The influence of the philosophy of pragmatism on social studies methodology.

Thesis (M.Ed.)--Boston University Misnumbered Pages 43, 4

The Use of Epidural Corticosteroids for Cervical Radiculopathy: An Interlaminar Versus Transforaminal Approach

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The Frequency and Content of Discussions About Alcohol Use in Primary Care and Application of the Chief Medical Officer’s Low-Risk Drinking Guidelines: A Cross-Sectional Survey of General Practitioners and Practice Nurses in the UK

ABSTRACT Aims: To examine how often General Practitioners (GPs) and Practice Nurses (PNs) working in primary care discuss alcohol with patients, what factors prompt discussions, how they approach patient discussions, and whether the Chief Medical Officer’s (CMO’s) revised low-risk drinking guidelines are appropriately advised. Methods: Cross-sectional survey with GPs and PNs working in primary care in the UK, conducted January-March 2017 (n=2,020). A vignette exercise examined what factors would prompt a discussion about alcohol, whether they would discuss before or after a patient reported exceeded the revised CMO guidelines (14 units per week), and whether the CMO’s drinking guidelines were appropriately advised. For all patients, participants were asked how often they discussed alcohol and how they approached the discussion (e.g. used screening tool). Results: The most common prompts to discuss alcohol in the vignette exercise were physical cues (44.7% of participants) or alcohol-related symptoms (23.8%). Most practitioners (70.1%) said they would wait until a patient was exceeding CMO guidelines before instigating discussion. Two-fifths (38.1%) appropriately advised the CMO guidelines in the vignette exercise, with PNs less likely to do so than GPs (OR=0.77, p=0.03). Less than half (44.7%) reportedly asked about alcohol always/often with all patients, with PNs more likely to ask always/often than GPs (OR=2.22, p<0.001). Almost three-quarters said they would enquire by asking about units (70.3%), compared to using screening tools. Conclusion: Further research is required to identify mechanisms to increase the frequency of discussions about alcohol and appropriate recommendation of the CMO drinking guidelines to patients.This research was supported by funding from Cancer Research UK. JMB is supported by the Medical Research Council (MRC) (Grant MC_UU_12015/4)

Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial: Design and rationale.

BACKGROUND: Acute decompensated heart failure (ADHF) is a leading cause of hospitalization in older persons in the United States. Reduced physical function and frailty are major determinants of adverse outcomes in older patients with hospitalized ADHF. However, these are not addressed by current heart failure (HF) management strategies and there has been little study of exercise training in older, frail HF patients with recent ADHF. HYPOTHESIS: Targeting physical frailty with a multi-domain structured physical rehabilitation intervention will improve physical function and reduce adverse outcomes among older patients experiencing a HF hospitalization. STUDY DESIGN: REHAB-HF is a multi-center clinical trial in which 360 patients ≥60 years hospitalized with ADHF will be randomized either to a novel 12-week multi-domain physical rehabilitation intervention or to attention control. The goal of the intervention is to improve balance, mobility, strength and endurance utilizing reproducible, targeted exercises administered by a multi-disciplinary team with specific milestones for progression. The primary study aim is to assess the efficacy of the REHAB-HF intervention on physical function measured by total Short Physical Performance Battery score. The secondary outcome is 6-month all-cause rehospitalization. Additional outcome measures include quality of life and costs. CONCLUSIONS: REHAB-HF is the first randomized trial of a physical function intervention in older patients with hospitalized ADHF designed to determine if addressing deficits in balance, mobility, strength and endurance improves physical function and reduces rehospitalizations. It will address key evidence gaps concerning the role of physical rehabilitation in the care of older patients, those with ADHF, frailty, and multiple comorbidities

A quasi-experimental evaluation of dried blood spot testing through community pharmacies in the Tayside region of Scotland

