Noncardiac inpatient has acute hypertension: Treat or not?

A retrospective study found more harm than benefit from treating elevated blood pressure in hospitalized noncardiac patients.

Can early introduction of gluten reduce risk of celiac disease?

This UK study revealed the benefits of introducing gluten at age 4 months.

Alcohol abstinence reduces A-fib burden in drinkers.

A recent Australian study demonstrated a significant reduction in A-fib recurrence and burden among regular drinkers who abstained from alcohol.

Updated USPSTF screening guidelines may reduce lung cancer deaths.

By nearly doubling the number of patients eligible for screening, as many as 60,000 US lives may be saved-but concerns may limit acceptance.

Automated office BP measurement: The new standard in HTN screening.

Obtain greater accuracy in blood pressure measurement with an automated office device.

Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study.

BACKGROUND: Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information. OBJECTIVE: The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense's Mobile Health Care Environment (MHCE) in a patient-centered medical home setting. METHODS: A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes. RESULTS: The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA1c (control mean -0.53, intervention mean -0.11; P=.006), and low-density lipoprotein cholesterol (control mean -7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA1c (control mean -0.09, intervention mean -0.52; P=.04), BMI (control mean 0.58, intervention mean -1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean -4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12). CONCLUSIONS: Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group. TRIAL REGISTRATION: ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.6993.

Patient-centered medical home: an emerging primary care model and the military health system.

The patient-centered medical home (PCMH) is a primary care model that aims to provide quality care that is coordinated, comprehensive, and cost-effective. PCMH is hinged upon building a strong patient-provider relationship and using a team-based approach to care to increase continuity and access. It is anticipated that PCMH can curb the growth of health care costs through better preventative medicine and lower utilization of services. The Navy, Air Force, and Army are implementing versions of PCMH, which includes the use of technologies for improved documentation, better disease management, improved communication between the care teams and patients, and increased access to care. This article examines PCMH in the Military Health System by providing examples of the transition from each of the branches. The authors argue that the military must overcome unique challenges to implement and sustain PCMH that civilian providers may not face because of the deployment of patients and staff, the military's mission of readiness, and the use of both on-base and off-base care by beneficiaries. Our objective is to lay out these considerations and to provide ways that they have been or can be addressed within the transition from traditional primary care to PCMH.

Update on a clinical measure for the assessment of problem solving.

PURPOSE: The Rapid Assessment of Problem Solving test (RAPS) is a clinical measure of problem solving based on the 20 Questions Test. This article updates clinicians on the RAPS, addresses questions raised about the test in an earlier article (R. C. Marshall, C. M. Karow, C. Morelli, K. Iden, & J. Dixon, 2003a), and discusses the clinical utility of the RAPS. METHOD: The RAPS was administered to 373 normal adults. Tests were analyzed to assess the impact of demographic, psychometric, and other factors on performance on the RAPS. To determine the effects of strategy selection on test scores, participants were assigned to novel, category-focused, or mixed strategy groups based on the types of first questions asked. RESULTS: Normal participants exhibited a range of performance levels on the RAPS. Participants in the novel strategy group performed significantly better than the participants in 2 other strategy groups. CONCLUSIONS: The RAPS is a clinically useful tool to examine problem solving that is easy to administer and to score. Findings suggest clinicians can use the RAPS with greater confidence than was the case 4 years ago. The RAPS is now part of the public domain and may be used by clinicians to assess clients' problem-solving deficits.

Using semantic feature analysis to improve contextual discourse in adults with aphasia.

PURPOSE: Semantic feature analysis (SFA) was used to determine whether training contextually related words would improve the discourse of individuals with nonfluent aphasia in preselected contexts. METHOD: A modified multiple-probes-across-behaviors design was used to train target words using SFA in 3 adults with nonfluent aphasia. Pretreatment, posttreatment, and follow-up sessions obtained language samples for the preselected contexts. Contexts included 4 story retellings and 4 procedure explanations. RESULTS: All participants improved naming ability for treated words. No generalization to untrained items was found. Within discourse samples, participants increased number of target words produced from pretreatment to posttreatment sessions but did not increase lexical diversity across samples. Participants maintained performance on standardized measures from the beginning to the end of the study. CONCLUSIONS: Results support and extend previous research by indicating that SFA improves confrontational naming ability and may benefit word retrieval in discourse production of closed-set contexts.

