Implementing the MOVE! Weight-Management Program in the Veterans Health Administration, 2007-2010: A Qualitative Study

IntroductionOne-third of US veterans receiving care at Veterans Health Administration (VHA) medical facilities are obese and, therefore, at higher risk for developing multiple chronic diseases. To address this problem, the VHA designed and nationally disseminated an evidence-based weight-management program (MOVE!). The objective of this study was to examine the organizational factors that aided or inhibited the implementation of MOVE! in 10 VHA medical facilities.MethodsUsing a multiple, holistic case study design, we conducted 68 interviews with medical center program coordinators, physicians formally appointed as program champions, managers directly responsible for overseeing the program, clinicians from the program's multidisciplinary team, and primary care physicians identified by program coordinators as local opinion leaders. Qualitative data analysis involved coding, memorandum writing, and construction of data displays.ResultsOrganizational readiness for change and having an innovation champion were most consistently the 2 factors associated with MOVE! implementation. Other organizational factors, such as management support and resource availability, were barriers to implementation or exerted mixed effects on implementation. Barriers did not prevent facilities from implementing MOVE! However, they were obstacles that had to be overcome, worked around, or accepted as limits on the program's scope or scale.ConclusionPolicy-directed implementation of clinical weight-management programs in health care facilities is challenging, especially when no new resources are available. Instituting powerful, mutually reinforcing organizational policies and practices may be necessary for consistent, high-quality implementation

Null fields in the outer Jovian magnetosphere: Ulysses observations

This paper reports on a magnetic field phenomenon, hereafter referred to as null fields, which were discovered during the inbound pass of the recent flyby of Jupiter by the Ulysses spacecraft. These null fields which were observed in the outer dayside magnetosphere are characterised by brief but sharp decreases of the field magnitude to values less than 1 nT. The nulls are distinguished from the current sheet signatures characteristic of the middle magnetosphere by the fact that the field does not reverse across the event. A field configuration is suggested that accounts for the observed features of the events

(Correcting) misdiagnoses of asthma: A cost effectiveness analysis

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background: The prevalence of physician-diagnosed-asthma has risen over the past three decades and misdiagnosis of asthma is potentially common. Objective: to determine whether a secondary-screening-program to establish a correct diagnosis of asthma in those who report a physician diagnosis of asthma is cost effective.Method: Randomly selected physician-diagnosed-asthmatic subjects from 8 Canadian cities were studied with an extensive diagnostic algorithm to rule-in, or rule-out, a correct diagnosis of asthma. Subjects in whom the diagnosis of asthma was excluded were followed up for 6-months and data on asthma medications and heath care utilization was obtained. Economic analysis was performed to estimate the incremental lifetime costs associated with secondary screening of previously diagnosed asthmatic subjects. Analysis was from the perspective of the Canadian healthcare system and is reported in Canadian dollars.Results: Of 540 randomly selected patients with physician diagnosed asthma 150 (28%; 95%CI 19-37%) did not have asthma when objectively studied. 71% of these misdiagnosed patients were on some asthma medications. Incorporating the incremental cost of secondary-screening for the diagnosis of asthma, we found that the average cost savings per 100 individuals screened was $35,141 (95$4,588-$69,278).Conclusion: Cost savings primarily resulted from lifetime costs of medication use averted in those who had been misdiagnosed.This work was funded by the Canadian Institute of Health Research, Canada and the University Of Ottawa Division Of Respiratory Medicine

Immunization with Cocktail of HIV-Derived Peptides in Montanide ISA-51 Is Immunogenic, but Causes Sterile Abscesses and Unacceptable Reactogenicity

BACKGROUND: A peptide vaccine was produced containing B and T cell epitopes from the V3 and C4 Envelope domains of 4 subtype B HIV-1 isolates (MN, RF, CanO, & Ev91). The peptide mixture was formulated as an emulsion in incomplete Freund's adjuvant (IFA). METHODS: Low-risk, healthy adult subjects were enrolled in a randomized, placebo-controlled dose-escalation study, and selected using criteria specifying that 50% in each study group would be HLA-B7+. Immunizations were scheduled at 0, 1, and 6 months using a total peptide dose of 1 or 4 mg. Adaptive immune responses in16 vaccine recipients and two placebo recipients after the 2nd immunization were evaluated using neutralization assays of sera, as well as ELISpot and ICS assays of cryopreserved PBMCs to assess CD4 and CD8 T-cell responses. In addition, (51)Cr release assays were performed on fresh PBMCs following 14-day stimulation with individual vaccine peptide antigens. RESULTS: 24 subjects were enrolled; 18 completed 2 injections. The study was prematurely terminated because 4 vaccinees developed prolonged pain and sterile abscess formation at the injection site-2 after dose 1, and 2 after dose 2. Two other subjects experienced severe systemic reactions consisting of headache, chills, nausea, and myalgia. Both reactions occurred after the second 4 mg dose. The immunogenicity assessments showed that 6/8 vaccinees at each dose level had detectable MN-specific neutralizing (NT) activity, and 2/7 HLA-B7+ vaccinees had classical CD8 CTL activity detected. However, using both ELISpot and ICS, 8/16 vaccinees (5/7 HLA-B7+) and 0/2 controls had detectable vaccine-specific CD8 T-cell responses. Subjects with moderate or severe systemic or local reactions tended to have more frequent T cell responses and higher antibody responses than those with mild or no reactions. CONCLUSIONS: The severity of local responses related to the formulation of these four peptides in IFA is clinically unacceptable for continued development. Both HIV-specific antibody and T cell responses were induced and the magnitude of response correlated with the severity of local and systemic reactions. If potent adjuvants are necessary for subunit vaccines to induce broad and durable immune responses, careful, incremental clinical evaluation is warranted to minimize the risk of adverse events. TRIAL REGISTRATION: ClinicalTrials.gov NCT00000886

