Primary Care Access for All: A Roadmap for Addressing the Primary Care Crisis in Rhode Island.

Background: Primary care in Rhode Island is in crisis. The dearth of primary care providers is already affecting access to services and the situation is likely to worsen unless major steps are taken. There are inadequate numbers of trainees in primary care medical residencies, nurse practitioner (NP) and physician assistant (PA) training programs who plan to practice primary care in our state.

Rhode Island's investment in primary care transformation: A case study.

Introduction: Rhode Island has received national recognition as a leader in statewide, multipayer, multistakeholder initiatives that focus on investments in primary care as a strategy to build a strong delivery system foundation that delivers high-quality, affordable health care.

Method: For this case study we summarize key structural, process and outcomes factors and lessons learned from internal and external evaluations and project based and stakeholder-engaged quality improvement efforts that helped Rhode Island become the most improved U.S.

Care Transformation Collaborative of Rhode Island: Building a Strong Foundation for Comprehensive, High-Quality Affordable Care.

As the Patient Centered Medical Home (PCMH) model has evolved nationally and in Rhode Island, there has been increased recognition that PCMH has not been sufficient to achieve desired cost and quality goals. In this article, we describe the evolving concept of "comprehensive primary care" in Rhode Island, which includes addressing the behavioral health and social determinants of health (SDOH) needs of patients. These needs are identified through systematic screening and dedicated care management and care coordination for patients who present with complex needs.

Integrated behavioral health practice facilitation in patient centered medical homes: A promising application.

Introduction: The purpose of this study was to assess the degree of behavioral health (BH) integration change in patient-centered medical homes (PCMHs) when using a practice facilitator (PF) specially trained in implementing integrated care and how a quasi-experimental design assists in this process.

Method: Twelve PCMHs, 8 Federally Qualified Health Centers and 4 private practices, with varying degrees of BH services participated in this study. The degree of BH integration was assessed with a quasi-experimental design using the Maine Health Access Foundation's Site Self Assessment (MeHAF SSA) at baseline and after implementing site-specific BH services.

Algorithm for the anesthetic management of cesarean delivery in patients with unsatisfactory labor epidural analgesia.

The management of a patient presenting with unsatisfactory labor epidural analgesia poses a severe challenge for the anesthetist wanting to provide safe anesthetic care for a cesarean delivery. Early recognition of unsatisfactory labor analgesia allows for replacement of the epidural catheter. The decision to convert labor epidural analgesia to anesthesia for cesarean delivery is based on the urgency of the cesarean delivery, airway examination, and the existence of a residual sensory and motor block.

Hollows on Mercury: MESSENGER evidence for geologically recent volatile-related activity.

High-resolution images of Mercury's surface from orbit reveal that many bright deposits within impact craters exhibit fresh-appearing, irregular, shallow, rimless depressions. The depressions, or hollows, range from tens of meters to a few kilometers across, and many have high-reflectance interiors and halos. The host rocks, which are associated with crater central peaks, peak rings, floors, and walls, are interpreted to have been excavated from depth by the crater-forming process.

Flood volcanism in the northern high latitudes of Mercury revealed by MESSENGER.

MESSENGER observations from Mercury orbit reveal that a large contiguous expanse of smooth plains covers much of Mercury's high northern latitudes and occupies more than 6% of the planet's surface area. These plains are smooth, embay other landforms, are distinct in color, show several flow features, and partially or completely bury impact craters, the sizes of which indicate plains thicknesses of more than 1 kilometer and multiple phases of emplacement. These characteristics, as well as associated features, interpreted to have formed by thermal erosion, indicate emplacement in a flood-basalt style, consistent with x-ray spectrometric data indicating surface compositions intermediate between those of basalts and komatiites.

Relative importance of gait vs. joint positioning on hip contact forces after total hip replacement.

Implant loosening is a common indication for total hip replacement (THR) revision. High contact forces and implant twisting moments are thought to be associated with implant loosening. Relationships between joint positioning and hip forces, or outcomes, have been investigated through in vivo and in vitro modalities.

Do gait adaptations during stair climbing result in changes in implant forces in subjects with total hip replacements compared to normal subjects?

Background: The study objective was to identify gait abnormalities and their relationships to hip loading during stair climbing after total hip replacement.

Hypotheses: (1) total hip replacement subjects would have significantly lower dynamic hip range of motion and peak external moments during stair climbing compared to normal subjects and (2) the peak twisting moment about the long axis of the implant and peak hip forces would be significantly reduced in subjects with total hip replacements compared to normal subjects.

Methods: Gait parameters during a stair climbing task were measured for 15 total hip replacement subjects and 15 matched normal subjects.

Preoperative gait adaptations persist one year after surgery in clinically well-functioning total hip replacement patients.

The purpose of this study was to evaluate whether preoperative gait adaptations persist one year after THR in the same set of subjects. The hypothesis tested was that hip dynamic range of motion and peak external moments during walking return to normal after THR. Hip kinematics and kinetics were measured for 28 subjects before and one year after THR and compared to those of 25 subjects with radiographically normal hips.

The relationship between toe-out angle during gait and progression of medial tibiofemoral osteoarthritis.

Background: A greater knee adduction moment increases risk of medial tibiofemoral osteoarthritis (OA) progression. Greater toe-out during gait shifts the ground reaction force vector closer to the centre of the knee, reducing the adduction moment. The present study was designed to test whether greater toe-out is associated with lower likelihood of medial OA progression.

Hip abduction moment and protection against medial tibiofemoral osteoarthritis progression.

