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.

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.

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.].

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.

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.

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.

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.

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.

The Mobility Scale for Acute Stroke predicts discharge destination after acute hospitalization.

OBJECTIVE: To evaluate the predictive validity of the Mobility Scale for Acute Stroke (MSAS) in determining discharge destination (home or not home) after an acute stroke. DESIGN: Cohort study. SUBJECTS: Two-hundred and twenty-three patients with acute ischemic or intraparenchymal hemorrhagic, unilateral stroke METHODS: The MSAS was administered as part of the initial physical therapy examination. The Receiver Operating Characteristic determined the optimal MSAS cutoff score associated with discharge home. A multiple logistic regression equation with discharge destination as the criterion variable (home or not home) was conducted with age, length of stay and optimal MSAS cutoff score as covariates. RESULTS: Subjects were discharged home 35.9% (n = 80) and not home 64.1% (n = 143) of the time. Mean age was 68.5 years (standard deviation 1.8). The ROC determined 26 to be the optimal cutoff score for the MSAS. Results of the multiple logistic regression equation indicated that controlling for age and length of stay, only the MSAS cutoff score of 26 reliably predicted discharge to home with an adjusted odds ratio of 57.79 with a 95% confidence interval of 20.09-166.21. CONCLUSION: The MSAS may be useful for predicting discharge destination from the acute hospital after stroke.

The development of skill and knowledge during a sport education season of track and field athletics.

PURPOSE: The purpose of this study was to examine the relative effectiveness of 2 forms of physical education instruction on students' skill and technical performance, as well as content knowledge in 3 track and field events. METHOD: Students from 6 classes in 3 Portuguese schools completed 900-min units conducted under the auspices of sport education or a more traditional teacher-directed format. Classes were randomly assigned to these conditions within each school. RESULTS: Although both groups improved significantly from pretest to posttest, the sport education classes outperformed the traditional classes in both technique and skill execution. Only the sport education group made significant improvements in content knowledge. When the students in the traditional group were tested at the point in time where they would usually complete a unit of physical education (450 min), there were no significant improvements in any of the study's variables. CONCLUSION: The explanation given for the superior performance outcomes of the sport education classes lies in the nature of formal competition and team affiliation, which are cornerstones of this pedagogical model. That is, students take their learning experiences more seriously than in traditional and often inauthentic classes. In terms of content knowledge, the fact that sport education has a level of content-embedded accountability that holds students accountable for their officiating duties is postulated as a significant contributor to their increased understanding of rules and protocols of athletic events.

Child mental health and service needs in Iraq: beliefs and attitudes of primary school teachers.

OBJECTIVE: To survey Iraqi primary school teachers' beliefs and attitudes about mental health and behavioural problems of children. METHODS: From 10 primary schools in Baghdad, 148 teachers were surveyed using a closed-response questionnaire to assess beliefs and attitudes regarding students' mental health and behavioural problems, needs, resources and limitations to teaching. RESULTS: Disruptive behaviours were rated as main problems by the largest proportions of teachers. In-service training on 'identifying students with social, emotional, or behavioural problems' and 'effective behaviour management' was rated very important by 70% of teachers. Most teachers received no training on mental health during their teaching career. There was low reported availability of a wide range of school-based mental health resources. CONCLUSIONS: Teachers in Iraq report substantial mental health and behavioural problems in primary school children and identify high unmet need for school-based mental health programmes and training.

Community-based newborn resuscitation among frontline providers in a low-resource country.

