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Biomedical subjects

L Sheppard

Publications and source records attributed to L Sheppard.

At least 37 records · Page 2Linked to original sources

Variability in annual Mini-Mental State Examination score in patients with probable Alzheimer disease: a clinical perspective of data from the Consortium to Establish a Registry for Alzheimer's Disease.

OBJECTIVE: To determine the variability in annual Mini-Mental State Examination scores of patients with Alzheimer disease enrolled in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD). PATIENTS: A total of 372 patients with probable Alzheimer disease with 1 or more years of follow-up. SETTING: Twenty-one CERAD clinical sites throughout the United States. RESULTS: An average annual decline of 3.4 points in CERAD patients returning for longitudinal reassessments was close to the SD of the measurement error of 2.8 points for the Mini-Mental State Examination. There was wide variability in individual rates of decline. Even with 4 years of follow-up, 15.8% of the patients had no clinically meaningful decline in Mini-Mental State Examination score (defined as a change in initial score >3, ie, 1 SD of measurement error). Validity of measurements of the rate of change in Mini-Mental State Examination scores improved with longer observation intervals and was reliable for most patients when observations were separated by 3 or more years. CONCLUSIONS: Although the Mini-Mental State Examination is a useful screening instrument to assess level of cognitive function, it has limited value in measuring the progression of Alzheimer disease in individual patients for periods less than 3 years because of a large measurement error and substantial variation in change in annual score.

Aged↗

Differences in stakeholder expectations in the outcome of physiotherapy management of acute low back pain.

OBJECTIVE: To compare stakeholder expectations of outcome of physiotherapy management of acute low back pain. DESIGN: Observational design using interviews and questionnaires. SETTING: Practice/workplace. STUDY PARTICIPANTS: The study sample was from South Australia. It comprised 74 physiotherapists randomly selected from professional association listings (49.3% response rate), 121 physiotherapy patients (recruited by participating physiotherapists when attending their first physiotherapy treatment for acute low back pain), 21 general practitioners randomly selected from medical practitioner listings in the metropolitan telephone book (36.2% response rate) and 13 third party payers of a total of 16 available insurers in the metropolitan area (82% response rate). MAIN OUTCOME MEASUREMENTS: Stakeholders reported expectations of outcome at the end of the first treatment session and at the completion of the episode of care. RESULTS: There were differences in expectations between stakeholders, as well as between naive and experienced patients. Overall, patients expected symptom relief at the end of the first treatment. Naive patients decided to return for further treatment based on the relationship established with the therapist, whereas experienced patients also expected some advice on their condition during the first contact. Physiotherapists and referrers expected symptom relief and then long-term management strategies to be provided, and third party payers expected cost-efficient management of the condition and patient satisfaction. CONCLUSION: Physiotherapists need to address potential imbalance of consumer knowledge and foster a quality partnership with their patients on the first visit to physiotherapy. Patients who are in pain may not derive full value from information provided in an untimely manner.

Acute Disease↗

Episodes of high coarse particle concentrations are not associated with increased mortality.

Fine particle concentration (i.e., particles <2.5 microm in aerodynamic diameter; PM2.5), but not coarse particle concentration, was associated with increased mortality in six U.S. cities. Others criticized this result, arguing that it could result from differences in measurement error between the two size ranges. Fine particles are primarily from combustion of fossil fuel, whereras coarse particles (i.e., particles between 2.5 and 10 microm in aerodynamic diameter) are all crustal material, i.e., dust. One way to determine if coarse particles are a risk for mortality is to identify episodes of high concentrations of coarse, but not fine, particles. Spokane, Washington, is located in an arid area and is subject to occasional dust storms after crops have been harvested. Between 1989 and 1995, we identified 17 dust storms in Spokane. The 24-hr mean PM10 concentration during those storms was 263 microg/m3. Using control dates that were the same day of the year in other years (but with no dust storm on that day) and that had a mean PM10 concentration of 42 microg/m3, we compared the rate of nonaccidental deaths on the episode versus nonepisode days. There was little evidence of any risk [relative risk (RR) = 1.00; 95% confidence interval (CI), 0.81-1.22] on the episode days. Defining episode deaths as those occurring on the same or following day as the dust storm produced similar results (RR = 1.01; CI, 0.87-1.17). Sensitivity analyses, which tested more extensive seasonal control, produced smaller estimates. We conclude that coarse particles from windblown dust are not associated with mortality risk.

