Quantifying neurologic disease using biosensor measurements in-clinic and in free-living settings in multiple sclerosis.

Technological advances in passive digital phenotyping present the opportunity to quantify neurological diseases using new approaches that may complement clinical assessments. Here, we studied multiple sclerosis (MS) as a model neurological disease for investigating physiometric and environmental signals. The objective of this study was to assess the feasibility and correlation of wearable biosensors with traditional clinical measures of disability both in clinic and in free-living in MS patients. This is a single site observational cohort study conducted at an academic neurological center specializing in MS. A cohort of 25 MS patients with varying disability scores were recruited. Patients were monitored in clinic while wearing biosensors at nine body locations at three separate visits. Biosensor-derived features including aspects of gait (stance time, turn angle, mean turn velocity) and balance were collected, along with standardized disability scores assessed by a neurologist. Participants also wore up to three sensors on the wrist, ankle, and sternum for 8 weeks as they went about their daily lives. The primary outcomes were feasibility, adherence, as well as correlation of biosensor-derived metrics with traditional neurologist-assessed clinical measures of disability. We used machine-learning algorithms to extract multiple features of motion and dexterity and correlated these measures with more traditional measures of neurological disability, including the expanded disability status scale (EDSS) and the MS functional composite-4 (MSFC-4). In free-living, sleep measures were additionally collected. Twenty-three subjects completed the first two of three in-clinic study visits and the 8-week free-living biosensor period. Several biosensor-derived features significantly correlated with EDSS and MSFC-4 scores derived at visit two, including mobility stance time with MSFC-4 z-score (Spearman correlation -0.546; p = 0.0070), several aspects of turning including turn angle (0.437; p = 0.0372), and maximum angular velocity (0.653; p = 0.0007). Similar correlations were observed at subsequent clinic visits, and in the free-living setting. We also found other passively collected signals, including measures of sleep, that correlated with disease severity. These findings demonstrate the feasibility of applying passive biosensor measurement techniques to monitor disability in MS patients both in clinic and in the free-living setting.

Effectiveness and Safety of an Independently Run Nurse Practitioner Outpatient Cardioversion Program (2009 to 2014).

Sustained growth in the arrhythmia population at Stanford Health Care led to an independent nurse practitioner-run outpatient direct current cardioversion (DCCV) program in 2012. DCCVs performed by a medical doctor, a nurse practitioner under supervision, or nurse practitioners from 2009 to 2014 were compared for safety and efficacy. A retrospective review of the electronic medical records system (Epic) was performed on biodemographic data, cardiovascular risk factors, medication history, procedural data, and DCCV outcomes. A total of 869 DCCVs were performed on 557 outpatients. Subjects were largely men with an average age of 65 years; 1/3 were obese; most had atrial fibrillation; and majority of subjects were on warfarin. The success rate of the DCCVs was 93.4% (812 of 869) with no differences among the groups. There were no short-term complications: stroke, myocardial infarction, or death. The length of stay was shortest in the NP group compared to the other groups (p <0.001). In conclusion, the success rate of DCCV in all groups was extremely high, and there were no complications in any of the DCCV groups.

A histological and mechanical analysis of the cardiac lead-tissue interface: implications for lead extraction.

The major risks of pacemaker and implantable cardioverter defibrillator extraction are attributable to the fibrotic tissue that encases them in situ, yet little is known about the cellular and functional properties of this response. In the present research, we performed a histological and mechanical analysis of human tissue collected from the lead-tissue interface to better understand this process and provide insights for the improvement of lead design and extraction. The lead-tissue interface consisted of a thin cellular layer underlying a smooth, acellular surface, followed by a circumferentially organized collagen-rich matrix. 51.8±4.9% of cells were myofibroblasts via immunohistochemistry, with these cells displaying a similar circumferential organization. Upon mechanical testing, samples exhibited a triphasic force-displacement response consisting of a toe region during initial tensioning, a linear elastic region and a yield and failure region. Mean fracture load was 5.6±2.1N, and mean circumferential stress at failure was 9.5±4.1MPa. While the low cellularity and fibrotic composition of tissue observed herein is consistent with a foreign body reaction to an implanted material, the significant myofibroblast response provides a mechanical explanation for the contractile forces complicating extractions. Moreover, the tensile properties of this tissue suggest the feasibility of circumferential mechanical tissue disruption, similar to balloon angioplasty devices, as a novel approach to assist with lead extraction.

