Training Appalachian, Hospital-based Occupational Therapists on the Use of Standardized, Occupation-based Outcome Measures and Treatment Concepts for Traumatic Upper Extremity Injuries: A Pilot Program

Executive Summary Background. Traumatic injuries to the upper extremity, such as crush injuries, tendon lacerations, burns, and amputations, are common and may result in missed work, decreased independence in activities of daily living, and decreased the quality of life. In urban areas, traumatic upper extremity injuries are often treated by a Certified Hand Therapist (CHT), who is an occupational or physical therapist with specialized training who has passed a national certification examination. In the Appalachian region of Kentucky, people with traumatic hand injuries are most likely to be treated in a hospital-based outpatient orthopedic setting that is primarily staffed with physical therapists who may have limited knowledge or skills in the treatment of upper extremity dysfunction. The entire region has only one known CHT, and there have been few referrals to occupational therapy. Less than half of all traumatic upper extremity injuries in this region received rehabilitation at all. Purpose. The purpose of the pilot study was to determine the current knowledge base of hospital-based occupational therapists about basic science and occupational performance skills necessary for the evaluation and treatment of traumatic upper extremity injuries. The pilot study identified if an educational program improved the therapists’ knowledge and use of functional outcome tools within a 90 day treatment period for the treatment of acute traumatic hand injuries. Theoretical Framework. The adult learning theory, Andragogy, developed by Malcolm Knowles (Knowles, 1985), emphasized self-directed learning and informal adult education. This applies well to healthcare professionals who have a need for continuing education in maintaining professional competence so was used as a guiding framework for this project. Methods. This project used a pretest/posttest research design. The participants (n=3) took a pretest and participated in an eight-hour educational program covering basic science, occupational performance treatment concepts and the utilization of standardized functional outcome tools for acute upper extremity injuries. Three standardized outcome measures typically used in hand rehabilitation were covered: The Canadian Occupational Performance Measure (COPM), the Quick Disability of the Arm, Hand, and Shoulder (QDASH), and the Global Rating of Change (Groc). Following the education session, the participants administered the three outcome tools to all patients with acute hand injuries at initial evaluation and discharge (COPM and QDASH), and fourth visit and discharge (GROC). The occupational therapy practitioners then participated in a post-test at 90 days after initial training. Results. All three therapists improved in their knowledge about the evaluation and treatment of traumatic UE injuries from pretest to posttest. The pretest indicated the therapists had minimal knowledge of the three standardized outcome measures. Only one of them indicated using two of the assessments (COPM and QDASH), and the other two reported no use of any of the assessments. All three therapists reported using all three tools after the education. At the end of 90 days, all three therapists demonstrated average COPM scores with clinically significant improvement. Two of the three therapists (Therapists 1 and 3) showed clinically acceptable QDASH scores. Because a score of 20 or less is considered good improvement per industry standard, Therapist 2 did not demonstrate good patient outcomes using the QDASH. The GROC findings revealed that Therapists 1 and 2 were able to demonstrate good patient outcomes. Therapist 3 showed that by the fourth visit, patients had actually gotten worse after occupational therapy care; however, by discharge patients had improved. Conclusions. The pilot study was limited in scope with a small sample size and patient population. The participants demonstrated a positive change in test scores and use of functional outcome measures, indicating an improved ability to treat patients with traumatic hand injuries.This pilot study will be a useful model for improving the knowledge base of occupational therapists working in the Appalachian region of Kentucky to ultimately improve the outcomes of patients with acute upper extremity injuries

Genome Sequencing of a Marine Spirillum, Oceanospirillum multiglobuliferum ATCC 33336T, from Japan

Oceanospirillum multiglobuliferum ATCC 33336T is a motile gammaproteobacterium with bipolar tufted flagella, noted for its low salt tolerance compared to other marine spirilla. This strain was originally isolated from the putrid infusions of Crassostrea gigas near Hiroshima, Japan. This paper presents a draft genome sequence for O. multiglobuliferum ATCC 33336T

Draft Genome Sequence of the Salt Water Bacterium Oceanospirillum linum ATCC 11336T

Oceanospirillum linum ATCC 11336T is an aerobic, bipolar-tufted gammaproteobacterium first isolated in the Long Island Sound in the 1950s. This announcement offers a genome sequence for O. linum ATCC 11336T, which has a predicted genome size of 3,782,189 bp (49.13% G+C content) containing 3,540 genes and 3,361 coding sequences

