24R,25-dihydroxyvitamin D3 promotes the osteoblastic differentiation of human mesenchymal stem cells.

Although 1α,25-dihydroxyvitamin D3 [1α,25(OH)2D3] is considered the most biologically active vitamin D3 metabolite, the vitamin D3 prohormone, 25-hydroxyvitamin D3 [25(OH)D3], is metabolized into other forms, including 24R,25-dihydroxyvitamin D3 [24R,25(OH)2D3]. Herein we show that 24R,25(OH)2D3 is fundamental for osteoblastic differentiation of human mesenchymal stem cells (hMSCs). Our approach involved analyses of cell proliferation, alkaline phosphatase activity, and pro-osteogenic genes (collagen 1A1, osteocalcin, vitamin D receptor [VDR], vitamin D3-hydroxylating enzymes [cytochrome P450 hydroxylases: CYP2R1, CYP27A1, CYP27B1 and CYP24A1]) and assessment of Ca(2+) mineralization of extracellular matrix. 24R,25(OH)2D3 inhibited hMSC proliferation, decreased 1α-hydroxylase (CYP27B) expression, thereby reducing the ability of hMSCs to convert 25(OH)D3 to 1α,25(OH)2D3, and promoted osteoblastic differentiation through increased alkaline phosphatase activity and Ca(2+) mineralization. 24R,25(OH)2D3 decreased expression of the 1α,25(OH)2D3 receptor, VDR. 24R,25(OH)2D3 but not 1α,25(OH)2D3 induced Ca(2+) mineralization dependent on the absence of the glucocorticoid analog, dexamethasone. To elucidate the mechanism(s) for dexamethasone-independent 1α,25(OH)2D3 inhibition/24R,25(OH)2D3 induction of Ca(2+) mineralization, we demonstrated that 1α,25(OH)2D3 increased whereas 24R,25(OH)2D3 decreased reactive oxygen species (ROS) production. 25(OH)D3 also decreased ROS production, potentially by conversion to 24R,25(OH)2D3. Upon inhibition of the vitamin D3-metabolizing enzymes (cytochrome P450s), 25(OH)D3 increased ROS production, potentially due to its known (low) affinity for VDR. We hypothesize that vitamin D3 actions on osteoblastic differentiation involve a regulatory relationship between 24R,25(OH)2D3 and 1α,25(OH)2D3. These results implicate 24R,25(OH)2D3 as a key player during hMSC maturation and bone development and support the concept that 24R,25(OH)2D3 has a bioactive role in the vitamin D3 endocrine system.

Hepatocyte growth factor and p38 promote osteogenic differentiation of human mesenchymal stem cells.

Hepatocyte growth factor (HGF) is a paracrine factor involved in organogenesis, tissue repair, and wound healing. We report here that HGF promotes osteogenic differentiation through the transcription of key osteogenic markers, including osteocalcin, osterix, and osteoprotegerin in human mesenchymal stem cells and is a necessary component for the establishment of osteoblast mineralization. Blocking endogenous HGF using PHA665752, a c-Met inhibitor (the HGF receptor), or an HGF-neutralizing antibody attenuates mineralization, and PHA665752 markedly reduced alkaline phosphatase activity. Moreover, we report that HGF promotion of osteogenic differentiation involves the rapid phosphorylation of p38 and differential regulation of its isoforms, p38α and p38ß. Western blot analysis revealed a significantly increased level of p38α and p38ß protein, and reverse transcription quantitative PCR revealed that HGF increased the transcriptional level of both p38α and p38ß. Using small interfering RNA to reduce the transcription of p38α and p38ß, we saw differential roles for p38α and p38ß on the HGF-induced expression of key osteogenic markers. In summary, our data demonstrate the importance of p38 signaling in HGF regulation of osteogenic differentiation.

Simulating geriatric home safety assessments in a three-dimensional virtual world.

Virtual worlds could offer inexpensive and safe three-dimensional environments in which medical trainees can learn to identify home safety hazards. Our aim was to evaluate the feasibility, usability, and acceptability of virtual worlds for geriatric home safety assessments and to correlate performance efficiency in hazard identification with spatial ability, self-efficacy, cognitive load, and presence. In this study, 30 medical trainees found the home safety simulation easy to use, and their self-efficacy was improved. Men performed better than women in hazard identification. Presence and spatial ability were correlated significantly with performance. Educators should consider spatial ability and gender differences when implementing virtual world training for geriatric home safety assessments.

