The development of a consensus statement for the prescription of powered wheelchair standing devices in Duchenne muscular dystrophy.

PURPOSE: To develop a consensus statement for the prescription of a Powered Wheelchair Standing Device (PWSD) in young people with Duchenne muscular dystrophy (DMD). MATERIALS AND METHODS: An international multidisciplinary panel comprising clinicians and users (young people with DMD) along with their parents was consulted. A literature review was undertaken and a Delphi method was utilised to generate consensus statements. To supplement limited literature, round one of the Delphi process comprised questions consistent with the International Classification of Functioning, Disability and Health model of disability to generate items based on expert opinion and was completed by 38 clinicians and nine users. Thirty-seven participants completed two further rounds rating the importance of each item with a five-point scale. Agreement of 70% or more participants for items indicated consensus. RESULTS: Consensus was reached for 47 of 80 items. Tolerance and comfort in supported standing for at least 10 min, ankle contracture less than 10 degrees and user goals reflecting motivation to use the standing function were agreed as necessary in guiding the decision to trial a PWSD. Evidence of family, therapist and servicing support were also considered critical in enabling continuity of PWSD use. CONCLUSIONS: PWSD is a mobility option that offers choice, control and opportunity for independence. This consensus statement can assist clinicians with decision-making around factors influencing successful implementation and optimisation of PWSD for young people with DMD.Implications for RehabilitationTolerance and comfort in supported standing for at least 10 minutes, ankle contracture limited to less than 10 degrees and the child's goals reflecting motivation to use the standing position were agreed to be necessary considerations in guiding the decision to trial a PWSD.Trialling a PWSD when the child is predicted to lose the ability to walk within a one to two year period was recommended although a PWSD could be suitable for a child who was unable to walk.Evidence of family, therapist and servicing support was considered critical in enabling continuity of PWSD use.

Ophthalmic complications following ocular penetration during routine dentistry in 13 cats.

CASE HISTORY Thirteen cats developed ophthalmic complications following dental procedures in Australia and New Zealand between December 2014 and February 2018. All cats had at least one maxillary tooth extracted and some received a transoral maxillary nerve block. CLINICAL FINDINGS Ocular signs were identified at a median of 1.5 (min 0, max 14) days following elective dental procedures and included fibrin in the anterior chamber, aqueous flare, vision loss and miosis. Response to medical management was poor overall, with 7/13 (54%) cats undergoing subsequent enucleation and one cat was subjected to euthanasia shortly after the dental procedure due to ocular disease. The remaining five cats were managed medically. Of these, four exhibited signs of persistent inflammation at the last ophthalmic assessment, and one was subsequently subjected to euthanasia due to reasons unrelated to ocular health. Active inflammation resolved in one cat, however the lesions caused by previous inflammation persisted. PATHOLOGICAL FINDINGS Assessment of six enucleated globes showed a variety of pathological changes, with marked fibrinous exudation and suppurative inflammation as predominant features. A scleral penetration site was identified in three globes. Four globes had lens capsule rupture and phacoclastic uveitis. DIAGNOSIS Endophthalmitis following iatrogenic globe penetration during routine dental procedures. CLINICAL RELEVANCE This case series demonstrates that globe penetration during dental procedures carries a poor prognosis for the eye. Clinicians should be aware of the risks of ocular trauma during dental procedures in cats and great care should be taken to avoid ocular penetration, particularly during tooth extractions. Transoral maxillary nerve blocks should be avoided or used with extreme caution in cats.

Improving the culture of evidence-based practice at a Magnet® hospital.

Evidence-based practice (EBP) is the foundation of quality care, but EBP is not widely adopted. This study evaluated the impact of a hospital-wide EBP nursing project on the organizational culture of a Magnet hospital. Results of pre- and postintervention surveys suggest the intervention increased the nurses' confidence in the hospital's EBP environment. Belief in EBP was related to confidence in implementing EBP in practice.

Challenges in using electronic health record data for CER: experience of 4 learning organizations and solutions applied.

OBJECTIVE: To document the strengths and challenges of using electronic health records (EHRs) for comparative effectiveness research (CER). METHODS: A replicated case study of comparative effectiveness in hypertension treatment was conducted across 4 health systems, with instructions to extract data and document problems encountered using a specified list of required data elements. Researchers at each health system documented successes and challenges, and suggested solutions for addressing challenges. RESULTS: Data challenges fell into 5 categories: missing data, erroneous data, uninterpretable data, inconsistencies among providers and over time, and data stored in noncoded text notes. Suggested strategies to address these issues include data validation steps, use of surrogate markers, natural language processing, and statistical techniques. DISCUSSION: A number of EHR issues can hamper the extraction of valid data for cross-health system comparative effectiveness studies. Our case example cautions against a blind reliance on EHR data as a single definitive data source. Nevertheless, EHR data are superior to administrative or claims data alone, and are cheaper and timelier than clinical trials or manual chart reviews. All 4 participating health systems are pursuing pathways to more effectively use EHR data for CER.A partnership between clinicians, researchers, and information technology specialists is encouraged as a way to capitalize on the wealth of information contained in the EHR. Future developments in both technology and care delivery hold promise for improvement in the ability to use EHR data for CER.

