Improving access to care for underserved communities through telemedicine.

ABSTRACT: Telemedicine use expanded rapidly during the COVID-19 pandemic, giving patients access to quality care while reducing the spread of infection. Although beneficial changes were made to reimbursement and privacy guidelines to increase the ease of telemedicine for clinicians, the lack of digital devices, Internet, digital knowledge, and trust in this method of delivery are potential barriers to telemedicine for healthcare visits, and may have widened the care gap for underserved patients. To ensure that patients of all socioeconomic levels have access to telemedicine requires education, expanding broadband Internet access across the United States, and offering free or reduced Internet services to patients in need.

Legally involved individuals in state hospitals and community mental health settings: Introduction to the special section.

Over the past several years, individuals with serious mental illness (SMI) have become involved with the legal system at an increasing rate. State psychiatric hospitals and community mental health programs have seen a high number of referrals and admissions at a time when resources and staffing have been challenges. Individuals with SMI continue to be highly represented among those incarcerated in jails and prisons, often for minor charges. This article serves as an introduction to a special section of Psychological Services on innovations in assessment and treatment of legally involved patients in state hospitals and community mental health settings. Data are presented on the prevalence of legal involvement among individuals with serious mental illness, including the exponential growth in individuals evaluated and found incompetent to stand trial. A brief summary of the articles in the special section is presented, broken down by themes of assessment, treatment, and policy. We hope that the studies described in this issue will lead to further exploration of problems, barriers, and potential solutions for individuals with SMI who become involved with the legal system. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Pipeline to the Physician Assistant Profession: A Look to the Future.

ABSTRACT: The current pipeline of physician assistant (PA) school applicants reflects the future workforce of the profession, which is why the admissions process with all its components and variables is so important. Many studies have shown that a workforce that represents the patients it cares for leads to improved health outcomes, especially among underrepresented minority populations. Yet, PA programs have made little progress over the past 2 decades in increasing the diversity of matriculants and graduates. As a profession, it is our collective responsibility to intentionally advance diversity, equity, and inclusion, and examining the admissions process would be the most logical place to start.

Reflections on a Physician Assistant Entrance Exam: Does the Profession Need One?

ABSTRACT: Standardized entrance exams are used in many health professions as one way to objectively measure knowledge and facilitate comparisons across student groups. The physician assistant (PA) profession has historically not employed a profession-specific entrance exam, and the idea was never seriously explored until the Physician Assistant College Admissions Test was developed recently by a commercial assessment publisher, with field testing in some volunteer programs in 2018 and the exam's first administration in May of 2020. The 2020 Physician Assistant Education Association Presidents Commission chose to investigate the issues raised by a consensus-derived, PA-specific entrance exam to stimulate more informed discussion on the efficacy of such an exam. While it may have the potential to enhance efficiency in PA admissions and reduce variability in admissions requirements, a PA entrance exam would also likely introduce new challenges, including increased costs, impact on the diversity of the applicant pool, and incongruence with an increasingly holistic admissions process. The biggest barrier would likely be the lack of current consensus on the knowledge, skills, and attributes that matriculants need to be successful in the program and in clinical practice. Development of a consensus-derived PA entrance exam would be a complex, expensive, and time-consuming endeavor, requiring considerable attention to technical issues of psychometric quality, process transparency, and legal defensibility. Changes being made to health professions admissions practices due to the COVID-19 pandemic, including the dropping of test scores as a requirement by some institutions, may make some of the issues raised in this paper more timely than ever.

Accreditation 101: Develop, Assess, and Report Program Goals.

The aim of this article is to highlight the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) accreditation requirements for PA program goals, describe methods for writing effective goals, provide examples and analysis of hypothetical goals, and encourage the use of effective reporting strategies. Programs are encouraged to use one of 3 mnemonic conventions with each providing a useful framework for identifying key elements of goals: FAST, SMART, and Objectives and Key Results. These 3 acronyms are easy to remember and will yield goals that are consistent with the requirements of ARC-PA.

