The 14th Annual Clinical and Professional Poster Session, coordinated by AAPA's Clinical and Scientific Affairs Council (CSAC), features abstracts in three categories: original research, case studies/clinical reports, and posters previously presented at medical or scientific conferences. The session consists of three galleries: one depicting posters presented by fellow members, another displaying posters created by PA students, and the third focused on PA education.
The poster session highlights the unique research that PAs, PA faculty, and PA students have accomplished during the past year and provides an excellent venue for extended informal discussion with meeting attendees.Posters listed alphabetically by title.
Oral Presentations
No. Title and Authors
1 Diabetic Limb Infections: An Analysis of Causative Organisms per Level of Infection. E. Simolke, M. Cunningham, R. Silberman, and J.W. Bellew
2 Horse-related Injuries and Deaths in Western Montana. B. A. Matheson, H. Parsons, S. Otoupalik, and J. B. Pickhardt
3 Teen Pregnancy: The PA's Perception of Their Role in Teen Counseling. R. Williams, O. Chen, and P. Pagels
CLINICAL AND PROFESSIONAL GALLERY
Original Research
No. Title and Authors
4 A Prospective, Randomized Evaluation of the Restore® Soft Tissue Implant in Rotator Cuff Repair. D. Rivenburgh and P. Davidson
5 An Evaluation of Prognostic Factors in a Prospective Cohort of Patients with Metastatic Renal Cell Carcinoma. T. Lawrence, S. Scott, and L. Pisters
6 Global Applicability of Physician Assistants. MM. Le?ger, R. McNellis, C. Legler, and D. Faringher
7 Old and Sleeping Rough: Elderly Homeless Persons on the Streets of Boston. J. Roncarati and J. O'Connell
8 Overview of Physician Assistants Working in Urology. J. Matthews and P. Langenstroer
9 Physician Assistant Rheumatology Fellowship to Meet the Demands for Arthritis Management. R. Hooker and S. Kazi
10 Patient Satisfaction with Physician Assistant, Nurse Practitioner, and Physician Care: A National Survey of Medicare Recipients. R. Hooker and D. Cipher
11 Physician Assistant and Nurse Practitioner Prescribing: 1997-2001. R. Hooker and D. Cipher
12 Physician Assistant Holland Occupational Codes. D. LaBarbera
13 Sleeping Rough in Boston: A Five-year Observational Study of a Cohort of Chronically Homeless Persons Living on the Streets of Boston, 2000-2004. J. Roncarati, J. O'Connell, C. Kane, and J. Allen
14 Soda Drinking Habits of Academy Students. K. Bourne, J. Mathey, C. Chareon, J. Dovre, and A. Cevallos
15 The Effects of Early Patient Education on Immunization Rates of Infants in Galveston County. T. Bigler and K. Stephenson
Case Studies/Clinical Reports
No. Title and Authors
16 A Novel "Four-Rod Technique" for Lumbopelvic Reconstruction: Theory and Technical Considerations. F. Shen, M. Harper, W. Foster, and I. Marks
17 A Rare Non-malignant Testicular Mass. M. Gould and V. Quintanilla
18 An Unusual Kidney Stone. M. Gould
19 Carpectomy and Reconstruction of Anterior Vertebral Body Tumors with an Expandable Cage through a Posterior-only Extracavitary Approach. F. Shen, S. Bhattacharjee, I. Marks, and M. Harper
20 Healthcare Delivery: A New Model to Replicate. S. Cohen, D. Parkhurst, C. Evans, and N. Soto
21 Metastatic Penile Carcinoma: A Rare Case. V. Quintanilla
22 Multiple Simultaneous Peripherally Inserted Central Catheters (PICCs) in Pediatric Critical Care Patients: A Novel Approach to the Need for Additional Vascular Access. C. Newman and J. Graf
23 Spontaneous Resolution of a Chiari I Malformation. J. Royo, T. Solomon, and R. Konen
24 Tantalum Trabecular Metal Spinal Interbody Implant for Vertebral Body Replacement: A Case Study. K. Toftey Scheffler
25 Use of Lidocaine 5% Patches for Persistent Sacroiliac Joint Dysfunction: A Retrospective Study. K. Toftey Scheffler
Previously Presented
No. Title and Authors
26 Exaggerated Pressor Responses to Apnea in Patients with Obstructive Sleep Apnea. J. Hardisty, J. Burk, and M. Smith
27 The Interrelationships between Length of Stay, Methadone Dosage, and Age at an Urban Opioid Treatment Program. C. Madray, L.S. Brown, M. Chu, and S. Kritz
EDUCATION GALLERY
Original Research
No. Title and Authors
28 Accidental Exposures of Physician Assistant Students. D. LeBarbera, J. Haan Riesman, J. Adams, and E. Ambrozevicius
29 An Assessment of the Effects on Learning of an Audience Response System in a Physician Assistant Program Classroom. D. Irvine
30 Development of a Standardized Set of Criteria to Be Used in Evaluation Across Multiple Health Professions Educational Programs. P. Dieter, V. Kaprielian, and J.K. Richardson
31 Key Points: Improving Student Retention of Lecture Content. R. Cupp, G. Landel, and K. Wick
32 Living Well with Health Conditions. W. Kennedy, E. Kennedy, D. Southard, and A. Southard
33 Medical Informatics in Clinical Education: Using PDAs in Patient Logging. D. Day, A. Griffin, C. Fox, and A. Huckstadt
34 Standardized Patients as Evaluators. B. Calhoun and D. Grzybicki
Previously Presented
No. Title and Authors
35 Integration of a Long-term Care Experience into Physician Assistant Education. D. Coniglio, P. Dieter, J. Copeland, and P. Castillo
STUDENT GALLERY
Original Research
36 Attitudes of Physician Assistants Toward Nutrition Education and Nutrition Issues Encountered in Clinical Practice. H. Coker, O. Chen, and P. Smith-Barbaro
37 Comparison of Empathy Scores in Physician Assistant Students and Physician Assistants in Clinical Practice. J. Altland, R. Fedor, C. Leatherman, J. Spencer, and B. Biearman
38 Developing an Academic Medicine Rotation in a Physician Assistant Program. C. Elinsky and G. Furey
39 Efficacy of a Multidisciplinary, Family-based, Weight Control Program and the Role of Incentives for Physical Activity in Improving Outcomes for Obese Children. A. Prudhomme, J. Mickow, D. LaBarabera, and V. Hammarlund
40 Evaluating Health Care Delivery to Patients of Limited English Proficiency at Abington Memorial Hospital. A. Casimir, M. O'Brien, and D. Schneider
41 Factors Influencing Physician Assistants to Practice in Pediatric Specialties. J. DeSocio, P. Pagels, and O. Chen
42 GEMS: Group Education of Metabolic Syndrome. G. Moyer, E. Hillier, S. Eli, and B. Biearman
43 Knowledge of Suicide Risk Factors in the Elderly: A Survey of Second-year Physician Assistant Students. C. Hayes, B. Wolf, and B. Biearman
44 The Impact of the Physician Assistant Student's Clinical Experiences on the Physician Assistant National Certifying Exam Blueprint and Physician Assistant National Certifying Exam Scores. A. Protzik, C. Marzano, C. McCaffrey, A. Zella, and B. Biearman
Case Studies/Clinical Reports
45 Maisonneuve Fracture in a 17-year-old Male. S. Muller, M. Vacala, and L. Martin
Oral Presentations
1. Diabetic Limb Infections: An Analysis of Causative Organisms per Level of Infection
E. Simolke, M. Cunningham, R. Silberman, and J.W. Bellew, Louisiana State University Health Sciences Center, Bossier City, Louisiana
Purpose: To aid in the establishment of an effective treatment regimen for diabetic limb infection, this study sought to examine differences in the incidence of typical microorganisms per level of diabetic lower extremity infection.
Methods: This was a prospective study of 94 patients at a hospital-based diabetic limb and wound care clinic during the period 1999-2002. Initial presentation of each wound infection was classified as mild, moderate, or severe, using a previously reported scale for diabetic foot infections. Mild infections were identified as being superficial, localized cellulitis with no systemic signs; moderate as abscess with cellulitis to the ankle and low-grade fever with increased white blood cell count (WBC); and severe infections as having sepsis with high fever, tissue gas, and proximal spread into leg. Anaerobic and aerobic cultures were obtained prior to antibiotic therapy by means of tissue culture when tolerated by the patient. Otherwise, a swab or aspirate was obtained. Transport of specimen to the lab within 72 hours was completed via a standard tube with reducing agents and resazurin in a buffered isotonic agar base. All culture results, sensitivities, culture technique, wound location, and description were entered onto data sheets. Types and incidence of 23 different organisms present in each infection classification were recorded. To assess differences in incidence of organisms per level of diabetic lower extremity infection, a 2 x 3 Chi Square analysis of frequency distribution was performed (organism present or not-present x infection classification).
Results: There were 94 total patients with limb infections: 27 mild, 54 moderate, 13 severe. Sixty-four isolates were collected by means of curettage, 20 by swab, and 11 by aspirate. Statistically significant difference in incidence of organism between infection classes was observed with bacteroides-prevotella species (p=.030), with a 31% incidence in the severe group versus only 3.7% and 9% in the mild and moderate groups. Likewise, strep agalactia showed a significant difference in incidence (p=.009), with 37% and 46% in the moderate and severe groups versus only 7.4% in the mild. The only other organism showing a significantly different incidence was group G streptococcus (p=.030), with 15.4% in the severe group versus 7% and 0% in the mild and moderate groups. Although not significant but of clinical interest, 44% of all 94 patients presented with staph aureus, with 11% being methicillin resistant staph aureus (MRSA). Of all patients, 56% presented with streptococcus, with strep agalactia being the most predominant species of strep at 30%.
Conclusion: There appears to be a higher prevalence of streptococcus species and anaerobes such as bacteroides-prevotella in severe infections. Furthermore, most diabetic foot infections presenting to our diabetic limb and wound care facility are polymicrobial with a predominance of staph aureus and streptococcus. Our rate of MRSA is alarmingly high, secondary to the fact that these patients presented from the community prior to antibiotic therapy. We conclude that initial presentation of diabetic foot infections should have broad antibiotic coverage, including coverage for anaerobes, especially in the case of severe limb and life-threatening infections.
2. Horse-related Injuries and Deaths in Western Montana
B. A. Matheson, H. Parsons, S. Otoupalik, and J. B. Pickhardt, St. Patrick Hospital, Missoula, Montana
Purpose: The purpose of this study is to identify the number, type, severity, and cause of horse-related injuries and deaths that presented to the emergency departments of 16 hospitals in western Montana. The information and knowledge gained is to be incorporated into an equestrian injury prevention program, with the ultimate goal of decreasing the incidence and severity of horse-related injuries and deaths in western Montana.
Methods: Sixteen hospitals voluntarily participated in this multi-center, retrospective, descriptive study of horse-related injuries in western Montana from 2002 to 2004. Included were 16 hospitals represented in the Western Regional Trauma Advisory Committee (WRTAC). Each hospital was given a copy of the description of the study and data-gathering worksheets. The health care provider caring for a patient presenting with a horse-related injury completed the worksheet. Data points collected included: initial treating facility, date of injury, age, mode of arrival, gender, safety equipment, disposition, injuries, and cause of injury. Data was compiled and analyzed by a multidisciplinary team.
Results: A total of 630 patients were included in the study, with 849 documented injuries. 55% were female and 45% male. Mean age was 37.2, with a standard deviation of 18 and range of 2-84. 92% were not wearing protective equipment and 8% were wearing protective equipment (helmet or Kevlar vest). The most common cause of injury was being bucked off (40%). 24% were not mounted on their horse when the injury occurred. 71% were discharged home from the emergency department, while 18% were admitted to the treating medical facility, 7% were transferred to a higher level of care, and two patients died. The most common injuries were extremity (37%), followed by head/neck (23%), chest (14%), pelvis (7%), abdomen (5%), and other (14%). All deaths were due to central nervous system injury. 20% presented to the emergency department via EMS. 27% required admission to a hospital.
Conclusion: Horse-related injuries comprise a significant number of emergency department visits in western Montana. Velocity of travel, height of the rider off the ground, and unpredictability of the animal all lend themselves to potential for serious injury. Medical providers should have a high index of suspicion for severe multi-system injury. Protective equipment is underutilized in western Montana. Although protective equipment would not likely decrease the most common injuries (extremity), they could potentially decrease the severity of life-threatening injuries (central nervous system and chest injuries). With nearly one-quarter of injuries resulting when the rider is not mounted on the horse, health care providers should encourage use of protective equipment when working around horses as well as when riding. Injury prevention programs stressing the potential severity of injuries, benefits of protective equipment, and indications to employ EMS must be made available to equestrians. Further investigation into the causes of equestrian accidents as well as reasons for underutilization of protective equipment should be considered.
3. Teen Pregnancy: The PA's Perception of Their Role in Teen Counseling
R. Williams, O. Chen, and P. Pagles, University of North Texas Health Science Center at Fort Worth, Fort Worth, Texas
Purpose: This study explored of physician assistants' (PA) perceptions on their role in counseling adolescents and their families on pregnancy prevention. The specific research questions were: (1) Do PAs believe that it is their responsibility to provide preventive counseling to adolescent patients and their families in regard to pregnancy prevention? (2) Do PAs believe that they are qualified to deliver preventive counseling? (3) How often do PAs deliver pregnancy prevention counseling to adolescents and/or their families? (4) In what settings are PAs most likely to provide this type of intervention?