Objective Comparison of uptake of dried blood spot testing (DBST) for hepatitis C virus (HCV) infection between community pharmacies and established services.&nbsp; Design Quantitative evaluation of a service development with qualitative process evaluation undertaken in parallel.&nbsp; Setting Six pharmacies from 36 community pharmacies within Dundee City, a large urban settlement with high levels of socioeconomic deprivation.&nbsp; Participants Patients in receipt of opioid substitution therapy (OST) not tested for HCV within 12 months. The 6 pharmacies provided OST for approximately 363 patients from a cohort of 1385 patients within Dundee City.&nbsp; Intervention Provision of DBST by pharmacists.&nbsp; Main outcome measure Receipt of DBST between January and December 2014.&nbsp; Results 43 of 143 service users with no record of testing from the 6 community pharmacies accepted DBST. Of 561 from the remaining 1022 service users with no record of testing, 75 were tested for HCV (30% vs 13%). The OR for increased uptake of testing within the 6 pharmacies was 2.25 (95% CI 1.48 to 3.41, Z statistic=3.81, p=&lt;0.0001) compared with other services. The DBST taken by the pharmacies provided 12 patients with a reactive test. The process evaluation identified key themes important to staff and recipients of the service. A logic model was constructed.&nbsp; Limitations Non-experimental service evaluation performed in community pharmacies records service activity in one location across a single time period.&nbsp; Interpretation Some evidence that DBST from community pharmacies may be feasible. Service users received the service positively. Staff reported that DBST was straightforward and achievable

Mandeville, Bernard

Peer reviewe

Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain

Abstract Background Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain patients. Methods Here we describe the process and outcomes of a project to operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Non-Cancer Pain into a computerized decision support system (DSS) to encourage good opioid prescribing practices during primary care visits. We based the DSS on the existing ATHENA-DSS. We used an iterative process of design, testing, and revision of the DSS by a diverse team including guideline authors, medical informatics experts, clinical content experts, and end-users to convert the written clinical practice guideline into a computable algorithm to generate patient-specific recommendations for care based upon existing information in the electronic medical record (EMR), and a set of clinical tools. Results The iterative revision process identified numerous and varied problems with the initially designed system despite diverse expert participation in the design process. The process of operationalizing the guideline identified areas in which the guideline was vague, left decisions to clinical judgment, or required clarification of detail to insure safe clinical implementation. The revisions led to workable solutions to problems, defined the limits of the DSS and its utility in clinical practice, improved integration into clinical workflow, and improved the clarity and accuracy of system recommendations and tools. Conclusions Use of this iterative process led to development of a multifunctional DSS that met the approval of the clinical practice guideline authors, content experts, and clinicians involved in testing. The process and experiences described provide a model for development of other DSSs that translate written guidelines into actionable, real-time clinical recommendations.http://deepblue.lib.umich.edu/bitstream/2027.42/78267/1/1748-5908-5-26.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/2/1748-5908-5-26.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/3/1748-5908-5-26-S3.TIFFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/4/1748-5908-5-26-S2.TIFFhttp://deepblue.lib.umich.edu/bitstream/2027.42/78267/5/1748-5908-5-26-S1.TIFFPeer Reviewe

Multiyear monitoring (2007-2013) of flat-tailed horned lizards (Phrynosoma mcallii)

Monitoring programs for species of conservation concern are notoriously flawed. Notably, many monitoring programs do not establish trigger points or a level of decline in population size that will result in management action. Here we report on the monitoring program for the Flat-tailed Horned Lizard (Phrynosoma mcallii) that has been established across its range throughout the United States by the Flat-tailed Horned Lizard Interagency Coordinating Committee (FTHL ICC). Impor- tantly, we examine whether a trigger point of 30% decline was detected in these populations. Between 2007 and 2013, we detected 955 P. mcallii on 2,714 occupancy surveys and captured 715 individuals on 1,861 demographic surveys. Occupancy surveys have demonstrated that the species occurs through- out the management areas and occupancy estimates range from 0.25–0.89. Demographic surveys have demonstrated that population trends over time are correlated across all management areas; however, they are probably driven by factors at smaller geographic scales. During the study no population decline \u3e 30% was detected after accounting for natural and stochastic fluctuations. Continued mon- itoring is called for to gain a greater understanding of what is driving the trends in populations both range-wide and at the scale of management areas