The Impact of Point-of-Care Hemoglobin A1c Testing on Population Health-Based Onsite Testing Adherence: A Primary-Care Quality Improvement Study.

BACKGROUND: The hemoglobin A1c (HbA1c) is a gold-standard test to diagnose and monitor diabetes mellitus and has been incorporated into population health performance metrics for quality care. However, patients and practices remain challenged in completing timely HbA1c tests. Point-of-care testing (POCT) for HbA1c provides a quick, easy, reliable method for monitoring diabetes in the primary care office setting. The objectives of this quality improvement study were to evaluate the impact of HbA1c POCT on onsite HbA1c testing frequency as a component of population health performance, as well as to measure the utility of HbA1c POCT in identifying clinically meaningful change in disease. METHOD: Prospective quality improvement cohort study among sequentially scheduled adult patients with diabetes due for HbA1c testing across three primary care practices. RESULTS: Practices with HbA1c POCT were 3.7 times less likely to miss HbA1c testing at the time of the visit compared with practices in which HbA1c POCT was not available (P < .001). Nearly one in four patients in each group were found to have clinically worsening diabetes (defined by an increase in HbA1c of ≥0.5% or 5.5 mmol/mol). Nearly half of those patients in the intervention group were identified by POCT. CONCLUSIONS: HbA1c POCT can improve population health-driven HbA1c testing adherence at office visits in primary care and may enable more timely intervention of diabetes management for patients with worsening disease.

Identifying Risk Factors Associated With Postoperative Infection Following Elective Lower-Extremity Total Joint Arthroplasty.

This article addresses the importance of identifying risk factors associated with postoperative infection following elective lower-extremity total joint arthroplasty. Specifically, this review discusses risk factors recognized by the American Academy of Orthopaedic Surgeons that should be carefully considered and assessed by the orthopaedic team in collaboration with the primary care provider before proceeding with surgery.

Validity of the Spot Vision Screener in detecting vision disorders in children 6 months to 36 months of age.

PURPOSE: To evaluate the Spot Vision Screener in detecting targeted vision disorders compared to cycloplegic retinoscopy in children <3 years of age. METHODS: Children, ages 6 months to 36 months underwent vision screening using the Spot Vision Screener. Results were compared to results of comprehensive eye examinations. Validity of the Spot was evaluated by calculating the area under the curve (AUC); the receiver operating characteristics (ROC) were used to determine optimal sensitivity and specificity for detection of targeted vision disorders. RESULTS: A total of 249 children were included. The AUC for detecting targeted vision disorders as defined by the study specific criteria using the Spot was 0.790. Compared to cycloplegic retinoscopy, the Spot underestimated hyperopia by 1.02 D (95% CI, 0.86-1.17 D). For hyperopia ≥4.5 D spherical equivalent (n = 10), the mean difference between the Spot and cycloplegic retinoscopy was 3.46 D (95% CI, 1.95-4.98 D). In contrast, the Spot overestimated astigmatism compared to cycloplegic retinoscopy (-1.00 D vs -0.48 D; P < 0.001) by -0.52 D (95% CI, 0.43-0.62 D). CONCLUSIONS: The Spot Vision Screener showed good overall validity in detecting targeted vision disorders. It was within 0.5 D and 1 D of cycloplegic retinoscopy with regard to low hyperopia and astigmatism. Higher hyperopic spherical equivalent refractive errors showed larger differences in mean values between the Spot and cycloplegic retinoscopy.

Primary Care-Based Health Coaching Intervention for Weight Loss in Overweight/Obese Adults: A 2-Year Experience.

