A Near-Peer Interprofessional Educational Fellowship Program for Training Pre-Clinical Medical Students in the Best Practices of Teaching and Learning.

Medical school often has opportunities for students to engage in peer or near-peer teaching, however structured teacher training is rarely conducted. We present an Educational Fellowship for rising M2 students as teaching assistants for first year Physician Assistant students. In this near-peer interprofessional teaching model, the M2 students learn pedagogical theory and best practices for teaching and learning. The curriculum and experience may be used by any healthcare profession. Since many healthcare professions have classes during the summer, we present our program as a conceptual model for other institutions.

Adopting Graduate Competencies in Opioid Prescribing for Massachusetts Physician Assistant Programs: A Statewide Public Health Response.

Opioid addiction has become a national epidemic. Morbidity and mortality from prescription and synthetic opioid use and abuse have increased at an alarming rate in recent years. Ensuring that physician assistant (PA) graduates have the knowledge to become safe prescribers of medications, including opiates, is a goal of PA training programs. Achieving that goal requires fostering PA student competence regarding current issues in pain control, drug use and misuse, polypharmacy, diversion, self-medication, and substance use disorder. We present a public health approach to addressing that need. Our approach involved developing consensus among the 9 PA programs in Massachusetts concerning the adoption and implementation of statewide, graduate core competencies for the prevention and management of prescription drug misuse. The process implemented in Massachusetts could be used as a model in other states and might be relevant to addressing other public health crises. We present the adopted competencies as well as individual PA programs' curricular approaches.

A National Survey of Quality Improvement Education in Physician Assistant Programs.

PURPOSE: Quality improvement (QI) is emerging as a leadership and career track for physician assistants (PAs). Information on how PA programs teach QI is sparse. This study aimed to define how PA programs are providing education in QI through a national program survey. METHODS: Curriculum survey questions were deployed as a part of the 2014-2015 Physician Assistant Education Association program survey. Questions were grouped into 4 categories: QI champion, pedagogy, integration strategy, and curriculum content. Differences between groups were analyzed, and logistic regression models were built to explore associations. RESULTS: All 194 (100%) PA programs responded to the survey. There were 137 (70.6%) programs that were teaching QI. The median number of total instructional hours was 12 (interquartile range = 16, overall range = 109). There were 37 (27%) programs that were categorized as having a "mature curriculum." Mature curricula were significantly associated with a QI champion who is an expert from an outside department/institution (odds ratio [OR], 5.05; 95% confidence interval [CI], 1.14-22.33) and with programs that have a QI capstone or thesis project (OR, 3.66; 95% CI, 1.14-11.72) whose educational hours correlated more with experiential learning (r = 0.51, P < .01), small group sessions (r = 0.42, P = .01), and web-based modules (r = 0.36, P = .03). CONCLUSION: Quality improvement is an important skill set for PAs, but nearly one-third of PA programs do not have a QI curriculum. Mature curricula were associated with more experiential learning and project-based learning (including capstone/thesis). This study captured many elements of QI education for PAs, which can be used by programs to develop and improve their curricula.

THE EFFECT OF TACKLING TRAINING ON HEAD ACCELERATIONS IN YOUTH AMERICAN FOOTBALL.

BACKGROUND: Many organizations have introduced frameworks to reduce the incidence of football related concussions through proper equipment fitting, coach education, and alteration of tackling technique. PURPOSE: The purpose of this study was to examine the effects of training in a vertical, head up tackling style on the number of head accelerations experienced while tackling in a controlled laboratory situation. The authors hypothesized that training in a head up tackling technique would reduce the severity of head acceleration experienced by participants. DESIGN: Controlled Laboratory Study. METHODS: Twenty-four participants (11.5 ± 0.6 years old, 60.5 ± 2.2 in, 110 ± 18.4 lbs.) with previous playing experience completed a one-day training session on tackling technique utilizing a tackling dummy. A subgroup of these participants completed an additional two days of training with a 48 hour retention test. Head accelerations were analyzed at baseline and end of training. Feedback consisted of verbal feedback utilizing the Qualitative Youth Tackling Scale (QYTS) and video tackling playback. RESULTS: A significant reduction in the number of peak linear head accelerations over 10 g and peak rotational head accelerations over 1885 deg/s2 were found in dummy tackling after training in both the one day and three day training regimens. A significant change in QYTS tackling form score was found between pretest and post-test (p = 0.004). Participants with larger steps had a 2.28, 4.42 and 4.14 increased odds ratio of sustaining head accelerations over 10, 15 and 20 g respectively. CONCLUSIONS: Training in a vertical, head up tackling style decreased the number of head accelerations over threshold values sustained while tackling; decreased step length may be the driving factor in the effectiveness of this tackling form. LEVEL OF EVIDENCE: Level 3b.