Hepatocyte growth factor (HGF) and 1,25-dihydroxyvitamin D together stimulate human bone marrow-derived stem cells toward the osteogenic phenotype by HGF-induced up-regulation of VDR.

Bone formation and remodeling require generation of osteoprogenitors from bone marrow stem cells (MSC), which are regulated by growth factors and hormones, with putative roles in mesenchymal cell differentiation. Hepatocyte growth factor (HGF) is a pleiotropic growth factor, and together with its high affinity receptor cMet are widely expressed in normal tissues. 1,25-dihydroxyvitamin D (1,25OHD) is the most active metabolite of vitamin D; produced mainly in the kidney, but also by osteoblasts. We previously reported that HGF and 1,25OHD act together to increase osteogenic differentiation of human MSC (hMSC) potentially through increasing p53. Although p53 does not induce the vitamin D receptor (VDR), p63, a member of the p53 family of transcription factors has been reported to up-regulate VDR expression in some tumor cell lines, and thus might play a part in HGF-regulated VDR expression. Our hypothesis is that the combination of HGF and 1,25OHD can induce hMSC differentiation by up-regulation of 1,25OHD and/or VDR expression to increase cell response(s) to 1,25OHD. Using real-time RT-qPCR, Western blots, luciferase reporter assays, and siRNAs, as well as antibodies to specific signaling molecules we showed that HGF induced VDR gene expression, as well as up-regulated p63 gene expression. p63 gene knockdown by siRNA eliminated the effects of HGF on VDR gene expression as measured by RT-qPCR, Western blots and luciferase reporter assay, and downstream on osteogenic differentiation markers, including alkaline phosphatase staining. Differentiation is a coordinated process of cell cycle exit and tissue-specific gene expression. These results suggest HGF might be a good candidate to coordinate the regulation of these two processes during hMSC osteogenic differentiation. p63 could be a key connecting molecule on the pathway of HGF-induced VDR expression. Understanding the role of these factors and their actions could have important clinical implications for the use of hMSC in the development of novel stem cell therapies.

Pilot study comparing changes in postural control after training using a video game balance board program and 2 standard activity-based balance intervention programs.

OBJECTIVE: To compare the impacts of Tai Chi, a standard balance exercise program, and a video game balance board program on postural control and perceived falls risk. DESIGN: Randomized controlled trial. SETTING: Research laboratory. PARTICIPANTS: Independent seniors (N=40; 72.5±8.40) began the training, 27 completed. INTERVENTIONS: Tai Chi, a standard balance exercise program, and a video game balance board program. MAIN OUTCOME MEASURES: The following were used as measures: Timed Up & Go, One-Leg Stance, functional reach, Tinetti Performance Oriented Mobility Assessment, force plate center of pressure (COP) and time to boundary, dynamic posturography (DP), Falls Risk for Older People-Community Setting, and Falls Efficacy Scale. RESULTS: No significant differences were seen between groups for any outcome measures at baseline, nor were significant time or group × time differences for any field test or questionnaire. No group × time differences were seen for any COP measures; however, significant time differences were seen for total COP, 3 of 4 anterior/posterior displacement and both velocity, and 1 displacement and 1 velocity medial/lateral measure across time for the entire sample. For DP, significant improvements in the overall score (dynamic movement analysis score), and in 2 of the 3 linear and angular measures were seen for the sample. CONCLUSIONS: The video game balance board program, which can be performed at home, was as effective as Tai Chi and the standard balance exercise program in improving postural control and balance dictated by the force plate postural sway and DP measures. This finding may have implications for exercise adherence because the at-home nature of the intervention eliminates many obstacles to exercise training.

Medical students' attitudes toward obese patient avatars of different skin color.