Reimagining Physician Assistant Education.

The physician assistant (PA) profession has successfully flourished for over 50 years, demand for graduates remains strong, and there is a wealth of research on the quality of care that PA graduates provide. Nevertheless, health care and education are constantly changing, and we must change with them. We must continually scan the horizon and consider how best to adapt to current issues like the clinical sites crisis, as well as evolutions in technology, pedagogy, and in our students themselves. The Physician Assistant Education Association Presidents Commission, a group of past presidents, sought to stimulate a conversation on "reimagining PA education" through the lens of advances in our knowledge of the neuroscience of learning and changes in technology, including simulation, and a broader focus on innovation and "thinking outside the box." Through interviews with PA faculty and leaders, we provide some examples of areas of innovation in education, especially on the possibilities presented by a more flexible approach to innovation from the accreditation body than many PA faculty might perceive. One initial conclusion is that PA educators should focus more on helping students to "think like clinicians" from the start of their education. This paper is primarily intended to stimulate dialog, and we encourage all PA educators to form-and more importantly, share-their own thoughts and questions, through the PAEA professional learning communities and Digital Learning Hub (PAEAlearning.org/learn/digital-learning-hub/).

Physician Assistant Program Goals: A Thematic Analysis.

PURPOSE: The purpose of this study was to provide a descriptive analysis of the goals of the accredited physician assistant (PA) programs across the country in order to obtain a baseline understanding of their themes. METHODS: Initial review of the goals resulted in the identification of recurring themes. The goals were evaluated relative to meeting the requirements specified in Standard A3.14 of the Accreditation Review Commission on Education for the Physician Assistant, including listing the goal with the defined benchmark expected and the program's progress in reaching the goal. Accreditation status was compared. RESULTS: Of the 238 accredited PA programs at the time of the study, 157 (66%) had Accreditation-Continued status, 56 (24%) were Accreditation-Provisional, and 25 (11%) had Accreditation-Probation status. The median number of 5 goals per program did not vary dependent on accreditation status. Only 43 of 238 PA programs (18%) provided goals with required benchmarks and supporting outcomes on their webpages. Almost all programs included at least one goal (and often more than one) with the theme of student acquisition of knowledge, skills, and attitudes needed to be a PA. Other commonly included themes in programmatic goals included the "capacity" of students to graduate from the PA program and become employed, valuing diversity and cultural differences, a comprehensive and strong curriculum, as well as alumni who are self-directed, lifelong learners. CONCLUSION: Program goals should be reviewed to ensure they include benchmarks that define success and report progress or outcomes in achieving those goals. Thematic analysis provides a powerful summary that then can be used to make conclusions across a large set of program data.

Using the Core Competencies for New Physician Assistant Graduates to Prioritize Admission Criteria for PA Practice in 2025.

In a fast-changing medical and educational environment, it is incumbent upon the physician assistant (PA) education community to periodically consider what the future practice environment might look like for our graduates. Changes in technology, regulation, reimbursement, health system economics, and health care delivery are among the many forces shaping the practice environment of the future. The 2018 Physician Assistant Education Association (PAEA) Presidents Commission reflected on what PA practice might look like in 2025 and used the Association's Core Competencies for New PA Graduates to consider what characteristics might therefore be required of the PA graduates who will practice in this future. We postulate that the future PA practice environment will require enhanced skills in such areas as interpreting technology-driven clinical data for patients and practices, consulting effectively with increasingly specialized members of health care teams, understanding population health and predictive analytics, and knowing how to access and critically assess new medical information. Working backward, we identify certain noncognitive attributes that will likely need to be prioritized in our admission processes and suggest some tools that can be used to assess them. These attributes include ethical responsibility, communication, critical thinking, situational judgment, and professionalism. As with all Presidents Commission articles, this piece is intended primarily to stimulate thought, dialogue, and future research. We encourage all faculty to participate in this dialogue, through the new PAEA Digital Learning Hub (https://paealearning.org/learn/digital-learning-hub/) and other channels.