INTER-RATER AGREEMENT AND VALIDITY OF A TACKLING PERFORMANCE ASSESSMENT SCALE IN YOUTH AMERICAN FOOTBALL.

BACKGROUND: Long term neurologic injury and concussion have been identified as risks from participation in American football. Altering tackling form has been recommended to reduce the risk of neurologic injury caused by head accelerations when tackling. The purpose of this research is to determine the inter-rater agreement and validity of the Qualitative Youth Tackling System (QYTS), a six-item feedback scale to correct tackling form, when utilized by novice and expert raters. HYPOTHESIS: Experienced raters will have higher levels of agreement with each other and with motion capture when compared to novice raters. METHODS: Both novice and experienced raters viewed video of youth athletes (ages 9-13) tackling a dummy in a laboratory setting along. The raters identified successful performance according to a binary rating scale for each component. Analysis of both the raters' agreement with each other and with an objective motion capture measure were completed. RESULTS: Fliess' Kappa measures between all raters were found to be moderate for head placement (k=.48), fair for cervical extension (k=.38), trunk inclination (k=.37), shoulder extension (k=.27) and step length (k=.29), and there was no agreement for pelvic height (k=.-16). When compared to the dichotomized validation measures of each of the five components provided by the motion capture system the average Cohen's Kappa agreement was substantial for pelvic height (k=.63), fair for step length (k=.34), cervical extension (k=.40), trunk inclination (k=.35), and slight for shoulder extension (k=.16). The experienced raters outperformed the novice raters in all categories. CONCLUSION: The results of this study indicate that skilled raters are better able to identify the movement patterns included in the QYTS when compared to a validation measure as well have higher rates of inter-rater agreement than novice raters. LEVEL OF EVIDENCE: 3b.

An opportunity for PAs as obstetrical laborists.

The obstetrical laborist, based on the hospitalist model, can improve quality and safety of labor and delivery care. A laborist can be a physician assistant (PA), certified nurse midwife, or obstetrician/gynecologist who provides care using a scheduled shifts model. Workforce trends show a rapid increase in certified nurse midwives and PAs, which could stimulate the laborist movement and increase opportunities for PAs.

Neuroplasticity Associated With Anterior Cruciate Ligament Reconstruction.

Study Design Controlled laboratory study. Background Anterior cruciate ligament (ACL) injury may result in neuroplastic changes due to lost mechanoreceptors of the ACL and compensations in neuromuscular control. These alterations are not completely understood. Assessing brain function after ACL injury and anterior cruciate ligament reconstruction (ACLR) with functional magnetic resonance imaging provides a means to address this gap in knowledge. Objective To compare differences in brain activation during knee flexion/extension in persons who have undergone ACLR and in matched controls. Methods Fifteen participants who had undergone left ACLR (38.13 ± 27.16 months postsurgery) and 15 healthy controls matched on age, sex, height, mass, extremity dominance, education level, sport participation, and physical activity level participated. Functional magnetic resonance imaging data were obtained during a unilateral knee motor task consisting of repeated cycles of knee flexion and extension. Results Participants who had undergone ACLR had increased activation in the contralateral motor cortex, lingual gyrus, and ipsilateral secondary somatosensory area and diminished activation in the ipsilateral motor cortex and cerebellum when compared to healthy matched controls. Conclusion Brain activation for knee flexion/extension motion may be altered following ACLR. The ACLR brain activation profile may indicate a shift toward a visual-motor strategy as opposed to a sensory-motor strategy to engage in knee movement. Level of Evidence Cohort, level 3. J Orthop Sports Phys Ther 2017;47(3):180-189. Epub 5 Nov 2016. doi:10.2519/jospt.2017.7003.

Maternal mental health and infant mortality for healthy-weight infants.

