent Death Reporting System throughout 2011-2013, the study population comprised registered suicides, aged 15 years and older. Decedents totaled 32,151. The outcome measure was relative odds of an authenticated suicide note. RESULTS:An authenticated suicide note was documented in 31% of the suicide cases. Inspection of the full multivariable model showed a suicide note was more likely to manifest among drug intoxication (adjusted odds ratio [OR], 1.70; 95% CI, 1.56, 1.85) and other poisoning suicides (OR, 2.12; 1.85, 2.42) than firearm suicides, the referent. Respective excesses were larger when there was no autopsy or autopsy status was unknown (OR, 1.86; 95% CI, 1.61, 2.14) and (OR, 2.25; 95% CI, 1.86, 2.72) relative to the comparisons with a forensic autopsy (OR, 1.62, 95% CI, 1.45, 1.82 and OR, 2.01; 95% CI, 1.66, 2.43). Hanging/suffocation suicides did not differ from the firearm referent given an autopsy. CONCLUSIONS:Suicide requires substantial affirmative evidence to establish manner of death, and affirmation of drug intoxication suicides appears to demand an especially high burden of proof. Findings and their implications argue for more stringent investigative standards, better training, and more resources to support comprehensive and accurate case ascertainment, as the foundation for developing evidence-based suicide prevention initiatives.

Background: Individuals with personality disorders (PDs) are high utilizers of primary care and mental health services; however, they struggle to utilize the care effectively and studies have shown a strong association between having a PD and higher impairment in social role functioning. This is especially important because PDs are highly comorbid with a wide range of other mental health disorders. The collaborative care model (CCM) for depression was developed with an emphasis on patient engagement and aimed to reduce health care utilization, while improving treatment outcomes in primary care. We hypothesized that the diagnosis of a personality disorder in primary care patients will negatively affect 6-month depression outcomes after enrollment into a CCM. Methods: This retrospective chart review study was conducted on patients enrolled into CCM over a period of 7 years with collection of 6-month follow-up data. A total of 2826 patients were enrolled into CCM with a clinical diagnosis of depression and a baseline Patient Health Questionnaire–9 (PHQ-9) ≥10 were included in the study cohort. Using the depression database, baseline and 6-month follow-up data were obtained. Adjusted odds ratios (AORs) were determined for both remission and persistent depressive symptoms using logistic regression modeling for the 6-month PHQ-9 outcome; while retaining all the study variables. Results: Of the 2826 CCM patients with depression in our study, 216 (7.6%) were found to have a PD. Patients with PD were younger (37.7 vs 42.5 years, P < .001) and more likely to be unmarried (36.1% vs 55.6%, P < .001) than patients without a PD. While age, marital status, clinical diagnosis, and Mood Disorders Questionnaire (MDQ) score were significant predictors of remission; anxiety symptoms, gender, and race were not. The presence of a PD diagnosis was associated with a 60% lower likelihood of remission at 6 months (AOR = 0.39; 95% CI 0.28-0.54). Conversely, patients without a PD were 2.5 times as likely to experience remission at 6-month remission compared to patients with PD (AOR =2.57; 95% CI 1.85-3.56). Conclusion: Patients with a personality disorder were more likely to have a recurrent depressive disorder diagnosis, an abnormal MDQ score, increased anxiety symptoms, and higher baseline PHQ-9 score. Patients with PD had worse CCM outcomes at 6 months with only 25.0% able to achieve remission versus 54.3% ( P < .001) without a PD. The presence of a PD with depression was associated with poor outcomes (reduced remission rates and increased persistent depressive symptoms rates) in comparison to patients without a diagnosis of PD, while treated within CCM.

