2010 Final Presentations

Summer Student Research & Clinical Assistantship Presentations

1. GardenFit: Prevention of Summer Weight Gain in Adolescents
2. Vitamin D testing and treatment practices of family physicians
3. Loss to follow-up of patients with abnormal cervical cytology in two family medicine residency clinics
4. Patient and physician predictions of time and severity of the common cold
5. An assessment of racial disparity in rates of H1N1-associated hospitalization
6. The effect of prolotherapy on subjects with osteoarthritic knee pain: a qualitative study
7. Outcomes of Community Clinic Based Deliveries in Wisconsin Amish Women

• View: 2010 SRCA 2009 Final Presentations - PowerPoint Slides (14 MB)

1. GardenFit: Prevention of Summer Weight Gain in Adolescents

Jessica Shackman, BS, Alexandra Adams, MD, PhD, and Tara LaRowe, PhD

Background: Childhood obesity is a growing problem in the United States. Overweight children are more likely to become overweight adults and have morbidity associated with weight gain. Research has shown that children gain more weight over the summer than during the school year. Garden Fit is an intervention aimed at increasing physical activity and consumption of healthy foods in order to decrease summer weight gain.

Methods: Sixteen middle school children with a BMI above the 85th percentile participated in the study, eleven of whom were enrolled in the Garden Fit intervention group. Baseline testing was completed before beginning the gardening program, and included sub VO2 max, body composition, and total energy expenditure. Children enrolled in Garden Fit participated in an 8-week summer gardening program for 3 hours each day. Participants also prepared lunch and snacks using fresh vegetables and fruits from the garden. Children completed questionnaires to assess their exposure to different fruits and vegetables.

Results: Baseline measures will be reassessed at the end of the 8-week intervention. Changes in VO2 max, body composition, and total energy expenditure in the Garden Fit participants will be compared to changes seen in the control children. Based on questionnaires, Garden Fit participants did show a small increase in their awareness of different types of vegetables after the first 4 weeks of gardening.

Conclusions: The effectiveness of the Garden Fit intervention is not known at this time. Limitations of the study include individual differences in motivation and participation, and food intake and physical activity level outside of the Garden Fit program.

2. Vitamin D testing and treatment practices of family physicians

Erin Reddy, BS and Sarina Schrager, MD

Background: Vitamin D deficiency may be related to a myriad of medical conditions from osteoporosis and fractures to autoimmune disorders. With the relatively recent focus on vitamin D and consequences of deficiency, many primary care physicians have started checking 1,25 OH vitamin D levels in practice. Unfortunately, there are no evidence based guidelines that recommend who should get a 25 OH vitamin D level, how a deficiency should be treated, and what follow up is indicated.

Methods: This study will include an electronic chart review of 365 randomly selected charts in the Department of Family Medicine clinics of patients who have had a 25 OH vitamin D level drawn. This review will examine demo-graphics of patients who have had their vitamin D levels checked, the treatment recommendations, and follow up.

Results: A total of 308 charts were included in this study. 192 (62.34%) had vitamin D levels in the deficient range (? 29). Recommendations for supplementation varied widely in respects to dosage and length of treatment with 94 (30.52%) receiving no recommendation to supplement, 185 (60.06%) advised to take 400-5000 IU daily, 59 (19.16%) told to take a dose of 50,000 IU anywhere from a monthly to weekly basis, and 31 (10.07%) patients directed to take 50,000 IU greater than once weekly.

Conclusions: Vitamin D deficiency is common amongst the population being tested by family physicians practicing in the UW Family Medicine clinics, however, there is little consensus as to the proper supplementation for Vitamin D deficiency.

3. Loss to follow-up of patients with abnormal cervical cytology in two family medicine residency clinics

Thomas Garvey, Ann Evensen, MD and Helen Luce, DO

Background: National guidelines on the management of cervical cytology abnormalities can create challenges for clinicians to ensure adequate follow-up. In a residency clinic, the follow-up may span the tenure of one or more resident physicians. Implementation of a spreadsheet to track and manage abnormal cervical pathology results may improve provider communication and patient compliance with recommended follow-up.