Developing a clinician-friendly aphasia test.

PURPOSE: The Kentucky Aphasia Test (KAT) is an objective measure of language functioning for persons with aphasia. This article describes materials, administration, and scoring of the KAT; presents the rationale for development of test items; reports information from a pilot study; and discusses the role of the KAT in aphasia assessment. METHOD: The KAT has 3 parallel test batteries, KAT-1, KAT-2, and KAT-3. Each battery contains the same orientation test and 6 subtests, each with 10 items, assessing expressive and receptive language functions. Subtests for KAT-1, KAT-2, and KAT-3 systematically increase in difficulty so that it is possible to assess individuals with severe, moderate, and mild aphasia, respectively. The KAT was administered to 38 participants with aphasia and 31 non-brain-damaged (NBD) participants. RESULTS: Results with the KAT clearly differentiated the language performance of individuals with and without aphasia. NBD participants made few errors, and overall scores on the test for individuals with aphasia were rarely within 1 SD of the NBD group. Performance of the participants with aphasia administered KAT-1, KAT-2, and KAT-3 suggested that the 3 versions of the test represent a hierarchy of difficulty. CONCLUSIONS: The KAT remains in its early stages of development. However, it does appear to meet the requirements for a "clinician-friendly" aphasia test and, as such, offers a rapid, convenient means of obtaining an objective score to determine changes in language functioning during the early postonset period.

The personalized cueing method: from the laboratory to the clinic.

PURPOSE: The personalized cueing method is a novel procedure for treating naming deficits of persons with aphasia that is relatively unfamiliar to most speech-language pathologists. The goal of this article is to introduce the personalized cueing method to clinicians so that it might be expanded and improved upon. It is also hoped that this article will promote further research in the treatment of naming deficits of clients with aphasia. METHOD: This clinical focus article (a) describes the origins of the personalized cueing method, the steps involved in creating personalized cues, and training and assessment procedures used with the personalized cueing method; (b) summarizes the published research supporting the use of the personalized cueing method; and (c) highlights some of the clinical advantages of this novel naming treatment for clients and clinicians. RESULTS: Research with the personalized cueing method indicates that durability (long-term naming accuracy) for items trained with the personalized cueing method exceeds that for items trained with phonological cueing and other methods. It further shows that as the stimuli used to train naming in the personalized cueing experiments have become more realistic, durability of personalized cueing has increased. CONCLUSION: Personalized cueing is a parsimonious approach for treatment of naming deficits of persons with aphasia that has shown positive treatment effects in 8-12 training sessions.

Communicative value of self cues in aphasia: A re-evaluation.

BACKGROUND: Adults with aphasia often try mightily to produce specific words, but their word-finding attempts are frequently unsuccessful. However, the word retrieval process may contain rich information that communicates a desired message regardless of word-finding success. AIMS: The original article reprinted here reports an investigation that assessed whether patient-generated self cues inherent in the word retrieval process could be interpreted by listener/observers and improve on communicative effectiveness for adults with aphasia. The newly added commentary identifies and reports tentative conclusions from 18 investigations of self-generated cues in aphasia since the 1982 paper. It further provides a rationale for increasing research on self-generated cueing and notes a surprising lack of attention to the questions investigated in the original article. The original research is also connected with more recent qualitative investigations of interactional, as opposed to transactional, communicative exchange. METHODS #ENTITYSTARTX00026; PROCEDURES: While performing single-word production tasks, 10 adults with aphasia produced 107 utterances that contained spontaneous word retrieval behaviours. To determine the "communicative value" of these behaviours, herein designated self cues or self-generated cues, the utterance-final (potential target) word was edited out and the edited utterances were dubbed onto a videotape. Six naïve observers, three of whom received some context about the nature of word retrieval in aphasia and possible topics for the utterances, and three of whom got no information, predicted the target word of each utterance from the word-finding behaviours alone. The communicative value of the self-generated cues was determined for each individual with aphasia by summing percent correct word retrieval and percent correct observer prediction of target words, based on word retrieval behaviours. The newly added commentary describes some challenges of investigating a "communicative value" outcome, and indicates what would and would not change about the methods, if we did the study today. OUTCOMES #ENTITYSTARTX00026; RESULTS: The observer group that was given some context information appeared to be more successful at predicting target words than the group without any such information. Self-generated cues enhanced communication for the majority of individuals with aphasia, with some cues (e.g., descriptions/gestures of action or function) appearing to carry more communicative value than others (e.g., semantic associates). The commentary again indicates how and why we would change this portion of the investigation if conducting the study at this time. CONCLUSIONS: The results are consistent with Holland's (1977) premise that people with aphasia do well at communication, regardless of the words they produce. The finding that minimal context information may assist observers in understanding the communicative intent of people with aphasia has important implications for training family members to interpret self-generated cues. The new commentary reinforces these conclusions, highlights potential differences between self cues that improve word-finding success and those that enhance message transmission, and points to some additional research needs.