Method: The researchers constructed a 21-item survey to collect the data. The survey was pilot-tested by three practicing PAs. The researchers then sent out e-mails to invite 951 practicing PAs, who are all current members of the Texas Association of Physician Assistants, to participate in this study. The e-mail contained a link to a Web site that housed the electronic survey. A follow-up e-mail was sent to the same potential respondents three weeks later. The Web site that hosted the survey remained accessible for a total of four weeks (Sept-Oct 2003). SPSS (11.0) software was used to perform Chi Square for testing statistical significance.
Results: 214 PAs responded to the survey (33% response rate). The overall demographic profiles of these respondents were very similar to AAPA's 2003 census (63% of the respondents were women, 50% of the respondents were practicing in a primary care setting, and 17% of the respondents were practicing in a rural area). Results of this study showed that: (1) 99% of the respondents agreed that it is the PA's responsibility to deliver teen pregnancy preventive counseling, and 86% of the respondents agreed that preventive counseling is an effective way of curbing adolescent pregnancy rates; (2) 85% of the respondents felt that they have the skills to deliver this counseling to adolescents, and 89% of the respondents felt comfortable delivering such messages; however, only 63% of the respondents reported that they have received training focused specifically on adolescent STD/HIV/pregnancy prevention; (3) 83% of the respondents reported that they provided teen pregnancy preventive counseling to less than one quarter of the adolescent patients and/or their families; (4) PAs who provided higher rates (>25%) of preventive counseling to adolescent patients were PAs who practice in a federally underserved setting (X2=22.63, p<.01), have higher adolescents populations in their practicing areas (X2=77.01, P<.01), practice in primary care (X2=84.69, P<.001), practice in a rural setting (X2=9.93, P<.01), and have specific training in STD/HIV/pregnancy prevention (X2=10.24, P<.01).
Conclusions: The results of this study showed that currently only about 17% of the PAs provided teen pregnancy preventive counseling to the adolescent patients and/or their families; but a high percentage of the PAs agreed that they should be actively involved in this type of counseling. Another result showed that there was a discrepancy between the PAs' confidence level of providing the teen pregnancy preventive counseling and the appropriate training they have received. Future research should focus more on exploring this discrepancy.
CLINICAL AND PROFESSIONAL GALLERY
Original Research
4. A Prospective, Randomized Evaluation of the Restore® Soft Tissue Implant in Rotator Cuff Repair
D. Rivenburgh and P. Davidson, Tampa Bay Orthopedic Specialist, Inc., Pinellas Park, Florida
Introduction: Rotator cuff repair reinforced with an orthobiologic soft tissue scaffold (Restore®-DePuy) was evaluated in a prospective, randomized, controlled study.
Method: 43 patients were randomized into either a trial group, which underwent a Restore® reinforced rotator cuff repair, or a control group, with no reinforcement. Patients underwent pre- and postoperative evaluation with standardized measurement tools and MRI scanning. Minimum follow-up was one year. An arthroscopic-assisted, mini-open repair technique was utilized. Patients in the treatment group had a Restore® patch sewn circumferentially around the repair construct.
Results: Preoperative trial and control results were similar. At every postoperative interval, the trial group, with the Restore® implant, maintained higher Constant and SST scores than the control group. Mean Restore®/Control Constant scores were 70.1 and 64.5 (p=0.23); mean SST scores were 10.1 and 8.3 (p=0.19). Two of three trial pain means were superior, but not statistically significant. All trial strength means were higher, but none was statistically significant. Trial group means were higher in 5 of 6 ROM measures, including active forward elevation (156° versus 132°, p=0.02) and active external rotation (50.9 versus 37.2, p=0.07).
Discussion/Conclusion: The Restore® soft tissue augmentation patch enhanced outcomes of mini-open rotator cuff repair in our study population. In 13 of 15 planned comparisons those patients repaired with the Restore® soft tissue augmentation patch achieved higher mean scores than the control group. No trends or statistically significant results were observed favoring the control group.
This study demonstrated enhanced outcome of rotator cuff repair using a xenographic augmentation patch.
5. An Evaluation of Prognostic Factors in a Prospective Cohort of Patients with Metastatic Renal Cell Carcinoma
T. Lawrence, S. Scott, and L. Pisters, Pearland, Texas
Introduction: Renal cell carcinoma has a poor prognosis in patients who develop metastatic disease, a diagnosis made in about a third of patients at first presentation. Currently, radical nephrectomy is the standard treatment for localized disease and in selected patients with metastatic disease. There is a relatively high resistance to chemotherapy for renal cell carcinoma. Trials of immunotherapy have shown some response but poor long-term durability. However, because this therapy is associated with high toxicity, patient selection obviates the need for identification of sound, demonstrable prognostic factors for risk stratification and prediction of treatment outcome. Prognostic indicators have been suggested, based on retrospective analysis of patients in a variety of medical centers. However, very few of these factors have been evaluated in a well-characterized, prospective cohort of patients.
Objectives: This prospective study evaluated previously reported prognostic indicators for survival in patients with metastatic renal cell carcinoma and compared these factors to determine which ones had independent prognostic value.
Methods: A chart review of a prospective cohort of patients consisting of the first 202 patients enrolled in a multicenter psychosocial study with a diagnosis of metastatic renal cell carcinoma was completed to evaluate distribution of metastatic disease, number of metastatic sites, location of metastatic disease, and labs at presentation (hemoglobin, calcium, albumin, and alkaline phosphatase) by subsequent statistical analyses. Endpoints of disease recurrence and death due to cancer were also reviewed to assess the prognostic value of each individual factor.
Results: Three factors were determined to have prognostic significance in predicting shorter survival of patients with metastatic renal cell carcinoma; namely, two or more metastatic sites (p=0.0075), liver metastases (p=0.0060), and elevated alkaline phosphatase (p=0.0065).
Conclusion: The number of metastatic sites, presence of liver metastases, and elevated alkaline phosphatase were found to be statistically significant prognostic factors in determining a shorter time to death for patients with metastatic renal cell carcinoma. This information can be used to counsel patients, follow treatment outcome, and stratify patients in the design of clinical trials.
6. Global Applicability of Physician Assistants
MM. Leger, R. McNellis, C. Legler, and D. Faringher, American Academy of Physician Assistants, Alexandria, Virginia
Background: In the mid 1960s, U.S. physicians and policymakers recognized a shortage of primary care physicians. In response, a new category of health care worker, the physician assistant (PA), was conceived to expand the delivery of quality medical care. Today, there are nearly 51,000 practicing PAs. The PA model exists internationally both historically and currently. However, the definition of PAs differs between countries and the concept is not uniformly applied.
Methods: The American Academy of Physician Assistants (AAPA) maintains an international country database, which is updated on a quarterly basis. Information is gathered from members of AAPA's Committee on International Affairs, PA educators, PAs in clinical practice, and AAPA staff.
Results: Information collected during January 2000-January 2004 was reviewed. Twenty-two countries, five countries each in Europe and Asia, four countries each in Africa and North America, one from South America, and three from Australia/Oceania, have either hosted workforce conferences on the PA profession, have formal affiliations with U.S. PA programs, or have hosted U.S. PA students. Others are actively examining the U.S. model, are utilizing U.S.-trained PAs in pilot programs, or currently have or will start a PA program within the next year.
Conclusion: In the U.S., the PA concept has grown and evolved since its origin. AAPA's database reflects extensive PAs activities in other countries. Many nations throughout the world are exploring or re-exploring the PA concept as a way to quickly and efficiently train and employ highly autonomous and flexible health workers to address their nation's health care needs.
7. Old and Sleeping Rough: Elderly Homeless Persons on the Streets of Boston
J. Roncarati and J. O'Connell, Boston Health Care for the Homeless Program, Boston, Massachusetts
Purpose: Homelessness in the waning years of life is a personal tragedy and a societal disgrace. Little is known about older individuals struggling to live out their days in parks, down back alleys, and under bridges. In order to improve our understanding of this vexing sub-group of older homeless persons, we prospectively followed 30 elderly individuals living on Boston's streets during the five-year period 2000-2004.
Methods: The Boston Health Care for the Homeless Program's (BHCHP) Street Team has cared for more than 800 individuals living on the streets of Boston each year. In January 2000, a cohort of 30 persons aged 60 or older was identified, including eight (27%) women and 22 (73%) men. The ages ranged from 60 to 82 years, with an average of 67 years. 28 (93%) had been homeless for at least a decade, of whom 14 (47%) had been homeless for more than two decades. The remaining two persons had been episodically homeless for more than five years. All 30 suffered from multiple chronic medical illnesses; 22 (73%) had documented DSM-IV diagnosis (7 (23%) schizophrenia, 6 (20%) bipolar disorder, 1 (3%) with OCD, 8 (27%) with either anxiety disorder or depression); and 17 (57%) had active substance abuse. Contact data is recorded on each patient at a weekly Street Team meeting. Other data sources include BHCHP´s electronic medical record, hospital records at MGH and BMC, and a supplemental street database maintained by the team.
Results: Ten (33%) individuals died: 9 men and one woman. Six of the decedents were men still living on the streets at the time of their deaths. Two deaths were traumatic: one suffered head trauma in an assault, while another was crushed by a car that overturned while he was sleeping next to a Jersey barrier. The other four men died of complications of chronic medical problems. One with advanced cirrhosis was found in a park after succumbing to a hemorrhage from esophageal varices. Another with advanced diabetes was found in a park and later died of sepsis. One man with COPD was found unconscious outside a shelter and later died in the ICU of aspiration pneumonia. The oldest member of this cohort died of heart failure at 82 years. The four other deaths occurred in persons who had been placed in nursing homes. At the end of five years, five men and three women are in nursing homes. Only five (17%) have been successful in finding stable housing. Of the remaining eight persons, seven (23%) remain on the streets after five years and one has been lost to follow-up.
Conclusions: The high morbidity and mortality among this cohort of 30 elderly rough sleepers poses significant challenges to those seeking to provide housing and health care services for this vulnerable subgroup of homeless persons and goals to continue to improve continuous primary care, despite marked difficulties in reaching out to this very elusive population is imperative.
8. Overview of Physician Assistants Working in Urology
J. Mathews and P. Langenstroer, Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin
Introduction: In the current cost-constrained medical environment, physician extenders can provide cost-efficient, high quality medical care. Physician assistants (PAs) are health care professionals licensed to practice medicine with physician supervision. With the team concept of the physician-PA relationship, the physician assistant is allowed to exercise medical decisions and provide a broad range of diagnostic and therapeutic services. The objective of this study is to analyze the scope of PA's working in urologic practices.
Methods: A nationwide survey was mailed to all known PAs working in urology practices. PA demographics included the type of practice, years in urology, gender, age, and educational level. We also evaluated the role of the PA in common urological procedures, i.e., cystoscopy and transrectal ultrasound with prostate needle biopsy, and their level of training and supervision associated with these procedures.
Results: 347 surveys were mailed and 207 (60%) were returned. Of these, 193 (93%) were working in urologic practice. The study cohort was comprised of 116 (60%) male and 77 (40%) female, with a mean age of 41. The practice distribution for the responding urologic PAs revealed 47% urology group practice, 16% academic, 16% solo practice, 12% government/military, 6% multiple specialty group, 2% hospital, and 1% unknown. Most, 75%, of the urology PAs have been practicing 10 years or less, with 91% having received either a bachelor's or master's degree. 26% of PAs report performing cystoscopy or transrectal ultrasound with prostate needle biopsy. The indications for these procedures were variable and practice specific. Both procedures were primarily supervised on an as-needed basis by a physician, with cystoscopy having the highest percentage of direct physician supervision (49% vs. 26%), compared to transrectal ultrasound and prostate needle biopsy.
Conclusions: The PA can play a vital role in urologic practices. This national survey acknowledges the team concept in the relationship between the physician and the physician assistant. The physician assistant is able to contribute to the urology practice by performing routine clinical activities and common urologic diagnostic procedures, which historically had been reserved for the physician.
9. Physician Assistant Rheumatology Fellowship to Meet the Demands for Arthritis Management
R. Hooker and S. Kazi, Department of Veterans Affairs, Dallas, Texas
The demand for rheumatology access is increasing at a time when the number of rheumatologists retiring is exceeding those entering practice. A physician assistant (PA) Rheumatology Fellowship was introduced as a strategy to help offset these deficits. The fellowship, inaugurated in 2004, is based in the Division of Rheumatology at the University of Texas Southwestern Medical Center through an arrangement with the Department of Veterans Affairs Healthcare System, Dallas, Texas. The PA joined the three existing physician rheumatology fellows as a fourth first-year trainee. After six months, an administrative assessment of the fellowship was undertaken. The findings revealed that the PA evaluated and treated 371 rheumatology patients (10% at the bedside) over the course of the first six months. The characteristics of the PA-assessed patients were older and more were male than typical urban rheumatology practices, but the types of disorders seen encompassed nearly the full spectrum of rheumatologic conditions. Most of the contemporary arthritic medications in use were prescribed, suggesting familiarity with a wide variety of patient conditions. The annual cost allocated to this fellowship is $35,000; the administrative expenses are considered marginal. Supervision costs are estimated at 10% of faculty time, but the net gain in patients seen is thought to be added value. The decision to incorporate a PA into an established, university-based rheumatology fellowship appears to be an effective strategy to provide additional rheumatology access and service to the employing institution. This training program for PAs may be a model that could be introduced into other rheumatology fellowships. The result would be a reliably and economically trained cadre of rheumatology providers incorporated into large practices that could help offset the looming deficit in board eligible rheumatologists. Economic studies are required to see if these findings remain valid.
