Teaching and Evaluating an Occupational Perspective in Canada: A Descriptive Qualitative Study.

Background. Occupation is the core domain of occupational therapy, and an occupational perspective is foundational for practice. Research has explored how an occupational perspective is taught. Yet, little has explored the Canadian occupational therapy educational context. There are national differences in core competencies and accreditation standards and nuances in how occupation is defined and what conceptual models are used. As such, a Canadian perspective may offer new understandings of value both within and outside of Canada. Purpose. To understand how, in Canada, educators teach and evaluate student occupational perspectives in entry-level master of occupational therapy programs. Method. This study used a descriptive qualitative design with an interpretive approach. Semi-structured interviews were used to gather data from 12 educators from Canadian entry-level occupational therapy programs. Reflexive thematic analysis was used for data analysis. Findings. Five themes were identified: (1) occupational perspectives as pedagogy (2) it's a process, not an end state; (3) "everybody is involved": a community of educators; (4) thinking critically; and (5) "hard to evaluate." Conclusion. The complex, dynamic, and contextualized nature of an occupational perspective calls for critical, reflexive, communal, and innovative pedagogical and assessment approaches.

One shot to control Pain: Decreasing postoperative opioid use in gynecologic oncology patients with intrathecal opioid injection.

OBJECTIVES: To determine whether regional anesthesia with single-shot intrathecal opioid injections (ITO) reduce postoperative pain and intravenous (IV) opioid use after exploratory laparotomy in major gynecologic surgeries. METHODS: A retrospective chart review of 315 consecutive cases of patients who underwent an exploratory laparotomy on the gynecologic oncology service from July 2015 to January 2018 was conducted. Single-shot ITO was offered to all patients undergoing open abdominal surgery. The primary outcomes of interest were IV opioid use in morphine equivalents during the first 48 hours after surgery. Univariate analyses were performed to estimate the effect of ITO on IV opioid use at 0, 6, 12, 24 and 48 hours after surgery. Longitudinal regression analyses were performed to estimate the effect of ITO on changes in outcomes of interest over time, adjusting for potential confounders. RESULTS: 35% (110/315) received ITO preoperatively. There were no differences in patient age, BMI, previous number of abdominal surgeries, history of opioid dependence, type of gynecologic surgery, or total EBL between the ITO and control groups. Preoperative ITO was associated with a significantly lower IV opioid requirement between 0 and 6 hours after surgery (9.7 ± 8.1 vs 14.3 ± 11.5, p < 0.0001) and between 6 and 12 hours after surgery (2.7 ± 3.8 vs 5.4 ± 9.5, p = 0.0054). There was no statistically significant difference in total hospital stay opioid requirement but median length of stay was increased by 1 day. CONCLUSIONS: Preoperative administration of ITO reduced IV opioid requirement in the first 12 hours postoperatively but was associated with median 1 day increase in hospital stay.

EEG power spectral dynamics associated with listening in adverse conditions.

Adverse listening conditions increase the demand on cognitive resources needed for speech comprehension. In an exploratory study, we aimed to identify independent power spectral features in the EEG useful for studying the cognitive processes involved in this effortful listening. Listeners performed the coordinate response measure task with a single-talker masker at a 0-dB signal-to-noise ratio. Sounds were left unfiltered or degraded with low-pass filtering. Independent component analysis (ICA) was used to identify independent components (ICs) in the EEG data, the power spectral dynamics of which were then analyzed. Frontal midline theta, left frontal, right frontal, left mu, right mu, left temporal, parietal, left occipital, central occipital, and right occipital clusters of ICs were identified. All IC clusters showed some significant listening-related changes in their power spectrum. This included sustained theta enhancements, gamma enhancements, alpha enhancements, alpha suppression, beta enhancements, and mu rhythm suppression. Several of these effects were absent or negligible using traditional channel analyses. Comparison of filtered to unfiltered speech revealed a stronger alpha suppression in the parietal and central occipital clusters of ICs for the filtered speech condition. This not only replicates recent findings showing greater alpha suppression as listening difficulty increases but also suggests that such alpha-band effects can stem from multiple cortical sources. We lay out the advantages of the ICA approach over the restrictive analyses that have been used as of late in the study of listening effort. We also make suggestions for moving into hypothesis-driven studies regarding the power spectral features that were revealed.

