Comparing Expectations: How Pharmacy Students View Physician Assistant and Medical Students.

PURPOSE: The aim of this prospective, perception scale study was to evaluate pharmacy student expectations and perceptions of student medical providers before and after interprofessional education (IPE). METHODS: Using pre- and postactivity surveys, the expectations and perceptions of 2 cohorts of third-year pharmacy students who worked with first-year physician assistant (PA) students and second-year medical (MD) students in an evidence-based, case-based IPE session were compared. RESULTS: Before engaging in the interprofessional activities, the pharmacy students' (N = 131) expectations were either similar for both student provider groups or greater for MD students. However, these expectations differed significantly from postactivity perceptions. After completion of the IPE experiences, when compared with MD students, PA students were perceived as having equal or greater knowledge of patient care (60.2 vs. 12%, P < .001), demonstrating equal or superior application of evidence-based practice (46.6 vs. 5.3%, P < .001), being equally or more collaborative (54.1 vs. 10.5%, P < .001), and being equally easy or easier to work with (69.9 vs. 10.5%, P < .001). CONCLUSION: The magnitude of shift in expectations and perceptions demonstrates the value of IPE and underscores the high caliber of PA educational standards.

Dietary patterns and hip fracture in the Adventist Health Study 2: combined vitamin D and calcium supplementation mitigate increased hip fracture risk among vegans.

BACKGROUND: Concerns regarding the adequacy of vegetarian diets with respect to fracture risk continue. OBJECTIVES: We aimed to explore the influence of 5 previously defined dietary patterns on hip fracture risk and whether this association is modified by concomitant calcium and vitamin D supplementation. METHODS: The Adventist Health Study 2 is a prospective cohort study in which participants were enrolled during 2002-2007; proportional hazards regression analyses were used to estimate fracture risk. Participants reside throughout the United States and Canada. A total of 34,542 non-Hispanic white peri- and postmenopausal women and men 45 y and older responded to the biennial hospital history form and were followed for a median of 8.4 y. RESULTS: The study identified 679 incident hip fractures during 249,186 person-years of follow-up. Fracture risk varied according to dietary pattern, with a clear effect modification by concurrent supplementation with both vitamin D and calcium. In multivariable models, including adjustment for calcium and vitamin D supplementation, female vegans had 55% higher risk of hip fracture (HR: 1.55; 95% CI: 1.06, 2.26) than nonvegetarians (NVEGs), whereas there was no association between diet pattern and hip fracture risk in men. When further stratifying females on supplement use with both vitamin D and calcium, vegans taking both supplements were at no greater risk of hip fracture than the subjects with other dietary patterns including the NVEGs. CONCLUSIONS: Without combined supplementation of both vitamin D and calcium, female vegans are at high risk of hip fracture. However, with supplementation the excessive risk associated with vegans disappeared. Further research is needed to confirm the adequacy of a vegan diet supplemented with calcium and vitamin D with respect to risk of fracture.

Vitamin-D dysregulation in early- and late-onset preeclampsia: A gestational-age matched study.

Vitamin D deficiency has been associated with preeclampsia, however, vitamin D supplementation studies have shown equivocal data on amelioration of this disease. We hypothesize that women with preeclampsia have an altered endogenous vitamin D homeostasis that counteracts the beneficial effects of vitamin D supplementation. Our study population consisted of 66 maternal/neonate dyads: 16 early-onset (<34 weeks) preeclampsia (EOP), 16 early-onset controls (EOC), 17 late-onset (≥34 weeks) preeclampsia (LOP), and 17 late-onset controls (LOC). Plasma levels of 25-OH-D and the bioactive metabolite 1α,25-(OH)2-D were studied by ELISA. Placental expression of vitamin D transporters (cubulin and megalin), metabolic genes (CYP2R1, CYP27B1, CYP24A1), and vitamin D binding protein (GC), were studied by real-time PCR, and the nuclear and cytosolic levels of the vitamin D receptor (VDR) protein were analyzed by immunoblotting. Maternal admission, maternal postpartum, and umbilical cord blood levels of 1α,25-(OH)2-D and placental nuclear vitamin D receptor protein levels, were significantly lower in EOP compared to EOC. In contrast LOP was characterized by lower 25-OH-D levels in maternal postpartum and cord blood, and decreased placental cubulin expression compared to LOC. Both EOP and LOP showed decreased placental expression of CYP2R1 and GC compared to controls. Multivariable linear regression analysis demonstrated that preeclampsia was a significant predictor of decreased 1α,25-(OH)2-D levels in early-onset subjects, while maternal BMI, but not preeclampsia, was the main predictor of decreased 25-OH-D in late-onset subjects. The highest positive correlation between the two vitamin D metabolites was observed in LOC umbilical cord blood. Finally, paired analysis of maternal metabolites before and after delivery indicated that women without preeclampsia had better maintenance of vitamin D levels. We conclude that EOP is characterized by decreased bioactivation of vitamin D and VDR in association with fetal growth restriction (FGR). In contrast, LOP is characterized by decreased 25-OH-D levels in association with decreased placental CYP2R1 and cubulin expression; and uncoupling of the 25-OH-D with the 1α,25-(OH)2-D metabolite.

