Activity Monitoring in Parkinson Disease: A Qualitative Study of Implementation Determinants.

BACKGROUND AND PURPOSE: There is interest in incorporating digital health technology in routine practice. We integrate multiple stakeholder perspectives to describe implementation determinants (barriers and facilitators) regarding digital health technology use to facilitate exercise behavior change for people with Parkinson disease in outpatient physical therapy. METHODS: The purposeful sample included people with Parkinson disease (n = 13), outpatient physical therapists (n = 12), and advanced technology stakeholders including researchers and reimbursement specialists (n = 13). Semistructured interviews were used to elicit implementation determinants related to using digital health technology for activity monitoring and exercise behavior change. Deductive codes based on the Consolidated Framework for Implementation Research were used to describe implementation determinants. RESULTS: Key implementation determinants were similar across stakeholder groups. Essential characteristics of digital health technology included design quality and packaging, adaptability, complexity, and cost. Implementation of digital health technology by physical therapists and people with Parkinson disease was influenced by their knowledge, attitudes, and varied confidence levels in using digital health technology. Inner setting organizational determinants included available resources and access to knowledge/information. Process determinants included device interoperability with medical record systems and workflow integration. Outer setting barriers included lack of external policies, regulations, and collaboration with device companies. DISCUSSION AND CONCLUSIONS: Future implementation interventions should address key determinants, including required processes for how and when physical therapists instruct people with Parkinson disease on digital health technology, organizational readiness, workflow integration, and characteristics of physical therapists and people with Parkinson disease who may have ingrained beliefs regarding their ability and willingness to use digital health technology. Although site-specific barriers should be addressed, digital health technology knowledge translation tools tailored to individuals with varied confidence levels may be generalizable across clinics.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content available at: http://links.lww.com/JNPT/A436 ).

Complex Nasal Reconstruction in a Wide-awake Ambulatory Setting: A Study of Efficacy and Perioperative Patient Experience.

The use of local anesthesia in nasal surgery has gained popularity as a cost-effective and safe alternative. With the potential benefit of reconstruction without using general anesthesia, the goal of the study was to evaluate the patient-reported experience in addition to surgical outcomes and perioperative complications. Methods: A mixed-methods study was completed with retrospective chart review and patient-reported outcome questionnaire. The primary outcome measures were demographics, oncologic and surgical details, and postoperative complications. Secondary outcome measures were aesthetic outcomes and procedure tolerance, which were gathered from the FACE-Q questionnaire. Results: Of the 22 patients who met inclusion criteria, nine patients (41%) had forehead flaps performed and 13 patients (59%) had multilayer reconstruction with local flaps and cartilage grafts. The average number of surgeries performed, including revisions, was 2.3 ± 0.2. The overall complication rate for reconstructions and revisions was 20%, most of these were minor complications. The overall subjective rating of patient's appearance was excellent with an average score of 83.9 (± 17.3) out of 100. There was minimal appearance distress as a product of the surgery with an average score of 84.9 (±18.8). On a scale of one to five, patients reported an average of 4.3 for convenience, 3.8 for efficiency of setup and procedure, and 3.4 out of 5 for comfortability with having an operation performed on their face wide awake. Conclusion: Our study demonstrated that complex nasal reconstruction performed under local anesthetic in a minor procedure setting is a feasible and safe option with good patient-reported outcomes.

Occupational Therapy for People with Early Parkinson's Disease: A Retrospective Program Evaluation.

Purpose: Clinical practice guidelines establish that occupational therapy (OT) services are indicated for people with early Parkinson's disease (PD). However, OT is uncommon compared to other rehabilitation services. This study describes the development and evaluation of a proactive, consultative OT program for people with early PD as a part of an integrated care approach. Materials and Methods: The program was developed by an occupational therapist adapting practice guidelines for people with early PD. Retrospective program evaluation occurred at an outpatient rehabilitation clinic. The consultative OT program for early PD includes a 90-minute evaluation with instruction in self-management techniques, individually tailored exercises, and follow-up recommendations. The program was evaluated with the RE-AIM framework. Postprogram semistructured interviews provided patient-reported program effectiveness and satisfaction. Results: In 2018, 23 individuals used OT out of 77 people with early PD who attended the proactive rehabilitation program. Most individuals (n = 16, 69.6%) were within Hoehn and Yahr stages 1-2 and were seen within 3 years of PD diagnosis. Participants presented with deficits in hand strength (60.0 ± 23.4 pounds) and dexterity (right hand 30.0 ± 8.0 seconds) and reported complaints about basic and/or instrumental activities of daily living (n = 15, 65.2%). Semistructured interviews (n = 16) revealed that most individuals (75%) reported high satisfaction. Of the 10 who recalled a home exercise program, 60% reported continued adherence. Consultative OT was delivered with fidelity in 22/23 individuals (96%). After one year, only two occupational therapists at one clinic had adopted the program, and the program is maintained in the organization. Conclusion: Occupational therapists reached people in the early stages of PD when a specific program was tailored to evaluate and target their specific needs. Motor activity deficits noted in individuals with early PD support future scaling and sustainability efforts of OT within this population. Quality improvement suggestions are discussed for future implementation and clinical trials.

