Christina Holt

Barriers to Outdoor Physical Activity in Wintertime Among Somali Youth

To identify barriers to outdoor physical activity in winter among Somali youth in Maine. Despite the many proven health benefits of physical activity among children, such as cardiovascular fitness and health status as an adult, there has been a decrease in physical activity among children in recent years. Specifically, children who are of low socio-economic status or are from communities where many immigrants are at increased risk for developing obesity. Immigrants are also less likely to be physically active. There are many potential barriers to wintertime physical activity among Somali youth in Maine, such as lack of financial resources, transportation, proper winter clothing, and appropriate knowledge of winter safety, and language and cultural barriers. For females, different attire required for outdoor activity may be a barrier. Somali parents and children were recruited from Portland, Maine to participate in focus groups led by a trained facilitator with a Somali translator and cultural broker. Transcripts were coded using NVIVO software to identify barriers to physical activity among Somali youth outside in winter. Eight focus groups were conducted. Sixty-one Somali community members were recruited. Participants felt outdoor physical activity is important, but note that it is decreased in winter. Barriers to outdoor activity in winter cited by focus group participants were lack of resources, health concerns, gender barriers for females, and knowledge barriers. Concern over lack of supervision while children play outside was also cited. This study revealed many of the underlying beliefs, barriers and cultural issues that impact Somali families’ intention to be active and ability to be active outdoors in winter. These findings can be used to generate research hypotheses and public health interventions regarding outdoor physical activity among Somali youth.

Temporal changes in tolerance of uncertainty among medical students: insights from an exploratory study.

Background Physicians’ tolerance of uncertainty (TU) is a trait potentially associated with desirable outcomes, and emerging evidence suggests it may change over time. Past studies of TU, however, have been cross-sectional and have not measured tolerance of the different, specific types of uncertainty that physicians confront. We addressed these limitations in a longitudinal exploratory study of medical students. Methods At the end of medical school (Doctor of Medicine degree) Years 1 and 4, a cohort of 26 students at a US medical school completed measures assessing tolerance of different types of uncertainty: 1) complexity (uncertainty arising from features of information that make it difficult to comprehend); 2) risk (uncertainty arising from the indeterminacy of future outcomes); and 3) ambiguity (uncertainty arising from limitations in the reliability, credibility, or adequacy of information). Change in uncertainty-specific TU was assessed using paired t-tests. Results Between Years 1 and 4, there was a significant decrease in tolerance of ambiguity (t=3.22, p=0.004), but no change in students’ tolerance of complexity or risk. Conclusions Tolerance of ambiguity – but not other types of uncertainty – decreases during medical school, suggesting that TU is a multidimensional, partially mutable state. Future studies should measure tolerance of different uncertainties and examine how TU might be improved.

Developing, evaluating and validating a scoring rubric for written case reports

Objectives The purpose of this study was to evaluate Family Medicine Clerkship students’ writing skills using an anchored scoring rubric. In this study, we report on the assessment of a current scoring rubric (SR) used to grade written case description papers (CDP) for medical students, describe the development of a revised SR with examination of scoring consistency among faculty raters, and report on feedback from students regarding SR revisions and written CDP. Methods Five faculty members scored a total of eighty-three written CDP using both the Original SR (OSR) and the Revised SR1 (RSR1) during the 2009-2010 academic years. Results Overall increased faculty inter-rater reliability was obtained using the RSR1. Additionally, this subset analysis revealed that the five faculty using the Revised SR2 (RSR2) had a high measure of inter-rater reliability on their scoring of this subset of papers (as measured by intra-class correlation (ICC) with ICC = 0.93, p < 0.001. Conclusions Findings from this research have implications for medical education, by highlighting the importance of the assessment and development of reliable evaluation tools for medical student writing projects.

Prescription Monitoring Program Trends Among Individuals Arrested in Maine for Trafficking Prescription Drugs in 2014

To evaluate controlled substance prescribing trends available in the Maine Prescription Monitoring Program (PMP) among individuals arrested for prescription drug “trafficking.” The demographic characteristics of the individuals who had matching prescription records in the PMP within 90 days of the arrest were identified.

