A clinical bulbar assessment scale (CBAS) for amyotrophic lateral sclerosis.

INTRODUCTION/AIMS: Comprehensive and valid bulbar assessment scales for use within amyotrophic lateral sclerosis (ALS) clinics are critically needed. The aims of this study are to develop the Clinical Bulbar Assessment Scale (CBAS) and complete preliminary validation. METHODS: The authors selected CBAS items from among the literature and expert opinion, and content validity ratio (CVR) was calculated. Following consent, the CBAS was administered to a pilot sample of English-speaking adults with El Escorial defined ALS (N = 54) from a multidisciplinary clinic, characterizing speech, swallowing, and extrabulbar features. Criterion validity was assessed by correlating CBAS scores with commonly used ALS scales, and internal consistency reliability was obtained. RESULTS: Expert raters reported strong agreement for the CBAS items (CVR = 1.00; 100% agreement). CBAS scores yielded a moderate, significant, negative correlation with ALS Functional Rating Scale-Revised (ALSFRS-R) total scores (r = -0.652, p < .001), and a strong, significant, negative correlation with ALSFRS-R bulbar subscale scores (r = -0.795, p < .001). There was a strong, significant, positive correlation with Center for Neurologic Studies Bulbar Function Scale (CNS-BFS) scores (r = 0.819, p < .001). CBAS scores were significantly higher for bulbar onset (mean = 38.9% of total possible points, SD = 22.6) than spinal onset (mean = 18.7%, SD = 15.8; p = .004). Internal consistency reliability (Cronbach's alpha) values were: (a) total CBAS, α = 0.889; (b) Speech subscale, α = 0.903; and (c) Swallowing subscale, α = 0.801. DISCUSSION: The CBAS represents a novel means of standardized bulbar data collection using measures of speech, swallowing, respiratory, and cognitive-linguistic skills. Preliminary evidence suggests the CBAS is a valid, reliable scale for clinical assessment of bulbar dysfunction.

Innovative Use of the Health Status Questionnaire-12 for Individual and Population Health.

PURPOSE: Demonstrate how self-reported health (SRH) percentile ranks can be used in public health and clinical practice for better interpretable data. METHODS: Secondary analysis was completed to standardize Health Status Questionnaire-12 Version 2.0 (HSQ-12) scores. The HSQ-12 is a multi-item measure of SRH, with a Total Health Status Scale (THSS) and two subscales, Physical Health Status Scale (PHSS) and Mental Health Status Scale (MHSS). The sample included adult (19 and older) participants in Medicaid, including a normed sample (n=7,110) and population cohorts of midlife women (n=417) and pregnant women (n=1,888). RESULTS: Normed percentile data for HSQ-12 using the Medicaid sample were calculated and populations of midlife and pregnant women were compared with the normed percentile ranks. Results illustrate differences in percentile rank scores for the various population cohorts. CONCLUSIONS: This innovative strategy has the potential to lead to decisions that may positively influence health policies, outcomes, and lower health costs.

Improving Student Understanding of Academic Assessment Vocabulary Words Using Visual Cues: A Collaborative Effort.

Many students have difficulty understanding terms from the academic register such as "analyze," "discuss," and "compare." This issue may be exacerbated for some Native American students, especially those who live on reservations with limited exposure to mainstream cultures. In this community-based participatory research project, academic investigators partnered with educators and community members from Native communities in Nebraska and South Dakota to expand students' academic vocabulary and improve student achievement. Together, we formed a team in which community members collaborated with academic investigators to develop word-wall cards incorporating dual-coding theory-that is, combining visual and verbal cues-to help students understand academic vocabulary words. Paivio's dual-coding theory postulates that verbal and visual information are encoded in separate but interconnected pathways and that concepts encoded via both pathways are more easily remembered. Accordingly, presenting information using multiple mediums, such as graphs, photographs, or demonstrations, may enhance learning. These cards were shared with community educators who used them in their classrooms. We present evidence that incorporating these multimodal tools into classrooms may improve students' understanding of academic vocabulary. Through this partnership, educators in Native American communities were able to represent their lived experiences. Teachers and administrators in Native American and non-Native classrooms could easily partner with other experts to incorporate similar innovations in their own schools and classrooms.

Computerized Tomography derived psoas muscle indices in a healthy young population in the United States.