College-Bound: Transition Planning Strategies for Students With Type 1 Diabetes.

Transition planning is mandated for students who receive special education services; however, it is not required for students with chronic conditions. Students with chronic conditions nearing graduation would benefit from more intensive attention to their post-high school self-care needs and responsibilities. Students with type 1 diabetes must be able to understand the necessary self-care of one of the most complicated and intensive chronic conditions yet there are no evidence-based strategies for how to help students transition from the support provided at school to independence at graduation. The need for a student with type 1diabetes to independently manage their diabetes is even greater as the student leaves home for college. School nurses, who are also certified diabetes educators, created a support group for seniors with type 1 diabetes. The group focused on life after high school and provided the students with a detailed checklist to help improve knowledge and prepare students for the transition to college. Participants felt better prepared to move on to college armed with their checklist and other resources to help when away from home.

Weight-based dosing of enoxaparin for VTE prophylaxis in morbidly obese, medically-Ill patients.

INTRODUCTION: In clinical trials, fixed-dose enoxaparin (40 mg once daily) reduces the risk of venous thromboembolism (VTE) in medically-ill patients. However, morbidly obese patients were under-represented in these trials and using fixed-dose enoxaparin in obese patients may be inadequate. We completed a pharmacokinetic study in morbidly obese, medically-ill patients to determine if weight-based dosing of enoxaparin for VTE prophylaxis was feasible, without excessive levels of anticoagulation, as determined by peak anti-Xa levels. MATERIALS AND METHODS: Twenty eight morbidly obese (BMI>or=35 kg/m(2)) patients were enrolled and completed the study protocol. Enoxaparin 0.5 mg/kg was administered once daily subcutaneously and peak anti-Xa levels were measured approximately 4-6 hours after the enoxaparin dose. RESULTS AND CONCLUSIONS: Overall, 46% of patients were female, the average age (+/-SD) was 54 (+/-11) years, and the average weight and BMI were 135.6 kg (+/-25.3) and 48.1 kg/m(2) (+/-11.1), respectively. The average daily dose of enoxaparin was 67 mg (+/-12). The average peak anti-Xa level was 0.25 (SD+/-0.11, range 0.08 to 0.59) units/mL. Peak anti-Xa levels did not significantly correlate with weight or BMI. There were no bleeding events, symptomatic VTE, or significant thrombocytopenia. In morbidly obese, medically-ill patients, use of weight-based enoxaparin dosed at 0.5 mg/kg once daily is feasible and results in peak anti-Xa levels within or near recommended range for thromboprophylaxis, without any evidence of excessive anti-Xa activity. These data suggest that this weight-based regimen may be more effective than standard fixed-dose enoxaparin. Clinical outcome studies are warranted to determine the clinical safety and efficacy of this regimen.

A safe, effective, and easy to use warfarin initiation dosing nomogram for post-joint arthroplasty patients.

Venous thromboembolism (VTE) is a complication after joint arthroplasty, and pharmacologic prophylaxis is recommended to reduce this risk. Warfarin is often used, but initial dosing and management can be difficult. We studied a single-center prospective cohort of consecutive (n = 351) post-joint arthroplasty/revision patients who were initiated on warfarin using a new initiation nomogram and then discharged to home with home health services. The mean time to an international normalized ratio (INR) of 2.0 or higher was 5 days, with a mean INR of 2.1 on the fifth postoperative day. Two patients (0.6%) had an INR higher than 5 in the first 10 days of therapy. Adverse events were uncommon: 4 patients (1.14%) had VTE, 1 had major bleeding episode, and 6 patients (1.7%) had minor bleeding. A specific warfarin dosing nomogram managed by an anticoagulation service and used in joint arthroplasty/revision patients who are discharged to home with home health services leads to effective anticoagulation with few associated adverse events.

