Songthip Ounpraseuth

Amniotic fluid and the clinical relevance of the sonographically estimated amniotic fluid volume: oligohydramnios.

The amniotic fluid volume (AFV) is regulated by several systems, including the in‐tramembranous pathway, fetal production (fetal urine and lung fluid) and uptake (fetal swallowing), and the balance of fluid movement via osmotic gradients. The normal AFV across gestation has not been clearly defined; consequently, abnormal volumes are also poorly defined. Actual AFVs can be measured by dye dilution techniques and directly measured at cesarean delivery; however, these techniques are time‐consuming, are invasive, and require laboratory support, and direct measurement can only be done at cesarean delivery. As a result of these limitations, the AFV is estimated by the amniotic fluid index (AFI), the single deepest pocket, and subjective assessment of the AFV. Unfortunately, sonographic estimates of the AFV correlate poorly with dye‐determined or directly measured amniotic fluid. The recent use of color Doppler sonography has not improved the diagnostic accuracy of sonographic estimates of the AFV but instead has led to overdiagnosis of oligohydramnios. The relationship between the fixed cutoffs of an AFI of 5 cm or less and a single deepest pocket of 2 cm or less for identifying adverse pregnancy outcomes is uncertain. The use of the single deepest pocket compared to the AFI to identify oligohydramnios in at‐risk pregnancies seems to be a better choice because the use of the AFI leads to an increase in the diagnosis of oligohydramnios, resulting in more labor inductions and cesarean deliveries without any improvement in peripartum outcomes.

Micrographia and related deficits in Parkinson's disease: a cross-sectional study.

Objectives To determine the prevalence and clinical features associated with micrographia in Parkinsons Disease (PD). Setting This study was conducted at a Movement Disorders clinic located in a Veteran Administration Hospital. Participants PD subjects were included only if they satisfied UK Parkinsons Disease Society criteria for diagnosis. Subjects with history of severe tremors, dystonia, dyskinesia, strokes, peripheral neuropathy and dementia were excluded. Design This was a case–control study where PD subjects were prospectively enrolled and their demographics, Hoehn & Yahr stage, Unified Parkinsons Disease Rating Scale and Mini Mental Status examination (MMSE) scores were recorded. All subjects were specifically asked for micrographia on history and the handwritings were quantitatively documented. Bradykinesia was determined by history and quantified by a finger tap, Purdue pegboard and a timed walk test. Similarly, hypophonia was determined by history and the volume of speech quantified using a decibel meter. Controls were enrolled for validation of handwriting test scores and decibel meter recordings. Primary outcome measures Prevalence of micrographia in the PD cohort and the clinical factors that correlate with micrographia. Results 68 subjects with PD were enrolled (68 men; mean age 72.3 years). Micrographia was identified in 63.2% of the cohort on verbal history and in 50% of the cohort when the handwriting test was used for ascertainment. Micrographia ascertained on history correlated significantly with disease severity (Hoehn & Yahr stage), motor impairment (Unified Parkinsons Disease Rating Scale), cognitive impairment (MMSE) and both bradykinesia and hypophonia determined by history and quantitative testing. Micrographia on handwriting test correlated with age (p=0.02), MMSE testing (p=0.04), hypophonia by history (p=0.01) and bradykinesia by quantitative testing (p=0.04). Conclusion Micrographia was found in nearly half of the PD cohort. Disease severity and impaired cognition were important clinical correlates. Micrographia had a significant relationship with bradykinesia and hypophonia, suggesting a possible overlap in their pathophysiology.

Late complications and long-term quality of life for survivors (>5 years) with history of head and neck cancer

Quality of life (QOL) outcomes become critical for survivors of head and neck cancer. Most QOL studies were based on <5‐year outcomes and very few addressed >5‐year outcomes. This study focused late complications and >5‐year outcomes and also compared the 2 standard treatments.