Specificity of the Minimal Clinically Important Difference of the Quick Disabilities of the Arm Shoulder and Hand (QDASH) for Distal Upper Extremity Conditions

Retrospective cohort design. The minimal clinically important difference (MCID) for the quick Disabilities of the Arm, Shoulder and Hand (QDASH) has been established using a pool of multiple conditions, and only exclusively for the shoulder. Understanding diagnoses-specific threshold change values can enhance the clinical decision-making process. Before and after QDASH scores for 406 participants with conditions of surgical distal radius fracture, non-surgical lateral epicondylitis, and surgical carpal tunnel release were obtained. The external anchor administered at each fourth visit was a 15-point global rating of change scale. The test-retest reliability of the QDASH was moderate for all diagnoses: intraclass correlation coefficient model 2, 1, for surgical distal radius = 0.71; non-surgical lateral epicondylitis = 0.69; and surgical carpal tunnel = 0.69. The minimum detectable change at the 90% confidence level was 25.28; 22.49; and 27.63 points respectively; and the MCID values were 25.8; 15.8 and 18.7, respectively. For these three distal upper extremity conditions, a QDASH MCID of 16-26 points could represent the estimate of change in score that is important to the patient and guide clinicians through the decision-making process

A Retrospective Cohort Study of QuickDASH Scores for Three Hand Therapy Acute Upper Limb Conditions

Introduction: The QuickDASH is a valid and reliable outcome measure widely used to assess the function and pain in arm, shoulder, and hand disabilities. A recent study introduced a QuickDASH 80% cut point test to gauge patients at risk of poor outcomes. However, the utility of this test has not been validated. Purpose: To determine typical QuickDASH scores for three upper limb conditions and to test the sensitivity and specificity of the QuickDASH 80% cut point test in predicting patients at risk of poor outcomes. Methods: This is a retrospective study with a total of 406 patient records for whom QuickDASH scores were examined. The sensitivity and specificity of the QuickDASH 80% cut point test was investigated for three acute upper limb conditions seen in hand therapy: surgical distal radius fracture, nonsurgical lateral epicondylitis, and carpal tunnel release. Results: Typical scores were determined for three upper limb conditions. The QuickDASH 80% cut point test per upper limb condition returned poor sensitivity between 28.57% and 41.67%. Conclusion: The results did not support the QuickDASH 80% cut point test as a predictor of final outcome in these three patient populations. Patients with the worse initial 20% scores were not correctly classified as worse 20% final scores. This study provides summary data from three upper limb conditions to provide clinicians with comparison data to establish goals and educate patients

Adherence of Individuals in Upper Extremity Rehabilitation: A Qualitative Study

OBJECTIVE: To describe the rehabilitation experiences, expectations, and treatment adherence of patients receiving upper extremity (UE) rehabilitation who demonstrated discrepancy between functional gains and overall improvement. DESIGN: Qualitative (phenomenologic) interviews and analysis. SETTING: Outpatient UE rehabilitation. PARTICIPANTS: Patients with acute UE injuries (N=10). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Concerns related to UE rehabilitation patients demonstrating discrepancy between outcome measures. RESULTS: Five key themes emerged from the interviews of patients demonstrating discrepancy in their self-reported patient outcomes: (1) desire to return to normal, (2) initial anticipation of brief recovery, (3) trust of therapist, (4) cannot stop living, and (5) feelings of ambivalence. Challenges included living with the desire to move back into life. Multiple factors affected patient adherence: cost of treatment, patient-provider relation (difference between therapist and patient understanding on what is important for treatment), and patients expecting the treating therapists to be an expert and fix their problem. CONCLUSIONS: Patient adherence to UE rehabilitation presents many challenges. Patients view themselves as laypersons and seek the knowledge of a dedicated therapist who they trust to spend time with them to understand what they value as important and clarify their injury, collaboratively make goals, and explain the intervention to get them in essence, back into life, in the minimal required time. When categorized according to the World Health Organization\u27s multidimensional adherence model, domains identified in this model include social and economic, health care team and system, condition-related, therapy-related, and patient-related dimensions. Assessing factors identified to improve efficiency and effectiveness of clinical management can enhance patient adherence

Discharge Identity of Medullary Inspiratory Neurons is Altered during Repetitive Fictive Cough