Background: Collaborative care management (CCM) is an evidence-based model that contributes to better outcomes for depression treatment in the primary care setting. Tobacco use increases overall economic costs, morbidity, and mortality and has been shown to impact behavioral health outcomes. Our study aims to observe clinical outcomes for depression treatment for patients with comorbid tobacco use and depression within the CCM model. Methods: A retrospective chart review study of 2826 adult patients with depression enrolled in CCM was performed to determine the association between regular tobacco use and depression outcomes. Baseline intake data consisting of clinical and demographic variables along with 6-month follow-up of Patient Health Questionnaire-9 (PHQ-9) scores for smokers (n = 727, 25.7%) and nonsmokers (n = 2099, 74.3%) were obtained. Depression remission was defined as a PHQ-9 score

Posttraumatic stress disorder (PTSD) has symptoms that exist along a spectrum that includes depression and the 2 disorders may coexist. Collaborative care management (CCM) has been successfully used in outpatient mental health management (especially depression and anxiety) with favorable outcomes. Despite this, there exist limited data on clinical impact of a diagnosis of PTSD on depression outcomes in CCM. The present study used a retrospective cohort design to examine the association of PTSD with depression outcomes among 2121 adult patients involved in CCM in a primary care setting. Using standardized self-report measures, baseline depression scores and 6-month outcome scores were evaluated. Seventy-six patients had a diagnosis of PTSD documented in their electronic medical record. Patients with PTSD reported more severe depressive symptoms at baseline (Patient Health Questionnaire–9 score of 17.9 vs 15.4, P < .001) than those without PTSD. Controlling for sociodemographic and clinical characteristics, a clinical diagnosis of PTSD was associated with lower odds (AOR = 0.457, CI = 0.274-0.760, P = .003) of remission at 6 months and was also associated with higher odds (AOR = 3.112, CI = 1.921-5.041, P < .001) of persistent depressive symptoms at 6 months after CCM. When coexisting with depression, a diagnosis of PTSD was associated with worse depression outcomes, when managed with CCM in primary care. Opportunities still exist for more aggressive management of depression in these patients to help improve remission as well as reduce persistent depressive symptoms.

Methicillin-resistant Staphylococcus aureus (MRSA) is a human pathogen that has diverse molecular heterogeneity. Most MRSA strains in the United States are pulsed-field gel electrophoresis USA100 sequence type (ST) 5 and USA300 ST8. Infections with MRSA ST239-III are common and found during health care–associated outbreaks. However, this strain has been rarely reported in the United States. As part of a study supported by the Prevention Epicenter Program of the Centers for Disease Control and Prevention (Atlanta, GA, USA), which evaluated transmission of MRSA among hospitals in Ohio, molecular typing identified 78 (6%) of 1,286 patients with MRSA ST239-III infections. Ninety-five percent (74/78) of these infections were health care associated, and 65% (51/78) of patients had histories of invasive device use. The crude case-fatality rate was 22% (17/78). Identification of these strains, which belong to a virulent clonal group, emphasizes the need for molecular surveillance.

During the pandemic (H1N1) 2009 outbreak, Minnesota, New Mexico, and Oregon used several surveillance methods to detect associated deaths. Surveillance using unexplained death and medical examiner data allowed for detection of 34 (18%) pandemic (H1N1) 2009–associated deaths that were not detected by hospital-based surveillance.

Purpose: Cellulitis in obese patients is associated with increased rates of treatment failure compared to those with normal body mass index (BMI); however, patients have not been extensively studied in the outpatient environment or stratified based on range of obesity and associated risk factors. This study looked at antibiotic dosing and treatment failure in the obese population from the primary care perspective and accounts for BMI range, weight, comorbid diabetes, and tobacco use. Methods: This study was a retrospective chart review of 637 adult primary care patients designed to evaluate rates of treatment failure of outpatient cellulitis among patients of varying BMI. Treatment failure was defined as ( a ) hospital admission for intravenous antibiotics, ( b ) prolonged antibiotic course, or ( c ) requiring a different antibiotic after initial course. Results: Adverse outcomes were not statistically significant between normal BMI and those with BMI ≥40 kg/m 2 . A subset of patients with a BMI ≥50 kg/m 2 was noted to have approximately twice the rate of adverse outcomes as the normal BMI group. While controlling for age, gender, race, diagnosis of diabetes mellitus, and tobacco use, a BMI of ≥50 kg/m 2 and a weight ≥120 kg was associated with adverse outcomes with an odds ratio of 2.440 (95% CI, 1.260-4.724; P = .008) and 2.246 (95% CI, 1.154-4.369; P = .017), respectively. Conclusions: Patients with cellulitis weighing >120kg or with a BMI ≥50 kg/m 2 were at greatest risk for treatment failure in the outpatient setting, even when controlling for comorbid diabetes and tobacco use. As morbid obesity continues to become more prevalent, it becomes imperative that primary care physicians have better antibiotic dosing guidelines to account for the physiologic effects of obesity to minimize the risk of increased morbidity, health care costs, and antibiotic resistance.