The effects of varied joint motion and loading conditions on posterior cruciate ligament fiber length behavior.

BACKGROUND: The posterior cruciate ligament has been described as being composed of 2 bands that reciprocally tighten and loosen with knee flexion, but the fiber anatomy and behavior may be more complex. HYPOTHESIS: The mechanical effects of defined loading conditions at discrete knee joint angles can vary significantly within the substance of the posterior cruciate ligament depending on the fiber region tested. STUDY DESIGN: Controlled laboratory study. METHODS: Nine intact, fresh-frozen cadaveric knees were instrumented with excursion filaments implanted within 4 fiber regions of the posterior cruciate ligament. Patterns of fiber behavior were analyzed as a function of the variable linear separation distance between tibial and femoral fiber attachment sites during joint motion under a simulated quadriceps contraction, tibial internal rotation, and tibial external rotation. Analysis of variance, the Newman-Keuls multiple comparisons procedure, and paired t tests were used to evaluate statistical significance. RESULTS: Compared with the control pattern of fiber behavior during unloaded passive knee motion from 0 degrees to 120 degrees , the quadriceps force caused loosening of most ligament fibers at knee flexion of less than 75 degrees . Tibial internal rotation significantly slackened the anterior and central fiber regions near extension and significantly tightened the central and posterior fiber regions with progressive flexion. External rotation had an effect similar to internal rotation on the anterior and central fiber regions but caused significant slackening of the posterior fiber regions from 0 degrees to 45 degrees . CONCLUSIONS: Distinct geographic regions within the posterior cruciate ligament have different functional roles depending on the joint angle and the type of load to which the knee is subjected. CLINICAL RELEVANCE: The specific graft placement parameters in a given surgical procedure relate to end-to-end length changes of the graft and may have important implications for postoperative rehabilitation and return to specific functional activities.

Kinetic analysis of 18F-fluorodihydrorotenone as a deposited myocardial flow tracer: comparison to 201Tl.

UNLABELLED: The goals of this investigation were to assess the accuracy of (18)F-fluorodihydrorotenone ((18)F-FDHR) as a new deposited myocardial flow tracer and to compare the results to those for (201)Tl. METHODS: The kinetics of these flow tracers in 22 isolated, erythrocyte- and albumin-perfused rabbit hearts were evaluated over a flow range encountered in patients. The 2 flow tracers plus a vascular reference tracer ((131)I-albumin) were introduced as a bolus through a port just above the aortic cannula. Myocardial extraction, retention, washout, and uptake parameters were computed from the venous outflow curves with the multiple-indicator dilution technique and spectral analysis. RESULTS: The mean +/- SD initial extraction fractions for (18)F-FDHR (0.85 +/- 0.07) and (201)Tl (0.87 +/- 0.05) were not significantly different, although the initial extraction fraction for (18)F-FDHR declined with flow (P < 0.0001), whereas the initial extraction fraction for (201)Tl did not. The washout of (201)Tl was faster (P < 0.001) and more affected by flow (P < 0.05) than was the washout of (18)F-FDHR. Except for the initial extraction fraction, (18)F-FDHR retention was higher (P < 0.001) and less affected by flow (P < 0.05) than was (201)Tl retention. Reflecting its superior retention, the net uptake of (18)F-FDHR was better correlated with flow than was that of (201)Tl at both 1 and 15 min after tracer introduction (P < 0.0001 for both comparisons). CONCLUSION: The superior correlation of (18)F-FDHR uptake with flow indicates that it is a better flow tracer than (201)Tl in the isolated rabbit heart. Compared with the other currently available positron-emitting flow tracers ((82)Rb, (13)N-ammonia, and (15)O-water), (18)F-FDHR has the potential of providing excellent image resolution without the need for an on-site cyclotron.

