Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis

Purpose: Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes. Method: We sought publications of recent (January 2000–May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up. Findings: We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72–0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66–0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50–0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43–0.64), lipid management (odds ratio 0.52; 0.38–0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67–0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43–0.78) and stroke unit admission (odds ratio 0.83; 0.77–0.89). Adherence with several key performance indicators appeared to have an additive benefit. Discussion: Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke. Conclusion: Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence

Conflated Constructs: Disentangling the Educative and Evaluative Functions of Preservice Teacher Supervision

University mentors require specialized knowledge and skill to support teacher candidate learning in the context of fieldwork. Without such knowledge and skill, interactions between university mentors and teacher candidates is often evaluative, thus undermining the educative potential of mentoring. We focus on mentoring practices employed in the context of the post-observation conference. Findings from a year-long implementation study show that when university mentors are introduced to an educative mentoring protocol and are provided with sustained professional development, their mentoring practices shift from an evaluative to an educative focus. University mentors indicate that this shift, initially perceived as unnatural, was supported through the scaffolding provided by the protocol and on-going professional development. Shifts in university mentors’ practices supported teacher candidate reflection and growth. By foregrounding the educative function, this work adds to the theory-based conceptualization of the knowledge and skills needed for the effective mentoring of those learning to teach

Stroke care in Africa: a systematic review of the literature

Background: Appropriate systems of stroke care are important to manage the increasing death and disability associated with stroke in Africa. Information on existing stroke services in African countries is limited. Aim: To describe the status of stroke care in Africa. Summary of review: We undertook a systematic search of the published literature to identify recent (1 January 2006–20 June 2017) publications that described stroke care in any African country. Our initial search yielded 838 potential papers, of which 38 publications were eligible representing 14/54 African countries. Across the publications included for our review, the proportion of stroke patients reported to arrive at hospital within 3 h from stroke onset varied between 10% and 43%. The median time interval between stroke onset and hospital admission was 31 h. Poor awareness of stroke signs and symptoms, shortages of medical transportation, health care personnel, and stroke units, and the high cost of brain imaging, thrombolysis, and outpatient physiotherapy rehabilitation services were reported as major barriers to providing best-practice stroke care in Africa. Conclusions: This review provides an overview of stroke care in Africa, and highlights the paucity of available data. Stroke care in Africa usually fell below the recommended standards with variations across countries and settings. Combined efforts from policy makers and health care professionals in Africa are needed to improve, and ensure access, to organized stroke care in as many settings as possible. Mechanisms to routinely monitor usual care (i.e., registries or audits) are also needed to inform policy and practice

Divergent drivers of leaf trait variation within species, among species, and among functional groups.

Understanding variation in leaf functional traits-including rates of photosynthesis and respiration and concentrations of nitrogen and phosphorus-is a fundamental challenge in plant ecophysiology. When expressed per unit leaf area, these traits typically increase with leaf mass per area (LMA) within species but are roughly independent of LMA across the global flora. LMA is determined by mass components with different biological functions, including photosynthetic mass that largely determines metabolic rates and contains most nitrogen and phosphorus, and structural mass that affects toughness and leaf lifespan (LL). A possible explanation for the contrasting trait relationships is that most LMA variation within species is associated with variation in photosynthetic mass, whereas most LMA variation across the global flora is associated with variation in structural mass. This hypothesis leads to the predictions that (i) gas exchange rates and nutrient concentrations per unit leaf area should increase strongly with LMA across species assemblages with low LL variance but should increase weakly with LMA across species assemblages with high LL variance and that (ii) controlling for LL variation should increase the strength of the above LMA relationships. We present analyses of intra- and interspecific trait variation from three tropical forest sites and interspecific analyses within functional groups in a global dataset that are consistent with the above predictions. Our analysis suggests that the qualitatively different trait relationships exhibited by different leaf assemblages can be understood by considering the degree to which photosynthetic and structural mass components contribute to LMA variation in a given assemblage

Use of waveform lidar and hyperspectral sensors to assess selected spatial and structural patterns associated with recent and repeat disturbance and the abundance of sugar maple (Acer saccharum Marsh.) in a temperate mixed hardwood and conifer forest.

