The Relationship Between Limit of Dysphagia and Average Volume Per Swallow in Patients with Parkinson’s Disease

The goal of this study was to obtain the limit of dysphagia and the average volume per swallow in patients with mild to moderate Parkinson’s disease (PD) but without swallowing complaints and in normal subjects, and to investigate the relationship between them. We hypothesize there is a direct relationship between these two measurements. The study included 10 patients with idiopathic PD and 10 age-matched normal controls. Surface electromyography was recorded over the suprahyoid muscle group. The limit of dysphagia was obtained by offering increasing volumes of water until piecemeal deglutition occurred. The average volume per swallow was calculated by dividing the time taken by the number of swallows used to drink 100 ml of water. The PD group showed a significantly lower dysphagia limit and lower average volume per swallow. There was a significantly moderate direct correlation and association between the two measurements. About half of the PD patients had an abnormally low dysphagia limit and average volume per swallow, although none had spontaneously related swallowing problems. Both measurements may be used as a quick objective screening test for the early identification of swallowing alterations that may lead to dysphagia in PD patients, but the determination of the average volume per swallow is much quicker and simpler.     

The Relationship Between HRCT and Pulmonary Function in Behcet’s Disease

The purpose of this study was to compare the pulmonary functions in female Behcets patients with or without pathological pulmonary lesions using high resolution computerized tomography (HRCT). Twenty-nine female patients aged 19–54 yrs and 20 healthy females aged 19–50 yrs (control group) were accepted into the study. HRCT images were taken and according to HRCT patients were divided into HRCT (+) and HRCT (–) groups (18 patients in each). Pulmonary function tests (PFT) through a spirometer were performed and FVC, FEV₁, FEF_25–75%, PEF, VC, RV, FRC, DLCO and DLCO/VA were determined. No statistically significant difference was observed when the PFT values were compared between HRCT (+) and HRCT (–) patients for the obtained results and the percentage of the expected values. When the PFT values were compared for both HRCT (+) and HRCT (–) patients with the control group separately there was no statistical difference between the best values. A statistically low DLCO/VA value was observed between the percentage of the expected values. It is concluded that though there is a pulmonary restriction in Behcets disease, this restriction has no relation to pulmonary functions. It would be useful to perform pulmonary function tests in the patients with Behcets disease both with or without any pathological findings in HRCT for obtaining information about pulmonary functions. We suggest that even when the results of the pulmonary function tests are normal, considering some pathological changes in HRCT, HRCT investigations may be useful for following up the disease.     

The Association Between Sensemaking During Physician Team Rounds and Hospitalized Patients’ Outcomes

BACKGROUND

Sensemaking is the social act of assigning meaning to ambiguous events. It is recognized as a means to achieve high reliability. We sought to assess sensemaking in daily patient care through examining how inpatient teams round and discuss patients.

OBJECTIVE

Our purpose was to assess the association between inpatient physician team sensemaking and hospitalized patients’ outcomes, including length of stay (LOS), unnecessary length of stay (ULOS), and complication rates.

DESIGN

Eleven inpatient medicine teams’ daily rounds were observed for 2 to 4 weeks. Rounds were audiotaped, and field notes taken. Four patient discussions per team were assessed using a standardized Situation, Task, Intent, Concern, Calibrate (STICC) framework.

PARTICIPANTS

Inpatient physician teams at the teaching hospitals affiliated with the University of Texas Health Science Center at San Antonio participated in the study. Outcomes of patients admitted to the teams were included.

MAIN MEASURES

Sensemaking was assessed based on the order in which patients were seen, purposeful rounding, patient-driven rounding, and individual patient discussions. We assigned teams a score based on the number of STICC elements used in the four patient discussions sampled. The association between sensemaking and outcomes was assessed using Kruskal-Wallis sum rank and Dunn’s tests.

KEY RESULTS

Teams rounded in several different ways. Five teams rounded purposefully, and four based rounds on patient-driven needs. Purposeful and patient-driven rounds were significantly associated with lower complication rates. Varying the order in which patients were seen and purposefully rounding were significantly associated with lower LOS, and purposeful and patient-driven rounds associated with lower ULOS. Use of a greater number of STICC elements was associated with significantly lower LOS (4.6 vs. 5.7, p = 0.01), ULOS (0.3 vs. 0.6, p = 0.02), and complications (0.2 vs. 0.5, p = 0.0001).