Background: Obesity is a major contributor to medical comorbidity and places a large economic burden on health care. This study examined the effectiveness of primary care-integrated health coaching for weight loss in overweight/obese patients. Participants/Methods: This observational clinical study with a retrospective comparison analysis was performed at an urban academic primary care practice. A total of 271 individuals with a BMI >25 kg/m2 were recruited and followed for 2 years. A standardized health coaching intervention was used to promote weight loss. The main outcome measures were weight loss as a percentage of initial body weight and proportion of patients with weight loss ≥5% initial body weight, controlling for relevant covariates. An activity-based cost assessment of health coaching for weight loss was also performed. Results: Health coaching was associated with a mean loss of 7.24% initial weight after 12 months (95% CI = 8.68 to 5.90) and 6.77% after 24 months (95% CI = 8.78 to 4.76). Coached patients were more likely to achieve ≥5% of initial weight loss at both 12 and 24 months (P < .001). Health coaching costs were $288.54 per participant over 1 year. Conclusions: Primary care-integrated health coaching was associated with statistically significant weight loss in overweight and obese adults.

Opioid Prescribing by Nurse Practitioners in Medicare Part D: Impact of State Scope of Practice Legislation.

Many state legislatures restrict nurse practitioner (NP) scope of practice as a way of addressing patient safety concerns. The purpose of this study was to investigate the influence of state NP scope of practice laws on the prescription of oxycodone and hydrocodone containing medications by NP and MD/DO/PA prescribers to Medicare Part D beneficiaries. Using the Medicare Part D public use file, we analyzed oxycodone and hydrocodone containing prescriptions per Medicare Part D beneficiary by prescriber type, NP state scope of practice, and geographic variables. Our results demonstrate that the state scope of practice variable had the same effect, in identical direction and significance, on NP opioid prescribing patterns as it had on MD/DO/PA prescribers, a group to whom NP scope of practice laws do not apply. Thus, scope of practice in this study was not an exclusive predictor of NP practice and prescribing.

Use of Simulation to Integrate Cultural Humility Into Advanced Health Assessment for Nurse Practitioner Students.

BACKGROUND: Increasing cultural humility among nursing students requires the application of knowledge and skills. The integration of an Objective Structured Clinical Examination (OSCE) offered nurse practitioner students practice in simulation. METHOD: This learning activity included pre- and postassessments of knowledge regarding cultural issues and level of student satisfaction. Course content included an exemplar video and a simulation interview with an African American standardized patient. RESULTS: Of the 65 students enrolled, 97% completed OSCE interviews and 81% completed pre- and postsurveys. A 2-domain 3 × 2-time within-subjects ANOVA indicated a statistically significant interaction effect, reinforced by descriptive statistics. Follow-up paired t tests detected a significantly large knowledge increase. Standardized patient scenarios scored highest for satisfaction, followed by critical thinking, and with self-confidence scoring lowest. CONCLUSION: The favorable knowledge outcomes from this teaching intervention support future applications of OSCE methodology for teaching sensitive cross-cultural content. [J Nurs Educ. 2017;56(9):567-571.].

Changing Resident Physician Studying Behaviors: A Randomized, Comparative Effectiveness Trial of Goal Setting Versus Use of WOOP.

BACKGROUND: Following through on one's goals to study is essential for effective, self-regulated learning. This can be difficult for residents because of clinical demands and limited personal time. WOOP (Wish, Outcome, Obstacle, Plan) is a self-regulation strategy, also known as mental contrasting with implementation intentions. WOOP increases follow-through on goals in many domains, although it has not, to our knowledge, been evaluated in medical education. OBJECTIVE: We compared the effect of WOOP versus goal setting on time residents spent studying. METHODS: Through a prospective, randomized, comparative effectiveness study, during a 1-month, intensive care unit rotation, we clustered anesthesiology residents in single-blind fashion to WOOP versus goal setting. Both groups received organized study materials. The intervention group performed WOOP to study more; the comparison group set goals to study more. Residents tracked studying with daily diaries. The primary outcome was total time spent studying toward stated goals. Time spent studying "non-goal" medical material was a secondary outcome. RESULTS: Of 34 eligible residents, 100% participated. Sixteen residents were randomized to the WOOP group and 18 to the goal-setting group. The WOOP group spent significantly more time studying toward their goals compared with the goal-setting group (median = 4.3 hours versus 1.5 hours; P = .021; g = 0.66). There was no significant difference in time spent studying non-goal medical material between groups (median = 5.5 hours versus 5.0 hours, P = .99). CONCLUSIONS: WOOP increased the time residents spent studying toward their goals as compared with setting goals alone.