10. Patient Satisfaction with Physician Assistant, Nurse Practitioner, and Physician Care: A National Survey of Medicare Recipients
R. Hooker and D. Cipher, Department of Veterans Affairs, Dallas, Texas
Objectives: To determine how satisfied consumers are with physician assistants (PA) and nurse practitioners (NP) care.
Design: National cross-sectional survey
Setting: Non-institutional, representative, random sample of people 65 years old and older
Participants: Medicare recipients from the 2000 and 2001 Medicare Satisfaction Survey, Consumer Assessment of Health Plans Survey section on Fee-for-Service who identified a primary care provider
Measurements: Patient sociodemographic characteristics and health care experience and satisfaction data were compared in which a generalist physician, PA, or NP was identified as the personal provider.
Results: 146,880 completed returns from 321,407 randomly sampled Medicare beneficiaries nationwide (45.7% of total surveyed) were analyzed with regard to satisfaction with their personal provider. Of this number, 3,770 (2.8%) identified a PA or an NP as their personal provider. For questions on satisfaction with their personal care clinician, results were similar for all three providers. Of the patients who reported an NP as their primary care provider, there were significantly higher proportions of Medicaid recipients than that of the patients who reported receiving care from a PA or physician. Of the patients who reported a physician as their primary care provider, there were significantly higher proportions of supplemental insurance recipients than that of the patients who reported receiving care from a PA or NP.
Conclusion: Findings suggest that patients are generally satisfied with their medical care and do not distinguish preferences based on types of providers. PAs, NPs, and physicians in primary care seemed to be viewed similarly regardless of patient characteristics. PAs and NPs may be a workforce that could be expanded to care for the rising needs of the elderly.
11. Physician Assistant and Nurse Practitioner Prescribing: 1997-2001
R. Hooker and D. Cipher, Department of Veterans Affairs, Dallas, Texas
Context: Physician assistants (PAs) and nurse practitioners (NPs) have licensure to practice in all states and prescriptive authority in 47 and 40 states respectively. The role and activity of this growing workforce in providing care to rural and underserved communities is an area of research interest. However, there have been no published studies that have examined PA and NP prescribing practices outside of pharmaceutical marketing efforts and none from a national standpoint comparing urban and rural settings.
Purpose: The objective of this study was to describe the characteristics of providers, patients, and the type of prescriptions written by PAs and NPs, and to compare these activities to physicians in both metropolitan and non-metropolitan settings.
Methods: We analyzed the activity of prescribers using the National Ambulatory Medical Care Survey (NAMCS). A representative sample of 120,424 primary care visits over a five-year period (1997-2001) was analyzed in which a prescription was written by a PA, NP, or physician in an urban and rural setting.
Findings: A PA or NP was the provider of record for 5% of the primary care visits. The three providers were likely to write a prescription for 60% to 70% of all visits, and the mean number of prescriptions was 1.3-1.5 per visit (range 0-5), depending on the provider. PAs were more likely to prescribe a controlled substance for a visit than physician or NP (19.5%, 12.4%, 10.9% respectively). Only in rural areas did differences emerge. In rural areas, NPs wrote significantly more prescriptions than physicians and PAs, and PAs prescribed significantly less than the other providers.
Conclusions: These findings suggest that, overall, PAs and NPs are prescribing in a manner similar to physicians, at least in the type of medications used in their patient management. In non-metropolitan areas, prescribing differences emerge between the three types of providers that bear further exploring.
12. Physician Assistant Holland Occupational Codes
D. LaBarbera, Rosalind Franklin University of Medicine and Science PA Department, Chicago, Illinois
Background: Holland's theory espouses that matching people to environments can lead to predictions of vocational choice, stability, and achievement outcomes. Holland codes personalities and environments according to six RIASEC types - Realistic, Investigative, Artistic, Social, Enterprising, and Conventional - in an effort to match people to vocations that will be rewarding. Holland's Self-Directed Search (SDS) identifies the types. Holland's published Physician Assistant code, ISA, may be outdated.
Purpose: To validate the PA vocational personality as measured by Holland's SDS Form R.
Methods: An original validated survey was mailed to a random sample of 2,325 members of AAPA's research assistance program mailing list. The survey captured demographics and measured vocational satisfaction in an effort to identify a pool of satisfied PAs for further study with the SDS. Survey respondents who indicated employment as PAs and were satisfied with their career choices were mailed the SDS booklet.
Research Instrument: The SDS Form R is embedded in more than 500 studies that support its reliability and validity. Users rate 11 activities for potential likes or dislikes; mark yes or no for 11 activity competencies; indicate interest in 14 different occupations; and rate 12 abilities on a scale of 1 to 7. SDS users calculate their scores and rank the RIASEC types in descending order to create a profile. The top three letters are the code.
Analytical Procedures: After double-checking the participant's calculations, the profile was calculated from the mean RIASEC levels. A one-way repeated measure ANOVA was used to analyze for significant differences between the RIASEC levels. Paired t-tests with the Bonferonni correction were used for post-hoc comparisons. To explore differences between groups (gender, specialty), independent samples t-tests were conducted.
Results: With a survey response rate near 50%, 945 PAs met the inclusion criteria for SDS participation. SDS booklets were returned at a 50.5% response rate, with 463 usable booklets. Several statistical comparisons (chi-squares, t-tests) of the survey respondents to selected demographics from AAPA's annual census survey demonstrated that the survey respondents were representative of the PA population at large. Similar comparisons of the SDS participants to the survey respondents showed that they were a representative sub-sample.
The new PA profile was identified as SIREAC (code SIR). Analysis of the profile resulted in S/I-R/E-A/C, in which a dash (-) separates the statistically significant letters and a slash (/) represents no statistical difference between the letters. The family/general practice (FP) PA profile was S-I-R/E/C/A; the surgical PA profile, I/S/R/E-CA. Gender differences showed that men (I/S/R-E-C/A) had significantly higher realistic and enterprising components than women (S/I-A/E/C-R) (p < 0.001), regardless of surgical and family/general practice specialties.
Conclusions: An updated PA profile was found. Gender findings are in accordance with Holland's work. Surgical PAs appear to have a higher R component than FP PAs. Implications of the study may extend into formal career counseling to guide individuals considering entry into the PA profession, as well as new PA graduates and PAs considering a job change, in hopes of bringing about increased vocational satisfaction.
13. Sleeping Rough in Boston: A Five-year Observational Study of a Cohort of Chronically Homeless Persons Living on the Streets of Boston, 2000-2004
J. Roncarati, J. O'Connell, C. Kane, and J. Allen, Boston Health Care for the Homeless Program, Boston, Massachusetts
Purpose: The obstacles to health care services faced by the subpopulation of homeless persons who live on the streets ("rough sleepers") are daunting. A dearth of literature exists to document the burden of medical illness of urban street dwellers. Efforts to care for this elusive population have been limited to acute and episodic interventions. Lack of continuity has obviated quality primary and preventive care. Boston Health Care for the Homeless Program's (BHCHP) Street Team, which consists of two internists, a physician assistant, a nurse, two psychiatrists, and a therapist, has evolved as a multidisciplinary team model of care that offers health care services directly on the streets of Boston. The Street Team works directly with day and night outreach teams from local agencies and conducts hospital-based clinics and inpatient care at Massachusetts General Hospital (MGH) and Boston Medical Center (BMC). Immediate access is available directly from the street to two public dual diagnosis detoxification units as well as BHCHP´s 90-bed medical respite program.
Methods: In January 2000, a cohort of 119 high-risk individuals was identified from more than 800 street persons cared for by the Street Team. All persons in this cohort were over age 18, had lived on the streets for at least six months, and meet one of several criteria for increased morbidity and mortality. The cohort does not differ demographically from the 7,000 sheltered homeless persons receiving BHCHP services. However, 88% of the high-risk cohort suffers from the tri-morbidity of chronic medical illness, major mental illness, and active substance abuse. Contact data is recorded on each patient at a weekly Street Team meeting. Other data sources include BHCHP's electronic medical record, hospital records at MGH and BMC, and a supplemental street database maintained by the team.
Results: After five years, the Street Team was able to identify the whereabouts of 114 (96%) of the 119 in the cohort: 33 (28%) were deceased; 7 (6%) are disabled or ill enough to have been placed in nursing homes; 2 (1.6%) are incarcerated; 10 (8.4%) are in emergency shelters, transitional shelters, or recovery programs; 38 (32%) individuals are housed in apartments or rooming houses or are living full-time with families and friends; 24 (20%) remain on the streets; and five individuals (4%) have been lost to follow-up. Primary care outcomes included: 65% had PPD documentation within the last year; 75% received a Pneumovax within the last 10 years; 38% received a flu vaccine. For female patients, eight (31%) of 26 women received a PAP smear, and five (23%) of the 22 women received a mammogram in the past two years.
Conclusions: Mortality and morbidity is high among those living on the streets of Boston. BHCHP´s service delivery model provided continuity of primary and preventive care to a high-risk cohort of rough sleepers, with primary care outcomes comparable to those achieved for the sheltered homeless population receiving care from BHCHP. The Street Team offers a model of street care for cities seeking strategies to reach this vulnerable and disenfranchised population.
14. Soda-drinking Habits of Academy Students
K. Bourne, J. Mathey, C. Chareon, J. Dovre, and A. Cevallos, Loma Linda University, Loma Linda, California
Purpose: Adolescents' beverage consumption has dramatically shifted from nutritional drinks such as milk and fruit juices to soft drinks in the last 10 years (Harnack and Stang, 1999). Proposals to limit access to school vending machines have been met with strong resistance by some school administrators and the National Soft Drink Association (Fried and Nestle, 2002). They suggest that soda-drinking habits in the home are no different from those at school. The purpose of our study is two fold: (1) to evaluate the frequency of consumption of soft drinks by high school students, and (2) to compare the extent to which students drink soft drinks at home versus at school.
Methods: A total of 147 high school adolescents, ages 15-19, participated in this study: 64 females and 81 males. We used a survey that included questions about serving size and frequency of consumption of 24 types of drinks at home vs. at school. We used Wilcoxon signed rank test to compare the frequency and serving size of these beverages at home versus at school.
Results: There was a significant difference in serving size consumed at home vs. at school for caffeinated coke, diet caffeinated coke, caffeine-free coke, and other caffeine-free soft drinks (P<0.05). There was also a significant difference in the frequency of consumption of other caffeine-free soft drinks at home vs. at school (P<0.05). There was no significant difference in the frequency of consumption of caffeinated coke, diet caffeinated coke, and caffeine-free coke at home vs. at school (P>0.05).
Conclusions: Although the frequency of soda consumption was similar at home vs. at school, larger serving sizes of sodas were consumed at school. The primary drink of choice among all students at home and school was water.
15. The Effects of Early Patient Education on Immunization Rates of Infants in Galveston County
T. Bigler and K. Stephenson, University of Texas Medical Branch, Galveston, Texas
Purpose: A longitudinal prospective cohort study at a university hospital to evaluate the efficacy of post-partum parental education to improve immunization compliance in Galveston County. In 1999, The Texas Retrospective Immunization Survey (TRIS) reviewed immunization records and reported a rate of 56.2% in Galveston County for subjects who were two years old.
Methods: Physician Assistant students on rotation in the newborn nursery performed the intervention, consisting of patient education regarding routine childhood vaccinations, specifically, a review of the recommended immunization schedule, the availability of free vaccination clinics, and the importance receiving the immunizations on time. All subjects enrolled in the study (control and intervention group) receive reminders in the mail about immunizations when their child is 2, 4, and 6 months old; those living in Galveston County also receive a list of the free community shot clinics. Using the statewide immunization registry, the child's records were reviewed to establish whether the child obtained the recommended vaccines, and a t-test was used to compare the rates of immunization between the intervention and control groups.
Results: A total of 487 subjects are enrolled to date, with a goal of 1,600 subjects. The pilot results in May 2004 showed that significantly more children in the intervention group (n=38) were up-to-date with their two-month vaccination series than the control group (n=76, p=0.046). At four months of age, no difference was found between the control (n=17) and the intervention group (n=30, p=0.840). At the time of this interim report (December 2004), 332 children have reached two months of age, 246 children have reached four months of age, and 88 have reached six months of age. At 2, 4 and 6 months of age, no statistically significant difference was found between the control and intervention group regarding compliance with the recommended immunization schedule (p=0.682, 0.102, 0.481 respectively). At two months of age, the immunization rate for children who live in Galveston County was 72.9%. At four months of age, the immunization rate for children who live in Galveston County was 58.2%.
Conclusion: Additional families are being enrolled and continuation of this research will determine if the PA student intervention makes a significant difference in immunization rates at 2, 4, 6, 12, and 35 months of age. Additional studies are needed to establish the accuracy of the immunization registry.
