04 Nov Go to the NCU library from your home page. Examine the guide to primary
This assignment consists of three parts:
For Parts 1 and 2:
Go to the NCU library from your home page. Examine the guide to primary and secondary sources to see what is available. This can be found under LibGuides → Research Process → Primary and Secondary Resources. Then go back to the library home page and either conduct a search using the Roadrunner Search or go to the Statista database in the A-Z Databases list to locate data to answer the following questions. The library's guide on Statistics may also be helpful.
Use tables and figures to explain your determination and support your rationale in answering the question. Be specific. Practice creating your own tables and figures to support your conclusion. You cannot use tables and/or figures from another source without copyright permission in your published dissertation research study. Be sure to cite the source of the table/figure using APA formatting.
Part 1: Internet Data Usage and Age Over Time
Does there appear to be a relationship between adult internet usage and age between 2000 and 2018?
Part 2: Data Breaches in Health Care Over Time
Has the incidence of data breaches in the health/medical sector increased in the last five years?
Part 3: Archived Dataset
Identify one dataset (also referred to as a database) publicly available for research. A list of possible sources is included in this week’s resources or choose one that may be appropriate for your research study topic. You do not need to open the dataset that includes raw numbers.
To operationalize the dataset, gather the following information about the dataset. Dataset information is most likely contained in a document separate from the dataset and may be identified as a database dictionary, codebook, or program record layout. For the assignment response, include the following information using the headings and format outlined here:
ASSIGNMENT OUTLINE START
Enter text on this line.
Enter text on this line.
Enter text on this line. (include link if available)
Include three to five sentences to provide context for the Reader. This may include industry, focus, and original purpose for collecting the data.
Enter text on this line.
For each of the four variables, separately list the following information, using separate headings for each variable. If the information is not available, then indicate ‘not available.’ Follow the template below for each of the variables/constructs.
State Variable Name [include dataset abbreviation if appropriate]
Definition of the Variable. Enter text here.
Source of Data. (This might be self-reported by business, self-reported by survey, observation, etc.)
Scoring of the Variable. Enter text here. For variables, this might be age in years, number of defects per quarter, group membership, etc. For constructs, this might be computation of multiple questions on a survey or multiple variables that make up the construct.
Level of Measurement. Enter text here. Below is a reminder of the measurement levels you learned in Statistics 1. Do not include the measurement level definitions in your assignment response.
Nominal. Nominal data are measured at the discrete level depicting independent categories with no underlying order. Examples of nominal data are sex, race, and organizational department membership.
Ordinal. Ordinal data are measured at the discrete level with separate categories that imply an underlying hierarchy. Examples of nominal data are education level, age groups, or simply categories of high, medium, and low. Some Likert scales may be deemed by the researcher as ordinal data.
Interval. Interval data are measured on a continuous scale with ‘equal-appearing’ intervals and without an absolute zero point. Examples of interval data are time, temperature, credit score, and test scores. Some Likert scales may be deemed by the researcher as interval data.
Ratio. Ratio data are measured on a continuous scale with equal intervals and an absolute zero point. Examples of ratio data are age, income, and defects per lot. A researcher may deem an otherwise ratio data as interval if, for purposes of the research, the measurement level truncates the zero point or otherwise holds a floor or ceiling effect.
Score Range and Interpretation. Enter text here. Include the total possible range of scores for the variable and how to interpret the range. The score range and interpretation might be ‘Six-point Likert scale with ‘1’ meaning “Not Satisfied at All,” and ‘6’ meaning ‘Completely Satisfied;’ or perhaps a four-point ordinal scale with ‘1’ meaning no use, ‘2’ meaning little use, ‘3’ meaning moderate use, and ‘4’ meaning a lot of use. For nominal variables that form a discrete category then identify the coding scheme, for example 1 = male; 2 = female.
Enter text here. Describe advantages, disadvantages, challenges, and benefits that you feel may should be considered if you were to use an archived dataset for your dissertation research study.
ASSIGNMENT OUTLINE STOP
Length: Your paper should be at least 5, but may be as long as 10 pages, if the table and/or figures are included. This does not include the title and reference page. You are encouraged to make effective use of tables and/or figures in your presentation.
References: Include a minimum of three (3) scholarly sources.