Citation and Characteristic Analysis of Physician Assistant Programs Placed on Accreditation-Probation, 2015-2017.

PURPOSE: The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) is responsible for accrediting the current 236 entry-level physician assistant (PA) programs in the United States. This study analyzes citations levied against PA programs by the ARC-PA and how those citations relate to the commission's ultimate accreditation decisions; in addition, this study compares PA program characteristics and assesses those characteristics as they relate to recent accreditation outcomes. METHODS: This study used citations for specific violations of ARC-PA Standards to analyze the ARC-PA's accreditation decisions from September 2015 through September 2017. The institutional characteristics of programs that received an accreditation-probation decision were compared with those that received an accreditation-continued or accreditation-provisional decision. Where possible, outcome decisions were benchmarked using national data obtained from publications distributed by the Physician Assistant Education Association. RESULTS: On average, programs that were placed on accreditation-probation during the time frame of this study had received their initial accreditation 16 years before being placed on probation. Altogether, 393 citations were levied against those programs (range: 2-60 citations; median: 13.5 citations). Physician assistant programs that were awarded provisional or continued accreditation were cited for slightly different Standards violations than PA programs that were placed on probation. The average 5-year pass rate for students taking the Physician Assistant National Certifying Examination for the first time was not very different for students from PA programs that were placed on probation and all other programs. CONCLUSIONS: Faculty members, institutions, and entities that support PA program development can use this information to compare PA programs. The results of this study can help PA programs identify areas of frequent noncompliance with the ARC-PA's Standards; provide context that PA programs can use to assess their performance against other programs in the accreditation process; and help PA programs identify areas in need of priority attention nationwide.

Systemic lupus erythematosus: a review of the disease and treatment options.

OBJECTIVE: To provide an up-to-date review of the etiology, epidemiology, clinical features, diagnostic findings, and treatment options for systemic lupus erythematosus (SLE). DATA SOURCES: A PubMed search of English language articles using a combination of words: elderly, systemic lupus erythematosus*, late onset systemic lupus erythematosus*, etiology, screening, diagnosis, or treatment to identify original studies, guidelines, and reviews on systemic lupus erythematosus, SLE, and late onset systemic lupus erythematosus, published 2000 to present. STUDY SELECTION AND DATA EXTRACTION: Original studies, clinical reviews, references, and guidelines were obtained and evaluated on their clinical relevance. DATA SYNTHESIS: The literature included guidelines and considerations for the etiology, diagnosis, screening, and management of SLE. CONCLUSION: SLE is a chronic autoimmune disorder. It predominantly affects younger women, but can occur in up to 20% of patients 50 years of age or older. SLE affects almost every system in the body, with varying degrees of severity. The diagnosis is based on criteria set by the American College of Rheumatology. Management is individualized and depends on presenting symptoms.

Hypothyroidism and subclinical hypothyroidism in the older patient.

OBJECTIVE: To review the etiology, precipitating factors, clinical findings, screening recommendations, and treatment for primary hypothyroidism and subclinical hypothyroidism in the older patient. DATA SOURCES: A PubMed search of English language articles using a combination of words: elderly, thyroid, hypothyroid,* subclinical hypothyroid,* etiology, screening, diagnosis, and treatment to identify original studies, guidelines, and reviews on primary hypothyroidism and subclinical hypothyroidism published between 1979 and present. STUDY SELECTION AND DATA EXTRACTION: Overall, 51 clinical reviews, original studies, references, and guidelines were obtained and evaluated on their clinical relevance to the older patient population. DATA SYNTHESIS: The literature included guidelines and considerations for the diagnosis, screening, and management of subclinical and overt primary hypothyroidism in the older patient. CONCLUSION: Females and individuals 60 years of age or older have a higher prevalence of primary hypothyroidism and subclinical hypothyroidism. While screening recommendations exist, the need or suggested age to initiate screening varies among organizations. TSH and free T4 values are used for diagnosing and monitoring. Levothyroxine remains the drug of choice for replacing endogenous thyroid hormone. Despite evidence to suggest its need, the treatment of subclinical hypothyroidism remains controversial.