Air Pollutants↗

An association between fine particles and asthma emergency department visits for children in Seattle.

Asthma is the most common chronic illness of childhood and its prevalence is increasing, causing much concern for identification of risk factors such as air pollution. We previously conducted a study showing a relationship between asthma visits in all persons < 65 years of age to emergency departments (EDs) and air pollution in Seattle, Washington. In that study the most frequent zip codes of the visits were in the inner city. The Seattle-King County Department of Public Health (Seattle, WA) subsequently published a report which showed that the hospitalization rate for children in the inner city was over 600/100,000, whereas it was < 100/100,000 for children living in the suburbs. Therefore, we conducted the present study to evaluate whether asthma visits to hospital emergency departments in the inner city of Seattle were associated with outdoor air pollution levels. ED visits to six hospitals for asthma and daily air pollution data were obtained for 15 months during 1995 and 1996. The association between air pollution and childhood ED visits for asthma from the inner city area with high asthma hospitalization rates were compared with those from lower hospital utilization areas. Daily ED counts were regressed against fine particulate matter (PM), carbon monoxide (CO), sulfur dioxide, and nitrogen dioxide using a semiparametric Poisson regression model. Significant associations were found between ED visits for asthma in children and fine PM and CO. A change of 11 microg/m3 in fine PM was associated with a relative rate of 1.15 [95% confidence interval (CI), 1.08-1.23]. There was no stronger association between ED visits for asthma and air pollution in the higher hospital utilization area than in the lower utilization area. These findings were seen when estimated PM2.5 concentrations were below the newly adopted annual National Ambient Air Quality Standard of 15 microg/m3.

Adolescent↗

Reproductive and offspring developmental effects following maternal inhalation exposure to methanol in nonhuman primates.

INTRODUCTION: In an effort to improve air quality and decrease dependence on petroleum, the federal government, industry, and other groups have encouraged development of alternative fuels such as methanol to substitute for gasoline or diesel fuel. Methanol is also a candidate to provide the hydrogen for fuel cells, which are being developed for a variety of power sources (including motor vehicle engines). Before people are exposed to increased concentrations of methanol, the potential health effects of such exposures require study. Methanol, a simple alcohol containing one carbon atom, occurs naturally in plants and animals and participates in human metabolism. People regularly consume low doses of methanol in fruits, vegetables, and fermented beverages as well as soft drinks and foods sweetened with aspartame (which breaks down to methanol in the gastrointestinal tract). Despite its ubiquitous presence, methanol can be highly toxic if sufficient quantities are consumed. Ingestion of methanol (usually in the form of wood alcohol or tainted alcoholic beverages) can result in metabolic acidosis, blindness, and even death. Although the body has the capacity to metabolize the low doses of methanol to which people are regularly exposed, it cannot handle high doses because too much methanol overwhelms the body's ability to remove a toxic metabolite (formate). When formate accumulates, methanol poisoning occurs. One factor that regulates the rate at which formate is removed is the liver level of a derivative of the vitamin folic acid. People who are deficient in folic acid (including 15% to 30% of pregnant women) may be particularly susceptible to the toxic effects of methanol. If methanol were to be widely adopted as a fuel, environmental exposures would increase through ingestion of contaminated drinking water, inhalation of vapors from evaporative and other emissions, and dermal contact. Current concentrations of methanol in ambient air are very low, 1 to 30 parts per billion (ppb). If all motor vehicles in the United States were converted to 100% methanol fuel, methanol levels in ambient air are estimated to increase approximately 1,000-fold (to 1 to 10 ppm in cities) and in a worst-case situation could occasionally reach concentrations as high as 200 ppm in enclosed spaces (HEI 1987). Inhaling these concentrations of methanol for short periods of time is not predicted to affect formate production and thus should not present a health risk. However, little is known about the consequences of long-term inhalation of methanol vapors, especially in susceptible populations of pregnant women and developing fetuses. HEI, therefore, developed a research program to address this information gap. APPROACH: Dr. Thomas Burbacher and colleagues of the University of Washington studied the effects of long-term exposure to methanol vapors on metabolism and reproduction in adult female monkeys (Macaca fascicularis) and developmental effects in their offspring, who were exposed prenatally to methanol. The investigators exposed adult female monkeys (11 to 12 animals/group) to one of four concentrations of methanol vapors (0, 200, 600, and 1,800 ppm) for 2.5 hours a day, seven days a week during the following periods: (1) before breeding, (2) during breeding, and (3) during pregnancy. They collected blood from the adults at regular intervals to monitor methanol levels (which served as a marker of internal dose) and formate concentrations. They also conducted pharmacokinetic studies to determine whether methanol disposition (which includes absorption, distribution, metabolism, and excretion) was altered as a result of repeated methanol exposures and to assess pregnancy-related changes. Because high doses of methanol damage the central nervous system, the infants (8 to 9 animals/group) were examined at regular intervals during the first nine months of life to assess their growth and neurobehavioral development. RESULTS: Exposure to methanol vapors did n

