Perceived barriers to accessing physical therapy services in Florida among individuals with low back pain

Background

Low back pain (LBP) affects up to 84% of adults and physical therapy (PT) has been reported to be an effective approach to conservative care. For those individuals with LBP referred to PT, the decision to initiate and follow through with care is influenced by numerous factors. Currently, a paucity of evidence exists to identify barriers for patients with LBP to access PT care. Thus, the purpose of this study was to investigate perceived barriers influencing the decision to pursue PT care in the state of Florida.

Methods

A purposive survey was administered via Qualtrics ESOMAR. Screener questions ensured candidates had LBP, resided in Florida, and were referred to PT. Participants that met the screener questions were offered an opportunity to participate in the full survey. Once a participant completed the full survey, variables assessing LBP, access to PT services, and potential barriers were analyzed. A partial least squares structural equation model (PLS-SEM) via WarpPLS 7.0 was used to explore which of the perceived barriers had the greatest influence on whether an individual with LBP was able to pursue PT care.

Results

The conceptual framework that demonstrated the best fit of direct effects of potential barriers to accessing care included six independent exogenous latent variables: (a) unaware of a PT clinic near their home or work, (b) had children but no childcare for them, (c) had long PT sessions (e.g., 60 min), (d) had more than one PT session per week, (e) had fewer days active per week, and (f) exercised fewer times per day. Together the six variables explained 19% of the variance related to following through with care (R ² = 0.19).

Conclusions

The ability of an individual with LBP to access PT care in the state of Florida is multifactorial. There appears to be three broad factors that are the primary barriers, which include (a) the logistic ability (location and access to childcare) to attend PT treatment, (b) how much time is dedicated to the PT treatment, and (c) activity frequency of the individual seeking care. These findings support previous conceptual frameworks for predicting PT treatment. Practitioners and policy makers should consider these barriers when developing plans for conservative management of LBP in Florida.

How Do Physicians Approach Intravenous Alteplase Treatment in Patients with Acute Ischemic Stroke Who Are Eligible for Intravenous Alteplase and Endovascular Therapy? Insights from UNMASK-EVT

BACKGROUND AND PURPOSE

With increasing use of endovascular therapy, physicians' attitudes toward intravenous alteplase in endovascular therapy-eligible patients may be changing. We explored current intravenous alteplase treatment practices of physicians in endovascular therapy- and alteplase-eligible patients with acute stroke using prespecified case scenarios and compared how their current local treatment practices differ compared with an assumed ideal environment.

MATERIALS AND METHODS

In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 of 22 case scenarios, among them 14 with guideline-based alteplase recommendations (9 with level 1A and 5 with level 2B recommendation) and were asked how they would treat the patient: A) under their current local resources, and B) under assumed ideal conditions. Answer options were the following: 1) anticoagulation/antiplatelet therapy, 2) endovascular therapy, 3) endovascular therapy plus intravenous alteplase, and 4) intravenous alteplase. Decision rates were calculated, and multivariable regression analysis was performed to determine variables associated with the decision to abandon intravenous alteplase.

RESULTS

In cases with guideline recommendations for alteplase, physicians favored alteplase in 82.0% under current local resources and in 79.3% under assumed ideal conditions (P < .001). Under assumed ideal conditions, interventional neuroradiologists would refrain from intravenous alteplase most often (6.28%, OR = 2.40; 95% CI, 1.01-5.71). When physicians' current and ideal decisions differed, most would like to add endovascular therapy to intravenous alteplase in an ideal setting (196/3861 responses, 5.1%).

CONCLUSIONS

In patients eligible for endovascular therapy and intravenous alteplase, we observed a slightly lower decision rate in favor of intravenous alteplase under assumed ideal conditions compared with the decision rate under current local resources.

