Comprehensive Assessment of the Activity Level of the ICF Using Both Capacity and Performance Measures: A Case Report.

Individuals with neurologic conditions seek physical therapy services to improve mobility in their daily lives. While clinicians commonly track activity capacity, measurement of activity performance in daily life is an emerging yet unstandardized practice within routine clinical physical therapy. The purpose of this case report is to (1) provide an example of the structure, clinical reasoning, and implementation of both activity capacity and activity performance level assessments across an episode of outpatient physical therapy and (2) to describe how objective activity performance in daily life tracking supported the physical therapy intervention and education plan. A 42-year-old woman presented to outpatient neurologic physical therapy with a rare autoimmune-mediated disorder with primary goals of independently caring for her youngest child and grandchild, walking without limitations in the home and community, participating in exercise, and returning to work due to deconditioning and dizziness. The patient participated in 12 visits across a span of 4.5 months targeting performance in daily life (steps per day), aerobic conditioning, and vestibular habituation. Activity capacity measurement served as a standardized assessment of what the patient was able to do in the clinic, and activity performance in daily life tracking via a Samsung wrist worn consumer-grade device provided a quantitative assessment of real-world daily stepping activity. Tracking of activity performance in daily life was an essential component of physical therapy management that provided an objective quantification of daily stepping activity to identify barriers and facilitators to increasing daily performance in an individual with a medical diagnosis of Susac syndrome.

Alterations in Aerobic Exercise Performance and Gait Economy Following High-Intensity Dynamic Stepping Training in Persons With Subacute Stroke.

BACKGROUND AND PURPOSE: Impairments in metabolic capacity and economy (O2cost) are hallmark characteristics of locomotor dysfunction following stroke. High-intensity (aerobic) training has been shown to improve peak oxygen consumption in this population, with fewer reports of changes in O2cost. However, particularly in persons with subacute stroke, inconsistent gains in walking function are observed with minimal associations with gains in metabolic parameters. The purpose of this study was to evaluate changes in aerobic exercise performance in participants with subacute stroke following high-intensity variable stepping training as compared with conventional therapy. METHODS: A secondary analysis was performed on data from a randomized controlled trial comparing high-intensity training with conventional interventions, and from the pilot study that formed the basis for the randomized controlled trial. Participants 1 to 6 months poststroke received 40 or fewer sessions of high-intensity variable stepping training (n = 21) or conventional interventions (n = 12). Assessments were performed at baseline (BSL), posttraining, and 2- to 3-month follow-up and included changes in submaximal (Equation is included in full-text article.)O2 ((Equation is included in full-text article.)O2submax) and O2cost at fastest possible treadmill speeds and peak speeds at BSL testing. RESULTS: Significant improvements were observed in (Equation is included in full-text article.)O2submax with less consistent improvements in O2cost, although individual responses varied substantially. Combined changes in both (Equation is included in full-text article.)O2submax and (Equation is included in full-text article.)O2 at matched peak BSL speeds revealed stronger correlations to improvements in walking function as compared with either measure alone. DISCUSSION AND CONCLUSIONS: High-intensity stepping training may elicit significant improvements in (Equation is included in full-text article.)O2submax, whereas changes in both peak capacity and economy better reflect gains in walking function. Providing high-intensity training to improve locomotor and aerobic exercise performance may increase the efficiency of rehabilitation sessions.Video Abstract available for more insights from the authors (see Supplemental Digital Content, http://links.lww.com/JNPT/A142).

Chromosome microarray proficiency testing and analysis of quality metric data trends through an external quality assessment program for Australasian laboratories.

Chromosome microarrays are an essential tool for investigation of copy number changes in children with congenital anomalies and intellectual deficit. Attempts to standardise microarray testing have focused on establishing technical and clinical quality criteria, however external quality assessment programs are still needed. We report on a microarray proficiency testing program for Australasian laboratories. Quality metrics evaluated included analytical accuracy, result interpretation, report completeness, and laboratory performance data: sample numbers, success and abnormality rate and reporting times. Between 2009 and 2014 nine samples were dispatched with variable results for analytical accuracy (30-100%), correct interpretation (32-96%), and report completeness (30-92%). Laboratory performance data (2007-2014) showed an overall mean success rate of 99.2% and abnormality rate of 23.6%. Reporting times decreased from >90 days to <30 days for normal results and from >102 days to <35 days for abnormal results. Data trends showed a positive correlation with improvement for all these quality metrics, however only 'report completeness' and reporting times reached statistical significance. Whether the overall improvement in laboratory performance was due to participation in this program, or from accumulated laboratory experience over time, is not clear. Either way, the outcome is likely to assist referring clinicians and improve patient care.

Quantitative Assessment of Parametric Uncertainty in Northern Hemisphere PAH Concentrations.

