Implementation and mixed-methods evaluation of "Walk with a Doc" program at Stony Brook

CONTEXT

Walking groups run by trained individuals, lasting under an hour in a natural environment, may be a cost-effective way by which to encourage sustainable changes in physical activity as well as foster companionship and a shared experience of wellness among participants. Walk with a Doc (WWaD) is a national program that provides a platform for medical professionals, including physicians and medical students, to deliver a short talk on a health topic prior to walking side by side with patients and community members.

OBJECTIVES

To evaluate the WWaD Chapter at Stony Brook following implementation, a questionnaire was designed utilizing a mixed-methods approach (i.e., containing qualitative and quantitative items) and administered to all attendees monthly prior to the health discussion. The aim of the questionnaire was fourfold: first, to obtain participant demographics; second, to obtain information on attendees' own perceptions of their health status and the role exercise plays in their health; third, to gain data on physical activity levels, including lengths of exercise sessions and types of activities performed; and fourth, to learn more about attendees' motivations and goals for participating in the walks.

METHODS

We received an IRB exemption. Physician and medical student volunteers were recruited from Stony Brook University Hospital, a suburban tertiary care center, to oversee program logistics. WWaD was scheduled to take place on the third Sunday of every month for 1 h at Heritage Park in Mount Sinai, New York. The event was advertised by volunteers to colleagues, peers, patients, and community members utilizing word of mouth, printed flyers, emails to listservs, and social media outlets. Each month, a physician volunteer oversaw a brief discussion (approximately 10 min in length).

RESULTS

Over the course of the 5 month evaluation period, 91 individuals participated in the walks, including repeat attendees. After excluding duplicate or incomplete entries, data from 30 participants were included in this analysis. The majority of participants were female (n=24) with a mean age of 50 years (range, 23-98 years). Feedback on WWaD program elements was largely positive. Participants commended the monthly speakers for "informative talks" (n=6) on "interesting topics" (n=4), with plans to review the supplemental information in educational pamphlets following the walk (n=4). The brochures were also deemed "helpful." Overwhelmingly, patients referred to the community gathering and team building aspects of WWaD as the "most enjoyable" aspect of the program (n=8) and a key driver for participation.

CONCLUSIONS

This mixed-methods study of the WWaD chapter at Stony Brook contributes to a growing body of evidence highlighting the value of walking groups as effective avenues for collaboration in producing accessible healthy behavior.

High mercury seafood consumption associated with fatigue at specialty medical clinics on Long Island, NY

We investigated the association between seafood consumption and symptoms related to potential mercury toxicity in patients presenting to specialty medical clinics at Stony Brook Medical Center on Long Island, New York. We surveyed 118 patients from April-August 2012 about their seafood consumption patterns, specifically how frequently they were eating each type of fish, to assess mercury exposure. We also asked about symptoms associated with mercury toxicity including depression, fatigue, balance difficulties, or tingling around the mouth. Of the 118 adults surveyed, 14 consumed high mercury seafood (tuna steak, marlin, swordfish, or shark) at least weekly. This group was more likely to suffer from fatigue than other patients (p = 0.02). Logistic regression confirmed this association of fatigue with frequent high mercury fish consumption in both unadjusted analysis (OR = 5.53; 95% CI: 1.40-21.90) and analysis adjusted for age, race, sex, income, and clinic type (OR = 7.89; 95% CI: 1.63-38.15). No associations were observed between fish intake and depression, balance difficulties, or tingling around the mouth. Findings suggest that fatigue may be associated with eating high mercury fish but sample size is small. Larger studies are needed to determine whether fish intake patterns or blood mercury tests warrant consideration as part of the clinical work-up in coastal regions.

Waterpipe a gateway to cigarette smoking initiation among adolescents in Irbid, Jordan: a longitudinal study

SETTING

According to anecdotal evidence, waterpipe smoking may lead to the initiation of cigarette smoking among young people. This hypothesis is yet to be examined using an appropriate study design and a theoretical model for behavioral change.

OBJECTIVE

To compare the risk of cigarette smoking initiation among waterpipe-only smokers and never smokers in a school-based sample of adolescents from Irbid, Jordan.