Radiomics-Based Intracranial Thrombus Features on CT and CTA Predict Recanalization with Intravenous Alteplase in Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Thrombus characteristics identified on non-contrast CT (NCCT) are potentially associated with recanalization with intravenous (IV) alteplase in patients with acute ischemic stroke (AIS). Our aim was to determine the best radiomics-based features of thrombus on NCCT and CT angiography associated with recanalization with IV alteplase in AIS patients and proximal intracranial thrombi.

MATERIALS AND METHODS

With a nested case-control design, 67 patients with ICA/M1 MCA segment thrombus treated with IV alteplase were included in this analysis. Three hundred twenty-six radiomics features were extracted from each thrombus on both NCCT and CTA images. Linear discriminative analysis was applied to select features most strongly associated with early recanalization with IV alteplase. These features were then used to train a linear support vector machine classifier. Ten times 5-fold cross-validation was used to evaluate the accuracy of the trained classifier and the stability of the selected features.

RESULTS

Receiver operating characteristic curves showed that thrombus radiomics features are predictive of early recanalization with IV alteplase. The combination of radiomics features from NCCT, CTA, and radiomics changes is best associated with early recanalization with IV alteplase (area under the curve = 0.85) and was significantly better than any single feature such as thrombus length (P < .001), volume (P < .001), and permeability as measured by mean attenuation increase (P < .001), maximum attenuation in CTA (P < .001), maximum attenuation increase (P < .001), and assessment of residual flow grade (P < .001).

CONCLUSIONS

Thrombus radiomics features derived from NCCT and CTA are more predictive of recanalization with IV alteplase in patients with acute ischemic stroke with proximal occlusion than previously known thrombus imaging features such as length, volume, and permeability.

John Nash and the Organization of Stroke Care

The concept of Nash equilibrium, developed by John Forbes Nash Jr, states that an equilibrium in noncooperative games is reached when each player takes the best action for himself or herself, taking into account the actions of the other players. We apply this concept to the provision of endovascular thrombectomy in the treatment of acute ischemic stroke and suggest that collaboration among hospitals in a health care jurisdiction could result in practices such as shared call pools for neurointervention teams, leading to better patient care through streamlined systems.

LOSS OF GROUP CARBOHYDRATE DURING MOUSE PASSAGES OF A GROUP A HEMOLYTIC STREPTOCOCCUS

In the course of rapid passages through mice a strain of group A type 27 hemolytic streptococcus was found to have lost its group carbohydrate without the loss of type-specific precipitinogens, agglutinogens, or its capacity to induce protective antibodies in rabbits, and without the acquisition of the carbohydrate of another group. The loss of group carbohydrate was shown to be complete, within the limits of the methods for its detection. Extracts of the anomalous strain did not react with group A antisera; and antisera prepared with organisms of this anomalous strain did not contain demonstrable antibodies for the group carbohydrate. Bacterial suspension of the anomalous strain failed to absorb any appreciable amount of group-specific antibody. The fact that the anomalous strain lacking group-specific carbohydrate, C, was derived from the original was established by the demonstration of persistence of its other characteristics, in particular the precipitinogens, agglutinogens, and antigens responsible for protective antibodies of type 27.

EXPERIMENTAL VIBRIO INFECTIONS OF DEVELOPING CHICK EMBRYOS

Developing chick embryos are highly susceptible to infection with strains on V. cholerae representing Gardner and Venkatraman's 6 groups and the types Inaba and Ogawa. There is a moderate decrease in susceptibility with advancing age of the embryo. The influence of dosage on survival rates is not marked, probably because a minimal dose, consisting of a very few organisms, is sufficient to produce death rapidly. Passive protection of a low order is conferred on the embryos by the introduction of inactivated specific immune serum at the time of inoculation of vibrios. This protective influence is enormously enhanced by the previous or simultaneous administration of guinea pig complement. The antigens of group I organisms which give rise to embryo-protective and bacteriolytic antibodies are dual in character. One antigen is shared by all members of the group and is productive of antibodies which will protect against infections with all strains of the group, of whatever type. The other antigen is type-specific, and its antibodies are protective and lytic only for organisms of the homologous type.