The Health and Libraries of Public Use Retrospective Study (HeLPURS).

BACKGROUND Public libraries may promote health through literacy, education and social connections. OBJECTIVE To conduct the first broad-based, quantitative exploration of health and public library patronage. METHODS Retrospective cross-sectional study. All 2925 adult patients at a general practice clinic living in a small north-eastern U.S. city were invited by mail to participate; 243 consented. Clinical variables from the medical records were combined with library usage variables from the public library patron database. The authors analysed how patient health characteristics were associated with library cardholding, average card use or recency of use. RESULTS Approximately 72% of participants held a library card; 40% of these had used it within the last month. Library cardholding was not associated with patient characteristics. Higher average card use was associated with pregnancy, having youth at home and depression severity. Lack of recent library usage was associated with current smoking (P = 0.01) and drug use (P = 0.01). Among ever-smokers, moderate/high card use and card use within six months were both associated with over two times the odds of quitting smoking. CONCLUSIONS Public libraries and health appear to intersect around substance abuse and depression-anxiety disorders. Moderate or higher use of public libraries is strongly associated with tobacco cessation.

Tolerability and Efficacy of 3 Approaches to Intra-articular Corticosteroid Injections of the Knee for Osteoarthritis: A Randomized Controlled Trial.

Background: Several studies have been performed suggesting that a superolateral approach to cortisone injections for symptomatic osteoarthritis of the knee is more accurate than anteromedial or anterolateral approaches, but there are little data to correlate clinical outcomes with these results. Additionally, there are minimal data to evaluate the pain of such procedures, and this consideration may impact physician preferences for a preferred approach to knee injection. Purpose: To determine the comparative efficacy and tolerability (patient comfort) of landmark-guided cortisone injections at 3 commonly used portals into the arthritic knee without effusion. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Adult, English-speaking patients presenting to a sports medicine clinic with knee pain attributed to radiographically proven grades I through III knee osteoarthritis were randomized to receive a cortisone injection via superolateral, anteromedial, or anterolateral approaches. Patients used a visual analog scale (VAS) to self-report comfort with the procedure. Western Ontario and McMaster Universities Arthritis Index (WOMAC) 3.1 VAS scores were used to establish baseline pain and dysfunction prior to the injection and at 1 and 4 weeks follow-up via mail. Results: A total of 55 knees from 53 patients were randomized for injection using a superolateral approach (17 knees), an anteromedial approach (20 knees), and an anterolateral approach (18 knees). The mean VAS scores for procedural discomfort showed no significant differences between groups (superolateral, 39.1 ± 28.5; anteromedial, 32.9 ± 31.5; anterolateral, 33.1 ± 26.6; P = .78). WOMAC scores at baseline were similar between groups as well (superolateral, 1051 ± 686; anteromedial, 1450 ± 573; anterolateral, 1378 ± 673; P = .18). The WOMAC scores decreased at 1 and 4 weeks for all groups, with no significant differences in reduction between the 3 groups. Conclusion: Other studies have shown that the superolateral portal is the most accurate. This study did not assess accuracy, but it showed that all 3 knee injection sites studied have similar overall clinical benefit at 4-week follow-up. Procedural pain was not significantly different between groups.

An argument for comprehensiveness as the "special sauce" in a recipe for the patient-centered medical home.

How can we study and quantify potential value that may be added by having primary care specialists (PCSs) from both family medicine and internal medicine provide preventive care services for women? Does seeing ones personal physician (PCP) make a difference? Early answers come from the study by Cohen and Coco in this issue: “Do physicians address other medical problems during preventive gynecologic visits?” Their assessment of a nationally representative sample of preventive gynecological visits uses self-reported data from the physicians to tell us “yes” and to quantify to what extent by specialty, region, and PCP status. This sampling of the content of womens preventive health visits allows us to get a flavor for how the majority of PCSs provide comprehensive care for concomitant acute and chronic issues in the context of individual preventive care visits. Patients are unlikely to parse their presenting concerns into the acute or chronic or preventive categories. The practice of addressing multiple issues during one visit improves the efficiency of addressing patient concerns. This may be a key to the special flavor of a true patient-centered medical home.