Abstract Waveform lidar imagery was acquired on September 26, 1999 over the Bartlett Experimental Forest (BEF) in New Hampshire (USA) using NASA\u27s Laser Vegetation Imaging Sensor (LVIS). This flight occurred 20 months after an ice storm damaged millions of hectares of forestland in northeastern North America. Lidar measurements of the amplitude and intensity of ground energy returns appeared to readily detect areas of moderate to severe ice storm damage associated with the worst damage. Southern through eastern aspects on side slopes were particularly susceptible to higher levels of damage, in large part overlapping tracts of forest that had suffered the highest levels of wind damage from the 1938 hurricane and containing the highest levels of sugar maple basal area and biomass. The levels of sugar maple abundance were determined through analysis of the 1997 Airborne Visible/Infrared Imaging Spectrometer (AVIRIS) high resolution spectral imagery and inventory of USFS Northern Research Station field plots. We found a relationship between field measurements of stem volume losses and the LVIS metric of mean canopy height (r2 = 0.66; root mean square errors = 5.7 m3/ha, p \u3c 0.0001) in areas that had been subjected to moderate-to-severe ice storm damage, accurately documenting the short-term outcome of a single disturbance event

Evidence That Nasal Insulin Induces Immune Tolerance to Insulin in Adults With Autoimmune Diabetes

OBJECTIVE: Insulin in pancreatic β-cells is a target of autoimmunity in type 1 diabetes. In the NOD mouse model of type 1 diabetes, oral or nasal administration of insulin induces immune tolerance to insulin and protects against autoimmune diabetes. Evidence for tolerance to mucosally administered insulin or other autoantigens is poorly documented in humans. Adults with recent-onset type 1 diabetes in whom the disease process is subacute afford an opportunity to determine whether mucosal insulin induces tolerance to insulin subsequently injected for treatment. RESEARCH DESIGN AND METHODS: We randomized 52 adults with recent-onset, noninsulin-requiring type 1 diabetes to nasal insulin or placebo for 12 months. Fasting blood glucose and serum C-peptide, glucagon-stimulated serum C-peptide, and serum antibodies to islet antigens were monitored three times monthly for 24 months. An enhanced ELISpot assay was used to measure the T-cell response to human proinsulin. RESULTS: β-Cell function declined by 35% overall, and 23 of 52 participants (44%) progressed to insulin treatment. Metabolic parameters remained similar between nasal insulin and placebo groups, but the insulin antibody response to injected insulin was significantly blunted in a sustained manner in those who had received nasal insulin. In a small cohort, the interferon-γ response of blood T-cells to proinsulin was suppressed after nasal insulin. CONCLUSIONS: Although nasal insulin did not retard loss of residual β-cell function in adults with established type 1 diabetes, evidence that it induced immune tolerance to insulin provides a rationale for its application to prevent diabetes in at-risk individuals

Benefits and Costs of Interventions to Improve Breast Cancer Outcomes in African American Women

Purpose Historically, African American women have experienced higher breast cancer mortality than white women, despite lower incidence. Our objective was to evaluate whether costs of increasing rates of screening or application of intensive treatment will be off-set by survival benefits for African American women. Methods We use a stochastic simulation model of the natural history of breast cancer to evaluate the incremental societal costs and benefits of status quo versus targeted biennial screening or treatment improvements among African Americans 40 years of age and older. Main outcome measures were number of mammograms, stage, all-cause mortality, and discounted costs per life year saved (LYS). Results At the current screening rate of 76%, there is little incremental benefit associated with further increasing screening, and the costs are high: $124,053 and$124,217 per LYS for lay health worker and patient reminder interventions, respectively, compared with the status quo. Using reminders would cost $51,537 per LYS if targeted to virtually unscreened women or$78,130 per LYS if targeted to women with a two-fold increase in baseline risk. If all patients received the most intensive treatment recommended, costs increase but deaths decrease, for a cost of $52,678 per LYS. Investments of up to$6,000 per breast cancer patient could be used to enhance treatment and still yield cost-effectiveness ratios of less than $75,000 per LYS. Conclusion Except in pockets of unscreened or high-risk women, further investments in interventions to increase screening are unlikely to be an efficient use of resources. Ensuring that African American women receive intensive treatment seems to be the most cost-effective approach to decreasing the disproportionate mortality experienced by this population

