Effect of Wheelchair Stroke Pattern on Upper Extremity Muscle Fatigue.

BACKGROUND: Shoulder dysfunction is common in persons with spinal cord injury (SCI) with an incidence of up to 63%. Dysfunction is a result of muscle imbalances, specifically denervated rotator cuff muscles that are repetitively used during manual wheelchair propulsion. OBJECTIVE: To determine which arm stroke technique, pump (P) or semicircular (SC), is most energy efficient for long periods of propulsion. DESIGN: A randomized study with repeated measures observations. SETTING: The study was performed at an institutional gait analysis laboratory. PARTICIPANTS: 18 able-bodied (AB) male participants were studied and randomized into one of 2 conditions, SC or P. METHODS: Shoulder muscle fatigue was measured by changes in Borg CR10 Rate of Perceived Exertion (Borg RPE) and upper extremity strength via a handheld dynamometer. Participants were studied and assigned into one of 2 conditions of wheelchair arm propulsion patterns, SC or P group, and propelled on a wheelchair treadmill for 10 minutes. MAIN OUTCOME MEASURES: The primary outcomes included recordings of Borg RPE scale during continuous wheelchair propulsion and pre- and post-test dynamometer testing means for bilateral elbow and shoulder extension. Analysis of covariance, t-tests, and Kruskal-Wallis tests were used in analyzing data. RESULTS: Although not significant (P = .23), the Borg RPE scores for the SC condition were consistently higher than the scores for the P condition. In addition, the dynamometer pre- and post-test readings demonstrated a larger decrease for the SC condition participants than for the P condition participants, but were not statistically significant. CONCLUSIONS: These data demonstrate that the SC wheelchair propulsion pattern appears to be more fatiguing to shoulder muscles than the P propulsion pattern. However, more data would need to be collected to find a significant difference. LEVEL OF EVIDENCE: II.

Psychotherapy practices for veterans with PTSD among community-based providers in Texas.

Significant changes in national health policy, like the Veterans Choice Act, have created growing opportunities for veterans to receive care outside of the Veterans Administration (VA), yet little is known about the attitudes and practices in PTSD care of community providers, particularly their use of evidence-based psychotherapies (EBPs). The authors assessed psychotherapy practices of community providers serving veterans with PTSD in Texas. They surveyed Texas mental health providers regarding their patient population, practice setting, and posttraumatic stress disorder (PTSD)-related screening, assessment, and treatment practices. They identified providers from state licensing board rosters and included a stratified sample of social workers, marriage and family therapists, and professional counselors (500 each), all psychologists with available email addresses (n = 3,986), and 106 providers known to have completed state-sponsored training for 1 of the EBPs for PTSD, cognitive processing therapy. Four hundred sixty-three eligible respondents returned surveys (15% response rate). Providers reported treating a mean of 7.9 veterans with PTSD in the past year (range = 0-200; SD = 20.5), using a variety of therapeutic approaches for PTSD. Only 15.0% of providers reported regularly conducting psychotherapy for PTSD following a treatment manual, and fewer than half reported any use of EBPs for PTSD with patients. Although many veterans are receiving treatment for PTSD in the community, many community-based mental health providers in Texas do not consistently use recommended treatments for PTSD. These findings may suggest an important opportunity for VA to engage and partner with community providers to achieve high-quality care for veterans. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Development and Validation of a Family Meeting Assessment Tool (FMAT).

CONTEXT: A cornerstone procedure in Palliative Medicine is to perform family meetings. Learning how to lead a family meeting is an important skill for physicians and others who care for patients with serious illnesses and their families. There is limited evidence on how to assess best practice behaviors during end-of-life family meetings. OBJECTIVES: Our aim was to develop and validate an observational tool to assess trainees' ability to lead a simulated end-of-life family meeting. METHODS: Building on evidence from published studies and accrediting agency guidelines, an expert panel at our institution developed the Family Meeting Assessment Tool. All fourth-year medical students (MS4) and eight geriatric and palliative medicine fellows (GPFs) were invited to participate in a Family Meeting Objective Structured Clinical Examination, where each trainee assumed the physician role leading a complex family meeting. Two evaluators observed and rated randomly chosen students' performances using the Family Meeting Assessment Tool during the examination. Inter-rater reliability was measured using percent agreement. Internal consistency was measured using Cronbach α. RESULTS: A total of 141 trainees (MS4 = 133 and GPF = 8) and 26 interdisciplinary evaluators participated in the study. Internal reliability (Cronbach α) of the tool was 0.85. Number of trainees rated by two evaluators was 210 (MS4 = 202 and GPF = 8). Rater agreement was 84%. Composite scores, on average, were significantly higher for fellows than for medical students (P < 0.001). CONCLUSION: Expert-based content, high inter-rater reliability, good internal consistency, and ability to predict educational level provided initial evidence for construct validity for this novel assessment tool.

