Pain and cognitive performance in adults with multiple sclerosis: A systematic review.

INTRODUCTION: Pain and cognitive dysfunction are separately known to be important manifestations of multiple sclerosis (MS). Although pain is a complex subjective phenomenon with affective and cognitive aspects, it is not known if people with MS reporting pain are at greater risk of reduced performance in objective tests of cognition. The presence or direction of any association remains to be clarified, as do the roles of confounders such as fatigue, medication and mood. METHODS: We conducted a systematic review of studies examining the relationship between pain and objectively measured cognition in adults with confirmed MS, according to a pre-registered protocol (PROSPERO 42,020,171,469). We carried out searches in MEDLINE, Embase and PsychInfo. Studies of adults with any subtype of MS, with chronic pain and in which cognitive evaluation was conducted by validated instruments were included. We evaluated the role of potential confounders (medication, depression, anxiety, fatigue and sleep) and described findings by eight pre-specified cognitive domains. Risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS: 11 studies (n = 3714 participants, range 16 to 1890 per study) were included in the review. Four studies included longitudinal data. Nine studies identified a relationship between pain and objectively measured cognitive performance. In seven of these studies, higher pain scores were associated with poorer cognitive performance. However, no evidence was available for some cognitive domains. Heterogeneous study methodology precluded meta-analysis. Studies infrequently controlled for the specified confounders. Most studies were judged to be at risk of bias. DISCUSSION: Several studies, but not all, identified a negative relationship between pain severity and objectively measured cognitive performance. Our ability to further characterise this relationship is limited by study design and lack of evidence in many cognitive domains. Future studies should better establish this relationship and delineate the neurological substrate underpinning it.

Trauma surgery at a designated COVID-19-free site during the pandemic: a safe model and a possible way to restart routine elective surgery.

AIMS: Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos' Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service. METHODS: All patients undergoing surgery during the COVID-19 pandemic at the orthopaedic surgical unit (OSU) in St. Woolos' Hospital from 23 March 2020 to 24 April 2020 were included. All patients that were operated on had a telephone follow-up two weeks after surgery to assess if they had experienced COVID-19 symptoms or had been tested for COVID-19. The nature of admission, operative details, and patient demographics were obtained from the health board's electronic record. Staff were assessed for sickness, self-isolation, and COVID-19 status. RESULTS: A total of 58 surgical procedures were undertaken at the OSU during the study period; 93% (n = 54) of patients completed the telephone follow-up. Open reduction and internal fixation of ankle and wrist fractures were the most common procedures. None of the patients nor members of their households had developed symptoms suggestive of COVID-19 or required testing. No staff members reported sick days or were advised by occupational health to undergo viral testing. CONCLUSION: This study provides optimism that orthopaedic patients planned for surgery can be protected from COVID-19 nosocomial transmission at separate COVID-19-free sites.Cite this article: Bone Joint Open 2020;1-6:302-308.

Translating CKD Research into Primary Care Practice: a Group-Randomized Study.

BACKGROUND: Chronic kidney disease (CKD) is common in the primary care setting. Early interventions may prevent progression of renal disease and reduce risk for cardiovascular complications, yet quality gaps have been documented. Successful approaches to improve identification and management of CKD in primary care are needed. OBJECTIVE: To assess whether implementation of a primary care improvement model results in improved identification and management of CKD DESIGN: 18-month group-randomized study PARTICIPANTS: 21 primary care practices in 13 US states caring for 107,094 patients INTERVENTIONS: To promote implementation of CKD improvement strategies, intervention practices received clinical quality measure (CQM) reports at least quarterly, hosted an on-site visit and 2 webinars, and sent clinician/staff representatives to a "best practice" meeting. Control practices received CQM reports at least quarterly. MAIN MEASURES: Changes in practice adherence to a set of 11 CKD CQMs KEY RESULTS: We observed significantly greater improvements among intervention practices for annual screening for albuminuria in patients with diabetes or hypertension (absolute change 22% in the intervention group vs. - 2.6% in the control group, p < 0.0001) and annual monitoring for albuminuria in patients with CKD (absolute change 21% in the intervention group vs. - 2.0% in the control group, p < 0.0001). Avoidance of NSAIDs in patients with CKD declined in both intervention and control groups, with a significantly greater decline in the control practices (absolute change - 5.0% in the intervention group vs. - 10% in the control group, p < 0.0001). There were no other significant changes found for the other CQMs. Variable implementation of CKD improvement strategies was noted across the intervention practices. CONCLUSIONS: Implementation of a primary care improvement model designed to improve CKD identification and management resulted in significantly improved care on 3 out of 11 CQMs. Incomplete adoption of improvement strategies may have limited further improvement. Improving CKD identification and management likely requires a longer and more intensive intervention.