CONCLUSIONS

Improving sensemaking may be a strategy for improving patient outcomes, fostering a shared understanding of a patient’s clinical trajectory, and enabling high reliability.KEY WORDS: complexity science, sensemaking, length of stay, complication rates, inpatient teams     

Relationship Between Peer Assessment During Medical School, Dean’s Letter Rankings, and Ratings by Internship Directors

BACKGROUND: It is not known to what extent the dean's letter (medical student performance evaluation [MSPE]) reflects peer-assessed work habits (WH) skills and/or interpersonal attributes (IA) of students. OBJECTIVE: To compare peer ratings of WH and IA of second- and third-year medical students with later MSPE rankings and ratings by internship program directors. DESIGN AND PARTICIPANTS: Participants were 281 medical students from the classes of 2004, 2005, and 2006 at a private medical school in the northeastern United States, who had participated in peer assessment exercises in the second and third years of medical school. For students from the class of 2004, we also compared peer assessment data against later evaluations obtained from internship program directors. RESULTS: Peer-assessed WH were predictive of later MSPE groups in both the second (F = 44.90, P < .001) and third years (F = 29.54, P < .001) of medical school. Interpersonal attributes were not related to MSPE rankings in either year. MSPE rankings for a majority of students were predictable from peer-assessed WH scores. Internship directors' ratings were significantly related to second- and third-year peer-assessed WH scores (r = .32 [P = .15] and r = .43 [P = .004]), respectively, but not to peer-assessed IA. CONCLUSIONS: Peer assessment of WH, as early as the second year of medical school, can predict later MSPE rankings and internship performance. Although peer-assessed IA can be measured reliably, they are unrelated to either outcome.     

Perceived Helpfulness of Physicians’ Communication Behavior and Breast Cancer Patients’ Level of Trust Over Time

OBJECTIVE  We evaluated the association between physicians’ communication behavior and breast cancer patients’ trust in their physicians. DESIGN  Longitudinal survey conducted at baseline, 2-month, and 5-month follow-up during first year of diagnosis. PARTICIPANTS  Newly diagnosed breast cancer patients (N = 246). MEASUREMENTS  We collected data on patient perceptions of the helpfulness of informational, emotional, and decision-making support provided by physicians and patients’ trust. Linear regression models evaluated the association of concurrent and prior levels of physician support with patients’ trust. RESULTS  At baseline, patients who received helpful informational, emotional, and decision-making support from physicians reported greater trust (p < 0.05, p < 0.001, and p < 0.01, respectively). At the 2-month assessment, baseline informational support and informational and emotional support at 2-months were associated with greater trust (p < 0.05, p < 0.01, and p < 0.05, respectively). At the 5-month assessment, only helpful emotional support from physicians at 5 months was associated with greater trust (p < 0.01). Interestingly, while perceived helpfulness of all three types of physician support decreased significantly over time, patient trust remained high and unchanged. CONCLUSIONS  Findings suggest that while informational and decision-making support may be more important to patient trust early in the course of treatment, emotional support from physicians may be important to maintain trust throughout the initial year of diagnosis.     

Crohn’s Disease: Presentation and Severity Compared Between Black Patients and White Patients

PURPOSE Common belief based on clinical experience suggests that Crohn’s disease is more severe among black patients, although little data exists on the effect of race on Crohn’s disease. We compared multiple variables among black patients with Crohn’s disease requiring surgery to those of white patients presenting to a university colorectal surgery unit during a five-year period.METHODS A total of 345 patients required surgery for Crohn’s disease between June 1998 and September 2003. The following data were abstracted from patient charts and a prospectively maintained database: age at diagnosis; age at first Crohn’s disease surgery; presenting symptoms; incidence, number and location of fistulas at presentation; number of Crohn’s disease operations; and family history of inflammatory bowel disease. Data regarding medical insurance coverage also were obtained. Complete data were evaluable on 178 patients. Patient variables were analyzed using the chi-squared, Fisher exact, and Student t-tests.RESULTS Mean age at diagnosis was 28 years for white males, 20 years for black males, 30 years for white females, and 28 years for black females (all p > 0.05). Thirty-seven percent of white females presented with obstructive symptoms vs. 12 percent of black females. (P = 0.011). Sixty-five percent of black females presented with inflammatory symptoms compared with 28 percent of white females (P = 0.001). Of females presenting with fistulas, 15 percent of black patients had a rectovaginal fistula compared with 5 percent of white patients. Seventeen percent of black males and 21 percent of white males had intra-abdominal fistulas. None of these differences were statistically significant. The incidence of fistulas at presentation, mean number of fistulas, total number of operations, and family history of inflammatory bowel disease did not differ.CONCLUSIONS Contrary to expectations, Crohn’s disease does not seem to be more severe among black patients, who had an earlier age of diagnosis, although this was not statistically significant. Overall, there was no difference in disease presentation. White females were more likely to present with obstructive symptoms compared with black females, who more often presented with inflammatory symptoms. Among patients with fistulas, the incidence of rectovaginal fistulas was higher in black females compared with white females, and white males were somewhat more likely to have intra-abdominal fistulas than black males. Although there was no demonstrated difference in incidence and mean number of fistulas at presentation, the number of operations for Crohn’s disease, or family history of inflammatory bowel disease among blacks and whites, there are differences in presenting symptoms among these populations.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.Reprints are not available.     