Genome-wide expression in veterans with schizophrenia further validates the immune hypothesis for schizophrenia.

This study aimed to test whether a dysregulation of gene expression may be the underlying cause of previously reported elevated levels of inflammatory cytokines in veterans with schizophrenia. We performed a genome-wide expression analysis in peripheral blood mononuclear cells from veterans with schizophrenia and controls, and our results show that 167 genes and putative loci were differently expressed between groups. These genes were enriched primarily for pathways related to inflammatory mechanisms and formed networks related to cell death and survival, immune cell trafficking, among others, which is in line with previous reports and further validates the inflammatory hypothesis of schizophrenia.

Autologous Stem Cell Transplantation: The Predictive Value of the Morse Fall Scale in Hospitalized Patients 
.

BACKGROUND: Falls are common in hospitalized patients undergoing autologous stem cell transplantation (ASCT). Research demonstrates that preventing patient falls requires knowledge of the risk factors and the circumstances preceding the patient's fall.
. OBJECTIVES: To identify risk factors related to falls in recipients of ASCT and assess the predictive value of the Morse Fall Scale (MFS).
. METHODS: Of the 288 patients who underwent transplantation during the study period, 14 were fallers. Twenty controls were randomly selected. The study used descriptive case-control analysis and simple logistic regression to analyze the data. 
. FINDINGS: Eight fallers and four non-fallers had high MFS scores. The logistic regression model indicated that patients with high MFS scores were 5.3 times more likely to fall and that for each day patients experienced diarrhea, their risk of fall increased 1.2 times.

Communicating With Dying Patients and Their Families: Multimedia Training in End-of-Life Care.

BACKGROUND: The need for end-of-life (EOL), high-impact education initiatives to prepare medical students to communicate with dying patients and their families and to cope with issues of death and dying, is well recognized. METHODS: Third-year medical students (n = 224), during their ambulatory rotation, completed a multimedia EOL curriculum, which included pre-/posttests, an online case-based module, didactic presentation, and a tablet computer application designed to demonstrate the signs and symptoms seen in the last hours of life for families of dying patients. Pre- and posttests were compared using Pearson χ2 or Fisher exact test, and improvement was measured by weighted κ coefficient. RESULTS: On preintervention surveys, the majority of students demonstrated positive attitudes toward the care of dying patients and their families. Despite this high pretest positive attitude, there was a statistically significant overall positive attitude change after the intervention. The lowest pretest positive attitudes and lowest posttest positive attitude shifts, although all statistically improved, involved addressing the thoughts and feelings of dying patients and in coping with their own emotional response. CONCLUSIONS: Medical students exposure to this multimedia EOL curriculum increases positive attitudes in caring for dying patients and their families.

Tough Conversations: Development of a Curriculum for Medical Students to Lead Family Meetings.