Squamoid Eccrine Ductal Carcinoma: Treatment and Outcomes.

BACKGROUND: Squamoid eccrine ductal carcinoma (SEDC) represents a subtype of eccrine carcinomas that are diagnostically challenging for both clinicians and dermatopathologists. OBJECTIVE: To provide an updated review of SEDC and examine patient outcomes with different treatment modalities. METHODS: A review of Ovid MEDLINE was performed to review the English language medical literature of SEDC. RESULTS: A comprehensive review of clinical presentation, histologic findings, rates of lymphovascular and metastatic disease, treatment modalities and recurrence rates are reviewed. LIMITATIONS: There is a limitation on available data because of the rare incidence. CONCLUSIONS: SEDC is a rare adnexal neoplasm with a relatively high rate of local recurrence, lymphovascular invasion, perineural invasion, and metastases. Clinicians should be aware of this entity as close follow-up is essential to detect recurrence and metastatic disease. Mohs micrographic surgery seems to result in superior patient outcomes.

Sustainment of proactive physical therapy for individuals with early-stage Parkinson's disease: a quality improvement study over 4 years.

BACKGROUND: Implementation science frameworks aided the development of a new, evidence-based clinical physical therapy program. The purpose of this report is to describe the process of sustaining a clinical program in practice for over 4 years. We present a framework for integrating tools for sustainability with the Knowledge-to-Action model in the context of a proactive physical therapy (PAPT) program for individuals with early-stage Parkinson's disease. METHODS: Sustainability of implementation strategies was addressed using the Dynamic Sustainability Framework and sustainability assessment tools. Repeated retrospective medical record reviews and phone interviews were used to evaluate the reach and adoption of the PAPT over 4 years. Characteristics of those who engaged with PAPT, implementation fidelity, and clinical effectiveness were assessed for year 1 and year 3. Sustainability was measured using RE-AIM, NHS Sustainability Model, and Clinical Sustainability Assessment Tool. RESULTS: Reach increased from 28 to 110 total patients per year and spread occurred from one to three sites. PAPT user age, sex, Hoehn and Yahr rating, time since diagnosis, and type of insurance were similar in year 1 and year 3 (p > 0.05). The program sustained its effect to help participants increase or maintain self-reported exercise (Y1, 95%; Y3, 100%). However, upon evaluation PAPT users in year 3 had longer time since symptom onset and worse UPDRS motor scores compared to the PAPT users in year 1 (p < 0.05). All sites sustained the core intervention components, with sustainability scores of 71/100 (± 9.9) on the NHS Sustainability Model and 6.1/7 (± 0.9) on the Clinical Sustainability Assessment Tool. CONCLUSIONS: Integrating multiple sustainability models and assessments supported continued effectiveness, spread, and sustainment of PAPT for 4 years. Effective planning, anticipating common healthcare changes, and addressing sustainability determinants early in program implementation were essential aspects of long-term success.

Frameworks for Parkinson's Disease Rehabilitation Addressing When, What, and How.

PURPOSE OF REVIEW: This review summarizes the evidence on rehabilitation for people with Parkinson's disease, including when to refer, what rehabilitation professionals should address, and how to deliver rehabilitation care. RECENT FINDINGS: Clinical practice guidelines support physical therapy, occupational therapy, and speech-language pathology for Parkinson's disease. However, integrating guidelines into practice may be difficult. Implementation studies take into account patient and clinician perspectives. Synthesizing guidelines with implementation research can improve local delivery. There is moderate to strong evidence supporting physical therapy, occupational therapy, and speech-language pathology soon after diagnosis and in response to functional deficits. We propose a framework of three pathways for rehabilitation care: (1) consultative proactive rehabilitation soon after diagnosis for assessment, treatment of early deficits, and promotion meaningful activities; (2) restorative rehabilitation to promote functional improvements; and (3) skilled maintenance rehabilitation for long-term monitoring of exercise, meaningful activities, safety, contractures, skin integrity, positioning, swallowing, and communication.