Literature search on risk factors for sarcoma: PubMed and Google Scholar may be complementary sources

<p>Abstract</p> <p>Background</p> <p>Within the context of a European network dedicated to the study of sarcoma the relevant literature on sarcoma risk factors was collected by searching PubMed and Google Scholar, the two information storage and retrieval databases which can be accessed without charge. The present study aims to appraise the relative proficiency of PubMed and Google Scholar.</p> <p>Findings</p> <p>Unlike PubMed, Google Scholar does not allow a choice between "Human" and "Animal" studies, nor between "Classical" and other types of studies. As a result, searches with Google Scholar produced high numbers of citations that have to be filtered. Google Scholar resulted in a higher sensitivity (proportion of relevant articles, meeting the search criteria), while PubMed in a higher specificity (proportion of lower quality articles not meeting the criteria, that are not retrieved). Concordance between Google Scholar and PubMed was as low as 8%.</p> <p>Conclusions</p> <p>This study focused just on one topic. Although further studies are warranted, PM and GS appear to be complementary and their integration could greatly improve the search of references in medical research.</p

Systematic review of safety checklists for use by medical care teams in acute hospital settings - limited evidence of effectiveness

<p>Abstract</p> <p>Background</p> <p>Patient safety is a fundamental component of good quality health care. Checklists have been proposed as a method of improving patient safety. This systematic review, asked "In acute hospital settings, would the use of safety checklists applied by medical care teams, compared to not using checklists, improve patient safety?"</p> <p>Methods</p> <p>We searched the Cochrane Library, MEDLINE, CINAHL, and EMBASE for randomised controlled trials published in English before September 2009. Studies were selected and appraised by two reviewers independently in consultation with colleagues, using inclusion, exclusion and appraisal criteria established a priori.</p> <p>Results</p> <p>Nine cohort studies with historical controls studies from four hospital care settings were included-intensive care unit, emergency department, surgery, and acute care. The studies used a variety of designs of safety checklists, and implemented them in different ways, however most incorporated an educational component to teach the staff how to use the checklist. The studies assessed outcomes occurring a few weeks to a maximum of 12 months post-implementation, and these outcomes were diverse.</p> <p>The studies were generally of low to moderate quality and of low levels of evidence, with all but one of the studies containing a high risk of bias.</p> <p>The results of these studies suggest some improvements in patient safety arising from use of safety checklists, but these were not consistent across all studies or for all outcomes. Some studies showed no difference in outcomes between checklist use and standard care without a checklist. Due to the variations in setting, checklist design, educational training given, and outcomes measured, it was unfeasible to accurately summarise any trends across all studies.</p> <p>Conclusions</p> <p>The included studies suggest some benefits of using safety checklists to improve protocol adherence and patient safety, but due to the risk of bias in these studies, their results should be interpreted with caution. More high quality and studies, are needed to enable confident conclusions about the effectiveness of safety checklists in acute hospital settings.</p

Cluster randomized trial of an active, multifaceted information dissemination intervention based on The WHO Reproductive health library to change obstetric practices: methods and design issues [ISRCTN14055385]

BACKGROUND: Effective strategies for implementing best practices in low and middle income countries are needed. RHL is an annually updated electronic publication containing Cochrane systematic reviews, commentaries and practical recommendations on how to implement evidence-based practices. We are conducting a trial to evaluate the improvement in obstetric practices using an active dissemination strategy to promote uptake of recommendations in The WHO Reproductive Health Library (RHL). METHODS: A cluster randomized trial to improve obstetric practices in 40 hospitals in Mexico and Thailand is conducted. The trial uses a stratified random allocation based on country, size and type of hospitals. The core intervention consists of three interactive workshops delivered over a period of six months. The main outcome measures are changes in clinical practices that are recommended in RHL measured approximately a year after the first workshop. RESULTS: The design and implementation of a complex intervention using a cluster randomized trial design are presented. CONCLUSION: Designing the intervention, choosing outcome variables and implementing the protocol in two diverse settings has been a time-consuming and challenging process. We hope that sharing this experience will help others planning similar projects and improve our ability to implement change