Objective: To test the hypothesis that a greater peak internal hip abduction moment is associated with a reduced likelihood of ipsilateral medial tibiofemoral osteoarthritis (OA) progression.

Methods: Fifty-seven persons with knee OA (by definite osteophyte presence and symptoms) were evaluated. Baseline assessments included kinematic and kinetic gait parameters, obtained with an optoelectronic camera system and force platform, with inverse dynamics used to calculate 3-dimensional moments at the joints; pain, using a separate visual analog scale for each knee; and alignment, using full-limb radiographs.

Overview of publicly funded managed behavioral health care.

Using MEDLINE and other Internet sources, the authors perform a systematic review of published literature. A total of 109 articles and reports are identified and reviewed that address the development, implementation, outcomes, and trends related to Managed behavioral health care (MBHC). MBHC remains a work in progress.

Thrust during ambulation and the progression of knee osteoarthritis.

Objective: To determine whether the presence of varus thrust at baseline increases the risk of progression of medial tibiofemoral osteoarthritis (OA), whether knees with thrust have a greater adduction moment, whether thrust has any additional impact on top of static varus, and whether thrust is associated with poor physical function outcome.

Methods: Two hundred thirty-seven patients with knee OA (definite osteophytes and symptoms) underwent baseline gait observation to assess varus thrust and full-limb radiography to assess alignment. Sixty-four of these 237 patients also underwent quantitative gait analysis to determine the maximum knee adduction moment.

Potential strategies to reduce medial compartment loading in patients with knee osteoarthritis of varying severity: reduced walking speed.

Objective: To determine whether reducing walking speed is a strategy used by patients with knee osteoarthritis (OA) of varying disease severity to reduce the maximum knee adduction moment.

Methods: Self-selected walking speeds and maximum knee adduction moments of 44 patients with medial tibiofemoral OA of varying disease severity, as assessed by using the Kellgren/Lawrence grade, were compared with those of 44 asymptomatic control subjects matched for sex, age, height, and weight.

Results: Differences in self-selected normal walking speed explained only 8.

Critical role of platelet P-selectin in the response to arterial injury in apolipoprotein-E-deficient mice.

Objective: Mice deficient in apolipoprotein-E (apoE-/-) experience severe hypercholesterolemia that is exacerbated by a high-fat Western-type diet and atherosclerotic lesions spontaneously develop. In addition, we have reported that deficiency of P-selectin dramatically protects against neointimal lesion formation after arterial injury in apoE-/- mice. To define the mechanism, bone marrow transplantation (BMT) after lethal irradiation was used to generate apoE-/- chimeric mice deficient in platelet, but not endothelial, P-selectin.

Dynamic loads are determinants of peak bone mass.

This study investigated the association between non-invasive measurements of bone mass and markers of dynamic and static hip joint loads in subjects expected to be at peak bone mass. The bone mineral density (BMD) and bone mineral content (BMC) of three proximal femoral sites (neck, greater trochanter, and total) were measured by dual energy X-ray absorptiometry, and the peak external joint moments at the hip during walking and jogging were calculated from gait analyses of 31 normal human subjects ranging in age from 30 to 49 years (18 females, 13 males). Various multiple regression analyses were performed to determine how much of the variance in BMD and BMC was explained by height, body mass, and the peak hip joint moments.

Asymmetric knee loading in advanced unilateral hip osteoarthritis.

Objective: Subjects with unilateral end-stage hip osteoarthritis (OA) who undergo total hip replacement (THR) preferentially require subsequent replacement of the contralateral knee compared with the ipsilateral knee. We investigated whether this nonrandom, preferential evolution of lower extremity OA from the hip to the contralateral knee joint may be related to asymmetries in dynamic joint loading at the knees, particularly the peak external knee adduction moment, which has been associated with the progression of knee OA.

Methods: Gait analysis was performed on 50 subjects who were preoperative for unilateral THR.

Use of a lateral offset short-leg walking cast before high tibial osteotomy.

The clinical results after high tibial osteotomy for the treatment of symptomatic varus gonarthrosis are unpredictable. Although preoperative gait analysis has been shown to be useful in predicting successful outcome after high tibial osteotomy, there are no readily available preoperative clinical tests for predicting success. The authors did a study to determine the effects of an offset short-leg walking cast as a potential predictor of clinical success after high tibial osteotomy.

Normalization of joint moments during gait: a comparison of two techniques.

Joint moments are commonly used to characterize gait. Factors like height and weight influence these moments. This study determined which of two commonly used normalization methods, body mass or body weight times height, most reduced the effects of height and weight on peak hip, knee, and ankle external moments during walking.

Comparison of clinical and dynamic knee function in patients with anterior cruciate ligament deficiency.

Background: Whether passive measures of isokinetic muscle strength deficits and knee laxity are related to the dynamic function of the anterior cruciate ligament-deficient knee remains unclear.

Hypotheses: Arthrometer measurements are not predictive of peak external knee flexion moment (net quadriceps muscle moment), isokinetic quadriceps muscle strength correlates with peak external knee flexion moment (net quadriceps muscle moment), and isokinetic hamstring muscle strength correlates with peak external knee extension moment (net flexor muscle moment).

Study Design: Cross-sectional study.

A new parametric approach for modeling hip forces during gait.

An analytical parametric model was developed to estimate the natural biological variations in muscle forces and their effect on the hip forces subject only to physiological constraints and not predefined optimization criterion. Force predictions are based on the joint kinematics and kinetics of each subject, a previously published muscle model, and physiological constraints on the muscle force distributions. The model was used to determine the hip contact forces throughout the stance phase of gait of a subject with a total hip replacement (THR).