Health hackathons: theatre or substance? A survey assessment of outcomes from healthcare-focused hackathons in three countries.

BACKGROUND: Healthcare-focused hackathons are 48-hour platforms intended to accelerate novel medical technology. However, debate exists about how much they contribute to medical technology innovation. The Consortium for Affordable Medical Technologies (CAMTech) has developed a three-pronged model to maximise their effectiveness. To gauge the success of this model, we examined follow-up outcomes. METHODS: Outcomes of 12 hackathons from 2012 to 2015 in India, Uganda and the USA were measured using emailed surveys. To minimise response bias, non-responding teams were coded as having made no progress. RESULTS: 331 individuals provided information on 196 of 356 projects (55.1% response rate), with no difference in responses from teams participating in different countries (Cramer's V=0.09, p=0.17). 30.3% of projects had made progress after a mean of 12.2 months. 88 (24.7%) teams had initiated pilot testing, with 42 (11.8%) piloting with care providers and 24 (6.7%) with patients. Overall, 97 teams (8.1 per hackathon) drafted business plans, 22 (1.8 per hackathon) had filed patents on their innovations and 15 (1.3 per hackathon) had formed new companies. Teams raised US$64.08 million in funding (average US$5.34 million per hackathon; median award size of $1800). In addition, 108 teams (30.3%) reported at least one member working on additional technologies with people they met at a hackathon. Individual confidence to address medical technology challenges was significantly increased after attending (t(1282)=192.77, p 0.001). CONCLUSION: CAMTech healthcare hackathons lead to consistent output with respect to medical technology innovation, including clinical trials, business plan development, securing investment capital/funding and new company formation.

Impact of Intensive Summer Reading Intervention for Children With Reading Disabilities and Difficulties in Early Elementary School.

Efficacy of an intensive reading intervention implemented during the nonacademic summer was evaluated in children with reading disabilities or difficulties (RD). Students (ages 6-9) were randomly assigned to receive Lindamood-Bell's Seeing Stars program ( n = 23) as an intervention or to a waiting-list control group ( n = 24). Analysis of pre- and posttesting revealed significant interactions in favor of the intervention group for untimed word and pseudoword reading, timed pseudoword reading, oral reading fluency, and symbol imagery. The interactions mostly reflected (a) significant declines in the nonintervention group from pre- to posttesting, and (2) no decline in the intervention group. The current study offers direct evidence for widening differences in reading abilities between students with RD who do and do not receive intensive summer reading instruction. Intervention implications for RD children are discussed, especially in relation to the relevance of summer intervention to prevent further decline in struggling early readers.

Preliminary Predictors of Initial Attendance, Symptom Burden, and Motor Subtype in a US Functional Neurological Disorders Clinic Population.

BACKGROUND AND OBJECTIVE: Although many patients present with functional neurological symptoms (FNS), few US clinics offer specialized FNS care, and data on clinic attendees remain limited. We determined predictors of initial attendance, symptom burden, and FNS subtype in the first patients referred to our Functional Neurological Disorders Clinic for suspected FNS. METHODS: We reviewed the charts of 62 consecutive patients (46 women, 16 men). Regression analyses investigated predictors of keeping the first scheduled clinic appointment. For the 49 patients who did keep that appointment, regression analyses examined neuropsychiatric factors associated with symptom burden and motor FNS subtypes. RESULTS: The odds of not keeping the first appointment were 10.4 times greater for patients referred from the emergency department than from other sources. The patients who kept their appointment reported a symptom burden that was significantly associated with a past FNS-related emergency department visit and a diagnosis of another medically unexplained somatic syndrome. The number of FNS findings on neurological examination also correlated with a history of an FNS-related emergency department visit. Patients with psychogenic non-epileptic seizures reported cognitive complaints and prior psychiatric hospitalizations significantly more often than did patients with other FNS. One fourth of all patients had two or more motor FNS. CONCLUSIONS: In our FNS cohort, patients were less likely to keep an initial clinic appointment if they were referred from the emergency department than from other sources. Patients with psychogenic non-epileptic seizures were more likely to report cognitive symptoms and past psychiatric hospitalizations than patients with other FNS.

