Nonemergent ED patients referred to community resources after medical screening examination: characteristics, medical condition after 72 hours, and use of follow-up services.

INTRODUCTION: Limited access to medical care has resulted in large numbers of patients seeking primary care for non-emergent emergency conditions in emergency departments. This influx of patients is contributing to overcrowding and delays in care for patients with emergencies. In response, a system was implemented in which persons with non-emergent medical conditions, following a medical screening examination, did not receive further ED assessment or treatment and instead were referred to community resources. The purpose of this study was to describe the characteristics of individuals who were referred to community-based services, their condition after 72 hours, and their use of follow-up health care services. METHODS: All referred cases (n=225) were reviewed for chief complaint and demographics. Phone contact was attempted after 72 hours to determine the person's condition and if community resources were utilized. RESULTS: Of the 225 cases, 52% were female, with a mean age of 33 years. Their most common chief complaints were extremity problems (16%), toothache (9%), and medication refill (8%). Follow-up phone contact was successful with 82 people (37%) an average of 14 days after their ED visit. The majority (55%) reported their condition had improved; 39%were unchanged, and 6% were worse. Thirty-one people(40%) accessed community resources and 8 (26%) returned to another emergency department. No clinically significant associations were found between patient demographics and use of community resources. DISCUSSION: Most people who were successfully contacted for follow-up and who had come to the emergency department with non-emergent chief complaints did not access community resources and their condition frequently improved. Additional studies, with improved follow-up, are needed before suggesting that referring individuals to community resources is an acceptable practice.     

Control of reach extent with the paretic and nonparetic arms after unilateral sensorimotor stroke: kinematic differences based on side of brain damage

Scaling of reach kinematics to targets that vary in distance is indicative of the use of planning and feedback-based adjustments. The control of reach extent, however, has not been reported for the paretic arm after stroke. The purpose of this study was to determine whether individuals post-stroke utilized planning (scaling acceleration magnitude) and feedback-based adjustments (scaling acceleration duration) to reach to targets that varied in distance. Individuals with mild-to-moderate motor impairment after stroke and nondisabled adults reached with both arms to targets presented at three distances (8, 16, 24 cm). Kinematic data were used to determine scaling of peak acceleration magnitude and duration to target distance and compared between arms (control, nonparetic, paretic). Despite differences in the magnitude of movement variables, individuals post-stroke utilized both planning and feedback-based adjustments to meet the demands of the task with the nonparetic and paretic arms in a similar manner as controls. However, there was variability in the use of planning with the paretic arm, some individuals utilized planning while others did not. After right brain damage, differences in reach control related to the specialized role this hemisphere plays in endpoint control were found in both arms; no hemisphere-specific changes were found after left brain damage (LBD). The appearance of hemispheric-specific effects after right but not LBD were not due to age, degree of motor impairment, or time post-stroke, but, instead, may be related to relative differences in visual-motor processing ability, lesion characteristics, or interhemispheric inhibition changes between groups.     

NMR‐based approach to the analysis of radiopharmaceuticals: radiochemical purity,specific activity,and radioactive concentration values by proton and tritium NMR spectroscopy

Compounds containing tritium are widely used across the drug discovery and development landscape. These materials are widely utilized because they can be efficiently synthesized and produced at high specific activity. Results from internally calibrated ³H and ¹H nuclear magnetic resonance (NMR) spectroscopy suggests that at least in some cases, this calibrated approach could supplement or potentially replace radio‐high‐performance liquid chromatography for radiochemical purity, dilution and scintillation counting for the measurement of radioactivity per volume, and liquid chromatography/mass spectrometry analysis for the determination of specific activity. In summary, the NMR‐derived values agreed with those from the standard approaches to within 1% to 9% for solution count and specific activity. Additionally, the NMR‐derived values for radiochemical purity deviated by less than 5%. A benefit of this method is that these values may be calculated at the same time that ³H NMR analysis provides the location and distribution of tritium atoms within the molecule. Presented and discussed here is the application of this method, advantages and disadvantages of the approach, and a rationale for utilizing internally calibrated ¹H and ³H NMR spectroscopy for specific activity, radioactive concentration, and radiochemical purity whenever acquiring ³H NMR for tritium location.     

Health care decision making in southern county

We combine two standard approaches to analyze power and influence in health policy formulation within a moderately large county in the south. Intrinsic methodologic weaknesses are discussed and several conclusions are drawn regarding power in the health care sector of that community. The most significant finding is the shift in power over time, away from the individuals to committees and health care organizations. The ignorance of most physicians about the broader health care issues that affect the community was reflected in their lack of recognition by others in the community as influential decision makers. The insular relationship of the university to the rest of the community was also noted. Past racial politics had a continuing effect on later health policy formulation. These findings are discussed in light of current and past issues. Because we had promised confidentiality to the persons we interviewed, fictitious names were given to the county, the institutions, and the interviewees.     