BACKGROUND: Few educational interventions have been developed to teach Family Meeting (FM) communication skills at the undergraduate level. We developed an innovative curriculum to address this gap. METHODS: Fourth year medical students during 2011-2013 (n = 674) completed training for conducting a FM. To assess the effectiveness of this training, students completed a FM Objective Structured Clinical Exam (OSCE) that included 15 domains rated on a 1-5 point Likert scale. Tasks included discussing prognosis, establishing goals of care and demonstrating conflict resolution skills. Students received one-to-one feedback from standardized family members and faculty observers. Group debriefings with faculty were held after the OSCE. RESULTS: Analysis of faculty feedback narratives revealed four themes in which students required improvement: 1) Discussing prognosis, 2) Explaining palliative care/hospice, 3) Avoiding medical jargon, and 4) Discussing cultural/religious preferences. Evaluation total mean score was 28.2 (Min 15, Max 63; SD 7.57), and identified student's need to; 1) Ask more about the degree of knowledge family members want, 2) Ask religious beliefs, and 3) Assess family members' level of education ( p < 0.001). Qualitative analysis of group debriefings suggested that student perception of the OSCE experience was positive overall. Students found the case to be realistic and immediate feedback to be helpful. CONCLUSIONS: Conducting a FM is an advanced skill. This study shows that it is possible to train fourth year students to lead FMs and identify their strengths, needs using a FM OSCE.

The Double Parallel Curriculum in Palliative Care: Teaching Learners to Teach End-of-Life Care at the Bedside.

CONTEXT: Dying is a natural process, yet physicians are often uncomfortable caring for dying patients. Learners have limited exposure to curriculum on caring for dying patients and often navigate these encounters without appropriate skills and confidence. We developed and implemented the Double Parallel Curriculum in Palliative Care (DP-PC): End-of-Life (EOL) module. The DP-PC focuses on teaching third-year medical students (MS3) to not only take care of patients in their last hours of life but give learners the confidence to teach patient's families what to expect as they hold vigil at their loved one's bedside. OBJECTIVES: To develop and implement an educational intervention that improves learners' knowledge and confidence in EOL patient and family care. To expand learner confidence to a dual level (learners become teachers) with a simplified and culturally sensitive electronic bedside teaching tool designed to guide learners and patients/families conversations. METHODS: Curriculum was completed during MS3 ambulatory rotation and included pre-/posttests, an online case-based module, faculty demonstration, and learner role-play using the bedside teaching tool. RESULTS: A total of 247 participants took the pretest, 222 participants took the posttest, and 222 participants matched the pre-/posttest surveys. Students' knowledge of EOL care and the confidence to teach other learners and families about EOL care significantly improved after completing the curriculum. CONCLUSION: The DP-PC is a technology-savvy educational intervention that improves learner confidence and knowledge toward caring for dying patients and their families. Easy access, technology-based teaching tools may enhance bedside teaching of health-care learners and improve the care of patients and their families at the end of life.

Edentulism and transplant-associated complications in patients with multiple myeloma undergoing autologous hematopoietic stem cell transplantation.

PURPOSE: Patients undergoing autologous hematopoietic stem cell transplantation (HSCT) are at risk for oral complications which may cause significant morbidity. The aim of this study was to compare the incidence of toxicities and complications in edentulous and dentate patients undergoing autologous HSCT for multiple myeloma. METHODS: We conducted a retrospective case-control study to analyze the incidence of bacteremia, fever, and oral mucositis, between edentulous and dentate patients. All patients underwent dental evaluation, received dental treatment if indicated, and were cleared before transplantation. The two groups were matched for age, gender, ethnicity, disease stage, time from diagnosis to transplant, performance status, and conditioning regimen. RESULTS: A total of 45 edentulous and 90 dentate patients were enrolled. All patients were male with a median age of 60 years and a mean performance status by Karnofsky score of 90 %. Two thirds had stage III MM with a median time from diagnosis to transplantation of 12 months, and all received melphalan as part of the conditioning regimen. The incidence of bacteremia (p = 0.553), fever (p = 0.245), severity of oral mucositis (p = 0.465), and other post-transplant toxicities were similar between both groups. CONCLUSIONS: There were no significant differences in the incidence of bacteremia, fever, severity of oral mucositis, or other complications between edentulous and dentate patients with multiple myeloma after autologous HSCT.

Medication Needs Vary for Terminally Ill Vietnam Era Veterans With and Without a Diagnosis of PTSD.

