Telehealth Ethics: The Role of Care Partners.

During telehealth encounters, care partners may assist with physical maneuvers or examinations. These care partners may be friends or family members of the patient. There are unique ethical considerations in the use of care partners during telehealth examinations, yet there is limited guidance for such interactions. Evidence-based guidelines should be created to ensure the safety and quality of telehealth encounters when care partners are used.

The effects of short-term musical training on the neural processing of speech-in-noise in older adults.

Experienced musicians outperform non-musicians in understanding speech-in-noise (SPIN). The benefits of lifelong musicianship endure into older age, where musicians experience smaller declines in their ability to understand speech in noisy environments. However, it is presently unknown whether commencing musical training in old age can also counteract age-related decline in speech perception, and whether such training induces changes in neural processing of speech. Here, we recruited older adult non-musicians and assigned them to receive a short course of piano or videogame training, or no training. Participants completed two sessions of functional Magnetic Resonance Imaging where they performed a SPIN task prior to and following training. While we found no direct benefit of musical training upon SPIN perception, an exploratory Region of Interest analysis revealed increased cortical responses to speech in left Middle Frontal and Supramarginal Gyri which correlated with changes in SPIN task performance in the group which received music training. These results suggest that short-term musical training in older adults may enhance neural encoding of speech, with the potential to reduce age-related decline in speech perception.

Dermatology ECHO - an innovative solution to address limited access to dermatology expertise.

INTRODUCTION: The present maldistribution of dermatologists in the USA may make it difficult for patients to access timely and quality care. Access to specialty care may be even more challenging for rural and underserved patients due to geographical limitations and other socioeconomic hardships. With over one-third of primary care patients seeking care for at least one skin problem, it is important to follow the American Academy of Dermatology Special Positioning Workgroup\'s core areas of impact regarding treatment of conditions that affect millions of patients by using a team-based approach and telemedicine technologies. The objective of this study was to demonstrate the Dermatology Extension for Community Healthcare Outcomes (ECHO) project approach in multidisciplinary telementoring and education of primary care providers (PCPs) in treatment and management of complex, costly, and common skin diseases via live interactive video technologies. METHODS: Dermatology ECHO is a distance education telementoring platform that uses a multidisciplinary case-based approach in a non-judgemental environment. A team of specialists, including general dermatologists, pediatric dermatologists, a dermatopathologist, a clinical psychologist, and a nurse practitioner, meets via video with a number of PCPs from isolated, rural, or underserved areas to discuss de-identified patient cases and present dermatology-specific continuing medical education (CME)-approved didactic presentations. The University of Missouri, Department of Dermatology, leads the first Dermatology ECHO in the USA. They partner with various primary care clinics across Missouri to provide mentoring in the treatment of skin conditions. Missouri Telehealth Network provides operational support through the Show-Me ECHO project. The network also assists with provider recruitment activities. RESULTS: The authors describe a patient case to illustrate the effect of ECHO on provider distance learning and patient outcomes. A 69-year-old woman from rural Missouri was spurred by a rooster. She presented to her primary care clinic six times over a 2-month period. She was prescribed several different medications and underwent tests and one procedure, including vaccination. After the patient\'s case was presented during the Dermatology ECHO session, she was correctly diagnosed with a Mycobacterium skin infection, and new recommendations were made. The patient improved significantly within 2 weeks. CONCLUSIONS: As specialty medical evidence-based recommendations continue to increase, providers practicing in isolated rural and underserved areas may find it challenging to keep up with the new knowledge. Dermatology ECHO creates a community of practice that allows participating providers to discuss complex cases, receive specific guidance and mentoring, and participate in CME presentations. The case presented here supports the authors\' observations that Dermatology ECHO is an appropriate platform for learning evidence-based medical knowledge via videoconferencing technology.

A language-familiarity effect for speaker discrimination without comprehension.

The influence of language familiarity upon speaker identification is well established, to such an extent that it has been argued that "Human voice recognition depends on language ability" [Perrachione TK, Del Tufo SN, Gabrieli JDE (2011) Science 333(6042):595]. However, 7-mo-old infants discriminate speakers of their mother tongue better than they do foreign speakers [Johnson EK, Westrek E, Nazzi T, Cutler A (2011) Dev Sci 14(5):1002-1011] despite their limited speech comprehension abilities, suggesting that speaker discrimination may rely on familiarity with the sound structure of one's native language rather than the ability to comprehend speech. To test this hypothesis, we asked Chinese and English adult participants to rate speaker dissimilarity in pairs of sentences in English or Mandarin that were first time-reversed to render them unintelligible. Even in these conditions a language-familiarity effect was observed: Both Chinese and English listeners rated pairs of native-language speakers as more dissimilar than foreign-language speakers, despite their inability to understand the material. Our data indicate that the language familiarity effect is not based on comprehension but rather on familiarity with the phonology of one's native language. This effect may stem from a mechanism analogous to the "other-race" effect in face recognition.