Physicians' biases for skin color and obesity may negatively affect health-care outcomes. Identification of these biases is the first step to address the problem. We randomized 128 U.S medical students into one of four animated videos of avatar physician-patient counseling sessions, varying the weight and skin color of an elderly patient avatar: white-thin, black-thin, white-obese and black-obese. Medical students viewed white obese avatars as unattractive, ugly, noncompliant, lazy, and sloppy. Medical students' comments suggested a paternalistic attitude toward avatar patients. Avatar-mediated experiences can elicit medical students' bias potentially enabling medical educators to implement bias reduction interventions.

Using anthropomorphic avatars resembling sedentary older individuals as models to enhance self-efficacy and adherence to physical activity: psychophysiological correlates.

The prevalence of obesity and associated health complications are currently at unprecedented levels. Physical activity in this population can improve patient outcomes. Virtual reality (VR) self-modeling may improve self-efficacy and adherence to physical activity. We conducted a comparative study of 30 participants randomized to 3 versions of a 3D avatar-based VR intervention about exercise: virtual representation of the self exercising condition; virtual representation of other person exercising and control condition. Participants in the virtual representation of the self group significantly increased their levels of physical activity. The improvement in physical activity for participants in the visual representation of other person exercising was marginal. The improvement for the control group was not significant. However, the effect sizes for comparing the pre and post intervention physical activity levels were quite large for all three groups. We did not find any group difference in the improvements of physical activity levels and self-efficacy among sedentary, overweight or obese individuals.

Sildenafil has little influence on cardiovascular hemodynamics or 6-km time trial performance in trained men and women at simulated high altitude.

UNLABELLED: Sildenafil improves maximal exercise capacity at high altitudes (∼4350-5800 m) by reducing pulmonary arterial pressure and enhancing oxygen delivery, but the effects on exercise performance at less severe altitudes are less clear. PURPOSE: To determine the effects of sildenafil on cardiovascular hemodynamics (heart rate, stroke volume, and cardiac output), arterial oxygen saturation (SaO2), and 6-km time-trial performance of endurance-trained men and women at a simulated altitude of ∼3900 m. METHODS: Twenty men and 15 women, endurance-trained, completed one experimental exercise trial (30 min at 55% of altitude-specific capacity +6-km time trial) at sea level (SL) and two trials at simulated high altitude (HA) while breathing hypoxic gas (12.8% FIo2) after ingestion of either placebo or 50 mg sildenafil in double-blind, randomized, and counterbalanced fashion. RESULTS: Maximal exercise capacity and SaO2 were significantly reduced at HA compared to SL (18%-23%), but sildenafil did not significantly improve cardiovascular hemodynamics or time-trial performance in either men or women compared to placebo and only improved SaO2 in women (4%). One male subject (5% of male subjects, 2.8% of all subjects) exhibited a meaningful 36-s improvement in time-trial performance with sildenafil compared to placebo. CONCLUSIONS: In this group of endurance trained men and women, sildenafil had very little influence on cardiovascular hemodynamics, SaO2, and 6-km time-trial performance at a simulated altitude of ∼3900 m. It appears that a very small percentage of endurance-trained men and women derive meaningful improvements in aerobic performance from sildenafil at a simulated altitude of ∼3900 m.

Human bone marrow-derived stem cell proliferation is inhibited by hepatocyte growth factor via increasing the cell cycle inhibitors p53, p21 and p27.

Human bone marrow-derived stem cells (hMSCs) are a major source of osteoprogenitors. Hepatocyte growth factor (HGF), a glycoprotein constitutively produced by hMSCs, is reported to act on differentiated osteoblasts and also osteoclasts. Moreover, HGF has been shown by us and others to enhance osteoblastic differentiation from hMSCs. Typically, the pro-differentiation effects of HGF have required cooperative action with regulatory factors such as vitamin D or bone matrix material. Here, we have pursued the molecular mechanisms underlying the osteogenic effect of HGF on hMSCs, the principal precursors to bone forming cells. HGF treatment of hMSCs reduced the cell number over time and increased G1/S cell-cycle arrest compared to control (non-treated) cells. RT-qPCR showed treatment with HGF increased gene expression of the cell-cycle inhibitors p53, p21, and p27, possibly explaining the cell growth inhibition and G1 arrest, a step critical to phenotypic differentiation. Transfection of siRNA specific for cMet, the HGF receptor, eliminated the HGF anti-proliferation effect on hMSCs and the HGF-mediated increase in p53, p21, and p27, strongly supporting a role for these cell-cycle inhibitors in HGF's regulation of hMSCs. HGF in combination with a known inducer of osteogenic differentiation, 1,25-dihydroxyvitamin D, significantly increased cell maturation/differentiation as indicated by an increase in several osteoblast markers. Taken together these results demonstrate that HGF significantly enhances hMSC osteoblast differentiation by 1,25-dihydroxyvitamin D.