METHODS

A total of 1454 cigarette-naïve participants were drawn from a longitudinal study on smoking behavior conducted in Irbid among 1781 seventh graders who were enrolled at baseline (2008) and completed the study questionnaire on smoking behavior annually until 2011. Grouped time-survival analysis was used to compare the risk of subsequent initiation of cigarette smoking between waterpipe smokers (n = 298) and never smokers (n = 1156) using adjusted hazard ratios (aHRs) and 95% confidence intervals (95%CI).

RESULTS

Risk of initiation of cigarette smoking among waterpipe smokers was significantly higher than among never smokers after adjusting for potential confounders (aHR 1.67, 95%CI 1.46-1.92). The association between waterpipe and cigarette smoking initiation was dose-dependent. The risk of initiating cigarette smoking increased with increase in the frequency of waterpipe smoking (P for linear trend < 0.001).

CONCLUSIONS

Waterpipe smoking led to the initiation of cigarette smoking among this cohort of Jordanian adolescents; the effect was dose-dependent.

Experience with early TEVAR treatment of uncomplicated type B aortic dissection

The current paradigm for the treatment of chronic type B aortic dissection involves primarily medical treatment. The patients are then followed for sequelae like progressive dissection or aneurysmal degeneration, selecting this subgroup for further intervention. The European Collaborator Registry, the Talent Thoracic Retrospective Registry, and several meta-analysis showed that the uncomplicated type B dissection patients who underwent thoracic endovascular aortic repair (TEVAR) outperformed their counterpart in the complicated group. The INSTEAD trial, the first randomized trial to examine whether TEVAR is better than medical management in the chronic stable dissection patients, showed no benefit early on although mid-term data might show some benefit. Clearly more randomized controlled trials are necessary to create a paradigm shift. In the United States, the FDA approved TEVAR devices are for the descending thoracic aortic aneurysm and transection only. The use of these devices for dissection is off-label or for investigation only. As future study might broaden the use of TEVAR for the chronic dissection patients, the use of TEVAR in hybrid surgery and in the ascending aorta is also broadening the indication for this technology. With two decades of innovation behind, TEVAR will continue to evolve and innovate in the years ahead.

Group visits: a qualitative review of current research

PURPOSE

The group visit model has emerged as one possible solution to problems posed by the limitations of current structures of care and the demands of a growing chronic illness load. In this article, we summarize current group visit research and develop suggestions for furthering this care model.

METHODS

An electronic review of all group visit articles published from the years 1974 to 2004 was conducted via the PubMed and MedLine databases. Reference sections of articles thus obtained were mined for additional citations. Articles were excluded if: (1) they were not research studies (ie, purely descriptive, with no evaluative component); or (2) the group visit intervention was subsumed under larger primary or hospital-based interventions.

RESULTS

Although the heterogeneity of the studies presented renders the assessment of this care model problematic, there is sufficient data to support the effectiveness of group visits in improving patient and physician satisfaction, quality of care, quality of life, and in decreasing emergency department and specialist visits.

CONCLUSION

Group visits are a promising approach to chronic care management for the motivated patient. Future research may benefit, however, from abandoning old nomenclatures and clearly defining the structure, processes of care, content of visits, and appropriate outcome measures.

Respiratory and allergic diseases: from upper respiratory tract infections to asthma