Your presentation should demonstrate thoughtful consideration of the ideas and concepts presented in the course and provide new thoughts and insights relating directly to this topic. Your response should reflect scholarly writing and current APA standards. Be sure to adhere to Northcentral University's Academic Integrity Policy.
A Primary Care Provider’s Guide to Accessibility After Spinal Cord Injury
Joseph Lee, MD,1,2 Jithin Varghese, MD,1,2 Rose Brooks,3 and Benjamin J. Turpen4
1The Centre for Family Medicine, Kitchener, Ontario, Canada; 2McMaster University, Hamilton, Ontario, Canada; 3Craig Hospital, Engelwood, Colorado; 4Washington, DC
Abstract: Individuals with spinal cord injury (SCI) continue to have shorter life expectancies, limited ability to receive basic health care, and unmet care needs when compared to the general population. Primary preventive health care services remain underutilized, contributing to an increased risk of secondary complications. Three broad themes have been identified that limit primary care providers (PCPs) in providing good quality care: physical barriers; attitudes, knowledge, and expertise; and systemic barriers. Making significant physical alterations in every primary care clinic is not realistic, but solutions such as seeking out community partnerships that offer accessibility or transportation and scheduling appointments around an individual’s needs can mitigate some access issues. Resources that improve provider and staff disability literacy and communication skills should be emphasized. PCPs should also seek out easily accessible practice tools (SCI-specific toolkit, manuals, modules, quick reference guides, and other educational materials) to address any knowledge gaps. From a systemic perspective, it is important to recognize community SCI resources and develop collaboration between primary, secondary, and tertiary care services that can benefit SCI patients. Providers can address some of these barriers that lead to inequitable health care practices and in turn provide good quality, patient-centered care for such vulnerable groups. This article serves to assist PCPs in identifying the challenges of providing equitable care to SCI individuals. Key words: accessibility, barriers, primary care, SCI
Top Spinal Cord Inj Rehabil 2020;26(2):79-84 © 2020 American Spinal Injury Association www.asia-spinalinjury.org doi: 10.46292/sci2602-79
Corresponding author: Joseph Lee, MD, The Centre for Family Medicine, 10B Victoria Street South, Kitchener, Ontario N2G 1 C5 Canada; [email protected]
requires significant assistance with transfers. What barriers might he face in your office?
The incidence and prevalence of traumatic SCI in the United States is approximately 12,500 per year and 906 cases per million, respectively.1 The average life expectancy for individuals with SCI remains significantly lower when compared to persons without SCI, and this is virtually unchanged since the 1980s. Although milestones and expected outcomes are based on level and completeness of injury, nearly three-quarters of patients are typically discharged into the community following inpatient rehabilitation.1 Typical functional outcomes for individuals with SCI have been described in detail.2 At 1-year post injury, 91% of SCI patients live in a private residence and 4% live in a skilled nursing facility (SNF). At 20 years post injury, the numbers are essentially similar, with 97% living in private residence and less than 1% in an SNF.3 PCPs are typically the first line of
Health Maintenance Checklist
1. Ensure general preventive care is up to date and be aware of secondary complications (e.g., spasticity, bowel and bladder dysfunction).
2. Schedule appointments according to patient cares/needs (i.e., later day, transportation availability, attendant care).
3. Solicit feedback from patient regarding overall clinic accessibility.
4. Refer to rehabilitation specialists accordingly.
John is a 50-year-old man who is a new patient presenting for a periodic health exam. He sustained a complete T3 spinal cord injury (SCI), American Spinal Injury Association Impairment Scale (AIS) B, at age 30. Since being discharged from rehabilitation 20 years ago, he has rarely seen a primary care physician (PCP). He reports that he has “put on a few pounds” and is coming in for a check-up; he’s been having difficulty with a wound on his buttocks that does not seem to be healing. He comes in his full-time manual wheelchair and
80 Topics in spinal cord injury rehabiliTaTion/spring 2020
contact within the health care system, and they have the unique opportunity to help manage SCI patients’ comprehensive health needs and serve as a link between the individual and multiple health care providers. However, the literature has shown that individuals with SCI are less likely to receive the same basic health care when compared to their peers and have unmet health care needs.4
The Institute of Medicine states that primary care is “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”5(p500) SCI patients have special longitudinal physical and psychosocial needs that are often not adequately managed within a primary care setting. Most common issues for their visit to PCPs include pressure sore management, bowel and urinary tract dysfunctions, shoulder pain, spasticity, and autonomic dysreflexia (AD).6 The care is often relationship-based and involves PCPs and specialists. The special needs often lead to inadequate treatment of their health issues and secondary complications, fewer preventive screenings, and less general health promotion.5,7 This article aims to describe and advocate for standardized care plans and address barriers that limit quality primary care for SCI patients.