We quantitatively examine the relative importance of uncertainty in emissions and physicochemical properties (including reaction rate constants) to Northern Hemisphere (NH) and Arctic polycyclic aromatic hydrocarbon (PAH) concentrations, using a computationally efficient numerical uncertainty technique applied to the global-scale chemical transport model GEOS-Chem. Using polynomial chaos (PC) methods, we propagate uncertainties in physicochemical properties and emissions for the PAHs benzo[a]pyrene, pyrene and phenanthrene to simulated spatially resolved concentration uncertainties. We find that the leading contributors to parametric uncertainty in simulated concentrations are the black carbon-air partition coefficient and oxidation rate constant for benzo[a]pyrene, and the oxidation rate constants for phenanthrene and pyrene. NH geometric average concentrations are more sensitive to uncertainty in the atmospheric lifetime than to emissions rate. We use the PC expansions and measurement data to constrain parameter uncertainty distributions to observations. This narrows a priori parameter uncertainty distributions for phenanthrene and pyrene, and leads to higher values for OH oxidation rate constants and lower values for European PHE emission rates.

The impact of continuing professional development versus traditional continuing pharmacy education on pharmacy practice.

BACKGROUND: The Institute of Medicine states that the new vision for continuing education (CE) for health-care professionals will be based on continuing professional development (CPD); however, information on the utility of CPD is lacking. OBJECTIVE: To assess the effect of CPD, compared with that of traditional continuing pharmacy education (CPE), on perceptions of factors related to pharmacy practice. METHODS: This 10-month, nonblinded, randomized controlled study recruited licensed pharmacists employed at a health maintenance organization (HMO). After completing a basic CPD course, participants were randomized to the intervention or control group. The control group was instructed to continue with traditional CPE. The intervention group participants completed 3 CPD workshops and were instructed to utilize the CPD approach for their learning needs. At baseline and follow-up, all participants completed a study questionnaire on perceptions of their pharmacy practices. The outcome measures were comparisons on follow-up and changes from baseline to follow-up in responses to the study questionnaire. RESULTS: One hundred pharmacists were enrolled. The intervention (n = 44, 7 lost to follow-up) and control (n = 47, 2 lost to follow-up) groups were similar at baseline. At follow-up, a higher percentage of intervention participants reported that they had better interactions with other health-care providers (always/frequently 32% vs 6%, respectively) and initiated practice/work changes (always/frequently 21% vs 0%, respectively) (both p < 0.01) as a result of their education activities. Compared with control participants at follow-up, intervention participants reported that their education activities improved patient care changes (46% vs 23%), professional knowledge (34% vs 6%), skills (48% vs 17%), and attitudes/values (43% to 11%) (all p < 0.05). However, intervention participants reported more often that time was a barrier to completing education activities (75% vs 32%, p < 0.001). CONCLUSIONS: Pharmacists who participated in CPD reported more often that their perceptions of various aspects of their pharmacy practice improved as a result of their education activities compared with pharmacists who participated in traditional CPE.

Assessment of postanesthesia short-term quality of life: a pilot study.

Quality of life is a major focus for researchers conducting studies on patient satisfaction and anesthetic outcomes. Efficacy and safety drive anesthesia providers' determination of the type of anesthesia administered, yet little consideration is given to postanesthesia quality of life from the patient's perspective. We hypothesized that patient-defined, postanesthesia short-term quality-of-life issues are significant factors to consider when selecting anesthesia. This study developed and piloted a tool to assess the impact of specific anesthetic techniques on postanesthesia short-term quality-of-life issues. In phase I, a panel of content experts developed a tool to measure postanesthesia short-term quality of life. In phase II, 50 same-day surgery subjects undergoing spinal or general anesthesia completed the tool on day 1 and on days 5, 6, or 7 postoperatively. The RAND 36-Item Health Survey was administered simultaneously to assess concurrent validity. Phase I resulted in a 40-item tool covering 3 domains. The Phase II pilot supported internal consistency and construct validity for the majority of tool items, although the tool did not correlate strongly with the RAND questionnaire. To confirm the dimensions used in the tool, we recommend a multicenter study permitting the application of factor analysis.

Frequency with which surgeons undertake pancreaticoduodenectomy determines length of stay, hospital charges, and in-hospital mortality.

Others have suggested that in certain technically challenging operations, outcome and experience are related. Because pancreaticoduodenectomy is a technically complex procedure, this study was undertaken to evaluate mortality, length of hospital stay, and hospital charges when compared to volume of experience. The database of the State of Florida Agency for Health Care Administration was queried for pancreaticoduodenectomies undertaken during a recent 33-month period. Length of stay, hospital charges, and in-hospital mortality were stratified by the frequency of pancreaticoduodenectomy. A total of 282 surgeons performed 698 pancreaticoduodenectomies over 33 months. Eighty-nine percent of surgeons performed one pancreaticoduodenectomy per year or less and accounted for 52% of the procedures. Overall mortality rate was 5.1%. Average hospital charges were $72,171.64. The more frequently pancreaticoduodenectomy was undertaken, the shorter the hospital stay (P = 0.025, regression analysis) and the lower the hospital charges (P = 0.008, regression analysis) and in-hospital mortality (P = 0.036, log likelihood ratio test). Surgeons who undertake pancreaticoduodenectomy more frequently have patients with shorter hospital stays, lower hospital charges, and lower in-hospital mortality rates, independent of hospital volume. Variations exist among surgeons and among different areas of the state. Data regarding cost and mortality are available for use in programs of cost and quality improvement.