Clinical coordination and the experiential year in physician assistant education.

PURPOSE: The purpose of this study was to examine how clinical coordination is accomplished within physician assistant (PA) education and to identify effective practices for placing PA students into experiential rotations. METHODS: A survey was sent to all fully accredited PA programs asking the clinical coordinators to provide information about themselves and their institutions, programs, activities, and the individuals for which they had responsibility. Data were analyzed using descriptive and inferential statistics. Ten independent variables were selected due to their expected potential to influence the following four dependent variables: length of most recent accreditation cycle, clinical coordination satisfaction, hours spent cultivating sites, and summed hours of clinical coordinator tasks that most directly impact students. Bivariate correlations between each independent variable and each dependent variable were calculated. The level of statistical significance was set at p < 0.05. RESULTS: Fifty-two out of 130 eligible programs (40%) responded in part to the survey. The tasks clinical coordinators performed and the level to which they were responsible to complete these tasks varied considerably. Clinical coordinators reported being satisfied with their roles, able to help others, and successful in their work. The correlation between clinical coordination satisfaction and the availability of the preceptor incentive of campus privileges was inversely significant (r(25) = -0.464, p = 0.01). CONCLUSION: This study provides an overview of PA program clinical coordination practices and may have implications for programs that wish to benchmark or develop strategies to normalize the activities associated with their program's experiential year.

Amnioexchange for the treatment of gastroschisis--an in vitro study to determine the volume and number of exchanges needed.

OBJECTIVE: Intestinal damage of neonates with gastroschisis is thought to be attributed to prolonged exposure to the toxic environment of the amniotic fluid. Amnioexchange/infusion has been a proposed method to improve bowel quality. The aim of the current study was to design an in vitro model to determine the volume and number of amnioexchanges needed to achieve a predetermined reduction in a solute contained within the original concentration of amniotic fluid. METHODS: We used a predetermined volume of normal saline to serve as the model for the amniotic cavity and the chloride anion as the surrogate for the noxious agent. Volumes of 250, 500, and 750 ml were used to represent the amniotic volume at different gestational ages. We performed a series of exchanges based on our calculated formula for each respective volume. The Student t test was used to calculate the differences between our expected and observed mean chloride concentrations (p < 0.05 = significance). RESULTS: The mean baseline chloride concentration was 100 mmol/l for each volume. Our formula overestimated the number of exchanges needed to reach a 75% reduction in chloride concentration for each volume, but this was not statistically significantly different from the observed number of exchanges (p < 0.05). CONCLUSION: Our formula required a correction factor of 3 or 4 fewer exchanges to obtain the desired 75% reduction in chloride concentration. It may be useful when investigations to study amnioexchange are undertaken for the treatment of fetuses with gastroschisis.

Diagnostic accuracy of cervicovaginal interleukin-6 and interleukin-6:albumin ratio as markers of preterm delivery.