Barriers to Primary Care
John may find it hard to get to his family physician because the clinic may be unsuitable for easy access. A cross-sectional observation study looked at barriers to health care access for 108 individuals with SCI (53% with paraplegia, 44% with tetraplegia) who use wheelchairs as their primary means of mobility. Approximately 91.1% of participants reported facility, clinic, and exam room barriers during primary care visits. There were similar findings with speciality care visits; 80.2% of the participants reported accessibility issues.8 Despite the Americans with Disability Act and Rehabilitation Act of 1973, significant barriers to primary care remain to individuals with physical disabilities. The box at the beginning of the article
outlines a general health maintenance checklist for addressing these barriers.
Having accessible parking, ramps, working elevators, restroom access, and wide doorways and hallways can markedly improve accessibility. Approximately one in four patients mentioned that typically primary care clinics did not account for the presence of a wheelchair and that the patients had trouble accessing the examination table.7,8 In many clinics, the examination tables require an uphill transfer onto a narrow surface that usually is not able to be raised or lowered. The average cost of a high–low examination table is upwards of $2,000, which is a barrier for many clinicians. Patients have reported a lack of transfer aids such as transfer boards, sling, and lifts and staff who have limited knowledge on how to use or assist with these safe transfers.7-9 A resource for office accessibility has been developed by the Canadian Disability Policy Alliance.10
In the earlier discussed survey of 108 adults with SCI, 89% reported that they did not have their weight examined, 88% were not asked to change into gowns or undress to be thoroughly examined, and 85.2% never got on the examination table.8 A wheelchair-accessible scale can help track a patient’s weight and body mass index (BMI) and can provide useful clinical information for the management of a patient’s overall health. Local or federal programs can provide financial assistance for PCPs to improve care accessibility, safety, and clinical efficiency.11
Transportation is often cited as a major accessibility barrier in the US SCI community, and it is a greater problem for patients located in rural settings because of the long distance to urban centers.11,12 Understanding and accommodating client transportation barriers (eg. travel time, distance, and cost) can lead to improved patient- centered care. One accommodation could be proactive outreach to community-centered partnerships with local buses, access-a-ride, accessible public transportation, and accessible Uber/Lyft resources. The willingness of the PCPs to accommodate afternoon visits and involve care partners are other ways to address such barriers.13
Primary care staff can advocate by helping patients navigate a complex system to improve their transport options. In exceptional cases,
Accessibility After SCI 81
an adapted vehicle that includes hand controls, adjustable seats, and/or ramps to access the vehicle can be purchased by patients who can afford it and want to drive on their own. State-funded programs such as vocational rehabilitation agencies can be utilized. Hand controls and other equipment, once purchased, are transferable to newer vehicles, and most private companies offer a variety of discounts to facilitate such transfers. This is important for SCI patients as it helps them achieve independence and improve their life satisfaction. PCPs can facilitate referrals to occupational therapists or specialty clinics who may provide assistance with the process of using an adapted vehicle.14 Participants in SCI focus groups have also advocated for increased use of internet resources to decrease transportation barriers.13 One such resource is the development of an online portal that lists accessible provider directories and their ratings. Major rehabilitation centers have such information, but it is not widespread or easily accessible. A centralized platform can better inform both patients and PCPs of clinics nearby that tailor their practice to include individuals with disability.