Patients with asthma and allergic rhinitis may benefit from hydration and a diet low in sodium, omega-6 fatty acids, and transfatty acids, but high in omega-3 fatty acids (i.e., fish, almonds, walnuts, pumpkin, and flax seeds), onions, and fruits and vegetables (at least five servings a day). Physicians may need to be more cautious when prescribing antibiotics to children in their first year of life when they are born to families with a history of atopy. More research is needed to establish whether supplementation with probiotics (lactobacillus and bifidobacterium) during the first year of life or after antibiotic use decreases the risk of developing asthma and allergic rhinitis. Despite a theoretic basis for the use of vitamin C supplements in asthmatic patients, the evidence is still equivocal, and long-term studies are needed. The evidence is stronger for exercise-induced asthma, in which the use of vitamin C supplementation at a dosage of 1 to 2 g per day may be helpful. It is also possible that fish oil supplements, administered in a dosage of 1 to 1.2 g of EPA and DHA per day, also may be helpful to some patients with asthma. Long-term studies of fish oil and vitamin C are needed for more definite answers. For the patient interested in incorporating nutritional approaches, vitamin C and fish oils have a safe profile. However, aspirin-sensitive individuals should avoid fish oils, and red blood cell magnesium levels may help in making the decision whether to use additional magnesium supplements. Combination herbal formulas should be used in the treatment of asthma with medical supervision and in collaboration with an experienced herbalist or practitioner of TCM. Safe herbs, such as Boswellia and gingko, may be used singly as adjuncts to a comprehensive plan of care if the patient and practitioner have an interest in trying them while staying alert for drug-herb interactions. No data on the long-term use of these single herbs in asthma exist. For the motivated patient, mind-body interventions such as yoga, hypnosis, and biofeedback-assisted relaxation and breathing exercises are beneficial for stress reduction in general and may be helpful in further controlling asthma. Encouraging parents to learn how to massage their asthmatic children may appeal to some parents and provide benefits for parents and children alike. Acupuncture and chiropractic treatment cannot be recommended at this time, although some patients may derive benefit because of the placebo effect. For patients with allergic rhinitis, there are no good clinical research data on the use of quercetin and vitamin C. Similarly, freeze-dried stinging nettle leaves may be tried, but the applicable research evidence also is poor. Further studies are needed to assess the efficacy of these supplements and herbs. Homeopathic remedies based on extreme dilutions of the allergen may be beneficial in allergic rhinitis but require collaboration with an experienced homeopath. There are no research data on constitutional homeopathic approaches to asthma and allergic rhinitis. Patients with COPD are helped by exercise, pulmonary rehabilitation, and increased caloric protein and fat intake. Vitamin C and n-3 supplements are safe and reasonable; however, studies are needed to establish their efficacy in COPD. On the other hand, there are convincing data in favor of N-acetyl-cysteine supplementation for the patient with COPD at doses ranging between 400 and 1200 mg daily. Red blood cell magnesium levels may guide the use of magnesium replacement. The use of L-carnitine and coenzyme Q10 in patients with COPD needs further study. The addition of essential oils to the dietary regimen of patients with chronic bronchitis is worth exploring. Patients with upper respiratory tract infections can expect a shorter duration of symptoms by taking high doses of vitamin C (2 g) with zinc supplements, preferably the nasal zinc gel, at the onset of their symptoms. Adding an herb such as echinacea or Andrographis shortens the duration of the common cold. The one study on Elderberry's use for the flu was encouraging, and the data on the homeopathic remedy Oscillococcinum interesting, but more studies should be performed. Saline washes may be helpful to patients with allergic rhinitis and chronic sinusitis. Patients also may try the German combination (available in the United States) of elderberry, vervain, gentian, primrose, and sorrel that has been tested in randomized clinical trials. Bromelain is safe to try; the trials of bromelain supplementation were promising but were never repeated. The preceding suggestions need to be grounded in a program based on optimal medical management. Patients need to be well educated in the proper medical management of their disease and skilled at monitoring disease stability and progress. Asthmatic patients need to monitor their bronchodilator usage and peak flow meter measurements to step up their medical treatment in a timely manner, if needed. Patients welcome physician guidance when exploring the breadth of treatments available today. A true patient-physician partnership is always empowering to patients who are serious about regaining their function and health.

Magnetic resonance imaging and cross sectional anatomy of the normal equine sinuses and nasal passages

The purpose of this investigation was to define the magnetic resonance imaging anatomy of the rostral part of the equine head. 10 mm-thick, T1-weighted images of two isolated equine cadaver heads were obtained using a 1.5 Tesla magnet and a body coil. MR images were compared to corresponding frozen cross-sections of the cadaver head. Relevant anatomic structures were identified and labeled at each level. The resulting images provided excellent anatomic detail of the oral and nasal cavities, paranasal sinuses and associated structures. Annotated MR images from this study are intended as a reference for clinical MR imaging studies of the equine head.