Injuries observed in a prospective transition from traditional to minimalist footwear: correlation of high impact transient forces and lower injury severity.

OBJECTIVES: Minimalist running is increasing in popularity based upon a concept that it can reduce impact forces and decrease injury rates. The purpose of this investigation is to identify the rate and severity of injuries in runners transitioning from traditional to minimalist footwear. The secondary aims were to identify factors correlated with injuries. METHODS: Fourteen habitually shod (traditional running shoes) participants were enrolled for this prospective study investigating injury prevalence during transition from traditional running shoes to 5-toed minimalist shoes. Participants were uninjured, aged between 22-41 years, and ran at least twenty kilometers per week in traditional running shoes. Participants were given industry recommended guidelines for transition to minimalist footwear and fit with a 5-toed minimalist running shoe. They completed weekly logs for identification of injury, pain using Visual Analogue Scale (VAS), injury location, and severity. Foot strike pattern and impact forces were collected using 3D motion analysis at baseline, 4 weeks, and 12 weeks. Injuries were scored according to a modified Running Injury Severity Score (RISS). RESULTS: Fourteen runners completed weekly training and injury logs over an average of 30 weeks. Twelve of 14 (86%) runners sustained injuries. Average injury onset was 6 weeks (range 1-27 weeks). Average weekly mileage of 23.9 miles/week prior to transition declined to 18.3 miles/week after the transition. The magnitude of the baseline impact transient peak in traditional shoes and in minimalist shoes negatively correlated with RISS scores (r = -0.45, p = 0.055 and r = -0.53, p = 0.026, respectively). CONCLUSION: High injury rates occurred during the transition from traditional to minimalist footwear. Non-compliance to transition guidelines and high injury rates suggest the need for improved education. High impact transient forces unexpectedly predicted lower modified RISS scores in this population.

Identification and Treatment of New Inflammatory Triggers for Complex Regional Pain Syndrome: Small Intestinal Bacterial Overgrowth and Obstructive Sleep Apnea.

Complex regional pain syndrome (CRPS) is evoked by conditions that may be associated with local and/or systemic inflammation. We present a case of long-standing CRPS in a patient with Ehlers-Danlos syndrome in which prolonged remission was attained by directing therapy toward concomitant small intestinal bacterial overgrowth, obstructive sleep apnea, and potential increased microglia activity. We theorize that cytokine production produced by small intestinal bacterial overgrowth and obstructive sleep apnea may act as stimuli for ongoing CRPS symptoms. CRPS may also benefit from the properties of low-dose naltrexone that blocks microglia Toll-like receptors and induces production of endorphins that regulate and reduce inflammation.

Promoting interprofessionalism: initial evaluation of a master of science in health professions education degree program.

This survey study assessed former students' perceptions on the efficacy of how well a newly implemented master's in health professions education degree program achieved its academic aims. These academic aims were operationalized by an author-developed scale to assess the following domains: a) developing interprofessional skills and identity; b) acquiring new academic skills; and c) providing a student-centered environment. The respondents represented a broad range of health care providers, including physicians, nurses, and occupational and physical therapists. Generalizability-theory was applied to partition the variance of the scores. Student's overwhelmingly responded that the program successfully achieved its academic aims.

Patient-reported outcomes in multiple sclerosis: Relationships among existing scales and the development of a brief measure.