These barriers to accessibility have broader implications. John may not have had any routine preventive care screenings.4,8,15 The lack of accessibility and proper equipment not only in the clinician’s office but also in health care facilities has resulted in patients receiving fewer preventive measures, including pap smears, pelvic examinations, colonoscopies, and mammograms, compared to non-SCI patients.16 Limited accessibility has also hindered preventive screening in other areas such as bone health and dental care.9,15
The development of secondary complications and the lack of appropriate care pose another significant set of health care problems. These complications involve issues related to bowel, bladder, pain, adaptive equipment, skin, and spasticity. Up to 34% of all such secondary complications are preventable with good support in primary care.17 Other broader issues such as psychological, sexual, reproductive, lifestyle, and community functioning contribute to poor standards of care among SCI patients.15
Attitudes, knowledge, and expertise
The negative stigma, marginalization, and lack of knowledge surrounding SCI patients often lead to isolation, exclusion, lack of acceptance, and embarrassment. These broad themes can result in inaccurate preconceptions and biases that lead to delays in diagnosis and treatment and decreased support. Practitioners need to be aware of and comfortable in communicating about disability. Patronizing encounters and the lack of courtesy, sensitivity, and respect have been frequently reported by patients.13 Resources that improve provider disability literacy and communication should be emphasized.18 Good disability etiquette such as spending more time with patients, having a face-to-face conversation, and good support during physical exams can dramatically improve the care and perceptions of SCI individuals. When referring care to other practitioners, providing resources about disability as part of patient referral package may help in dispelling misperceptions and increase awareness of the specific disability and specific patient needs.13 Empowering PCPs through education and exposure may mitigate such preconceptions.
PCPs are often uncomfortable in managing care for SCI patients due to lack of training, low patient volumes, and the perception of the process as being time consuming.7,12 This is further highlighted by 47% of emergency room residents not having adequate knowledge in six categories of post-SCI care (autonomic dysreflexia, urinary tract infection, posttraumatic syringomyelia, gastrointestinal system problems, pulmonary disturbances, and cardiac complications).19 Many individuals with SCI have been educated on some of these aspects of their care in inpatient rehabilitation centers, and so it is important for PCPs to demonstrate willingness to collaborate and build capacity in managing these issues.
Evidence consistently shows that patients with SCI have a 40% to 60% prevalence of obesity, which puts them at higher risk for cardiovascular disease (CVD), cancer, and other metabolic issues.20 They are 200% more likely to have cardiovascular issues than their non-SCI peers.21 Body mass index (BMI) is commonly used among the able-bodied population to calculate
82 Topics in spinal cord injury rehabiliTaTion/spring 2020
risk for CVD, however, this calculation may give an inaccurate picture of SCI patients’ risk. Following SCI, patients lose a significant portion of their lean body mass due to atrophy, and consequently they have a higher percentage of fat mass that is not represented in a BMI calculation. Based on the decrease in lean mass and increase in fat mass, a BMI of >22 has been recommended to signify risk for obesity and obesity-related chronic diseases.22 The most accurate way to assess fat mass would be to use bioelectrical impedance analysis (BIA), but this requires access to special equipment and for patients to prepare for the analysis by fasting. Waist circumference is a more practical method that can be utilized without special tools or preparation and has more recently been utilized to look at obesity and risk factors in patients with SCI. A recent study found that a waist circumference measurement of >94 cm correlated to CVD risk factors.23 A limitation of this cutoff is that waist circumference was measured in supine at the smallest part of the waist, which requires the patient to transfer to a mat or table; this again highlights the importance of a high–low table and the ability to transfer a more dependent patient using a lift.
In 2016, a Primary and Community Care Spinal Cord Injury Summit was conducted in Ontario, Canada, with the goal of understanding key needs and future directions.6 The summit involved key stakeholders such as PCPs, individuals with SCI, researchers, allied health, policy makers, and funders. The summit yielded five areas of recommendation for improving primary care to individuals with SCI:
• Application of best practices • Improved knowledge translation and
dissemination of information/resources • Improve accessibility and system issues • Enhanced SCI research in primary care • Improved communication between health
It has been suggested that novel approaches are needed in managing the care for individuals with SCI.15 The Mobility Clinic in Ontario, Canada, has developed an accessible interprofessional clinic with the objective of facilitating care for
individuals and their PCPs. Resources such as the Spinal Cord Injury Primary Care Toolkit (SCIPCT) and accredited Case-Based Learning Modules (CBLMs) have been developed to help improve primary care knowledge, and training other PCPs is a priority.24,25
The needs of individuals with SCI are often complex and require involvement of more than the PCP alone. Allied health professionals such as occupational therapists, physiotherapists, assistive technology professionals, and dietitians have specific expertise to assist in providing quality care for individuals with SCI. They can provide wheelchair adjustments, home visits, exercise regimens, rehabilitation, and share community resources that improve day-to-day functioning of patients. They often have gone beyond the role of health providers by using strategies to combat social isolation and encouraging community participation.26 Unfortunately, these services are not uniformly accessible by patients and PCPs due to issues such as insufficient funding, wait lists, and recruitment challenges, particularly in rural settings. PCPs and their staff can advocate for community engagement and can establish partnerships to share local facilities.26 Therapists have a vital role in facilitating as social partners, arranging for peer mentors, bringing together family and friends, engaging patients in the community, and problem solving, and they need to be seen within the context of providing good primary care.
