Recovery of Function After Acquired Neurological Injury

The articles in this Special Issue on Recovery of Function After Neurological Injury include an impressive range of clinical diagnoses, scientific approaches, and theoretical frameworks that demonstrate the breadth and depth of occupational therapy in the restoration of function after neurological injury. An emerging theme throughout is the need for the profession of occupational therapy to identify and use more efficient methods for diagnosing and treating people with neurological injuries to improve their quality of life and the impact of care.

Understanding Occupational Therapists' Knowledge and Confidence When Assessing for Spatial Neglect: A Special Issue Review

IMPORTANCE

Spatial neglect (SN)-failure to respond to stimuli on the side of the body contralateral to a poststroke lesion-is one of the most disabling impairments for stroke survivors, and 80% of stroke survivors may have undetected SN. Occupational therapists' evaluations should include determining the impact of poststroke SN.

OBJECTIVE

To investigate occupational therapists' confidence, knowledge, current practices, barriers, and facilitators when assessing for SN in adult stroke survivors.

DESIGN

A 30-item survey was created with guidance from stroke rehabilitation occupational therapists who reviewed the survey for face and content validity.

SETTING

Online survey.

PARTICIPANTS

Occupational therapist survey responders (N = 76).

OUTCOMES AND MEASURES

Self-report assessments were used to measure occupational therapists' confidence in identifying SN, SN assessment practices, and barriers to and facilitators of SN assessment. Knowledge of SN signs and symptoms, neuroanatomy, and clinical presentation were measured with a three-question quiz.

RESULTS

Eighty-one percent of the respondents reported a high level of confidence in identifying SN, and 70% reported routinely assessing for SN, with 81% using clinical observation rather than standardized tools as the primary assessment method. Barriers to SN assessment included time and resources.

CONCLUSIONS AND RELEVANCE

Most respondents, despite reporting high levels of confidence with routine SN assessments, did not use standardized SN measures and demonstrated suboptimal knowledge of SN. These results emphasize the need to increase clinical education about SN and its assessments. Plain-Language Summary: This study gathered baseline information on an underinvestigated topic-occupational therapists' education, confidence, current practices, barriers, and facilitators when assessing for spatial neglect in adult stroke survivors. The study results also contribute to future research on occupational therapists' current confidence and knowledge when assessing for spatial neglect.

Differences in rehabilitation evaluation access for rural and socially disadvantaged stroke survivors

BACKGROUND

Most stroke survivors have ongoing deficits and report unmet needs. Despite evidence that rehabilitation improves stroke survivors' function, access to occupational and physical therapy is limited. Describing access to care for disadvantaged communities for different levels of stroke severity will provide proportions used to create Markov economic models to demonstrate the value of rehabilitation.

OBJECTIVES

The objective of this study was to explore differences in the frequency of rehabilitation evaluations via outpatient therapy and home health for Medicare Part B ischemic stroke survivors in rural and socially disadvantaged locations.

METHODS

We completed a retrospective, descriptive cohort analysis using the 2018 and 2019 5% Medicare Limited Data Sets (LDS) from the Centers for Medicare and Medicaid Services using STROBE guidelines for observational studies. We extracted rehabilitation Current Procedural Terminology (CPT) codes for those who received occupational or physical therapy to examine differences in therapy evaluations for rural and socially disadvantaged populations.

RESULTS

Of the 9,076 stroke survivors in this cohort, 44.2% did not receive any home health or outpatient therapy. Of these, 64.7% had a moderate or severe stroke, indicating an unmet need for therapy. Only 2.0% of stroke survivors received outpatient occupational therapy within the first year Rural and socially disadvantaged communities accessed rehabilitation evaluations at lower rates than general stroke survivors.

CONCLUSIONS

These findings describe the poor access to home health and outpatient rehabilitation for stroke survivors, particularly in traditionally underserved populations. These results will influence future economic evaluations of interventions aimed at improving access to care.

Impact of Spatial Neglect on Activity and Participation: A Mixed-Methods Study

Post-stroke neglect is disabling, yet it is unclear whether existing assessments capture the extent neglect affects activity and participation. The objective of the study is to explore stroke survivor and caregiver perspectives on how neglect affects activity and participation and to compare their experiences to neglect assessments items. We conducted an explanatory sequential mixed-methods study by conducting semi-structured interviews with stroke survivors (n = 7) and caregivers (n = 7) analyzed using thematic analysis. Stroke survivors completed the Catherine Bergego Scale (CBS) and Behavioral Inattention Test (BIT). Descriptive analyses characterized participant's neglect. The standardized CBS and BIT tests indicated that stroke survivors demonstrated mild-to-moderate (CBS) or no-to-mild (BIT) neglect. In contrast, the qualitative data revealed serious safety concerns and significant ongoing difficulties participating in school, work, and family activities because of neglect. Current assessments may not measure the impact of neglect on activity or participation in life for stroke survivors.

Development of a Short Form Assessment Combining the Fugl-Meyer Assessment-Upper Extremity and the Wolf Motor Function Test for Evaluating Stroke Recovery

OBJECTIVE

To use Rasch methodologies to combine the items of the Fugl-Meyer Assessment-Upper Extremity (FMA-UE, motor skill) and the Wolf Motor Function Test (WMFT, motor function) onto a single measurement metric and create an FMA-UE+WMFT short form.