Impact of Breast Milk, Respiratory Insufficiency, and Gastroesophageal Reflux Disease on Enteral Feeding in Infants With Omphalocele.

OBJECTIVES: The aim of this study was to document the process of achieving full enteral feeding in infants with omphalocele and to identify factors that affect feeding success. METHODS: After institutional review board approval (study no. 5100169), 123 infants with omphalocele, born between 1993 and 2011 were reviewed. Mortalities were excluded. All survivors had complete follow-up. Variables suspected to impact enteral feeding in infants with non-giant versus giant omphalocele were compared. Independent t test, Mann-Whitney, and χ test were used. Regression evaluated for variable independence. RESULTS: Of 123 infants with omphalocele, 97 (79%) survived, 62/97 (64%) had non-giant, and 35/97 (36%) giant omphalocele. For survivors, the mean gestational age was 37 ±â€Š4 weeks with median follow-up of 4.4 years (range: 1.4-7.4 years). The median time to full feeds was 4 days (range: 0-85 days) for non-giant versus 8 days (range: 1-96 days) for giant, a significant difference (P < 0.01). Breast milk significantly decreased time to full feeds independent of omphalocele size. Giant omphalocele infants had a significantly higher incidence of respiratory insufficiency at birth (P < 0.01) and sac rupture (P = 0.02), but fewer chromosomal anomalies (P = 0.04). Respiratory insufficiency at birth (P < 0.01) and gastroesophageal reflux disease (P < 0.01) independently delayed feeding in omphalocele infants. CONCLUSIONS: Infants with non-giant omphalocele can achieve full enteral feeds within the first week of life, but giant omphalocele infants require significantly more time. Breast milk independently promotes feeding success whereas gastroesophageal reflux disease and respiratory insufficiency at birth independently delay feeding in infants with omphalocele.

Non-sedentary Lifestyle Can Reduce Hip Fracture Risk among Older Caucasians Adults: The Adventist Health Study-2.

AIMS: The beneficial effect of physical activity on reducing hip fracture risk has been supported in many previous studies. The present cohort study explores the relationship between total daily physical activity expressed as MET-hour/day and hip fracture risk among men over 50 years of age and postmenopausal women (n=22,836). METHODOLOGY: Associations between self-reported hip fracture incidence and total daily physical activity and selected lifestyle factors were assessed using Cox proportional hazard regression. RESULTS: In gender-specific multivariable models, total activity above average (≥ 51 MET-hours per day for men, ≥ 48 MET-hours per day for women) compared to those with sedentary lifestyle (< 40 MET-hours per day) reduced the risk of hip fracture by 60% among men (HR=0.40, 95%CI: 0.23-0.70) (Ptrend=0.002) and 48% among women (HR=0.52, 95%CI: 0.32-0.84) (Ptrend=0.01). CONCLUSION: Our findings suggest that a moderate level of physical activity and avoiding a sedentary lifestyle can reduce the risk of hip fracture among the elderly.

Impact of Walking and Running on the Heel bone: the Adventist Health Study-2.