Improving Perinatal Regionalization for Preterm Deliveries in a Medicaid Covered Population: Initial Impact of the Arkansas ANGELS Intervention

OBJECTIVE To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001-2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expanded the consulting capacity of the academic medical centers maternal fetal medicine practice. DATA SOURCES A dataset of linked Medicaid claims and birth certificates for the time period by clustering Medicaid claims by pregnancy episode. Pregnancy episodes were linked to residential county-level demographic and medical resource characteristics. Deliveries occurring before 35 weeks gestation (n=5,150) were used for analysis. STUDY DESIGN Logistic regression analysis was used to examine time trends and individual, county, and intervention characteristics associated with delivery at hospitals with NICU, and delivery at the academic medical center. PRINCIPAL FINDINGS Perceived risk, age, education, and prenatal care characteristics of women affected the likelihood of use of the NICU. The perceived availability of local expertise was associated with a lower likelihood that preterm infants would deliver at the NICU. ANGELS did not increase the overall use of NICU, but it did shift some deliveries to the academic setting. CONCLUSION Perinatal regionalization is the consequence of a complex set of provider and patient decisions, and it is difficult to alter with a voluntary program.

Dose-dependent relationship of physical and depressive symptoms with health-related quality of life in patients with heart failure

Background: Patients with heart failure (HF) have poor health-related quality of life (HRQOL). The vast majority of patients have physical symptoms, and about 30–40% have depressive symptoms. The combined effects of physical and depressive symptoms on HRQOL have not been examined fully in HF. Purposes: To examine the combined effects of physical and depressive symptoms on HRQOL using repeated measures, controlling for covariates (i.e. age, education level, New York Heart Association (NYHA) functional class, financial status, and health perception). Methods: Patients (N = 224, 62 ± 12 years old, 67% male, 38% NYHA functional class III/IV) provided data on physical (Symptom Status Questionnaire) and depressive symptoms (Beck Depression Inventory II) at baseline and HRQOL (Minnesota Living with Heart Failure Questionnaire) at baseline and 12 months. Patients were divided into three groups based on presence of physical and depressive symptoms: a) no symptom group, b) one symptom group (dyspnea or fatigue), and c) two symptom group (physical and depressive symptoms). Repeated measures ANOVA was used to analyze the data. Results: The least squares mean scores of baseline and 12-month HRQOL differed significantly in the three groups after controlling for the covariates (26.4 vs. 36.6 vs. 53.1, respectively, all pairwise p values < 0.001). There was no time-by-group interaction or time main effect. Conclusion: Physical and depressive symptoms have a dose–response relationship with HRQOL. Further research is needed to provide effective interventions to improve physical and depressive symptoms, in turn, HRQOL.

Job and career satisfaction among pharmacy preceptors.

Objectives. To examine the perceived benefit of job and career satisfaction among pharmacist preceptors and to explore other factors that might influence satisfaction. Methods. A cross-sectional self-administered survey instrument was mailed to pharmacists in the South Central region of the United States who had active 2010 licenses to investigate whether being a pharmacist preceptor increases job and career satisfaction. Results. Twenty-three percent of the 363 respondents were active preceptors and 62% of these reported that they had been preceptors at some point in the past. Being an active preceptor was significantly related to increased job satisfaction (p = 0.01) but not to career satisfaction. Having a perceived benefit of continuing education and being professionally challenged at work also were associated with increased job and career satisfaction (p < 0.001). Conclusions. Pharmacist preceptors have higher levels of self-reported job satisfaction.

Diagnostic concordance among dermatopathologists using a three-tiered keratinocytic intraepithelial neoplasia grading scheme