DESIGN

Secondary analysis of preintervention data from 2 upper extremity stroke rehabilitation trials. Confirmatory factor analysis and Rasch rating scale analysis were first applied to examine the properties of the pooled item bank and then item response theory methodologies were used to develop the short form. Confirmatory factor analysis and Rasch analysis were then applied to the short form to examine the dimensionality and measurement properties.

SETTING

Outpatient academic medical research center.

PARTICIPANTS

Data from 167 participants who completed the FMA-UE and WMFT (rating scale score) were pooled (N=167). Participants were eligible if they had a stroke ≥3 months prior and had upper extremity (UE) hemiparesis and excluded if they had severe UE hemiparesis, severe UE spasticity, or UE pain.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The dimensionality and measurement properties of the pooled 30-item FMA-UE and the 15-item WMFT and short form were examined.

RESULTS

Five items from the pool of 45 items were misfit and were removed. The 40-item pool demonstrated adequate measurement properties. A 15-item short form was then developed and met rating diagnostic scale criteria. All items on the 15-item short form met the Rasch fit criteria, and the assessment met criteria for reliability (Cronbach alpha=.94), separation (person separation = 3.7), and strata (number of strata = 5).

CONCLUSIONS

Items from the FMA-UE and WMFT can be pooled to create a psychometrically sound 15-item short form.

Determining the Marginal Cost Differences of a Telehealth Versus an In-person Occupational Therapy Evaluation Session for Stroke Survivors Using Time-driven Activity-based Costing

OBJECTIVE

To estimate the marginal cost differences and care delivery process of a telerehabilitation vs outpatient session.

DESIGN

This study used a time-driven activity-based costing approach including (1) observation of rehabilitation sessions and creation of manual time stamps, (2) structured and recorded interviews with 2 occupational therapists familiar with outpatient therapy and 2 therapists familiar with telerehabilitation, (3) collection of standard wages for providers, and (4) the creation of an iterative flowchart of both an outpatient and telerehabilitation session care delivery process.

SETTING

Telerehabilitation and outpatient therapy evaluation.

PARTICIPANTS

Three therapists familiar with care deliver for telerehabilitation or outpatient therapy (N=3).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Marginal cost difference between telerehabilitation and outpatient therapy evaluations.

RESULTS

Overall, telerehabilitation ($225.41) was more costly than outpatient therapy ($168.29) per session for a cost difference of $57.12. Primary time drivers of this finding were initial phone calls (0 minutes for OP therapists vs 35 minutes for TR) and post documentation (5 minutes for OP vs 30 minutes for TR) demands for telerehabilitation.

CONCLUSIONS

Telerehabilitation is an emerging platform with the potential to reduce costs, improve health care inequities, and facilitate better patient outcomes. Improvements in documentation practices, staffing, technology, and reimbursement structuring would allow for a more successful translation.

Neuromotor Rehabilitation Interventions After Pediatric Stroke: A Focused Review

Pediatric stroke is a condition that often results in life-long motor, cognitive, or sensory deficits for children. The purpose of this focused review is to compile the most recent literature on pediatric stroke neuromotor interventions and summarize evidence for use by rehabilitation providers and researchers. Terms including stroke, pediatric, and neuromotor were searched with appropriate MeSH terms. Information was collected regarding interventions conducted and outcome measures used for each article. Interventions and outcome measures were organized based on ICF components (Body Structure and Function, Activity, Participation, and Environmental Factors). 16 articles were included after full-text screens. From these 16 articles, a large majority of them included some form of neuromodulation as a part of intervention. Results identified a potentially problematic gap between domains addressed by interventions and measured by outcomes, with a need to include more expansive outcome measures in research studies. There are several areas of potential growth in pediatric stroke literature. Research studies should be precise when describing included samples. As interventions for pediatric stroke shift toward neuromodulation and other neurologic treatments, there is a need for well-defined populations, both clinically in the community as well as in research studies. There is also a need for US guidelines for rehabilitation after pediatric stroke. Overall, the trend in the literature seems to suggest that combining some form of neuromodulatory technique with existing recommended rehabilitation technique (ex: CIMT) may promote overall recovery for children after stroke, though further research is needed.

Crafting Community-Based Participatory Research Stroke Interventions

Stroke exerts a tremendous burden on individuals, families, communities, and health systems globally. Even more troublesome are the striking disparities faced across diverse populations. These disparities are further exacerbated by the COVID-19 pandemic. Despite efforts to advance stroke research, substantial gaps remain in understanding factors that contribute to stroke disparities, including the Social Determinants of Health. Strategically designed studies and tailored interventions are needed to bridge the inequities high-risk populations face and to meet their specific needs. Community-based participatory research offers an approach to equitably partner with community members to understand and work collaboratively to address community-specific health priorities. In this focused update, we highlight the main processes of community-based participatory research studies and share exemplars from our team's work in stroke research and from the literature. As we continue to face an increasing prevalence of stroke, compounded by the COVID-19 pandemic and ongoing implications of the Social Determinants of Health, partnering with communities to address community-driven health priorities can inform interventions targeted to overcome the disparities faced by certain populations.