Care management and the transition of older adults from a skilled nursing facility back into the community.

After hospitalization, many older adults require skilled nursing care. Although some patients receive services at home, others are admitted to a skilled nursing facility. In the current fragmented health care system, hospitals are financially incentivized to discharge frail older adults to a facility for postacute care as soon as possible. Similarly, many skilled nursing facilities are incentivized to extend the posthospitalization period of care and to transition the patient to custodial nursing home care. The resulting overuse of institution-based skilled nursing care may be associated with various adverse medical social and financial consequences. Care management interventions for more efficient and effective skilled nursing facility use must consider the determinants involved in the decisions to admit and maintain patients in skilled nursing facilities. As we await health care reform efforts that will address these barriers, opportunities already exist for care managers to improve the current postacute transition processes.

Sildenafil does not improve steady state cardiovascular hemodynamics, peak power, or 15-km time trial cycling performance at simulated moderate or high altitudes in men and women.

Sildenafil improves oxygen delivery and maximal exercise capacity at very high altitudes (≥ 4,350 m), but it is unknown whether sildenafil improves these variables and longer-duration exercise performance at moderate and high altitudes where competitions are more common. The purpose of this study was to determine the effects of sildenafil on cardiovascular hemodynamics, arterial oxygen saturation (SaO(2)), peak exercise capacity (W (peak)), and 15-km time trial performance in endurance-trained subjects at simulated moderate (MA; ~2,100 m, 16.2% F(I)O(2)) and high (HA; ~3,900 m, 12.8% F(I)O(2)) altitudes. Eleven men and ten women completed two HA W (peak) trials after ingesting placebo or 50 mg sildenafil. Subjects then completed four exercise trials (30 min at 55% of altitude-specific W (peak) + 15-km time trial) at MA and HA after ingesting placebo or 50 mg sildenafil. All trials were performed in randomized, counterbalanced, and double-blind fashion. Sildenafil had little influence on cardiovascular hemodynamics at MA or HA, but did result in higher SaO(2) values (+3%, p < 0.05) compared to placebo during steady state and time trial exercise at HA. W (peak) at HA was 19% lower than SL (p < 0.001) and was not significantly affected by sildenafil. Similarly, the significantly slower time trial performance at MA (28.1 ± 0.5 min, p = 0.016) and HA (30.3 ± 0.6 min, p < 0.001) compared to SL (27.5 ± 0.6 min) was unaffected by sildenafil. We conclude that sildenafil is unlikely to exert beneficial effects at altitudes <4,000 m for a majority of the population.

Development and pilot testing of a self-management internet-based program for older adults with overactive bladder.

OBJECTIVES: To implement and pilot test our Self-Management Internet-Based Program for Older Adults with Overactive Bladder (OAB-SMIP) in a group of older adults with overactive bladder (OAB) to determine its usability and outcomes, including knowledge, self-efficacy, perception of bladder condition, and health-related quality of life. METHODS: In a single-group study design with pre- and post-tests, we recruited 25 men and women age 55 or older with symptoms of OAB. The OAB-SMIP intervention consisted of 3 multimedia e-learning tutorials, social networking features, and other online resources delivered over 6 weeks. RESULTS: Participants enjoyed the OAB-SMIP and found it easy to use. Participants demonstrated increased knowledge (SMD=4.17, large effect size), and their symptoms improved after the intervention (SMD=1.20-1.30, large effect sizes). Participants improved their overall self-efficacy (SMD=1.84, large effect size) as well as their self-efficacy in performing pelvic muscle exercises (SMD=1.41, large effect size) and controlling urge symptoms (SMD=1.32, large effect size), and there were significant increases in health-related quality of life (SMD=1.13, large effect size) after exposure to the OAB-SMIP. We did not find any significant gender differences. CONCLUSIONS: Participants using the OAB-SMIP improved their knowledge, symptoms, self-efficacy in performing pelvic muscle exercises and overall management of OAB, as well as health-related quality-of-life scores.