The 21st-century epidemic of pharmaceutical and other drug-intoxication deaths in the United States (US) has likely precipitated an increase in misclassified, undercounted suicides. Drug-intoxication suicides are highly prone to be misclassified as accident or undetermined. Misclassification adversely impacts suicide and other injury mortality surveillance, etiologic understanding, prevention, and hence clinical and public health policy formation and practice.To evaluate whether observed variation in the relative magnitude of drug-intoxication suicides across US states is a partial artifact of the scope and quality of toxicological testing and type of medicolegal death investigation system.This was a national, state-based, ecological study of 111,583 drug-intoxication fatalities, whose manner of death was suicide, accident, or undetermined. The proportion of (nonhomicide) drug-intoxication deaths classified by medical examiners and coroners as suicide was analyzed relative to the proportion of death certificates citing one or more specific drugs and two types of state death investigation systems. Our model incorporated five sociodemographic covariates. Data covered the period 2008-2010, and derived from NCHS's Multiple Cause-of-Death public use files.Across states, the proportion of drug-intoxication suicides ranged from 0.058 in Louisiana to 0.286 in South Dakota and the rate from 1 per 100,000 population in North Dakota to 4 in New Mexico. There was a low correlation between combined accident and undetermined drug-intoxication death rates and corresponding suicide rates (Spearman's rho = 0.38; p

The impact and prevalence of antimicrobial drug resistance in rural community healthcare settings is uncertain. Prospective surveillance in 51 rural hospitals in Idaho and Utah examined the epidemiologic features of clinical cases of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). Thirty-two cases of VRE were reported; for 6, the patient had no prior healthcare exposure or coexisting condition. Among the 724 MRSA cases available for evaluation, 405 (56%) were healthcare-associated (HA-MRSA), and 319 (44%) were community-associated (CA-MRSA). The characteristics of HA-MRSA and CA-MRSA patients with coexisting factors were similar, which suggests community transmission of healthcare strains. CA-MRSA cases without coexisting factors, however, demonstrated features previously reported for community strains. MRSA infections were substantially more frequent than VRE in rural communities in the western United States. Based on epidemiologic criteria, a large proportion of MRSA cases were community-associated. CA-MRSA rates were predictive of institutional MRSA rates.

Increasing infectious disease deaths, the emergence of new infections, and bioterrorism have made surveillance for infectious diseases a public health concern. Medical examiners and coroners certify approximately 20% of all deaths that occur within the United States and can be a key source of information regarding infectious disease deaths. We hypothesized that a computer-assisted search tool (algorithm) could detect infectious disease deaths from a medical examiner database, thereby reducing the time and resources required to perform such surveillance manually. We developed two algorithms, applied them to a medical examiner database, and verified the cases identified against the opinion of a panel of experts. The algorithms detected deaths with infectious components with sensitivities from 67% to 94%, and predictive value positives ranging from 8% to 49%. Algorithms can be useful for surveillance in medical examiner offices that have limited resources or for conducting surveillance across medical examiner jurisdictions.

