What are Effective Strategies to Reduce Low-Value Care? An Analysis of 121 Randomized Deimplementation Studies

Background: Low-value care is healthcare leading to no or little clinical benefit for the patient. The best (combinations of) interventions to reduce low-value care are unclear. Purpose: To provide an overview of randomized controlled trials (RCTs) evaluating deimplementation strategies, to quantify the effectiveness and describe different combinations of strategies. Methods: Analysis of 121 RCTs (1990-2019) evaluating a strategy to reduce low-value care, identified by a systematic review. Deimplementation strategies were described and associations between strategy characteristics and effectiveness explored. Results: Of 109 trials comparing deimplementation to usual care, 75 (69%) reported a significant reduction of low-value healthcare practices. Seventy-three trials included in a quantitative analysis showed a median relative reduction of 17% (IQR 7%-42%). The effectiveness of deimplementation strategies was not associated with the number and types of interventions applied. Conclusions and Implications: Most deimplementation strategies achieved a considerable reduction of low-value care. We found no signs that a particular type or number of interventions works best for deimplementation. Future deimplementation studies should map relevant contextual factors, such as the workplace culture or economic factors. Interventions should be tailored to these factors and provide details regarding sustainability of the effect.</p

AMBER : a near infrared focal instrument for the VLTI

10 pagesInternational audienceAMBER is the General User near-infrared focal instrument of the Very Large Telescope interferometer. Its specifications are based on three key programs on Young Stellar Objects, Active Galactic Nuclei central regions, masses and spectra of hot Extra Solar Planets. It has an imaging capacity because it combines up to three beams and very high accuracy measurement are expected from the spatial filtering of beams by single mode fibers and the comparison of measurements made simultaneously in different spectral channels

Standardized, comprehensive, hospital-based circuit training in people with multiple sclerosis (MS-FIT): Results on feasibility, adherence and satisfaction of the training intervention.

Background: We developed a standardized, comprehensive, ambulatory, hospital-based neurorehabilitation program ("MS-Fit") to improve disability, activities of daily living and quality of life in people with multiple sclerosis (PwMS). Aim: To assess feasibility, adherence and satisfaction of the training intervention. Design: Prospective multi-center cohort study analysis. Population: PwMS, aged 18 to 75 years, complaining about multiple sclerosis-related disability affecting activities of daily living and/or quality of life. Methods: A standardized, ambulatory, hospital-based circuit training consisting of six workstations (aerobic exercise training, strength upper limbs, balance, manual dexterity, reactivity, strength and flexibility lower limbs) was performed two hours, twice weekly, for two months in groups of two to six participants supervised by experienced physiotherapists. Physiotherapists adapted the type and intensity of training according to the participants' individual performance using a training booklet. Program satisfaction and adherence were evaluated using a questionnaire and the attendance rate (clinicaltrials.gov Identifier: NCT02440516). Results: 55 participants started (mean age 52.82 years +/- 10.68 standard deviation, range 29-74; 69% female; median Expanded Disability Status Scale 3.5, range 1.0-7.0) and 49 (89%) finished the training program. Main reasons to drop out during the training were lack of time, travel problems, social issues or uthoff's phenomenon during the summer. All participants finalizing the training achieved >80% (mean 92.26%, ±7.59) attendance rate and sent back the questionnaire. Overall participant's satisfaction was high with a median of 9 points (range 4-10) on a Likert scale from 0-10. Program quality was rated "good" with an overall median score of 39/50 points (range 26-50) and 95% of the participants would recommend the program to others. Conclusions: MS-Fit is a feasible training program with high patient satisfaction and adherence. It enables high intensity ambulatory training and can be easily reproduced due to its standardized nature. Clinical rehabilitation impact: MS-FIT enables a standardized ambulatory high intensity training that is easily reproducible. Participants benefit from group training and from individual adaption of the training through professional supervision

Antimyelin antibodies as predictors of disability after clinically isolated syndrome