AIMS: Physical activity is well recognized for its bone health benefit. We examined the benefit of walk/run/jog on bone health using broadband ultrasound attenuation (BUA) of the calcaneus. METHODOLOGY: Caucasian and African American males (n=593) and females (n=1,106) had their calcaneal BUA measured two years later after enrollment into the AHS-2. The association between calcaneal BUA (dB/Mhz) and the distance of walk/run/ jog level per week (miles) was assessed using multiple linear regression. RESULTS: In a multivariable model adjusted for important covariates, BUA was positively associated with BMI (P < .001), total calcium intake (P =0.31), total protein intake (P =0.38) and inversely associated with age (P < .001) and smoking (P < .05). Compared to women who did not walk/ run/ jog, women walking 10 or more miles per week had an increase in BUA by 4.08 (dB/Mhz) (P trend=0.03). Similarly, compared to men who did not walk/ run/ jog, men walking 10 or more miles per week had an increase in BUA by 5.97 (dB/Mhz) (P trend=0.01). CONCLUSIONS: We concluded that BUA is positively associated with walk/ run/jog after accounting for age, BMI, smoking status, calcium intake, protein intake and estrogen usage.

Factors associated with mortality after Nissen fundoplication in children.

PURPOSE: The purpose of this article was to identify factors associated with mortality after Nissen fundoplication in children. METHODS: After Institutional Review Board approval, children younger than 18 years, from two children's hospitals, with Nissen fundoplication performed between January 1994 and December 2010, were retrospectively reviewed. Inclusion required complete data and follow-up to October 2011. Survivors and nonsurvivors were compared, using t-tests for continuous and chi-square tests for categorical variables, to identify factors associated with mortality. Patient factors present before the first fundoplication were analyzed. Surgical factors were surgical complications, gastrostomy placement, operative technique, and redos. Logistic regression evaluated for independence of variables. RESULTS: A total of 823 children were identified, 412 were included and 63 died (15.3%). The median follow-up time for the cohort was 3.7 years (mean, 4.5 ± 3.2 years). For nonsurvivors, the median time to death after fundoplication was 6.0 months (mean, 13.2 ± 8.0 months). Significant factors after univariate analysis were surgical complications (p = 0.001), female gender (p = 0.001), neurological impairment (p = 0.010), and fundoplication performed before the age of 18 months (p = 0.035). Independent predictors were surgical complications, odds ratio (OR), 3.30 (95% confidence interval [CI], 1.31-8.29), neurological impairment, OR, 2.58 (95% CI, 1.38-4.83), fundoplication before the age of 18 months, OR, 2.46 (95% CI, 1.23-4.94), and female gender, OR, 2.25 (95% CI, 1.26-4.00). CONCLUSION: After Nissen fundoplication in children, surgical complications, neurological impairment, fundoplication performed before the age of 18 months, and female gender are associated with mortality. The median time to death for nonsurvivors was 6 months.

Legumes and meat analogues consumption are associated with hip fracture risk independently of meat intake among Caucasian men and women: the Adventist Health Study-2.

OBJECTIVE: In contrast to non-vegetarians, vegetarians consume more legumes and meat analogues as sources of protein to substitute for meat intake. The present study aimed to assess the association between foods with high protein content (legumes, meat, meat analogues) by dietary pattern (vegetarians, non-vegetarians) and hip fracture incidence, adjusted for selected lifestyle factors. DESIGN: A prospective cohort of Adventist Health Study-2 (AHS-2) enrollees who completed a comprehensive lifestyle and dietary questionnaire between 2002 and 2007. SETTING: Every two years after enrolment, a short questionnaire on hospitalizations and selected disease outcomes including hip fractures was sent to these members. SUBJECTS: Respondents (n 33,208) to a baseline and a follow-up questionnaire. RESULTS: In a multivariable model, legumes intake of once daily or more reduced the risk of hip fracture by 64% (hazard ratio = 0·36, 95% CI 0·21, 0·61) compared with those with legumes intake of less than once weekly. Similarly, meat intake of four or more times weekly was associated with a 40% reduced risk of hip fracture (hazard ratio = 0·60, 95% CI 0·41, 0·87) compared with those whose meat intake was less than once weekly. Furthermore, consumption of meat analogues once daily or more was associated with a 49 % reduced risk of hip fracture (hazard ratio = 0·51, 95% CI 0·27, 0·98) compared with an intake of less than once weekly. CONCLUSIONS: Hip fracture incidence was inversely associated with legumes intake and, to a lesser extent, meat intake, after accounting for other food groups and important covariates. Similarly, a high intake of meat analogues was associated with a significantly reduced risk of hip fracture.