Case Studies/Clinical Reports
16. A Novel "Four-Rod Technique" for Lumbopelvic Reconstruction: Theory and Technical Considerations
F. Shen, M. Harper, W. Foster, and I. Marks, University of Virginia, Department of Orthopedic Surgery, Charlottesville, Virginia
Study Design: Surgical technique with case example
Objective: To report on a novel technique that allows for the placement of four separate longitudinal rods across the lumbopelvic junction
Summary of Background Data: Despite advances in surgical techniques and instrumentation, lumbopelvic fixation remains a significant challenge. Fusions to the pelvis create long lever arms and generate high forces across the lumbosacral junction resulting in high rates of screw pullout and implant fracture. In the attempt to achieve better bony fixation, techniques described include the use of bone cement, hydroxyapaptite, and expandable screws. Although this has decreased the incidence of screw pullout, it has not addressed the problem of rod fracture at the lumbopelvic junction.
Method: Four separate longitudinal rods are placed across the lumbopelvic junction that couples proximal lumbar screw anchors to four separate pelvic fixation points. Proximal lumbar fixation anchors are based on alternating Roy-Camille "straight ahead" screws and Magerl "lateral to medial converging" pedicle screws. Four distal pelvic fixation anchors are used based on one pair of Galveston-like screws and one pair of proximal iliac wing screws.
Results: Early results of both ex vivo and in vivo reconstruction demonstrates that careful insertion of the lumbar and pelvic screws allows for divergent placement of the pedicle screw heads in a manner that two longitudinal rods can be placed per side resulting in a total of four-longitudinal rods across the lumbopelvic junction. Selection of cross links in various combinations allows for additional axial and torsional stability depending on the desired reconstruction.
Conclusion: Longer follow-up is necessary, and biomechanical and finite element studies are needed to demonstrate long-term efficacy of this technique; however, early results demonstrated that such a construct is feasible and that immediate postoperative weight bearing is possible and reasonable.
17. A Rare Non-malignant Testicular Mass
M. Gould and V. Quintanilla, The Urology Center, Madison, Connecticut
This is a 22-year-old male, who noted a painless right scrotal mass on testicular self-exam. He initially was seen by his primary care practitioner, who ordered a scrotal ultrasound and sent him for urologic consultation. He presents as a well appearing man in no distress. He has no significant past medical or surgical history. His family history is positive for prostate cancer. His physical exam revealed a nodule in the right testis, while the rest of his exam was unremarkable. The scrotal ultrasound was reviewed, showing a focal well-circumscribed oval mass within the mid to upper pole of the right testicle, with a mildly echoic inner rim and echogenic material anteriorly. Tumor markers were drawn and later found to be negative. The patient was counseled about the possibility of a tumor, given the intratesticular nature of the mass. A right orchiectomy was performed two days later. The final pathology revealed an epidermoid cyst.
Testicular cancer is the most common solid tumor in men ages 15-35 years old. The incidence of testicular tumors is 2-3/100,000. It is more common in the right testis and only 2-3% occur bilaterally. It is one of the few neoplasms associated with elevated serum markers. On average, 50%-60% of these neoplasms are associated with elevated serum markers.
Epidermoid cysts are a rare non-cancerous testicular mass accounting for 1% of all intratesticular lesions. The diagnosis of epidermoid cysts can be suggested by ultrasound, as was this case; however, the diagnosis is made histological after the mass has been removed. Epidermoid cysts are benign and have no malignant potential, and, although rare, the testicle has to be removed to assure no cancer is present. Recently, some surgeons have tried testicular sparing procedures that remove the mass only, but the standard of care remains complete orchiectomy.
Although rare, this case highlights the importance of testicular self-exam and a supportive patient/provider relationship in early diagnosis and improved outcome.
18. An Unusual Kidney Stone
M. Gould, The Urology Center, Madison, Connecticut
A 77-year-old woman presented with hematuria and a positive urine culture of Proteus. She subsequently passed a stone and brought it for analysis. Of note: her history states passing a stone 10 years ago without any evaluation or treatment. She has a past medical history of progressed Alzheimer's, hypertension, and previous hysterectomy. Currently her medications include Triamterene/hydrochlorothiazide, Divalproex Sodium, and folic acid; an allergy to PCN is noted. On exam, she was quiet and non-communicative; she was accompanied by her daughter and son. There appeared to be no pain to palpation or CVA tenderness. She was unable to provide a clean catch urine specimen for analysis. The stone returned as pure Triamterene. A CT scan obtained after her visit revealed a residual stone in the lower pole of the left kidney, no hydronephrosis or evidence of other renal disease. Her Triamterene/hydrochlorothiazide was removed from her medication regime and replaced with another diuretic.
Triamterene stones are rare, approximately 0.13%, and are usually caused when Triamterene is given in combination with hydrochlorothiazide. This combination diuretic therapy is often given in the treatment of hypertension to avoid the potassium depletion that oral hydrochlorothiazide causes when given alone. Up to 70% of orally administered Triamterene appears in urine, and a few patients have developed pure or mixed triamterene stones. Pure triamterene stones occur 36% of the time and mixed with calcium oxalate and uric acid in the remaining stones usually as a nucleus. Patients who have developed triamterene stones usually have a history of nephrolithiasis. Rarely other medications, such as indinavir and silicate (antacid preparations), have been associated with the formation of stones.
The prescriber of these medications should be aware of the potential risks and benefits and consider not using Triamterene, but other potassium-sparing diuretics such as amiloride in patients with a history of nephrolithisis.
19. Carpectomy and Reconstruction of Anterior Vertebral Body Tumors with an Expandable Cage Through a Posterior-only Extracavitary Approach
F. Shen, S. Bhattacharjee, I. Marks, and M. Harper, University of Virginia, Department of Orthopedic Surgery, Charlottesville, Virginia
Background Context: The presence of either neurological deficits or mechanical instability due to spinal metastases typically requires surgical intervention. Isolated posterior decompressions in the form of laminectomies have poor outcomes. Management focuses on addressing the site of anterior compression and reconstructing the spinal column. Typically this requires an anterior approach with or without a posterior fusion and instrumentation. These procedures can be associated with significant morbidity and mortality. Studies evaluating the role of posterior extracavitary approach for vertebral body resection and reconstruction for metastases are limited.
Purpose: Evaluate the feasibility of resecting and reconstructing the vertebral body through a posterior extracavitary approach.
Study Design/Setting: Retrospective consecutive case series.
Patient Sample: Nine patients at a single institution with neurological deficits or mechanical instability secondary to metastases or fracture.
Outcomes Measured: Because all lesions but one addressed were metastatic cancers, the goal was not to review long-term fusion rates, but to determine feasibility based on change in neurologic status, number of levels fused, length of surgery, estimated blood loss (EBL), total hospital stay, and length of stay after surgery.
Methods: All patients were positioned prone on a radiolucent table that could be rotated. Intraoperative neuromonitoring was utilized in all cases. At all levels where a rib was present, a segment was resected. The ipsilateral nerve root was ligated in most cases. In all cases, a corpectomy and full decompression could be performed from the posterior-only approach. No patient required a separate anterior procedure. The anterior column reconstruction was performed with an expandable titatnium cage through the same extra-cavitary approach. Postoperative management included antibiotics, steroid taper, mechanoprophylaxis, and immediate mobilization for DVT prophylaxis. No chest tubes or postoperative bracing was required.
Results: Average age was 54 years old (range 17 to 73 years). There were six females and three male patients. Final diagnoses was three metastatic adeno lung, one prostate, one bone cyst, one breast, one plasmacytoma, one trauma, and one renal cell carcinoma. Levels involved were one T4, one T5, one T7, one T8, two T9, two L1, and one L5. An average of 4.3 levels was fused (range 3 to 5). Average EBL and length of surgery was 1,344 cc (range 300 to 4800) and 6.5 hrs. (range 4.97 to 8 hrs.). Average length of hospital stay and stay after surgery was 7.3 days and 5.9, respectively. On average, patients were ambulating by postoperative day 3.25. No patients had deterioration of their neurologic function due to the surgery; there was an increase in motor grade in one of four patients. One cage required repositioning in the immediate postoperative period and one superficial skin infection occurred; otherwise, there were no DVTs, pneumothoraxes, pneumonias, or other complications a minimum of 12-week postoperative period.
Conclusions: In our series of patients, there was no deterioration in neurologic status. In all cases, an anterior corpectomy and reconstruction with expandable cage was performed through a posterior-only extracavitary approach. No brace treatment was required. Our complication rate is similar to those reported in anterior alone and circumferential spinal procedures. Posterior extracavitary spinal decompression and reconstruction is an acceptable alterative for the management of metastatic spinal lesions to the vertebral body.
20. Health Care Delivery: A New Model to Replicate
S. Cohen, D. Parkhurst, C. Evans, and N. Soto, Barry University, Plantation, Florida
Purpose: To devise and implement a model for the creation of free primary health care clinics; to improve access to care for underserved populations in urban, suburban, and rural areas; and to train clinicians in the model to encourage placement of such professionals in these underserved centers.
Discussion: Reducing disparities among minorities and the medically underserved is enormously significant to the mission of any health care institution. This project was dedicated to finding solutions to access for an identified population of medically underserved, multicultural, urban, and suburban homeless; migrant farm workers; senior citizens; African Americans; Native Americans; and Hispanics.
Methods: Project Health CARE (Collaborative Area Resource Effort) developed a model for a free multidisciplinary health clinic concept for medically underserved areas. This model was placed into action with one primary and two satellite working clinics in underserved service areas where access to primary health care was limited or difficult.
Conclusion: The implemented model has been successful at providing services to the identified population at a savings of more than $1 million to the system and to users of the clinics. In the past three years, the clinic has provided free medical services to more than 18,000 patients and trained more than 125 students from different medical fields. The program has been responsible for directing new graduate clinicians to consider careers involving serving these and other underserved populations.
21. Metastatic Penile Carcinoma: A Rare Case
V. Quintanilla, Hamden, Connecticut
This is a 71-year-old male with an unremarkable past medical history who was found to have a large, fungating penile mass on genital exam after being referred to urology by his primary medical physician for further evaluation of recurrent E. Coli urinary tract infections. He was diagnosed with squamous cell carcinoma of the penis by pathology and underwent a total penectomy with perineal urethrostomy. A bilateral inguinal lymph node dissection was also performed, revealing one right inguinal lymph node positive for metastatic, well-differentiated squamous cell carcinoma.
Carcinoma of the penis is a rare tumor in the United States and accounts for less than 1% of all cancers among males. It is most common in the sixth decade of life in uncircumcised males. Additional factors such as balanitis obliterans and condylomatas caused by human papillomavirus may increase the risk of developing penile carcinoma. Most neoplasms of the penis originate from squamous epithelium, and 25% of patients have regional metastases present in the inguinal lymph nodes at the time of diagnosis. Primary tumors that are small and well differentiated may be treated with a partial penectomy, while those with larger, poorly differentiated tumors may require total penectomy in addition to inguinal lymphadectomy. Prognosis is dependent on the patient's extent of lymph node involvement, with a greater survival rate seen in those patients without lymph node involvement. This case is presented to help stress to physician assistants the importance of a thorough genital exam.
22. Multiple Simultaneous Peripherally Inserted Central Catheters (PICCs) in Pediatric Critical Care Patients: A Novel Approach to the Need for Additional Vascular Access
C. Newman and J. Graf, Baylor College of Medicine, Department of Pediatrics, Houston, Texas
Introduction: The use of Peripherally Inserted Central Catheters (PICCs) in the pediatric population has grown significantly in recent years. Bedside placement, ease of removal, low reported infection rates, and suitability for home infusion therapy have all contributed to this growth. With the introduction of double-lumen PICCs in sizes suitable for pediatric patients, these lines have also become a vascular access option for the management of select critically ill patients. However, both the lack of triple-lumen devices of suitable size for the pediatric population and the inability of some patients to tolerate placement of a double-lumen device via a peripheral vein have acted to limit the PICC's functionality in this population. In this report, we offer three scenarios where this limitation was overcome by the use of multiple PICCs. In each scenario, unique factors precluded the placement of multi-lumen percutanous central lines.
Cases:
Case I: A 2-year-old male with pulmonary hypoplasia and pulmonary hypertension was transferred to the ICU in respiratory failure. The patient had an existing left arm PICC, but additional access was needed. A history of ECMO therapy, multiple previous CVLs, and known thrombi in several great vessels precluded placement of a percutaneous CVL. Right arm PICC placement was attempted, but stenosis of the subclavian vein precluded central placement. Instead, a midline catheter was placed with the tip at the auxiliary vein level. The midline catheter remained functional for 46 days, at which point it was removed.
Case II: An 18-year-old male with AIDS was admitted to the progressive care unit for management of dehydration, malnutrition, and chronic diarrhea. The patient required multiple incompatible intravenous medications. His profound malnutrition, scoliosis, and fixed contractures of all four limbs precluded percutaneous CVL placement, and the small caliber of his basilic veins precluded placement of a multilumen PICC. Single lumen PICCs were placed via both left and right basilic veins. Both lines remained in place and functional until the patient expired 10 days later.
Case III: A 4-month-old male was admitted to the intensive care unit for acute liver and renal failure. The patient had a single-lumen PICC in the right arm and a triple-lumen hemodialysis catheter in the right internal jugular vein at time of admission. Additional access was needed due to multiple incompatible medications and blood products. Multiple attempts to place a subclavian CVL had been unsuccessful and fungal colonization of the patient's neck and groin precluded percutaneous CVL placement. A dual-lumen PICC was placed via the left basilic vein. All lines remained functional until the patient expired seven days later.