The Relationship Between Type 2 Diabetic Patients’ Early Medical Care–Seeking Consistency to the Same Clinician and Health Care System and Their Clinical Outcomes

The literature has demonstrated that the continuity of diabetes care can lower medical service utilization and expenses. However, few studies have examined the effects of patients’ medical care–seeking behaviors in the early stage after the diagnosis of diabetes on their long-term prognoses.This study aimed to examine the association of medical care–seeking behavior in the first year following diabetes diagnosis on the occurrence of diabetes-related complications among patients in Taiwan. This is a retrospective data collection with follow-up analysis and a nationwide population-based dataset in Taiwan. A total of 89,428 newly diagnosed type 2 diabetes mellitus patients during the period from 2000 to 2006 were followed up until 2010. The patients’ medical care–seeking behaviors were classified as follows: high consistency to a physician, high consistency to a medical setting, medium consistency to providers, and low consistency to providers. The occurrence of diabetes-related complications and all-cause mortality were the primary outcomes of this study. Chi-square tests, ANOVAs, and Cox proportional hazard models were applied to examine the relationships between the predictors and medical outcomes.Compared to the patients with high medical care–seeking consistency to a physician, the multivariate-adjusted hazard ratios of diabetes-related complications occurrence among patients in the high consistency to a medical setting, medium consistency, and low consistency categories were 1.112 (95% CI 1.089–1.136, P < 0.001), 1.226 (95% CI 1.205–1.248, P < 0.001), and 1.536 (95% CI 1.504–1.567, P < 0.001) in outpatient visits and 1.032 (95% CI 0.992–1.074, P = 0.121), 1.056 (95% CI 1.022–1.092, P = 0.001), and 1.208 (95% CI 1.164–1.254, P < 0.001) in complication-incurred hospitalizations, respectively. The monotonic trend was sustained across different strata of age, gender, and disease complexity.The findings of this study suggest that the incentives of continuity of care and physician–patient relationship management should be reinforced during the early stage of diabetes care in future medical care systems.     

The Relationship Between HB Bart's Levels in Cord Blood and the Deletions of α-Globin Genes

A relationship between Hb Bart's levels in cord blood and the number of α-globin genes has been established by screening cord blood samples from 1,075 newborn babies. Diagnosis was made by gene mapping of DNA samples with restriction endonuclease digestion. The presence of Hb Bart's was determined with a discontinuous microelectrophoresis on cellulose acetate at pH 8.34. The establishment of this relationship allows an early diagnosis of α-thalassemia by this simple microelectrophoretic procedure.     

Non-Verbal Communication Between Primary Care Physicians and Older Patients: How Does Race Matter?

BACKGROUND  

Non-verbal communication is an important aspect of the diagnostic and therapeutic process, especially with older patients. It is unknown how non-verbal communication varies with physician and patient race.     

The Role of Patient Activation on Patient–Provider Communication and Quality of Care for US and Foreign Born Latino Patients

BACKGROUND

Previous research has shown positive effects of patient activation on healthcare outcomes, but there is practically no information on the generalization of these findings for Latino patients. Little data are available on whether patient activation is associated with healthcare outcomes for Latino patients and whether activation varies by language proficiency and nativity status.

OBJECTIVE

We examined the levels of activation by characteristics of Latino patients (e.g. nativity, language, health status). We investigated whether patient activation relates to the quality of care received and enhanced doctor–patient communication for Latino patients.

DESIGN

We conducted analyses of 1,067 US born and foreign born Latinos who participated in the second wave of the PEW/RWJF Hispanic Healthcare Survey during 2008.

PARTICIPANTS

Participants were self-identified Latinos (18+) with a doctor visit, living in the contiguous United States who could be contacted by telephone.