A multicenter study of the incidence and factors associated with redo Nissen fundoplication in children.

AIM: The objective of this study was to identify the incidence and factors associated with redo Nissen fundoplication in children. METHODS: After Institutional Review Board approval (5100277), data for children under 18 years of age from two children's hospitals with fundoplication performed between January 1994 and December 2010 were reviewed. Children with one fundoplication were compared to those with redos to identify factors associated with redo. Variables were compared using t-tests for continuous and chi-square tests for categorical variables. Logistic regression evaluated for independence. RESULTS: There were 823 patients and 54.7% were male. A redo fundoplication was required in 100 (12.2% of cohort); 82 had 1 redo, 14 had 2 redos, and 4 had 3 redos. Follow-up ranged from 0.01 to 16.9 years (median: 2.9 years). Factors associated with redo were: younger age at first fundoplication, (p=0.002), hiatal dissection (p<0.001), and male gender (p=0.008). Independent predictors of redo were: hiatal dissection at first fundoplication, OR: 8.45 (95% CI: 2.45-29.11), retching, OR: 3.59 (95% CI: 1.56-8.25) and younger age at first fundoplication, OR: 0.98 (95% CI: 0.97-0.98). CONCLUSION: The incidence of redo fundoplication in children is 12.2%. The risk of redo is significantly increased if patients are younger, have retching, and if the esophageal hiatus is dissected at the first fundoplication.

The effect of virtual reality gaming on dynamic balance in older adults.

BACKGROUND: physical therapy interventions that increase functional strength and balance have been shown to reduce falls in older adults. AIM: this study compared a virtual reality group (VRG) and a control group (CG). DESIGN: randomised controlled 6-week intervention with pre- and post-test evaluations. SETTING: outpatient geriatric orthopaedic and balance physical therapy clinic. POPULATION: forty participants were randomised into two groups. METHOD: the VRG received three different Nintendo® Wii FIT balance interventions three times per week for 6 weeks and the CG received no intervention. RESULTS: compared with the CG, post-intervention measurements showed significant improvements for the VRG in the 8-foot Up & Go test [median decrease of 1.0 versus -0.2 s, (P=0.038) and the Activities-specific Balance Confidence Scale (6.9 versus 1.3%) (P=0.038)]. CONCLUSION: virtual reality gaming provides clinicians with a useful tool for improving dynamic balance and balance confidence in older adults.

Contrast in usage of FCAT-approved anatomical terminology between members of two anatomy associations in North America.

Almost 12 years since the publishing of Terminologia Anatomica (TA) by the Federative Committee on Anatomical Terminology (FCAT), there has yet to be a unified adoption of FCAT-recommended anatomical terms by North American anatomists. A survey was sent to members of the Human Anatomy & Physiology Society (HAPS) to compare the frequency of FCAT term usage with a previous study involving the American Association of Anatomists (AAA). The HAPS differed from AAA in being composed mostly of biologists (56.5%) who teach anatomy with only 18.3% of respondents having terminal degrees in anatomy. The survey included the same 25 sets of synonymic names for selected gross anatomical structures or related terms used for the AAA survey. Overall results indicate that the FCAT preferred term had the highest frequency of usage in only 40.0% of the survey questions, demonstrating 4% lower compliance than AAA respondents. Compliance with FCAT preferred terms ranged from 92.2% to 1.7% usage. When compared with AAA anatomists, there were reversals in predominant usage between FCAT and non-FCAT terms for six sets of anatomical structures: HAPS respondents predominantly used non-FCAT terms for adrenal gland (88.7%), antecubital fossa (57.4%), patellar tendon (65.2%), ligamentum capitis femoris (36.5%), while preferring the FCAT anterior circumflex humeral artery (45.2%) and anterior/posterior preferred over ventral/dorsal (41.7%). Almost 54% of HAPS anatomists were not familiar with the FCAT, nearly 21% higher than the AAA.

Frequency in usage of FCAT-approved anatomical terms by North American anatomists.