Objective: Psoas muscle metrics from diagnostic computerized tomography (CT) scans are emerging as clinically relevant biomarkers. Most muscle metrics from the US population are from older cohorts with co-morbidities. Published reports from a young or healthy population in the United States on psoas muscle metrics optimized for age, body mass index (BMI), and sex are lacking. This study determines the psoas muscle index (PMI) and psoas muscle density (PMD) for a normal young Midwestern US population. Methods: Retrospective cross-sectional analysis of pre-existent abdominal non-contrast CT scans from a young (19-40 years old), Midwestern, predominately Caucasian population was conducted within Aquarius iNtuition software automatically after manual identification of the psoas muscle. Electronic medical records provided access to subject data and archived CT scans were reviewed. Results: From 193 (45 male, 148 female) CT scans, for males, PMI was 5.9 cm2/m2 (SD=1.7) and PMD 48.4 HU (SD=5.5); for females PMI was 5.4 cm2/m2 (SD=1.4) and PMD 48.18 HU (SD=5.5). BMI was significantly correlated with PMI and PMD for both men (p<0.001, p<0.001 respectively) and women (p<0.001, p<0.001 respectively). Conclusion: Psoas muscle metrics are newly generated for PMI and PMD in a healthy population, allowing for future comparison studies determining muscle status.

Obesity bias in primary care providers.

BACKGROUND AND OBJECTIVES: At the forefront of the obesity epidemic, obesity bias is an under-recognized and widely prevalent barrier to optimal care of the obese patient, even among primary care professionals. Recommendations for the reduction of obesity bias include increasing provider awareness about the complex etiology of obesity and the difficulties obtaining sustainable weight loss. METHODS: Obesity bias was measured in primary care professionals (n=233) participating in a continuing education program, using the Anti-Fat Attitudes Questionnaire (AFAQ). Three sub-factors, "Fear of Fat," "Willpower," and "Dislike," were evaluated. Participants were divided into three primary care experience groups: least experienced (0--9 years, n=67), moderately experienced (10--19 years, n=49), and most experienced (20+ years, n=98). "Fear of Fat" and "Willpower" components were found to be more prevalent than "Dislike"; however, scores on the "Dislike" subscale were highest and significantly more prevalent in the group with the most experience. RESULTS: Results indicated that more experienced primary care professionals reported greater bias toward obese people than less experienced colleagues. CONCLUSIONS: Ongoing continuing education that recognizes the wide prevalence of obesity, encourages respect for people of size, and mitigates obesity stigma should be promoted for all providers, particularly those who have been in practice for many years.

The effect of HMG-CoA reductase inhibitors on cognition in patients with Alzheimer's dementia: a prospective withdrawal and rechallenge pilot study.

BACKGROUND: Statins are well-known for their cardiovascular benefits. However, the cognitive effects of statins are not well understood. We hypothesized that individuals with preexisting dementia would be more vulnerable to statin-related cognitive effects. OBJECTIVE: The aim of this study was to evaluate the impact on cognition of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor (statin) discontinuation and rechallenge in individuals with Alzheimer's dementia (AD) on statins at baseline. METHODS: A 12-week prospective, open-label study was conducted in a geriatric clinic setting. Eighteen older subjects underwent a 6-week withdrawal phase of statins followed by a 6-week rechallenge. The primary outcome measure was cognition, measured by the Mini-Mental State Examination (MMSE); secondary outcome measures were the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery, Activities of Daily Living (ADL) scale, Instrumental ADL (IADL) scale, and fasting cholesterol. The change in outcome measures was assessed using repeated-measures ANOVA and paired t tests. RESULTS: At the end of the intervention, there was a significant difference across time for MMSE score (P = 0.018), and total cholesterol (P = 0.0002) and a trend toward change across time for ADL (P = 0.07) and IADL (P = 0.06) scale scores. Further analyses using paired t tests indicated improvement in MMSE scores (Δ1.9 [3.0], P = 0.014) with discontinuation of statins and a decrease in MMSE scores (Δ1.9 [2.7], P = 0.007) after rechallenge. Total cholesterol increased with statin discontinuation (P = 0.0003) and decreased with rechallenge (P = 0.0007). The CERAD score did not show a change across time (P = 0.31). There was a trend toward improvement in ADL (P = 0.07) and IADL (P = 0.06) scale scores with discontinuation of statins, but no change with rechallenge. CONCLUSIONS: This pilot study found an improvement in cognition with discontinuation of statins and worsening with rechallenge. Statins may adversely affect cognition in patients with dementia.

Wii-fit for improving gait and balance in an assisted living facility: a pilot study.

Objectives. To determine the effects on balance and gait of a Wii-Fit program compared to a walking program in subjects with mild Alzheimer's dementia (AD). Methods. A prospective randomized (1 : 1) pilot study with two intervention arms was conducted in an assisted living facility with twenty-two mild AD subjects. In both groups the intervention occurred under supervision for 30 minutes daily, five times a week for eight weeks. Repeated measures ANOVA and paired t-tests were used to analyze changes. Results. Both groups showed improvement in Berg Balance Scale (BBS), Tinetti Test (TT) and Timed Up and Go (TUG) over 8 weeks. However, there was no statistically significant difference between the groups over time. Intragroup analysis in the Wii-Fit group showed significant improvement on BBS (P = 0.003), and TT (P = 0.013). The walking group showed a trend towards improvement on BBS (P = 0.06) and TUG (P = 0.07) and significant improvement in TT (P = 0.06). Conclusion. This pilot study demonstrates the safety and efficacy of Wii-Fit in an assisted living facility in subjects with mild AD. Use of Wii-Fit resulted in significant improvements in balance and gait comparable to those in the robust monitored walking program. These results need to be confirmed in a larger, methodologically sound study.