Decisional balance among potential implantable cardioverter defibrillator recipients: development of the ICD-decision analysis scale (ICD-DAS).

INTRODUCTION: Sudden cardiac death is a well-documented public health problem and the implantable cardioverter defibrillator (ICD) has demonstrated benefit in reducing mortality. Prospective patients must identify and evaluate the ICD's pros and cons and produce a personal decision. The purpose of this study was to create and evaluate a measure of patient-evaluated pros and cons of the ICD, and its relationship to patient decision regarding ICD implantation. METHODS AND RESULTS: The ICD-decision analysis scale (ICD-DAS) was created and tested in prospective ICD recipients (N = 104). Factor analysis was performed to evaluate interitem relationships, and subsequently, identified subscales; additional psychosocial measures were used to predict the ICD decision. A two-factor measure for ICD decision making was established with two subscales: ICD Pros and ICD Cons. The subscales have high internal consistency and were strong predictors of intent to choose an ICD. Other psychosocial measures were not significantly predictive of ICD Choice, yet simultaneous entry of ICD Pros and Cons subscales resulted in a significant increase in R(2) , F(2, 59) = 19.36, P < 0.001. The full model was significantly greater than zero, F(11, 70) = 5.017, P < 0.001, R(2)  = 0.48. CONCLUSION: The ICD-DAS provides the first empirically tested and clinically useful approach to understanding the specific pros and cons for prospective ICD patients. The measure can assist clinicians with patient-centered discussions regarding sudden cardiac arrest treatments. The ICD-DAS will allow for the provision of tailored education or counseling and may be used to predict postdecision outcomes.

Phlebitis in amiodarone administration: incidence, contributing factors, and clinical implications.

BACKGROUND: Intravenous amiodarone is an important treatment for arrhythmias, but peripheral infusion is associated with direct irritation of vessel walls and phlebitis rates of 8% to 55%. Objectives To determine the incidence and factors contributing to the development of amiodarone-induced phlebitis in the coronary care unit in an academic medical center and to refine the current practice protocol. METHODS: Medical records from all adult patients during an 18-month period who received intravenous amiodarone while in the critical care unit were reviewed retrospectively. Route of administration, location, concentration, and duration of amiodarone therapy and factors associated with occurrence of phlebitis were examined. Descriptive statistics and regression methods were used to identify incidence and phlebitis factors. RESULTS: In the final sample of 105 patients, incidence of phlebitis was 40%, with a 50% recurrence rate. All cases of phlebitis occurred in patients given a total dose of 3 g via a peripheral catheter, and one-quarter of these cases (n = 10) developed at dosages less than 1 g. Pain, redness, and warmth were the most common indications of phlebitis. Total dosage given via a peripheral catheter, duration of infusion, and number of catheters were significantly associated with phlebitis. CONCLUSIONS: Amiodarone-induced phlebitis occurred in 40% of this sample at higher drug dosages. A new practice protocol resulted from this study. An outcome study is in progress.

Special considerations in wound bed preparation 2011: an update©.

This article builds and expands upon the concept of wound bed preparation introduced by Sibbald et al in 2000 as a holistic approach to wound diagnosis and treatment of the cause and patient-centered concerns such as pain management, optimizing the components of local wound care: Debridement, Infection and persistent Inflammation, along with Moisture balance before Edge effect for healable but stalled chronic wounds.

Beds: practical pressure management for surfaces/mattresses.

The prevention and management of pressure ulcers, including support surface selection, are a primary focus of healthcare providers. This article discusses the forces contributing to pressure ulcer formation and explores choosing therapeutic support surface features based on the patient's clinical needs and on using the evidence-informed support surface algorithm and decision trees.

Ankle brachial index screening in asymptomatic older adults.