BACKGROUND: Absence of fetal fibronectin (fFN) in the cervicovaginal fluid (CVF) of women with symptoms of preterm labor is an excellent predictor of women who will not deliver within 2 weeks of testing. Preliminary studies suggest interleukin (IL)-6 performs similarly to fFN. The positive predictive values of both these assays are poor. Inconsistent specimen collection may explain this poor performance. The objective of this study was to validate the clinical utility of cervicovaginal IL-6 and investigate the utility of the IL-6:albumin ratio to predict delivery within 14 days. METHODS: We quantified albumin and IL-6 with the DPC Immulite in 660 CVF specimens collected for physician-ordered fFN analysis. The clinical utility of IL-6 and IL-6:albumin to predict delivery within 14 days of collection was determined. RESULTS: The sensitivity, specificity, and positive and negative likelihood ratios for delivery within 14 days were 65%, 87%, 4.8, and 0.4, respectively, for fFN and 35%, 91%, 3.8, and 0.7 for IL-6, with a 250 ng/L cutoff. With a preterm delivery prevalence of 4.7%, positive and negative predictive values were 19% and 98%, respectively, for fFN and 16% and 97% for IL-6. The areas under the ROC curves were 0.71 and 0.51 for IL-6 and IL-6:albumin, respectively. Odds ratios for delivery within 14 days of collection were 11.8 (P <0.0001), 5.5 (P = 0.0001), and 2.4 (P = 0.06) for fFN, IL-6, and IL-6:albumin, respectively. CONCLUSIONS: Cervicovaginal IL-6 may have utility for predicting preterm labor while offering the potential for substantial cost savings. Assay performance characteristics are not improved by normalizing IL-6 to albumin.

Bovine cardiac troponin T is not accurately quantified with a common human clinical immunoassay.

The detection of myocardial injury in cattle caused by the ingestion of cardiotoxic compounds or cardiac diseases would be facilitated by the availability of a rapid and specific quantitative serum assay for cardiac troponins. Therefore, the accuracy of the only cardiac troponin T (cTnT) immunoassay to receive approval by the US Food and Drug Administration for the measurement of cTnT in human serum was evaluated to quantify the protein in bovine serum. Recovery experiments were performed by the addition of purified bovine cTnT to normal bovine serum. Cardiac troponin T was quantified using an immunoassay commonly used for the measurement of cTnT in human serum. The immunoassay demonstrated a well correlated (r = 0.99) and linear dose-dependent response to bovine cTnT but with poor accuracy (slope = 0.024; 95% CI = 0.018 to 0.030). The mean recovery of bovine cTnT was 2.4% across a concentration range of 10 ng/ml to 1,000 ng/ml. These studies demonstrate that a commonly used immunoassay for the measurement of cTnT in human serum demonstrates poor accuracy for the quantification of bovine cTnT.

The relationships among insight, social support, and depression in psychosis.

We assessed the role of satisfaction with social support as a mediating factor in the relationship between insight and depression in psychosis. Forty inpatients with schizophrenia-spectrum disorders self-completed measures of insight, social support, and depression. Results showed a curvilinear relationship between insight and satisfaction with support: those with high and low insight tended to have higher satisfaction with support than those with moderate insight. Satisfaction also had a negative relationship with depression. We found no direct relationship between insight and depression. This was consistent with satisfaction with social support mediating the relationship between global insight and depression.

Immunofixation reveals an apparent alpha heavy chain caused by precipitation of fibrinogen with IgA antiserum.

BACKGROUND: Fibrinogen present in serum specimens can interfere with the interpretation of serum protein electrophoresis. We report here the unexpected precipitation of fibrinogen by an IgA antiserum used in immunofixation electrophoresis. METHODS: Immunofixation electrophoresis of plasma combined with ethanol precipitation, serial dilution of plasma, and fibrinogen adsorption of the antiserum were used to investigate the apparent immunoreactivity of a commercial source of IgA antiserum to fibrinogen. RESULTS: Fibrinogen immunoreactivity by IgA antiserum was observed at fibrinogen concentrations > or =0.93 g/l. Ethanol precipitation of plasma removed fibrinogen and prevented the immunofixation of the protein by the IgA antiserum. Adsorption of the IgA antiserum with human fibrinogen removed its ability to precipitate fibrinogen, demonstrating cross-reactivity between the IgA antiserum and fibrinogen. CONCLUSIONS: Commercial sources of antiserum used for immunofixation electrophoresis may contain antibodies with specificity towards proteins typically absent from serum such as fibrinogen and can produce clinically misleading results.