Animals↗

Effects of ambient air pollution on nonelderly asthma hospital admissions in Seattle, Washington, 1987-1994.

As part of the Clean Air Act, Congress has directed EPA to set air quality standards to protect sensitive population groups from air pollutants in the ambient environment. People with asthma represent one such group. We undertook a study of the relation between measured ambient air pollutants in Seattle and nonelderly hospital admissions with a principal diagnosis of asthma. We regressed daily hospital admissions to local hospitals for area residents from 1987 through 1994 on particulate matter less than 10 and 2.5 microm in aerodynamic diameter (PM10 and PM2.5, respectively); coarse particulate mass; sulfur dioxide (SO2); ozone (O3); and carbon monoxide (CO) in a Poisson regression model with control for time trends, seasonal variations, and temperature-related weather effects. With the exception of seasonally monitored O3, we supplemented incomplete pollutant measures in a multiple imputation model to create a complete time series of exposure measures. We found an estimated 4-5% increase in the rate of asthma hospital admissions associated with an interquartile range change in PM (19 microg/m3 PM(10),11.8 microg/m3 PM2.5, and 9.3 microg/m3 coarse particulate mass) lagged 1 day; relative rates were as follows: for PM10, 1.05 [95% confidence interval (CI) = 1.02-1.08]; for PM2.5, 1.04 (95% CI = 1.02-1.07); and for coarse particulate mass, 1.04 (95% CI = 1.01-1.07). In single-pollutant models we also found that a 6% increase in the rate of admission was associated with an interquartile range change in CO (interquartile range, 924 parts per billion; 95% CI = 1.03-1.09) at a lag of 3 days and an interquartile range change in O3 (interquartile range, 20 parts per billion; 95% CI = 1.02-1.11) at a lag of 2 days. We did not observe an association for SO2. We found PM and CO to be jointly associated with asthma admissions. We estimated the highest increase in risk in the spring and fall seasons.

Adult↗

Technology in education: what is appropriate for rural and remote allied health professionals?

Recent technological advances provide exciting opportunities for the delivery of education to rural and remote allied health professionals. Distance education modes can overcome barriers of distance and cost. However, the use of technologies may allow distance education to be more interactive for rural and remote professionals. Technologies that can be used are audioconferencing, videoconferencing, electronic mail (email), CD-ROM and the Internet. Combinations of any of these technologies and traditional forms of educational delivery are possible. The important objective is to create a learning environment that maximises interactivity and develops information literacy.

Allied Health Personnel↗

The validity of radiographic estimation of total lung capacity in patients with respiratory disease.