BACKGROUND: Screening for peripheral arterial disease (PAD) by measuring ankle brachial index (ABI) in asymptomatic older adults is currently recommended to improve cardiovascular disease risk assessment and establish early treatment, but it is not clear if the strategy is useful in all populations. We examined the prevalence and independent predictors of an abnormal ABI (<0.90), in an asymptomatic sample of 1,017 adults, 60 to 69 years old, enrolled in the ADVANCE study. METHODS: Baseline data collected between December 2001 and January 2004 among the healthy older controls enrolled in ADVANCE was examined. Frequency distributions and prevalence estimates of an abnormal ABI were calculated, using both standard and modified definitions of ABI. Stepwise logistic regression was used to examine independent predictors of ABI <0.90. Signal detection analysis using recursive partitioning was employed to explore potential demographic and clinical variables related to ABI <0.90. RESULTS: The prevalence of ABI <0.90 was 2% when using the standard definition and 5% when using a modified definition. ABI prevalence did not differ by gender (P > .05). Compared with subjects who had a normal ABI (0.90-1.39), subjects with an ABI <0.90 were more likely to currently smoke, be physically inactive, have a coronary artery calcium score >10, and an FRS >20% (P ≤ .02). Independent predictors of ABI <0.90 when using the standard definition included currently smoking, physical inactivity, and body mass index >30 (all P values ≤.03), and when using the modified definition included currently smoking, physical inactivity, and hypertension (all P values ≤.04). Currently, smoking was the only significant variable for ABI <0.90 derived through recursive partitioning (P = .02), and indicated that prevalence of ABI <0.90 was 1.5% for nonsmokers, while it was 6.6% for current smokers. CONCLUSIONS: ABI screening in generally healthy individuals 60 to 69 years old may result in lower prevalence rates of a positive result than estimates based on studies in clinical populations. The modified definition for calculating ABI captured more asymptomatic adults with suspected peripheral arterial disease. More evaluation of the appropriate role of ABI screening in unselected populations is needed before routine screening is implemented.

Factors associated with potential medication-herb/natural product interactions in a rural community.

CONTEXT: Use of both conventional medicines and herbs/natural products are increasing in the United States. Consequently, individuals are more likely to be exposed to potentially harmful interactions between these products. OBJECTIVE: To examine the use of both herbs/natural products and conventional medications in a rural community, examine the prevalence of potential interactions between herbs/natural products and conventional medications, and identify factors associated with exposure to such interactions. DESIGN: Population-based epidemiological study. SETTING: Data for this paper were collected between 1999 and 2004 as part of the Johnston County Osteoarthritis Project. PARTICIPANTS: Limited to civilian, noninstitutionalized, white or African American residents, aged 45 years or older, of Johnston County, North Carolina. Data used in this paper are from 2523 individuals who completed face-to-face interviews. MAIN OUTCOME MEASURES: Prevalence of herb/natural product use and exposure to potential interactions between these products and conventional medications. RESULTS: Nineteen percent (n=488) of participants used at least 1 herb/natural product. Among those who used both conventional medications and herbs/natural products, more than 1 in 5 (97 [21.9%]) were using a combination of products associated with a potential interaction. Odds of exposure to a potential interaction were lower among people who had health insurance and increased with the number of products used. CONCLUSIONS: Many people are exposed to potential interactions between herbs/natural products and conventional medications. Research is needed to better understand the effect such interactions may have on patient care.

A lesson in treating the whole patient: Todd Nicholson's story.

The authors present a patients story to demonstrate the usefulness of a complete patient approach, incorporating V.A.C. therapy, to achieving clinical success from the patients perspective. The article discusses why a total patient approach is important and therapeutic flexibility increases the chance of a successful outcome for all involved.

Incidental findings on cardiac multidetector row computed tomography among healthy older adults: prevalence and clinical correlates.

BACKGROUND: With the widespread use of cardiac multidetector row computed tomography (MDCT), the issue of incidental findings is receiving increasing attention. Our objectives were to evaluate the prevalence of incidental findings discovered during cardiac MDCT scanning and to identify clinical variables associated with incidental findings. METHODS: This cross-sectional analysis involved a population-based sample recruited from an integrated health care delivery system in Northern California as part of the Atherosclerotic Disease, Vascular Function and Genetic Epidemiology (ADVANCE) Study. Healthy men and women aged 60 to 69 years without diagnosed cardiovascular disease underwent cardiac MDCT for the detection and quantification of coronary artery calcification. The images were prospectively evaluated for incidental findings. RESULTS: A total of 459 participants underwent MDCT scanning, and the overall prevalence of any incidental finding was 41%. Of the 459 participants, 105 (23%) had at least 1 incidental finding that was recommended for clinical or radiological follow-up examination, the most common of which was single or multiple pulmonary nodules (18%). Participants with and without incidental findings had comparable baseline demographics and selected clinical variables, although there were significantly fewer men and a significantly lower prevalence of the metabolic syndrome in those with incidental findings. CONCLUSIONS: Incidental findings, especially pulmonary nodules, are common in cardiac MDCT performed to assess coronary artery calcification in older healthy adults. The net risks and benefits of looking for noncardiac abnormalities during cardiac MDCT should be rigorously evaluated.