Role of phase variation of type 1 fimbriae in a uropathogenic Escherichia coli cystitis isolate during urinary tract infection.

Type 1 fimbrial phase-locked mutants of uropathogenic Escherichia coli cystitis isolate F11 were used to assess the role of the invertible element during urinary tract infection. Compared to the wild type, the phase-locked off mutant was attenuated, and constitutive production of type 1 fimbriae by the phase-locked on mutant did not provide a competitive advantage.

Coordinate expression of fimbriae in uropathogenic Escherichia coli.

Uropathogenic Escherichia coli is the most common etiological agent of urinary tract infections. Bacteria can often express multiple adhesins during infection in order to favor attachment to specific niches within the urinary tract. We have recently demonstrated that type 1 fimbria, a phase-variable virulence factor involved in adherence, was the most highly expressed adhesin during urinary tract infection. Here, we examine whether the expression of type 1 fimbriae can affect the expression of other adhesins. Type 1 fimbrial phase-locked mutants of E. coli strain CFT073, which harbors genes for numerous adhesins, were employed in this study. CFT073-specific DNA microarray analysis of these strains demonstrates that the expression of type 1 fimbriae coordinately affects the expression of P fimbriae in an inverse manner. This represents evidence for direct communication between genes relating to pathogenesis, perhaps to aid the sequential occupation of different urinary tract tissues. While the role of type 1 fimbriae during infection has been clear, the role of P fimbriae must be further defined to assert the relevance of coordinated regulation in vivo. Therefore, we examined the ability of P fimbrial isogenic mutants, constructed in a type 1 fimbrial-negative background, to compete in the murine urinary tract over a period of 168 h. No differences in the colonization of these mutants were observed. However, comparison of these results with previous studies suggests that inversely coordinated expression of adhesin gene clusters does occur in vivo. Interestingly, the mutant that was incapable of expressing either type 1 or P fimbriae compensated by synthesizing F1C fimbriae.

Diagnostic considerations in the measurement of human chorionic gonadotropin in aging women.

BACKGROUND: Human chorionic gondadotropin (hCG) screening tests are performed on nearly all female patients of childbearing age before any medical intervention. Although older women usually have negative hCG test results, positive results do occur and may cause clinical confusion. We examined changes with age in serum hCG concentrations in nonpregnant women and investigated the use of serum follicle-stimulating hormone (FSH) measurements as an aid to interpreting higher than expected ("positive") hCG results. METHODS: We used 240 serum specimens for each of 4 female cohorts: pregnant, > or =18 years; nonpregnant, 18-40 years (premenopausal); nonpregnant, 41-55 years (perimenopausal); and nonpregnant, >55 years (postmenopausal). Patients were excluded if they had an ectopic pregnancy, a history of trophoblastic disease or a germ-cell tumor, or if no chart was available for review. Quantitative hCG and FSH tests were performed on each specimen. RESULTS: Serum hCG concentrations in nonpregnant women increased with the age of the women. hCG results were higher and significantly different (P < 0.0001) for nonpregnant women >55 years (<2.0 to 13.1 IU/L) compared with nonpregnant women 18-40 years (<2.0 to 4.6 IU/L) and 41-55 years (<2.0 to 7.7 IU/L). Nineteen nonpregnant women >40 years of age had hCG concentrations > or = 5.0 IU/L, all with an FSH concentration >32.4 IU/L. The highest FSH concentration in pregnancy was 7.3 IU/L. CONCLUSIONS: Serum hCG increases with age in nonpregnant women. A cutoff of 14.0 IU/L should be used when interpreting hCG results in women >55 years of age. Pregnancy is unlikely in perimenopausal women 41-55 years of age with an hCG between 5.0 and 14.0 IU/L if serum FSH is >20.0 IU/L.