Embracing Life with ALS: the Role of Occupational Therapy from Diagnosis to End of Life Care

Purpose: The purpose of this scholarly project was to develop a comprehensive document that describes the role of the occupational therapist in working with clients and families affected by Amyotrophic Lateral Sclerosis CALS) from diagnosis to end-of-life care. Method: A literature review was conducted using the AJOT, PubMed, CINAHL, and OT SEARCH databases. Information was gathered regarding current literature of ALS, the disease process, occupational therapy\u27s role in ALS treatment, caregiver\u27s role in end-of-life care, assistive technology, palliative care options, and additional support strategies. Additional ALS material was gathered from the ALS Association\u27s informational manuals. Results: Designed from the perspective of the Canadian Model of Occupational Performance-Enablement, the product, Embracing Life with ALS: The Role of . Occupational Therapy from Diagnosis to End-of-Life Care , was created. The role of the occupational therapist was integrated within the Canadian Model\u27s ten enablement skills, eight action points, and significant findings from the literature review. Special attention was placed on an assistive technology section for compensation in order to allow the client to remain as independent as possible throughout the disease progression. Conclusions: The occupational therapy document created encourages a holistic approach to ALS care that involves both the client and the family in collaboration with the occupational therapist. The document addresses physical, mental, emotional, and spiritual aspects of the client enabling them to engage in meaningful occupation and increase quality of life

How Traits of Emotional Intelligence Affect Perceived Stress in Entry-Level Doctor of Occupational Therapy Students

Purpose: Students in an entry-level Doctor of Occupational Therapy (OTD) programs are subject to high levels of stress and emotional burnout. Effective management of stress impacts life satisfaction and academic performance. Emotional intelligence (EI) has been shown to relate to lower stress levels in allied health students. Despite this, little has been done to investigate the emotional demands of an occupational therapy education. Methods: Participants were a convenience sample of 51 entry-level Doctor of Occupational Therapy Students recruited from the Southwest and Midwest cohorts of an OTD program. The participants were surveyed approximately 30 days after beginning their semester curriculum. Participants included 43 females and 8 males (n=51) with an age range of 21-36 years old. The sample was composed of 18 first-year (OT1) students, 17 second-year (OT2), and 16 third-year (OT3) students. A cross-sectional survey design was used, and the Assessing Emotions Scale and the Perceived Stress Scale questionnaires were both used to gather self-reported data regarding emotional intelligence and perceived stress. Emotional intelligence was correlated with perceived stress scores using the Spearman Rho analysis on SPSS program 25. Additionally, Kruskal Wallis analysis was used to determine if PSS and EI scores were significantly related to the year in the program. Mann Whitney U analysis was used to determine if PSS and EI scores were significantly related to gender. Results: A significant moderate negative correlation was found in this sample between emotional intelligence and perceived stress (rs= -0.391 with p= 0.005). There were no other significant relationships between variables. Conclusion: These findings have applications for developing educational programming and curriculum that may help equip Doctor of Occupational Therapy Students with the skills they need to thrive in their future profession. Additionally, opportunities exist for OTD students to increase EI and improve stress management levels and improve overall wellness

What are emergency ambulance services doing to meet the needs of people who call frequently? A national survey of current practice in the United Kingdom

Background Emergency ambulance services are integral to providing a service for those with unplanned urgent and life-threatening health conditions. However, high use of the service by a small minority of patients is a concern. Our objectives were to describe: service-wide and local policies or pathways for people classified as Frequent Caller; call volume; and results of any audit or evaluation. Method We conducted a national survey of current practice in ambulance services in relation to the management of people who call the emergency ambulance service frequently using a structured questionnaire for completion by email and telephone interview. We analysed responses using a descriptive and thematic approach. Results Twelve of 13 UK ambulance services responded. Most services used nationally agreed definitions for ‘Frequent Caller’, with 600–900 people meeting this classification each month. Service-wide policies were in place, with local variations. Models of care varied from within-service care where calls are flagged in the call centre; contact made with callers; and their General Practitioner (GP) with an aim of discouraging further calls, to case management through cross-service, multi-disciplinary team meetings aiming to resolve callers’ needs. Although data were available related to volume of calls and number of callers meeting the threshold for definition as Frequent Caller, no formal audits or evaluations were reported. Conclusions Ambulance services are under pressure to meet challenging response times for high acuity patients. Tensions are apparent in the provision of care to patients who have complex needs and call frequently. Multi-disciplinary case management approaches may help to provide appropriate care, and reduce demand on emergency services. However, there is currently inadequate evidence to inform commissioning, policy or practice development

Transient Ischaemic attack Emergency Referral (TIER): randomised feasibility trial results