Reliability and validity of the power-mobility community driving assessment.

The Power-Mobility Community Driving Assessment (PCDA) is a performance-based measure designed to assess driving performance of individuals using power wheelchairs or scooters in community environments. This article reports the results of pilot testing and an evaluation of the assessment's reliability and validity. Pilot testing was conducted with a random selection of Canadian occupational therapists working in the area of mobility. Although the response rate was very low, feedback confirmed the utility of the measure and contributed to one substantive scoring revision. Reliability and validity testing was conducted with a sample of 34 drivers. Internal consistency results were positive. Interrater reliability was fair to high but limited by the lack of variability in the scores. Construct validity hypotheses were tested on the relationships between PCDA scores and vision, perception, cognition, and environmental accessibility. Results indicated no relationships between the PCDA and perceptual and cognitive function and only a weak trend for a relationship with environmental accessibility. Concurrent validity was established: PCDA scores were positively associated with the judgments of therapists familiar with the driving performance of participants. In summary, the PCDA has moderate to good reliability, and content and concurrent validity results were found. More research is needed, particularly on the underlying constructs of successful driving performance. At this point, rehabilitation professionals and their clients are urged to use this assessment to establish driving performance rather than relying on assessments of perception, cognition, or environmental accessibility to predetermine whether someone will receive power mobility. Clinicians may find this a useful tool to identify where clients are able to drive safely in community settings, to identify specific learning needs, and, through those, to promote independent living for drivers of power-mobility devices.

Best practice recommendations for the prevention and treatment of pressure ulcers: update 2006.

PURPOSE: The purpose of this article is to enhance the professional nurses' knowledge of the best practice recommendations for the prevention and treatment of pressure ulcers. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in wound care. OBJECTIVES: After reading this article and taking this test, the reader should be able to: 1. Interpret the pathway to assess and treat pressure ulcers. 2. Differentiate the Registered Nurses' Association of Ontario (RNAO) levels of evidence. 3. Identify the scientific evidence for treatment recommendations.

Ethnic differences in coronary artery calcium in a healthy cohort aged 60 to 69 years.

Measurement of coronary artery calcium (CAC) has been proposed as a screening tool, but CAC levels may differ according to race and gender. Racial/ethnic and gender distributions of CAC were examined in a randomly selected cohort of 60- to 69-year-old healthy subjects. Demographic, race/ethnicity (R/E), and clinical characteristics and assessment of CAC were collected. There were 723 white/European, 105 African-American, 73 Hispanic, and 67 East Asian subjects (597 men, 369 women) included in this analysis. Men had a significantly higher prevalence of any CAC (score>10) than women (76% vs 41%; p<0.0001). For men, the unadjusted odds of having any CAC was 2.2 (95% confidence interval [CI] 1.3 to 3.8) for whites compared with African-Americans. For women, CAC scores were not significantly different across ethnic groups. After adjustment for coronary risk factors, African-American and East Asian R/E remained associated with a lower prevalence of CAC in men (adjusted odds ratios [ORs] 0.33 and 0.47, respectively), as well as older age (OR 1.2, 95% CI 1.1 to 1.3), known hyperlipidemia (OR 1.7, 95% CI 1.1 to 2.7), and history of hypertension (OR 2.2, 95% CI 1.4 to 3.3). In women, Asian R/E (OR 2.5, 95% CI 1.1 to 5.7), history of smoking (adjusted OR 2.8, 95% CI 1.3 to 6.1), and known hyperlipidemia (adjusted OR 2.0, 95% CI 1.3 to 3.1) were associated with a higher prevalence of CAC independent of other risk factors. In conclusion, our data indicate that the presence of CAC varied significantly across selected race/ethnic groups independent of traditional cardiovascular risk factors.

Clinical utility of the Stanford brief activity survey in men and women with early-onset coronary artery disease.