This retrospective pilot study aims to evaluate the clinical impact of palliative care in the treatment of terminally ill Vietnam Veterans with a history of posttraumatic stress disorder (PTSD) versus those without PTSD, as it pertains to medications for symptom control at the end of life (EOL). Active prescriptions for benzodiazepines, hypnotics, antidepressants, and antipsychotic medications at the EOL were recorded. During EOL care, 28 (72%) participants with PTSD used these medications versus 55 (40%) of the non-PTSD participants (P = .0005). There was significant correlation between a lifetime diagnosis of PTSD with antidepressant use (P = .0002) and hypnotics (P = .0085) during EOL care but not with benzodiazepines or antipsychotics. The higher utilization of certain medication classes among participants with PTSD may indicate that PTSD treatment should continue at the EOL to improve care.

Does the CDC Definition of Fever Accurately Predict Inflammation and Infection in Persons With SCI?

Background: Pneumonia and septicemia have the greatest impact on reduced life expectancy in persons with spinal cord injury (SCI). Fever is often the first presenting symptom of infection or inflammation. Thermoregulatory dysfunction in persons with SCI may preclude a typical febrile response to infection or inflammation and thus delay diagnostic workup. Objective: To determine the core temperature of persons with SCI in the setting of infection or inflammation and the frequency with which it meets criteria for the CDC definition of fever (>100.4°F). Methods: Retrospective review of hospitalized SCI patients over 5 years with a diagnosis of infection or inflammation (DI), defined by serum leukocytosis. In this study, 458 persons with paraplegia (PP) and 483 persons with tetraplegia (TP) had 4,191 DI episodes. Aural temperatures (Tau) on the day of DI, 7 days prior, and 14 days afterwards were abstracted from medical records. Main outcome measures were average Tau at DI, frequency of temperatures >100.4°F at DI, and average baseline temperatures before and after DI. Results: Average Tau at DI was 98.2°F (±1.5) and 98.2°F (±1.4) in the TP and PP groups, respectively, with only 11.6% to 14% of DI resulting in Tau >100.4°F. Baseline temperatures ranged from 97.9°F (±0.7) to 98.0°F (±0.8). Conclusion: SCI persons with leukocytosis infrequently mount a fever as defined by the CDC, and baseline temperatures were subnormal (<98.6°F). Thermoregulatory dysfunction likely accounts for these findings. Tau >100.4°F is not a sensitive predictor of infection or inflammation in persons with SCI. Clinicians should be vigilant for alternative symptoms of infection and inflammation in these patients, so diagnostic workup is not delayed.

Hospitalizations and emergency room visits after initiation of long-acting injectable antipsychotics.

INTRODUCTION: Long-acting injectable antipsychotics (LAIs) serve as a means to ensure medication adherence with the intention of improving outcomes for psychiatric patients. Evidence remains inconclusive regarding the impact of LAIs on relapses and psychiatric hospitalizations rates. METHODS: The primary objective of this retrospective pre/post study was to determine whether initiating an LAI in a veteran population with schizophrenia, schizoaffective disorder, or bipolar disorder is associated with a decrease in the 1-year rate of psychiatric hospitalizations and emergency room (ER) visits. RESULTS: For the combined primary endpoint, the 1-year rate of psychiatric hospitalizations and ER visits for patients with schizophrenia, schizoaffective disorder, or bipolar disorder was not significantly reduced after initiation of LAIs (n = 50, median [interquartile range]: 1.5 [1, 3] to 1 [0, 3], P = .055). However, the secondary endpoint of the 1-year rate of psychiatric hospitalizations was reduced (1 [0, 3] to 0 [0, 2], P = .026). Additionally, for those who received injections on a regular basis, the 1-year rate of hospitalizations and ER visits was significantly reduced (2 [1, 3] to 0 [0, 1.5], P = .009). DISCUSSION: This retrospective study suggests that the initiation of LAIs is associated with a reduced rate of psychiatric hospitalizations as well as a reduced rate of psychiatric hospitalizations and ER visits for those patients who receive injections on a regular basis.

Implementation of a CIWA-Ar alcohol withdrawal protocol in a veterans hospital.