Post-operative infection with fresh frozen allograft: reported outcomes of a hospital-based bone bank over 14 years.

Femoral head bone allografts have traditionally been used to provide mechanical stability to areas of bony deficiency, or for its osteoinductive and osteoconductive properties. Concerns have been raised over increased infection rates following the use of fresh-frozen graft tissue. This retrospective study aims to investigate the outcomes of fresh frozen femoral heads kept in a regulated, non-commercial bone bank at a university teaching hospital.The local bone bank database was used to identify released femoral heads during a 14 year study period (September 1999-December 2013) whereby a retrospective review of patient records was undertaken to determine clinical outcome. During the observed study period, 427 femoral heads were released from cold storage. Of these, 270 femoral heads had a mean follow-up of 347 days. 157 femoral heads were excluded due to insufficient follow-up data (n = 132) or discarded due to breaks in the cold chain prior to use (n = 25). Of the 270 included femoral heads, 231 (85.6 %) had no reported complications with good graft incorporation. In the remaining 39 with reported complications, only 5 (2.6 %) developed a postoperative infection. Our findings suggest that the use of fresh frozen allograft does not materially increase the risk of post-operative bacterial infection. Our reported post-operative infection rates are comparable with infection rates of other similar studies on fresh frozen allograft use.

Learning from primary care meaningful use exemplars.

BACKGROUND: Submission of clinical quality measures (CQMs) data are 1 of 3 major requirements for providers to receive meaningful use (MU) incentive payments under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act. Some argue that CQMs are the most important component of MU. Developing an evidence base for how practices can successfully use electronic health records (EHRs) to achieve improvement in CQMs is essential and may benefit from the study of exemplars who have successfully implemented EHRs and demonstrated high performance on CQMs. METHODS: Conducted in PPRNet, a national primary care practice-based research network, this study used a multimethod approach combining an EHR-based CQM performance assessment, a provider survey, and focus groups among high CQM performers. Practices whose providers had attested for stage 1 MU were eligible for the study. Performance on 21 CQMs included in the 2014 MU CQM set and a summary measure was assessed as of October 1, 2013, through an automated data extract and standard analytic procedures. A web-based provider survey, conducted in November to December 2013, assessed provider agreement, staff education, use of EHR reminders, standing orders, and EHR-based patient education related to the 21 CQMs. The survey also had more general questions about the practices' use of EHR functionality and quality improvement (QI) strategies. Statistical analyses using general linear mixed models assessed the associations between responses to the survey and CQM performance, adjusted for several practice covariates. Three focus groups, held in early 2014, provided an opportunity for clinicians to provide their perspectives on the validity of the statistical analyses and to provide context-specific examples from their practice that supported their assessment. RESULTS: Seventy-one practices completed the study, and 319 (92.1%) of their providers completed the survey. There was wide variability in performance on the 21 CQMs among the practices. Mean performance ranged from 89.8% for tobacco use screening and counseling to 12.9% for chlamydia screening. In bivariate analyses, more positive associations were found between CQM performance and staff education, use of standing orders, and EHR reminders than for provider agreement or EHR-based patient education. In multivariate analyses, EHR reminders were most frequently associated with individual CQM performance; several EHR, practice QI, and administrative variables were associated with the summary quality measure. CONCLUSIONS: Purposeful use of EHR functionality coupled with staff education in a milieu where QI is valued and supported is associated with higher performance on CQM.