A clinical measure for the assessment of problem solving in brain-injured adults.

Rapid Assessment of Problem Solving (RAPS) is a clinical test of verbal problem-solving skills for brain-injured persons. This modification of F. A. Mosher and J. R. Hornsby's (1966) Twenty Questions Test (20Q) reduces the memory demands of the test for brain-injured clients. This article provides background on the 20Q Test and modifications made for RAPS. It describes RAPS materials, administration, and scoring procedures and reports RAPS results for 70 normal participants. Normal participants solved RAPS problems with an average of 5 questions. Questions were predominantly constraint seeking and focused on semantic categories or features. Normal participants also reflected substantial variability in their performance on RAPS. This appeared to be related to 2 metacognitive abilities associated with problem solving, planning, and shifting set. The performance of 3 chronic traumatically brain injured individuals is also described and compared to the normal sample to illustrate clinical applications of RAPS.

Problem-solving by traumatically brain injured and neurologically intact subjects on an adaptation of the twenty questions test.

PRIMARY OBJECTIVE: RAPS (Rapid Assessment of Problem-Solving) is a clinical measure for assessing verbal problem-solving in hard-to-test patients or those that may not be able to tolerate a longer, more detailed assessment. The design of the test is based on Mosher and Hornsby's Twenty Question test, but RAPS contains several modifications to facilitate its use with brain-injured individuals. This study used RAPS to compare the verbal problem-solving ability of subjects that were neurologically intact and subjects that had chronic traumatic brain injuries. METHODS AND PROCEDURES: Twenty-one adults that were neurologically intact (NI) and 21 adults that had incurred a traumatic brain injury (TBI) matched for age, gender and education took part in the study. Before being tested with RAPS, participants signed an IRB-approved consent form and completed a battery of neurocognitive measures. RAPS entailed the solving of three verbal problems. Each problem involved an array of 32 pictures of common objects (e.g. football) arranged in a 4x 8 grid. The subjects were instructed to ask yes/no questions to determine which picture the examiner was 'thinking of '. Three scores were computed for each problem solved: number of questions asked, percentage of constraint-seeking questions, and question-asking efficiency scores for the first four questions. OUTCOMES: No learning effects across the problems were found for any of the RAPS measures. Scores were averaged across the three problems to determine group effects. Groups of TBI and NI subjects did not differ significantly in the number of questions asked in solving RAPS problems. Members of the NI group asked significantly more constraint-seeking questions (e.g. Is it an animal?) than those in the TBI group, and the subjects that had incurred brain injuries did more guessing than the NI group. Over 70% of the time, guessing took place after the semantic category containing the target picture was known to the subject. Guesses took the form of pseudo-constraint questions (e.g. Is it the animal with a long neck?) rather than frank guesses (e.g. Is it the giraffe?). These trends were seen for both groups. Question-asking efficiency scores, computed for the first four questions of each problem, reflected the amount of information gained by the subjects' questions. It was anticipated that subjects' questioning strategies would target larger rather than smaller number of pictures and systematically reduce the number of total pictures under consideration. Question-asking efficiency scores were significantly higher for the group of NI subjects. Both groups increased question-asking efficiency scores across the first four questions, and there was no significant group x question interaction. Further analysis of the question-asking efficiency scores revealed that questions from the group of NI subjects tended to target multiple categories of pictures and larger single semantic categories of pictures on the 32-item problem-solving board, whereas those from the group of TBI subjects often targeted smaller categories or portions of categories. CONCLUSIONS: Two meta-cognitive functions, planning and strategy shifting, appeared to explain most of the differences in the verbal problem-solving performance between the groups. Both groups, however, demonstrated a range of abilities on RAPS. Until a larger normative database for RAPS is available, it behooves clinicians using the test to analyse results on an individual basis, to consider the subject's pre-morbid problem-solving ability and to weigh those factors associated with brain injury that could affect RAPS performance.