Several patient-reported outcome (PRO) measures are commonly used in multiple sclerosis (MS) research, but the relationship among items across measures is uncertain. We proposed to evaluate the associations between items from a standard battery of PRO measures used in MS research and to develop a brief, reliable and valid instrument measure by combining these items into a single measure. Subjects (N = 537) enrolled in CLIMB complete a PRO battery that includes the Center for Epidemiologic Studies Depression Scale, Medical Outcomes Study Modified Social Support Survey, Modified Fatigue Impact Scale and Multiple Sclerosis Quality of Life-54. Subjects were randomly divided into two samples: calibration (n = 269) and validation (n = 268). In the calibration sample, an Exploratory Factor Analysis (EFA) was used to identify latent constructs within the battery. The model constructed based on the EFA was evaluated in the validation sample using Confirmatory Factor Analysis (CFA), and reliability and validity were assessed for the final measure. The EFA in the calibration sample revealed an eight factor solution, and a final model with one second-order factor along with the eight first-order factors provided the best fit. The model combined items from each of the four parent measures, showing important relationships among the parent measures. When the model was fit using the validation sample, the results confirmed the validity and reliability of the model. A brief PRO for MS (BPRO-MS) that combines MS-related psychosocial and quality of life domains can be used to assess overall functioning in mildly disabled MS patients.

Reliance on auditory feedback in children with childhood apraxia of speech.

UNLABELLED: Children with childhood apraxia of speech (CAS) have been hypothesized to continuously monitor their speech through auditory feedback to minimize speech errors. We used an auditory masking paradigm to determine the effect of attenuating auditory feedback on speech in 30 children: 9 with CAS, 10 with speech delay, and 11 with typical development. The masking only affected the speech of children with CAS as measured by voice onset time and vowel space area. These findings provide preliminary support for greater reliance on auditory feedback among children with CAS. LEARNING OUTCOMES: Readers of this article should be able to (i) describe the motivation for investigating the role of auditory feedback in children with CAS; (ii) report the effects of feedback attenuation on speech production in children with CAS, speech delay, and typical development, and (iii) understand how the current findings may support a feedforward program deficit in children with CAS.

Effect of Lidocaine on Swallowing During FEES in Patients With Dysphagia.

PURPOSE: The aims of this study were to assess the effects of 0.2 mL of 4% atomized lidocaine on swallowing and tolerability during Fiberoptic Endoscopic Evaluation of Swallowing (FEES). METHODS: A single blinded study was conducted with 17 dysphagic patients, who received 4 standardized boluses in 2 sequential FEES exams under 2 conditions: non-anesthetized (decongestant only) and anesthetized (lidocaine 4%+decongestant). After each procedure, patients rated their pain on the Wong Baker FACES Pain Rating Scale. Clinicians scored each swallow with the Penetration Aspiration Scale (PAS) and an author-developed Residue Rating Scale. Because the assessments were ordinal, a series of Wilcoxon signed-rank tests were conducted to detect differences between the 2 conditions. RESULTS: No significant differences were detected between groups on PAS or residue in the 4 boluses. Pain scores, however, were significantly lower in the anesthetized condition than the decongested-only condition (P=.035). CONCLUSION: The findings of this study indicated that 0.2 mL of 4% lidocaine enhanced exam tolerability and did not impair the swallow in dysphagic patients.

Working memory and the revision of syntactic and discourse ambiguities.

Two hundred participants, 50 in each of 4 age ranges (19-29 years, 30-49 years, 50-69 years, 70-90 years) were tested for short-term working memory, speed of processing, and online processing of 3 types of sentences in which an initially assigned syntactic structure and/or semantic interpretation had to be revised. Self-paced reading times were longer for the segments that signaled the need for revision; there also were interactions of age and sentence type and speed of processing and sentence type, but not of working memory and sentence type on reading times for these segments. The results provide evidence that working memory does not support the processes that revise the structure and interpretation of sentences and discourse.