PURPOSE: To determine the utility of the Stanford Brief Activity Survey (SBAS) as a quick screening tool in a clinical population, where no other measure of physical activity was available. METHODS: The SBAS was administered to 500 younger cases in the Atherosclerotic Disease Vascular Function and Genetic Epidemiology (ADVANCE) study, a case-control genetic association study, between December 2001 and January 2004. Younger cases in the ADVANCE study included men (<46 years old) and women (<56 years old) diagnosed with early-onset coronary artery disease. Frequency distributions of the SBAS and associations between SBAS activity categories and selected cardiovascular disease risk factors by sex were calculated. RESULTS: Subjects were 45.9 +/- 6.4 years old, 68% married, 61% women, 51% white, and 21% college graduates. Clinical diagnoses for early-onset coronary artery disease included 61% myocardial infarction, 23% coronary revascularization procedure, and 16% angina pectoris. In women, associations between all cardiovascular disease risk factors examined across SBAS categories were statistically significant (P trend < .01). In men, the associations across SBAS categories were statistically significant (P trend < .01), except for body mass index (P trend = .065). Adjustment for body mass index, age, ethnicity, and education with interactions by sex did not change the results. CONCLUSION: Subjects in the higher SBAS activity categories had more favorable cardiovascular disease risk profiles than did their less active counterparts, regardless of sex. The SBAS can be recommended for use in clinical populations providing immediate feedback on current physical activity level.

Validation of a new brief physical activity survey among men and women aged 60-69 years.

The Stanford Brief Activity Survey (SBAS), a new two-item physical activity survey, and the Stanford Seven-Day Physical Activity Recall (PAR) questionnaire were administered to men and women, aged 60-69 years, in the Atherosclerotic Disease VAscular functioN and genetiC Epidemiology (ADVANCE) Study. Frequency distributions of SBAS activity levels, as well as a receiver operating curve, were calculated to determine if the SBAS can detect recommended physical activity levels of 150 or more minutes/week at moderate or greater intensity, with PAR minutes/week. Data were collected between December 2001 and January 2004 from 1,010 participants (38% women) and recorded. Subjects were 65.8 (standard deviation: 2.8) years of age, 77% were married, 55% were retired, 23% were college graduates, and 68% were Caucasian. SBAS scores related significantly in an expected manner to PAR minutes/week (p < 0.01), energy expenditure (kcal/kg per day) (p < 0.01), and selected cardiovascular disease risk biomarkers (p < 0.01). The SBAS of physical activity at moderate intensity had a sensitivity of 0.73 and a specificity of 0.61. The SBAS is a quick assessment of the usual amount and intensity of physical activity that a person performs throughout the day. The SBAS needs further validation in other populations but demonstrated the potential of being a reasonably valid and inexpensive tool for quickly assessing habitual physical activity in large-scale epidemiology studies and clinical practice.

Patient knowledge, beliefs, and behavior concerning the prevention and treatment of glucocorticoid-induced osteoporosis.

OBJECTIVE: To obtain descriptive information concerning the extent to which patients taking oral glucocorticoids recall receiving osteoporosis prevention counseling, and to identify factors associated with the practice of 3 behaviors (i.e., calcium intake, vitamin D intake, and bone mineral density [BMD] testing) recommended for patients receiving glucocorticoid therapy. METHODS: The study assessed cross-sectional data derived from telephone interviews and mailed questionnaires completed by 227 patients who were currently taking oral prednisone. Questions assessed current calcium and vitamin D intake and history of BMD testing. RESULTS: Approximately one-third of participants (36.3%) reported that they had received osteoporosis prevention counseling. Among those who reported receiving counseling, most (73.2%) remembered being told about the importance of obtaining an adequate amount of calcium. Other topics were remembered less frequently. Slightly more than half of study participants (51.1%) were obtaining the recommended amount of calcium. Fewer were obtaining the recommended amount of vitamin D (35.2%) or had received a BMD test within the past year (33.5%). The most consistent predictors of behavior were counseling status and patients' perceptions of the difficulty associated with performing the behavior. CONCLUSION: Most patients receiving oral glucocorticoids receive insufficient counseling concerning the prevention of osteoporosis; patients either are not being counseled or they are being counseled in a manner that is not sufficient to promote subsequent recall and behavior change. Research is needed to develop effective strategies to educate patients about the prevention of glucocorticoid-induced osteoporosis.