STUDIES ON THE ANTIGENIC COMPOSITION OF GROUP A HEMOLYTIC STREPTOCOCCI : IV. RELATED T BUT DISTINCT M ANTIGENS IN TYPES 15, 17, 19, 23, 30, AND IN TYPES 4, 24, 26, 28, 29, 46. IDENTIFICATION BY SLIDE AGGLUTINATION

1. The occurrence of closely related T antigens in the series composed of types 15, 17, 19, 23, and 30 accounts for most of the cross reactions observed among these types. Similarly T antigens, unrelated to the first series but mutually related, occur in a second series comprising types 4, 24, 26, 28, 29, and 46. 2. Matt variants of each of the eleven types studied possess type-specific M antigens demonstrable either by precipitin or agglutinin reactions. 3. In seven of these types, strains have been encountered which do not possess the T antigen usually associated with the type in question. 4. Procedures are outlined in the appendix for preparing specific antisera for the classification of these types by the slide agglutination technique.

TYPING GROUP A HEMOLYTIC STREPTOCOCCI BY M PRECIPITIN REACTIONS IN CAPILLARY PIPETTES

A method is described for performing type-specific anti-M precipitin tests on group A hemolytic streptococci in 1 mm. capillary pipettes. These tests require so much less precipitating serum than was formerly used that the method now seems to be practical.

Analgesia for day-case shoulder surgery

BACKGROUND

Single-shot nerve blocks provide excellent postoperative analgesia for a limited period and are increasingly used in day-case units. They allow early patient discharge following painful operative procedures that would otherwise require overnight hospitalization. We investigated the adequacy of analgesia at home after the block had worn off.

METHODS

A prospective audit by telephone 1 week after surgery of 50 consecutive patients who had had a single-shot interscalene block for day-case shoulder arthroscopic surgery.

RESULTS

The mean length of adequate sensory block was 22.5 h (9-48 h) after which 20% of patients had a maximum visual analogue scale (VAS) score of 5/5. Most patients did not take analgesics as prescribed and two patients (5.4%) required additional analgesia from their family doctor or accident and emergency department.

CONCLUSIONS

We conclude that analgesia at home is often inadequate after painful day-case surgical procedures if single-shot local anaesthetic blockade is used.

Hypoxaemia and supplemental oxygen therapy in the first 24 hours after myocardial infarction: the role of pulse oximetry

OBJECTIVE

To assess the incidence and degree of hypoxaemia in patients with acute myocardial infarction and evaluate the nation-wide perception and usage of oxygen therapy.

DESIGN

Postal survey of all coronary care units (CCU) in England of their use of prescribed oxygen and pulse oximetry. Prospective randomised study of 50 patients presenting within 24 hours of onset of myocardial infarction, half of whom received oxygen therapy. Oxygen saturation (SpO2) as continuously measured by pulse oximetry, and arrhythmias and ST segment changes were recorded on simultaneous 24-hour ambulatory Holter monitors.

RESULTS

In 53% of UK coronary care units oxygen is not routinely prescribed but in only 3% is a pulse oximeter used to aid management. In patients presenting with acute myocardial infarction the incidence of hypoxaemia (SpO2 < 90%) was 70% and severe hypoxaemia 35% in those not given oxygen, compared with only 27% and 4% in patients given oxygen therapy. The only patient to receive oxygen on clinical grounds had an oxygen saturation of 71%. Severe hypoxaemia (SpO2 < 80%) occurred significantly less often (1 and 7 patients, p < 0.05) in patients given oxygen. There were no differences in arrhythmias or ST segment changes between groups.

CONCLUSION

Hypoxaemia occurs frequently in patients in the first 24 hours after acute myocardial infarction. It is effectively and easily treated with supplemental oxygen which can be guided by pulse oximetry. This is rarely done. Measurements of oxygen saturation are therefore justified in all patients to guide oxygen therapy unless there is a decision to give all patients supplemental oxygen: this we believe to be unnecessary.