Professional development through attending conferences: reflections of a health librarian.

In this article, guest writer Ruth Jenkins from Berkshire Heathcare Foundation Trust reflects on two conferences she attended in 2014, LILAC and SLA. Through the process of reflection, she considers the benefits that attending conferences can have to library and information professionals in the health sector. In particular, she discusses the opportunities and areas for learning and professional development that conferences can offer including evidence-based practice and current awareness, gaining new knowledge and objectivity, and networking and the unexpected benefits of conferences. Ruth also offers some practical hints and tips on ways to facilitate your attendance at conferences, including through awards and funding. H.S.

Lateral unicompartmental knee replacements: early results from a District General Hospital.

Lateral unicompartment knee replacements are performed infrequently in the United Kingdom. This study evaluates the experience of two knee surgeons in a District General Hospital for all lateral unicompartmental arthroplasties performed between October 2007 and August 2011. Two different implants were used in this time period, the Oxford domed and the Zimmer fixed-bearing system. Twenty-seven procedures were completed in this time span (15 Oxford domed and 12 Zimmer fixed bearing), all of which once completed were followed up and 21 patients completed an Oxford knee score. Average Oxford knee scores were 36.6 (95 % CI 29.0-44.2) for the Oxford domed prosthesis and 28.6 (19.8-37.5) for the Zimmer fixed-bearing prosthesis (p = 0.15). One patient with an Oxford domed prosthesis required revision for bearing dislocation. The follow-up Oxford knee scores support the use of this technique as an alternative to total knee replacement but with no significant difference in functional outcome. Our results, however, may encourage a more cautious approach to the use of a mobile-bearing prosthesis in favour of a fixed-bearing prosthesis.

Relationships between environmental stressors and stress biobehavioral responses of preterm infants in NICU.

Although research has demonstrated that the neonatal intensive care unit (NICU) is a stressful environment for preterm and high-risk infants, little research validates the suspected relationships between infant biobehavioral responses and environmental stress in the NICU. This exploratory study examined the relationship between environmental stress and biobehavioral responses of preterm infants. The study used a repeated-measures research design to examine research variables in one group of preterm infants. Measurements of research variables were recorded every 2 minutes during two 60-minute observation periods for each research day (1 hour in the morning and 1 hour in the afternoon) and conducted over 2 days. A convenience sample of 37 preterm infants was recruited from 2 medical centers in Taiwan. A total of 4164 observations were made and recorded during the study. There was a statistically significant (P < .05) relationship between environmental stressors and changes in physiological signals. There were also statistically significant (P < .05) relationships between environmental stress and some specific stress behaviors. This research is applicable to neonatal clinical practice because it demonstrates the importance of recognizing the preterm infant's biological stress responses to environmental stressors, allowing for early interventions to reduce the possibility of more serious physiological or pathological changes in the status of the preterm infant.

The prevalence of chronic diseases and multimorbidity in primary care practice: a PPRNet report.

INTRODUCTION: Multimorbidity (multiple chronic illnesses) greatly affects the delivery of health care and assessment of health care quality. There is a lack of basic epidemiologic data on multimorbidity in the United States. This article addresses the prevalence of 24 chronic illnesses and multimorbidity from primary care practices across the United States. METHODS: This cross-sectional study was conducted in the PPRNet, a practice-based research network among 226 practices in 43 states that maintains a clinical database derived from a common electronic health record. Practices providing data as of October 1, 2011, and their active adult patients comprised the population used for analyses. The prevalence of each chronic illness and multimorbidity were calculated. RESULTS: Included in these analyses were 148 practices with 667,379 active patients. Median prevalence across practices ranged from 35.8% for hypertension to 0.23% for Parkinson disease, with wide variability among practices for all conditions. Multimorbidity increased steeply with age, leveling off at age 80; overall, 45.2% of patients had more than one chronic illness. CONCLUSION: Multimorbidity is a prevalent problem in primary care practice, a finding with implications for health care delivery and payment, quality assessment, and research.

