Susan E. Bennett

Who should be screened for asymptomatic carotid artery stenosis? Experience from the Western New York Stroke Screening Program.

Objective. Identification of significant asymptomatic carotid artery stenosis (ACAS) is important because of the stroke‐risk reduction observed with carotid endarterectomy. The authors developed and validated a simple scoring system based on routinely available information to identify persons at high risk for ACAS using data collected during a community health screening program at various sites in western New York. A total of 1331 unselected volunteers without previous stroke, transient ischemic attack, or carotid artery surgery were evaluated by personal interview and duplex ultrasound. The main outcome measure was carotid artery stenosis >60% by duplex ultrasound. In the derivation set (n= 887), 4 variables were significantly associated with ACAS >60%: age >65 years (odds ratio [OR] = 4.1, 95% confidence interval [CI] = 2.6–6.7), current smoking (OR = 2.0, 95% CI = 1.2–3.5), coronary artery disease (OR = 2.4, 95% CI = 1.5–3.9), and hypercholesterolemia (OR = 1.9, 95% CI = 1.2–2.9). Three risk groups (low, intermediate, and high) were defined on the basis of total risk score assigned on the basis of the strength of association. The scheme effectively stratified the validation set (n= 444); the likelihood ratio and posttest probability for ACAS in the high‐risk group were 3.0 and 35%, respectively, and in the intermediate and low‐risk groups were 1.4 and 20% and 0.4 and 7%, respectively. Routinely available information can be used to identify persons in the community at high risk for ACAS. Doppler ultrasound screening in this subgroup may prove to be cost‐effective and have an effect on stroke‐free survival.

Active range of motion utilized in the cervical spine to perform daily functional tasks.

This was a descriptive study to examine active range of motion required in the cervical spine during functional tasks of daily living. The objective of this study was to determine the mean active range of motion of the cervical spine required to perform 13 daily functional tasks. Previous research has examined the absolute ranges of cervical motion for women and men 20–60 years of age; however, no previous study has determined the amount and type of motion that is required for routine activities of daily living. Twenty-eight college-aged students (n = 28) served as healthy subjects and performed three trials of 13 daily tasks of functional activity. The subjects starting position and end range of motion for flexion–extension, rotation, and side bending of each task were observed and recorded using the cervical range of motion device. The three trials were averaged, and ranges of motion across the 28 subjects were reported. Of the 13 daily functional tasks performed, tying shoes (flexion–extension 66.7°), backing up a car (rotation 67.6°), washing hair in the shower (flexion–extension 42.9°), and crossing the street (rotation head left 31.7° and rotation head right 54.3°) required the greatest full active range of motion of the cervical spine. Flexion–extension and rotation of the cervical spine are important to enable functional activity. Four of the 13 daily tasks performed required 30–50% of active range of motion. Side bending was seen to be coupled with rotation in completion of tasks. This article provides a baseline of normal motion of the neck required for activities of daily living and can be used in the assessment of disease states and disability.

Creating a Patient-Centered Radiology Practice Through the Establishment of a Diagnostic Radiology Consultation Clinic

OBJECTIVE The purposes of this study were to assess the feasibility of and to create a referral mechanism for a diagnostic radiology consultation clinic. SUBJECTS AND METHODS A pilot program was instituted with patients from a single primary care clinic over a 3-week period. Patients with findings of common problems at routine imaging, such as atherosclerosis, emphysema, and hepatic steatosis, were eligible to participate. As the patients arrived for their routine primary care visits, office staff informed them of the opportunity to formally meet with a radiologist to review their most recent imaging findings. The office staff of the primary care clinic then contacted the radiologist covering the diagnostic radiology consultation clinic to schedule a consultation. A survey was administered before and after the session. RESULTS Twenty-two patients participated (88% participation rate). Participants rated the consultation as very helpful (mean, 4.8 on 1-5 scale), and all participants would take the opportunity to review studies with the radiologist again. Significantly more patients preferred the involvement of the radiologist in communicating the results of an imaging examination after the consultation compared with before the consultation (p = 0.001). After the consultation session, patients had significantly improved understanding of a radiologists role (p = 0.004), and all participants were able to correctly identify the radiologist as a physician who interprets medical images. CONCLUSION A referral mechanism for a diagnostic radiology consultation clinic can be effectively integrated into the everyday workflow of both the referring physician and the radiologist. The consultations are useful to patients and help to increase their awareness of the role of the radiologist.