OBJECTIVES: The objective of this study was to determine if severe mental illness and/or a history of substance use in mothers of babies of a healthy weight was associated with infant mortality. STUDY DESIGN: This was a cross-sectional observational study using CareSource historical billed Medicaid Managed Care plan (MMC) claims in Ohio. METHODS: CareSource is Ohio's largest MMCP, serving approximately 1.2 million Medicaid consumers. Claims from 89,159 babies of a healthy weight (≥ 2500 grams) and their mothers were selected from the CareSource Ohio MMCP population from January 2011 through December 2014. The mental health and substance abuse status of the mother was identified from claim history. A logistic regression model was used to estimate the odds ratio for infant mortality based on the presence or absence of maternal severe mental illness (MSMI) or maternal substance abuse (MSU). RESULTS: The logistic regression model fit showed that the odds of infant mortality for infants born weighing 2500 grams or more was significantly higher when the mother was treated either for MSMI (χ2(1): P = .026) or MSU (χ2(1): P = .006) at any time before or after delivery. CONCLUSIONS: Findings indicate that to address infant mortality, a focus on only babies born premature or low birth weight will result in missing a notable segment of the population that requires attention. Mothers who have babies with a healthy weight of at least 2500 grams, but who are diagnosed with either MSMI or MSU, need at least equal attention if inroads are to be made in reducing infant mortality.

Age and sex alone are insufficient to predict human rib structural response to dynamic A-P loading.

Thoracic injuries from motor vehicle crashes (MVCs) are common in children and the elderly and are associated with a high rate of mortality for both groups. Rib fractures, in particular, are linked to high mortality rates which increase with the number of fractures sustained. Anthropomorphic test devices (ATDs) and computational models have been developed to improve vehicle safety, however these tools are constructed based on limited physical datasets. To-date, no study has explored variation of rib structural properties across the entire age spectrum with data obtained using the same experimental methodology to allow for comparison. One-hundred eighty-four ribs from 93 post mortem human subjects (PMHS) (70 male, 23 female; ages 4-99) were subjected to dynamic bending tests simulating a frontal impact to the thorax. Structural mechanical properties were calculated and a multi-level statistical model quantified the sample variance as explained by age and sex. Displacement (δX), peak force (Fpeak), linear structural stiffness (K), energy absorption to fracture (Utot), and plastic properties including post-yield energy absorption (UPl), plastic displacement (δPl), and the ratio of elastic to secant stiffness (K-ratio) all showed negative relationships with age, while only Fpeak, K, and Utot were dependent on sex. Despite these relationships being statistically significant, only 7-39% of variance is explained by age and only 3-17% of variance is explained by sex. This demonstrates that variability in bone properties is more complex than simply chronological age- and sex-dependence and should be explored in the context of biological mechanisms instead.

Feasibility, Preliminary Efficacy, and Lessons Learned From a Garden-Based Lifestyle Intervention for Cancer Survivors.

BACKGROUND: Cancer survivors remain at increased risk for secondary malignancies, comorbidities, and all-cause mortality. Lifestyle behaviors, such as diet and physical activity, are strongly linked to a decreased risk of chronic disease and improved health outcomes, yet a paucity of research has been conducted in this vulnerable population. METHODS: Adult cancer survivors were recruited to participate in Growing Hope, an experimental single-group study designed to assess the feasibility and efficacy of a theory-driven and evidence-based intervention. For 4 months, 22 participants received group and individual education and had access to harvesting fresh produce at an urban garden. Data on program satisfaction, compliance, diet, and physical activity were collected via surveys; anthropometrics, blood values, and skin carotenoids were objectively measured. RESULTS: The intervention resulted in significant improvements in consumption of fruits and vegetables (P = .003), decreased consumption of red and processed meats (P = .030) and sugar-sweetened beverages (P = .020). Levels of skin carotenoids, fasting blood glucose, and non-high density lipoprotein cholesterol were also significantly improved (P = .011, P = .043, and P = .05, respectively). CONCLUSIONS: The results of this study support the feasibility and efficacy of a multifaceted, garden-based intervention for cancer survivors. In addition, these preliminary results demonstrate a positive impact aligning with the current lifestyle recommendations for cancer survivorship. Larger randomized controlled trials are warranted to define impact on sustained health outcomes.

The National Institutes of Health Stroke Scale Lacks Validity in Chronic Hemiparetic Stroke.