Approach to treatment of cicatricial ectropion: a systematic review and meta-analysis comparing surgical and minimally invasive options.

Cicatricial ectropion can involve the skin, subcutaneous tissue, muscle, and septum to result in chronic tearing and keratopathy. Surgery involving the orbital rim or eyelid is a common cause. Minimally invasive techniques may provide alternative options for correction, but the comparative benefit to surgery is unknown. To compare the efficacy of surgical and minimally invasive minimally invasive treatment options for cicatricial ectropion. A comprehensive literature search of Medline, EMBASE, and the Cochrane Library published from 1960 to August 2019 was performed for studies that described any treatment of cicatricial ectropion. 1391 studies were found, of which 31 had extractable data for 299 patients. Pooling of outcome data occurred for the primary and secondary outcomes. The complete and partial response rates to treatment (primary outcomes) as well as the recurrence rate and physician global assessment of cosmesis (secondary outcomes) were analyzed. Surgical correction resulted in complete correction in 79% of patients compared to 63% of hyaluronic acid treated patients. Hyaluronic acid injection had a better aesthetic outcome, but a higher recurrence rate overall. Hyaluronic acid filler with a high G' along with delayed dissolution trended toward a lower recurrence rate. Other minimally invasive treatments had little data. The literature found was limited to mostly single-center, observational studies. Hyaluronic acid may be a viable alternative for cicatricial ectropion in those patients who cannot undergo surgery. Further prospective studies are required to routinely recommend minimally invasive techniques.

Using Implementation Frameworks to Provide Proactive Physical Therapy for People With Parkinson Disease: Case Report.

BACKGROUND AND PURPOSE: European clinical practice guidelines recommend physical therapy for people with Parkinson disease (PD) soon after diagnosis to provide education, physical activity advice, and individualized interventions when needed. However, therapy is frequently not used until after gait and balance problems occur. The purpose of this administrative case study is to present the application of a proactive physical therapy (PAPT) approach at 1 rehabilitation center using implementation frameworks to support the (1) implementation process, (2) determinants of implementation success, and (3) implementation evaluation. CASE DESCRIPTION: The PAPT program targeted people with PD before the onset of significant mobility dysfunction. It was initiated in 1 outpatient neurological rehabilitation center. The program used shared decision-making to promote long-term maintenance of independent exercise. The Knowledge-to-Action Framework was used by champions to plan implementation processes. Implementation barriers were addressed using the Consolidated Framework for Implementation Research. The program was evaluated using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework with mixed methods. OUTCOMES: In the program's first year, 38 people were referred, 28 were evaluated, and 20 participated in the 6-month program evaluation. Following PAPT, the number of participants reporting regular participation in aerobic, strengthening, and flexibility exercise approximately doubled, while those engaging in balance activities increased from 1 to 8. They reported a median of 140 minutes of aerobic exercise per week. Implementation barriers included location, insurance coverage, and difficulty scheduling long-term follow-up visits. Participants reported physical and emotional benefits of the program. DISCUSSION: Implementation frameworks assisted with the implementation and evaluation of a PAPT delivery model that helped people with PD to increase and maintain independent exercise participation.

Aesthetic Dermatologic Surgery Training in Canadian Residency Programs.

BACKGROUND:: The public and other physicians expect dermatologists to be experts on aesthetic dermatology services. In Canada, current challenges may limit residents from achieving competency in aesthetic dermatology during their training. This may adversely affect patient safety, create medicolegal risks, and deter graduates from offering aesthetic procedures. OBJECTIVES:: The objective of this article is to characterize the curriculum, hands-on learning opportunities, and perceptions of aesthetic dermatologic training in Canadian dermatology residency training programs. METHODS:: An online survey of faculty and residents within Canadian dermatology residency programs was performed. The main outcome measures were the hours of formal aesthetic dermatology teaching, the frequency of hands-on dermatology resident training with injectables and devices, and comparing faculty and resident perspectives regarding resident aesthetic dermatology training. RESULTS:: Thirty-six faculty members (40%) and 47 residents (34%) responded to the survey. Lasers, fillers, neuromodulators, and mole removal were most commonly taught in the 10 hours or fewer of formal instruction. Residents commonly observed rather than performed procedures. High dissatisfaction among residents was reported with the quality and quantity of aesthetic dermatology training. Faculty and resident respondents supported increasing aesthetic dermatology education, and approximately 70% of residents plan to offer aesthetic services. Discounted pricing or resident-led clinics were felt to be ways to increase resident hands-on experience. CONCLUSIONS:: The standardization of core competencies in aesthetic dermatologic procedures is essential to ensure patient safety and practitioner competence. At present, formal aesthetic dermatology training in residency may be insufficient for hands-on training. The majority of dermatology faculty and resident respondents support increasing aesthetic dermatology training.