Using Subthreshold Vibratory Stimulation During Poststroke Rehabilitation Therapy: A Case Series

Subthreshold vibratory stimulation to the paretic wrist has been shown to prime the sensorimotor cortex and improve 2-week upper extremity (UE) therapy outcomes. The objective of this work was to determine feasibility, safety, and preliminary efficacy of the stimulation over a typical 6-week therapy duration. Four chronic stroke survivors received stimulation during 6-week therapy. Feasibility/safety/efficacy were assessed at baseline, posttherapy, and 1-month follow-up. For feasibility, all participants wore the device throughout therapy and perceived the stimulation comfortable/safe. Regarding safety, no serious/moderate intervention-related adverse events occurred. For efficacy, all participants improved in Wolf Motor Function Test and UE use in daily living based on accelerometry and stroke impact scale. Mean improvements at posttherapy/follow-up were greater than the minimal detectable change/clinically important difference and other trials with similar therapy without stimulation. In conclusion, the stimulation was feasible/safe for 6-week use. Preliminary efficacy encourages a larger trial to further evaluate the stimulation as a therapy adjunct.

Pediatric unilateral spatial neglect: A systematic review

PURPOSE

Unilateral spatial neglect (USN), an inability to attend to one side of space or one's body, is commonly reported in adult stroke survivors and is associated with poor outcomes. USN has been reported in pediatric survivors of stroke, but its impact is unclear. The purpose of this systematic review was to summarize and evaluate the literature regarding USN in pediatric stroke survivors.

METHODS

PRISMA guidelines, Scopus, CINAHL, PubMed, and other relevant databases were searched with terms including "children", "stroke", and "unilateral neglect", with the ages of participants limited from to birth to 18 years. Data were extracted from studies on the clinical presentation of pediatric USN, the assessment of this condition, treatment options, or USN recovery.

RESULTS

A total of 18 articles met inclusion criteria. There were no current prevalence data available. USN presents similarly in children compared to adults. Several different USN assessments were used, however, there were little data regarding treatment options. Furthermore, the data suggest that not all children fully recover.

CONCLUSION

This systematic review reveals a lack of quality research to inform the assessment and treatment of children with USN. Although the literature spans decades, there remain no guidelines for standardized assessment or treatment. Similar to adults, paper-and-pencil testing may be less able to identify USN than functional assessments. It is likely that there are children who struggle with undetected USN-related deficits years after their injuries. With a rise of pediatric stroke survivors, there is a pressing need for clinicians to be educated about USN in children, clinical presentations, assessments, and treatments.

Feasibility, Safety, and Preliminary Efficacy of Using Vibratory Stimulation During Task Practice Therapy in Chronic Stroke Survivors

Date Presented 03/26/20

Imperceptible vibratory stimulation of the wrist was evaluated as an adjunct to poststroke upper-extremity rehabilitation. Using stimulation during six-week task-practice therapy was feasible and safe. Promising improvement in function was retained at one-month follow-up. The improvement was greater than those reported in literature with similar therapy. This result encourages a large randomized controlled trial to examine the efficacy of using the stimulation during therapy in improving outcomes.

Primary Author and Speaker: Amanda Vatinno

Contributing Authors: Lucion Hall, Hannah Cox, Alison Fluharty, Catilyn Taylor, Alexandra Wease, Allison Davis, Shannon Cain, Michelle Woodbury, Na Jin Seo

Feasibility of and Adherence to a Home-Based Video Game Rehabilitation Protocol

Date Presented 03/28/20

As the population ages and stroke prevalence rises, there will be an increased need for therapeutic interventions in the home that can help improve motor recovery in stroke survivors. A home-based video game protocol can help satisfy this need. This study evaluates the feasibility of and adherence to a home-based video game protocol designed specifically for stroke survivors. This has implications for the field of OT in the home, through telerehabilitation, and in clinics.

Primary Author and Speaker: Emerson Hart

Additional Authors and Speakers: Michelle Woodbury

Contributing Authors: Austen Hayes, Larry Hodges, Kevin Jett, Christian Finetto, Scott Hutchison

Neglect May Not Impact Real-World Paretic Arm Use in the Chronic Stage of Stroke Recovery

Date Presented 04/05/19

Nonuse of the paretic arm is highly prevalent after stroke. In the chronic stage of stroke, individuals with neglect have similar patterns of paretic arm use as individuals without neglect when matched for paretic arm motor impairment. These findings highlight how critical it is that stroke rehabilitation therapists address paretic arm nonuse in therapy.

Primary Author and Speaker: Emily Grattan

Additional Authors and Speakers: Michelle Woodbury

Barriers and Facilitators of Stroke Recovery: Perspectives From African Americans With Stroke, Caregivers and Healthcare Professionals

INTRODUCTION AND GOAL

Stroke is a serious health condition that disproportionally affects African-Americans relative to non-Hispanic whites. In the absence of clearly defined reasons for racial disparities in stroke recovery and subsequent stroke outcomes, a critical first step in mitigating poor stroke outcomes is to explore potential barriers and facilitators of poststroke recovery in African-American adults with stroke. The purpose of this study was to qualitatively explore poststroke recovery across the care continuum from the perspective of African-American adults with stroke, caregivers of African-American adults with stroke, and health care professionals with expertise in stroke care.

MATERIALS AND METHODS

This qualitative descriptive study included in-depth key informant interviews with health care providers (n = 10) and focus groups with persons with stroke (n = 20 persons) and their family members or caregivers (n = 19 persons). Data were analyzed using thematic analysis according to the Social Ecological Model, using both inductive and deductive approaches.