Conclusion: Use of percutaneously placed multi-lumen central venous lines will likely remain the primary vascular access option for critically ill children. However, this report offers the use of multiple simultaneous PICCs as an alternative approach in those circumstances where traditional approaches may not be practicable.
23. Spontaneous Resolution of a Chiari I Malformation
J. Royo, T. Solomon, and R. Konen, Texas Scottish Rite Hospital, McKinney, Texas
Introduction: A Chiari I malformation is the elongation of the cerebellar vermis with herniation of its caudal end through the foramen magnum. Herniation of greater than 5mm is compatible with a Chiari type I malformation. The degree of tonsillar herniation correlates directly with the severity of symptoms. We present a girl with a Chiari I malformation that spontaneously resolved based on MR imaging.
Case Report: This is a 3-year-old girl who was referred for neurological evaluation secondary to left hemiparesis. She was the product of an uncomplicated twin pregnancy delivered vaginally at term. Patient was noted by Mom to have left-sided weakness at 11 months. As part of her neurological workup, she underwent magnetic resonance imaging (MRI) of the brain. The initial MRI revealed a signal abnormality in the anterior-medial right thalamus, most likely representing a small area of gliosis. The sagittal images incidentally revealed pointing of the cerebellar tonsils with extension at least 10 mm. below the foramen magnum. These findings were consistent with a Chiari I malformation. The remainder of the brain showed no edema or signs of increased intracranial pressure. No previous lumbar puncture had been performed. Two years later, the patient underwent a second MRI, which revealed a mild degree of tonsillar ectopia measuring approximately 6 mm below. The previous focal lesion was unchanged. A third MRI, completed seven years after the first, revealed no evidence of a Chiari I malformation.
Discussion: Can you outgrow a Chiari I malformation? As a result of MRIs being so readily available, Chiari I malformations are now increasingly encountered as incidental findings. There are several factors that can contribute to transient tonsillar herniation: Intracranial hypotension caused by lumbar punctures, shunting, or chronic cerebrospinal fluid leakage. These patients often complain of postural headaches, and there are usually other MRI features such as small ventricles and dural enhancement. This was very unlikely in our patient, as no previous CSF studies had been performed and patient had no complaints of headache. Cerebral edema and intracranial masses would also be a potential cause of cerebellar tonsillar herniation. There was no evidence of either in our patient.
So the question has been raised: Can one outgrow a Chiari I malformation? In our patient, we feel that this may be the only explanation. The cerebellar tonsils normally ascend with age, and, from 2 to 12 years, there is rapid linear growth. Our patient grew 46cm from the age of 3 to 10. With this skeletal growth and enlargement of the posterior fossa, the cerebellar tonsils may have been pulled out of the foramen magnum. As discovery of incidental Chiari I malformations increase, it will be interesting to see if this phenomenon exists.
24. Tantalum Trabecular Metal Spinal Interbody Implant for Vertebral Body
Replacement: A Case Study
K. Toftey Scheffler, Mayo Clinic, Department of Orthopedic Surgery, Rochester, Minnesota
Purpose: A look at the first use of a tantalum trabecular metal interbody implant in the lumbar spine at the Mayo Clinic.
Methods: This 72-year-old Caucasian male with a diagnosis of metastatic colon cancer to the spine, as well as liver and brain, presents with severe low back pain. Previous treatments include systemic chemotherapy, local radiation therapy, and failed vertebroplasty at L3. Pain is currently being treated with an intra-thecal morphine pump, resulting in significant Central Nervous System lethargy and confusion. MRI shows a pathological fracture at L3 with bony tumor in the spinal canal, abutting the thecal sac, resulting in severe spinal stenosis and a focal kyphotic deformity. Electromyography showed evidence of a cauda equina syndrome. Prior to surgery, lumbar artery embolization was performed. Surgically, an anterior corpectomy of L3 was performed, removing the bony tumor and cement mass. Strut grafting from L2-L4 was performed, using a trabecular metal implant. This was stabilized with a low-profile lateral locking plate spanning from L2-L4.
Results: Following recovery in the hospital, the patient was transferred to a rehabilitation unit for intense physical and occupational therapy. After a brief stay, he was transferred home. The patient experienced a dramatic relief in pain, and his intra-thecal morphine pump was reduced significantly. His mobility and abilities to perform activities of daily living improved; he was able to walk a considerable distance. Any further neurological damage was prevented.
Conclusions: The benefits of an interbody fusion include restoration of intervertebral height and preservation of normal spinal column alignment. Along with the corpectomy, the fusion allowed for the decompression of the associated neural elements, reducing pain and improving function. The tantalum trabecular metal strut graft provides spine surgeons an alternative to allograft bone. The trabecular metal material offers high volume porosity, which may allow greater tissue ingrowth, resulting in earlier fixation when compared to allograft bone. It has mechanical and physical properties similar to bone; compressive strength of the porus metal can withstand most physiological forces. It also has a high coefficient of friction, transferring physiologic load to bone, reducing stress shielding. Tantalum metal has excellent biocompatibility; its low antigenicity reduces the risk of an immune response in the host. Cost of the implant is also less than allograft bone. Many of these characteristics help to explain the use of tantalum metal for many years in applications such as cranioplasty plates, pacemaker leads, and total hip arthroplasty. Tantalum trabecular implants may offer several advantaged over current implants used for interbody fusion. Perhaps these implants will play a larger role in the future of spinal surgery.
25. Use of Lidocaine 5% Patches for Persistent Sacroiliac Joint Dysfunction: A Retrospective Study
K. Toftey Scheffler, Mayo Clinic, Department of Orthopedic Surgery, Rochester, Minnesota
We are reporting on our experiences with 10 patients (seven male and three female) who have known sacroiliac joint dysfunction proven by fluoroscopically guided SIJ injection (age ranged from 25 to 78). They all had two to four weeks of relief after the injections utilizing Bupivacaine 0.5% and 80mg of depomedrol. After their symptoms returned, they were treated with lidocaine 5% transdermal patches (Lidoderm®) to the affected area 12 to 24 hours.(1) Lidoderm® is an FDA-approved local anesthetic patch used in the treatment of post-herpetic neuralgia. The duration of the study was 24 weeks. Responses were characterized as follows: excellent (greater than 70% reduction in symptoms), good (50-70% improvement), fair (20-50% improvement), and poor (less than 20% improvement). Patient interview, examination, numeric pain scale, and the McGill short form pain questionnaire was used to grade response. Twenty percent of the patients had a greater than 70 percent improvement. Sixty percent of the patients had a 50-70 percent improvement. Ten percent had a 20-50% improvement. Ten percent had a less than 20 percent improvement with significant degenerative disc disease and previous spinal fusion, to cloud his pain picture. No significant complications were reported. With the use of lidocaine 5% patches applied over the sacroiliac joints, we have found a significant improvement in pain relief accompanied by prolonged duration of relief. Mild rash was experienced in three patients but resolved without treatment. More extensive studies are needed to confirm Lidoderm's® place in our treatment armamentarium.
Previously Presented
26. Exaggerated Pressor Responses to Apnea in Patients with Obstructive Sleep Apnea
J. Hardisty, J. Burk, and M. Smith, Colleyville, Texas
Purpose: Patients with obstructive sleep apnea (OSA) have high basal sympathetic nerve activity (SNA) and a high incidence of hypertension. Elevated chemoreflex gain is hypothesized to explain this relation; however, the relation of chemoreflex activation and pressor responses during apnea remains unknown. Therefore, we tested the hypotheses that: (1) the hypoxia-mediated SNA response to voluntary apnea predicts the blood pressure response at varying degrees of hypoxia, and furthermore, that the pressor responses are augmented in untreated OSA patients; and (2) that altered chemoreflex function in OSA patients is predictive of blood pressure response to hypoxic apnea.
Methods: In an experimental setting, nine subjects with untreated OSA and 10 healthy subjects breathed, at random, 1 min. of normoxic or hypoxic gas (21%, 16%, or 12% oxygen) followed by a 20 s voluntary apnea. Muscle SNA (microneurography) and arterial pressure (Finapres) were measured continuously. In a clinical setting, arterial pressure (auscultation and Finapres) was measured in 20 subjects, with untreated OSA and 24 control subjects during three bouts of 20 s voluntary apnea.
Results: Chemoreflex gain (estimated as the SNA response/change in oxygen saturation) significantly correlated with arterial pressure responses in both groups (0.71< R< 0.86; p<0.001). In addition, chemoreflex gain was augmented in OSA subjects (p<0.01), and the SNA and systolic pressure responses were significantly greater in OSA subjects (p<0.05) at each level of hypoxic apnea. Clinically, the peak systolic pressure response was greater (p< 0.001) in OSA patients (22.3 +/- 1.5 mmHg) than controls (8.5 +/- 1.4 mmHg).
Conclusions: These data support the hypotheses that the blood pressure responses to voluntary apnea are augmented in OSA and that this response is related to augmented muscle SNA responses. In addition, the blood pressure response during apnea is related to chemoreflex gain. Furthermore, the peak systolic pressure response to voluntary apnea is augmented in untreated OSA patients, and thus, may be used as a noninvasive measure of chemoreflex gain and augmented sympathetic activity in OSA.
27. The Interrelationships between Length of Stay, Methadone Dosage, and Age At an Urban Opioid Treatment Program
C. Madray, L.S. Brown, M. Chu, and S. Kritz, Addiction Research and Treatment Corporation, Brooklyn, New York
Purpose: The strategy for treating narcotic abusers in Opioid Treatment Programs (OTPs) is based on the goal of reducing illicit drug use. When evaluated separately at OTPs, length of stay (LOS) and methadone dosage have been found to correlate with opiate toxicology results. Surprisingly, however, there is a dearth of literature that looks at the interrelationships between these two variables.
Methods: Correlation of LOS and methadone dosage with opiate toxicology results was examined during a three-month period for 2,959 adults enrolled in seven OTPs. Age was also evaluated. LOS was divided into three groups: Group 1(>30 days to ?1 year), Group 2 (>1 year to ?5 years), and Group 3 (>5 years). The mean methadone dosage and mean age for each LOS group was calculated. Opiate toxicology results were calculated in two ways: (1) the percentage of positive opiate toxicology results for all tests done within each LOS group, in the aggregate; and (2) the percentage of individual patients with any positive/all negative toxicology results for tests done within each LOS group.
Results: There was a statistically significant difference in mean methadone dosage between patients with LOS >30 days and <1 year, LOS >1 year and <5 years, and LOS >5 years (p<0.01). Notably, the mean methadone dosage for LOS >5 years was less than the other two LOS groups. It was found that LOS significantly correlated with opiate toxicology results (p<0.01), consistent with previous literature findings. There was a statistically significant correlation between methadone dosage and opiate toxicology results (p<0.01), also consistent with previous literature findings. However, LOS (t=-12.66; p<0.001) was found to have a greater effect than methadone dosage (t=5.88; p<0.001) on opiate toxicology results. Mean age for the three LOS groups was evaluated, and a statistically significant correlation with LOS was found. In addition, age had an effect on toxicology results (t=5.04; p<0.001), but LOS had the greatest effect. These findings demonstrate that the LOS correlation with opiate toxicology results is strongest and is much more clinically relevant than either methadone dosage or age.
Conclusion: The correlation of length of stay with opiate toxicology results was strongest and was consistent with most other studies reported in the literature. The correlation of methadone dosage with opiate toxicology results was not as strong and may be explained by the fact that patients with longer stays in treatment are better stabilized due to the impact of non-pharmacological interventions (for example, counseling, etc.). The correlation of age with opiate toxicology results was not as strong as for methadone dosage and may not be clinically relevant. Methadone should be viewed as a tool to enhance other aspects of treatment in order to promote longer LOS, ultimately yielding a higher percentage of negative opiate toxicology results.
EDUCATION GALLERY
Original Research
28. Accidental Exposures of Physician Assistant Students
D. LeBarbera, J. Haan Riesman, J. Adams, and E. Ambrozevicius, Rosalind Franklin University of Medicine and Science, Physician Assistant Department, Chicago, Illinois
Purpose: To calculate a private university's physician assistant student reporting rate of accidental exposures and to identify reasons for non-reporting.
Methods: PA Classes of 2001-2004 (207 PAs) were tracked for accidental exposures with exposure reports gathered per the PA Department's protocol and a written survey given in class near the close of their clinical training.
Research Instruments: The Accidental Exposure Form includes: rotation number, discipline, date, time, exposure type, narrative of incident, and documentation of required notifications to the rotation site, PA Department, Office of Student Affairs, and an option for a telephone consultation with an Infectious Disease physician (PA program medical director) at no charge.
An original survey queried into accidental exposures during clinical training and, for those with exposures, the type of injury, number of and type of rotation, adherence to Universal Precautions, and if a report was filed with the PA Department. Open-ended items queried the classes of 2002-2004 for reasons for non-reporting.
Analytical Procedures: Frequencies and qualitative coding of exposure records and surveys were conducted. The number of exposures per the surveys was compared to departmental reports. A one-way Chi Square analysis was performed to determine if the reporting rate of PA students was statistically different than for that reported in the literature for medical students.
