Spasticity management with botulinum toxin: Development and evaluation of a tool for audit

Copyright © 2012 Foundation for Rehabilitation InformationOBJECTIVE: To develop and evaluate tools for the audit of spasticity management with botulinum toxin. DESIGN: Audit tools to assess the organisation of services and process of care were developed with a consensus process. The tools were piloted across 8 services using a retrospective case note audit. Inter-rater reliability was assessed, using percentage agreement and kappa scores. Clinicians involved in the pilot were surveyed and qualitative feedback was analysed. RESULTS: Eight services (100%) completed service Organisation tools and 7 (88%) returned process of Care tools. One hundred sets of clinical records were audited, with 34 used to assess inter-rater reliability. Eleven items on the process of care tool demonstrated a good degree of inter-rater agreement, but 6 require further development. In the qualitative analysis clinicians stated that the tools captured indicators of quality, and that they would use them again. They recommended that patient satisfaction was included as a measure of quality. The audit has been used practically in the pilot services to provide an impetus for quality improvement. Conclusions: The majority of the audit questions showed a good level of reliability, and clinician feedback supports face validity but a larger scale evaluation is required

Effect of using an exercise and nutrition secure email message on the implementation of health promotion in a large health care system

Background and Program: Secure email messaging is used to provide timely communication between healthcare providers and patients with medical information and education. There have been increasing rates of overweight and obesity among military healthcare patients. To address this issue, we utilized a secure email messaging system that is primarily used for medication refills. This commentary demonstrates the extent to which the message was viewed and how much the message was liked. Preliminary Results: Of the 16,020 individuals emailed, 7,011 participants (43.8%) opened the email, and 1,023 patients (14.6% of those who opened it) completed the survey. Satisfaction rate for the health promotion message was 77.2%. Participants reported an intent to eat more fruit and vegetables (49.6%), decrease portion sizes (38.8%), and increase physical activity (51.1%), while 33.6% reported having no intent to change. Conclusion: The majority were satisfied with the health promotion message. This email method enables a single provider to have increased contact with patients. It is unknown if this message reached higher risk or harder to reach participants, a patient subset that could benefit most from this type of communication. This study is unique in that to our knowledge it is the first one to use secure email messaging in the military healthcare system for health promotion

Cytotoxic Hydrogen Bridged Ruthenium Quinaldamide Complexes Showing Induced Cancer Cell Death by Apoptosis

This report presents the first known p-cymene ruthenium quinaldamide complexes which are stablized by a hydrogenbridging atom, [[{(p-cym)RuIIX(N,N)}{H+ }{(N,N)XRuII(p-cym)}][PF6] (N,N = functionalised quinaldamide and X = Cl or Br). These complexes are formed by a reaction of [p-cymRu(-X)2]2 with a functionalised quinaldamide ligand. When filtered over NH4PF6, and under aerobic conditions the equilibrium of NH4PF6 NH3 + HPF6 enables incorporation of HPF6 and the stabilisation of two monomeric ruthenium complexes by a bridging H+ , which are counter-balanced by a PF6 counterion. Xray crystallographic analysis is presented for six new structures with O···O distances of 2.430(3)-2.444(17) Å, which is significant for strong hydrogen bonds. Chemosensitivity studies against HCT116, A2780 and cisplatin-resistant A2780cis human cancer cells showed the ruthenium complexes with a bromide ancillary ligand to be more potent than those with a chloride ligand. The 4'-fluoro compounds show a reduction in potency for both chloride and bromide complexes against all cell lines, but an increase in selectivity towards cancer cells compared to non-cancer ARPE-19 cells, with a selectivity index > 1. Mechanistic studies showed a clear correlation between IC50 values and induction of cell death by apoptosis

Using Stakeholder Engagement to Overcome Barriers to Implementing Patient-reported Outcomes (PROs) in Cancer Care Delivery: Approaches From 3 Prospective Studies