FINDINGS

Persons with stroke and their caregivers identified social support, resources, and knowledge as the most salient factors associated with stroke recovery. Perceived barriers to recovery included: (1) physical and cognitive deficits, mood; (2) medication issues; (3) lack of support and resources; (4) stigma, culture, and faith. Health care providers identified knowledge/information, care coordination, and resources in the community as key to facilitating stroke recovery outcomes.

CONCLUSIONS

Key findings from this study can be incorporated into interventions designed to improve poststroke recovery outcomes and potentially reduce the current racial-ethnic disparity gap.

The Impact of Reported Depression on Disability Following Stroke

Date Presented 3/30/2017

An ischemic stroke survivor who persistently reports anxiety or depression feelings throughout the 1st year poststroke is 12.6 times more likely to require assistance for daily activities compared with a survivor who makes no such report, results that suggest a need for enhanced screening and treatment.

Primary Author and Speaker: Scott Hutchison

Contributing Authors: Michelle Woodbury, Annie Simpson

Anosognosia of Neglect During Performance of Daily Activities

Date Presented 3/30/2017

This poster highlights how common anosognosia is among clients after stroke and how important it is for practitioners to assess for anosognosia and plan treatment to address it in this client population.

Primary Author and Speaker: Emily Grattan

Contributing Authors: Elizabeth Skidmore, Michelle Woodbury

OPTN/SRTR 2015 Annual Data Report: Kidney

The first full year of data after implementation of the new kidney allocation system reveals an increase in deceased donor kidney transplants among black candidates and those with calculated panel-reactive antibodies 98%-100%, but a decrease among candidates aged 65 years or older. Data from 2015 also demonstrate ongoing positive trends in graft and patient survival for both deceased and living donor kidney transplants, but the challenges of a limited supply of kidneys in the setting of increasing demand remain evident. While the total number of patients on the waiting list decreased for the first time in a decade, this was due to a combination of a decrease in the number of candidates added to the list and an increase in the number of candidates removed from the list due to deteriorating medical condition, as well as an increase in total transplants. Deaths on the waiting list remained flat, but this was likely because of an increasing trend toward removing inactive candidates too sick to undergo transplant.

Linking Measurement to Treatment: A Standardized Method to Specify Task Difficulty for Stroke Rehabilitation Sessions

Date Presented 4/17/2015

In this proof-of-concept study, we tested the feasibility of using a standardized measurement framework to inform a stroke rehabilitation program design in which person ability and task difficulty were matched and progressed over nine therapy sessions. Results indicate improved upper-extremity motor skills.

Pharmacokinetics of tulathromycin after subcutaneous injection in North American bison (Bison bison)

Tulathromycin is approved for the treatment of respiratory disease in cattle and swine. It is intended for long-acting, single-dose injection therapy (Draxxin), making it particularly desirable for use in bison due to the difficulty in handling and ease of creating stress in these animals. The pharmacokinetic properties of tulathromycin in bison were investigated. Ten wood bison received a single 2.5 mg/kg subcutaneous injection of Draxxin. Serum concentrations were measured by liquid chromatography-mass spectrometry (LC-MS) detection. Tulathromycin demonstrated early maximal serum concentrations, extensive distribution, and slow elimination characteristics. The mean maximum serum concentration (Cmax) was 195 ng/mL at 1.04 h (tmax) postinjection. The mean area under the serum concentration-time curve, extrapolated to infinity (AUC0-inf ), was 9341 ng · h/mL. The mean apparent volume of distribution (Vd /F) and clearance (Cls/F) was 111 L/kg and 0.4 L/h/kg, respectively, and the mean half-life (t1/2) was 214 h (8.9 days). Compared to values for cattle, Cmax and AUC0-inf were lower in bison, while the Vd /F was larger and the t1/2 longer. Tissue distribution and clinical efficacy studies in bison are needed to confirm the purported extensive distribution of tulathromycin into lung tissue and to determine whether a 2.5 mg/kg subcutaneous dosage is adequate for bison.

Examination of the Factor Structure of the Disabilities of the Arm, Shoulder, and Hand Questionnaire

OBJECTIVE. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is a global scale evaluating the impact of upper-extremity disorders. We sought to validate or challenge the unidimensional factor structure of the DASH.

METHOD. Secondary analysis was performed on data collected from outpatient clinics. Factor analysis was performed in two steps, exploratory factor analysis (EFA) followed by confirmatory factor analysis (CFA). To provide further support for unidimensionality, fit statistics were calculated using the Andrich Rasch rating-scale model.

RESULTS. EFA revealed three potential factors (eigenvalues = 18.40, 1.56, and 1.54). CFA was performed fitting a three-factor model. Tucker-Lewis Index (.99) and standardized root mean square residual (.05) values indicated good fit. Comparative fit index (.89) and root mean square error of approximation (.13) did not. When divided into three constructs, only one item misfit.

CONCLUSION. More research is needed to determine situations in which division of the DASH may enhance interpretability.

Measurement structure of the Wolf Motor Function Test: implications for motor control theory

BACKGROUND

Tools chosen to measure poststroke upper-extremity rehabilitation outcomes must match contemporary theoretical expectations of motor deficit and recovery because an assessment's theoretical underpinning forms the conceptual basis for interpreting its score.

OBJECTIVE

The purpose of this study was to investigate the theoretical framework of the Wolf Motor Function Test (WMFT) by (1) determining whether all items measured a single underlying trait and (2) examining the congruency between the hypothesized and the empirically determined item difficulty orders.