Recent Measures to Improve Radiology Reporting: Perspectives From Primary Care Physicians

PURPOSE There is considerable interest in improving radiology reporting practices. It has been suggested recently that reporting practices could be improved by more direct involvement of radiologists in delivering results to patients and by making clear recommendations within the radiology report. The opinions of primary care physicians about these initiatives are not well known. The authors surveyed primary care physicians to better understand their views. METHODS An online survey was distributed to 229 primary care physicians through an internal list server, and responses were collected confidentially. RESULTS There were 100 responses (a 43.6% response rate). The majority of respondents were satisfied with radiology reporting and recommendations in general. Ninety-five percent of respondents felt that ordering physicians should deliver the results of examinations. No respondents felt that radiologists should deliver results directly to patients. Ninety-four percent of respondents felt medicolegally obligated by recommendations made by radiologists within their reports. Twenty-three percent of respondents felt more medicolegally obligated if the recommendation is set apart from the clinical impression, while 58% of respondents felt less medicolegally obligated if qualifying language is added to the recommendation. CONCLUSIONS Primary care physicians prefer to deliver the results of examinations themselves and feel medicolegally obligated by recommendations within radiology reports, even though this seems to be influenced by the wording and location of the recommendations within reports. Radiologists should consider these factors when contemplating changes in reporting practices.

Intrathecal baclofen in multiple sclerosis: Too little, too late?

The majority of patients with multiple sclerosis (MS) have symptoms of spasticity that increasingly impair function as the disease progresses. With appropriate treatment, however, quality of life can be improved. Oral antispasticity medications are useful in managing mild spasticity but are frequently ineffective in controlling moderate to severe spasticity, because patients often cannot tolerate the adverse effects of increasing doses. Intrathecal baclofen (ITB) therapy can be an effective alternative to oral medications in patients who have a suboptimal response to oral medications or who cannot tolerate dose escalation or multidrug oral regimens. ITB therapy may be underutilized in the MS population because clinicians (a) are more focused on disease-modifying therapies rather than symptom control, (b) underestimate the impact of spasticity on quality of life, and (c) have concerns about the cost and safety of ITB therapy. Delivery of ITB therapy requires expertly trained staff and proper facilities for pump management. This article summarizes the findings and recommendations of an expert panel on the use of ITB therapy in the MS population and the role of the physician and comprehensive care team in patient selection, screening, and management.

Psychiatric complications of progesterone and oral contraceptives.

Progesterone plays a critical role in the menstrual cycle, pregnancy, and sexuality. Its role in premenstrual syndrome, dysmenorrhea, and postpartum disorders is outlined. Oral contraceptives seem to affect mood and behavior in some women without preexisting psychiatric illness, sometimes inducing depression and loss of libido. When used as psychotropic agents, they can have mood-stabilizing effects and relieve premenstrual syndrome.

Structural analysis and immunogenicity of Pseudomonas aeruginosa immunotype 2 high molecular weight polysaccharide.

We analyzed high molecular weight polysaccharide (PS) from the Fisher immunotype 2 (IT-2) strain of Pseudomonas aeruginosa for molecular composition and structure, then determined its immunogenicity in healthy adults. The PS was composed of 2-acetamido-2,6-dideoxygalactose (N-acetyl fucosamine) and glucose in a molar ratio of 2:1. Structural analysis by carbon-13 and proton nuclear magnetic resonance confirmed that the high molecular weight PS was structurally identical to that of the O-specific side chain of the lipopolysaccharide. PS differed from this material in molecular size. Immunization of 19 adult volunteers with doses of 50-100 micrograms of PS resulted in significant rises (P less than 0.04-P less than 0.0001) in binding antibody levels and killing antibody titers 2 and 4 wk postimmunization. The only reaction to the vaccine was localized tenderness at the immunization site. Analysis of the immunoglobulin isotype response to the vaccine showed a rise in specific serum IgG and IgA antibodies. Heterologous responses to other P. aeruginosa PS antigens were not seen. The antibody levels attained by vaccination were comparable with those in acute-phase serum samples of patients who survived sepsis with IT-2 P. aeruginosa and were significantly higher (P less than 0.03) than specific antibody levels in bacteremic patients who died. These results confirm that PS is a high molecular weight, immunogenic form of the P. aeruginosa IT-2 serotype antigen, eliciting levels of type-specific antibody comparable with those seen among patients surviving an episode of P. aeruginosa sepsis.