Preliminary evidence of a blunted anti-inflammatory response to exhaustive exercise in fibromyalgia.

Exercise intolerance, as evidenced by a worsening of pain, fatigue, and stiffness after novel exertion, is a key feature of fibromyalgia (FM). In this pilot study, we investigate whether; insufficient muscle repair processes and impaired anti-inflammatory mechanisms result in an exaggerated pro-inflammatory cytokine response to exhaustive exercise, and consequently a worsening of muscle pain, stiffness and fatigue in the days post-exercise. We measured changes in muscle pain and tenderness, fatigue, stiffness, and serum levels of neuroendocrine and inflammatory cytokine markers in 20 women with FM and 16 healthy controls (HCs) before and after exhaustive treadmill exercise. Compared to HCs, FM participants failed to mount the expected anti-inflammatory response to exercise and experienced a worsening of symptoms post-exercise. However, changes in post-exertional symptoms were not mediated by post-exertional changes in pro-inflammatory cytokine levels. Implications of these findings are discussed.

Tapped out: do people with aphasia have rhythm processing deficits?

PURPOSE: In this study, the authors tested whether people with aphasia (PWAs) show an impaired ability to process rhythm, both in terms of perception and production. METHOD: Two experiments were conducted. In Experiment 1, 16 PWAs and 15 age-matched control participants performed 3 rhythm tasks: tapping along to short rhythms, tapping these same rhythms from memory immediately after presentation, and making same-different judgments about pairs of tapped rhythms that they heard. Comparison tasks measured same-different judgment ability with visual stimuli and nonverbal working memory (Corsi blocks). In Experiment 2, 14 PWAs and 16 control participants made same-different judgments for pairs of auditory stimuli that differed in terms of rhythm or pitch (for comparison). RESULTS: In Experiment 1, PWAs performed worse than control participants across most measures of rhythm processing. In contrast, PWAs and control participants did not differ in their performance on the comparison tasks. In Experiment 2, the PWAs performed worse than control participants across all conditions but with a more marked deficit in stimulus pairs that differed in rhythm than in those that differed in pitch. CONCLUSIONS: The results support the hypothesis that at least some PWAs exhibit deficits of rhythm and timing. This may have implications for treatments involving tapping or other rhythmic cues.

CALM Pregnancy: results of a pilot study of mindfulness-based cognitive therapy for perinatal anxiety.

Many women experience anxiety during pregnancy with potential negative effects on maternal, birth, and child outcomes. Because of potential risks of fetal exposure to psychotropic medications, efficacious non-pharmacologic approaches are urgently needed. However, no published studies of psychotherapeutic treatments for anxiety in pregnancy exist. Mindfulness-based cognitive therapy (MBCT) may substantially reduce anxiety and co-morbid symptoms in people with anxiety disorders. Coping with Anxiety through Living Mindfully (CALM) Pregnancy is an adaptation of MBCT designed to address anxiety in pregnant women. This study examined the feasibility, acceptability, and clinical outcomes of the CALM Pregnancy intervention in pregnant women anxiety. Twenty-four pregnant women with generalized anxiety disorder (GAD) or prominent symptoms of generalized anxiety participated in an open treatment trial of the CALM Pregnancy group intervention. Psychiatric diagnoses were determined by structured clinical interview, and self-report measures of anxiety, worry, depression, self-compassion, and mindfulness were completed at baseline and post-intervention. Qualitative feedback was elicited via questionnaire. Twenty-three participants completed the intervention with high attendance and good compliance with home practice. Completers showed statistically and clinically significant improvements in anxiety, worry, and depression, and significant increases in self-compassion and mindfulness. Of the 17 participants who met GAD criteria at baseline, only one continued to meet criteria post-intervention. Participants regarded their experience in the intervention to be overwhelmingly positive. MBCT in the form of the CALM Pregnancy intervention holds potential to provide effective, non-pharmacological treatment for pregnant women with anxiety. These promising findings warrant further testing of the intervention with a randomized controlled trial.