Results: Surveys were collected from 200 of 204 PA students (98.0% response rate). Exposures were noted by 22.0% (n=60), of which 60% (n=36) indicated percutaneous injuries and 40% (n=24), mucous membrane exposures. There were 54 exposures sustained during six 6-week core rotations: emergency medicine, 50.0% (n=27); surgery, 28.0% (n=15); women's health, 10.0% (n=5); family medicine, 6.0% (n=3), internal medicine, 4.0% (n=2), and pediatrics, 2.0% (n=1). No pattern was seen with respect to the number of the rotation and the amount of exposures. Universal Precautions were used by 95% of those exposed; 65% (n=39) reported self-inflicted injuries, whereas 35% (n=20) of injuries were inflicted by others; 28.3% followed reporting protocol. Reasons for non-reporting included: insignificant exposure, unclear or tedious reporting protocol, reported exposure to hospital, hospital has protocol, and embarrassment or fear. Reasons for reporting included: to follow protocol, to seek medical treatment, to avoid health insurance issues, and a belief that the injury was significant.
Of PA students not exposed, 80% thought they would report the incident, primarily to follow protocol. Reasons for reporting or not reporting were similar to those given by PA students with exposures.
Departmental documents revealed 27 exposures, of which 81.5% were percutaneous (n=22) and 18.5% (n=5), mucus membrane; 76.9% (n=20) were self-inflicted and 23.1% (n=6) inflicted by others.
The reporting rate of PA students (45%) was not statistically different than the literature estimates on medical students (30%).
Conclusions: This university's PA students' accidental exposures mirror what is know about medical student exposures in terms of reporting rates, disciplines, and reasons for non-reporting. PA students reported greater adherence to universal precautions (95%) than what is seen in the literature for medical students (40-50%). Under-reporting is a problem for these PA students, similar to that reported in the literature for medical students.
29. An Assessment of the Effects on Learning of an Audience Response System in a Physician Assistant Program Classroom
D. Irvine, Albany Medical College, Albany, New York
Purpose: To determine if the use of an audience response system in a PA program classroom would have a beneficial effect on student learning.
Methods: An interactive audience response system (ARS), which displayed student responses to review questions during PowerPoint™ presentations, was utilized during a diagnostic methods class in a master's level PA program. Students in lecture classes were presented with questions to which they responded with the ARS (identified as type 1). They were also presented questions that were reviewed and discussed but did not require a response (type 2). These questions were utilized on a subsequent multiple choice examination along with a group of questions the students had not reviewed (type 3).
It was hypothesized first, that the students would perform best on type 1 questions and have the most difficulty with type 3; and second, that the performance on type 1 questions would improve in this cohort of students as compared with the prior cohort.
Results: The results for the entire question pool, while demonstrating the predicted trend, do not meet statistical significance. However, after stratifying the questions by difficulty and separately analyzing the data for the more difficult (upper) half, it was possible to demonstrate a statistically significant improvement in student performance on those questions. Results indicated that students performed significantly better on the type 1 questions than on the type 3 questions (p <0.01). The performance on the type 1 questions was also significantly better than on the type 2 questions (p <0.001). They students did not perform significantly better on the type 2 questions than on the type 3 questions (p=0.13).
On comparison with the prior cohort, it was demonstrated that these students performed better on all three types of questions. However, the degree of improvement for the more difficult questions was significantly greater (p=0.03) for the ones presented with the audience response system.
Conclusions: It was concluded, then, that the use of the ARS significantly improves student learning (defined as ability to respond correctly on post-test, multiple-choice examinations based on course objectives) when used in a master's-level PA program classroom. This improvement is confined to examination questions that test above the knowledge level in Bloom's taxonomy of cognitive performance.
It is also concluded that further studies should be performed to ascertain if these results could be generalized to the larger population of master's level physician assistant students.
30. Development of a Standardized Set of Criteria to be used in Evaluation across Multiple Health Professions Educational Programs
P. Dieter, V. Kaprielian, and J.K. Richardson, Duke University Medical Center, Durham, North Carolina
Purpose: Duke University's Department of Community and Family Medicine (CFM) reports its experience in developing a comprehensive evaluation system, which has been implemented across the department's 12 educational programs, including a PA program, a Doctor of Physical Therapy program, physician residencies, fellowships, a continuing education program, and a medical student clinical experience in family medicine.
Methods: In November 2001, the chair of Duke's Department of Community and Family Medicine convened an Evaluation Task Force to consider common evaluation issues in the department's 12 educational programs. Within 15 months, the task force developed a comprehensive evaluation system that incorporated periodic survey assessment of the curricula and programs by faculty, learners, graduates, and employers, as well as an annual reporting system for "inputs" (e.g., application data, students matriculated, attrition, and faculty data) as well as outcome data (primarily data on numbers graduated, pass rates on certifying or board examinations, and employment data for recent graduates). Most of this data was collected electronically.
Results: Despite the diversity of the CFM Department's educational programs, there was sufficient "common ground" among the programs to develop a series of surveys which could be used by all the educational programs. Each survey contained approximately 10 simple, generic survey items (e.g., "the evaluation process is fair," "the faculty is responsive to feedback," etc.), which the respondent rated from 1 (strongly disagree) to 4 (strongly agree). Individual programs were able to supplement the questions, but not replace any, to maintain a core set of uniform questions. The evaluation system was implemented in February 2003 with a faculty survey. Of the four surveys (faculty, learner, graduate, employer), only the faculty surveys were administered and collected by the chair's office. Other surveys were administered by the individual programs on an annual basis; data was collated within the programs, as well as reported to the department chair's office.
The evaluation system is now two years old, allowing for comparison of annually collected data. Additional benefits of the department-wide evaluation system include: ready access to consistently collected data, by both individual program and the chair's office; the ability to compare a program's performance to others within the department and receive peer educator advice; and the ability to use the generic surveys to monitor trends and also to "drill down" with additional evaluation when a general problem is noted.
Conclusions: Despite some initial resistance from faculty, it was possible to develop a core educational evaluation system that could be used by all programs within the CFM department. Simple, generic questions yielded useful data and allowed the programs and CFM department to monitor data in a consistent manner.
31. Key Points: Improving Student Retention of Lecture Content
R. Cupp, G. Landel, and K. Wick, MEDEX Northwest PA Program, Seattle, Washington
Purpose: The effectiveness of lectures in assuring student learning has been questioned. One possible explanation for the perceived inadequacy of the simple lecture format may be that there is too much data for the student to prioritize and assimilate during lectures on complex material. We suggested, as a possible solution, the introduction of and emphasis on "key points" during lectures as a means to direct students toward the most important aspects of the subject matter. This type of approach is supported in some of the limited research available on this topic.
Methods: This PA program offers 11 one- to two-hour lectures covering the history-taking phase of the basic provider-patient interaction. To test the key points concept, the lecturer identified five key points during two of these lectures - chest pain and dysphagia - as important for inclusion during history-taking. The remaining nine lectures included similarly important concepts, but these were not emphasized as key points during the presentations. All students in the class (42) were then sent an e-mail emphasizing the importance of asking the appropriate questions during the patient encounter. All students were evaluated after the 11-week quarter, with history-taking examinations utilizing a student "patient" in the encounter. The students' questions to their "patients" were assessed to determine whether they included the specified key points for the two topics under study (test topics). This was compared with two other history-taking exam topics for which clearly-identified key points could be but had not been provided (control topics): hemoptysis and hematuria. Each student was given two history-taking exams: one test topic and one control topic. Academic grading for the history-taking exams was assessed independently of the key points evaluation.
Results: We found that the students asked all five key points 29% of the time whereas 0% asked all five of the selected "most important" questions about the control topics. Students asked three or more of the key points 86% of the time for test topics, and three or more of the "most important" questions about the control topics 33% of the time.
Discussion: Faculty emphasis on five key points in the lectures on chest pain and dysphagia enabled students to recall this information more frequently than they were able to recall similar information of equal importance in the evaluation of hemoptysis and hematuria. This suggests that using key points is superior to a lecture technique in which key points are not emphasized clearly. Further study would be required to evaluate whether it is the threat of testing on this material or the emphasis on importance to patient care that has a greater effect on improved student recall. (Additional information from our didactic classes in two other locations may help to provide an initial review of this question.) It may also be that teaching this material in an alternate format such as Problem-Based Learning or small student groups would also increase retention of the information.
32. Living Well with Health Conditions
W. Kennedy, E. Kennedy, D. Southard, and A. Southard, Jefferson College of Health Sciences, Roanoke, Virginia
The Jefferson College of Health Sciences' PA program has started a community outreach project aimed at providing community residents living in rural southwest Virginia who suffer from chronic disease the education and coping skills needed to effectively self-manage their disease, thus improving their quality of life. This program starts in the first year of the PA program as Chronic Disease Self Management (CDSM) training, based on the Stanford model, and is then placed into action during the rotation year as a community health rotation in either Norton or Saltville, Virginia. The community health rotation is a three-tiered rotation, which includes community outreach, clinical experiences, and the CDSM program itself. Following a needs assessment of these two areas, it was found that southwest Virginia has long had higher rates of morbidity and mortality related to chronic illness, compared to the state and nation, due to factors such as: education, poverty, diet, access to care, and cultural factors unique to these rural Appalachian populations. Population aging will worsen chronic health problems. Specifically, the areas of disease focus are cardiovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, and cancer.
The CDSM program goals are: to increase community residents' knowledge of how to effectively self-manage their chronic disease; to increase community residents' skills for effective self-management of their chronic disease; to increase community residents' self-efficacy for self-management of their chronic disease; and to increase health care providers' use of a consistent self-management approach, with emphasis on patient role, standardized assessment, effective interventions culturally competent care, care planning, problem solving, and follow -up. These goals are achieved through six 4-hour classes taught by two master trainer PA students. These classes teach the participants techniques on addressing health care concerns, improving the activities of daily living, stress relieving techniques, how to design an action plan, and how to implement that plan toward a future with better health.
Currently, the PA students are working diligently with internal medicine and family practice physicians to encourage patient referrals to the CDSM program. Patients with chronic disease processes have had their charts flagged to encourage the physician to discuss the CDSM program with that patient. In addition, the students are conducting community outreach with local libraries, churches, community centers, and health-related businesses to make the public aware of the CDSM program in their community.
Following the completion of our pilot program in the spring of 2004, the participants reported positive results in self-efficacy. These findings indicate that the southwest Virginia communities are responsive to the CDSM program and are ready to become proactive in their health care and quality of life. In addition, this program has made many practitioners in these communities aware of the need to address chronic diseases and utilize the resources made available to them. The CDSM program has enabled participants to work with their practitioner in a common endeavor.
33. Medical Informatics in Clinical Education: Using PDAs in Patient Logging
D. Day, A. Griffin, C. Fox, and A. Huckstadt, Wichita State University PA Department, Wichita, Kansas
Introduction: Students in the clinical phase of education record patient encounters to: (1) demonstrate the scope of clinical experience of each rotation; and (2) demonstrate student experience in diagnosis and procedures to potential employers. Various methods have been used to collect this data such as hand-written cards, Web-based logging, and PDA logging using patient-logging software.
Purpose: The purpose of this preliminary study is to compare the use of PDAs in capturing patient-logging data with web-based and handwritten methods.
Methods: All patient encounters were recorded by students and collected from their PDAs for analysis. The mean results were compared in a descriptive fashion to the means of previously recorded Web-based and handwritten patient logging data.
Results: Patient-logging using PDAs were a more accurate method of data collection compared to Web-based and handwritten methods previously used. The mean number patient encounters per rotation were: 2,305 for Web-based logging; 2,667 for handwritten cards; and 6,621 for PDA logging.
Conclusions: The mean number of patient encounters using PDA logging was three times higher than Web-based logging. Both the Web-based and handwritten methods of data collections were delayed methods, with a time lapse between the patient encounter and the recording of the encounter, causing errors when recording data. Students using PDAs with patient-logging software were able to immediately record the patient encounter. Handwritten recording had a slightly higher mean than Web-based recording.
34. Standardized Patients as Evaluators
B. Calhoun and D. Grzybicki, Duquesne University, School of Health Sciences, Pittsburgh, Pennsylvania
Background: Current medical education reform includes replacement of the traditional didactic lecture paradigm with interactive problem-based learning, case-based instruction, and small discussion group teaching. Within this interactive framework, use of standardized patients and simulated patient encounters can provide comprehensive evaluation of students' integration of physical examination skills, medical knowledge, and clinical problem solving. Incorporating standardized patients and simulated patient encounters into the initial, traditionally didactic phase of learning of PA students can identify weaknesses relating to content knowledge, clinical skills, and interpersonal skills that may otherwise go unrecognized until students are fully immersed in their clinical rotations.
Methods: Seven individuals were recruited to serve as mock patients for students enrolled in the History and Physical Examination II course at Duquesne University during the spring 2004 semester. Each patient had extensive experience in the healthcare system as a consumer. Patients were given a pre-encounter overview of the course and its major learning objectives and were asked to provide their own medical history when interviewed by the students and to comply with the physical examination. During the patient encounter, students were observed and evaluated not only by a faculty member using standardized, institutional competency checklists, but also by the mock patients for: (1) communication and interviewing skills, (2) social interactions, and (3) professionalism, using a post-encounter-written, self-administered evaluation questionnaire requiring patients to rate the students on a scale from 1 to 10 on 13 specific items.