There is controversy whether determination of antibodies against myelin, myelin oligodendrocyte glycoprotein, and myelin basic protein in serum from patients with a first episode suggestive of multiple sclerosis is of prognostic value. We evaluated whether detection of antimyelin antibodies in serum indicates a worse course with earlier time to a second relapse and increased progression of disability. We conducted a prospective study at the Department of Neurology, Inselspital Bern, Switzerland from 2004 to 2008 in patients presenting with a clinically isolated syndrome (CIS) and a follow-up of at least 4 months. Antimyelin antibodies were assessed by Western blot. Results were correlated with clinical course and sex. Among 93 consecutive patients with a CIS, 74 (80%) were positive for either one or both antimyelin antibodies. A relapse occurred in 49 (53%) and the median EDSS was 2 (range 1-3.5) after a mean observation period of 20 months. Presence of antimyelin antibodies at CIS neither increased the risk for a second relapse nor for progression of disability. Stratification for gender did not reveal differences for any of the clinical surrogates. The sole determination of antimyelin antibodies in serum is of limited prognostic value for the identification of patients with different short-term course

Loss of paraplegin drives spasticity rather than ataxia in a cohort of 241 patients with SPG7

International audiencePatients with SPG7 had a mean age of 35.5 ± 14.3 years (n = 233) at onset and presented with spasticity (n = 89), ataxia (n = 74), or both (n = 45). At the first visit, patients with a longer disease duration (>20 years, n = 62) showed more cerebellar dysarthria (p < 0.05), deep sensory loss (p < 0.01), muscle wasting (p < 0.01), ophthalmoplegia (p < 0.05), and sphincter dysfunction (p < 0.05) than those with a shorter duration (<10 years, n = 93). Progression, measured by Scale for the Assessment and Rating of Ataxia evaluations, showed a mean annual increase of 1.0 ± 1.4 points in a subgroup of 30 patients. Patients homozygous for loss of function (LOF) variants (n = 65) presented significantly more often with pyramidal signs (p < 0.05), diminished visual acuity due to optic atrophy (p < 0.0001), and deep sensory loss (p < 0.0001) than those with at least 1 missense variant (n = 176). Patients with at least 1 Ala510Val variant (58%) were older (age 37.6 ± 13.7 vs 32.8 ± 14.6 years, p < 0.05) and showed ataxia at onset (p < 0.05). Neuropathologic examination revealed reduction of the pyramidal tract in the medulla oblongata and moderate loss of Purkinje cells and substantia nigra neurons

Coarelli et al., Table 4

Table 4. New SPG7 variants found in the analyzed cohort

AMBER: the near-infrared focal instrument for the Very Large Telescope Interferometer

International audienceAMBER is a focal instrument for the Very Large Telescope Interferometer working in the near infrared from 1.1 to 2.4 micrometers . It has been designed having in mind the General User of interferometric observations and the full range of his possible astrophysical programs. However the three programs used to define the key specifications have been the study of Young Stellar Objects, the study of Active Galactic Nuclei dust tori and broad line regions and the measure of masses and spectra of hot Extra Solar Planets. AMBER combines up to three beams produced by the VLTI 8 m Unit Telescopes equipped with Adaptive Optics and/or by the 1.8 m Auxiliary Telescopes. The fringes are dispersed with resolutions ranging from 35 to 10000. It is optimized for high accuracy single mode measurements of the absolute visibility, of the variation of the visibility and phase with wavelength (differential interferometry) and of phase closure relations with three telescopes. The instrument and its software are designed to allow a highly automated user friendly operation and an easy maintenance

AMBER, the near-infrared spectro-interferometric three-telescope VLTI instrument

Context: Optical long-baseline interferometry is moving a crucial step forward with the advent of general-user scientific instruments that equip large aperture and hectometric baseline facilities, such as the Very Large Telescope Interferometer (VLTI). Aims: AMBER is one of the VLTI instruments that combines up to three beams with low, moderate and high spectral resolutions in order to provide milli-arcsecond spatial resolution for compact astrophysical sources in the near-infrared wavelength domain. Its main specifications are based on three key programs on young stellar objects, active galactic nuclei central regions, masses, and spectra of hot extra-solar planets. Methods: These key science goals led to scientific specifications, which were used to propose and then validate the instrument concept. AMBER uses single-mode fibers to filter the entrance signal and to reach highly accurate, multiaxial three-beam combination, yielding three baselines and a closure phase, three spectral dispersive elements, and specific self-calibration procedures. Results: The AMBER measurements yield spectrally dispersed calibrated visibilities, color-differential complex visibilities, and a closure phase allows astronomers to contemplate rudimentary imaging and highly accurate visibility and phase differential measurements. AMBER was installed in 2004 at the Paranal Observatory. We describe here the present implementation of the instrument in the configuration with which the astronomical community can access it. Conclusions: .After two years of commissioning tests and preliminary observations, AMBER has produced its first refereed publications, allowing assessment of its scientific potential