This study investigated the stability of the discharge identity of inspiratory decrementing (I-Dec) and augmenting (I-Aug) neurons in the caudal (cVRC) and rostral (rVRC) ventral respiratory column during repetitive fictive cough in the cat. Inspiratory neurons in the cVRC (n = 23) and rVRC (n = 17) were recorded with microelectrodes. Fictive cough was elicited by mechanical stimulation of the intrathoracic trachea. Approximately 43% (10 of 23) of I-Dec neurons shifted to an augmenting discharge pattern during the first cough cycle (C1). By the second cough cycle (C2), half of these returned to a decrementing pattern. Approximately 94% (16 of 17) of I-Aug neurons retained an augmenting pattern during C1 of a multi-cough response episode. Phrenic burst amplitude and inspiratory duration increased during C1, but decreased with each subsequent cough in a series of repetitive coughs. As a step in evaluating the model-driven hypothesis that VRC I-Dec neurons contribute to the augmentation of inspiratory drive during cough via inhibition of VRC tonic expiratory neurons that inhibit premotor inspiratory neurons, cross-correlation analysis was used to assess relationships of tonic expiratory cells with simultaneously recorded inspiratory neurons. Our results suggest that reconfiguration of inspiratory-related sub-networks of the respiratory pattern generator occurs on a cycle-by-cycle basis during repetitive coughing

An Integrated Process for Co-Developing and Implementing Written and Computable Clinical Practice Guidelines

The goal of this article is to describe an integrated parallel process for the co-development of written and computable clinical practice guidelines (CPGs) to accelerate adoption and increase the impact of guideline recommendations in clinical practice. From February 2018 through December 2021, interdisciplinary work groups were formed after an initial Kaizen event and using expert consensus and available literature, produced a 12-phase integrated process (IP). The IP includes activities, resources, and iterative feedback loops for developing, implementing, disseminating, communicating, and evaluating CPGs. The IP incorporates guideline standards and informatics practices and clarifies how informaticians, implementers, health communicators, evaluators, and clinicians can help guideline developers throughout the development and implementation cycle to effectively co-develop written and computable guidelines. More efficient processes are essential to create actionable CPGs, disseminate and communicate recommendations to clinical end users, and evaluate CPG performance. Pilot testing is underway to determine how this IP expedites the implementation of CPGs into clinical practice and improves guideline uptake and health outcomes

The state of the Martian climate

60°N was +2.0°C, relative to the 1981–2010 average value (Fig. 5.1). This marks a new high for the record. The average annual surface air temperature (SAT) anomaly for 2016 for land stations north of starting in 1900, and is a significant increase over the previous highest value of +1.2°C, which was observed in 2007, 2011, and 2015. Average global annual temperatures also showed record values in 2015 and 2016. Currently, the Arctic is warming at more than twice the rate of lower latitudes

Lassa Fever in Post-Conflict Sierra Leone

Background: Lassa fever (LF), an often-fatal hemorrhagic disease caused by Lassa virus (LASV), is a major public health threat in West Africa. When the violent civil conflict in Sierra Leone (1991 to 2002) ended, an international consortium assisted in restoration of the LF program at Kenema Government Hospital (KGH) in an area with the world's highest incidence of the disease. Methodology/Principal Findings Clinical and laboratory records of patients presenting to the KGH Lassa Ward in the post-conflict period were organized electronically. Recombinant antigen-based LF immunoassays were used to assess LASV antigenemia and LASV-specific antibodies in patients who met criteria for suspected LF. KGH has been reestablished as a center for LF treatment and research, with over 500 suspected cases now presenting yearly. Higher case fatality rates (CFRs) in LF patients were observed compared to studies conducted prior to the civil conflict. Different criteria for defining LF stages and differences in sensitivity of assays likely account for these differences. The highest incidence of LF in Sierra Leone was observed during the dry season. LF cases were observed in ten of Sierra Leone's thirteen districts, with numerous cases from outside the traditional endemic zone. Deaths in patients presenting with LASV antigenemia were skewed towards individuals less than 29 years of age. Women self-reporting as pregnant were significantly overrepresented among LASV antigenemic patients. The CFR of ribavirin-treated patients presenting early in acute infection was lower than in untreated subjects. Conclusions/Significance: Lassa fever remains a major public health threat in Sierra Leone. Outreach activities should expand because LF may be more widespread in Sierra Leone than previously recognized. Enhanced case finding to ensure rapid diagnosis and treatment is imperative to reduce mortality. Even with ribavirin treatment, there was a high rate of fatalities underscoring the need to develop more effective and/or supplemental treatments for LF