Medication assessments by care managers reveal potential safety issues in homebound older adults.

BACKGROUND: Over-the-counter (OTC) medications, benzodiazepines, and barbiturates are not covered under many Medicare drug benefit plans; hence, their use by homebound older adults is largely unreported. Furthermore, the tiered design of Medicare drug formularies may in fact promote the use of older but potentially inappropriate medications. Little is known about the use of these medications in the homebound older adult population. OBJECTIVE: To determine the prevalence of the use by homebound older adults of OTC drugs, dietary supplements (vitamins, minerals, and herbal products), Part D-excluded medications (benzodiazepines and barbiturates), and potentially inappropriate medications (according to Beers criteria). METHODS: Patients were enrollees in a home and community-based Medicaid waiver provider. All clients were older than 65 and were dually eligible for Medicare and Medicaid. All clients met Florida Medicaid's medical and financial criteria for nursing home placement. The medication list was obtained by geriatric care managers during a home assessment. RESULTS: A total of 3911 older adults (mean [SD] age 83.6 [8.0] years) were taking an average of 9.9 [4.8] drugs. Of these individuals, 74.5% were using an OTC medication, 41.9% were using a dietary supplement, 29.6% were using a benzodiazepine or barbiturate, and 25.2% were using at least 1 potentially inappropriate medication. CONCLUSIONS: Based on data gathered by a geriatric care management assessment, we found that most of the homebound older adults enrolled in our study used medications not included in their Medicare drug benefit. The use of potentially inappropriate medications was also common in this population. Future drug safety initiatives involving the elderly will benefit from engaging care managers in identifying and addressing the potential hazards posed by commonly used prescribed and nonprescribed medications.

Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project.

A substantial proportion of hospitalizations of nursing home (NH) residents may be avoidable. Medicare payment reforms, such as bundled payments for episodes of care and value-based purchasing, will change incentives that favor hospitalization but could result in care quality problems if NHs lack the resources and training to identify and manage acute conditions proactively. Interventions to Reduce Acute Care Transfers (INTERACT) II is a quality improvement intervention that includes a set of tools and strategies designed to assist NH staff in early identification, assessment, communication, and documentation about changes in resident status. INTERACT II was evaluated in 25 NHs in three states in a 6-month quality improvement initiative that provided tools, on-site education, and teleconferences every 2 weeks facilitated by an experienced nurse practitioner. There was a 17% reduction in self-reported hospital admissions in these 25 NHs from the same 6-month period in the previous year. The group of 17 NHs rated as engaged in the initiative had a 24% reduction, compared with 6% in the group of eight NHs rated as not engaged and 3% in a comparison group of 11 NHs. The average cost of the 6-month implementation was $7,700 per NH. The projected savings to Medicare in a 100-bed NH were approximately $125,000 per year. Despite challenges in implementation and caveats about the accuracy of self-reported hospitalization rates and the characteristics of the participating NHs, the trends in these results suggest that INTERACT II should be further evaluated in randomized controlled trials to determine its effect on avoidable hospitalizations and their related morbidity and cost.

The response of elderly veterans to daily vitamin D3 supplementation of 2,000 IU: a pilot efficacy study.

OBJECTIVES: To determine the prevalence of hypovitaminosis D (serum 25-hydroxyvitamin D<32 ng/mL; HVD) in a population of elderly veterans and conduct a preliminary assessment of the efficacy of supplementation with cholecalciferol in correcting HVD. DESIGN: Randomized, double-blind, placebo-controlled clinical trial. SETTING: Geriatric clinic at the Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida. PARTICIPANTS: Veterans aged 70 and older. INTERVENTION: Oral cholecalciferol 2,000 IU daily or placebo for 6 months. MEASUREMENTS: Serum calcium, 25-hydroxyvitamin D, parathyroid hormone, and 24-hour urinary calcium. RESULTS: Of the 34 participants who completed the study, 62% had HVD at baseline. In the treatment group, mean serum 25-hydroxyvitamin D level rose from 28.4±7.9 ng/mL at baseline to 42.7±10.5 ng/mL at the end of the trial, but levels remained less than 32 ng/mL in three of 17 (18%) of the participants. In the placebo group, the baseline level of 27.7±8.3 ng/mL remained unchanged (28.8±8.7 ng/mL). Supplementation did not alter serum or urinary calcium levels and did not result in any adverse events. CONCLUSION: These initial observations suggest that, in older veterans, cholecalciferol 2,000 IU daily for 6 months is generally safe and corrects HVD in most but not all individuals.