Hospitalists assess the causes of early hospital readmissions.

BACKGROUND: Hospital readmissions are receiving increasing attention as an indicator of health care quality and waste. Hospitalists provide a unique perspective on the underlying processes that result in acute care readmissions and the extent to which readmissions can be prevented. OBJECTIVE: The study assessed the views of hospitalists on the preventability of readmissions and the most important ways to prevent future readmissions. DESIGN AND MEASUREMENTS: A group of 17 hospitalists serving four community hospitals reviewed the details of 300 consecutive 21-day readmissions. Each used a structured data collection form to code information from inpatient and outpatient charts on patient characteristics, process measures, preventability, and potential interventions. RESULTS: Overall, 15% of readmissions were rated as overtly preventable, but with wide variation among hospitalists in their ratings of preventability. Perceptions of preventability appear to be a function of readmission timing, the similarity of diagnoses between admissions, medication issues, and the presence of certain chronic diseases (eg, chronic obstructive pulmonary disease [COPD]). Hospitalists were more likely to recommend familiar interventions under their control for a readmissions termed preventable, such as extending the initial hospital stay or addressing medications and patient education at discharge. They less often identified outpatient case management, home services, or physician nursing home visits as viable prevention strategies. CONCLUSIONS: The study points to the multifactorial nature of interventions needed to prevent readmissions, the tradeoffs between hospital length of stay and readmission, and the importance of fostering a culture of optimism and engagement to outpatient components of the health system to reduce hospital readmissions.

Increasing vancomycin serum trough concentrations and incidence of nephrotoxicity.

BACKGROUND: conflicting evidence regarding the association of vancomycin serum concentrations with efficacy and toxicity has resulted in controversy regarding optimal target concentrations. Recent publications recommend attaining higher vancomycin trough concentrations of 15 to 20 mg/L for target infections, yet limited research is available assessing the correlation of vancomycin serum concentrations with toxicity. The aim of this study was to evaluate the association between vancomycin serum trough concentrations and nephrotoxicity. METHODS: a 2-phase retrospective analysis was completed. Phase 1 evaluated 2493 courses of vancomycin completed between January 2003 and December 2007. The analysis describes a 5-year trend in vancomycin prescribing practices and assesses the association of nephrotoxicity with baseline serum creatinine, vancomycin serum trough concentrations, and duration of vancomycin therapy. Phase 2 examined patients receiving vancomycin therapy during 2007 to evaluate specific risk factors for development of nephrotoxicity. RESULTS: the proportion of vancomycin serum trough concentrations ≥ 15 mg/L and ≥ 20 mg/L increased significantly over time. Statistical analysis identified vancomycin serum trough concentrations ≥ 14 mg/L, duration of vancomycin therapy ≥ 7 days, and baseline serum creatinine levels ≥ 1.7 mg/dL as independent predictors of nephrotoxicity. Phase 2 analysis again implicated mean vancomycin serum trough concentration as a significant predictor of nephrotoxicity. Nephrotoxicity resolved in 81% (17/21) of cases evaluated. CONCLUSIONS: a higher vancomycin serum trough concentration and prolonged vancomycin therapy are associated with an increased risk of nephrotoxicity. The decision to target increased vancomycin trough concentrations should be based on an assessment of the severity of the infection and must consider the nephrotoxicity risk associated with increased vancomycin levels.

Excess cost and length of stay associated with voluntary patient safety event reports in hospitals.

This study estimates excess cost and length of stay associated with voluntary patient safety event reports at 3 hospitals. Voluntary patient safety event reporting has proliferated in hospitals in recent years, yet little is known about the cost of events captured by this type of system. Events captured in an electronic reporting system at 3 urban community hospitals in Portland, Oregon, are evaluated. Cost and length of stay are assessed by linking event reports to risk-adjusted administrative data. Hospital stays with an event report are 17% more costly and 22% longer than stays without events. Medication and treatment errors are the most expensive and most common events, representing 77% of all event types and 77% of added costs. Ninety percent of events result in no measurable harm. Patient safety events captured by voluntary event reporting reflect significant waste and inefficiency in hospital stays.

Provider feedback to improve 5A's tobacco cessation in primary care: a cluster randomized clinical trial.

