AAPM task group report 305: Guidance for standardization of vendor-neutral reject analysis in radiography.

Reject rate analysis is considered an integral part of a diagnostic radiography quality control (QC) program. A rejected image is a patient radiograph that was not presented to a radiologist for diagnosis and that contributes unnecessary radiation dose to the patient. Reject rates that are either too high or too low may suggest systemic department shortcomings in QC mechanisms. Due to the lack of standardization, reject data often cannot be easily compared between radiography systems from different vendors. The purpose of this report is to provide guidance to help standardize data elements that are required for comprehensive reject analysis and to propose data reporting and workflows to enable an effective and comprehensive reject rate monitoring program. Essential data elements, a proposed schema for classifying reject reasons, and workflow implementation options are recommended in this task group report.

A spatial-temporal study of complementary and alternative medicine (CAM) by type: exploring localization economies implications in urban areas in Ontario.

OBJECTIVES: This study adds to the geography of complementary and alternative medicine (CAM) literature by comparing the spatial-temporal patterns of five types of CAM within 19 cities in light of clustering benefits from localization economies. METHODS: CAM office location points and nearest neighbour, standard distance, local spatial autocorrelation, and Mann-Whitney analyses are utilized to test potential clustering tendencies of CAM types over time. RESULTS: It is shown that 'within' (chiropractors near chiropractors, for example) and 'amongst' (chiropractors proximate to other CAM types) spatial clustering occurs in 2007 and 2017. This implies the persistent influence of localization economies. CONCLUSIONS: Continued clustering of CAM within urban locations already replete with CAM offices will widen spatial disparities through time. This has implications for policy-makers concerned with dispersing medical resources over space for better accessibility.

Palliative ketamine: the use of ketamine in central post-stroke pain syndrome-a case report.

Ketamine has played a versatile role in medicine due to its wide spectrum of uses in history including use in sedation, catalepsy, somatic analgesia, bronchodilation, and recent trial in complex chronic pain syndromes. There is very little, if any, discussion in the literature of ketamine use in stroke, particularly in improving symptoms of pain after stroke. We present a case of a 40-year-old female with a past medical history of right-sided thalamic ischemic stroke complicated by Central post-stroke pain syndrome (CPSP) presented for refractory severe diffuse pain causing debility and immobility. The patient failed outpatient medical therapy consisting of anxiolytics, serotonin, and norepinephrine reuptake inhibitors. This led to increased opioid use which resulted in dependence and opioid-hyperalgesia. Upon admission, the patient was unable to sit still, with severe, sharp 10/10 pain localized to her left lower extremity. Palliative medicine was consulted for management of refractory central neuropathic pain. Inpatient oral ketamine was initiated, and titrated over the patient's hospital course. During this time, the patient showed marked improvement in GAD-7, PHQ-9, and Short Mcgill pain scores while significantly decreasing opioid requirements. We present this case to demonstrate how oral ketamine usage in centrally mediated neuropathic pain such as in CPSP can lead to pain control, decreased opioid usage, and overall improved quality of life.

Ketamine Administration by Special Operations Medical Personnel During Training Mishaps.

BACKGROUND: Opioids can have adverse effects on casualties in hemorrhagic shock. In 2014, the Committee on Tactical Combat Casualty Care (CoTCCC) recommended the use of ketamine at the point of injury (POI). Despite these recommendations the adherence is moderate at best. Poor use may stem from a lack of access to use ketamine during training. The United States Special Operations Command (USSOCOM) is often in a unique position, they maintain narcotics for use during all training events and operations. The goal of this work is to demonstrate that ketamine is safe and effective in both training and operational environments. METHODS: This was a retrospective, observational performance improvement project within United States Special Operations Command and Air Combat Command that included the US Army's 75th Ranger Regiment, 160th Special Operations Aviation Regiment, and US Air Force Pararescue. Descriptive statistics were used to calculate the doses per administration to include the interquartile range (IQR), standard deviation (SD) and the range of likely doses using a 95% confidence interval (CI). A Wilcoxon signed-rank test was used to compare the mean pre-ketamine pain scores to the mean post-ketamine on a 0-to-10 pain scale. RESULTS: From July 2010 to October 2017, there was a total of 34 patients; all were male. A total of 22 (64.7%) received intravenous ketamine and 12 (35.3%) received intramuscular ketamine and 8 (23.5%) received intranasal ketamine. The mean number of ketamine doses via all routes administered to patients was 1.88 (SD 1.094) and the mean total dose of all ketamine administration was 90.29mg (95% CI, 70.09-110.49). The mean initial dose of all ketamine administration was 47.35mg (95% CI, 38.52-56.18). The median preketamine pain scale for casualties was noted to be 8.0 (IQR 3) and the median post-ketamine pain scale was 0.0 (IQR 3). CONCLUSION: Ketamine appears to be safe and effective for use during military training accidents. Military units should consider allowing their medics to carry and use as needed.