Controlled substance prescribing trends and physician and pharmacy utilization patterns: epidemiological analysis of the Maine Prescription Monitoring Program from 2006 to 2010

The Maine Prescription Monitoring Program (PMP) was created to prevent prescription drug misuse and diversion. The PMP collects data for all Schedule II, III and IV prescriptions dispensed by pharmacies licensed in Maine. This article presents a retrospective analysis of the PMP for prescribing trends and utilization patterns from state fiscal year 2006 to 2010. The sample included 11,542,850 Schedule prescriptions for 1,024,649 unduplicated patients in a 5-year database of the PMP. The number of controlled prescriptions steadily increased from 2.05 million in 2006 to 2.51 million in 2010. Opioid analgesics and stimulants were found to be the most commonly prescribed and fastest growing scheduled drug categories, respectively. Most individuals (82.9%) accessed their controlled drugs from one to two prescribers and pharmacies. Patients who utilized five prescribers and more used a greater number of pharmacies than those who utilized less than five prescribers (p < 0.001). The dramatic increase in the number of controlled prescriptions shown in this study has important public health implications.

Factors Affecting Physicians’ Intentions to Communicate Personalized Prognostic Information to Cancer Patients at the End of Life An Experimental Vignette Study

Purpose. To explore the effects of personalized prognostic information on physicians’ intentions to communicate prognosis to cancer patients at the end of life, and to identify factors that moderate these effects. Methods. A factorial experiment was conducted in which 93 family medicine physicians were presented with a hypothetical vignette depicting an end-stage gastric cancer patient seeking prognostic information. Physicians’ intentions to communicate prognosis were assessed before and after provision of personalized prognostic information, while emotional distress of the patient and ambiguity (imprecision) of the prognostic estimate were varied between subjects. General linear models were used to test the effects of personalized prognostic information, patient distress, and ambiguity on prognostic communication intentions, and potential moderating effects of 1) perceived patient distress, 2) perceived credibility of prognostic models, 3) physician numeracy (objective and subjective), and 4) physician aversion to risk and ambiguity. Results. Provision of personalized prognostic information increased prognostic communication intentions (P < 0.001, η2 = 0.38), although experimentally manipulated patient distress and prognostic ambiguity had no effects. Greater change in communication intentions was positively associated with higher perceived credibility of prognostic models (P = 0.007, η2 = 0.10), higher objective numeracy (P = 0.01, η2 = 0.09), female sex (P = 0.01, η2 = 0.08), and lower perceived patient distress (P = 0.02, η2 = 0.07). Intentions to communicate available personalized prognostic information were positively associated with higher perceived credibility of prognostic models (P = 0.02, η2 = 0.09), higher subjective numeracy (P = 0.02, η2 = 0.08), and lower ambiguity aversion (P = 0.06, η2 = 0.04). Conclusions. Provision of personalized prognostic information increases physicians’ prognostic communication intentions to a hypothetical end-stage cancer patient, and situational and physician characteristics moderate this effect. More research is needed to confirm these findings and elucidate the determinants of prognostic communication at the end of life.

Using Controlled Substance Receipt Patterns to Predict Prescription Overdose Death

Background: This study evaluates complete state data from controlled substance prescribing trends in the prescription monitoring program (PMP) database and their association with the risk of prescription drug overdose death. Summary: Maine PMP records of individuals who died of prescription overdose deaths between 2006 and 2010 were selected (n = 690). For each subject, an age, gender, and residence matched cohort of PMP users in a 50: 1 ratio was identified (n = 34,500). Key Messages: Prescription opioids contributed to 480 of 690 prescription deaths, many co-ingestions were noted, and OR for overdose death increased with milligram of morphine equivalent (MME)/day >100. The majority who were prescribed MME >100 per day received a prescription within 90 days of overdose matching the toxicology cause of death. Conclusions: Medication profiles available through state PMP can identify dosing of prescriptions associated with drug overdose death.