The treatment of venous thromboembolism in special populations.

Anticoagulant therapy for the typical venous thromboembolism patient is straightforward with predictably favorable outcomes. However, for certain patients with venous thromboembolism, there remains uncertainty and controversy about optimal treatment. These controversial areas include venous thromboembolism patients with: heparin resistance, renal insufficiency, morbid obesity, cancer, antiphospholipid antibody syndrome, recurrent thrombosis despite appropriate anticoagulation, and patients with unprovoked VTE who may or may not benefit from thrombophilia testing. This review summarizes the current data for these special patient populations with venous thromboembolism and provides our recommendations for management.

Argatroban dosing of patients with heparin-induced thrombocytopenia and an elevated aPTT due to antiphospholipid antibody syndrome.

OBJECTIVE: To describe the clinical characteristics, management, and outcomes of patients with heparin-induced thrombocytopenia with thrombosis (HITTS) or without thrombosis (HIT) who also had an elevated baseline activated partial thromboplastin time (aPTT) due to antiphospholipid antibody syndrome (APS). CASE SUMMARY: Four patients with HIT/HITTS and an elevated baseline aPTT due to APS were identified. Two patients had venous thrombosis, 1 had limb ischemia, and 1 had isolated HIT. All 4 were managed with a weight-based fixed dose of argatroban without laboratory monitoring. None of the patients had thrombotic or bleeding complications once therapy was initiated. DISCUSSION: Management of patients with HIT/HITTS and an abnormal baseline aPTT due to APS is problematic. We review alternative management strategies, such as monitoring direct thrombin inhibitors with the ecarin clotting time or thrombin inhibition time or using an alternative anticoagulant, such as fondaparinux. As of March 13, 2006, none of these management strategies has been evaluated in a clinical trial for this patient population. We report the successful use of weight-based, fixed-dose argatroban without laboratory monitoring in patients with APS. CONCLUSIONS: Use of a fixed-dose argatroban regimen without laboratory monitoring is a potential management strategy for patients with HIT/HITTS and an elevated baseline aPTT due to APS.

Venous thromboembolism prevention in the acutely ill medical patient: a review of the literature and focus on special patient populations.

Although venous thromboembolism (VTE) is a major public health problem, until recently, our understanding of the risk of VTE in hospitalized acutely ill medical patients has been incomplete. Fortunately, over the past 5 years, there has been an increasing body of literature that highlights the risk of VTE in the nonsurgical patient, identifies unique patient-risk factors, and defines adequate preventative measures. This review highlights the current literature with regard to epidemiology of VTE in hospitalized medical patients and the risk-stratification of these patients and deals with optimal preventative regimens and prevention strategies in special patient groups.

Venous thromboembolism prophylaxis in medically ill patients and the development of strategies to improve prophylaxis rates.

Venous thromboembolism (VTE) is common but often unrecognized in medically ill patients. Over the past 5 years, three large-scale placebo-controlled trials enrolling a total of 5500 medically ill patients have highlighted the risk of VTE in this group. These trials have helped to define a specific at-risk patient profile, including those admitted to the hospital with severe congestive heart failure, respiratory illness, acute infection, and inflammatory bowel disease. We performed a retrospective review of patients admitted to the medical service at our tertiary care center to define how common the at-risk medical patient is and to evaluate and improve prophylaxis rates in this patient group. The study was conducted in two phases. Based on admission characteristics, patients were stratified into high-risk or low-risk groups for the development of VTE. During the pre-intervention phase, 75% of patients admitted to the medical service were characterized as increased risk for VTE, yet only 43% of these high-risk patients received prophylaxis of any sort. After interventions designed to increase awareness of VTE, we conducted a second review period. In this post-intervention phase, where 79% of patients were at risk for VTE, prophylaxis rates improved to 72%. Based on these results, we conclude that the majority of patients admitted to the medical service at our tertiary care center constitute a high-risk population that warrants consideration for VTE prophylaxis. Implementation of strategies to improve prophylaxis rates, including educational sessions and risk stratification guidelines, can be successful and improve identification and prophylaxis of this population.