Results: Thirty students, seven racially diverse patients, and seven faculty members participated in this academic exercise. Overall, the students performed well in all 13 categories and were rated highest in respecting personal space (mean 9.6; range 8-10) and acting in a professional manner (mean 9.56; range 5-10). Students were rated the lowest on allowing enough response time for answers while obtaining the history (mean 8.93; range 5-10) and on providing clear instructions during the physical examination (mean 8.88; range 4-10). However, as evident from the score ranges, individual students were identified through this process who were given low scores for particular items, information that was not fully evident to program faulty prior to the patient encounters. Patient evaluation thus served to inform program faculty of potential individual students' needs for additional focused attention on practicing and developing interpersonal skills. Students participating in this exercise were very interested in how they were evaluated by their patients and were responsive to constructive criticism based on patient evaluations.
Conclusions: Competency-based evaluation of PA students by program faculty during the initial, traditionally didactic phase of learning is, of necessity, limited by a lack of authenticity in evaluating student interpersonal skills when working with patients. With minimal training, standardized patients may serve as highly useful evaluators for student interpersonal abilities, thus informing program faculty of student needs early in training, needs that otherwise may remain unknown or may be revealed only late in training by chance encounters with patients and/or clinical preceptors personally willing to report student interpersonal skill deficiencies.
35. Integration of a Long-term Care Experience into Physician Assistant Education
D. Coniglio, P. Dieter, J. Copeland, and P. Castillo, Duke University PA Program, Department of Community and Family Medicine, Durham, North Carolina
Introduction: The aging population, and the growing need of health care consumers for long-term medical care in aging and special needs populations has made integration of a long-term care (LTC) experience a necessary part of the didactic and clinical education for PA students. The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) Standards state that PA students should have clinical experience in the long-term care setting. We describe here a model for integrating a long-term care experience into the didactic and clinical experience for PA students enrolled at our institution.
Methods: Initial planning for the LTC experience included developing a course syllabus, preparing didactic material, identifying course instructors and preceptors, and securing appropriate institutional affiliation agreements with local LTC facilities. The course was integrated into an existing course, Patient Assessment, in which students learn the requisite skills for obtaining and presenting the History and Physical Examination (H&P). Elements of the H&P unique to the long-term care setting were taught by the LTC preceptors. Over a 10-week period, students were given didactic instruction and made three visits to the LTC facilities. Each encounter lasted four hours and included time for small group interaction with the preceptor and additional time for the students to perform assessments. Each visit was structured to introduce a new element of the LTC curriculum: history, physical, and functional assessment. Student performance was assessed by program faculty evaluation of a written H&P, one of several elements of the patient assessment course.
Results: At the conclusion of the course, the students were asked to evaluate the LTC experience. More than 70% of survey respondents agreed or strongly agreed that instructors were well prepared, available for student instruction, and knowledgeable in the content area; 4%-12 % of respondents had no opinion; and 4%-12% of respondents did not agree or strongly disagreed that preceptors were well prepared, available, or content knowledgeable. 59% of respondents agreed or strongly agreed that the LTC experience was a valuable part of the curriculum, with 14% having no opinion, 25% disagreeing or strongly disagreeing. 95% of respondents disagreed or strongly disagreed with the timing of the LTC experience in the curriculum, with 5% having no opinion.
Conclusion: This LTC experience was integrated into a patient assessment course to give students didactic instruction regarding the assessment of the LTC patient, with clinical encounters scheduled on three occasions over 10 weeks. The students rated the exposure to the unique nature of long-term care a valuable addition to their didactic and clinical training. Post-course evaluation of the LTC experience by students and faculty indicate a need for a closer integration of this experience with the geriatrics component of clinical medicine rather than patient assessment; and, additional didactic instruction in LTC assessment tools to complement the clinical experience.
36. Attitudes of PAs Toward Nutrition Education and Nutrition Issues Encountered in Clinical Practice
H. Coker, O. Chen, and P. Smith-Barbaro, University of Texas Health Science Center at Fort Worth, Fort Worth, Texas
Purpose: Nutrition education has been recognized as an important part of medical training, but physicians often feel unprepared when providing nutrition education to their patients because of lack of adequate nutrition training. The purpose of this study was to investigate how often PAs, who are trained in the medical model, encounter patients needing nutrition education or medical nutrition therapy, and to assess how comfortable PAs feel when attempting to address those needs.
Method: The investigators developed a 26-question, self-reported survey instrument with no subject identifiers, which was designed to be completed in approximately 10 minutes. The survey was reviewed for content by three registered, licensed dietitians and reviewed for clarity by two advanced practice nurses and one public health specialist. The prospective participants consisted of 718 PAs practicing in Texas. E-mail addresses of the participants were obtained with permission from the Texas Association of Physician Assistants. An e-mail was sent to the PAs asking them to participate in the survey. The e-mail included a link to a Web site that the prospective participants could select to respond to the survey. After the Web surveys were completed, responses were pulled into the Web Excel database. Chi square statistical analysis was performed using SPSS (11.2) to test the statistical differences among sets of data.
Results: Seven hundred eighteen PAs received the e-mails and 134 PAs responded (18% response rate). Eighty percent of respondents reported that their patients had nutrition-related inquiries at least once per day and sometimes up to 10 times per day. Most (77.7%) PAs who responded to the survey felt competent or very competent providing basic preventive nutrition counseling as well as disease specific nutrition counseling (70.0%). PAs' sense of competency had a significant correlation with a positive perception of the nutrition education that they received in PA school (X2= 21.360, p<.01). Those who felt competent in their abilities spent more time in basic nutrition therapy (X2=26.593, p=.002) and disease-specific nutrition therapy (X2=29.521, p=.001) than those who felt less incompetent. Another important finding was that those PAs who felt more competent in their abilities spent more time discussing nutrition issues with their patients than those who felt less competent (X2= 29.521, p<.001).
Conclusion: If, in fact, nutrition knowledge is an important part of medical training and practice, it would be prudent for PAs to become knowledgeable and competent in core nutrition guidelines. Based on the results of this survey, many PAs in Texas feel that nutrition education is important to their professional education and future practice. Educators in PA programs may need to consider these issues in curriculum planning. PAs, for the most part, feel a good degree of competency in educating their patients on nutrition; however, whether or not their feelings of competency truly reflect competency may need to be determined by further research.
37. Comparison of Empathy Scores in Physician Assistant Students and Physician Assistants in Clinical Practice
J. Altland, R. Fedor, C. Leatherman, J. Spencer, and B. Biearman, Chatham College, Pittsburgh, Pennsylvania
Purpose: The purpose of this study was to evaluate and compare empathy scores in PA students and PAs in clinical practice. Empathy is the vicarious experience of another's feelings. Empathy is important in encouraging open communication between the clinician and patient, and studies have shown that providing support and reassurance to patients significantly influences positive health outcomes.
Previous studies performed using a population of medical students has shown that there is a decline in empathy scores of medical students during medical school. This study seeks to establish if empathy in PAs deteriorates as they leave graduate school and enter clinical practice.
Methods: The population of this study consisted of PA students from the classes of 2004, 2005, and 2006 from two PA programs, and clinically practicing PA volunteers from the 2004 state physician assistant conference. These subjects were administered a revised version of the Jefferson Scale of Physician Empathy consisting of 20 Likert-type items. Associations between empathy scores, gender, and time in practice or school will be analyzed using an independent means t-test, analysis of variance, and correlation coefficients. The empathy scores for the PA students and the PAs in clinical practice will be compared by a t-test for independent means and correlation coefficient, while controlling for gender. The level of significance will be set at P <0.05 and all t-tests will be two-tailed.
Results: Results for this study are currently pending and data collection is ongoing. It is anticipated that the empathy scores in PA students will be higher than those in PAs in clinical practice and that the scores will accordingly decrease within these populations with increasing time in graduate school or clinical practice, respectively.
Conclusions: There have not been any studies published comparing the empathy scores between PA students and PAs in clinical practice. However, research has shown that PA students consistently scored higher on an observer-rated instrument of empathetic skills than medical students. Other studies have shown that providing support and reassurance to patients significantly influences positive health outcomes, leading to ensuing inclusion of empathy-cultivating educational objectives in many medical school curriculums. Physician assistants are intimately involved with patient care and education. Therefore, early understanding of empathy as well as maintenance of this trait should be an important aspect of PA programs to instill in their students in an effort to help promote better health care standards and subsequent better patient outcomes.
38. Developing an Academic Medicine Rotation in a Physician Assistant Program
C. Elinsky and G. Furey, Massachusetts College of Pharmacy and Health Sciences, Manchester, New Hampshire
Purpose: The purpose of this research project was to identify the PA programs who have an existing rotation in academic medicine, to determine the contents of the rotation, and to determine how the student is evaluated for the rotation. Identifying what exists at present may assist programs in developing or augmenting a rotation in academic medicine. In addition, providing students with initial formal training may in time ameliorate the PA faculty shortage.
Methods: A survey of all 134 PA programs was conducted to obtain information regarding the rotation in academic medicine. The survey was approved by Massachusetts College of Pharmacy and Health Sciences Internal Review Board as well as the APAP Research Institute.
SurveyMonkey (SurveyMonkey.com) was used as the vehicle to deliver this survey via e-mail to each of the 134 programs. Ten questions were composed and were as follows:
1. What is the length of your program in months?
2. How long has your program been in existence?
3. What is the number of clinical students per year?
4. Do you or are you in the process of developing a rotation in academic medicine for the clinical phase students?
5. What is the length of the rotation?
6. Which of the following activities are included in the rotation?
7. What of the following are additional rotation requirements of the rotation?
8. How are the students evaluated?
9. How long have you offered this rotation?
10. How many students per year participate in the academic medicine rotation?
Results: To date, 45 of the 134 programs responded to the survey. Information obtained from the returned surveys included the following: 44% of the respondents are 24 months in length, 41% of the respondents have been in existence for 6-10 years, 40% of the respondents have 31-40 clinical students per year, 28% of the respondents have or are in the process of developing an academic medicine rotation for students, 87% of the respondents have clinical rotations 4-6 weeks in length, 43% of the respondents have offered the rotation for >5 years, and up to 6 students participate each year of those who responded. Regarding the content area of the academic medicine rotation, the following information was obtained: lecturing, tutoring, case presentations to junior students, laboratory assisting, curriculum planning, site visits, and shadowing core faculty or administrators are activities included in the rotation. Additional requirements of the rotation include completion of a research project and mandatory readings. Evaluation of the students included a faculty evaluation, end of rotation exam, and/or a research paper.
Conclusions: Valuable information has been gathered regarding the present status of academic medicine rotations in PA programs. This information may allow PA programs the opportunity to develop or expand on an academic medicine rotation. By providing an academic medicine rotation, there is great potential for the talented and interested PA student to enter and remain in academia, which would be a great asset in these days of PA faculty shortage and for the growth of the profession.
39. Efficacy of a Multidisciplinary, Family-based Weight Control Program and the Role of Incentives for Physical Activity in Improving Outcomes for Obese Children
A. Prudhomme, J. Mickow, D. LaBarabera, and V. Hammarlund, Rosalind Franklin University, Physician Assistant Program, Chicago, Illinois
Objective: The purpose of this study was to investigate the efficacy of a multidisciplinary, family-based weight control program and the role of incentives (gift certificates) for physical activity in improving outcomes for obese children.
Methods: Forty-one obese children (BMI > 95th percentile), aged 6-17 years, completed a 26-week weight control program between January 2001 and June 2004. The program included a high protein/moderate fat diet, fun physical activities, and behavior modification. Support strategies included weekly parental participation and group sessions including up to 15 children.
After an initial medical evaluation, children were given individualized diets, physical activity prescriptions, and take-home materials. They participated in weekly two-hour sessions. A game-playing, hands-on approach was used to teach the basic principles of good nutrition, portion control, regular physical activity, and other healthy lifestyle habits. Additional related take-home materials were strategically distributed. Anthropometric measurements (height, weight, percent body fat, BMI) and fasting blood lipids levels (total cholesterol, LDL, HDL, triglycerides) were obtained at the beginning and end of the program.
Participants were asked to record types and amounts of physical activity on a one-page Weekly Activity Record, which was confirmed by a parent's signature. Completion of a total of 60 minutes of activity per day for five days per week was required to earn a weekly incentive of one $10 certificate to a local athletic store.
Differences between high and low certificate earners, genders, and ages were investigated with independent t-tests. Changes in anthropometric and laboratory values were analyzed with paired t-tests. The relationship between the number of certificates earned and weight loss parameter changes was examined with Pearson Product Moment Correlations. For all statistical tests, ?=0.05.
Results: Descriptive statistics were reported for anthropometrics, lipids, and other data for the 24 male and 17 female subjects. Subjects were not statistically different at the beginning or end of the program in terms of anthropometric measurements or lipid levels by gender. Similarly, no differences were found for low vs. high earners or for younger vs. older children.
The weight control variables demonstrated statistically significant improvement after program participation except for triglycerides (weight, BMI, and percent body fat, p<0.01; total cholesterol and LDL, p=0.01; HDL, p=0.02).
The mean number gift certificates earned was 3.15 + 4.67 (ranging from 0 to 17). Correlation coefficients between certificates earned and outcomes were very low and without significance.
Extreme values in two cases (17 certificates each) were preadolescent males of a medium socioeconomic status with a high degree of support and engagement from both parents.
Conclusion: Children participating in a 26-week multidisciplinary, family-based weight control program achieved statistically significant improvements in anthropometric and lipid values, irrespective of gender, age divisions, or certificates earned. Although incentive data did not demonstrate statistical significance, further study is warranted based on the favorable response for some subjects.