Flow heterogeneity following global no-flow ischemia in isolated rabbit heart.

The purpose of this study was to evaluate flow heterogeneity and impaired reflow during reperfusion after 60-min global no-flow ischemia in the isolated rabbit heart. Radiolabeled microspheres were used to measure relative flow in small left ventricular (LV) segments in five ischemia + reperfused hearts and in five nonischemic controls. Relative flow heterogeneity was expressed as relative dispersion (RD) and computed as standard deviation/mean. In postischemic vs. preischemic hearts, RD was increased for the whole LV (0.92 +/- 0.41 vs. 0.37 +/- 0.07, P < 0.05) as well as the subendocardium (Endo) and subepicardium considered separately (1.28 +/- 0.74 vs. 0.30 +/- 0.09 and 0.69 +/- 0.22 vs. 0.38 +/- 0.08; P < 0.05 for both comparisons, respectively) during early reperfusion. During late reperfusion, the increased RD for the whole LV and Endo remained significant (0.70 +/- 0.22 vs. 0.37 +/- 0.07 and 1.06 +/- 0.55 vs. 0.30 +/- 0.09; P < 0.05 for both comparisons, respectively). In addition to the increase in postischemic flow heterogeneity, there were some regions demonstrating severely impaired reflow, indicating that regional ischemia can persist despite restoration of normal global flow. Also, the relationship between regional and global flow was altered by the increased postischemic flow heterogeneity, substantially reducing the significance of measured global LV reflow. These observations emphasize the need to quantify regional flow during reperfusion after sustained no-flow ischemia in the isolated rabbit heart.

Having the courage to be competent: persons and families living with aphasia.

UNLABELLED: This paper provides examples and illustrations of how aphasic people can and do demonstrate their competence in managing their lives despite chronic aphasia. It discusses a number of ways in which aphasic persons and their families can learn to live fully despite the intrusion of aphasia. EDUCATIONAL OBJECTIVES: After reading this paper, participants should (1) have a more fully developed appreciation of what it means to live courageously with aphasia, (2) recognize the importance of developing a lifespan perspective following the onset of aphasia, and (3) better understand competence in aphasia.

Quantitative gated blood pool SPECT: analysis of 3-dimensional models for the assessment of regional myocardial wall motion.

BACKGROUND: Gated blood pool single photon emission computed tomography (SPECT) (GBPS) uses truly 3-dimensional (3D) data, requiring attention to appropriate reference systems and segmentation models for proper quantification. To date, optimal 3D reference models have not been evaluated. In this study several techniques for 3D GBPS were evaluated. METHODS AND RESULTS: Static and dynamic cardiac phantom evaluations were performed, and GBPS studies for 3 healthy subjects and 9 patients were processed by a variety of 3D analysis techniques to determine the optimum parameters for identification of abnormal segments when compared with coronary arteriography and left ventriculography. Left ventricular wall motion was quantified by calculation of regional ejection fraction (rEF) through use of count, volume, and cord length changes from end diastole to end systole. Three contractile models were evaluated: (1) fixed center of mass (COM), (2) floating COM, and (3) a modification of the method developed by Slager et al (J Am Coll Cardiol 1986;7:317-26), based on the motion of implanted endocardial markers. Eight, twelve, and eighteen 3D segments were analyzed by means of the 3 contractile models and correlated against coronary artery disease assessed by coronary arteriography. Single-head gamma-camera acquisition provided adequate counting statistics to reliably compute rEF for up to 18 left ventricular segments. Using count changes the overall results were able to identify myocardium supplied by diseased coronary arteries when compared with coronary arteriography. Cord length and, to a lesser degree, volume changes provided somewhat poorer sensitivities and specificities when compared with rEF computed from regional count changes, as compared with coronary arteriography. CONCLUSIONS: Three-dimensional quantitative GBPS appears to be a sensitive method for assessing wall motion defects due to coronary artery disease.