Neuropsychological impairment in deficit vs. non-deficit schizophrenia.

This study aimed to assess the severity and specificity of cognitive impairments that affect individuals with deficit versus non-deficit schizophrenia. We compared 26 patients with the deficit subtype of schizophrenia (SZ-D) and 79 with non-deficit schizophrenia (SZ-ND) to 316 healthy adults (NC). All study participants completed a battery with 19 individual cognitive measures. After adjusting their test performance for age, sex, race, education and estimated premorbid IQ, we derived regression-based T-scores for each measure and the six derived cognitive domains including attention, psychomotor speed, executive function, verbal fluency, visual memory, and verbal memory. Multivariate analyses of variance revealed significant group effects for every individual measure and domain of cognitive functioning (all ps<0.001). Post hoc comparisons revealed that patients with SZ-D performed significantly worse than NCs in every cognitive domain. They also produced lower scores than the SZ-ND group in every domain, but only the difference for verbal fluency reached statistical significance. The correlations of the effect sizes shown by the SZ-D and SZ-ND patients were of intermediate magnitude for the individual tests (r=0.56, p<0.01) and higher, but not statistically significant for the cognitive domains (r=0.79, p=0.06). Patients with SZ-D demonstrate cognitive deficits that are both common and distinct from those shown by patients with SZ-ND. Their impairment of verbal fluency is consistent with the observation that poverty of speech is a clinically significant feature of patients with SZ-D.

Neuropsychological functioning in bipolar disorder and schizophrenia.

BACKGROUND: Some patients with bipolar disorder (BD) demonstrate neuropsychological deficits even when stable. However, it remains unclear whether these differ qualitatively from those seen in schizophrenia (SZ). METHODS: We compared the nature and severity of cognitive deficits shown by 106 patients with SZ and 66 patients with BD to 316 healthy adults (NC). All participants completed a cognitive battery with 19 individual measures. After adjusting their test performance for age, sex, race, education, and estimated premorbid IQ, we derived regression-based T-scores for each measure and the six cognitive domains. RESULTS: Both patient groups performed significantly worse than NCs on most (BD) or all (SZ) cognitive tests and domains. The resulting effect sizes ranged from .37 to 1.32 (mean=.97) across tests for SZ patients and from .23 to .87 (mean=.59) for BD patients. The Pearson correlation of these effect sizes was .71 (p<.001). CONCLUSIONS: Patients with bipolar disorder suffer from cognitive deficits that are milder but qualitatively similar to those of patients with schizophrenia. These findings support the notion that schizophrenia and bipolar disorder show greater phenotypic similarity in terms of the nature than severity of their neuropsychological deficits.

Naturopaths in Ontario, Canada: geographic patterns in intermediately-sized metropolitan areas and integration implications.

Evaluating conventional medicine (CM) and complementary and alternative medicine (CAM) with respect to integration opportunities (such as patient referrals and professional knowledge sharing) and possible geographic implications is novel. This research utilizes nearest neighbour and local spatial autocorrelation statistical analyses and surveys directed towards Doctors of Naturopathic Medicine (NDs) and their patients to better understand the geographic patterns of NDs and potential integration qualities. While the statistical tests reveal that the offices of NDs and Doctors of Medicine (MDs) display clustered patterns in intermediately-sized census metropolitan areas in Ontario and that the majority of NDs are near MDs, proximity is not manifesting in discernible integration tendencies between NDs and MDs. The NDs polled were strongly in favour of greater integration with the CM sector (as were their patients) to: achieve better patient health outcomes and to gain efficiencies within the health care system. Yet, both surveys also indicate that the barriers to integration are substantial and, generally speaking, centre on the perception that many MDs lack respect for, and/or knowledge about, naturopathic approaches. It is speculated that as students in conventional medical schools are increasingly exposed to CAM approaches, perhaps more MDs in the future will be receptive to greater integration with CAM. Should this occur, then it is also possible that geographic proximity may be a catalyst for deeper CAM-CM integration; as it has been for CAM-CAM relationships.

Optimizing ADAS-Cog Worksheets: A Survey of Clinical Trial Rater s' Perceptions.