Affective reactivity to cry sounds predicts young women's reactivity and behavior in a simulated caregiving task.

Different populations of adults (experienced vs. inexperienced caregivers, men vs. women, abusive vs. nonabusive parents, etc.) have been reported to differ in their affective reactions to the sounds of infant crying. These differences are thought to impact caregiving behavior and, in some instances, to affect long-term outcomes for infants. There can be great intra-group variation, however, even when group differences are significant; modeling developmental process will require a finer grained approach. We have undertaken a pair of studies intended to validate the Negative Affect Scale (NA) from the PANAS as a measure of individuals' affective reactivity to cry sounds. In Study 1, 306 young women who were not yet mothers listened either to infant crying or to birdsong. The results supported the NA as a measure of reactivity to crying. In Study 2, a new sample of 301 young women listened to crying in a screening task; a group of "high reactors" (n = 21) and a group of "low reactors" (n = 22) then participated in a simulated caregiving situation. Individuals' affective reactivity to the caregiving simulation mirrored their affective reactivity in the screening task, and rates and overall organization of caregiving behavior differed between the groups. Changes in negative affect, then, appear to be both a result of infant crying and a determinant of some aspects of caregiving behavior. Further studies will extend these laboratory results to real infants and their caregivers, and further validate the NA as a measure of individual differences in reactivity to cry sounds.

Photodistributed sarcoidosis: a case report and approach to management.

Sarcoidosis is an idiopathic disease, characterized by non-caseating granulomas in multiple organs/tissues. Cutaneous involvement occurs in approximately one-quarter of patients with a wide variety of presenting morphologies. This case report describes a case of photodistributed sarcoidosis, a rare cutaneous variant, with systemic involvement. A 42-year-old man presented with a history of a pruritic, rash with photoexacerbated annular plaques along with arthralgias and bone pain. Compared to previous reports of photodistributed sarcoidosis, our case presented with annular plaques rather than papules, and there was no prior exposure to ionizing radiation. He was treated successfully with prednisone and hydroxychloroquine. It is important to include sarcoidosis in the differential of photodistributed dermatoses.

The Accuracy of Measurements of Nonmelanoma Skin Cancer Sizes Referred to the Mohs Surgery Clinic.

BACKGROUND: Tumour size is a crucial factor used to plan Mohs procedures. Larger tumours require more time and stages of excision, and they need to be triaged as a higher priority. Therefore, the accuracy in measurement of tumour size is critical. OBJECTIVE: To investigate if there is a significant difference in accuracy of tumour measurements in referrals between dermatologists and nondermatologists. METHODS AND MATERIALS: Performed a retrospective study of 180 referrals from dermatologists and 47 referrals from nondermatologists to The Ottawa Hospital Riverside Mohs Surgery Clinic. We compared the mean size difference of tumours between the preoperative size and the size reported on referral. RESULTS: Average reported size upon referral of nonmelanoma skin cancer (NMSC) was 1.39 cm2 and 1.35 cm2 from dermatologists and nondermatologists, respectively ( P = .881). During the preoperative assessment, tumour sizes were 0.65 cm2 and 1.45 cm2 larger than that reported from dermatologists and nondermatologists, respectively ( P < .05). The duration between referral and preoperative assessment was 3 to 4 months for both groups ( P = .26). CONCLUSION: The accuracy of tumour measurements between dermatologists and nondermatologists differed significantly, as nondermatologists underestimated the size of NMSCs. This directly affects triaging patients and operative management in Mohs surgery. To compensate for size underestimation, early and prompt referrals of NMSCs from nondermatologists are warranted.

Injectable Diphenhydramine Used as Anaesthetic for Wide Local Excision With Flap Closure.

BACKGROUND: Lidocaine-allergic patients pose a challenge for cutaneous surgical procedures. We present a case of a successful wide local excision with flap closures on the face using topical tetracaine followed by infiltration with 1% diphenhydramine. CASE SUMMARY: An 84-year-old woman, with a lidocaine intolerance, presented to the Mohs surgery clinic for wide local excision of a nodular basal cell carcinoma on her right medial cheek. Successful anaesthesia was achieved using topical 4% tetracaine followed by intradermal and subcutaneous injection of 1% diphenhydramine. Haemostasis was achieved with both electrocautery and suture ligation. Sliding rotation flaps were closed using both deep and superficial sutures. Other than some mild discomfort and temporary hyperemia on injection, the patient tolerated the procedure well with no long-term complications. CONCLUSION: Diphenhydramine is a very useful alternative in lidocaine-intolerant patients for cutaneous procedures including punch and shave biopsies, cyst removals, small elliptical excisions, and wide local excisions.