BACKGROUND: The National Institutes of Health Stroke Scale (NIHSS) is purported to be associated with long-term outcomes. This study determined the concurrent validity of the NIHSS with the Stroke Impact Scale (SIS), a previously validated measure of health status in chronic stroke survivors. METHODS: The NIHSS and the SIS were administered to 147 subjects before participation in a multicenter, randomized, controlled trial. A Spearman's rho was used to determine correlations between NIHSS total score and (1) SIS physical dimension scores, (2) SIS overall perception of recovery scores, and (3) the SIS activities and independent activities of daily living (ADL/IADL) scores. SIS score variation and medians between subjects who scored a zero versus a nonzero on the NIHSS was also assessed. RESULTS: There was no association between total NIHSS scores and SIS physical dimension scores, SIS overall perception of recovery scores, and SIS ADL/IADL scores (P = -.036, P = .782; P = -.039, P = .640; P = -.054, P = .520; respectively). Lastly, significant variation and similar median scores on the SIS were found between those scoring a zero on the NIHSS versus those who did not score a zero. CONCLUSIONS: The NIHSS has no association with health status in chronic stroke and lacks association with measures of impairment and functional limitation. From these findings, we conclude that the NIHSS has poor validity to discern long-term poststroke outcomes and is not associated with health status. Because of possible limitation in the NIHSS's ability to accurately determine outcomes in this population, we recommend restriction of its use to the acute stage of recovery.

The effect of age on the structural properties of human ribs.

Traumatic injury from motor vehicle crashes is a major cause of morbidity and mortality in the United States. The thorax is particularly at risk in motor vehicle crashes and is studied extensively by the injury biomechanics community. Unfortunately, most samples used in such research generally do not include children or the very elderly, despite the common occurrence of thorax injuries at both ends of the age spectrum. Rib fractures in particular, are one of the most common injuries, especially in the elderly, and can greatly affect morbidity, mortality, and quality of life. As the proportion of older adults in the population increases, such age-related fragility fractures will continually grow as a worldwide problem. Additionally, the risk of rib fracture significantly increases with age with confounding deleterious effects. Studies on elderly ribs are not uncommon, however very few studies exist which explore the mechanical properties and behavior of immature human bone, especially of ribs. Previous research identifying rib properties has provided useful information for numerous applications. However, no study has included a comprehensive sample of all ages (pediatric through elderly) in which ribs are tested in the same repeatable set-up. The goal of this study is to characterize differences in rib structural response across the age spectrum. One-hundred forty excised ribs from 70 individuals were experimentally tested in a custom-built pendulum fixture simulating a dynamic frontal impact. The sample includes individuals of ages ranging from six to 99 years old and includes 58 males and 12 females. Reported data include fracture location, displacement in the X and Y directions at fracture (δX, δY), force at fracture (FX), and linear structural stiffness (K). δX and K exhibit a statistically significant linear decrease with age (p<0.0001). FX reveals a trend in which a peak is reached in the young adult years (25-40). Detailed mechanical property data, as provided here, will prove useful for application in computational modeling efforts, which are vital to help prevent injury and to understand injury mechanisms from childhood through old age.

Impact of tetrabenazine on gait and functional mobility in individuals with Huntington's disease.

Chorea may contribute to balance problems and walking difficulties that lead to higher fall rates in individuals with Huntington's disease (HD). Few studies have examined the effects of tetrabenazine (TBZ), an anti-choreic drug, on function and mobility in HD. The purpose of this study was to compare: 1) gait measures in forward walking, 2) balance and mobility measures, and 3) hand and forearm function measures on and off TBZ. We hypothesized that use of TBZ would improve gait, transfers and hand and forearm function. Eleven individuals with HD on stable doses of TBZ were evaluated while off medication and again following resumption of medication. Significant improvements were found on the Unified Huntington's Disease Rating Scale (UHDRS) motor scores, Tinetti Mobility Test (TMT) total (t=4.20, p=0.002) and balance subscale (t=-4.61, p=0.001) scores, and the Five Times Sit-to-Stand test (5TSST, t=3.20, p=.009) when on-TBZ compared to off-TBZ. Spatiotemporal gait measures, the Six Condition Romberg test, and UHDRS hand and forearm function items were not changed by TBZ use. Improved TMT and 5TSST performance when on drug indicates that TBZ use may improve balance and functional mobility in individuals with HD.

Factors associated with longer length of stay for mental health emergency department patients.