RESULTS

US born Latinos had significantly (P?<?0.001) greater patient activation scores than foreign born Latinos (75 versus 70). Latinos classified as bilingual and those reporting excellent health evidenced higher mean activation scores as compared to Spanish-speaking Latinos and those reporting fair or poor health. After adjusting for demographics, health status, other language and service use factors, patient activation was strongly associated with self-reported quality of care and better doctor–patient communication among both US and foreign born Latino respondents.

CONCLUSIONS

Interventions that augment patient activation could increase quality of care and improved patient–provider communication, potentially reducing health care disparities for Latinos.

     

The Role of Patients’ Explanatory Models and Daily-Lived Experience in Hypertension Self-Management

BACKGROUND

Uncontrolled hypertension remains a significant problem for many patients. Few interventions to improve patients?? hypertension self-management have had lasting effects. Previous work has focused largely on patients?? beliefs as predictors of behavior, but little is understood about beliefs as they are embedded in patients?? social contexts.

OBJECTIVE

This study aims to explore how patients?? ??explanatory models?? of hypertension (understandings of the causes, mechanisms or pathophysiology, course of illness, symptoms and effects of treatment) and social context relate to their reported daily hypertension self-management behaviors.

DESIGN

Semi-structured qualitative interviews with a diverse group of patients at two large urban Veterans Administration Medical centers.

PARTICIPANTS (OR PATIENTS OR SUBJECTS)

African-American, white and Latino Veterans Affairs (VA) primary care patients with uncontrolled blood pressure.

APPROACH

We conducted thematic analysis using tools of grounded theory to identify key themes surrounding patients?? explanatory models, social context and hypertension management behaviors.

RESULTS

Patients?? perceptions of the cause and course of hypertension, experiences of hypertension symptoms, and beliefs about the effectiveness of treatment were related to different hypertension self-management behaviors. Moreover, patients?? daily-lived experiences, such as an isolated lifestyle, serious competing health problems, a lack of habits and routines, barriers to exercise and prioritizing lifestyle choices, also interfered with optimal hypertension self-management.

CONCLUSIONS

Designing interventions to improve patients?? hypertension self-management requires consideration of patients?? explanatory models and their daily-lived experience. We propose a new conceptual model ?? the dynamic model of hypertension self-management behavior ?? which incorporates these key elements of patients?? experiences.     

Crohn’s Colitis: The Incidence of Dysplasia and Adenocarcinoma in Surgical Patients

Purpose Data supporting an increased risk of colorectal cancer in patients with Crohn’s colitis are inconsistent. Despite this, clinical recommendations regarding colonoscopic screening and surveillance for patients with Crohn’s colitis are extrapolated from chronic ulcerative colitis protocols. The primary aim of our study was to determine the incidence of dysplasia and carcinoma in pathology specimens of patients undergoing segmental or total colectomy for Crohn’s disease of the large bowel. In addition, we sought to identify risk factors associated with the development of dysplasia and carcinoma. Methods We performed a retrospective review of all patients operated on at our institution for Crohn’s colitis between January 1992 and May 2004. Data were retrieved from patient charts, operative notes, and pathology reports. Logistic regression was used to model the probability of having dysplasia or adenocarcinoma. Results Two hundred twenty-two patients (138 females) who underwent surgical resection for the treatment of Crohn’s colitis were included in the study. Mean age at surgery was 41 (range, 15–82) years and the mean duration of disease was 10 (range, 0–53) years. There were five cases of dysplasia (2.3 percent) and six cases of adenocarcinoma (2.7 percent). Three patients with dysplasia and one with adenocarcinoma were diagnosed on preoperative colonoscopy; while the other cases were discovered incidentally on pathologic examination of resected specimens. Factors associated with the presence of dysplasia or adenocarcinoma included older age at diagnosis (38.2 vs. 30.3 years, P = 0.02), longer disease duration (16.0 vs. 10.1 years, P = 0.05), and disease extent (90 percent extensive vs. 59 percent limited, P = 0.05). Conclusions Patients with severe Crohn’s colitis requiring surgery are at significant risk for developing dysplasia and adenocarcinoma, particularly when diagnosed at an older age, after longer disease duration, and with more extensive colon involvement. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005. Reprints are not available     

The Relationships Between States’ DUI Penalties and HIV-Positive Adults’ Drinking Behaviors

Evidence that persons with HIV who reside in states with stricter DUI penalties drink less might suggest that changes to alcohol policy might improve the health of persons with HIV and reduce the rate of new infections. Using multi-level modeling and data from the national HIV Cost and Services Utilization Study, we examined how states’ DUI-related fines, jail time, license suspension, and court-referred treatment/education policies were related to past month drinking/not (n = 2,255) and among drinkers (n = 1,117), drinking frequency, drinks per occasion, and engagement in frequent heavy drinking. Fine strictness was negatively related to all outcomes. Residents in states with court-referred treatment/education had more current drinkers. Results suggested that punitive DUI policies might curb a variety of drinking behaviors whereas harm reduction DUI policies (e.g., court treatment programs) might have been established in response to higher drinking rates.     