Methods: We identified all patients with a first abnormal cervical pathology result between November 2005 and November 2007 (Control group, 67 patients) and between November 2008 and May 2010 (Experimental group, 97 patients), both inclusive. The Experimental group was followed using a spreadsheet that listed a patient's abnormal result, the next recommended step, and the due date for this step. This spreadsheet was reviewed monthly, and noncompliant patients were identified and reminded of the need for evaluation by telephone and/or letter. All patients were evaluated for adequate follow-up for up to two steps following the initial cytological abnormality. Each step was scored as "appropriate" or "inappropriate" based on ASCCP guidelines, and "inappropriate" steps were reviewed to see if the need for follow-up was adequately communicated to patients.

Results: The number of follow-up steps that were performed appropriately increased by 4.4%, but this result was not statistically significant (p-value = 0.597, two-tailed). The number of steps with adequate provider communication increased by 9.0% (p-value = 0.043, two-tailed).

Discussion: Use of an abnormal cervical cytology spreadsheet improved provider communication of the recom-mended follow-up to patients, but did not significantly improve patient compliance with recommended follow-up.

4. Patient and physician predictions of time and severity of the common cold

Joshua Taylor, BS and Bruce Barrett, MD, PhD

Background: The common cold produces significant impacts on quality of life and results in economic costs in diagnosis, treatment, and lost work hours. It is not known whether physicians seeing patients at the beginning of a cold can predict the subsequent duration and severity. The objective of this study is to determine whether, and to what extent, physicians or patients can predict the duration/severity of the common cold.

Methods: Patients enlisted in the study within 36 hours of symptom onset. Patients were divided into 4 groups, no pill, blinded Echinacea, blinded placebo, and labeled Echinacea. Those groups were divided into groups with no physician visit, standard physician visit or enhanced patient-oriented physician visits. For the two-thirds randomized to a physician visit, the clinician was asked to predict subsequent duration/severity. Patients self-rated their cold symptoms twice daily from intake until their colds had resolved, up to a maximum of 14 days. The current study compares patient and physician predictions of duration/severity to the actual colds using scatter plots with R2 values.

Results: R2 values were higher for severity predictions. Most comparisons showed a positive correlation without tight correlation. Statistical analysis, to determine power and significance, is pending.

Conclusions: Neither patients nor physicians were able to predict duration of the cold. Predictions about Severity were slightly better. Patients seemed slightly better at predicting severity than physicians. Usefulness of R2 may be compromised by the scoring system. These findings support the idea that expectations do not correlate with duration/severity.

5. An assessment of racial disparity in rates of possible risk factors for H1N1-associatated hospitalization: Dane County, Wisconsin.

Jessica S. Tischendorf, BS, Jonathan L. Temte, MD, PhD, Thomas Schlenker, MD, MPH, Amanda Kita, BS, MPH and Chuck Illingworth, MS

Background: Investigation completed by the Dane County-City of Madison Department of Public Health revealed a nine-fold disparity in crude hospitalization rates for H1N1 influenza between black and non-Hispanic whites in Dane County (104.6 per 100,000 for black vs. 15.3 per 100,000 for non-Hispanic white)-three times the disparity observed for the state of Wisconsin. This study examines prevalence of risk factors associated with H1N1 hospitalization in clinical populations in Dane County and any racial differences in these prevalences.

Methods: This study is a retrospective, cross-sectional study of potential risk factors for H1N1 hospitalization in Dane county. From the UW-Department of Family Medicine clinical data warehouse, de-identified patient records segregated by age, race and ethnicity for all unique individuals with a visit from January 2008 to December 2009 were acquired and sorted into four primary demographic groups: black children (0-17 years) and adults, and white children and adults. Counts and prevalence (cases/1000) of the following potential risk factors were obtained: malignant neoplasms, diabetes mellitus, hemoglobinopathies, neurological disease, heart disease, chronic lung disease, asthma, renal disease, pregnancy, tobacco exposure and obesity.