Background: Early assessment of patients with suspected transient ischaemic attack (TIA) is crucial to provision of effective care, including initiation of preventive therapies and identification of stroke mimics. Many patients with TIA present to emergency medical services (EMS) but may not require hospitalisation. Paramedics could identify and refer patients with low-risk TIA, without conveyance to the ED. Safety and effectiveness of this model is unknown. Aim: To assess the feasibility of undertaking a fully powered randomised controlled trial (RCT) to evaluate clinical and cost-effectiveness of paramedic referral of patients who call EMS with low-risk TIA to TIA clinic, avoiding transfer to ED. Methods: The Transient Ischaemic attack Emergency Referral (TIER) intervention was developed through a survey of UK ambulance services, a scoping review of evidence of prehospital care of TIA and convening a specialist clinical panel to agree its final form. Paramedics in South Wales, UK, were randomly allocated to trial intervention (TIA clinic referral) or control (usual care) arms, with patients’ allocation determined by that of attending paramedics. Predetermined progression criteria considered: proportion of patients referred to TIA clinic, data retrieval, patient satisfaction and potential cost-effectiveness. Results: From December 2016 to September 2017, eighty-nine paramedics recruited 53 patients (36 intervention; 17 control); 48 patients (31 intervention; 17 control) consented to follow-up via routine data. Three intervention patients, of seven deemed eligible, were referred to TIA clinic by paramedics. Contraindications recorded for the other intervention arm patients were: Face/Arms/Speech/Time positive (n=13); ABCD2 score >3 (n=5); already anticoagulated (n=2); crescendo TIA (n=1); other (n=8). Routinely collected electronic health records, used to report further healthcare contacts, were obtained for all consenting patients. Patient-reported satisfaction with care was higher in the intervention arm (mean 4.8/5) than the control arm (mean 4.2/5). Health economic analysis suggests an intervention arm quality-adjusted life-year loss of 0.0094 (95% CI −0.0371, 0.0183), p=0.475. Conclusion: The TIER feasibility study did not meet its progression criteria, largely due to low patient identification and referral rates. A fully powered RCT in this setting is not recommended. Trial registration number: ISRCTN85516498

Identification of the Inorganic Pyrophosphate Metabolizing, ATP Substituting Pathway in Mammalian Spermatozoa

Inorganic pyrophosphate (PPi) is generated by ATP hydrolysis in the cells and also present in extracellular matrix, cartilage and bodily fluids. Fueling an alternative pathway for energy production in cells, PPi is hydrolyzed by inorganic pyrophosphatase (PPA1) in a highly exergonic reaction that can under certain conditions substitute for ATP-derived energy. Recombinant PPA1 is used for energy-regeneration in the cell-free systems used to study the zymology of ATP-dependent ubiquitin-proteasome system, including the role of sperm-borne proteasomes in mammalian fertilization. Inspired by an observation of reduced in vitro fertilization (IVF) rates in the presence of external, recombinant PPA1, this study reveals, for the first time, the presence of PPi, PPA1 and PPi transporter, progressive ankylosis protein ANKH in mammalian spermatozoa. Addition of PPi during porcine IVF increased fertilization rates significantly and in a dose-dependent manner. Fluorometric assay detected high levels of PPi in porcine seminal plasma, oviductal fluid and spermatozoa. Immunofluorescence detected PPA1 in the postacrosomal sheath (PAS) and connecting piece of boar spermatozoa; ANKH was present in the sperm head PAS and equatorial segment. Both ANKH and PPA1 were also detected in human and mouse spermatozoa, and in porcine spermatids. Higher proteasomal-proteolytic activity, indispensable for fertilization, was measured in spermatozoa preserved with PPi. The identification of an alternative, PPi dependent pathway for ATP production in spermatozoa elevates our understanding of sperm physiology and sets the stage for the improvement of semen extenders, storage media and IVF media for animal biotechnology and human assisted reproductive therapies

Care pathways for low-risk transient ischaemic attack

Background: In secondary care, the urgency of review for transient ischaemic attack (TIA) has relied upon the use of the ABCD2 score, but this tool is not validated for use by emergency ambulance crews. There is a need to evaluate alternative care pathways for patients who might be eligible for direct referral to TIA clinics without prior conveyance to the emergency department (ED). Aim: The aim of this national survey was to describe current service provision across the UK for pre-hospital emergency care of patients with TIA. Methods: The authors approached all UK Ambulance trusts (n=13) by email, asking them to provide details of TIA patient referral pathways. Findings: Twelve ambulance services responded to the survey and nine reported that they had no current pathway; one had discontinued a pathway because of service reconfiguration; and three were currently using one. All pathways used the ABCD2 tool to screen patients and classified patients as low-risk if the ABCD2 score was 3 or below. Non-conveyance exclusion criteria varied. Although compliance with referral pathways was audited in an initial pilot in one service, no other evaluations of the effectiveness of pathways were reported. Conclusion: A minority of UK ambulance services report introducing referral pathways for low-risk TIA patients, avoiding initial assessment in the ED. Safety, effectiveness and acceptability of such pathways have not been evaluated to date. Abstract published with permissio

The transient ischaemic attack 999 emergency referral (tier) feasibility trial: development of a complex intervention

Background Transient Ischaemic Attack (TIA) is a neurologic event with symptom resolution within 24 hours. Early specialist assessment of TIA reduces risk of stroke and death. NICE (2008) recommends patients with TIA are seen in specialist clinics within 24 hours (if high risk) and seven days (if low risk). We aimed to develop a complex intervention for patients with low risk TIA presenting to the emergency ambulance service. The intervention was then to be used in the TIER feasibility trial, in line with the MRC guidance on staged development and evaluation of complex interventions. Methods We conducted three interrelated activities to produce the TIER intervention: • Survey of UK Ambulance Services (n=13) to gather information about TIA pathways already in use • Scoping review of literature describing prehospital care of patients with TIA • Synthesis of data and definition of the intervention by specialist panel of: paramedics; ED and stroke consultants; service users; ambulance service managers. Results The panel defined the TIER intervention to include: 1. Protocol for paramedics to assess patients presenting with TIA and identify and refer low risk patients for prompt (<7 day) specialist review at TIA clinic 2. Patient Group Directive and information pack to allow paramedic administration of aspirin to patients left at home with referral to TIA clinic 3. Referral process via clinical desk in ambulance control room 4. Training package for paramedics 5. Agreement with TIA clinic service provider to ensure rapid review of referred patients Conclusion We followed MRC guidance to develop a clinical intervention which assesses and refers low risk TIA patients requesting 999 care. We will test feasibility of implementing and evaluating this in the TIER feasibility trial. We will then develop a fully powered randomised multicentre trial, if findings indicate this is appropriate. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0