The electronic health record (EHR) may be an effective tool to help clinicians address tobacco use more consistently. To evaluate the impact of EHR-generated practice feedback on rates of referral to a state-level tobacco quitline, we conducted a cluster randomized clinical trial (feedback versus no feedback) within 19 primary care clinics in Oregon. Intervention clinics received provider-specific monthly feedback reports generated from EHR data. The reports rated provider performance in asking, advising, assessing, and assisting with tobacco cessation compared with a clinic average and an achievable benchmark of care. During 12 months of follow-up, EHR-documented rates of advising, assessing, and assisting were significantly improved in the intervention clinics compared with the control clinics (p<.001). A higher case-mix index and presence of a clinic champion were associated with higher rates of referral to a state-level quitline. EHR-generated provider feedback improved documentation of assistance with tobacco cessation. Connecting physician offices to a state-level quitline was feasible and well accepted.

Evaluation of patient care interventions and recommendations by a transitional care pharmacist.

A "transitional care pharmacist" (TCP) was deployed within an acute care setting to identify opportunities for improved continuity of care. The provision of medication reconciliation services, drug consultation, patient counseling and planning for after-hospital care was time consuming but also fruitful, resulting in roughly nine interventions per patient. Areas with the greatest potential for morbidity reduction were the resumption of home medications during the acute stay and at discharge. Allergy identification was a key contribution at admission, as was the provision of a detailed follow-up plan at discharge. Targeting high-risk patients and spreading portions of the work to other disciplines could achieve added efficiency in this service. Results have value to hospitals implementing medication reconciliation programs.

The feasibility of connecting physician offices to a state-level tobacco quit line.

BACKGROUND: Telephone counseling for tobacco cessation is an effective and evidence-based approach to address tobacco use. The wide dissemination of region- and state-level quit lines has been a major goal for public health agencies. However, connecting patients in primary care settings to state-level quit lines has not been evaluated. METHODS: Observational study describing two methods (fax referral and providing a brochure) to connect private physician offices with a state-level quit line in Oregon. This study describes the resources required to create a clinical pathway for the 5A's in primary care (ask, advise, assess, assist, and arrange) using a state-level telephone quit line as an intervention for cessation in primary care clinics sharing a common electronic medical record system, focusing on the costs and generalizability of this approach. RESULTS: Of the 15,662 smokers identified in 19 primary care clinics, 745 patients were referred to the Oregon Tobacco Quit Line during the study period. The program cost in the first year was $15 to $22 per patient connected with the quit line; in subsequent years, the cost decreased to $4 to $6 per quit-line connection. CONCLUSIONS: Connecting private physician offices to a state-level quit line is feasible, can be accomplished at low cost with minimal use of resources, and may be cost effective. Regional, state, and local tobacco quit lines should consider a physician office "quit-line connection" as a practical approach to increase utilization.

TGF-beta 1 and IFN-gamma direct macrophage activation by TNF-alpha to osteoclastic or cytocidal phenotype.

TNF-related activation-induced cytokine (TRANCE; also called receptor activator of NF-kappaB ligand (RANKL), osteoclast differentiation factor (ODF), osteoprotegerin ligand (OPGL), and TNFSF11) induces the differentiation of progenitors of the mononuclear phagocyte lineage into osteoclasts in the presence of M-CSF. Surprisingly, in view of its potent ability to induce inflammation and activate macrophage cytocidal function, TNF-alpha has also been found to induce osteoclast-like cells in vitro under similar conditions. This raises questions concerning both the nature of osteoclasts and the mechanism of lineage choice in mononuclear phagocytes. We found that, as with TRANCE, the macrophage deactivator TGF-beta(1) strongly promoted TNF-alpha-induced osteoclast-like cell formation from immature bone marrow macrophages. This was abolished by IFN-gamma. However, TRANCE did not share the ability of TNF-alpha to activate NO production or heighten respiratory burst potential by macrophages, or induce inflammation on s.c. injection into mice. This suggests that TGF-beta(1) promotes osteoclast formation not only by inhibiting cytocidal behavior, but also by actively directing TNF-alpha activation of precursors toward osteoclasts. The osteoclast appears to be an equivalent, alternative destiny for precursors to that of cytocidal macrophage, and may represent an activated variant of scavenger macrophage.

Osteoclast lineage commitment of bone marrow precursors through expression of membrane-bound TRANCE.