Fidelity to the healing relationship: a medical student's challenge to contemporary bioethics and prescription for medical practice.

As a medical  student, I observed that different physicians had strikingly different attitudes and approaches when caring for patients. The care of one patient in particular continues to challenge my understanding of illness and moral responsibility in the practice of medicine. In this paper, I illustrate the care of this patient in order to evaluate the dominant ethics I was taught in medical school, in theory and in practice, and argue neither principlism nor the ethics of care fully captures the moral responsibility of physicians. Emphasising fidelity to the healing relationship, a core principle derived from Pellegrino's virtue theory, I conclude that this approach to clinical ethics fully explains physician responsibility. Pellegrino deconstructs the practice of medicine to clarify the moral event within the clinical encounter and offers a sufficiently useful and justified approach to patient care.

The Moral Agency of Physician Organizations: Meeting Obligations to Advocate for Patients and the Public.

The close of the American College of Physician's (ACP) centennial year is an opportune time to reflect on the organization's important role in professional development and advocating for sound health policy. Organized medicine provides a professional home where members can participate in scholarly activities and access guidance that will help them to be better doctors. Professional organizations also serve patients by improving physicians' knowledge and skill, being a public repository of health-related information, and advocating for improvement of public health. High-functioning medical professional organizations, such as ACP, also function intentionally as moral agents through well-designed efforts to advocate for patients and the public.

The human voice areas: Spatial organization and inter-individual variability in temporal and extra-temporal cortices.

fMRI studies increasingly examine functions and properties of non-primary areas of human auditory cortex. However there is currently no standardized localization procedure to reliably identify specific areas across individuals such as the standard 'localizers' available in the visual domain. Here we present an fMRI 'voice localizer' scan allowing rapid and reliable localization of the voice-sensitive 'temporal voice areas' (TVA) of human auditory cortex. We describe results obtained using this standardized localizer scan in a large cohort of normal adult subjects. Most participants (94%) showed bilateral patches of significantly greater response to vocal than non-vocal sounds along the superior temporal sulcus/gyrus (STS/STG). Individual activation patterns, although reproducible, showed high inter-individual variability in precise anatomical location. Cluster analysis of individual peaks from the large cohort highlighted three bilateral clusters of voice-sensitivity, or "voice patches" along posterior (TVAp), mid (TVAm) and anterior (TVAa) STS/STG, respectively. A series of extra-temporal areas including bilateral inferior prefrontal cortex and amygdalae showed small, but reliable voice-sensitivity as part of a large-scale cerebral voice network. Stimuli for the voice localizer scan and probabilistic maps in MNI space are available for download.

Clinic-based versus outsourced implementation of a diabetes health literacy intervention.

BACKGROUND: We compared two implementation approaches for a health literacy diabetes intervention designed for community health centers. METHODS: A quasi-experimental, clinic-randomized evaluation was conducted at six community health centers from rural, suburban, and urban locations in Missouri between August 2008 and January 2010. In all, 486 adult patients with type 2 diabetes mellitus participated. Clinics were set up to implement either: 1) a clinic-based approach that involved practice re-design to routinely provide brief diabetes education and counseling services, set action-plans, and perform follow-up without additional financial resources [CARVE-IN]; or 2) an outsourced approach where clinics referred patients to a telephone-based diabetes educator for the same services [CARVE-OUT]. The fidelity of each intervention was determined by the number of contacts with patients, self-report of services received, and patient satisfaction. Intervention effectiveness was investigated by assessing patient knowledge, self-efficacy, health behaviors, and clinical outcomes. RESULTS: Carve-out patients received on average 4.3 contacts (SD = 2.2) from the telephone-based diabetes educator versus 1.7 contacts (SD = 2.0) from the clinic nurse in the carve-in arm (p < 0.001). They were also more likely to recall setting action plans and rated the process more positively than carve-in patients (p < 0.001). Few differences in diabetes knowledge, self-efficacy, or health behaviors were found between the two approaches. However, clinical outcomes did vary in multivariable analyses; carve-out patients had a lower HbA1c (ß = -0.31, 95 % CI -0.56 to -0.06, p = 0.02), systolic blood pressure (ß = -3.65, 95 % CI -6.39 to -0.90, p = 0.01), and low-density lipoprotein (LDL) cholesterol (ß = -7.96, 95 % CI -10.08 to -5.83, p < 0.001) at 6 months. CONCLUSION: An outsourced diabetes education and counseling approach for community health centers appears more feasible than clinic-based models. Patients receiving the carve-out strategy also demonstrated better clinical outcomes compared to those receiving the carve-in approach. Study limitations and unclear causal mechanisms explaining change in patient behavior suggest that further research is needed.