Robotic resistance/assistance training improves locomotor function in individuals poststroke: a randomized controlled study.

OBJECTIVE: To determine whether providing a controlled resistance versus assistance to the paretic leg at the ankle during treadmill training will improve walking function in individuals poststroke. DESIGN: Repeated assessment of the same patients with parallel design and randomized controlled study between 2 groups. SETTING: Research units of rehabilitation hospitals. PARTICIPANTS: Patients (N=30) with chronic stroke. INTERVENTION: Subjects were stratified based on self-selected walking speed and were randomly assigned to the resistance or assistance training group. For the resistance group, a controlled resistance load was applied to the paretic leg at the ankle to resist leg swing during treadmill walking. For the assistance group, a load that assists swing was applied. MAIN OUTCOME MEASURES: Primary outcome measures were walking speed and 6-minute walking distance. Secondary measures included clinical assessments of balance, muscle tone, and quality of life. Outcome measures were evaluated before and after 6 weeks of training and at 8 weeks' follow-up, and compared within group and between the 2 groups. RESULTS: After 6 weeks of robotic training, walking speed significantly increased for both groups, with no significant differences in walking speed gains observed between the 2 groups. In addition, 6-minute walking distance and balance significantly improved for the assistance group but not for the resistance group. CONCLUSIONS: Applying a controlled resistance or an assistance load to the paretic leg during treadmill training may induce improvements in walking speed in individuals poststroke. Resistance training was not superior to assistance training in improving locomotor function in individuals poststroke.

Tumor detection after inflammation or fibrosis on Mohs levels.

BACKGROUND: In Mohs micrographic surgery (MMS), many surgeons will take an additional level based solely on the presence of inflammation or fibrosis. OBJECTIVE: To determine the frequency with which this occurs and parameters predicting tumor discovery on successive levels. MATERIALS AND METHODS: A retrospective study was performed on 22,419 cases treated with MMS between 1996 and May 2011. The surgeons reviewed their own slides in cases where tumor was detected after a level was taken for inflammation or fibrosis. RESULTS: An additional level was taken for inflammation or fibrosis in 6,233 cases (27.8%), resulting in tumor detection in 121 cases (1.9%). Additional levels were taken for inflammation in 66.6% and fibrosis in 63.0%. Fourteen collision tumors were identified and were preceded by inflammation in 71% of cases. DISCUSSION: Factors that may predict the presence of tumor at subsequent levels include eccentrically placed or shallow first levels failing to completely encompass a previous surgical scar. The presence of dense inflammation may signal an adjacent collision tumor. CONCLUSION: Taking an additional Mohs level when dense inflammation or fibrosis is present may be warranted to ensure complete tumor removal.

Observation of amounts of movement practice provided during stroke rehabilitation.

UNLABELLED: Lang CE, MacDonald JR, Reisman DS, Boyd L, Jacobson Kimberley T, Schindler-Ivens SM, Hornby TG, Ross SA, Scheets PL. Observation of amounts of movement practice provided during stroke rehabilitation. OBJECTIVE: To investigate how much movement practice occurred during stroke rehabilitation, and what factors might influence doses of practice provided. DESIGN: Observational survey of stroke therapy sessions. SETTING: Seven inpatient and outpatient rehabilitation sites. PARTICIPANTS: We observed a convenience sample of 312 physical and occupational therapy sessions for people with stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We recorded numbers of repetitions in specific movement categories and data on potential modifying factors (patient age, side affected, time since stroke, FIM item scores, years of therapist experience). Descriptive statistics were used to characterize amounts of practice. Correlation and regression analyses were used to determine whether potential factors were related to the amount of practice in the 2 important categories of upper extremity functional movements and gait steps. RESULTS: Practice of task-specific, functional upper extremity movements occurred in 51% of the sessions that addressed upper limb rehabilitation, and the average number of repetitions/session was 32 (95% confidence interval [CI]=20-44). Practice of gait occurred in 84% of sessions that addressed lower limb rehabilitation and the average number of gait steps/session was 357 (95% CI=296-418). None of the potential factors listed accounted for significant variance in the amount of practice in either of these 2 categories. CONCLUSIONS: The amount of practice provided during poststroke rehabilitation is small compared with animal models. It is possible that current doses of task-specific practice during rehabilitation are not adequate to drive the neural reorganization needed to promote function poststroke optimally.