Organizational attributes and screening and brief intervention in primary care.

Overconsumption of alcohol is well known to lead to numerous health and social problems. Prevalence studies of United States adults found that 20% of patients meet criteria for an alcohol use disorder. Routine screening for alcohol use is recommended in primary care settings, yet little is known about the organizational factors that are related to successful implementation of screening and brief intervention (SBI) and treatment in these settings. The purpose of this study was to evaluate organizational attributes in primary care practices that were included in a practice-based research network trial to implement alcohol SBI. The Survey of Organizational Attributes in Primary Care (SOAPC) has reliably measured four factors: communication, decision-making, stress/chaos and history of change. This 21-item instrument was administered to 178 practice members at the baseline of this trial, to evaluate for relationship of organizational attributes to the implementation of alcohol SBI and treatment. No significant relationships were found correlating alcohol screening, identification of high-risk drinkers and brief intervention, to the factors measured in the SOAPC instrument. These results highlight the challenges related to the use of organizational survey instruments in explaining or predicting variations in clinical improvement. Comprehensive mixed methods approaches may be more effective in evaluations of the implementation of SBI and treatment.

Preventive services delivery in patients with chronic illnesses: parallel opportunities rather than competing obligations.

PURPOSE: Whether patients with 1 or more chronic illnesses are more or less likely to receive recommended preventive services is unclear and an important public health and health care system issue. We addressed this issue in a large national practice-based research network (PBRN) that maintains a longitudinal database derived from electronic health records. METHODS: We conducted a cross-sectional study as of October 1, 2011, of the association between being up to date with 10 preventive services and the prevalence of 24 chronic illnesses among 667,379 active patients aged 18 years or older in 148 member practices in a national PBRN. We used generalized linear mixed models to assess for the association of being up to date with each preventive service as a function of the patient's number of chronic conditions, adjusted for patient age and encounter frequency. RESULTS: Of the patients 65.4% had at least 1 of the 24 chronic illnesses. For 9 of the 10 preventive services there were strong associations between the odds of being up to date and the presence of chronic illness, even after adjustment for visit frequency and patient age. Odds ratios increased with the number of chronic conditions for 5 of the preventive services. CONCLUSIONS: Rather than a barrier, the presence of chronic illness was positively associated with receipt of recommended preventive services in this large national PBRN. This finding supports the notion that modern primary care practice can effectively deliver preventive services to the growing number of patients with multiple chronic illnesses.

Integration and sustainability of alcohol screening, brief intervention, and pharmacotherapy in primary care settings.

OBJECTIVE: At-risk drinking and alcohol use disorders are common in primary care and may adversely affect the treatment of patients with diabetes and/or hypertension. The purpose of this article is to report the impact of dissemination of a practice-based quality improvement approach (Practice Partner Research Network-Translating Research into Practice [PPRNet-TRIP]) on alcohol screening, brief intervention for at-risk drinking and alcohol use disorders, and medications for alcohol use disorders in primary care practices. METHOD: Nineteen primary care practices from 15 states representing 26,005 patients with diabetes and/or hypertension participated in a group-randomized trial (early intervention vs. delayed intervention). The 12-month intervention consisted of practice site visits for academic detailing and participatory planning and network meetings for "best practice" dissemination. RESULTS: At the end of Phase 1, eligible patients in early-intervention practices were significantly more likely than patients in delayed-intervention practices to have been screened (odds ratio [OR] = 3.30, 95% CI [1.15, 9.50]) and more likely to have been provided a brief intervention (OR = 6.58, 95% CI [1.69, 25.7]. At the end of Phase 2, patients in delayed-intervention practices were more likely than at the end of Phase 1 to have been screened (OR = 5.18, 95% CI [4.65, 5.76]) and provided a brief intervention (OR = 1.80, 95% CI [1.31, 2.47]). Early-intervention practices maintained their screening and brief intervention performance during Phase 2. Medication for alcohol use disorders was prescribed infrequently. CONCLUSIONS: PPRNet-TRIP is effective in improving and maintaining improvement in alcohol screening and brief intervention for patients with diabetes and/or hypertension in primary care settings.