STUDY OBJECTIVE: To evaluate the validity of a state-of-the-art computerized planimetry technique for estimation of total lung capacity (TLC) from chest radiographs, when applied to patients with clinical lung disease receiving routine chest radiographs. DESIGN: Retrospective clinical survey. SETTING: An occupational medicine diagnostic clinic. PATIENTS: A convenience sample of 40 subjects with asbestos-related lung disease, 5 patients with nonasbestos-related restrictive defects, 15 subjects with occupational asthma, and 10 subjects with irritant tracheobronchitis. RESULTS: Estimation of TLC using state-of-the-art computerized algorithms demonstrated limited agreement with conventional measures of TLC when applied to patients with occupational lung disease receiving routine chest radiographs. The most pronounced differences occurred in patients with asbestos-related lung disease and restrictive defects, where the radiographic method of measurement significantly overestimated helium dilution TLC by 986 mL (r=0.73, p<0.001) and 1,135 mL (r=0.82, p<0.05), respectively. Good inspiratory effort was associated with significantly increased radiographic TLC relative to helium dilution TLC; however, radiographic features did not fully account for the observed differences between radiographic and helium dilution techniques. CONCLUSIONS: Our findings suggest that this planimetric technique should not be used as a substitute for conventional measures of TLC in clinic populations receiving routine radiographs. The large diagnostic group specific mean differences observed between radiographic and conventional measures of TLC also suggest that this method is of limited utility in clinical evaluation of occupational lung disease.

Adult↗

Head injury and risk of Alzheimer's disease by apolipoprotein E genotype.

Head injury and apolipoprotein E (APOE)-epsilon 4 (e4) genotype have each been associated with increased risk of Alzheimer's disease. If APOE-e4 affects neuronal viability and branching, and if response to head injury differs in e4 patients, then the association between head injury and Alzheimer's disease may vary with the presence of the e4 allele. The authors examined this association in a case-control study conducted between 1987 and 1995 among enrollees of the Group Health Cooperative of Puget Sound, a health maintenance organization in Seattle, Washington. Proxy informants reported prior head injury with loss of consciousness for 32 of 349 patients with probable Alzheimer's disease and for 16 of 342 control subjects of similar age and sex who had been randomly selected from the same population (odds ratio (OR) = 2.1, 95% confidence interval (CI) 1.1-3.8). Elevated risk was observed among men (OR = 4.2, 95% CI 1.5-11.5) but not among women (OR = 1.1, 95% CI 0.5-2.6). No significant variation in the head injury-Alzheimer's disease risk relation by APOE-e4 genotype was found among 230 cases and 309 controls (OR = 3.1 (95% CI 0.7-14.6) for persons with at least one e4 allele and OR = 2.0 (95% CI 0.8-5.2) for those without e4). Neither age, education, race, type of proxy informant, nor duration of relationship with the proxy confounded the association. Head injury with loss of consciousness, although uncommon in this sample, was associated with increased risk of Alzheimer's disease. APOE-e4 was an independent risk factor which neither modified nor confounded the association. Susceptibility to Alzheimer's disease as conferred by APOE-e4 does not appear to increase the risk associated with head injury.

Aged↗

Tuberculosis in health care settings and the estimated benefits of engineering controls and respiratory protection.

Intra-institutional spread of tuberculosis (Tb) has re-emerged as a substantial public and occupational health threat. To characterize the person-hours and lifetime risks of Tb-related morbidity and mortality, we performed a risk assessment for health care workers (HCWs) developing Tb-related morbidity and mortality at varying levels of exposure, engineering controls, and respiratory protection. Under average conditions of exposure, one Tb skin-test conversion is estimated to occur for every 2650 person-hours of work by unprotected workers. With higher exposures, a skin-test conversion for an unprotected worker may occur in as few as 3 person-hours. Use of respiratory protection is estimated to reduce risks by the following proportions: surgical mask, 2.4-fold; disposable dust, fume, mist, or disposable high-efficiency particulate air filtering (HEPA) mask, 17.5-fold; elastomeric HEPA cartridge respirator, 45.5-fold; or powered air-purifying respirator (PAPR), 238-fold. Assuming a lifetime exposure of 250 hours, the risk of a skin-test conversion is estimated to be 9%. We conclude that HCWs are at substantial risk for Tb-related morbidity and mortality, and that administrative controls, engineering controls, and respirators offer substantial benefits in risk reduction.