The distinction between actinic keratosis (AK) and squamous cell carcinoma in‐situ (SCCIS) is a subject of discussion among dermatopathologists. A previous study determined that there was excellent interobserver agreement among dermatopathologists using the current two‐tiered grading system. Presently, we assessed concordance among dermatopathologists using a three‐tiered keratinocytic intraepithelial neoplasia (KIN) diagnostic system. At the 2006 meeting of the American Society of Dermatopathology (ASDP), registration personnel solicited 125 registrants by randomly inserting an invitation into 125 registration packets. Participants reviewed 15 glass slides representing a spectrum of keratinocytic atypia from AK to SCCIS. Participants were asked to choose 1 or 2 but not 3 grades of KIN that best reflected the changes on each slide. Thirty‐two of the 125 solicited enrollees participated in the study. There were 16 volunteers for a total of 48 participants. The inter‐observer agreement for all participants was 0.575 (moderate agreement). The overall inter‐observer agreement for anatomic pathologist‐dermatopathologists (AP‐DP), dermatopathologist‐dermatologists (DP‐D) and anatomic pathologist‐dermatologist‐dermatopathologists (AP‐DP‐D) was 0.665, 0.609 and 0.670 (substantial agreement), respectively. There is high concordance among dermatopathologists using a three‐tiered diagnostic system for KIN. The observed agreement suggests that dermatopathologists are reliably able to categorize the continuum of keratinocytic atypia in a manner that may have diagnostic relevance.

Estimating misclassification error: a closer look at cross-validation based methods

BackgroundTo estimate a classifier’s error in predicting future observations, bootstrap methods have been proposed as reduced-variation alternatives to traditional cross-validation (CV) methods based on sampling without replacement. Monte Carlo (MC) simulation studies aimed at estimating the true misclassification error conditional on the training set are commonly used to compare CV methods. We conducted an MC simulation study to compare a new method of bootstrap CV (BCV) to k-fold CV for estimating clasification error.FindingsFor the low-dimensional conditions simulated, the modest positive bias of k-fold CV contrasted sharply with the substantial negative bias of the new BCV method. This behavior was corroborated using a real-world dataset of prognostic gene-expression profiles in breast cancer patients. Our simulation results demonstrate some extreme characteristics of variance and bias that can occur due to a fault in the design of CV exercises aimed at estimating the true conditional error of a classifier, and that appear not to have been fully appreciated in previous studies. Although CV is a sound practice for estimating a classifier’s generalization error, using CV to estimate the fixed misclassification error of a trained classifier conditional on the training set is problematic. While MC simulation of this estimation exercise can correctly represent the average bias of a classifier, it will overstate the between-run variance of the bias.ConclusionsWe recommend k-fold CV over the new BCV method for estimating a classifier’s generalization error. The extreme negative bias of BCV is too high a price to pay for its reduced variance.

Trajectories in Use of Substance Abuse and Mental Health Services Among Stimulant Users in Rural Areas

OBJECTIVE This study examined substance abuse and mental health service utilization during a three-year period among stimulant users living in rural areas. METHODS Participants (N=710) were interviewed at baseline and every six months for 36 months. One-step transition probabilities were constructed between the two types of service use for each consecutive pair of interviews to examine the resulting steady-state probabilities among multiple one-step transition matrices. RESULTS Most participants received no substance abuse or mental health services. On average, the probabilities of reporting use of the same types of services during the 36-month follow-up were 82% for receiving neither service, 9% for receiving only mental health treatment, 6% for receiving only substance abuse treatment, and 2% for receiving both services. CONCLUSIONS Further study is needed to determine factors that affect the decision to seek mental health or substance abuse treatment among residents of rural communities.

Correlation of ultrasound estimated with dye-determined or directly measured amniotic fluid volume revisited.

Background/Aims: To examine the relationship of the amniotic fluid index (AFI) and single deepest pocket (SDP) with an AFV as modelled by Brace or Magann. Methods: AFI and SDP were evaluated for their correlation with an actual AFV using the Spearman correlation coefficient. Results: 482 AFI and 468 SDP pregnancies were evaluated. There was a significant association between the AFI and SDP and an actual AFV (p < 0.0001). The AFI range of 5.1-20 was better correlated than 5.1-24 for normal AFVs Brace (κ = 0.175) and Magann (κ = 0.356) versus 5.1-24 (κ = 0.150 and κ = 0.319), respectively. The agreement level t for the AFI (κ = 0.175) and SDP (κ = 0.126) using Brace was slight and for the AFI (κ = 0.356) and SDP (κ = 0.295) using Magann was fair. Conclusions: Both the AFI and SDP were correlated with actual AFV using both models. AFI of 5.1-20 better categorizes normal volumes. Although the Magann model correlates AFI/SDP and AFV better, the superiority is minimal.