Osteoclast formation from hemopoietic precursors is induced by TRANCE (also called RANKL, ODF, and OPGL), a membrane-bound ligand expressed by bone marrow stromal cells. Because soluble recombinant TRANCE is a suboptimal osteoclastogenic stimulus, and to eliminate the need for such dependence on stromal cells, membrane-bound TRANCE was expressed in hematopoietic precursors using retroviral gene transfer. Four TRANCE-expressing osteoclast cell lines were established that continuously generate large numbers of multinucleated cells and express tartrate-resistant acid phosphatase and calcitonin receptors. The multinuclear cells are long-lived and either fuse continuously with each other and with mononuclear cells to form enormous syncytia, or separate to form daughter multinuclear cells. When formed on bone, but not on plastic, the majority of multinuclear cells develop actin rings on bone, and resorb bone, suggesting that bone matrix may provide additional signals that facilitate osteoclastic functional maturation. Surprisingly, multinuclear cells originate from fusion of proliferating mononuclear cells that strongly express the mature macrophage markers F4/80 and Fc receptor, which are not expressed by osteoclasts. These results indicate that osteoclasts can be derived from F4/80-positive and Fc receptor-positive cells, and that TRANCE induces osteoclastic differentiation partly by suppressing the macrophage phenotype.

A role for TGFbeta(1) in osteoclast differentiation and survival.

Recently, tumour necrosis factor-related activation-induced cytokine (TRANCE) was shown to be necessary for osteoclast formation. We now report that TGF(beta), a cytokine enriched in bone matrix, is also required. TGF(beta) not only powerfully synergized with TRANCE for induction of osteoclast-like cells (OCL) from bone marrow precursors and monocytes, but OCL formation was abolished by recombinant soluble TGF(beta) receptor II (TGF(beta)sRII). Preincubation in TGF(beta) was as effective as simultaneous incubation with TRANCE. TGF(beta)-preincubation enhanced OCL formation at least partly by preventing the development of resistance to OCL-induction that otherwise occurs when precursors are incubated in M-CSF. OCL formed in TRANCE also showed more rapid apoptosis than OCL in TRANCE plus TGF(beta). Like TGF(beta), incubation on bone matrix prolonged and enhanced the sensitivity of precursors to OCL-induction by TRANCE, and this was reversed by TGF(beta)sRII. Taken together, this data is compelling evidence for a model in which TGF(beta) in matrix or released from bone-lining or other cells maintains and enhances the osteoclast-forming potential of precursors as they migrate towards sites of cell-bound TRANCE. Thus, the specific circumstances necessary for osteoclast formation and survival are TRANCE expression on osteoblastic cells and TGF(beta) in bone.

Activin A is an essential cofactor for osteoclast induction.

Recently, receptor activator of NF-kappaB ligand (RANKL) was shown to be necessary for osteoclast formation. We now report that activin A, a cytokine enriched in bone matrix and secreted by osteoblasts and osteoclasts, powerfully synergized with RANKL for induction of osteoclast-like cells (OCL) from bone marrow precursors depleted of stromal cells. Moreover, OCL formation in RANKL was virtually abolished by soluble type II A activin receptors (ActR-II(A)), suggesting that activin A is essential for OCL formation. Activin A was most effective when precursors were exposed to RANKL and activin A simultaneously: resistance to OCL-induction that occurs when precursors are pre-incubated in M-CSF was reduced. Incubation on bone matrix also enhanced the sensitivity of precursors to OCL-induction by RANKL; and this was prevented by soluble ActR-II(A). Thus, activin A in bone matrix, or released from osteoblastic or other cells, enhances the osteoclast-forming potential of precursors and synergizes with RANKL in inducing osteoclastic differentiation.

Therapy using conversation analysis: helping couples adapt to aphasia in conversation.

This study focuses on the assessment and treatment of the conversations of a couple where one partner has aphasia. The assessment and treatment, informed by conversation analysis, are described, and some implications for the relation between language and psychosocial issues discussed.

Clinical practice evaluation at Providence Health System.

Over the past seven years, Providence Health System (PHS) in Portland, Oregon, has used an outcomes research paradigm to study treatment of back pain, coronary artery disease, total joint replacement, and cancer. In presenting case studies of each of these areas, the authors chronicle the evolution of clinical practice evaluation at PHS, beginning with early studies in the 1960s, to the establishment of the Center for Outcomes Research and Education (CORE), to the formation of a new systemwide strategy that is responsive to the evolving health care marketplace.

Measuring the success of treatment in patient terms.

Measuring the success of major surgeries such as total hip and total knee replacement is important for both case selection and public policy. Patients, purchasers, and practitioners must choose among clinical scoring systems, health status measures, and patient satisfaction ratings to monitor performance and ensure appropriate use of costly procedures. The present study compares results from the Medical Outcomes Study Short Form 36 (SF-36) Health Status Survey and clinical scoring systems to direct patient ratings of success. Data come from a study of 128 total knee-replacement procedure and 211 total hip replacements. Analyses indicate that for both hip and knee patients, success is related closely to posttreatment physical function and bodily pain. Patient ratings of success also are related to the clinical scores used by physicians. Success is related less to change from pretreatment function for knee patients than for hip patients. Although patient ratings of success are generally consistent with other outcome measures, their relationship to patient expectations, satisfaction, and attributions need to be understood before they can become a useful tool for performance monitoring and case selection.