Results: Preliminary assessment suggests significant disparities between black and non-Hispanic white Dane County residents in the prevalence of diabetes mellitus, hemoglobinopathies, chronic lung disease, renal disease, pregnancy, tobacco exposure, and obesity.

Conclusions: The differences between black and non-Hispanic whites for prevalence of risk factors for H1N1 hospitalization explain part of the disproportionate hospitalization rates. Additional investigation into severity of illness may further explain the disparity in hospitalization rates in Dane County.

6. Qualitative aspects of treatment with prolotherapy for knee osteoarthritis in a multi-method study

Lane Benes, BS, Luke Fortney, MD, Andrew Slattengren, DO, Jessica Grettie, BS, Jeffrey Patterson, DO, David Rabago, MD

Background: Prolotherapy is a localized injection-based treatment for chronic musculoskeletal pain consisting of an irritant solution. Objective results in the parent study suggest a 30-40% improvement in overall knee osteoarthritis (OA) related quality of life compared to baseline status. The qualitative response of patients receiving prolotherapy is not known.

Methods: We conducted semi-structured, in-depth telephone interviews with 25 participants randomly selected from three recent knee OA prolotherapy studies. Transcribed responses were discussed by co-authors to identify major themes; disagreements were resolved by consensus.

Results: Qualitative data reflected variability in subject outcomes; most had substantial symptom reduction and quality of life improvement. Six themes emerged: most participants reported (1) long-lasting (1 year) reduction in knee pain and improved ability to perform activities of daily living; (2) most improvement occurred after the second treatment session; (3) self-limited negative aspects of prolotherapy including numerous injections, pain during and immediately following treatment; (4) safety; there were no long-term or unexpected side effects; (5) an initial informational meeting and positive prolotherapist-participant interactions helped foster optimism toward prolotherapy; (6) they would consider receiving prolotherapy in the future and would recommend it to others.

Conclusion: Most subjects reported that prolotherapy produced effective, long-lasting results without side effects. Positive treatment effects usually required at least two injection sessions, which were perceived by most subjects as painful but worth the effort. Clear, complete description of the rationale and procedures in the study, and positive prolotherapist-subject interaction may have enhanced adherence to treatment appointment and tolerance of the therapy.

7. Outcomes of Community Clinic-Based Deliveries in a Wisconsin Amish Community

Jim Deline, MD; Lee Dresang, MD; Laura Lynch, BA; John Frey, MD; Mark Gideonsen, MD; Patrick McKenna, MD; Lisa Varnes-Epstein, MHS, PA-C

Background: For over 18 years, the LaFarge Clinic in Southwestern Wisconsin has provided an alternative to home birthing for Amish women, whose religious and cultural beliefs foster a different attitude toward childbirth, including management of labor, risk factors, and birth outcomes. In collaboration with Amish midwives and families, the staff of the clinic has developed a variety of methods of managing labor and delivery of high risk pregnancies that have resulted in exceptional birth outcomes. This study examines the birth experience and maternity care outcomes at a clinic specializing in management of Amish women with high-risk pregnancies.

Methods: Intrapartum and delivery data was recorded for 938 Amish and Mennonite deliveries from 1993-2010 at a primary care birthing suite in LaFarge, Wisconsin. Main outcome measures include maternal and fetal outcomes and complications, mode of delivery, number of prenatal visits, infant weight, APGAR scores, and use of labor augmentation.

Results: A preliminary analysis of data from 1993-2006 has been completed. Results include low number of prenatal visits (µ = 2.60), mean 1 and 5 minute APGAR scores of 7.25 and 8.67, respectively; low use of anesthesia (4.8%), 43 vaginal births after cesarean attempted (7% of all births), and 3.2% of all births resulting in cesarean section. A complete analysis of data from 1993-2010 is in progress.

Conclusions: LaFarge clinic has positive maternal and fetal outcomes and may serve as a model for birthing centers within other Amish communities and in settings within and outside the United States with limited access to medical services and technology.