Primary care delivery model
Despite improvements in care over the last two decades, there has been limited consensus on a robust primary care delivery model that supports content, pathway, and delivery. There are 14 SCI Model Systems that manage, admit, and advance the treatment for SCI patients in the United States.2 The US Department of Veterans Affairs Spinal Cord Injuries and Disorders System of Care consists of a national network of hubs and spokes. There are 24 hubs that provide primary and specialty care. Primary care is often delivered at the local “spokes” sites.27 For example, annual comprehensive exams are done at the spoke or local clinics compared to
Accessibility After SCI 83
colonoscopy, cancer screening, and management of refractory secondary complications that are coordinated with the hub or specialized centers. This hub and spoke model of care is different from other models of care employed in Canada and Europe.27 The model has been successful, but there is little research on its long-term outcomes compared to the private system of SCI in the United States.
Due to the complexity of care involved with SCI patients, interdisciplinary collaboration is needed within and between settings. Interviews conducted among health care providers, community- based non-health providers, and policy makers managing chronic neurological conditions including SCI found that there was increased competition for scarce resources, and there was duplication of services, limited leadership, and lack of proper handouts, knowledge, and expertise.28 Sharing electronic health records and aligning services across regions also appears to be a challenge. The goal of educating patients and their families, having a proactive team of primary care providers, and having a person- centered health advocacy can lead to better health outcomes with SCI.
John was able to independently transfer onto the high–low examination table in the clinic room. On examination, he has a stage 1 pressure injury over the right ischial tuberosity. You counsel him on proper nutrition, weight shifts, and use of pressure-reducing devices and surfaces. A referral to an occupational therapist to evaluate his wheelchair cushions, mattress, and bed would be appropriate. Using a wheelchair-accessible scale, you calculate his BMI to be 24, which would be considered within the normal weight range for the general population. However, using a cutoff of 22 for people with SCI, he now falls at the risk category for obesity and obesity-related diseases. You recommend a referral to a nutritionist to discuss dietary and caloric requirements and encourage him to exercise. Referral to a physical therapist who can
provide a tailored exercise regimen for home or the gym can be useful. Lastly, as a PCP you schedule a follow-up with John in a few weeks to monitor his pressure injury care and overall cardiovascular health.
SCI and other physical disabilities are complex, chronic conditions that often lead to inappropriate use of health care services, increased health care costs, and fragmented care. More importantly, these conditions often lead to poorer overall individual health outcomes. PCPs need to consider the physical, attitudinal, knowledge-based, and systemic barriers that exist and be proactive in addressing them. Novel and collaborative approaches are needed to change the trajectory of care for persons with physical disabilities. By addressing these barriers and incorporating an informed team-based approach, PCPs can improve the quality of patient care and improve individual health outcomes.
Key Take Home Points
1. Ensure an accessible clinic and equipment with knowledge of proper use for SCI patients to provide comprehensive care.
2. Be vigilant for common secondary compli- cations of SCI (primarily bowel, bladder, autonomic dysreflexia, spasticity, and skin changes) in addition to diseases that affect the general population.
3. Identify local rehabilitation centers and associated assessible clinics near you. Proactively seek referral sources and knowledge of community resources such as rehabilitation centers, local gyms, and assistive technology professionals.
4. Educate staff about removing attitudinal and physical barriers in primary care clinic.
The authors report no conflicts of interest.