The effect of meals of differing composition on exercise tolerance in patients with angina pectoris

In this study we compared different dietary constituents and their effect on the angina threshold. We compared carbohydrate-rich, fat-rich and balanced liquid diets on effort tolerance in 14 patients of mean (range) 61 (41-73) years of age with chronic stable angina. On four different occasions at least 1 week apart, patients had exercise treadmill tests after an overnight fast and then after a rest period of 1 h ingested one of three different approximately isocalorific (about 4000 kJ) liquid drinks of 600 ml consisting mainly of: fat, carbohydrate or a balanced meal with an equal volume of water as control. Meals were given in random order. Analysis of the mean (SD) differences in heart rate between fasting and the post-prandial state for the different meals revealed a significant increase between water and the other meals, fat (+4(6) beats.min-1 P < 0.002), balanced (+9(17) beats.min-1 P < 0.004), and carbohydrate (+10(12) beats.min-1 P < 0.0002). There was no significant difference between the groups as regards systolic or diastolic blood pressure. Cardiac output increased following the meals but decreased after water; however, there was a significant difference between water and balanced meals. Exercise tolerance fell following all the meals but was significantly greater after a balanced (mean (SD) -108(129) s P < 0.01) and carbohydrate meal (-92(52) s P < 0.001). The reduction in exercise duration following a fat meal (-36(53)s) was not significantly different from that following water (-8(43) s) but was significantly smaller than after a carbohydrate meal (P < 0.02). Time to 1 mm of ST depression showed similar changes to that of total exercise duration, being significantly lower after a carbohydrate (mean (SD) -76(77) s P < 0.01) and balanced meal (-76(63) s P < 0.005). Time to 1 mm ST depression, although reduced by a fat meal (-15(84) s) was significantly less than after a carbohydrate meal (P < 0.02). In conclusion, patients with chronic stable angina have impaired effort tolerance and a lower angina threshold after high calorie containing liquid meals. Meals rich in carbohydrate have greater effects than meals where the majority of calories are derived from fat. Patients should be advised to avoid exercise in the first 30 min after eating.

Unsatisfactory management of patients with myocardial infarction admitted to general medical wards

Patients admitted with acute myocardial infarction to general medical wards fared less well than those admitted over the same period to the coronary care unit. The median age of the 119 patients admitted to the general wards was 75 years, compared to 64 years for those on the coronary care unit. Although 13 of the 119 fulfilled the local guidelines for thrombolysis, none received it, only 64% were given aspirin and 49% nitrates. The death rate for these patients was 29% compared to 12% of those given thrombolysis on the coronary care unit and 26% of those who were ineligible for thrombolysis but had been admitted to the coronary care unit. Of the survivors on the general wards, 80% were given aspirin as secondary prevention, and 37% were given a beta-adrenergic blocker. None was referred to the hospital cardiac rehabilitation programme.

Anaesthesia and the obese patient

The obese patient is likely to have pre-operative impairment of cardiovascular and respiratory function. These impairments will tend to increase in the per- and post-operative period and place the patient at risk of myocardial ischaemia and hypoxaemia. The physical effects of obesity mean that all patients require endotracheal intubation during anaesthesia and this may be difficult to achieve. The difficulties in moving and positioning the patient and difficulties in gaining access for monitoring and venous cannulation add to the problems. Anaesthesia and surgery may present a considerable risk for obese patients and should not be undertaken without full understanding of the potential problems.

Psychological and war stress symptoms among deployed and non-deployed reservists following the Persian Gulf War

The present study examined the incidence of war-related psychological distress among Persian Gulf War veterans. A total of 591 Army, Navy, and Marine reservists were administered the Mississippi PTSD Scale, the Beck Depression Inventory, and the SCL-90R. Combat-deployed reservists showed significantly higher levels of psychological symptomatology that non-deployed reservists, generally corresponding to levels of stress exposure. No significant effects were found for race or prior combat exposure, but significant differences were found between combat-deployed male and female reservists. Despite the brevity and the outcome of the Persian Gulf War, significant symptomatology exists among this population.