The EXCITE trial: attributes of the Wolf Motor Function Test in patients with subacute stroke

The Wolf Motor Function Test (WMFT) has been used in rehabilitation studies of chronic stroke patients, but until now its psychometric properties have not been evaluated in patients with subacute stroke. Two hundred twenty-nine participants with subacute stroke (3-9 months postinjury) at 7 research sites met inclusion criteria for the EXCITE Trial and were randomized into immediate or delayed (by 1 year) constraint-induced movement therapy treatment. All evaluations were undertaken by assessors standardized in the administration of the WMFT and masked to treatment designation. Participants were also assessed using the Fugl Meyer Motor Assessment (FMA). Delayed group members had measurements repeated 2 weeks following baseline assessment to determine learning or exposure effects. The results demonstrate that the WMFT differentiated higher from lower functioning participants across sites; scores were uninfluenced by hand dominance or affected side. Women exhibited slower performance times than men. The Functional Ability scale (FAS) portion of the WMFT also revealed lower scores among lower functioning participants and women. Minimal changes were observed after repeating the WMFT among delayed group participants 2 weeks later. The FMA revealed similar results when the total group was divided into higher and lower functional levels at its midpoint score of 33. The WMFT discriminates higher from lower functioning participants tested across research sites. Comparable findings using the FMA support the criterion validity of the WMFT.     

Sensory cueing effects on maximal speed gait initiation in persons with Parkinson's disease and healthy elders

Researchers have suggested that sensory cues can improve gait initiation in persons with Parkinson's disease (PD); however, there is little research that documents the effects of sensory cues on gait initiation. The purpose of this study was to examine the effects of auditory and cutaneous sensory cues on maximal speed gait initiation in person's with PD and healthy elderly. Seven persons with PD of moderate severity (mean AGE=69 years) and seven age, gender, and height matched healthy elders participated. Temporal, kinematic and center of pressure (COP) data were recorded as participants performed eight trials within four randomly ordered conditions (no cue (NC), a single auditory cue (SA), repetitive auditory cues (RA), and repetitive cutaneous cues (RC)). In each condition, participants were instructed to perform each gait initiation trial at their maximal speed. In all conditions, person's with PD reacted more slowly and moved less far than did the matched elders. Relative to conditions with NCs, sensory cueing resulted in decreased double limb support (DLS), and increased COP displacement and velocity in both groups. However, in both groups, displacements and velocities of the swing limb and sacrum during the sensory-cued conditions were less than those during the NC condition. These results suggest that when movement speed is a primary goal, sensory cues may interfere with swing limb and body movement outcomes during the gait initiation task in both person's with PD and healthy elders.     

Hemispheric specialization in the co-ordination of arm and trunk movements during pointing in patients with unilateral brain damage

During pointing movements involving trunk displacement, healthy subjects perform stereotypically, selecting a strategy in which the movement is initiated with either the hand or trunk, and where the trunk continues after the end of the hand movement. In a previous study, such temporal co-ordination was not found in patients with left-hemispheric brain lesions reaching with either their dominant paretic or with their non-dominant non-paretic arm. This co-ordination deficit may be associated in part with the presence of a lesion in the dominant left hemisphere. If so, then no deficit should be observed in patients with stroke-related damage in their non-dominant right hemisphere moving with their ipsilesional arm. To verify this, 21 right-hand dominant adults (7 who had had a stroke in the right hemisphere, 7 who had had a stroke in the left hemisphere and 7 healthy subjects) pointed to two targets located on a table in front of them in the ipsilateral and contralateral workspace. Pointing was done under three movement conditions: while not moving the trunk, while bending the trunk forward and while bending the trunk backwards. The experiment was repeated with the non-paretic arm of patients with stroke and for the right and left arms of healthy subjects. Kinematic data were recorded (Optotrak). Results showed that, compared to healthy subjects, arm-trunk timing was disrupted in patients with stroke for some conditions. As in patients with lesions in the dominant hemisphere, arm-trunk timing in those with lesions in the non-dominant hemisphere was equally more variable than movements in healthy subjects. However, patients with dominant hemisphere lesions used significantly less trunk displacement than those with non-dominant hemisphere lesions to accomplish the task. The deficit in trunk displacement was not due to problems of trunk control or sitting balance since, in control experiments, all subjects were able to move the trunk the required distance, with and without the added weight of the limb. Results support the hypothesis that the temporal co-ordination of trunk and arm recruitment during pointing movements is mediated bilaterally by each hemisphere. However, the difference in the range of trunk displacement between patients with left and right brain lesions suggests that the left (dominant) hemisphere plays a greater role than the right in the control of movements involving complex co-ordination between the arm and trunk. Electronic Publication     

Methods for a multisite randomized trial to investigate the effect of constraint-induced movement therapy in improving upper extremity function among adults recovering from a cerebrovascular stroke

This article describes the study design, methodological considerations, and demographic characteristics of a phase III RCT to determine if 1) constraint-induced therapy (CI therapy) can be applied with therapeutic success 3 to 9 months after stroke across different sites, 2) gains that might occur persist over 2 years, 3) initial level of motor ability determines responsiveness to CI therapy, and 4) the treatment effect differs between those treated before 9 months and after 1 year. Six sites will screen and recruit poststroke survivors stratified on initial level of motor ability and after randomization allocate participants to immediate or delayed intervention. Primary outcomes include a laboratory-based measure of function (Wolf Motor Function Test [WMFT]) and a real-world participant-centered functional use measure (Motor Activity Log [MAI]). Secondary outcomes concern function, behavior, and compliance. This is the first multisite, single-blind RCT of a formal training intervention for upper extremity rehabilitation in subacute stroke in the United States.