BACKGROUND: Mental health patients can experience long lengths of stay in the emergency department (ED). Reducing boarding times for mental health patients might improve care for all ED patients. OBJECTIVE: The objective of this study was to identify patient factors that are correlated with extremely long lengths of stay (EL-LOS) for mental health patients in the ED. METHODS: A retrospective, case-control study compared mental health patients experiencing lengths of stay longer than 24 h to those with lengths of stay <24 h. The study was conducted at an urban, academic ED and Level I trauma center. Sequential chi-squared tests were used to detect significant differences on the outcome measure. Logistic regression was used to determine factors that made significant contributions to predicting EL-LOS. The outcome measure was patients' length of stay in the ED. The factors analyzed were patient demographics, insurance status, day of arrival and departure, placement (admitted locally, admitted remotely, or discharged), chief complaint, and diagnostic category. RESULTS: Patient-level factors associated with EL-LOS were self-pay status, admission to inpatient care, transfer to a remote facility, and suicidal ideation. Admission to inpatient care and self-pay status made significant nonredundant contributions to predicting EL-LOS. In addition, mental health patients arriving on a weekday were significantly more likely to be admitted to inpatient care than those arriving on weekends. CONCLUSIONS: Factors were identified that correlated with long lengths of stay in the ED for mental health patients. Increasing timely access to inpatient beds for mental health patients, in particular by improving access to insurance that covers inpatient psychiatric care and eliminating unique mental health requirements to obtain prior authorization for placement, would likely reduce these patients' lengths of stay.

Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners.

OBJECTIVE: Although there is a growing recognition of the importance of active communication behaviours from the incoming clinician receiving a patient handover, there are currently no agreed-upon measures to objectively describe those behaviours. This study sought to identify differences in incoming clinician communication behaviours across levels of clinical training for physicians and nurses. METHODS: Handover observations were conducted during shift changes for attending physicians, resident physicians, registered nurses and nurse practitioners in three medical intensive care units from July 2011 to August 2012. Measures were the number of interjections from the incoming clinician and the communication mode of those interjections. Each collaborative cross-check, a specific type of interactive question, was subsequently classified by level of assertiveness. RESULTS: 133 patient handovers were analysed. Statistical differences were found in both measures. Higher levels of training were associated with fewer interjections, and a higher proportion of interactive questioning to detect erroneous assessments and actions by the incoming provider. All groups were observed to use the least assertive level of a collaborative cross-check, which contributed to misunderstandings. Nurses used less assertive collaborative cross-checks than physicians. CONCLUSIONS: Differences across clinician type and levels of clinical training were found in both measures during patient handovers. The findings suggest that training could enable physicians and nurses to learn communication competencies during patient handovers which were used more frequently by more experienced practitioners, including interjecting less frequently and using interactive questioning strategies to clarify understanding, and assertively question the appropriateness of diagnoses, treatment plans and prognoses. Accompanying cultural change initiatives might be required to routinely employ these strategies in the clinical setting, particularly for nursing personnel.

Assistive devices alter gait patterns in Parkinson disease: advantages of the four-wheeled walker.

Gait abnormalities are a hallmark of Parkinson's disease (PD) and contribute to fall risk. Therapy and exercise are often encouraged to increase mobility and decrease falls. As disease symptoms progress, assistive devices are often prescribed. There are no guidelines for choosing appropriate ambulatory devices. This unique study systematically examined the impact of a broad range of assistive devices on gait measures during walking in both a straight path and around obstacles in individuals with PD. Quantitative gait measures, including velocity, stride length, percent swing and double support time, and coefficients of variation were assessed in 27 individuals with PD with or without one of six different devices including canes, standard and wheeled walkers (two, four or U-Step). Data were collected using the GAITRite and on a figure-of-eight course. All devices, with the exception of four-wheeled and U-Step walkers significantly decreased gait velocity. The four-wheeled walker resulted in less variability in gait measures and had less impact on spontaneous unassisted gait patterns. The U-Step walker exhibited the highest variability across all parameters followed by the two-wheeled and standard walkers. Higher variability has been correlated with increased falls. Though subjects performed better on a figure-of-eight course using either the four-wheeled or the U-Step walker, the four-wheeled walker resulted in the most consistent improvement in overall gait variables. Laser light use on a U-Step walker did not improve gait measures or safety in figure-of-eight compared to other devices. Of the devices tested, the four-wheeled-walker offered the most consistent advantages for improving mobility and safety.