METHODS

Confirmatory factor analysis (CFA) and Rasch analysis were applied to existing WMFT Functional Ability Rating Scale data from 189 participants in the EXCITE (Extremity Constraint-Induced Therapy Evaluation) trial. Fit of a 1-factor CFA model (all items) was compared with the fit of a 2-factor CFA model (factors defined according to item object-grasp requirements) with fit indices, model comparison test, and interfactor correlations.

RESULTS

One item was missing sufficient data and therefore removed from analysis. CFA fit indices and the model-comparison test suggested that both models fit equally well. The 2-factor model yielded a strong interfactor correlation, and 13 of 14 items fit the Rasch model. The Rasch item difficulty order was consistent with the hypothesized item difficulty order.

CONCLUSION

The results suggest that WMFT items measure a single construct. Furthermore, the results depict an item difficulty hierarchy that may advance the theoretical discussion of the person ability versus task difficulty interaction during stroke recovery.

415 INDUCTION OF FOLLICULAR WAVE EMERGENCE IN WOOD BISON BY FOLLICULAR ABLATION OR TREATMENT WITH ESTRADIOL AND PROGESTERONE

Reclamation of Canada’s threatened wood bison (Bison bison athabascae) herd is complicated by endemic disease. As part of an overall goal to conserve bison genetics, the specific objective of this study was to develop a protocol to control follicular wave emergence in bison for the purposes of ovarian superstimulation and collection of disease-free oocytes. In an initial study, the synchronizing effect of follicular ablation and estradiol (E2) treatment was examined. Ablation was effective, but the effects of E2 (5 mg) were confounded by treatment-induced ovulation in some animals. Two experiments were done to determine the effect of a reduced dose of E2 or the addition of progesterone (P4) in comparison with follicular ablation. Bison cows (n = 19), ≥3 years old, were scanned for 14 days to determine the mean and variance in the interval to follicular wave emergence (control phase). In Experiment 1, bison were assigned randomly to 2 groups: follicular ablation (n = 9) or 2 mg of E2i.m. (n = 10). In Experiment 2, the same bison were randomly assigned to 2 groups: follicular ablation (n = 9) or 2 mg of E2+ 100 mg of P4 i.m. (n = 10). Ablation involved transvaginal ultrasound-guided aspiration of all follicles ≥5 mm. Wave emergence was determined retrospectively by identification of the follicle destined to become dominant at an initial diameter of 4 to 5 mm, with a concurrent increase in the number of follicles ≥4 mm. The interval and variation in the interval to emergence of a new follicular wave was compared among the control phase and treatment groups by ANOVA. In Experiment 1, the interval to new wave emergence (mean ± SEM) was 4.9 ± 0.66, 1.1 ± 0.11, and 2.4 ± 0.47 days from the start of the control phase, follicular ablation, and E2 treatment, respectively (P < 0.001). The degree of synchrony (residuals) was 2.4 ± 0.36, 0.2 ± 0.09, and 1.2 ± 0.24 days for the control phase, follicular ablation, and E2 treatment, respectively (P < 0.001). Ovulation was detected in 1 bison treated with E2. In Experiment 2, the interval to new wave emergence (mean ± SEM) was 4.9 ± 0.66, 1.2 ± 0.15, and 2.9 ± 0.31 days from the start of the control phase, follicular ablation, and E2 + P4 treatment, respectively (P < 0.001). The degree of synchrony was 2.4 ± 0.36, 0.2 ± 0.08, and 0.7 ± 0.20 days for the control phase, follicular ablation, and E2 + P4 treatment, respectively (P < 0.001), and no ovulations were detected. In conclusion, follicular ablation, E2, and E2 + P4 treatments all shortened and decreased the variability in the interval to new wave emergence in bison, but follicular ablation consistently produced a quicker and more synchronous response. Supported by grants from the Advancing Canadian Agriculture and Agri-Food Fund (ACAAF), the Agri-Food Innovation Fund, Parks Canada, the World Wildlife Fund, and the Northwest Territories.

224 A COMPARATIVE STUDY BETWEEN WOOD AND PLAINS BISON

In Canada, brucellosis and tuberculosis threaten an estimated 4500 wood bison (Bison bison athabascae), a species considered at risk by the Committee on the Status of Endangered Wildlife In Canada (COSEWIC). To help rescue this species, our Wood Bison Reproductive Research group proposes to employ advanced reproductive technologies. Unfortunately, little is known about the reproductive physiology of the wood bison, which hinders the application of these reproductive technologies. In order to modify advanced reproductive techniques developed in cattle for use in wood bison, the large amounts of semen, embryos, and oocytes from wood bison required are not available. The purpose of this study was to compare semen collected from the more abundant and closely related plains bison (Bison bison bison) with that of wood bison. Semen from 3 wood and 4 plains bison were collected by electro-ejaculation during the summer of 2007. Andrological parameters of morphology and motility were recorded on fresh semen, extended semen, and post-thawed semen samples. A Student's t-test was used to compare the results of these two groups. Semen was cryopreserved using two commercially available cryopreservation media (Andromed and Triladyl, Minitube Canada, Ingersoll, Ontario, Canada). Sperm morphology and motility were not different between electro-ejaculated samples from plains and wood bison (P > 0.05). Also, no difference was found in the survival rate of sperm from the electro-ejaculated samples between plains and wood bison after freezing and then thawing using an egg-yolk based extender (Triladyl) or an extender containing no products of animal origin (Andromed). A difference between cryopreservation media was found; post-thaw motility of Triladyl-treated sperm was higher (29%) than that of the Andromed-treated sperm (12%). Due to lack of previous success with preserving electro-ejaculated semen in media free of animal-origin products, motility assays were performed to evaluate if spermatozoa retrieved from epididymides of plains bison can be cryopreserved in Andromed. Interestingly, cyropreserved epididymal spermatozoa had a higher motility than cryopreserved electro-ejaculated sperm after freezing-thawing procedures using a medium containing no products of source animal (respectively, 30% v. 7%). This result suggests that there may be a factor secreted by the reproductive accessory glands that interferes with the post-thaw survivability of bison sperm. In conclusion, this study supports the hypothesis that semen from plains bison behaves similarly to that of wood bison semen during cryopreservation and therefore could be used to establish protocols for advanced reproductive technologies in wood bison. This project was supported by Canadian Adaptation and Rural Development in Saskatchewan.