Humans↗

Intracranial aneurysms: detection and characterization with MR angiography with use of an advanced postprocessing technique in a blinded-reader study.

PURPOSE: To assess magnetic resonance (MR) angiography for the detection and characterization of angiographically proved intracranial aneurysms by using an advanced method of postprocessing, in a blinded-reader study. MATERIALS AND METHODS: One hundred fifty-eight vessels were examined with catheter angiography and three-dimensional time-of-flight MR angiography in 44 patients with 63 aneurysms and 15 patients with no aneurysm at catheter angiography. Postprocessing was performed off-line with an advanced multifeature-extraction, ray-tracing algorithm. MR angiograms were interpreted independently by three neuroradiologists blinded to the catheter angiographic results for presence, location, size, and morphology of the aneurysm. Proof of diagnosis was consensus reading of catheter angiograms. RESULTS: Mean sensitivity for detection of aneurysms was 75% (range, 70%-79%). As a screening tool (ie, detection of at least one aneurysm necessitating catheter angiography), mean sensitivity was 91% for all aneurysms and 95% for aneurysms larger than 3 mm. This method was not adequate for detection of lobulation or size of aneurysm. CONCLUSION: MR angiography with an advanced method of postprocessing can result in highly sensitive, specific studies for the diagnosis of intracranial aneurysms that are of sufficient size to be considered for surgical treatment, but it is inadequate for characterization of aneurysms.

Adult↗

Structuring the acquisition and retrieval environment to facilitate learning in individuals with dementia of the Alzheimer type.

Three experiments using variations of the Subject Performed Task (SPT) paradigm examined whether structuring the learning and retrieval environment would improve learning in individuals with mild to moderate dementia of the Alzheimer type (DAT). Experiment 1 examined the role of enactment at encoding and retrieval, and found that with appropriate retrieval support DAT volunteers do benefit from enactment at encoding. Experiment 2 showed that recall was further enhanced when the list of SPTs formed a cohesive, goal-directed sequence of actions. In Experiment 3, DAT subjects acquired a more complex action-based sequence and maintained it accurately over a short period of time. It is concluded that the provision of contextual support at encoding and at retrieval can enhance residual memory in individuals with DAT.

Aged↗

Impact of sample selection on APOE epsilon 4 allele frequency: a comparison of two Alzheimer's disease samples.

OBJECTIVE: In a highly selected sample of unrelated Alzheimer's disease (AD) patients, we found that the APOE epsilon 4 allele frequency was higher than previously reported. Differing selection and ascertainment criteria may lead to these differences. To address this possibility, we compared the epsilon 4 allele frequency in two samples of AD patients selected from the same geographical area. SETTING AND PARTICIPANTS: Cases (n = 55) and controls (n = 99) from a research clinic-based sample were compared with subjects (n = 537) from a community-based AD patient sample. The samples consisted of unrelated cases who met NINCDS/ADRDA criteria for probable AD. DESIGN AND MEASUREMENTS: Clinical characteristics and APOE genotype data were obtained from AD cases and controls from both samples. RESULTS: Frequency of APOE epsilon 4 allele in the research cases compared with the community cases (0.45 vs 0.36) was nearly significant. We compared demographic and clinical characteristics that might account for this difference and found that the research cases were younger, had an earlier age of onset, and had more advanced disease than the community cases. After onset age was controlled, there was no overall difference between epsilon 4 allele frequency of the two samples. CONCLUSIONS: We found that the epsilon 4 allele frequency tended to be higher in the research AD sample compared the community-based sample. The two samples differed in several demographic and clinical characteristics. We conclude that research-based samples may lead to enrollment of younger patients with more severe disease who have higher APOE epsilon 4 allele load. This potential selection bias must be considered in the interpretation of studies of APOE allele frequency.

Age of Onset↗

Predictors of mortality in patients diagnosed with probable Alzheimer's disease.

