A Randomized, Controlled Trial of a Shared Panel Management Program for Small Practices.

OBJECTIVES: To determine whether a shared panel management program was effective at improving quality of care for patients with uncontrolled chronic disease. DATA SOURCES: Data were extracted from electronic health records. STUDY DESIGN: Randomized controlled trial of a panel management program initiated by New York City Department of Health and Mental Hygiene. Patients from 20 practices with an uncontrolled chronic disease and a lapse in care were assigned to the intervention (a phone call requesting that the patient schedule a physician appointment) or usual care. Outcomes were visits to physician practices, body mass index measurement, blood pressure measurement and control, use of antithrombotics, and low-density lipoprotein measurement and control. PRINCIPAL FINDINGS: Panel managers were able to successfully speak with 1,676 patients (14.7 percent of the intervention group). There were no significant differences in outcomes between the intervention and usual care groups. Successfully contacted patients were more likely to have an office visit within 1 year of randomization (45.6 percent [95 percent CI: 22.8, 26.9] vs. 38.1 percent [95 percent CI: 36.8, 39.3]) and more likely to be on antithrombotics (24.4 percent [95 percent CI: 17.7, 31.0]) versus those in the usual care group (17.0 percent [95 percent CI: 13.9, 20.0]) but had no other difference in quality. CONCLUSIONS: A shared, low-intensity panel management program run by a city health department did not improve quality of care for patients with chronic illnesses and lapses in care.

Pediatric rehabilitation: 2. Environmental factors affecting participation.

OBJECTIVE: This self-directed learning module highlights the environmental factors that influence the participation of children and youth with disabilities in life situations, including activities of self-care, mobility, socialization, education, recreation, and community life. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. This module emphasizes the participation of children with disabilities in adapted sports and reviews mobility devices to promote function, in the context of the International Classification of Functioning and in reference to the Americans with Disabilities Act. It provides the physiatrist with strategies to promote community participation, functional independence and healthcare transitions for children with disabilities as they approach adulthood. The goal of this article is to improve the learner's treatment strategies to maximize the participation of children and youth with disabilities in all settings, particularly schools and communities.

Pediatric rehabilitation: 3. Facilitating family-centered treatment decisions.

OBJECTIVE: This self-directed learning module focuses on the role of accurate diagnosis, psychological support, and family integration of children who have chronic impairments such as pain, spasticity, or cognitive disability. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The role of therapeutic, medical (traditional and nontraditional) and psychological interventions that improve family and individual function are emphasized. The goal of this article is to refine a learner's knowledge of the impact family-centered care can have on the medical, psychological, financial, and functional capabilities of families to improve treatment decisions in the context of children with disability.

Pediatric rehabilitation: 4. Prescribing assistive technology to promote community integration.

OBJECTIVE: This self-directed learning module highlights the equipment and assistive technology needs of children and youth with disabilities. This article specifically focuses on preparing families and patients for equipment transitions that occur over the course of childhood and adolescence including progressing from stroller to wheelchair to powerchair, as well as job training and use of augmentative communication. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to modify the learner's current practice techniques to ensure that assistive technology is used to promote community integration from early childhood through transition and into adulthood.

Pediatric rehabilitation: 1. Common medical conditions in children with disabilities.

OBJECTIVE: This self-directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learner's knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.

Pediatric rehabilitation: 5. Transitioning teens with disabilities into adulthood.

OBJECTIVE: This self-directed learning module focuses on preparing adolescent patients with special health care needs for adulthood by promoting their independence in their own self-care; helping them to navigate issues of sexuality, marriage, and parenting; preparing the patient and family to make guardianship decisions during the transition between childhood and adulthood; and planning for higher education or vocation. Emphasis will be on the role of the physiatrist in providing this guidance and its importance in improving the patient's quality of life. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to refine the learner's knowledge of preparing adolescent patients with special health care needs for adulthood to improve their quality of life.

Potential clinical impact of compounded versus noncompounded intrathecal baclofen.

OBJECTIVE: To assess the differences between commercial and pharmacy-compounded preparations of baclofen for intrathecal administration. DESIGN: Random sample. SETTING: Pharmacies in the United States advertising compounded intrathecal baclofen preparation. PARTICIPANTS: Not applicable. INTERVENTIONS: Intrathecal baclofen (ITB) samples were collected from 1 Food and Drug Administration-approved commercial source and 6 compounding pharmacies. An independent analysis of drug concentration and density was conducted. Information regarding ordering process, manufacturing, packaging, storage, and expiration was collected. MAIN OUTCOME MEASURE: Comparison of concentration and density variations. RESULTS: Twenty-nine ITB samples in concentrations of 2000, 3000, 4000, 5000, and 6000 microg/mL were analyzed. Over 40% of compounded samples were more than 5% above or below labeled concentration. Twenty-two percent of compounded samples were more than 10% above or below labeled concentration. The only samples with no concentration deviation and consistent drug density were the commercially available, noncompounded products. CONCLUSIONS: Compounding pharmacies have variable practices in the provision of ITB. A high incidence of concentration inaccuracy existed. The use of compounded ITB may result in unintended dose alterations. Variable clinical efficacy, or life-threatening overdose or withdrawal may occur in patients who are sensitive to slight dose fluctuations. Given the variability of these compounded ITB samples, informed consent to use these products and understanding of potential side effects should be reviewed with patients.