OBJECTIVES: The South Texas Veterans Health Care System (STVHCS) implemented a Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)-based alcohol-withdrawal protocol in June 2013. The aim of this study was to determine the efficacy and safety of the new protocol. The primary objective was the evaluation of whether implementation of the CIWA-Ar alcohol-withdrawal protocol decreased the average length of hospital stay for patients admitted with alcohol withdrawal syndrome (AWS) as compared with treatment before the introduction of the protocol. Secondary endpoints evaluated benzodiazepine (BZD)-prescribing practices, use of adjunctive medications for AWS, and safety outcomes. METHODS: We reviewed 748 admissions with documented AWS or alcohol-related diagnoses during the study periods of July 2012 to December 2012 (preprotocol) and July 2013 to December 2013 (postprotocol). Patients in the preprotocol group needed to have a scheduled dose of a BZD in the electronic medical record, and those assigned to the postprotocol group needed to have at least one documented CIWA-Ar note in their electronic medical record. Exclusion criteria included prior conditions that interfered with accurate treatment of alcohol withdrawal. RESULTS: There were no statistical differences in baseline characteristics between groups. No difference was found in the primary endpoint of length of stay when comparing hospitalizations pre- and postprotocol implementation (3.84 ± 2.31 days vs 3.82 ± 2.7 days; P = 0.667). There was no statistical significance in total cumulative dose of BZD, daily dose of BZD, or duration of BZD use when compared pre- and postprotocol. No safety events requiring further intervention occurred. CONCLUSIONS: Implementation of a CIWA-Ar protocol at our institution did not result in a decreased duration of hospital stay; however, a decline in prescribing fixed-schedule BZDs was documented.

Differential correlations between inflammatory cytokines and psychopathology in veterans with schizophrenia: potential role for IL-17 pathway.

Pro-inflammatory cytokines have been consistently reported to be elevated in schizophrenia patients. However, it is not known whether cytokines influence the presentation of psychotic symptoms. To address this issue, we evaluated the relationship between levels of inflammatory molecules and psychopathological parameters in patients with schizophrenia. We hypothesized that severity of symptoms would correlate with increased levels of inflammatory cytokines. Serum samples from 47 veterans with a diagnosis of schizophrenia and 20 healthy controls were tested for levels of 38 cytokines/chemokines involved in regulation of immune/inflammatory reactions using a Millipore multiplex bead array in a Luminex 100 system. We found significantly increased levels of GRO, MCP-1, MDC, and sCD40L, and significantly decreased levels of IFN-γ, IL-2, IL-12p70, and IL-17, in schizophrenia patients compared to controls. In addition, we observed positive correlations between levels of cytokines and the Positive and Negative Symptoms Scale (PANSS) scores in subjects with schizophrenia for G-CSF, IL-1ß, IL1ra, IL-3, IL-6, IL-9, IL-10, sCD40L and TNF-ß. Pathway analyses showed these cytokines to be part of the IL17 pathway. Using principal component analyses, we found the factor that included these cytokines and IL-17 to be associated with positive, general and total PANSS scores. These results suggest that alterations in this pathway may play a role in development of psychotic symptoms in schizophrenia.

Do Ames dwarf and calorie-restricted mice share common effects on age-related pathology?

Since 1996, aging studies using several strains of long-lived mutant mice have been conducted. Among these studies, Ames dwarf mice have been extensively examined to seek clues regarding the role of the growth hormone/insulin-like growth factor-1 axis in the aging process. Interestingly, these projects demonstrate that Ames dwarf mice have physiological characteristics that are similar to those seen with calorie restriction, which has been the most effective experimental manipulation capable of extending lifespan in various species. However, this introduces the question of whether Ames dwarf and calorie-restricted (CR) mice have an extended lifespan through common or independent pathways. To answer this question, we compared the disease profiles of Ames dwarf mice to their normal siblings fed either ad libitum (AL) or a CR diet. Our findings show that the changes in age-related diseases between AL-fed Ames dwarf mice and CR wild-type siblings were similar but not identical. Moreover, the effects of CR on age-related pathology showed similarities and differences between Ames dwarf mice and their normal siblings, indicating that calorie restriction and Ames dwarf mice exhibit their anti-aging effects through both independent and common mechanisms.

Improving learning about familial risks using a multicomponent approach: the GRACE program.