Association Between Prior Experiences of Discrimination and Patients’ Attitudes Towards Health Care Providers Collecting Information About Race and Ethnicity

BACKGROUND  Previously, we reported a high level of comfort among Californians for collecting race/ethnicity information by health care providers (HCPs). However, minorities were less comfortable providing race/ethnicity information and were more worried than non-Hispanic whites about the potential misuse of this information. OBJECTIVE  To determine if perceived experiences of discrimination (both in general and in medical care) were associated with comfort providing race/ethnicity information, and conversely, to worry about providing the information. DESIGN AND PARTICIPANTS  Telephone survey of 480 Californians, including 101 whites, 98 Asians, 173 Hispanics, 82 blacks, and 26 multiracial individuals. MEASUREMENTS  Comfort level giving HCPs information about race/ethnicity (measured on a 1–10 scale, with text anchors of “very uncomfortable” at 1 and “very comfortable” at 10), worry that the information could be used to discriminate against patients, and worry that the information could be used to find undocumented immigrants. Worry was measured using a four-point Likert scale- not worried at all, a little worried, somewhat worried, and very worried. Respondents were also asked about perceived discrimination in general and perceived discrimination in medical care. RESULTS  Compared to whites, Hispanics (Beta-coefficient (BC) = -1.16, SE = 0.51) and Mandarin/Cantonese-speaking Asians (BC = -1.40, SE = 0.65) reported significantly less comfort giving HCPs information about their race/ethnicity, while blacks (BC = 0.70, SE = 0.16), Hispanics (BC = 0.91, SE = 0.18), and multiracial individuals (BC = 0.63, SE = 0.24) were significantly more worried that race/ethnicity information could be used to discriminate against them. Adjusting for perceived experiences of discrimination in general and in medical care partially explained the higher discomfort and worry among minorities. CONCLUSIONS  Perceived experiences of discrimination are associated with greater discomfort and worry about providing race/ethnicity data. Health care institutions should consider how they can address the public’s concerns about possible misuses of data.     

Differences in Yeast Intolerance Between Patients with Crohn’s Disease and Ulcerative Colitis

Purpose Alimentary factors, especially those modifying the intestinal flora, may influence the course of inflammatory bowel disease. It is known that T and B cells of patients with Crohn’s disease can be stimulated with the yeast antigen, mannan. We evaluated the impact of eating habits with special respect to food containing yeast on the course of inflammatory bowel disease. Methods Questionnaires were sent to 180 German-speaking patients of the Inflammatory Bowel Disease Outpatient Clinic at the University Hospital Bern, Switzerland. The following information was obtained by the questionnaires: (1) course of disease, (2) eating habits, (3) environmental data, and (4) inflammatory bowel disease questionnaire. The survey was anonymous. Results A total of 145 patients (80.5 percent 95 with Crohn’s disease, and 50 with ulcerative colitis) responded. Food items containing yeast were better tolerated by patients with ulcerative colitis than by patients with Crohn’s disease. A significant difference between the two groups was observed concerning food containing raw yeast (dough, P = 0.04; and pastry, P = 0.001). Conclusions Food items containing raw yeast led to more frequent problems for patients with Crohn’s disease than for patients with ulcerative colitis. This observation supports our previous data, which showed the stimulatory effect of the yeast antigen, mannan, on B and T cells of patients with Crohn’s disease but not of controls. Poster presentation at Digestive Disease Week (DDW), organized by the American Gastrointestinal Association, Chicago, Illinois, May 14 to 19, 2005.     

Hypothesis Discrepancy Between Intra- and Interpopulation Studies of the Relationship Between Dietary Salt and Blood Pressure: Fact or Fiction?

It is a paradox that intra-population studies fail to show significant correlation between sodium excretion and blood pressure while a clear relationship exists in cross-cultural studies. Since daily variation of sodium excretion is high, the discrepancy between the two observations could be due to non -comparable data on sodium excretion. This is a discussion of the hypothesis that the finding of a significant correlation or not between sodium excretion and blood pressure depends on the statistical analysis of the data.