Declines in student obesity prevalence associated with a prevention initiative - King County, Washington, 2012.

The United States has invested heavily, through public and private sector initiatives, in actions to prevent youth obesity by promoting healthy eating and physical activity. This report documents recent trends in youth obesity in King County, Washington, which implemented a Communities Putting Prevention to Work (CPPW) obesity prevention initiative during 2010-2012, including a school-based component. Similar large-scale obesity prevention initiatives did not occur elsewhere in Washington. Beginning in 2004, the Washington State Department of Health began monitoring youth obesity through the biennially administered Washington State Healthy Youth Survey (HYS). Based on data from this survey, neither King County nor the rest of Washington showed statistically significant changes in obesity prevalence in 2006, 2008, and 2010, relative to 2004. In 2012, however, King County youth obesity prevalence showed a statistically significant decrease, while no change occurred in the remainder of the state. Within King County, CPPW was implemented only in low-income school districts to address geographic inequities in obesity rates. Analysis within King County comparing CPPW and non-CPPW school districts before and after the intervention (2010 versus 2012) revealed a statistically significant decline in obesity prevalence in CPPW schools yet no change in non-CPPW schools. This decline in CPPW schools was significantly different than in non-CPPW schools. These findings suggest that school-based policy, systems, and environment changes might help reduce youth obesity, warranting further evaluation of short- and long-term impacts on population health.

Aspirin use and knowledge in the community: a population- and health facility based survey for measuring local health system performance.

BACKGROUND: Little is known about the relationship between cardiovascular risk, disease and actual use of aspirin in the community. METHODS: The Measuring Disparities in Chronic Conditions (MDCC) study is a community and health facility-based survey designed to track disparities in the delivery of health interventions for common chronic diseases. MDCC includes a survey instrument designed to collect detailed information about aspirin use. In King County, WA between 2011 and 2012, we surveyed 4633 white, African American, or Hispanic adults (45% home address-based sample, 55% health facility sample). We examined self-reported counseling on, frequency of use and risks of aspirin for all respondents. For a subgroup free of CAD or cerebral infarction that underwent physical examination, we measured 10-year coronary heart disease risk and blood salicylate concentration. RESULTS: Two in five respondents reported using aspirin routinely while one in five with a history of CAD or cerebral infarction and without contraindication did not report routine use of aspirin. Women with these conditions used less aspirin than men (65.0% vs. 76.5%) and reported more health problems that would make aspirin unsafe (29.4% vs. 21.2%). In a subgroup undergoing phlebotomy a third of respondents with low cardiovascular risk used aspirin routinely and only 4.6% of all aspirin users had no detectable salicylate in their blood. CONCLUSIONS: In this large urban county where health care delivery should be of high quality, there is insufficient aspirin use among those with high cardiovascular risk or disease and routine aspirin use by many at low risk. Further efforts are needed to promote shared-decision making between patients and clinicians as well as inform the public about appropriate use of routine aspirin to reduce the burden of atherosclerotic vascular disease.

Content and style comparison of physician communication in teledermatology and in-person visits.

BACKGROUND: The body of research is rapidly growing regarding the use of telemedicine in patient care, including cost-effectiveness, patient access, patient outcomes, etc. Less has been done describing physician communication during different aspects of the clinical visit (i.e., education, assessment, treatment, etc.) during actual versus virtual patient visits. The purpose of this study was to evaluate dermatology healthcare providers' communication via both modalities with regard to content and style. SUBJECTS AND METHODS: In-person and teledermatology patient visits were observed, audio-recorded, and transcribed over an 8-month period. A content analysis was performed. RESULTS: The Wilcoxon rank sum test was used to compare the content differences between visit modalities for each category. A p value of 0.05 was considered as significant for all tests. There were no statistically significant differences between modalities in the average number of physician words in seven of eight communication categories: small talk, clinical assessment, psychosocial issues, patient education, patient compliance, patient treatment, and administrative issues (p value range, 0.16-0.91). As well, the same communication themes occurred in each modality to essentially the same degree. For instance, assessment and discussion of treatment occurred in 100% of in-person and teledermatology visits, as did small talk. CONCLUSIONS: This research indicates that physician providers communicate with similar style and content whether using teledermatology or in-person.