Religious coping and mental health outcomes: an exploratory study of socioeconomically disadvantaged patients.

OBJECTIVE: This study was designed to investigate the association between religious coping and mental health in a socioeconomically disadvantaged population. METHODS: Participants were selected as they presented for mental healthcare at a community health center for patients with little, if any, financial resources or insurance. A total of 123 patients participated in this study. Multiple regression analysis was used to identify religious coping predictors for mental health outcomes. RESULTS: Positive religious coping (PRC) was significantly associated with and predictive of better mental health (P < .01). Conversely, negative religious coping (NRC) was found to be significantly associated with poorer mental health scores (P = .031) with gender, income, and ethnicity controlled for in the model. The relationship between NRC and inferior mental health outcomes was more robust than the relationship between PRC and improved mental health scores. CONCLUSIONS: This study illustrates the important association between PRC and NRC and mental health outcomes among economically disadvantaged patients. Interpretation of these findings and clinical implications are offered.

Influence of a rural family medicine rotation on residency selection: MS3 versus MS4.

BACKGROUND AND OBJECTIVES: Many family medicine educators feel that a required clinical rotation in family medicine has a positive influence on medical students' selection of family medicine residencies. We investigated the effect of a rural family medicine rotation on students' residency choices and examined the differences between a third-year and a fourth-year rotation. METHODS: We surveyed 1,260 students before and after they participated in a required rural family medicine rotation. RESULTS: The rotation had a small positive effect on student interest in family medicine. Over 20 years, there was a net gain of 4.7% (93 students) from before to after the rotation. Moving the rural rotation from the MS4 to the MS3 year resulted in a significant decline in the number of students who switched their preferences toward family medicine and ultimately matched to a family medicine residency. CONCLUSIONS: When the rotation occurs in the third year, there is more time following the rotation for other influences to exert an impact on a student's specialty choice, resulting in a small "bleed" away from family medicine. It might be useful to develop programs that continue to pique the interest in family medicine during their fourth year.

Mind-body therapy: attitudes, beliefs and practices of graduate faculty and students from accredited marriage and family therapy programs in the U.S. and Canada.

CONTEXT: Interest in CAM and mind-body therapies (MBT) among mental health professionals has increased over the last decade. Individuals seeking treatment for mental health concerns often use MBTs and expect clinicians to be aware of such treatments. Yet, current data reveal a critical gap in training, practice, and the needs of those seeking treatment. OBJECTIVE: To determine the attitudes, beliefs, and practices of marriage and family therapists regarding MBTs. DESIGN: Electronic survey method using Likert-type scale questions. PARTICIPANTS: Clinical faculty members and graduate students (N = 140) from accredited Marriage and Family Therapy programs in the United States and Canada. RESULTS: Findings revealed that a majority of respondents believed that graduate programs should introduce MBT topics during course of training and that MBTs are valuable in the treatment of various clinical problems. Respondents were familiar with at least one form of MBT and reported using such in personal and professional settings.

Preceptorship rurality does not affect medical students' shelf exam scores.

OBJECTIVE: This study's objective was to determine whether junior medical students' end-of-rotation shelf exam scores varied by the preceptorship county's rurality. METHODS: Student learning during rural preceptorship experiences, 1999 to 2005, was assessed using the students' scores on the National Board of Medical Examiners family medicine subject examination. Rurality was measured using both population density and the rural-urban continuum (RUC) codes. RESULTS: Exam scores were collected between January 1999 and May 2005 for 734 students. Mean scores did not vary significantly by rurality, although they did vary significantly by semester. Test scores of students in rural locations were not statistically significantly different from those of students in urban preceptorships. CONCLUSIONS: Students assigned to preceptorships in rural locations scored at the same levels as students in urban preceptorships. The finding that there were no differences in medical students' exam scores based on the rurality of their family medicine preceptorship site indicates a substantial degree of educational equivalency between urban and rural preceptorships.

Improving female preventive health care delivery through practice change: an Every Woman Matters study.