Introduction: Patient-reported outcome (PRO) measures used during cancer care delivery improve communication about symptoms between patients and clinicians and reduce service utilization for uncontrolled symptoms. However, uptake of PROs in routine cancer care has been slow. In this paper, we describe stakeholder engagement activities used to overcome barriers to implementing PROs. Implementation occurred in 2 study settings: PROs completed in the waiting room and reviewed during clinical visits to guide symptom management for multiple myeloma (visit-based PROs); and weekly PROs completed by cancer patients between chemotherapy visits to monitor symptoms at home (remote PROs). Methods: PRO implementation steps across studies included: (1) clinician and patient input on key symptoms, PRO measures, and identifying which PRO responses are clinically concerning to better target nursing actions; (2) developing PRO-based clinical decision support (CDS) for responding to concerning PROs; (3) training clinicians and clinical research assistants to interpret PROs and use software; and (4) describing implementation impact (frequency of concerning PRO responses and nursing actions). Discussion: Clinician and patient input was critical for identifying key symptoms, PRO measures, and clinically concerning response options. For the visit-based PRO observational study, all symptom scores appeared on a clinician dashboard, and those rated ≥1 by patients (on a 0–4 or 0–10 scale) had PRO-based CDS available for access. For the 2 remote PROs trials, stakeholders recommended that the 2 “worst” response options (eg, PRO responses of “often”/“always” or “severe”/“very severe”) would trigger an automated email alert to a nurse along with PRO-based CDS. In each study, PRO-based CDS was tailored based on clinician input. Across studies, the most common nursing response to concerning PROs was counseling patients on (or providing care plans for) self-management of symptoms. In the trials, the percentage of weekly remote PROs generating an alert to a nurse ranged from 13% at an academic center to 36% in community oncology practices. Key Points: Across 3 prospective studies, PROs implemented into cancer care enabled tailored care based on issues identified on PROs. Stakeholder engagement was critical for successful implementation. This paper assists in addressing important PRO implementation challenges by describing a stakeholder-driven approach

Advance care planning in chronic kidney disease: a survey of current practice in Australia

Aim: Advance care planning (ACP) in nephrology is widely advocated but not always implemented. The aims of this study were to describe current ACP practice and identify barriers/facilitators and perceived need for health professional education and chronic kidney disease (CKD)-specific approaches. Methods: An anonymous cross-sectional survey was administered online. Nephrology health professionals in Australia and New Zealandwere recruited via professional societies, email lists and nephrology conferences. Multiple regression explored the influence of respondents’ attributes on extent of involvement in ACP and willingness to engage in future. Results: A total of 375 respondents included nephrologists (23%), nurses (65%), social workers (4%) and others (8%) with 54% indicated that ACP at their workplace was performed ad hoc and 61% poorly. Perceived barriers included patient/family discomfort (84%), difficulty engaging families (83%), lack of clinician expertise (83%) and time (82%), health professional discomfort (72%), cultural/language barriers (65%), lack of private space (61%) and lack of formal policy/procedures (60%). Respondents overwhelmingly endorsed the need for more dialysis-specific ACP programs (96%) and education (95%). Whilst 85% thought ACP would be optimally performed by specially trained staff, comments emphasized that all clinicians should have a working proficiency. Respondents who were more willing to engage in future ACP tended to be non-physicians (odds ratio (OR) 4.96, 95% confidence intervals (CI) 1.74–14.07) and reported a greater need for CKD-specific ACP materials (OR 10.88, 95% CI 2.38–49.79). Conclusion: Advance care planning in nephrology needs support through education and CKD-specific resources. Endorsement by nephrologists is important. A multidisciplinary approach with a gradient of ACP expertise is also recommended

How Informed Is the Decision About Breast Reconstruction After Mastectomy?: A Prospective, Cross-sectional Study

to assess how informed patients are about breast reconstruction, and how involved they are in decision making

Development and implementation of an Internet-based survivorship care program for cancer survivors treated with hematopoietic stem cell transplantation.

The Internet provides a widely accessible modality for meeting survivorship care needs of cancer survivors. In this paper, we describe the development and implementation of an Internet site designed as a base from which to conduct a randomized controlled trial to meet psycho-educational needs of hematopoietic stem cell transplantation (HSCT) survivors

Helminth antigens modulate human PBMCs, attenuating disease progression in a humanised mouse model of graft versus host disease

Fasciola hepatica is a trematode worm that causes fascioliasis, a neglected tropical disease in humans and livestock. To gain insight into the host-parasite interactions that facilitate infection, we have investigated the immunomodulatory properties of the parasite's tegumental coat (FhTeg), a major antigen source that is sloughed off and renewed every 2–3 h as the worm migrates through host tissue. Using mouse models of infection, we have previously shown that FhTeg induces a novel phenotype of dendritic cells that induce anergic CD4+ T-cells. We proposed that this induced state of hyporesponsiveness characterised by suppression of cell proliferation and cytokine secretion was one mechanism by which F. hepatica prevented host protective immunity to support the parasite survival. To determine if the same mechanisms are utilised during human infections, we have now examined the interaction of FhTeg with human PBMCs. FhTeg binds to and modulates cytokine production in human PBMCs, in particular targeting the CD4+ population resulting in reduced levels of TNF, IL-2 and IFNγ and increased markers of anergy. Furthermore, the adoptive transfer of FhTeg stimulated PBMCs to a humanised model of acute graft versus host disease (GvHD) attenuated disease progression by increasing survival and reducing pathological scores. These mice also displayed a significant decrease in the total number of human CD4+ cells expressing TNF, IL-2 and IFNγ in the spleen, liver and lung. This study therefore concurs with evidence from ruminant and murine models of infection suggesting that anergic CD4+ T cells are associated with successful Fasciola hepatica infection and highlights an important role for FhTeg in contributing to the overall immunosuppressive effects of this parasite