Blending voices of Mexican American cancer caregivers and healthcare providers to improve care.

PURPOSE/OBJECTIVES: To identify and categorize healthcare provider perceptions of the meaning of cancer to Mexican American female family caregivers, including comparisons to caregiver themes in previous research. RESEARCH APPROACH: Descriptive, qualitative. SETTING: Three focus groups held in a publicly funded cancer clinic in the southwestern United States. PARTICIPANTS: 20 healthcare providers in diverse roles. METHODOLOGIC APPROACH: Tape recording of focus group discussions and transcription of content produced textual data for individual and team analysis. MAIN RESEARCH VARIABLES: Healthcare provider understanding, caregiver learning, and support needs. FINDINGS: Five major themes emerged related to the meaning of cancer to Mexican American caregivers: Caregivers fear the cancer diagnosis, interpret cancer as punishment, value maintenance of hope, believe in God and the doctor, and selectively disclose medical information. CONCLUSIONS: Healthcare providers identified most themes defined by Mexican American caregivers in an earlier study. However, provider identification of additional themes supports a blending of voices and partnerships between Mexican American cancer caregivers and providers to address caregiver literacy and support needs during the cancer cycle. INTERPRETATION: Understanding the cultural meaning of cancer to Mexican American caregivers provides a foundation for healthcare providers to define appropriate caregiver interventions in the cancer trajectory and to meet caregiver support and learning needs. Partnering of caregivers and providers also can ensure culturally sensitive care for Mexican American families experiencing cancer.

Radiotherapy for pancreatic neuroendocrine tumors.

PURPOSE: Pancreatic neuroendocrine tumors (PNTs) are rare malignant neoplasms considered to be resistant to radiotherapy (RT), although data on efficacy are scarce. We reviewed our institutional experience to further delineate the role of RT for patients with PNTs. METHODS AND MATERIALS: Between 1986 and 2006, 36 patients with PNTs were treated with RT to 49 sites. Of these 36 patients, 23 had radiographic follow-up data, which were used to determine the tumor response rate and freedom from local progression. Long-term toxicity was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events. RESULTS: The overall response rate to RT was 39% (13% complete response, 26% partial response, 56% stable disease, and 4% progressive disease). A significant difference in the freedom from local progression between the groups receiving either greater than or less than the median 2 Gy/fraction biologically equivalent dose of 49.6 Gy was found, with all radiographic progression occurring in patients who had received

Adapted recreational and sports programs for children with disabilities: A decade of experience.

OBJECTIVE: To identify and describe community based adapted sports and recreational programs (SARPs) for children with physically disabilities, documenting program types, benefits, challenges, growth and/or decline, and lessons they have learned over a 10-year period. METHODS: In 1996, a total of 277 children's hospitals and freestanding rehabilitation hospitals stating that they provided pediatric rehabilitation services were contacted and asked to provide information regarding adapted recreational and sports programs in their region. Seventy-nine SARPs were identified, contacted, and survyed about programming, benefits and challenges they faced. They were then re-surveyed in 2006 for comparison data. RESULTS: Ten years ago, the average SARP served 25 or fewer clients and was led by a therapeutic recreation specialist with assistance from volunteers. Most programs had been in place for 5 years or more, met weekly for 2-3 hours, and were recreational in orientation. Activities varied, with basketball, aquatics, horseback riding and snow skiing being most common. Fund-raisers and grants supported most programs, and securing funding was their greatest challenge. Participant benefits noted by programs included improved socialization, enhanced physical fitness, increased self esteem, improved therapeutic skills (ADL's, transfers, etc.), enhanced cognition, expanded client independence, improved community relations, and enhanced leisure skills. Ten years later, the majority of SARPs noted similar benefits, and reported an increase in number of participants despite continued challenges with funding and staffing. Leadership and mentorship by those with disabilities was still very low, but community awareness of the abilities of those with disabilities had increased. CONCLUSIONS: Adapted sports and recreation programs surveyed in 1996 and again in 2006, report overall that their health is good, and many have retained the same programming, financial support mechanisms, leadership and participant mix over the years. Many have increased athlete participation despite financial challenges being a predominant concern. They report that their staying power is dependent on many factors, including leadership, participant referrals, an ample supply of volunteers, and consistent community and financial support. They feel that their success is important to the physical and psychological well-being of individuals with disabilities and that an increased focus on corporate sponsorship, participation and mentorship by those with disabilities may assist with future growth. Increased school involvement, development of more competitive vs. recreational programs, and improved research documenting the physical and psychological benefits of adapted sports programs were also recommended to improve future SARP stability.

Cerebral palsy masking spinal muscular atrophy.