Assessment of X-ray fluorescence capabilities for nail and hair matrices through zinc measurement in keratin reference materials.

BACKGROUND: Novel and emerging biomarkers of zinc status are being developed to help study and address zinc deficiency around the world. Two potential biomarkers, nail and hair, involve the measurement of zinc from easily accessible keratin-based components of the body. Portable X-ray fluorescence (XRF) is a relatively new approach to the assessment of zinc in nail or hair, and has a number of compelling advantages compared with other techniques. The aim of the current study was to test the ability of XRF to measure zinc in keratinized reference materials (RMs) designed to simulate nail and hair. METHODS: Four Keratin Matrix RMs were prepared and characterized for numerous trace elements by the New York State Department of Health's Wadsworth Center. The Keratin Matrix RMs consisted of powdered samples of caprine (goat) horns pooled from several animals. Concentrations of zinc, as assessed by inductively coupled plasma mass spectrometry (ICP-MS), were similar to what would be expected from human nail or hair tissues. Repeat measurements of the RMs were made using a portable XRF system. The XRF zinc results were compared with the ICP-MS zinc concentrations. Three different approaches to quantifying the zinc content by XRF were performed: (1) zinc signal to total signal ratio, (2) zinc signal to sulfur signal ratio, and (3) system output zinc concentration. RESULTS: The portable XRF results from a given RM were found to be consistent across repeat trials under all three approaches to XRF quantitation. Precision, calculated as the relative standard deviation of repeat measurements ranged from an average result of 0.8 % (using the system output zinc concentration method) to 6.1 % (using the zinc signal to sulfur signal ratio method). Measurement of the RMs provided XRF zinc results which scaled well with ICP-MS zinc concentration, particularly when using the XRF zinc to total and system zinc concentration methods. A Bland-Altman plot showed that the XRF system zinc concentration output exceeded the ICP-MS zinc concentration by, on average, 10.2 % ± 1.2 %. CONCLUSION: Overall, both accuracy and precision of measurement were found to be promising for portable XRF, provided appropriate conversions to concentration are introduced. The results of this study indicate that portable XRF is an effective and dependable method of assessing zinc concentration in keratinized tissue RMs. This will have implications for the future use of portable XRF to monitor zinc status in humans through measurements of nail and hair.

Diagnostic and treatment concordance in primary care participants and dermatologists utilizing Extension for Community Health Outcomes (ECHO).

INTRODUCTION: Suboptimal access to dermatologic care is dependent on patient location and insurance type. Although there have been attempts to address access issues, barriers to providing excellent dermatologic care to all patients at the right time still exist. The objective of this study was to investigate the clinical impact of Dermatology Extension for Community Healthcare Outcomes (ECHO) project participation on primary care providers' diagnostic and treatment tendencies and accuracy. METHODS: This was a retrospective cohort study constructed using Dermatology Extension for Community Healthcare Outcomes case and recommendation data from November 2015 to June 2021. The University of Missouri-based Dermatology Extension for Community Healthcare Outcomes specialty hub team offers regularly scheduled live interactive tele-mentoring sessions for primary care providers who practice in rural and underserved areas. 524 patient cases presented by 25 primary care providers were included in the analysis. Of those, 449 cases were included in diagnostic concordance, and 451 in treatment concordance analysis. RESULTS: Less than 40% of all diagnoses were fully concordant with an expert panel. Over 33% of patients were misdiagnosed, and over 26% received partially correct diagnosis. Only 16% of all treatment recommendations were fully concordant with an expert panel. DISCUSSION: Diagnostic and treatment accuracy of participants is low, and Dermatology Extension for Community Healthcare Outcomes platform ensured patients received correct diagnosis and treatment quickly. Although tele-dermatology models are effective, they continue to be underutilized. Dermatologists in practice and training should be encouraged to adopt innovative clinical educational models, like Dermatology ECHO, to expand access to dermatologic expertise for the most marginalized populations.