AIM: To enhance learning (knowledge, attitudes and practices) about the importance of family health history (FHH) information and familial risks. METHODS: A pre-post design with one group was employed in this study. Five learning sessions were conducted with a community-based sample (n = 75) recruited from five counties in Texas, USA. Each learning session included: a short online video; enactive instructions on how to use the online Surgeon General FHH tool; and a presentation on how to assess familial risks. Participants completed the pre-post knowledge, attitudes and practices questionnaires and the study's satisfaction survey, and participated in a short focus group interview. RESULTS: Participants' average age was 48.1 ± 13.3 years. Over half of the participants (79%) were female, and 55% described themselves as non-Hispanic White. Our findings showed significant changes (p < 0.05) in participants' specific knowledge about factors that affect their familial risks. Similarly, significant changes (p < 0.05) in participants' attitudes toward familial risks assessment for common disease complications and confidence in controlling these risks have been documented. Participants' reported a high level of satisfaction in using online FHH tools, yet no significant change (p > 0.05) was detected in their reported practices regarding sharing FHH information with their providers or relatives. Focus group interviews revealed that participants were uncertain about providers' or relatives' reactions to sharing FHH information. CONCLUSION: Using different learning styles may have a significant impact on improving knowledge and attitudes about familial risks.

Effects of maternal nutrient restriction, intrauterine growth restriction, and glucocorticoid exposure on phosphoenolpyruvate carboxykinase-1 expression in fetal baboon hepatocytes in vitro.

BACKGROUND: The objective of this study was to develop a cell culture system for fetal baboon hepatocytes and to test the hypotheses that (i) expression of the gluconeogenic enzyme phosphoenolpyruvate carboxykinase-1 (PEPCK-1) is upregulated in hepatocytes isolated from fetuses of nutrient-restricted mothers (MNR) compared with ad libitum-fed controls (CTR), and (ii) glucocorticoids stimulate PEPCK-1 expression. METHODS: Hepatocytes from 0.9G CTR and MNR fetuses were isolated and cultured. PEPCK-1 protein and mRNA levels in hepatocytes were determined by Western blot and quantitative PCR, respectively. RESULTS: Fetuses of MNR mothers were intrauterine growth restricted (IUGR). Feasibility of culturing 0.9G fetal baboon hepatocytes was demonstrated. PEPCK-1 protein levels were increased in hepatocytes isolated from IUGR fetuses, and PEPCK-1 mRNA expression was stimulated by glucocorticoids in fetal hepatocytes. CONCLUSIONS: Cultured fetal baboon hepatocytes that retain their in vivo phenotype provide powerful in vitro tools to investigate mechanisms that regulate normal and programmed hepatic function.

Effect of a primary care continuing education program on clinical practice of chronic obstructive pulmonary disease: translating theory into practice.

OBJECTIVES: To describe the development and implementation process and assess the effect on self-reported clinical practice changes of a multidisciplinary, collaborative, interactive continuing medical education (CME)/continuing education (CE) program on chronic obstructive pulmonary disease (COPD). METHODS: Multidisciplinary subject matter experts and education specialists used a systematic instructional design approach and collaborated with the American College of Chest Physicians and American Academy of Nurse Practitioners to develop, deliver, and reproduce a 1-day interactive COPD CME/CE program for 351 primary care clinicians in 20 US cities from September 23, 2009, through November 13, 2010. RESULTS: We recorded responses to demographic, self-confidence, and knowledge/comprehension questions by using an audience response system. Before the program, 173 of 320 participants (54.1%) had never used the Global Initiative for Chronic Obstructive Lung Disease recommendations for COPD. After the program, clinician self-confidence improved in all areas measured. In addition, participant knowledge and comprehension significantly improved (mean score, 77.1%-94.7%; P<.001). We implemented the commitment-to-change strategy in courses 6 through 20. A total of 271 of 313 participants (86.6%) completed 971 commitment-to-change statements, and 132 of 271 (48.7%) completed the follow-up survey. Of the follow-up survey respondents, 92 of 132 (69.7%) reported completely implementing at least one clinical practice change, and only 8 of 132 (6.1%) reported inability to make any clinical practice change after the program. CONCLUSION: A carefully designed, interactive, flexible, dynamic, and reproducible COPD CME/CE program tailored to clinicians' needs that involves diverse instructional strategies and media can have short-term and long-term improvements in clinician self-confidence, knowledge/comprehension, and clinical practice.