It has been 10 years since the Federative Committee on Anatomical Terminology (FCAT) published Terminologia Anatomica (TA), the current authority on anatomical nomenclature. There exists a perceived lack of unity among anatomists to adopt many FCAT recommended anatomical terms in TA. An e-mail survey was sent to members of the American Association of Anatomists (AAA) to determine the frequency of FCAT term usage by North American anatomists. The survey consisted of 29 questions, including 25 different sets of synonymic names for selected gross anatomical structures or related terms. Overall results indicate that the FCAT preferred term had the highest frequency of usage in only 44.0% of the survey questions. As frequency of use of FCAT terms decreased, the corresponding frequency of use of non-FCAT terms increased. Some questions showed almost complete compliance with the FCAT preferred terms (highest = 98.4% usage) to almost complete disregard for the FCAT terms (lowest = 0.8% usage). A slight association (P = 0.06) may exist between FCAT familiarity and concern for usage of synonymic terms. The more familiar anatomists were with the FCAT, the more concerned they were with anatomic synonyms.

Can APB 2000 be used to discern sincerity of effort in unimpaired subjects from maximal performance in subjects with shoulder pain?

The automated pegboard (APB 2000), which has been found to objectively quantify motor performance, was used to differentiate maximal motor performance among subjects with shoulder pain, healthy unimpaired subjects performing normally and also while feigning shoulder pain. Six participants with shoulder pain and 15 healthy unimpaired individuals participated. Individuals with shoulder pain were tested on the APB 2000 using their affected upper extremity. Unimpaired participants were instructed to perform normally on the test with randomly selected upper extremity and to feign shoulder pain with the other upper extremity. The two tests for the unimpaired participants were conducted 1 week apart. There were significant differences in mean performance time for normal, patient, and feigned performance, with 80, 111, and 149 sec for the three groups respectively (p < 0.0005). There was also considerable overlap in the three distributions of performance times. These preliminary findings suggest that the APB 2000 is able to distinguish performance time between these three groups. Whether it can be used to distinguish between maximal performance and submaximal performance in individuals suspected of submaximal performance requires further study.

Effects of meat consumption and vegetarian diet on risk of wrist fracture over 25 years in a cohort of peri- and postmenopausal women.

BACKGROUND: Evidence suggesting that a diet high in fruits and vegetables may be beneficial to bone health has sparked interest in the potential benefit of a vegetarian diet. However, other studies have raised a question regarding the adequacy of protein in such a diet. OBJECTIVE: The aim of the present study was to take a whole foods approach in examining the effects of foods high in protein on the risk of wrist fracture (WF) in a cohort with a significant proportion consuming a meat-free diet. DESIGN: A cohort study of women who completed two lifestyle surveys 25 years apart. SUBJECTS: One thousand eight hundred and sixty-five peri- and postmenopausal women at the time of the first survey. RESULTS: There was a significant interaction between meat consumption and foods high in vegetable protein. Among vegetarians, those who consumed the least vegetable protein intake were at highest risk for fracture. However, increasing levels of plant-based high-protein foods decreased WF risk, with a 68% reduction in risk (hazard ratio (HR) = 0.32, 95% confidence interval (CI) 0.13-0.79) in the highest intake group. Among those with lowest vegetable protein consumption, increasing meat intake decreased the risk of WF, with the highest consumption decreasing risk by 80% (HR = 0.20, 95% CI 0.06-0.66). CONCLUSIONS: The finding that higher consumption frequencies of foods rich in protein were associated with reduced WF supports the importance of adequate protein for bone health. The similarity in risk reduction by vegetable protein foods compared with meat intake suggests that adequate protein intake is attainable in a vegetarian diet.

The effect of whole body vibration on lower extremity skin blood flow in normal subjects.