The organizational social context of mental health services and clinician attitudes toward evidence-based practice: a United States national study.

UnlabelledABSTBACKGROUND: Evidence-based practices have not been routinely adopted in community mental health organizations despite the support of scientific evidence and in some cases even legislative or regulatory action. We examined the association of clinician attitudes toward evidence-based practice with organizational culture, climate, and other characteristics in a nationally representative sample of mental health organizations in the United States.MethodsIn-person, group-administered surveys were conducted with a sample of 1,112 mental health service providers in a nationwide sample of 100 mental health service institutions in 26 states in the United States. The study examines these associations with a two-level Hierarchical Linear Modeling (HLM) analysis of responses to the Evidence-Based Practice Attitude Scale (EBPAS) at the individual clinician level as a function of the Organizational Social Context (OSC) measure at the organizational level, controlling for other organization and clinician characteristics.ResultsWe found that more proficient organizational cultures and more engaged and less stressful organizational climates were associated with positive clinician attitudes toward adopting evidence-based practice.ConclusionsThe findings suggest that organizational intervention strategies for improving the organizational social context of mental health services may contribute to the success of evidence-based practice dissemination and implementation efforts by influencing clinician attitudes

Ultra-high foraging rates of harbor porpoises make them vulnerable to anthropogenic disturbance

This study was partly funded by the German Federal Agency for Nature Conservation (BfN) under the contract Z1.2-5330/2010/14 and the BfN-Cluster 7 “Effects of underwater noise on marine vertebrates.” D.M.W. and P.T.M. were also supported by the Danish National Research Foundation (FNU) and the Carlsberg Foundation, and M.J. was also supported by the Marine Alliance for Science and Technology Scotland (MASTS) and by a Marie Curie-Sklodowska award.The question of how individuals acquire and allocate resources to maximize fitness is central in evolutionary ecology. Basic information on prey selection, search effort, and capture rates are critical for understanding a predator’s role in its ecosystem and for predicting its response to natural and anthropogenic disturbance. Yet, for most marine species, foraging interactions cannot be observed directly. The high costs of thermoregulation in water require that small marine mammals have elevated energy intakes compared to similar-sized terrestrial mammals [1]. The combination of high food requirements and their position at the apex of most marine food webs may make small marine mammals particularly vulnerable to changes within the ecosystem [2–4], but the lack of detailed information about their foraging behavior often precludes an informed conservation effort. Here, we use high-resolution movement and prey echo recording tags on five wild harbor porpoises to examine foraging interactions in one of the most metabolically challenged cetacean species. We report that porpoises forage nearly continuously day and night, attempting to capture up to 550 small (3–10 cm) fish prey per hour with a remarkable prey capture success rate of >90%. Porpoises therefore target fish that are smaller than those of commercial interest, but must forage almost continually to meet their metabolic demands with such small prey, leaving little margin for compensation. Thus, for these “aquatic shrews,” even a moderate level of anthropogenic disturbance in the busy shallow waters they share with humans may have severe fitness consequences at individual and population levels.PostprintPeer reviewe

Item and Scale Differential Functioning of the Mini-Mental State Exam Assessed Using the Differential Item and Test Functioning (DFIT) Framework

To illustrate the application of the Differential Item and Test Functioning (DFIT) method using English and Spanish versions of the Mini-Mental State Examination (MMSE)