This study presents a comprehensive radiographic evaluation of bone regeneration within a pedicled muscle flap for the reconstruction of critical size mandibular defect. The surgical defect (20 mm × 15 mm) was created in the mandible of ten experimental rabbits. The masseter muscle was adapted to fill the surgical defect, a combination of calcium sulphate/hydroxyapatite cement (CERAMENT™ |SPINE SUPPORT), BMP-7 and rabbit mesenchymal stromal cells (rMSCs) was injected inside the muscle tissue. Radiographic assessment was carried out on the day of surgery and at 4, 8, and 12 weeks postoperatively. At 12 weeks, the animals were sacrificed and cone beam computerized tomography (CBCT) scanning and micro-computed tomography (µ-CT) were carried out. Clinically, a clear layer of bone tissue was identified closely adherent to the border of the surgical defect. Sporadic radio-opaque areas within the surgical defect were detected radiographically. In comparison with the opposite non operated control side, the estimated quantitative scoring of the radio-opacity was 46.6% ± 15, the mean volume of the radio-opaque areas was 63.4% ± 20. Areas of a bone density higher than that of the mandibular bone (+35% ± 25%) were detected at the borders of the surgical defect. The micro-CT analysis revealed thinner trabeculae of the regenerated bone with a more condensed trabecular pattern than the surrounding native bone. These findings suggest a rapid deposition rate of the mineralised tissue and an active remodelling process of the newly regenerated bone within the muscle flap. The novel surgical model of this study has potential clinical application; the assessment of bone regeneration using the presented radiolographic protocol is descriptive and comprehensive. The findings of this research confirm the remarkable potential of local muscle flaps as local bioreactors to induce bone formation for reconstruction of maxillofacial bony defects.

Background: The inclusion of mental health issues in the evaluation of multimorbidity generally has been as the presence or absence of the condition rather than severity, complexity, or stage. The hypothesis for this study was that clinical outcome of the depression 6 months after enrollment into collaborative care management would have a role in predicting future complexity of care tier. Methods: This study was a retrospective chart review of 1894 primary care patients who were diagnosed with major depressive disorder or dysthymia as of December 2012. Multiple logistic regression analysis was used to test the independent associations between each variable and the odds of being included in the higher tiers (HT) group. Results: Age (odds ratio [OR] = 1.022, confidence interval [CI] = 1.013-1.030, P < .001), female gender (OR = 1.380, CI = 1.020-1.868, P = .037), being married (OR = 0.730, CI = 0.563-0.947, P = .018), and the presence of comorbidities (1, OR = 1.986, CI = 1.485-2.656, P < .001; ≥2, OR = 4.678, CI = 3.242-6.750, P < .001) were independently associated with future HT levels. The presence of persistent depressive symptoms (PHQ-9 ≥10) at 6 months conferred 2.280 (CI = 1.673-3.107, P < .001) times likely odds of HT level compared with clinical remission at 6 months. Conclusion: Patients with the diagnosis of major depression or dysthymia had greater odds of complex tier levels in the future, if depression was not treated to remission by 6 months. This study demonstrated the importance of the goal of significant improvement (ie, remission) of depression symptoms by 6 months (especially those older patients with more comorbidity) from entering into the higher complexity tiers.

Purpose: The purpose of this study was to compare continuity of care for family medicine patients using retail medicine clinics to continuity for patients not using retail clinics. Retail medicine clinics have become popular in some markets. However, their impact on continuity of care has not been studied. Methods: Electronic medical records of adult primary care patients seen in a large group practice in Minnesota in 2011 were analyzed for this study. Two randomly chosen groups of patients were selected (N = 400): those using 1 of 3 retail walk-in clinics staffed by nurse practitioners in addition to standard office care and a comparison group that only used standard office care. Continuity was measured as the percentage of visits that involved the primary care provider. We also compared patients who made zero visits to their primary care providers with those who made some visits to their primary care providers. Results: Continuity of care was lower for patients who used retail clinics than for patients who did not use retail clinics (0.17 vs 0.44, mean difference 0.27). The percentage of patients who made zero visits to their primary care providers was 54.5 for users of retail clinics versus 31.0 for those who did not use retail clinics. Conclusions: Continuity of care should be monitored as retail medicine continues to expand.