BACKGROUND: The Alzheimer's Disease Assessment Scale-Cognitive subscale (ADASCog) remains the most widely used test of longitudinal cognitive functioning in Alzheimer's disease (AD) clinical trials. Unlike most neuropsychological tests, the ADAS-Cog source documentation worksheets are not uniform across clinical trials, and vary by document layout, inclusion of administration and/or scoring instructions, and documentation of subtest scoring (e.g., recording correct versus incorrect scores), among other differences. Many ADAS-Cog test administrators (raters) participate in multiple AD trials and switching between different ADAS-Cog worksheets may increase the likelihood of administration and/or scoring mistakes that lessen the reliability of the instrument. An anonymous online survey sought raters' experiences with ADAS-Cog worksheets and their opinions on the design and content of the worksheets. RESULTS: Results of the survey indicated preference for structure and standardization of the ADASCog worksheets, which has been considered in the development of a standard ADAS-Cog source document by the Alzheimer's Disease Cooperative Study (ADCS) Working Group.

Student outcomes associated with service-learning in a culturally relevant high school program.

The Hawaiian Studies Program (HSP) integrates the learning of Hawaiian culture with more traditional secondary curriculum in science, social studies, and English. Students also participate in weekly community service-learning sessions. Fifty-five HSP students and 29 peers (who were not involved in the program), completed a survey measuring: students' connection to, pride in, and responsibility for their community; civic attitudes; and career knowledge and preparedness. HSP teachers, community members, and students were also interviewed about program outcomes. Compared to other peers, HSP students tended to report feeling more connected to their community and school and to agree that they had career-related skills. Participants believed that service- learning contributed to these outcomes by making connections between school and community life and by exposing students to a variety of careers.

Early weight development of goats experimentally infected with Mycobacterium avium subsp. paratuberculosis.

Johne's disease is an infectious chronic inflammatory bowel disease in ruminants. The key factor for the management of this disease is an early positive diagnosis. Unfortunately, most diagnostics detect animals with Johne's disease in the clinical stage with positive serology and/or positive fecal cultures. However, for effective management of the disease within herds, it is important to detect infected animals as early as possible. This might only be possible with the help of parameters not specific for Johne's disease but that give an early indication for chronic infections such as weight development. Here we report our findings on the development of total body weight and weight gain during the first six months of goats experimentally infected to induce Johne's disease. Twenty dairy goat kids age 2 to 5 days were included in this study. Goats were divided into two groups: a negative control group and a positive infected group. The weight was obtained weekly throughout the study. Goats of the positive group were infected at the age of seven weeks. We detected significant changes in weight gain and total body weight as early as one week after infection. Differences are significant throughout the six month time period. Weight as a non-specific parameter should be used to monitor infection especially in studies on Johne's disease using the goat model. Our study suggests that goats with Johne's disease have a reduced weight gain and reduced weight when compared with healthy goats of the same age.

Comparing spatial accessibility to conventional medicine and complementary and alternative medicine in Ontario, Canada.

Health care investigations rarely consider conventional medicine (CM) and complementary and alternative medicine (CAM) simultaneously and spatial accessibility empirical research that incorporates both CM and CAM locations is novel. In this study, residents within municipalities of the Ontario province of Canada are compared in terms of spatial accessibility to a range of health care supplier 'destinations'. While areas with larger urban agglomerations generally exhibit superior levels of spatial accessibility to health care and diversity in medical service choice in comparison to more peripheral areas, considerable heterogeneity in accessibility occurs in both urban and rural settings. This study's identification of subtle spatial imbalances appends the literature by more precisely qualifying the typically reported 'urban-rich, rural-poor' assessment of health care service condition and also reinforces the need for policy-makers to appraise health care spatial accessibility differentials as a function of both CM and CAM endowment.

The role of context in risky choice.

Human choice behavior was assessed in a concurrent-chain schedule, where two equal initial links (IL) each led to a distinct terminal-link (TL). One TL was associated with a fixed ratio schedule of reinforcement, while the other was associated with a bi-valued mixed ratio schedule of reinforcement, whose arithmetic mean equaled the Fixed TL schedule. The fixed component (FR50; FR25; FR5) was arranged to be equal to the alternative mixed component in each condition (FR1/99; FR1/49; FR1/9), and choice behavior was measured by proportion of responses to each IL. In addition, the IL duration varied across conditions (VI 30s; VI 15s; FI 1s). Preference for the mixed option was observed with longer durations (e.g., when IL=VI 30s and TL=FR1/99). Participants were relatively indifferent in other conditions, though the results suggested a monotonic increase in preference as either durations or programmed efforts increased. It is concluded that both choice and the conditioned reinforcement value of the mixed option is contextually based, so that the value of a stimulus correlated with an immediate reward (i.e., FR 1) is enhanced the greater the temporal context in which the FR1 is embedded.

Development, psychometric properties, and validity of the hopkins adult reading test (HART).