OBJECTIVE: We sought to identify factors associated with mortality in persons recently diagnosed with probable Alzheimer's disease (AD). BACKGROUND: Predicting mortality in AD in needed both in patient care and public health planning. Previous studies have identified several factors which contribute to mortality in AD, but few longitudinal studies of population-based cohorts exist. METHODS: In a longitudinal follow-up study 327 patients with newly diagnosed probable AD (mean Mini-Mental State Examination [MMSE] score of 20) from a large, stable health maintenance organization were identified. Demographic characteristics, dementia severity, and comorbid conditions were identified at enrollment. Patients were followed longitudinally (median 3.3 years, total 898 person-years). Baseline characteristics were used to predict survival in univariate and multivariate models. RESULTS: Increased mortality was seen in patients with probable AD (9.0 deaths per 100 person-years) compared with the community population adjusted for age and gender (4.3 deaths per 100 person-years). On univariate analysis we found increased age, male gender, impairment on MMSE or Blessed dementia rating scale (DRS), rate of MMSE decline, wandering or agitation, vascular disease, and sensory impairment affecting the ability to read or hear to be moderately associated with decreased survival. After adjusting for age and gender in a multivariate model, Blessed DRS score and sensory impairment affecting the ability to read were independently associated with decreased survival. CONCLUSIONS: Short-term mortality is increased in patients newly diagnosed with probable AD. Measures of dementia severity, measures of general debility, and vascular disease are associated with increased mortality. Of these, general debility and sensory impairment were more strongly associated with shortened survival.

Aged↗

Analysis of the physiotherapy industry: challenges for marketing.

The physiotherapy industry can be analysed using Porter's (1979) five forces. Physiotherapy uses medical, geographic and funding segmentation. The power of the buyers in these segments is considerable. Substitutes are posing a threat to physiotherapy with few barriers to entry to operate in the health care environment. The suppliers, particularly doctors, have significant power in referring clients. Competitive rivalry for these clients can exist between individual physiotherapists and multi-disciplinary clinics. The difference in orientation of private and public physiotherapy can also be a basis for rivalry. Repositioning to view the client as both the supplier and recipients enables the physiotherapy industry to gain competitive advantage and ensures long term growth.

Acupuncture Therapy↗

Maximizing accuracy and precision using individual and grouped exposure assessments.

OBJECTIVES: Random errors in exposure data were explored to determine their effect on exposure-response relationships using individual, grouped, or combined (grouped and individual) exposure assessment methods. METHODS: Monte Carlo simulations were conducted by generating small "studies" of one hundred subjects divided into four exposure groups. Observed exposure data were generated for each individual using assumed inter- and intraindividual variances and a lognormal distribution. The data were used to calculate the following three estimates of exposure: an individual mean, a group mean, and a hybrid estimate using the James-Stein shrinkage estimator. The exposure estimates were regressed on generated (continuous) "health outcomes," and the regression results were stored and analyzed. RESULTS: Random errors in exposure data resulted in attenuation of the exposure-response relationship when the individual estimates were used, especially when the within-subject variability was high. The attenuation was substantially controlled by the group mean estimate, however, at a cost of decreased precision. The hybrid estimator simultaneously controlled both bias and imprecision in the observed exposure-response function. CONCLUSIONS: While estimates of exposure based on individual means may result in attenuation of the exposure-response relationship, grouped estimates may control bias while decreasing precision. Combining individual and group estimates can simultaneously control both types of error. However, further research is required to determine how robust these findings are to different error structures, grouping strategies, exposure-response models, and exposure assessment methods.

Bias↗

On the reliability and precision of within- and between- population estimates of relative rate parameters.

Comparisons of individual- and aggregate-level analyses of data from a multigroup observational study are made using an exponential form relative rate model. Stratified, analytic random effects, and aggregate random effects analyses are studied. Estimating equations are developed to give a consistent estimation procedure across analyses and corresponding information matrices are compared. Simulation studies provide insight into the efficiency and bias of relative rate parameter estimates with respect to covariate dispersion, confounding, and covariate measurement error.

Aged↗