Patient, Rheumatologist and Therapist Perspectives on the Implementation of an Allied Health Rheumatology Triage (AHRT) Initiative in Ontario Rheumatology Clinics.

PURPOSE: The objective of this qualitative study was to explore patient, rheumatologist, and extended role practitioner (ERP) perspectives on the integration of an allied health rheumatology triage (AHRT) intervention in Ontario rheumatology clinics. Triage is the process of identifying the urgency of a patient's condition to ensure they receive specialist care within an appropriate length of time. This research explores the clinical/logistical impact of triage by occupational and physical therapists with advanced arthritis training (ERPs), including facilitators and barriers of success, and recommendations for future application. PARTICIPANTS AND METHODS: Semi-structured telephone interviews were held with participating rheumatologists, ERPs, and a sample of patients from each clinical site (4 community, 3 hospital) in five Ontario cities. Interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed using basic qualitative description. Two independent researchers compared coding and achieved consensus. RESULTS: Patients (n=10), rheumatologists (n=6), and ERPs (n=5) participated in the study and reported reduced wait-times to rheumatology care, diagnosis, and treatment for those with inflammatory arthritis (IA). Rheumatologists and ERPs perceived that the intervention improved clinical efficiency and quality of care. Patients reported high satisfaction with ERP assessments, valuing early joint examination/laboratory tests, urgent referral if needed, and the provision of information, support, and management strategies. Facilitators of success included: supportive clinical staff, regular communication and collaboration between rheumatologist and ERP, and sufficient clinical space. Recommendations included extending ERP roles to include stable patient follow-up, and ERP care between scheduled rheumatology appointments. CONCLUSION: Findings support the integration of ERPs in a triage role in the community and hospital-based rheumatology models of care. Future research is needed to explore the impact of utilizing ERPs for stable patient follow-up in rheumatology settings.

Rehabilitation service models for people with physical and/or mental disability living in low- and middle-income countries: A systematic review.

OBJECTIVE: To compare models of rehabilitation services for people with mental and/or physical disability in order to determine optimal models for therapy and interventions in low- to middle-income countries. DATA SOURCES: CINAHL, EMBASE, MEDLINE, CENTRAL, PsycINFO, Business Source Premier, HINARI, CEBHA and PubMed. STUDY SELECTION: Systematic reviews, randomized control trials and observational studies comparing >2 models of rehabilitation care in any language. Date extraction: Standardized forms were used. Methodological quality was assessed using AMSTAR and quality of evidence was assessed using GRADE. DATA SYNTHESIS: Twenty-four systematic reviews which included 578 studies and 202,307 participants were selected. In addition, four primary studies were included to complement the gaps in the systematic reviews. The studies were all done at various countries. Moderate- to high-quality evidence supports the following models of rehabilitation services: psychological intervention in primary care settings for people with major depression, admission into an inpatient, multidisciplinary, specialized rehabilitation unit for those with recent onset of a severe disabling condition; outpatient rehabilitation with multidisciplinary care in the community, hospital or home is recommended for less severe conditions; However, a model of rehabilitation service that includes early discharge is not recommended for elderly patients with severe stroke, chronic obstructive pulmonary disease, hip fracture and total joints. CONCLUSION: Models of rehabilitation care in inpatient, multidisciplinary and specialized rehabilitation units are recommended for the treatment of severe conditions with recent onset, as they reduce mortality and the need for institutionalized care, especially among elderly patients, stroke patients, or those with chronic back pain. Results are expected to be generalizable for brain/spinal cord injury and complex fractures.

Safety and efficacy of testosterone gel 1% augmentation in depressed men with partial response to antidepressant therapy.

The current study evaluates the efficacy and safety of testosterone (T) gel 1% augmentation on depressive symptoms and quality of life in treatment-resistant, depressed, hypogonadal men older than 50 years of age who are receiving antidepressants. The authors hypothesized that T augmentation would improve depressive symptoms and quality of life. Eighteen hypogonadal men entered the study who had had an adequate trial of antidepressant therapy and had significant depressive symptoms. Participants were continued on their antidepressant and were randomized to receive either placebo or active T gel (5 g) to be applied once a day. Participants were tested on 6 occasions: screening visit, an initial session (pretreatment), at 6 and 12 weeks during the first treatment condition, and at 18 and 24 weeks during the crossover condition. The authors found a significant improvement in depressive symptoms from baseline to 12 weeks of testosterone treatment. However, a statistical difference between placebo and testosterone treatment phases was not demonstrated. The limitations of the study, including the chronicity and severity of patients' depression, variability in T levels, and a small sample size, probably influenced the ability to detect a discernable difference. Nevertheless, the study shows that T gel augmentation may be helpful in hypogonadal males with depression.