224 OVARIAN FOLLICLE DEVELOPMENT DURING SEASONAL TRANSITION IN WAPITI

Wapiti are seasonally polyestrous. The transition into and out of the breeding season is marked by resumption of ovulation in autumn and cessation of ovulation in winter. Onset of ovulatory cyclicity is distinct and associated with aggressive breeding behavior of stags in rut. Cessation of ovulation at the end of the breeding season is not distinguished by behavioral patterns. The objective of the present study was to characterize follicular and luteal dynamics in wapiti during the transitional periods into and out of the breeding seasons. Transition from anestrus to estrus was monitored in 15 hinds, aged 2 to 14 years, over two successive seasons (11 in year 1, with 5 hinds from year 1 used again in year 2 along with 4 new hinds; n = 20 observations). Transition from estrus to anestrus was monitored in 11 hinds over 1 season (n = 11 observations). Hinds were maintained on a farm near Saskatoon, Saskatchewan (52°07′N, 106°38′W). The ovaries were examined daily during September through October by transrectral ultrasonography using a B-mode ultrasound machine and a 7.5 MHz linear array transducer for transition to estrus, and December through April for transition to anestrus. The first ovulation was recorded on September 15 and all hinds had ovulated for the first time by October 7. In 17 of 20 observations, the duration of the first interovulatory interval (IOI) was 9.3 ± 0.4 days (mean ± SEM). With one exception, these IOIs were characterized by one wave of follicular development. The remaining three IOIs ranged from 16 to 23 days and consisted of two or three waves of follicle development. The second ovulation occurred by October 15 in hinds with a short IOI and by October 17 in all remaining hinds. The mean dates of first and last ovulation were September 25 and February 7, respectively, an interval of 135 days. The median date of the last ovulation was February 15 and the range was from December 3 to March 22. Duration of the last IOI of the season (21.2 ± 0.6 days) was similar to the notional 21-day cycle for wapiti, but longer (P < 0.05) than the duration of the first IOI (10.9 ± 1.0 days). Maximum diameters of the first 2 ovulatory follicles were similar (11.3 ± 0.4 vs. 11.3 ± 0.2 mm), but were larger (P < 0.05) than the last 2 ovulatory follicles of the breeding season (10.3 ± 0.3 vs. 10.1 ± 0.4 mm). Maximum diameter of the corpus luteum (CL) tended (P = 0.06) to be smaller for the short IOI than for longer IOI of the first and last cycles. Diameter of the last CL of the season was not different from that of the previous CL (12.8 ± 0.6 vs. 12.5 ± 0.6 mm); however, it was detected for a longer period (22.3 ± 1.2 vs. 19.3 ± 0.7 days; P < 0.05). Estrous cycles during transition into the breeding season have been described as being irregular and those out of the breeding season as increasingly long. In the present study, the transition periods were characterized by regular events. Transition to regular estrous cycles was preceded by one short (9 days) IOI. The last IOI of the breeding season was the same as that reported during the rut. Transition to anestrus occurred most commonly in February and was marked by a failure of the dominant follicle to ovulate after luteal regression.

Pharmacokinetics of florfenicol in North American elk (Cervus elaphus)

Florfenicol pharmacokinetics after administration of a single subcutaneous (s.c.) dose of 40 mg/kg of body weight in adult elk (Cervus elaphus) was investigated. Serum florfenicol concentrations were determined by a sensitive high-performance liquid chromatographic method with limit of quantification of 0.03 microg/mL. Florfenicol pharmacokinetic parameters in elk were estimated using a noncompartmental approach. After a single s.c. injection, florfenicol concentrations remained above 1 microg/mL for approximately 36 h and above 0.5 microg/mL for approximately 72 h. Following s.c. injection, florfenicol was absorbed rapidly with a mean maximum concentration (C(max)) of 3.7 microg/mL achieved at 4.2 h (T(max)). The C(max) value in elk is similar to values reported in cattle at the same dose, suggesting that the 40 mg/kg s.c. dose achieves therapeutic concentrations in elk. A mean elimination half-life (t(1/2)) of 44 h is shorter than that reported in cattle. The more rapid elimination half-life in elk suggests that elk may require a multiple dose regimen for therapeutic success with s.c. Nuflor. We recommend s.c. Nuflor be administered subcutaneously to elk every 24 h at a dose level of 40 mg/kg.