Chorismate mutase:prephenate dehydratase from Acinetobacter calcoaceticus. Purification, properties and immunological cross-reactivity

The bifunctional P protein (chorismate mutase: prephenate dehydratase) from Acinetobacter calcoaceticus has been purified. It was homogeneous in polyacrylamide gels and was more than 95% pure on the basis of the immunostaining of purified P protein with the antibodies raised against the P protein. The native enzyme is a homodimer (Mr = 91,000) composed of 45-kDa subunits. A twofold increase in the native molecular mass of the P protein occurred in the presence of L-phenylalanine (inhibitor of both activities) or L-tyrosine (activator of the dehydratase activity) during gel filtration. Chorismate mutase activity followed Michaelis-Menten kinetics with a Km of 0.55 mM for chorismate. L-Phenylalanine was a relatively poor non-competitive inhibitor of the mutase activity. The chorismate mutase activity was also competitively inhibited by prephenate (reaction product). Substrate-saturation curves for the dehydratase activity were sigmoidal showing positive cooperativity among the prephenate-binding sites. L-Tyrosine activated prephenate dehydratase strongly but did not abolish positive cooperativity with respect to prephenate. L-Phenylalanine inhibited the dehydratase activity, and the substrate-saturation curves became increasingly sigmoidal as phenylalanine concentrations were increased with happ values changing from 2.0 (no phenylalanine) to 4.0 (0.08 mM L-phenylalanine). A sigmoidal inhibition curve of the dehydratase activity by L-phenylalanine gave Hill plots having a slope of -2.9. Higher ionic strength increased the dehydratase activity by reducing the positive cooperative binding of prephenate, and the sigmoidal substrate-saturation curves were changed to near-hyperbolic form. The happ values decreased with increase in ionic strength. Antibodies raised against the purified P protein showed cross-reactivity with the P proteins from near phylogenetic relatives of A. calcoaceticus. At a greater phylogenetic distance, cross-reaction was superior with P protein from Neisseria gonorrhoeae than with that from the more closely related Escherichia coli.

Oxygen and hydrogen isotopes in fruit and vegetable juices

(18)O/(16)O ratios from the juices of a number of fruits and vegetables were measured and found to be isotopically more enriched than the water in which they grew. Fast-growing high-water-content vegetables exhibited less enrichment than slower growing fruits such as apples, pears, and plums. (18)O/(16)O measurements were also made on the water from various sections of several plants, and the enrichment was found to occur in the following order: leaves > fruit > stem >/= ground water.D/H and (18)O/(16)O measurements were made on a series of grape juice samples and, when plotted against each other, gave a slope of 3.9, indicating that the physical process causing this enrichment was probably evaporation, i.e. evapotranspiration.

Mechanism of induction of RNA tumor viruses by halogenated pyrimidines

Frome these studies on JLS V-9 cells, a number of conclusions can be drawn about the mechanism of MuLV induction by halogenated pyrimidines. The compounds can induce virus from otherwise healthy cells as long as deoxycytidine is present along with the inducing agent. The compounds must be present during the S phase of the cell cycle and must be incorporated into DNA in order to induce virus (Teich et al. 1973). Only one strand of DNA need be substituted by BrdU or IdU in order to induce virus, because a one-hour period of incorporation leads to induction. From these results it is possible to construct a model for how halogenated pyrimidines are able to induce viruses from otherwise uninfected cells. Because the critical period for the incorporation of the compound is a restricted segment of the S phase of the cell, there would appear to be a critical segment of the genetic information of the cell which, when substituted with BrdU or IdU, leads to a transcriptional derepression. Presumably the critical segment of DNA is either a controlling element of the integrated provirus or it is a separate gene which controls the expression of the integrated provirus. Whichever is true, these results strongly imply that the search for specific repressors of the segments of mammalian DNA is likely to be successful and that RNA tumor viruses may offer a system in which such repression systems can be identified and investigated.