Electronic search strategies to identify reports of cluster randomized trials in MEDLINE: low precision will improve with adherence to reporting standards

BACKGROUND: Cluster randomized trials (CRTs) present unique methodological and ethical challenges. Researchers conducting systematic reviews of CRTs (e.g., addressing methodological or ethical issues) require efficient electronic search strategies (filters or hedges) to identify trials in electronic databases such as MEDLINE. According to the CONSORT statement extension to CRTs, the clustered design should be clearly identified in titles or abstracts; however, variability in terminology may make electronic identification challenging. Our objectives were to (a) evaluate sensitivity ( recall ) and precision of a well-known electronic search strategy ( randomized controlled trial as publication type) with respect to identifying CRTs, (b) evaluate the feasibility of new search strategies targeted specifically at CRTs, and (c) determine whether CRTs are appropriately identified in titles or abstracts of reports and whether there has been improvement over time. METHODS: We manually examined a wide range of health journals to identify a gold standard set of CRTs. Search strategies were evaluated against the gold standard set, as well as an independent set of CRTs included in previous systematic reviews. RESULTS: The existing strategy (randomized controlled trial.pt) is sensitive (93.8%) for identifying CRTs, but has relatively low precision (9%, number needed to read 11); the number needed to read can be halved to 5 (precision 18.4%) by combining with cluster design-related terms using the Boolean operator AND; combining with the Boolean operator OR maximizes sensitivity (99.4%) but would require 28.6 citations read to identify one CRT. Only about 50% of CRTs are clearly identified as cluster randomized in titles or abstracts; approximately 25% can be identified based on the reported units of randomization but are not amenable to electronic searching; the remaining 25% cannot be identified except through manual inspection of the full-text article. The proportion of trials clearly identified has increased from 28% between the years 2000-2003, to 60% between 2004-2007 (absolute increase 32%, 95% CI 17 to 47%). CONCLUSIONS: CRTs should include the phrase cluster randomized trial in titles or abstracts; this will facilitate more accurate indexing of the publication type by reviewers at the National Library of Medicine, and efficient textword retrieval of the subset employing cluster randomization

Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up

<p>Abstract</p> <p>Background</p> <p>In Denmark, approximately 12,000 hip and knee arthroplasties were performed in 2006, and the hospital costs were close to US$ 110,000,000. In a randomized clinical trial, we have recently demonstrated the efficacy of accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty compared to current intervention under ideal circumstances. We do not, however, know whether these results could be reached under usual circumstances of healthcare practice. We therefore investigated whether length of stay after implementation of accelerated perioperative care and rehabilitation after hip and knee arthroplasty could be reduced in a normal healthcare setting, and how the achieved results matched those observed during the randomized clinical trial.</p> <p>Methods</p> <p>An effectiveness study as a before-after trial was undertaken in which all elective primary total hip and total knee arthroplasty patients were divided into a before-implementation group receiving the current perioperative procedure, and an after-implementation group receiving the new accelerated perioperative care and rehabilitation procedures as provided by a new multi-disciplinary organization. We used the Breakthrough Series Collaborative Model for implementation. The primary outcome measure was in hospital length of stay (LOS), and the secondary outcome measure was adverse effects within 3 months postoperatively.</p> <p>Results</p> <p>We included a total of 247 patients. Mean LOS was significantly (<it>P </it>< 0.001) reduced by 4.4 (95% CI 3.8–5.0) days after implementation of the accelerated intervention, from 8.8 (SD 3.0) days before implementation to 4.3 (SD 1.8) days after implementation. No significant differences in adverse effects were observed. LOS in this effectiveness study was significantly lower than LOS reported in the efficacy study.</p> <p>Conclusion</p> <p>Accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty was successfully and effectively implemented. Results obtained during usual hospital circumstances matched the results achieved under ideal circumstances in this group of patients.</p

Clinical reports of pulmonary metastasectomy for colorectal cancer: a citation network analysis

INTRODUCTION: Pulmonary metastasectomy for colorectal cancer is a commonly performed and well-established practice of similar to 50 years standing. However, there have been no controlled studies, randomised or otherwise. We sought to investigate the evidence base that has been used in establishing its status as a standard of care.METHODS: Among 51 papers used in a recent systematic review and quantitative synthesis, a citation network analysis was performed. A total of 344 publications (the 51 index papers and a further 293 cited in them) constitute the citation network.RESULTS: The pattern of citation is that of a citation cascade. Specific analyses show the frequent use of historical or landmark papers, which add authority. Papers expressing an opposing viewpoint are rarely cited.CONCLUSIONS: The citation network for this common and well-established practice provides an example of selective citation. This pattern of citation tends to escalate belief in a clinical practice even when it lacks a high-quality evidence base and may create an impression of more authority than is warranted.British Journal of Cancer (2011) 104, 1085-1097. doi: 10.1038/sj.bjc.6606060 www.bjcancer.comPublished online 8 March 2011 (c) 2011 Cancer Research U