Spinal muscular atrophy (SMA) is an autosomal recessive anterior horn cell disease that results in progressive muscular weakness and atrophy without sensory involvement. A wide clinical spectrum that ranges from early death to essentially normal adult live exists. We describe a case of two 12 years olds, who represent two of three surviving non-identical quadruplets, born at 25 weeks gestational age. A diagnosis of hypotonic cerebral palsy (CP) was made in early childhood and early intervention services were initiated. At 3 years of age, MRI's showed white matter changes. Both briefly attained Gross Motor Functional Classification Scale (GMFCS) 3 status, but by 12 years of age their ambulatory abilities had decreased to Level 4. Physical Medicine and Rehabilitation (PM&R) physicians were consulted. On exam, distal lower extremities atrophy, hypotonia, hyporeflexia, and muscle weakness were noted. Neither child had upper motor neuron signs or spasticity. Cognition was normal. Neuromuscular disorder was suspected and genetic testing confirmed spinal muscular atrophy in both patients. While prior MRI/CT demonstrated static encephalopathy, recognition of symptoms and signs consistent with neuromuscular disease should have led to a secondary diagnosis. Therapeutic and surgical treatment decisions may have differed. Fragmentation of care and lack of a comprehensive team approach also contributed to the delay in recognition of their dual diagnosis.

A family medicine training collaborative in early abortion.

OBJECTIVES: This study's objective was to assess participation and perceived benefits of abortion training among residents at programs with integrated early abortion care. INTERVENTION: We developed a collaborative early abortion training network. RESULTS: Residents at training sites had high participation (71%) and were more likely to report familiarity and comfort with providing early abortion care than comparison sites. Residents reported benefits to overall training (78%), satisfaction (55%), and plans to provide abortion care (40%). CONCLUSIONS: This collaborative abortion training program was valued by residents and was associated with greater self-assessed skills and positive attitudes toward providing early abortion care than at comparison sites.

The use of near-infrared spectroscopy in skin care applications.

BACKGROUND: Near-infrared (NIR) spectroscopy was used to document the skin water content as a function of product usage and changes in the % relative humidity (%RH) in vitro and in vivo. The objective of the investigation was to determine if the NIR could provide comparable skin water content information as that obtained using gravimetric, conductivity, or visual assessment methods without having to invoke complex chemometric calculations. METHODS: NIR data were obtained using an NIR5000 spectrophotometer with a fiber optic probe (Smartprobe) attachment to complete the clinical studies and a Direct Contact Analyzer module to carry out the in vitro experiments. Conductivity measurements were completed using the Skicon 200, which measures conductance at a fixed frequency of 3.5 MHz. Three moisturization-based clinical studies were carried out assessing the NIR's ability to detect skin hydration changes. In Clinical Study A, NIR and Skicon data were collected for panelists who had only washed their outer calf with water over a 4-week period. During this time, the daily average %RH was recorded. In Clinical Study B, 10% solutions of glycerin, choline chloride, and the sodium salt of pyrrolidone carboxylic acid were applied to the panelist's outer calf and biophysical measurements were completed to assess the hydration and desorption properties of these humectants. In Clinical Study C, a 10% solution of choline chloride was applied to panelist's outer calf and the cumulative effect of using this product was evaluated over a 3-week period. For all in vitro studies, porcine skin was used as the substrate. RESULTS: Comparable NIR, Skicon, and visual dryness results were obtained for most of the product usage-based clinical experiments completed. However, the NIR was particularly more effective at detecting skin water content differences as a function of %RH changes. In the absence of abrupt (>50%) relative humidity variations, there was a direct correlation between the NIR readings and the %RH (R(2)=0.83) unlike what was observed for the Skicon measurements (R(2)=0.22). CONCLUSIONS: NIR spectroscopy demonstrated the changes in the skin water content as a function of product usage; the results were consistent with those obtained using the Skicon conductivity meter and visual dryness assessment scores. More importantly, the differences detected were obtained without having to use chemometric manipulations in the data analysis as is the common practice. Of all the methods used, the NIR gave the best linear regression for %RH-induced skin water content changes.

Initiating abortion training in residency programs: issues and obstacles.

OBJECTIVES: Early abortion is a common outpatient procedure, but few family medicine residencies provide abortion training. We wished to assess experiences and obstacles among residency programs that have worked to establish early abortion services. METHODS: From 2001-2004, 14 faculty participated in a collaborative program to initiate abortion training at seven family medicine residencies. Ten focus groups with all trainees were followed by individual semi-structured interviews with a smaller group (n=9) that explored the progress and obstacles they experienced. Individual interviews were recorded and analyzed to identify major themes and sub-themes related to initiating abortion training. RESULTS: Five of seven sites established abortion training. Five major themes were identified: (1) establishing support, (2) administration, (3) finance, (4) legal matters, and (5) security/demonstrators. Faculty from sites where training was ultimately established rated the sub-themes of billing/reimbursement, obtaining staff support, and state/hospital regulations as most difficult. Gaining support from within the department and institution was most difficult for the two sites that could not establish training. None experienced difficulty with security/demonstrators. CONCLUSIONS: Developing the clinical and administrative capacity to provide early abortion services in family medicine residency programs is feasible. Support from leadership within departments and from the wider institution is important for implementation.