Human marrow-isolated adult multilineage-inducible (MIAMI) cells protect against peripheral vascular ischemia in a mouse model.

BACKGROUND AIMS: The treatment of peripheral vascular disease (PVD) with stem cells potentially offers a promising strategy. We tested marrow-isolated adult multilineage-inducible (MIAMI) cells to induce neovascularization in a mouse model of critical hindlimb ischemia (CLI). METHODS: CLI was induced in the right hindlimb of Balb/C mice. One million MIAMI cells, normally grown at 3% O2, were injected in the adductor muscle along the ischemic region. All animals (n = 11 per group) were immunosuppressed with cyclosporine daily for the entire period. Human foreskin fibroblast (HFF) cells and phosphate-buffered saline (PBS) were used as controls. Blood perfusion in the ischemic right and non-ischemic left hindlimbs was measured. RESULTS: Compared with animals receiving HFF cells or PBS, MIAMI cells significantly improved blood perfusion, necrosis and inflammation in the ischemic limb. A fraction of injected MIAMI cells expressed CD31 and von Willebrand factor (vWF). MIAMI cells in vitro, under pro-angiogenic growth conditions, differentiated into endothelial-like cells and expressed endothelial markers such as CD31 and vWF, determined by quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR), and CD31 and kinase insert domain receptor (KDR), determined by immunofluorescence. Moreover, MIAMI cells formed vascular endothelial-like tubules in the presence of matrigel. Bioplex immunoassay analysis showed increased secretion of angiogenic/anti-inflammatory factors by the MIAMI cells under 3% O2 compared with 21% O2, including monocyte chemoattractant protein-1 (MCP-1), fractalkine (Ftk), growth-related oncogene (GRO), vascular endothelial growth factor (VEGF), interleukin (IL)-6 and IL-8. Furthermore, transcripts for anti-inflammatory molecules stanniocalcin-1 (STC-1) and tumor necrosis factor-α-stimulated gene 6 (TSG-6) were up-regulated several fold. CONCLUSIONS: MIAMI cells can be very useful for patients affected by CLI. MIAMI cells promote blood vessel formation and reduce inflammation and necrosis in ischemic tissue.

The positive attitudes and perceptions of care managers about advance directives.

In a previous intervention, we found that reminders from care managers failed to increase the number of their homebound older adult clients with advance directives. Thus, in the current study, we looked at the perceptions and attitudes of care managers about the need to discuss advance directives with their clients. Ninety-five care managers serving community-based nursing home-eligible older adults completed an 18-question survey, which found that care managers overwhelmingly believe it is important to address advance directives. Only 3.2% reported that discussing advance directives is time consuming. No attitudinal barriers were identified. Given their positive attitudes about advance directives, care managers need educational interventions that will provide the knowledge and skills to interact effectively with clients who are resistant to addressing end-of-life issues.

Avatar-mediated home safety assessments: piloting a virtual objective structured clinical examination station.

BACKGROUND: Avatars and virtual worlds offer medical educators new approaches to assess learners' competency in home-safety assessments that are less time-consuming and more flexible than traditional home visits. We sought to evaluate the feasibility and acceptability of implementing an avatar-mediated, 3-dimensional (3-D) home simulation as a virtual objective structured clinical examination station for geriatric medicine fellows. METHODS: We developed a 3-D home simulation in the virtual world Second Life (Linden Lab, San Francisco, CA) containing 50 safety hazards that could affect the safety of an elderly person at home. Eight geriatric medicine fellows participated in a 16-station objective structured clinical examination, with one station assigned to the 15-minute 3-D virtual world simulation, where the fellow's "home visit" was performed by navigating his or her avatar in the virtual world simulation. The fellows were instructed to find the home safety hazards in the simulated environment and then provide specific written recommendations. Two reviewers independently scored the fellows' written findings against an inventory-based checklist. RESULTS: The geriatric medicine fellows scored a mean of 43% ± SD 9 on the inventory-based checklist. The scoring of the 2 reviewers showed a high interrater reliability (88%). Six of the 8 participants (75%) rated the simulation as "excellent." Four of the 5 women (80%) and none of the 3 men (20%) participating in the virtual objective structured clinical examination needed navigation assistance in the 3-D virtual house. CONCLUSION: The 3-D, avatar-based, virtual geriatric home safety objective structured clinical examination is a practical and acceptable alternative to the traditional home safety visits in an objective structured clinical examination setting.