40. Evaluating Health Care Delivery to Patients of Limited English Proficiency at Abington Memorial Hospital
A. Casimir, M. O'Brien, and D. Schneider, Arcadia University, Glenside, Pennsylvania
Background: Between 1990 and 2000, the United States experienced the largest influx of immigrants in its history. As a result, the number of people who spoke a language other than English increased. The U.S. Department of Health and Human Services developed the term Limited-English Proficiency (LEP) to identify the portion of population who are non-English-speaking or limited-English speaking. Studies conducted on the delivery of health care to these individuals have found that communication barriers impede health care access, utilization, and the overall quality of care.
Purpose: The purpose of this study is to evaluate the delivery of health care for patients of LEP and those of non-LEP in an ambulatory care setting. Specifically, we will focus on the delivery of preventive screening measures, such as mammogram, blood pressure, colon and prostate cancer, and influenza vaccine administered in the last 12 months. Based on the results of this study, recommendations will be made on improving the delivery of care at Abington Memorial Hospital.
Methods: A convenience sample will be selected at the Ambulatory Service Unit at Abington Hospital. Criteria for inclusion are patients age 18 or older who have an established medical history in the clinic and speak a primary language of Spanish, Korean, or English. A standardized English Proficiency Scale will be used to identify patients of LEP and those of non-LEP. The scale consists of scenarios in which the patients are asked to respond on how well they feel they would be able to interact in English in the given scenarios. The responses are based on a four-item descriptive Likert scale. After identifying our sample, data will be collected from retrospective chart reviews. The purpose of the chart review is to identify preventive screening measures that have been offered to these patients in the last 12 months.
Results: Results are pending. Data will be analyzed to test the null hypothesis that there is no difference in the delivery of care between LEP and non-LEP patients. Approval from the Institutional Review Boards of Arcadia University and Abington Memorial Hospital was received in January 2005. There will be a two-month data collection period starting in January 2005.
Conclusion: We expect our study will show some insight as to whether the delivery of health care to patients of LEP differs from non-LEP patients. We also anticipate that if there is a difference, the main reason for differences in care may be patients' difficulty in communicating with their providers. Therefore, our goal is to provide recommendations for the clinic on how to bridge the gap in communication and hence improve the delivery of health care to the overall patient population.
41. Factors Influencing Physician Assistants to Practice in Pediatric Specialties
J. DeSocio, P. Pagels, and O. Chen, University of North Texas Health Science Center, Fort Worth, Texas
Purpose: The purpose of this study was to better understand the factors that influenced clinical PAs to choose work in pediatric specialties.
Methods: The sample consisted of 1,241 PAs registered with Louisiana, Oklahoma, or Texas state chapters of AAPA. A survey containing 21 questions was developed to collect the data. The researchers sent out e-mails to invite the above PAs to participate in the research. This cover letter summarized the goals of this study and contained an URL that linked to the survey. The PAs accessed the survey by selecting the URL from within the cover letter. The following week, a reminder e-mail was sent to the same sample population. After completing the data collection, Statistical Package of Social Science software version 11.0 was used to perform descriptive analysis.
Results: A total of 402 PAs responded to the survey (response rate of 32.4%). After excluding some uncompleted surveys, the valid surveys were 378. Twenty-nine (7.7 %) respondents were PAs working pediatric jobs, 30 (7.9 %) worked a pediatric job in the past, 279 (73.8 %) had never worked in pediatrics, and 40 (10.6 %) respondents did not specify.
Among the 59 respondents who had worked a pediatric job during their PA career, the most popular factors influencing the pursuit of this pediatric job were: practice site location (22.0%), salary/benefits (18.6%), and patient population (15.3%). The top reasons for terminating pediatric jobs were: other (19.2 %), salary/benefits (15.4 %), and patient population (15.4 %). Almost half (41.9%) of the respondents without prior pediatric job experience reported they would consider pediatrics for future employment. Nearly all respondents (96.6%) currently working in pediatrics planned to continue their job.
Conclusions: The results of this study showed that PAs of various clinical experiences reported a high interest in pediatrics, and those PAs currently working pediatric jobs indicated an overwhelming willingness to remain working in pediatric medicine. However, only 4% of clinical PAs have worked in pediatric jobs over the last decade. Revealing the factors influencing PAs to pursue pediatric medicine can provide useful information on recruiting PAs to enter pediatric specialties.
The results indicated that salary/benefits and patient population are top factors for both accepting and terminating pediatric employment. Offering improved salary /benefits options may be the key to increasing PA employment within pediatric medicine.
Major limitations of this study included a low response rate, incomplete non-randomized cluster sampling, and a lack of significance testing. Future studies should direct at including sampling pediatricians and nurse practitioners to the study, increase sample size, and avoid "if-then" type of questions on the survey.
42. GEMS: Group Education of Metabolic Syndrome
G. Moyer, E. Hillier, S. Eli, and B. Biearman, Chatham College, Physician Assistant Program, Pittsburgh, Pennsylvania
Background: Metabolic Syndrome, also known as Syndrome X, is defined as the combination of concomitant insulin resistance, obesity, hypertension, and dyslipidemia. Because of the prevalence of this syndrome, managing these conditions can be difficult using standard medications alone without educating patients about this syndrome as one disease. GEMS, Group Education on Metabolic Syndrome, is a six-session educational program based on the Health Yourself! Healthy Lifestyles curriculum, a program developed to help educate participants about proper nutrition and diet, exercise and fitness, and conducting a healthy lifestyle. GEMS will include discussions on Metabolic Syndrome, highlighting the conditions that make up the disease and educating participants about effective ways to help control this condition.
Purpose: To determine the effect of GEMS on Metabolic Syndrome.
Methods: The study was a prospective six-session program extending over a 12-week period. Ten participants, all of whom were underserved women with Metabolic Syndrome, greater than 18 years of age, and patients of the Northside Christian Health Center, volunteered to participate in this program. Women who volunteered, but were excluded, included those who did not meet the criteria for Metabolic Syndrome as previously diagnosed by clinicians at Northside Christian Health Center, those who did not receive medical clearance from the clinicians at Northside Christian Health Center, and those who were pregnant during the time of the study. Prior to the first session, each participants' most recent fasting blood glucose level, hemoglobin A1c, fasting triglycerides, and cholesterol were obtained from the participants' charts at the Health Center. These laboratory values were obtained again by the clinicians at Northside Christian Health Center following the completion of the GEMS program. At the first session, an epidemiological survey was given. At each successive session, participants' height, weight, pulse, and blood pressure were measured and important topics relevant to Metabolic Syndrome were discussed in a group interactive fashion.
Results: Data are pending as the study is ongoing. The efficacy endpoint of the GEMS program was decrease in the participants' weight, pulse, blood pressure, fasting hemoglobin A1c, blood glucose, cholesterol, and triglyceride levels from baseline following completion of the program.
Conclusion: Metabolic Syndrome effects more than 20% of American adults and its incidence continues to rise with the increasing weight and age of American society. Intensive, small-group patient education about the disease with a focus on lifestyle modification, as used with the GEMS program, adds an additional beneficial element to complete health care for women with Metabolic Syndrome.
43. Knowledge of Suicide Risk Factors in the Elderly: A Survey of Second-year Physician Assistant Students
C. Hayes, B. Wolf, and B. Biearman, Chatham College, Physician Assistant Program, Pittsburgh, Pennsylvania
Purpose: Suicide was the 11th leading cause of death in the United States in 2002. Among the populations who commit suicide, the rate for the geriatric population is higher than at any other point in the course of life. A consistent finding in many studies of suicide in older populations is the observation that a large number of elderly suicide victims had seen a primary care provider in the last days to weeks of life. There have been few, if any, studies conducted to determine how knowledgeable primary care providers are at determining suicide risk factors in the elderly. Because almost half of the students currently enrolled in a PA program will go on to employment in primary care, this study aims to determine the knowledge base of second-year PA students regarding elderly suicide characteristics and risk factors.
Methods: The population for the study consisted of all second-year PA students from three PA programs. All participants received a two-part survey. The first section of the survey included questions regarding the participants' age, gender, school currently attending, and whether or not they wish to work in primary care. The second section consisted of statements to which students were asked to respond on a four-point modified Likert scale (strongly agree, agree, disagree, strongly disagree). The statements were designed to test the participant's knowledge about the epidemiology, risk factors, and clinical characteristics of suicide and depression in the elderly. The questions focused on risk factors and characteristics of elderly depression and suicide as reported in the current literature. The frequency of agreement and disagreement will be compared for each individual knowledge question. Logistic regression analysis will be used to examine the determinants of knowledge using the following predictors: gender, school at which they are currently attending, and whether or not they wish to work in primary care in the future. The modified Likert scale will be dichotomized for use in logistic regression analysis (strongly agree/agree versus disagree/strongly disagree). The level of significance will be set at p< 0.05.
Results: Currently, the results of this study are pending as survey collection and analysis are ongoing. Preliminary results indicate that second-year students are generally knowledgeable regarding the epidemiology, risk factors, and clinical characteristics of suicide and depression in the elderly. In addition, we plan to examine determinants of knowledge such as gender and the school at which the student currently attends.
Conclusions: There have been no studies conducted to determine the knowledge base of PA students regarding suicide risk factors in the elderly. Almost half of the students currently enrolled in a PA program will go on to employment in primary care. It is therefore important to determine whether students are equipped to detect elderly suicide characteristics as older depressed patients are more likely to see a primary care provider than a mental health worker. Increased knowledge is the key to intervention in preventing suicide among the elderly.
44. The Impact of the PA Student's Clinical Experiences on the PA National Certifying Exam Blueprint and PA National Certifying Exam Scores
A. Protzik, C. Marzano, C. McCaffrey, A. Zella, and B. Biearman, Chatham College, Physician Assistant Program, Pittsburgh, Pennsylvania
Purpose: The purpose of this retrospective study was to determine the influence of the PA student's clinical experiences, at the professional level of their education, in relationship to Physician Assistant National Certifying Exam (PANCE) blueprint and ultimately PANCE scores.
Methods: Physician assistant students from an urban PA program retrieved patient log records from graduating classes of 2003 and 2004. Ten students' records were chosen at random from each of the main disciplines of study including: primary care, internal medicine, women's health, surgery, and pediatrics. Diagnosis was correlated with the body system categories on the PANCE blueprint. PANCE scores were obtained from NCCPA for these two classes from this PA program. Data will be evaluated by exploratory data analysis and Chi square.
Results: It is anticipated that the more closely clinical experiences correlate with the PANCE blueprint, the more successful the students will be on the PANCE as reflected by their scores.
Conclusion: The literature is replete with information identifying predictors of success of a PA. In addition to degree granted, program length, and other program characteristics, this study will show a positive relationship between clinical experiences and PANCE scores. Evaluation of clinical experiences may be considered as other predictors of success for the future of the PA.
Case Studies/Clinical Reports
45. Maisonneuve Fracture in a 17-year-old Male
S. Muller, M. Vacala, and L. Martin, South University Physician Assistant Program, Sandersville, Georgia
Introduction: Injuries to the ankle joint result in approximately 10% of emergency room visits, and ankle fractures are one of the most common injuries treated by orthopedic surgeons. The most common ankle injury is the inversion ankle sprain. Medial ankle injuries involving the deltoid ligament are much less common. When they do occur, these injuries usually involve the syndesmosis, and may include a fracture in the ankle joint or lower leg. A fracture that involves the proximal fibula is known as a Maisonneuve fracture, and is considered to be a highly unstable ankle injury. This instability is attributed to the disruption of the syndesmosis ligament and interosseous membrane. Depending on the severity of the injury, the Maisonneuve fracture may be treated either conservatively or surgically. This case presentation discusses screw fixation for the surgical treatment of a Maisonneuve fracture, and how this treatment option allowed the patient to return to high school athletics.
Case Report: A 17-year-old white male injured his left ankle while skim boarding at the beach. Orthopedic evaluation three days following the injury revealed tenderness in the proximal fibula. There was significant tenderness over the medial malleolus and deltoid ligament, with slight tenderness over the lateral ligaments and with dorsiflexion of the foot. Radiographs taken at the emergency room reveal a talar shift of about 2 millimeters of the ankle. Anterior-posterior and lateral radiographs reveal a spiral fracture of the proximal fibula about 6 centimeters distal to the proximal tip. The patient was a senior in high school and was a three sport all-state athlete. Surgical intervention was preferred by the patient with the hopes of returning to athletic activity at some point during his senior year. The patient was prepared for surgery, and a 4.5-millimeter Synthes screw was placed in the center of the fibula, aiming slightly anteriorly from slightly posteriorly. Postoperatively, the patient's leg was stable to external rotation stress. Postoperative management consisted of placing the patient in a cam walker. He was non-weight-bearing on crutches for six weeks. Gentle active dorsiflexion and plantarflexion exercises began at 10 days postoperative, and a physical therapy program was initiated at three weeks postop. The syndesmotic screw was removed at eight weeks and progressive rehabilitation continued. At week 13, the patient began light practice with his football team, and at week 15 he started at quarterback for his team. He played the final six football games and led his team to a state championship. He played in 30 basketball games and led his team to a state basketball championship as well. He was also able to compete in baseball.
Conclusion: Ankle injuries that involve the syndesmosis have a high risk for chronic pain, arthrosis, and ankle instability. A syndesmotic injury with a Maisonneuve fracture is a severe but uncommon injury and requires appropriate treatment. As presented in this case, it is important for the clinician to consider the patient's goals when determining a treatment plan for this injury.