Medication Safety in Primary Care Practice: results from a PPRNet quality improvement intervention.

Reducing medication errors is a fundamental patient safety goal; however, few improvement interventions have been evaluated in primary care settings. The Medication Safety in Primary Care Practice project was designed to test the impact of a multimethod quality improvement intervention on 5 categories of preventable prescribing and monitoring errors in 20 Practice Partner Research Network (PPRNet) practices. PPRNet is a primary care practice-based research network among users of a common electronic health record (EHR). The intervention was associated with significant improvements in avoidance of potentially inappropriate therapy, potential drug-disease interactions, and monitoring of potential adverse events over 2 years. Avoidance of potentially inappropriate dosages and drug-drug interactions did not change over time. Practices implemented a variety of medication safety strategies that may be relevant to other primary care audiences, including use of EHR-based audit and feedback reports, medication reconciliation, decision-support tools, and refill protocols.

Implementing and evaluating electronic standing orders in primary care practice: a PPRNet study.

BACKGROUND: A standing order (SO) authorizes nurses and other staff to carry out medical orders per practice-approved protocol without a clinician's examination. This study implemented electronic SOs into the daily workflow of primary care practices; identified methods and strategies; determined barriers and facilitators; and measured changes in quality indicators resulting from electronic SOs. METHODS: Within 8 practices using the Practice Partner® electronic health record (EHR), a customized health maintenance template provided SOs for screening, immunization, and diabetes measures. EHR data extracts were used to calculate the presence and use of these measures on health maintenance templates and performance over 21 months. Qualitative observation/interviews at practice site visits, network meetings, and correspondence enabled synthesis of implementation issues. RESULTS: Improvements in template presence, use, and performance were found for 14 measures across all practices. Median improvements in screening ranged 6% to 10%; immunizations, 8% to 17%, and diabetes, 0% to 18%. Two practices achieved significant improvement on 14 of the 15 measures. All practices significantly improved on at least 3 of the measures. CONCLUSIONS: A small sample of primary care practices implemented SOs for screening, immunizations and diabetes measures supported by PPRNet researchers. Technical competence and leadership to adapt EHR reminder tools helped staff adopt new roles and overcome barriers.

Colorectal cancer screening in primary care: theoretical model to improve prevalence in the practice partner research network.

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Half of Americans older than age 50 are not current with recommended screening; research is needed to assess the impact of interventions designed to increase receipt of CRC screening. The Colorectal Cancer Screening in Primary Care (C-TRIP) study is a theoretically informed group randomized trial within 32 primary care practices. Baseline median proportion of active patients aged 50 years or older up-to-date with CRC screening among the 32 practices was 50.8% (N = 55,746). Men were more likely to have been screened than women (52.9% vs. 49.2%, respectively). Patients 50 to 59 years of age were less likely to be up-to-date with screening (45.4%) than those in the 60 to 69 years and 70 to 79 years groups (58.5% in both groups). Opportunities exist to increase the proportion of CRC screening received in adults aged 50 and older. C-TRIP evaluates the effectiveness of a model for improvement for increasing this proportion.

Colorectal cancer screening in primary care: translating research into practice.