BACKGROUND: The levels of breast and cervical cancer screening in Nebraska primary care remain suboptimal despite awareness of their importance, and despite implementation of the Every Woman Matters program to assist low-income women. The GAPS model was used to develop a practice-based intervention to identify and reduce barriers to delivery of breast and cervical cancer screening services. METHODS: Seven primary care practices actively participated in this multimethod case study. A research nurse collected data and facilitated the intervention process at each site. Qualitative data from field notes, patient encounters, and in-depth interviews of physicians and key informants were collected to describe the process of Papanicolaou and mammogram service delivery, and to identify barriers/facilitators to screening, and potential change areas. Chart reviews provided information regarding the preintervention and postintervention identification/execution of Papanicolaou smears and mammograms. Qualitative and quantitative analyses led to individual practice case studies. Cross case comparisons identified common themes. RESULTS: The individual practice plans for change had many commonalities, ie, developing screening databases and reminder systems. The biggest differences involved practice contexts. Despite use of the GAPS model and a financial incentive to obtain "buy in" from providers and staff, change was difficult for all but 2 of the practices. CONCLUSION: The complexity of practice context and its effect on change cannot be underestimated. Individual practice providers and staff are often unaware of the potential challenges, and unable/unwilling to overcome them.

Physicians' perspectives on caring for cognitively impaired elders.

PURPOSE: This study aims to develop an in-depth understanding of the issues important to primary care physicians in providing care to cognitively impaired elders. DESIGN AND METHODS: In-depth interviews were conducted with 20 primary care physicians. Text coded as "cognitive impairment" was retrieved and analyzed by use of grounded theory analysis techniques. RESULTS: A patient's impaired ability to provide an accurate history and to participate in self-care hindered the usual process of care, often resulting in greater medical uncertainty and feelings of inadequacy and frustration for the physician. Shifting the goal of care from "curing" the patient's illness to "caring" for the patient's quality of life was also problematic. The doctor-patient relationship changed dramatically as others became involved in care, often with attendant ethical dilemmas related to patient autonomy and the locus of decision making. Many physicians described a deep sense of loss and grief as the personhood of patients faded. The increased complexity and prominent social and emotional issues were difficult to manage in the context of the current model of practice. IMPLICATIONS: Profound changes occur in the process of care with cognitively impaired patients. The increased complexity mandates an expanded model of care that addresses the prominent psychosocial and ethical aspects of care as well as the medical ones.

Depression treatment in primary care.

BACKGROUND: Depression costs the United States dollars 40 billion annually. Primary care physicians play a key role in the identification and treatment of depression. This study focused on the treatment options recommended by physicians and whether physicians were following the recommended treatment guidelines. METHODS: We recorded treatment recommendations by examining charts for all patients with newly detected depression. The patients were from 44 family medicine practitioners and 23 general internal medicine practitioners in a Midwest university medical center setting. RESULTS: For both medical specialties combined, pharmacotherapy was the most widely used intervention (recommended for 52% of patients), whereas psychotherapy alone was the least frequently used intervention (recommended for 4% of patients). Family medicine practitioners recommended combination treatment (pharmacotherapy and psychotherapy) more frequently than did general internal medicine practitioners (P = .022), and female physicians recommended combination treatment more frequently than did male physicians (P = .010). CONCLUSIONS: Pharmacotherapy was found to be the most widely used treatment despite current evidence-based recommendations. Barriers to effective treatment plan are discussed. The implications for mental health interventions, combination therapy, and cost offset are also discussed. Further research exploring the negotiation process during the patient-provider encounter would shed light on patient and physician factors influencing treatment decisions.

Experience with routine vaginal pH testing in a family practice setting.

BACKGROUND: Despite recommendations by Centers for Disease Control and the American College of Obstetricians and Gynecologists, pH testing is infrequently performed during the evaluation of vaginitis. Consequently, little information exists on its use in a primary care setting. OBJECTIVE: The aim of this study was to describe our experience with routine pH testing, particularly the relationship between symptoms, pH and wet-mount microscopy. METHOD: A retrospective chart review was performed on 203 consecutive cases evaluated for vaginitis by wet-mount microscopy. RESULTS: Of the 203 cases, 21 had normal pH and no symptoms and 182 had symptoms, elevated pH or both; 85% of cases had abnormal wet-mount findings, including 75% with clue cells, 14% with Trichomonas vaginalis, 13% with yeast and 14% with mixed infections. Asymptomatic infection was present in 42% of cases with clue cells alone, 44% of cases with Trichomonas vaginalis alone, 38% of all trichomoniasis cases and 33% of cases with mixed infections. Elevated pH was associated with clue cells (p < 0.001), trichomoniasis (p = 0.01) and mixed infections (p = 0.003). Normal pH was associated with negative wet mount (p < 0.001) and to a lesser degree with uncomplicated vulvovaginal candidiasis (p = 0.06). CONCLUSION: Routine pH testing increased detection of trichomoniasis and bacterial vaginosis by prompting microscopy in a significant proportion of asymptomatic cases.