Outcome Measures for Individuals With Multiple Sclerosis: Recommendations From the American Physical Therapy Association Neurology Section Task Force

Various studies have described the benefits of using outcome measures (OMs) in physical therapist practice1–3; however, multiple barriers interfere with their use (eTab. 1).1,3,4 Most notably, a limited understanding of how to select and apply the best OM has been reported to be a barrier.3,4 Wedge et al3 reported that physical therapists do not always critically evaluate the psychometric properties of OMs, are unfamiliar with OM-related resources, and have difficulties determining patient suitability for particular OMs. Physical therapists working with people with multiple sclerosis (MS) have additional challenges when selecting OMs. Multiple sclerosis is a complex, heterogeneous, and progressive disorder causing a wide variety of symptoms among patients.5,6 Symptom variability in individual patients throughout the course of the disease also must be considered. Additionally, people with MS are treated in a variety of settings, which may affect OM selection and use (eg, due to limited space and equipment in a home environment). Thus, selecting 1 or 2 OMs for use with all people with MS is challenging, requiring the clinician to determine the most appropriate OMs to measure relevant constructs. Although some resources exist to assist the physical therapist with identifying and selecting OMs for people with MS,7–13 literature is lacking that describes a consensus-based method to determine which OMs are appropriate for people with MS at various disability levels and in different practice settings. In 2009, the American Physical Therapy Association (APTA) Neurology Section (“the Section”) began a process to develop recommendations for the use of OMs for patients with neurological conditions, beginning with stroke (information pertaining to the Sections OM recommendations is available elsewhere14). The following year, the Section expanded its efforts by creating a task force …

Exercise as prescriptive therapy in multiple sclerosis: A consensus conference white paper

Community-based studies are required to accurately describe the supportive services needed by people with multiple sclerosis (MS). Characteristics that influence (or result from) care-seeking may introduce bias into other types of studies. The Participation and Activity Limitation Survey (PALS) was a post-census survey conducted by Statistics Canada in association with a 2006 national census. The PALS collected data from a sample of 22,513 respondents having health-related impairments according to their census forms. The survey collected self-reported diagnostic data and obtained ratings for items assessing impairment as well as perceived met and unmet needs for care and support. It identified 245 individuals with MS, leading to an estimated (weighted) population prevalence of 0.2% (200 per 100,000). As expected, those with MS reported more-severe health problems than did those with other types of disability, particularly in the areas of mobility, dexterity, and cognition; they were also more likely to report having multiple caregivers. People with MS also reported more unmet health-care needs than did those with other forms of disability, particularly with respect to meal preparation, housework, shopping, and chores. Despite their more negative health status and greater reliance on caregivers, people with MS reported participation in society comparable to that of people without MS. Thus, people with MS report greater needs than do people with other forms of health-related disability and utilize supportive services more often. However, they also report higher levels of unmet needs. The substantial needs of people with MS are only partially addressed by existing services.

Toward a Consensus on Rehabilitation Outcomes in MS: Gait and Fatigue: Report of a CMSC Consensus Conference, November 28–29, 2007

A multidisciplinary consensus conference was held on November 28–29, 2007, by the Consortium of Multiple Sclerosis Centers (CMSC) to determine the most appropriate outcome measures for gait and fatigue in people with multiple sclerosis (MS). The goals of this conference were to 1) improve understanding of gait and fatigue outcome measures being used by rehabilitation professionals treating people with MS; 2) establish consensus on outcome measures; and 3) establish consensus on required follow-up for transfer of this knowledge to rehabilitation professionals. The consensus conference and this document are the initial steps toward achieving the stated goals. Although many measures of fatigue exist, it was recommended that a global outcome measure for fatigue be developed that would 1) include a screen for the functional ramifications of fatigue for activities and participation; 2) be quick and easy to administer; 3) demonstrate psychometric integrity for MS; and 4) examine fatigue over a continuum of the M...