Introduction: Collaborative care management (CCM) for the treatment of depression has been shown to be an effective therapy. CCM can be seen as a resource intensive treatment. Early identification of patients who would not be effectively treated with CCM could allow for alteration of therapy or change in modality. Methods: A retrospective case-controlled study used 132 patients with prolonged enrollment (>1 year) in CCM (cases) and 396 randomized CCM patients who achieved remission within 6 months (controls). The hypothesis was that by studying the epidemiology of patients in prolonged care management (PCM), characteristics could be determined to help define this group. Results: With regression modeling, the odds of a patient having PCM at 1 year was highly significant for those unmarried patients (odds ratio [OR] = 1.736, confidence interval [CI] = 1.115-2.703, P = .015) with dysthymia (OR = 2.362, CI = 1.104-5.052, P = .027) and severe depression (OR = 2.856, CI = 1.551-5.260, P = .001). The adjusted baseline Patient Health Questionnaire–9 (PHQ-9) score showed a difference of 16.0 for the cases versus 14.8 for the controls ( P < .001). By 10 weeks, the difference is much larger at (10.7 vs 4.9, P < .001). At 26 weeks, the control group had an adjusted average PHQ-9 score of 2.0, whereas the case group was still elevated at 10.2 ( P < .001). Conclusions: Case-controlled analysis of PCM patients demonstrated independent predictors (such as unmarried status, diagnosis of dysthymia or severe depression), however, no baseline data was of sufficient clarity to suggest changes in clinical practice. The trend of the patient’s PHQ-9 over time was strongly suggestive of allowing differentiation between the groups.

Obesity and depression are often comorbid conditions. There appears to be a bidirectional relationship between these. Obesity at baseline has been shown to increase the risk of onset of depression and depression at baseline increased the odds for developing obesity. Less is understood about the impact of obesity on depression treatment outcomes. The authors’ hypothesis was that obesity (body mass index [BMI] ≥30 kg/m 2 ) and morbid obesity (BMI ≥ 40 kg/m 2 ) would each have negative effects on depression remission rates after 6 months of enrollment into collaborative care management for depression. In a retrospective analysis of 1111 depressed patients with a PHQ-9 (Patient Health Questionnaire) score of 10 or greater, multivariate analysis for the odds ratio of achieving remission at 6 months demonstrated that the patient’s BMI at baseline was not an independent risk factor for depression outcome at 6 months. Collaborative care management for depression has been shown to be effective for improving depression outcomes, yet minimal prior research has focused on other clinical comorbidities that might affect outcomes. Although obesity was common in the study population, it was reassuring, based on this study that 6-month depression treatment outcomes do not appear to be significantly affected by the patient’s baseline BMI.

Major depressive disorder is common in primary care. Depression Improvement Across Minnesota—Offering a New Direction (DIAMOND), using a collaborative care model, was first implemented in March 2008 starting with 5 clinics and expanding to more than 70 clinics statewide by 2010. This was intended to improve depression management and to augment the relationship between the patient, the primary care provider, and the psychiatrist. Prior retrospective studies have demonstrated the clinical effectiveness of our program. This study was designed to examine those patients who were in clinical remission (defined as a Patient Health Questionnaire–9 [PHQ-9] score