OBJECTIVE: To evaluate a birth asphyxia management program among community midwives in a low-resource rural setting. METHODS: Concise training with provision of positive-pressure ventilation devices was implemented in Indonesia in 2005. The effectiveness of the intervention among community-based midwives between October 2007 and September 2008 was evaluated. The intervention cohort was compared with a neighboring control cohort. RESULTS: Overall, 242 intervention and 106 control midwives were surveyed. In total, 3116 births were attended, 84.0% of deliveries occurred at home, and 97.4% of midwives had not previously owned a resuscitation device. When positive-pressure ventilation was administered, newborn survival on day 1 was equivalent in the 2 cohorts (88.4% versus 84.4%; P=0.66). However, significantly more newborns in the intervention group underwent ventilation (risk ratio 2.3; 95% confidence interval, 1.4-8.0). The intervention group had significantly greater scores on both knowledge (t[144.35]=10.52; P<0.001) and confidence (t[134.17]=11.66; P<0.001). CONCLUSION: Focused community-based resuscitation training and device delivery resulted in a significantly increased proportion of newborns receiving life-saving positive-pressure breaths, in addition to improved provider knowledge and confidence. Furthermore, the program demonstrated the establishment of an effective training infrastructure within a disrupted health system.

A risk-factor guided approach to reducing lactic acidosis and hyperlactatemia in patients on antiretroviral therapy.

BACKGROUND: Stavudine continues to be used in antiretroviral treatment (ART) regimens in many resource-limited settings. The use of zidovudine instead of stavudine in higher-risk patients to reduce the likelihood of lactic acidosis and hyperlactatemia (LAHL) has not been examined. METHODS: Antiretroviral-naïve, HIV-infected adults initiating ART between 2004 and 2007 were divided into cohorts of those initiated on stavudine- or zidovudine-containing therapy. We evaluated stavudine or zidovudine use, age, sex, body mass index (BMI), baseline CD4 cell count, creatinine, hemoglobin, alanine aminotransferase, and albumin as predictors of time to LAHL with Cox Proportional Hazards (PH) regression models. RESULTS: Among 2062 patients contributing 2747 patient years (PY), the combined incidence of LAHL was 3.2/100 PY in those initiating stavudine- and 0.34/100 PY in those initiating zidovudine-containing ART (RR 9.26, 95% CI: 1.28-66.93). In multivariable Cox PH analysis, stavudine exposure (HR 14.31, 95% CI: 5.79-35.30), female sex (HR 3.41, 95% CI: 1.89-6.19), higher BMI (HR 3.21, 95% CI: 2.16-4.77), higher creatinine (1.63, 95% CI: 1.12-2.36), higher albumin (HR 1.04, 95% CI: 1.01-1.07), and lower CD4 cell count (HR 0.96, 95% CI: 0.92-1.0) at baseline were associated with higher LAHL rates. Among participants who started on stavudine, switching to zidovudine was associated with lower LAHL rates (HR 0.15, 95% CI: 0.06-0.35). Subgroup analysis limited to women with higher BMI≥25 kg/m2 initiated on stavudine also showed that switch to zidovudine was protective when controlling for other risk factors (HR 0.21, 95% CI .07-0.64). CONCLUSIONS: Stavudine exposure, female sex, and higher BMI are strong, independent predictors for developing LAHL. Patients with risk factors for lactic acidosis have less LAHL while on zidovudine- rather than stavudine-containing ART. Switching patients from stavudine to zidovudine is protective. Countries continuing to use stavudine should avoid this drug in women and patients with higher BMI.

Neospora caninum: adoptive transfer of immune lymphocytes precipitates disease in BALB/c mice.

Neospora caninum is a recently described apicomplexan parasite first isolated from a dog in 1988 and has subsequently been shown to infect a wide range of mammals. In mice, Neospora can cause primary pneumonia, myositis, encephalitis, radiculoneuritis, and pancreatitis. Whereas, certain aspects of the host immune response to Toxoplasma gondii have been well studied, not as much is known about the full immune response to Neospora. This paper examines whether or not immune splenocytes are able to adoptively transfer protection against N. caninum infection in BALB/c mice. Mice receiving immune enriched CD8+ cells had severe neurological signs by 19 days post infection. Mice receiving immune enriched CD4+ cells had mild neurological signs on day 22 post infection. It would appear that additional immune cells can precipitate disease in the presence of circulating lymphocytes.