Linkage analysis of candidate regions using a composite neurocognitive phenotype correlated with schizophrenia

As schizophrenia is genetically and clinically heterogeneous, systematic investigations are required to determine whether ICD-10 or DSM-IV categorical diagnoses identify a phenotype suitable and sufficient for genetic research, or whether correlated phenotypes incorporating neurocognitive performance and personality traits provide a phenotypic characterisation that accounts better for the underlying variation. We utilised a grade of membership (GoM) model (a mathematical typology developed for studies of complex biological systems) to integrate multiple cognitive and personality measurements into a limited number of composite graded traits (latent pure types) in a sample of 61 nuclear families comprising 80 subjects with ICD-10/DSM-IV schizophrenia or schizophrenia spectrum disorders and 138 nonpsychotic first-degree relatives. GoM probability scores, computed for all subjects, allowed individuals to be partly assigned to more than one pure type. Two distinct and contrasting neurocognitive phenotypes, one familial, associated with paranoid schizophrenia, and one sporadic, associated with nonparanoid schizophrenia, accounted for 74% of the affected subjects. Combining clinical diagnosis with GoM scores to stratify the entire sample into liability classes, and using variance component analysis (SOLAR), in addition to parametric and nonparametric multipoint linkage analysis, we explored candidate regions on chromosomes 6, 10 and 22. The results indicated suggestive linkage for the familial neurocognitive phenotype (multipoint MLS 2.6 under a low-penetrance model and MLS>3.0 under a high-penetrance model) to a 14 cM area on chromosome 6, including the entire HLA region. Results for chromosomes 10 and 22 were negative. The findings suggest that the familial neurocognitive phenotype may be a pleiotropic expression of genes underlying the susceptibility to paranoid schizophrenia. We conclude that use of composite neurocognitive and personality trait measurements as correlated phenotypes supplementing clinical diagnosis can help stratify the liability to schizophrenia across all members of families prior to linkage, allow the search for susceptibility genes to focus selectively on subsets of families at high genetic risk, and augment considerably the power of genetic analysis.

Do constitutional types really exist? A further study using grade of membership analysis

'Constitutional types' are a feature of homeopathy. Constitutions are constellations of mental, physical and general features. We present results of a 152-item 'Constitutional Type Questionnaire' (CTQ), relating to 19 major constitutional remedies. Patients referred to the Royal London Homoeopathic Hospital (RLHH) were recruited from outpatient clinics. Each remedy was assigned eight associated features. Each item is rated as it applies to the subject most of the time on a five-point scale. Grade of Membership analysis (GOM) was used for evaluation of remedy profiles. Four hundred and forty-seven individuals provided usable data. Demographic data were collected. A nine pure type solution provided the best fit to the data. Few subjects had exclusive 'membership' of one pure type. There are some difficulties in interpretation; for instance some groups were characterised by the absence of 'constitutional' features. Some pure types are coherent, recognisable types. The results give some support to the homeopathic concept of constitution. CTQ results correlate quite well with the actual prescribing of homeopaths. Further validation with other cohorts is required and with refinement it might become a useful screening method. It cannot simulate complex information processing performed by homeopathic practitioners.

Email, voicemail, and privacy: what policy is ethical?

Business people repeatedly asked Computer Professionals for Social Responsibility (CPSR) to recommend a policy to deal with email and voicemail. After many such requests to our organization, we attempted to construct guidelines that we could endorse. This paper outlines the guidelines that we proposed and the public reaction to them. The paper discusses the tensions inherent in a business environment, and the means of identifying ethical behavior for both companies and their employees.

Use of grade membership analysis to profile the practice styles of individual physicians in the management of acute low back pain

The objective of this study was to investigate Grade of Membership analysis (GoM) as a means of profiling the practice styles of individual physicians. GoM uses maximum likelihood techniques to estimate occurrences of management items that define unique practice styles. It also provides statistical estimates (grade of membership coefficients) of how well each individual physician's practice fits the identified styles. Data sources were responses to a mailed survey asking 814 physicians to select from predetermined management options in three scenarios depicting patients with acute low back pain. Four distinct types of practice style were identified: watchful waiting; investigative; guideline based; and physiotherapy focused. Most physicians were characterized by high grades of membership in the two profiles that most closely matched existing guidelines for the management of acute low back pain. GoM successfully identified characteristic practice styles, and the GoM coefficients obtained provided descriptions of individual management approaches. GoM is data driven and less subject to judgment than opinion-based measures of performance. It has several potential applications in identifying physicians for whom some form of intervention would be beneficial.

The Diagnostic Interview Schedule for Children (DISC-2.1) in Spanish: reliability in a Hispanic population

The reliability across time, informants and interviewers of the Spanish translation of the DISC-2.1 was tested on a Puerto Rican Hispanic sample using a test-retest design. Levels of reliability between clinic and community samples and between younger and older children were compared to explore the sources of low reliability for certain psychiatric disorders. Parents' reports tended to be more reliable than those of their children, although the difference was less obvious with older children. Reliability was generally higher for the externalizing disorders and when the second interviewer was a psychiatrist rather than a lay interviewer.