BACKGROUND: Circulation plays a vital role in tissue healing. Increases in muscle flexibility and strength, secretion of hormones important in the regeneration and repair process, blood flow, and strength of bone tissues has been attributed to whole body vibration (WBV) combined with exercise. The purpose of the study was to determine the effects of short-duration, high-intensity, isometric weight bearing exercise (vibration exercise [VE]) and vibration only on skin blood flow (SBF). MATERIAL/METHODS: Forty-five subjects 18-43 years of age were randomly divided into three groups: Group 1 - VE, Group 2 - exercise only, and Group 3 - vibration only. SBF was measured using a laser Doppler imager at three time intervals: 1) initial base line, 2) immediately following intervention, and 3) 10-minutes following intervention. RESULTS: There was no significant difference between the three groups' SBF prior to intervention. Immediately following the intervention a difference among groups was found. Post hoc testing revealed that Group 3 subjects' mean SBF was significantly increased at both post-intervention time intervals. CONCLUSION: The study findings suggest that short duration vibration alone significantly increases SBF; doubling mean SBF for a minimum of 10 minutes following intervention. The emerging therapeutic modality of WBV as a passive intervention appears to increase SBF in individuals with healthy microcirculation.

The effect of vigorous physical activity and risk of wrist fracture over 25 years in a low-risk survivor cohort.

Recent studies have suggested that a high level of recent physical activity increases the risk of a wrist fracture in postmenopausal women. The relationship of more distant past physical activity to wrist fracture is less clear, and most studies have relied on recall of physical activity much earlier in life. The aim of this study was to assess the risk of wrist fracture in a subset of women who had completed a recent questionnaire and also had participated in a cohort study 25 years earlier, 1865 women who were perimenopausal and postmenopausal in 1976 and had completed the 1976 and 2002 Adventist Health Study lifestyle questionnaires. Data on risk factors including physical activity were collected from the 1976 survey. Subjects reported wrist fractures occurring since baseline, and the approximate time of fracture, in the 2002 questionnaire. Incidence of wrist fracture was 3.7/1000 person-years of follow up. There was a dose-response inverse relationship between level of physical activity and wrist fracture with a 37% reduction of risk for the highest level of physical activity with respect to the lowest level (HR, 0.63; 95% CI, 0.45, 0.89). The effect of physical activity changed little in the final multivariable model (HR, 0.61; 95% CI, 0.43, 0.87). In this cohort of women with a relatively low incidence of wrist fracture, higher levels of physical activity at baseline were protective against risk of fracture during 25 years of follow-up.

The immediate effects of soft tissue mobilization with proprioceptive neuromuscular facilitation on glenohumeral external rotation and overhead reach.

STUDY DESIGN: Randomized controlled 2-group. pretest-posttest, multivariate study of patients with shoulder musculoskeletal disorders. OBJECTIVES: The purpose of this study was to evaluate the immediate effect of soft tissue mobilization (STM) with proprioceptive neuromuscular facilitation (PNF) to increase glenohumeral external rotation at 45 degrees of shoulder abduction and overhead reach. BACKGROUND: It is postulated that limitation in glenohumeral external rotation, when measured at 45 degrees of shoulder abduction, represents subscapularis muscle flexibility deficits and is associated with the inability to fully reach overhead. No research, however, is available to demonstrate whether intervention strategies intended to improve subscapularis flexibility and glenohumeral external rotation range of motion at 45 degrees of shoulder abduction will improve a patient's ability to reach overhead. METHODS AND MEASURES: Twenty patients (10 males, 10 females; age range, 21-83 years) with limited glenohumeral external rotation and overhead reach of 1 year duration or less served as subjects. The subjects were randomly assigned to a treatment group, which consisted of soft tissue mobilization to the subscapularis and proprioceptive neuromuscular facilitation to the shoulder rotators, or a control group. Goniometric measurements of glenohumeral external rotation at 45 degrees abduction and overhead reach were taken preintervention and immediately postintervention for the treatment group or at prerest and postrest periods for the control group. RESULTS: The treatment group improved by a mean of 16.4 degrees (95% confidence interval [CI, 12.5 degrees-20.3 degrees) of glenohumeral external rotation, as compared to less than a 1 degree gain (95% CI, -0.2 degrees-2.0 degrees) in the control group (P < .0005). Overhead reach in the treatment group improved by a mean of 9.6 cm (95% CI, 5.2-14.0 cm) in comparison to a mean gain of 2.4 cm (95% CI, -0.8-5.6 cm) for the control group (P = .009). CONCLUSION: These findings suggest that a single intervention session of STM and PNF was effective for producing immediate improvements in glenohumeral external rotation and overhead reach in patients with shoulder disorders.