Health professionals and students encounter multi-level barriers to implementing high-value osteoarthritis care: a multi-national study.

OBJECTIVE: Consistent evidence-practice gaps in osteoarthritis (OA) care are observed in primary care settings globally. Building workforce capacity to deliver high-value care requires a contemporary understanding of barriers to care delivery. We aimed to explore barriers to OA care delivery among clinicians and students. DESIGN: A cross-sectional, multinational study sampling clinicians (physiotherapists, primary care nurses, general practitioners (GPs), GP registrars; total possible denominator: n = 119,735) and final-year physiotherapy and medical students (denominator: n = 2,215) across Australia, New Zealand and Canada. Respondents answered a survey, aligned to contemporary implementation science domains, which measured barriers to OA care using categorical and free-text responses. RESULTS: 1886 clinicians and 1611 students responded. Items within the domains 'health system' and 'patient-related factors' represented the most applicable barriers experienced by clinicians (25-42% and 20-36%, respectively), whereas for students, 'knowledge and skills' and 'patient-related factors' (16-24% and 19-28%, respectively) were the most applicable domains. Meta-synthesis of qualitative data highlighted skills gaps in specific components of OA care (tailoring exercise, nutritional/overweight management and supporting positive behaviour change); assessment, measurement and monitoring; tailoring care; managing case complexity; and translating knowledge to practice (especially among students). Other barriers included general infrastructure limitations (particularly related to community facilities); patient-related factors (e.g., beliefs and compliance); workforce-related factors such as inconsistent care and a general knowledge gap in high-value care; and system and service-level factors relating to financing and time pressures, respectively. CONCLUSIONS: Clinicians and students encounter barriers to delivery of high-value OA care in clinical practice/training (micro-level); within service environments (meso-level); and within the health system (macro-level).

Rheumatoid arthritis antirheumatic drug trials: effects of a standardized instructional videotape on the reliability of observer-dependent outcome measures.

AIMS: A study was designed to assess the effects of a standardized instructional videotape on reducing interobserver variability for several commonly used observer-dependent outcome measures. METHODS: During a single day, six rheumatologists independently examined six patients with rheumatoid arthritis (RA) in a predetermined order using a Latin square design, before and after viewing a standardized videotape demonstrating 13 examination techniques. Reliability coefficients were calculated based on the variance components of the analysis of variance (ANOVA) table. RESULTS: Prestandardization reliability coefficients were >0.80 for all measures and remained above 0.80 following standardization. CONCLUSIONS: It is usually assumed that serial measurement in clinical trials should be performed by the same assessor because of concern regarding interobserver variability. However, the high levels of prestandardization interobserver reliability observed in this study indicate that, for these variables, serial measurements in a clinical trial could be made by different assessors, assuming they were equally skilled. This observation has important implications for outcome measurement in RA clinical trials. Although high levels of prestandardization reliability precluded the demonstration of any significant effect, we speculate that the videotape might be effective in training less-experienced assessors. Reductions in observer variability have the potential to diminish sample size requirements for RA antirheumatic drug studies. The use of a videotape to achieve this goal offers cost and convenience advantages over one-on-one training procedures, and this method should be further assessed in less-experienced assessors.

Reduction of tumor necrosis factor alpha and interleukin-1 beta levels in human synovial tissue by interleukin-4 and glucocorticoid.

The effects of recombinant human interleukin-4 (IL-4) and the glucocorticoid, dexamethasone, on tumor necrosis factor alpha (TNF alpha) and interleukin-1 beta (IL-1 beta) levels in cultures of rheumatoid and osteoarthritic synovial tissue were studied. Low concentrations of IL-4 and dexamethasone suppressed the levels of both cytokines in the supernatants of both types of tissue after stimulation with lipopolysaccharide (LPS); the IL-1 beta and TNF alpha levels were measured by ELISA. It is suggested that it is the monocyte/macrophage in the synovial tissues that is responsive to the inhibitors. It is proposed that glucocorticoids may act on synovial tissue in this manner in vivo and IL-4 may do so if administered intraarticularly.

Disturbed proprioception following a period of muscle vibration in humans.

Forearm position matching tasks were performed by blindfolded subjects before and after applying vibration for 60 s to the biceps or triceps muscle of one arm. Following cessation of vibration, statistically significant alignment (proprioceptive) errors occurred when a movement lengthened the previously vibrated muscle. The error was such that the length of the post-vibrated muscle was greater than the length of the same muscle in the non-vibrated arm. This effect is the opposite to that which occurs during vibration.

A new aspect of the collision test principle: cell body distance from recording site.

A theoretical method is described for estimating the distance between a spike recording-site, possibly axonal, and the corresponding cell body of unknown location. The method requires that an orthodromic spike be recorded following an antidromic spike, with estimation of a collision interval analogous to that used for establishing antidromicity. To calculate the distance between recording-site and cell body, values are needed for the collision interval between antidromic and succeeding orthodromic spikes, the refractory period of the spike, and the antidromic conduction speed. Problems may arise in determining the last value. The method is illustrated with antidromic spikes recorded in the medial thalamus of the cat upon stimulating the caudate nucleus.

An electrophysiological study of thalamo-caudate neurones in the cat.

Thalamo-caudate projection neurones were identified in cats by antidromic activation from the caudate nucleus, under chloralose anaesthesia or in cerveau isolé preparations. Units in nuclei centralis lateralis, medialis dorsalis, and centrum medianum-parafascicularis responded antidromically to one or more electrodes of a caudate nucleus array at latencies ranging from 0.4 to 16 ms. The responses did not appear to result from stimulus spread to the internal capsule. A separate population of medial thalamic units responded postsynaptically to caudate stimulation, at modal latency exceeding modal antidromic latency by 2 ms. Comparison of apparent conduction velocities for each thalamic nucleus indicated that the postsynaptic responses were activated by collaterals of thalamo-caudate neurones. A proportion of thalamo-caudate neurones responded to somatic stimulation; some of these were inhibited by caudate stimulation, and a few discharged on substantia nigra stimulation. These results demonstrate the possibility of somatic afferent and nigrofugal inputs to the caudate nucleus mediated by neurones of the medial thalamus.