The prevalence of women with breast implants in the United States--1989

Most estimates of the number of women with breast implants appear to be extrapolations of industry or clinical data. While both provide valuable information, the former about the total number of devices ever produced or sold and the latter about the cumulative number of surgeries performed, neither can be used to directly estimate the prevalence of women with silicone gel or saline implants. In 1989, Market Facts, Inc., conducted a mail survey of 40,000 households chosen as representative of the population of the United States and received responses from 70.7%. Overall, the prevalence was 8.08 per 1,000 women with about 60% of the devices reportedly implanted for cosmetic reasons. The procedure was more common among Whites of the higher socio-economic classes. Based upon the results of this survey, the total number of US women in 1989 with breast implants was estimated to be 815,700 (95% confidence interval: 715,757-924,729).

A statistical analysis of the classification of depression in a mixed community and clinical sample

Depressive symptoms in three samples are assessed using grade-of-membership analysis to clarify the distribution of depressive symptoms across traditional affective diagnoses. The technique is used to examine whether depressive symptoms and symptoms frequently associated with depressive disorders cluster into recognizable syndromes or pure types that parallel current operational diagnoses. Three hundred and ninety subjects were studied to address the question: among a mixed population with a range of depressive symptoms, will syndromes resembling endogenous depression and demoralization emerge from the range of presentation of depressive symptoms? A single pure type is nearly identical to the DSM-III classification of major depression with melancholia. No such pure type emerged that resembled demoralization.

Estimates of the prevalence of childhood maladjustment in a community survey in Puerto Rico. The use of combined measures

A two-stage epidemiologic survey was carried out on a probability sample of the population aged 4 through 16 years in Puerto Rico. The survey used the Child Behavior Checklist as a screening instrument, and prevalence rates were estimated on the basis of clinical diagnoses and other measures provided by child psychiatrists during the second stage. Maladjustment was operationally defined through the use of combined measures, including DSM-III diagnosis and a scale of functional impairment. Data were provided on the demographic correlates of maladjustment and on the comorbidity of DSM-III diagnostic domains. The prevalence rates obtained vis-à-vis the availability of mental health services on the island reflected a major public health problem.

Depressive symptoms and depressive diagnoses in a community population. Use of a new procedure for analysis of psychiatric classification

A multivariate classification technique was used to examine whether depressive symptoms and symptoms frequently associated with depressive disorders would cluster into recognizable syndromes that parallel traditional DSM-III psychiatric diagnoses. An analysis was made of all respondents in the Epidemiologic Catchment Area (ECA) project of the Piedmont region of North Carolina who reported suffering from depressive symptoms (n = 406) at the second wave of the ECA study. The analysis identified five profiles of symptoms that adequately described the interrelationships of the symptoms as reported in the population. One profile included a set of symptoms nearly identical to the symptoms associated with the DSM-III classification of major depression. Other depressive syndromes emerged and included a premenstrual syndrome among younger women and a mixed anxiety/depression syndrome. The existence of these other depressive syndromes may explain the present discrepancy in the epidemiologic literature between a high prevalence of depressive symptoms and a low prevalence of traditional depressive diagnoses in community populations.

Malignant melanoma in the elderly

Advancing age is associated with poorer prognosis in malignant melanoma. We studied 3,872 cases of malignant melanoma to evaluate whether the effect of age could be analyzed relative to sex, tumor depth, primary site, and other clinical and pathologic variables. The sex distribution by age shows a slight female predominance in the early and late decades but male predominance in the middle years. The percentage of patients with metastatic disease at initial diagnosis did not vary with age, despite greater diameter and depth of lesions in the older patients. In fact, in the older age groups, initial nodal metastasis occurred slightly less frequently. Trunk primaries decreased in frequency with increasing age, while extremity lesions remained relatively constant, and face, nose, and ear lesions increased. This was in part related to the histopathologic type, as lentigo maligna lesions increased in frequency with age, superficial spreading lesions were somewhat less frequent in the older age group and nodular types were fairly constant. On the basis of both Clark's level and Breslow thickness, there was an increasing proportion of deeper penetrating lesions in the older age group. The mean diameter of these lesions on the skin surface was also greater for the older patients. This would suggest that lesions in the older individual remain confined to the local site longer, penetrate and spread, but do not necessarily metastasize more rapidly. Cox model regression analysis of survival time within stage showed that age was highly significant as a poor prognostic factor. Though the adverse relation of advancing age with survival was partially explained by predominance of other unfavorable factors, such as primary site, depth of lesion, or histologic type, age remained an independent poor prognostic factor (chi 2 = 5.3; P = .02) for death due to melanoma.

Somatization disorder in a US southern community: use of a new procedure for analysis of medical classification

The authors examine somatization disorder in a community population, using grade of membership analysis, a new multivariate analytical technique for the analysis of medical classification. The technique is used to examine whether somatic symptoms will cluster into a clinical syndrome resembling somatization disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), if no a priori assumptions are made about the interrelationship of somatic symptoms or their clustering into clinical syndromes. Grade of membership analysis is applied to all respondents in the US National Institute of Mental Health Epidemiological Catchment Area Project of the Piedmont region of North Carolina reporting three or more somatic symptoms from the somatization disorder section of the Diagnostic Interview Schedule. The analysis indicates that seven 'pure' types, roughly analogous to clusters in cluster analysis, best describe the interrelationship of the symptoms included in the analysis. One 'pure' type in the analysis is nearly identical to DSM-III somatization disorder and is associated with demographic characteristics consistently found among patients with DSM-III somatization disorder. The present results demonstrate that symptoms associated with this disorder do cluster in a highly predictable fashion and represent a strong validation of the natural occurrence of an entity resembling somatization disorder.