Telehealth-assisted care coordination of older veterans with type 2 diabetes lowers coronary heart disease risk despite clinical inertia.

BACKGROUND: The purpose of this study was to determine the impact of a telehealth care coordination (T-Care) program on coronary heart disease (CHD) risk in older adults with type 2 diabetes (T2D). METHODS: Forty-one patients with T2D, 68.7 (±8.9) years old, were enrolled in the T-Care program and followed up for 2 years. Data were collected on blood pressure (BP), lipids, and medications. CHD risk or Framingham risk score (FRS) was estimated by using the calculation for 10-year CHD risk based on the risk estimates derived from the experience of the Framingham Heart Study. Clinical inertia was defined as the lack of dose adjustment or new medication for BP or lipid management when appropriate, per standard-of-care guidelines. RESULTS: After 2 years of T-Care intervention, significant reductions were demonstrated in FRS (23.4 ± 13.5 to 18.2 ± 10.4, P = 0.007), systolic BP (140 ± 22.7 to 128.2 ± 18.5 mm Hg, P = 0.05), and diastolic BP (74 ± 13.8 to 68.7 ± 13.9 mm Hg, P = 0.07), but not low-density lipoprotein (LDL) cholesterol (100.2 ± 30.1 to 91.2 ± 26.6 mg/dL, P = 0.7). Clinical inertia for lipids was found in 17.1% of our patients; only those without clinical inertia showed significant reduction in the LDL cholesterol component of the FRS. In contrast, clinical inertia for BP was documented in 12.2% of our patients, but reduction in the BP component of the FRS was independent of the presence of clinical inertia. CONCLUSION: Participation in a T-Care program may lead to significantly reduced CHD risk among older patients with T2D, despite clinical inertia.

The script concordance test as a measure of clinical reasoning skills in geriatric urinary incontinence.

OBJECTIVES: To validate the use of a script concordance test (SCT), a tool to assess clinical reasoning in contexts of uncertainty, which are common in clinical geriatrics practice, on geriatric urinary incontinence (UI) to discriminate levels of expertise in this content area. DESIGN: A reference panel (15 geriatricians) and 12 respondents (10 senior geriatrics fellows and 2 interns) completed an online 100-item SCT test covering major topics in UI. The test was then optimized by discarding items with negative item-total correlation; the remaining 70 questions covered all major topics in UI. The test was then administered to a second group of participants with different levels of experience, mostly from the University of Miami: eight geriatricians, nine junior geriatrics fellows, 53 internal medicine residents, and 26 medical students. Investigators assessed test reliability and construct validity (to discriminate between levels of expertise). SETTING: Tertiary academic medical center and affiliated medical school. PARTICIPANTS: Medical students, internal medicine residents, geriatric medicine fellows, and practicing geriatricians. MEASUREMENTS: Seventy-item SCT. RESULTS: The Cronbach alpha for the 70-item test was 0.72. Mean scores were 75.3 ± 7.9 for geriatricians (n = 23), 69.0 ± 9.3 for senior geriatrics fellows (n = 10), 66.4 ± 6.8 for junior geriatrics fellows n = (9), 66.1 ± 5.7 for residents (n = 53), and 65.6 ± 8.5 for students (n = 26). Using analysis of variance, significant differences were found between the mean scores of the geriatricians and all other participants except senior fellows. CONCLUSION: The geriatric UI SCT demonstrated moderate reliability and evidence of construct validity, discriminating between experienced and nonexperienced physicians.