84 Topics in spinal cord injury rehabiliTaTion/spring 2020
1. Granger C V, Karmarkar AM, Graham JE, et al. The Uniform Data System for Medical Rehabilitation: Report of patients with traumatic spinal cord injury discharged from rehabilitation programs in 2002- 2010. Am J Phys Med Rehabil. 2012;91(4):289- 299. doi:10.1097/PHM.0b013e31824ad2fd
2. Somers MF. Spinal Cord Injury: Functional Rehabilitation. 3rd ed. Upper Saddle River, NJ: Prentice Hall; 2010.
3. Biering-Sørensen F, DeVivo MJ, Charlifue S, et al. International Spinal Cord Injury Core Data Set (version 2.0)-including standardization of reporting. Spinal Cord. 2017;55(8):759-764. doi:10.1038/ sc.2017.59
4. Noreau L, Noonan VK, Cobb J, Leblond J, Dumont FS. Spinal cord injury community survey: Understanding the needs of Canadians with SCI. Top Spinal Cord Inj Rehabil. 2014;20(4):265-276. doi:10.1310/ sci2004-265
5. Ho CH. Primary care for persons with spinal cord injury – not a novel idea but still under-developed. J Spinal Cord Med. 2016;39(5):500-503. doi:10.1080/ 10790268.2016.1182696
6. Milligan J, Lee J, Smith M, et al. Advancing primary and community care for persons with spinal cord injury: Key findings from a Canadian summit. J Spinal Cord Med. December 2018:1-11. doi:10.1080/ 10790268.2018.1552643
7. Milligan J, Lee J. Enhancing primary care for persons with spinal cord injury: More than improving physical accessibility. J Spinal Cord Med. 2016;39(5):496- 499. doi:10.1179/2045772315Y.0000000041
8. Stillman MD, Frost KL, Smalley C, Bertocci G, Williams S. Health care utilization and barriers experienced by individuals with spinal cord injury. Arch Phys Med Rehabil. 2014;95(6):1114-1126. doi:10.1016/j.apmr.2014.02.005
9. Lofters A, Chaudhry M, Slater M, et al. Preventive care among primary care patients living with spinal cord injury. J Spinal Cord Med. 2018:1-7. doi:10.1080/ 10790268.2018.1432308
10. Canadian Disability Policy Alliance. Primary Care Accessibility Checklist. http://18.104.22.168/~disabio5/ wp-content/uploads/2012/09/FHT-access-chklst-24- Jun-111.pdf. Accessed June 25, 2019.
11. Canadian Disability Policy Alliance. Improving Accessibility of Family Health Teams Evaluation Report. http://www.disabilitypolicyalliance.ca/ wp-content/uploads/2014/01/Family-Health- Teams.pdf. Accessed June 25, 2019.
12. McMillan C, Lee J, Milligan J, Hillier LM, Bauman C. Physician perspectives on care of individuals with severe mobility impairments in primary care in Southwestern Ontario, Canada. Health Soc Care Community. 2016;24(4):463-472. doi:10.1111/hsc.12228
13. Kroll T, Jones GC, Kehn M, Neri MT. Barriers and strategies affecting the utilisation of primary preventive services for people with physical disabilities: A qualitative inquiry. Health Soc Care Community. 2006;14(4):284-293. doi:10.1111/ j.1365-2524.2006.00613.x
14. Biering-Sørensen F, Hansen RB, Biering-Sørensen J. Mobility aids and transport possibilities 10-45
years after spinal cord injury. Spinal Cord. 2004;42(12):699-706. doi:10.1038/sj.sc.3101649
15. McColl MA, Aiken A, McColl A, Sakakibara B, Smith K. Primary care of people with spinal cord injury: Scoping review. Can Fam Physician. 2012;58(11):1207-1216, e626-35. http://www. ncbi.nlm.nih.gov/pubmed/23152456.
16. Song SH, Svircev JN, Teng BJ, Dominitz JA, Burns SP. A safe and effective multi-day colonoscopy bowel preparation for individuals with spinal cord injuries. J Spinal Cord Med. 2018;41(2):149-156. doi:10.108 0/10790268.2016.1258968
17. van Loo MA, Post MWM, Bloemen JHA, van Asbeck FWA. Care needs of persons with long-term spinal cord injury living at home in the Netherlands. Spinal Cord. 2010;48(5):423-428. doi:10.1038/sc.2009.142
18. United Spinal Association. Disability Etiquette, Tips on Interacting with People with Disabilities. https:// www.unitedspinal.org/pdf/DisabilityEtiquette.pdf. Accessed September 25, 2019.