BACKGROUND: Colorectal cancer (CRC) screening is recommended for all adults 50 to 75 years old, yet only slightly more than one-half of eligible people are current with screening. Because CRC screening is usually initiated upon recommendations of primary care physicians, interventions in these settings are needed to improve screening. OBJECTIVES: To assess the impact of a quality improvement intervention combining electronic medical record based audit and feedback, practice site visits for academic detailing and participatory planning, and "best-practice" dissemination on CRC screening in primary care practice. RESEARCH DESIGN: Two-year group randomized trial. SUBJECTS: Physicians, midlevel providers, and clinical staff members in 32 primary care practices in 19 States caring for 68,150 patients 50 years of age or older. MEASURES: Proportion of active patients up-to-date (UTD) with CRC screening (colonoscopy within 10 years, sigmoidoscopy within 5 years, or at home fecal occult blood testing within 1 year) and having screening recommended within past year among those not UTD. RESULTS: Patients 50 to 75 years in intervention practices exhibited significantly greater improvement (from 60.7% to 71.2%) in being UTD with CRC screening than patients in control practices (from 57.7% to 62.8%), the adjusted difference being 4.9% (95% confidence interval, 3.8%-6.1%). Recommendations for screening also increased more in intervention practices with the adjusted difference being 7.9% (95% confidence interval, 6.3%-9.5%). There was wide interpractice variation in CRC screening throughout the intervention. CONCLUSIONS: A multicomponent quality improvement intervention in practices that use electronic medical record can improve CRC screening.

Relationships between environmental stressors and stress biobehavioral responses of preterm infants in NICU.

Although research has demonstrated that the neonatal intensive care unit (NICU) is a stressful environment for preterm and high-risk infants, little research validates the suspected relationships between infant biobehavioral responses and environmental stress in the NICU. This exploratory study examined the relationship between environmental stress and biobehavioral responses of preterm infants. The study used a repeated-measures research design to examine research variables in one group of preterm infants. Measurements of research variables were recorded every 2 minutes during two 60-minute observation periods for each research day (1 hour in the morning and 1 hour in the afternoon) and conducted over 2 days. A convenience sample of 37 preterm infants was recruited from 2 medical centers in Taiwan. A total of 4164 observations were made and recorded during the study. There was a statistically significant (P < .05) relationship between environmental stressors and changes in physiological signals. There were also statistically significant (P < .05) relationships between environmental stress and some specific stress behaviors. This research is applicable to neonatal clinical practice because it demonstrates the importance of recognizing the preterm infant's biological stress responses to environmental stressors, allowing for early interventions to reduce the possibility of more serious physiological or pathological changes in the status of the preterm infant.

Surrogate consent for genomics research in intensive care.

Surrogate decision makers may be poorly prepared to give informed consent for genomics research for their loved ones in intensive care. A review of the challenges and strategies associated with obtaining surrogates' consent for genomics research in intensive care patients revealed that few well-controlled studies have been done on this topic. Yet, a major theme in the literature is the role of health care professionals in guiding surrogates through the informed consent process rather than simply witnessing a signature. Informed consent requires explicit strategies to approach potential surrogates effectively, educate them, and ensure that informed consent has been attained.

An application of a modified constrained randomization process to a practice-based cluster randomized trial to improve colorectal cancer screening.

BACKGROUND: When designing cluster randomized trials, it is important for researchers to be familiar with strategies to achieve valid study designs given limited resources. Constrained randomization is a technique to help ensure balance on pre-specified baseline covariates. METHODS: The goal was to develop a randomization scheme that balanced 16 intervention and 16 control practices with respect to 7 factors that may influence improvement in study outcomes during a 4-year cluster randomized trial to improve colorectal cancer screening within a primary care practice-based research network. We used a novel approach that included simulating 30,000 randomization schemes, removing duplicates, identifying which schemes were sufficiently balanced, and randomly selecting one scheme for use in the trial. For a given factor, balance was considered achieved when the frequency of each factor's sub-classifications differed by no more than 1 between intervention and control groups. The population being studied includes approximately 32 primary care practices located in 19 states within the U.S. that care for approximately 56,000 patients at least 50 years old. RESULTS: Of 29,782 unique simulated randomization schemes, 116 were determined to be balanced according to pre-specified criteria for all 7 baseline covariates. The final randomization scheme was randomly selected from these 116 acceptable schemes. CONCLUSIONS: Using this technique, we were successfully able to find a randomization scheme that allocated 32 primary care practices into intervention and control groups in a way that preserved balance across 7 baseline covariates. This process may be a useful tool for ensuring covariate balance within moderately large cluster randomized trials.