In 2008, the Institute for Clinical Systems Improvement (ICSI) in Minnesota implemented a model of collaborative care management (CCM) for treatment of depression in primary care. This resulted in significant improvements on both clinical response and remission over usual care, although an increase in utilization metrics has been observed. Mental health comorbidities have previously been significantly associated with an increased likelihood of not responding to initial treatment. This retrospective study hypothesized that patients with mental health comorbidities are more likely to be associated with patients who were readmitted into CCM with recurrent depression. A total of 145 patients who had completed CCM were studied; of these, 32 were diagnosed with recurrent depression and were readmitted to CCM, and 113 were in remission for at least 4 months. There were no statistically significant demographic differences between the 2 groups. The initial screening GAD-7 score for anxiety was significantly increased in the readmission group (12.81 vs 9.20, P = .001) as was the average length of treatment from initial diagnosis to remission (168.09 vs 120.99 days, P = .002). All other initial screening tests were not different between the groups. When controlling for the independent variables by multiple logistic regression, the odds ratio for GAD-7 was 1.1156 (CI = 1.0.192 to 1.2212, P = .0177) and for days of treatment in CCM was 1.0123 (CI = 1.0041 to 1.0206, P = .0033). Patients who are readmitted to CCM for recurrent depression have a statistically increased risk of associated anxiety and a longer treatment course than those who have remained in remission for at least 4 months.

Postpartum depression (PPD) has emerged as an important issue for pediatricians and family practitioners because of detrimental effects on children. PPD occurs in 10% to 22% of women who have recently given birth, but fewer than half of cases are recognized. Despite the impact of PPD, many primary care clinicians do not have systemic screening approaches implemented. This paper will review the development of a screening protocol for PPD in a multispecialty clinic, with the implementation utilizing depression care managers and the preliminary results of our process. Of the 333 screened examinations during the 4-month study, 38.1% (n = 127) were performed for the 2-month well child examination; 33.6% (n = 112) were for the 4-month examination, with 28.2% (n = 94) being performed for the 6-month well child examination. Only 15 (4.5%) were positive for possible depression with a screening compliance rate of 47.9%. No significant difference was noted in the timing of the well child visit with a positive screening test result, nor was there any difference in family medicine versus pediatric colleagues in the utilization of the screening or diagnosis of PPD. Implementation of PPD screening in a multispecialty clinic can be effective, given utilization of depression care managers.

The collaborative care management (CCM) model has been demonstrated to be significantly more effective compared to usual care (UC) in depression management although an initial increase in cost measures was seen. In this paper, cost measures as well as clinical response were analyzed on patients with available follow-up data at six months. Records of 219 patients with follow-up data in CCM group and 119 in UC group were reviewed. At six months, there was a statistically significant clinical response rate among patients in CCM compared to UC group ( P < 0.0001). Likewise, 65% in CCM group was “symptom-free” at 6 months vs. 31.9% in UC group ( P < 0.0001). Among the responders in both groups, there was no statistical difference in cost measures. However, cost measures were significantly higher among non-responders compared to responders within CCM. Between the two models, the non-responders in UC had lower cost measures than the non-responders under CCM.

A collaborative care model (CCM) has been implemented for management of depression. This paper studies the impact that the CCM had on cost measures for the period of six months after initial diagnosis of depression compared to patients receiving usual care (UC). There was a significant increase in the CPT costs for the six months following diagnosis in the CCM group ($451.35 vs. $323.50, P < 0.001). The average CPT cost rank and CPT cost differential were also significantly increased in the CCM group. The adjusted means of the CPT costs were (when controlling for prior utilization) $452.11 for the CCM group and $322.09 for UC (P < 0.001). In the CCM group; there were 161 patients (73.5%) that achieved a clinical response for their depression compared to the UC group, which had a 15.1% (18/119) response rate (P < 0.001). There also was a significant difference between the groups in those who were symptoms free of their depression (PHQ-9 score < 5), with the CCM having 59.4% of the patients symptom-free compared to 10.9% of the UC group (P < 0.001). In this group of patients, CCM is associated with markedly improved clinical outcomes for depression, however with a modest short-term increase in CPT costs.

Intraosseous schwannomas are rare benign tumors that most often occur at the mandible or sacrum. We present an unusual case of a bilobed schwannoma of the distal humerus with both intraosseous and extraosseous components. The extraosseous component was non-enhancing on initial MRI and enhanced on a subsequent MRI obtained after biopsy. We hypothesize that this change was attributable to decreased intra-tumoral pressure secondary to biopsy-related disruption of the tumor capsule.