19. DiPonio L, Roth R, Gater D, et al. The management of patients with chronic spinal cord injury in emergency departments: Utilization and a knowledge survey of emergency medicine residents. Top Spinal Cord Inj Rehabil. 2011;17:38-45.
20. Shojaei MH, Alavinia SM, Craven BC. Management of obesity after spinal cord injury: A systematic review. J Spinal Cord Med. 2017;40(6):783-794. doi:10.1080/10790268.2017.1370207
21. Gorgey AS, Gater DR. Prevalence of obesity after spinal cord injury. Top Spinal Cord Inj Rehabil. 2007;12(4):1-7. doi:10.1310/sci1204-1
22. Laughton GE, Buchholz AC, Martin Ginis KA, Goy RE, SHAPE SCI Research Group. Lowering body mass index cutoffs better identifies obese persons with spinal cord injury. Spinal Cord. 2009;47(10):757- 762. doi:10.1038/sc.2009.33
23. Ravensbergen HRJC, Lear SA, Claydon VE. Waist circumference is the best index for obesity-related cardiovascular disease risk in individuals with spinal cord injury. J Neurotrauma. 2014;31(3):292-300. doi:10.1089/neu.2013.3042
24. CFFM FHT Primary Care Mobility Clinic. Provider Educational Materials. http://mobilityclinic.ca/provider- educational-materials/. Accessed June 25, 2019.
25. Milligan J, Lee J, Hillier LM, Slonim K, Craven C. Improving primary care for persons with spinal cord injury: Development of a toolkit to guide care. J Spinal Cord Med. 2018:1-10. doi:10.1080/10790268.2018. 1468584
26. Price P, Stephenson S, Krantz L, Ward K. Beyond my front door: The occupational and social participation of adults with spinal cord injury. OTJR Occup Particip Heal. 2011;31(2):81-88. doi:10.3928/15394492- 20100521-01
27. Donnelly C, McColl MA, Charlifue S, et al. Utilization, access and satisfaction with primary care among people with spinal cord injuries: A comparison of three countries. Spinal Cord. 2007;45(1):25-36. doi:10.1038/sj.sc.3101933
28. Jaglal SB, Guilcher SJT, Bereket T, et al. Development of a Chronic Care Model for Neurological Conditions (CCM-NC). BMC Health Serv Res. 2014;14(1):409. doi:10.1186/1472-6963-14-409
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Biological Psychiatry GOS
Secondary Sources of Negative Symptoms in Those Meeting Criteria for a Clinical High-Risk Syndrome
Tina Gupta, Gregory P. Strauss, Henry R. Cowan, Andrea Pelletier-Baldelli, Lauren M. Ellman, Jason Schiffman, and Vijay A. Mittal
ABSTRACT BACKGROUND: Negative symptoms are diagnostic characteristics of schizophrenia. They can result from primary (i.e., idiopathic) or secondary (i.e., due to other factors such as depression, anxiety, psychosis, disorganization, medication effects) features of the illness. Although secondary sources of negative symptoms are prevalent among individuals meeting criteria for clinical high-risk syndromes that are due to high rates of comorbidity, the extent to which secondary sources account for variance in negative symptom domains is unknown. Addressing this gap is an important step in informing vulnerability models and treatments for negative symptoms. This study aimed to inves- tigate secondary sources of negative symptoms in those meeting criteria for a clinical high-risk syndrome (N = 192). METHODS: Simultaneous regression and hierarchical partitioning methods were used to determine the proportion of variance explained by selective serotonin reuptake inhibitor use, anxiety, depression, unusual thought content, and disorganized communication in predicting severity of five negative symptom domains (avolition, anhedonia, aso- ciality, blunted affect, and alogia). RESULTS: Findings revealed that depression explained the largest proportion of variance in avolition, asociality, and anhedonia. Anxiety was the most predictive of blunted affect, and selective serotonin reuptake inhibitor use explained the most varia
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