Economic rationalism and the cost efficiency of hospital chaplaincy: an Australian study.

Health care reform is also occurring in Australia and effects hospital chaplaincy programs. "Economic rationalism" is the philosophic foundation of this effort and its contrast with the values inherit in hospital chaplaincy are highlighted. Selected research results from the Australian system are described and the authors offer a perspective on the cost efficiency of hospital chaplaincy.

Colorectal trauma: primary repair or anastomosis with intracolonic bypass vs. ostomy.

This prospective, randomized, controlled study was undertaken to compare primary repair or anastomosis with intracolonic bypass vs. ostomy in severe colon and intraperitoneal rectal injury. Patients were randomized at surgery following confirmation of injury. Data collected included demographics, mechanism and location of injury, trauma score (TS), injury severity score (ISS), penetrating abdominal trauma index (PATI), complications, length of hospital stay, and hospital charges. Twenty-two patients were studied: 11 with intracolonic bypass and 11 controls. The experimental and control groups were statistically similar in demographics and mechanism of injury, severity of injury (TS = 13.8 vs. 12.8; ISS = 27.5 vs. 24.2; PATI = 40.5 vs. 35.0), and complication rate. Length of stay (12.2 days vs. 20.7 days) and charges $27,885 vs. $53,599) tended to be greater in controls, and the comparison did not include subsequent colostomy closure. This study supports intracolonic bypass as a safe alternative to ostomy in severe colon and intraperitoneal rectal trauma.

Physician review improves hospital DRG reimbursement in injury.

This was a prospective study of all DRG reimbursed trauma patients discharged during an 11-month period. Initial DRGs were assigned by hospital coding specialists (HCS). A surgeon (SURG) subsequently reviewed each chart and assigned DRGs to maximize reimbursement. The data for 244 patients were: age = 36.5 years, Trauma Score (TS) = 13.8, Injury Severity Score (ISS) = 16.9, and length of stay (LOS) = 10.3 days. Total charges for the 244 patients were $4,261,208 with an initial HCS projected reimbursement of $1,687,963. The SURG review resulted in a total projected reimbursement of $1,956,476, an increase of $268,513 in revenue (p less than 0.001). Charges correlated strongly with LOS and ISS. The HCS-coded and SURG-coded reimbursements also correlated positively with LOS and ISS, but to a lesser extent. The SURG review of DRG assignment improved hospital reimbursement for the injured patients. However, this reimbursement fell well below hospital billings.

Safety and efficacy of laparoscopic cholecystectomy. A prospective analysis of 100 initial patients.

Laparoscopic cholecystectomy quickly emerged as an alternative to open cholecystectomy. However its safety, efficacy, and morbidity have yet to be fully evaluated. During the first 6 months of 1990, we performed 100 consecutive laparoscopic cholecystectomies with no deaths and a morbidity rate of 8% (8 of 100 patients; 4 major, 4 minor). There were 81 women and 19 men, with a mean age of 46.1 years (range, 17 to 84 years). All patients had a preoperative history consistent with symptomatic biliary tract disease, and most had proved gallstones by sonography. This included four patients with acute cholecystitis. Mean operating time improved significantly from month 1 to month 6 (122 +/- 45.4 minutes versus 78.5 +/- 30 minutes, respectively), indicating a rapid learning curve. Mean hospital stay was 27.6 hours, reflecting a policy of overnight stay. Postoperative narcotic requirements were limited to oral or no medications in more than 70% of patients. A regular diet was tolerated by 83% of the patients by the morning following the procedure. Median time of return to full activity was 12.8 +/- 6.8 days after operation. In addition analysis of the hospital costs of these 100 cases demonstrates a modest cost advantage over standard open cholecystectomy (n = 58) (mean, $3620.25 +/- $1005.00 versus $4251.76 +/- $988.00). There was one minor bile duct injury requiring laparotomy and t-tube insertion, two postoperative bile collections, and one clinical diagnosis of a retained stone that passed spontaneously. Four patients required conversion to open cholecystectomy because of technical difficulties with the dissection. Although there is a significant learning curve, laparoscopic cholecystectomy is a safe and effective procedure that can be performed with minimal risk. Laparoscopic cholecystectomy should be performed by surgeons who are trained in biliary surgery and knowledgeable in biliary anatomy, and, as with all operations, it should be performed with meticulous attention to technique.

Assessment of anastomotic blood supply by Doppler ultrasound in operations upon the colon.

Doppler ultrasound was used to determine whether or not colonic anastomoses have sufficient blood supply for healing to occur. Experimental anastomoses placed at, or 1 centimeter from, the last audible arterial signal healed; those placed 2 or 3 centimeters distally had a high incidence of disruption. Results were statistically significant by chi-square analysis, p less than 0.05. Clinical parameters of intestinal viability would not have predicted anastomotic failure.