We describe the development of a 35-item, oral word-reading test with two equivalent forms (HART-A and HART-B) designed to estimate premorbid abilities. Both forms show excellent internal consistency (coefficients alpha>.91) and test-retest reliability (Pearson rs >.90). HART performance was combined with demographic variables to generate regression equations that predict IQ scores obtained concurrently and 4-8 years earlier. The resulting models explained 61% of full scale IQ (FSIQ) variability in 327 healthy adults. The FSIQs that can be estimated range from below 73 to above 131. Combined with demographic variables, these two brief word reading tests accurately predict a broader range of IQs than Blair and Spreen's (1989) longer version. Equivalent forms make it especially useful for longitudinal studies.

The vulnerability to coaching across measures of effort.

Neuropsychologists are increasingly called upon to conduct evaluations with individuals involved in personal injury litigation. While the inclusion of measures of effort within a test battery may help clinicians determine whether a client has put forth full effort, attorney coaching may allow dishonest clients to circumvent these efforts. The purpose of this study was to determine the degree to which frequently used measures of effort are susceptible to coaching, as well as to explore and classify strategies undertaken by coached malingering simulators. Overall, coached simulators performed significantly better on 7 of 14 measured variables. Potential improvements in the external validity of the simulation design were also explored.

Interrater and test-retest reliability of a fixed condition design fluency test.

Despite its potential as a unique neuropsychological test, the emergence of a psychometrically sound research foundation for Jones-Gotman and Milner's (1977) Design Fluency Test (DFT) has been constrained by the lack of consistent administration and scoring practices and limited information about its reliability. Here we describe an approach to administering and scoring the fixed condition DFT that is modeled on Jones-Gotman and Milner's original method and that clarifies procedural ambiguities. Results include interrater and long-term test-retest reliability analyses using this approach. First, based on five raters who scored 50 DFT protocols, good to excellent intra-class correlation coefficients were obtained for all DFT scores. Second, in a broadly representative sample of 87 healthy adults who were tested twice over an average of 5 1/2 years, the test-retest reliabilities for total and novel design scores ranged from good to excellent. This study demonstrates that the fixed condition DFT can be scored reliably using these procedures and that the reliability coefficients for DFT total and novel designs scores are comparable to those of other commonly used neuropsychological tests.

The use of word-reading to estimate "premorbid" ability in cognitive domains other than intelligence.

Diagnostic neuropsychological assessment requires the clinician to estimate a patient's premorbid abilities. Word reading tests, such as the National Adult Reading Test-Revised (NART-R), provide reasonably accurate estimates of premorbid IQ, but their capacity to benchmark other premorbid cognitive abilities remains unclear. In this extension of an earlier report, we administered the NART-R, an abbreviated Wechsler Adult Intelligence Scale (WAIS-R or WAIS-III), and 26 other cognitive measures to 322 reasonably healthy adults. While NART-R performance correlated robustly (rs > or = .72) with concurrent Verbal and Full Scale IQ, its correlation with all other cognitive measures was significantly lower. Thus, while it is appealing to use word reading as a proxy for premorbid functioning in other cognitive domains, the NART-R has limited utility for this because it does not predict current performance on other cognitive tests as well as it predicts IQ in healthy adults.

Behavioral aspects of Lesch-Nyhan disease and its variants.

Self-injury is a defining feature of lesch-nyhan disease (LND) but does not occur in the less severely affected Lesch-Nyhan variants (LNV). The aim of this study was to quantify behavioral and emotional abnormalities in LND and LNV. Thirty-nine informants rated 22 patients with LND (21 males, 1 female), 11 males with LNV, and 11 healthy controls (HC; 10 males, 1 female) using two well-validated rating scales. The age of patients with LND ranged from 12 years 7 months to 38 years 3 months (mean 22 y 11 mo; sd 7 y 8 mo), whereas the age range of those with LNV was 12 years 9 months to 65 years (mean 30 y 7 mo; sd 15 y 2 mo), and the healthy controls were aged 12 years 4 months to 31 years 3 months (mean 17 y 10 mo; sd 5 y 7 mo). Behavioral ratings were based on the Child Behavior Checklist and the American Association On Mental Retardation's Adaptive Behavior Scale--Residential And Community, 2nd edition. Statistical analyses revealed that patients with LND showed severe self-injury together with problematic aggression, anxious-depressed symptoms, distractibility, motor stereotypes, and disturbing interpersonal behaviors. Patients with LNV were rated as being intermediate between the HC and LND groups on all behavior scales. Although the LNV group did not differ from hcs on most scales, their reported attention problems were as severe as those found in LND. We conclude that self-injurious and aggressive behaviors are nearly universal and that other behavioral abnormalities are common in LND. Although patients with LNV typically do not self-injure or display severe aggression, attention problems are common and a few patients demonstrate other behavioral anomalies.