Measuring impact of a quality improvement initiative on glaucoma clinic flow using an automated real-time locating system.

BACKGROUND: Lean methodology helps maximize value by reducing waste, first by defining what value and waste are in a system. In ophthalmology clinics, value is determined by the number of patients flowing through the clinic for a given time. We aimed to increase value using a lean-methodology guided policy change, then assessed its impact on clinic flow using an automated radiofrequency identification (RFID) based real-time locating system (RTLS). METHODS: A total of 6813 clinical visits occurred at a single academic institution's outpatient glaucoma clinic between January 5, 2018 to July 3, 2018. Over that period, 1589 patients comprising 1972 (29%) of visits were enrolled, with 1031 clinical visits occurring before and 941 visits after a policy change. The original policy was to refract all patients that improved with pinhole testing. The policy change was not to refract patients with a visual acuity ≥20/30 unless a specific request was made by the patient. Pre-post analysis of an automated time-motion study was conducted for the data collected 3 months before and 3 months after the policy change occurred on March 30, 2018. Changes to process and wait times were summarized using descriptive statistics and fitted to linear mixed regression models adjusting for appointment type, clinic volume, and daily clinic trends. RESULTS: One thousand nine hundred twenty-three visits with 1588 patients were included in the analysis. Mean [SD] age was 65.9 [14.7] years and 892 [56.2%] were women. After the policy change, technician process time decreased by 2.9 min (p < 0.0001) while daily clinical patient volume increased from 51.9 ± 16.8 patients to 58.4 ± 17.4 patients (p < 0.038). No significant difference was found in total wait time (p = 0.18) or total visit time (p = 0.83). CONCLUSIONS: Real-time locating systems are effective at capturing clinical flow data and assessing clinical practice change initiatives. The refraction policy change was associated with reduced technician process time and overall the clinic was able to care for 7 more patients per day without significantly increasing patient wait time.

Methylphenidate improves executive functions in patients with traumatic brain injuries: a feasibility trial via the idiographic approach.

BACKGROUND: Road traffic accidents are known to be the main cause of traumatic brain injury (TBI). TBI is also a leading cause of death and disability. This study, by means of the idiographic approach (single-case experimental designs using multiple-baseline designs), has examined whether methylphenidate (MPH - trade name Ritalin) had a differential effect on cognitive measures among patients with TBI with the sequel of acute and chronic post-concussion syndromes. The effect on gender was also explored. METHODS: In comparison with healthy controls, patients with TBI (acute and chronic) and accompanying mild cognitive impairment (MCI) were screened for their integrity of executive functioning. Twenty-four patients exhibiting executive dysfunction (ED) were then instituted with the pharmacological intervention methylphenidate (MPH). The methylphenidate was administered using an uncontrolled, open label design. RESULTS: The administration of methylphenidate impacted ED in the TBI group but had no effect on mood. Attenuation of ED was more apparent in the chronic phases of TBI. The effect on gender was not statistically significant with regard to the observed changes. CONCLUSIONS: To our knowledge, this is the first feasibility trial from the Arabian Gulf to report the performance of a TBI population with mild cognitive impairment according to the IQCODE Arabic version. This investigation confirms anecdotal observations of methylphenidate having the potential to attenuate cognitive impairment; particularly those functions that are critically involved in the integrity of executive functioning. The present feasibility trial should be followed by nomothetic studies such as those that adhere to the protocol of the randomized controlled trial. This evidence-based research is the foundation for intervention and future resource allocation by policy- or public health decision-makers.

Medication Adherence and Liquid Level Tracking System for Healthcare Provider Feedback.

A common problem for healthcare providers is accurately tracking patients' adherence to medication and providing real-time feedback on the management of their medication regimen. This is a particular problem for eye drop medications, as the current commercially available monitors focus on measuring adherence to pills, and not to eye drops. This work presents an intelligent bottle sleeve that slides onto a prescription eye drop medication bottle. The intelligent sleeve is capable of detecting eye drop use, measuring fluid level, and sending use information to a healthcare team to facilitate intervention. The electronics embedded into the sleeve measure fluid level, dropper orientation, the state of the dropper top (on/off), and rates of angular motion during an application. The sleeve was tested with ten patients (age ≥65) and successfully identified and timestamped 94% of use events. On-board processing enabled event detection and the measurement of fluid levels at a 0.4 mL resolution. These data were communicated to the healthcare team using Bluetooth and Wi-Fi in real-time, enabling rapid feedback to the subject. The healthcare team can therefore monitor a log of medication use behavior to make informed decisions on treatment or support for the patient.

Dissection of complex adult traits in a mouse synthetic population.

Finding the causative genetic variations that underlie complex adult traits is a significant experimental challenge. The unbiased search strategy of genome-wide association (GWAS) has been used extensively in recent human population studies. These efforts, however, typically find only a minor fraction of the genetic loci that are predicted to affect variation. As an experimental model for the analysis of adult polygenic traits, we measured a mouse population for multiple phenotypes and conducted a genome-wide search for effector loci. Complex adult phenotypes, related to body size and bone structure, were measured as component phenotypes, and each subphenotype was associated with a genomic spectrum of candidate effector loci. The strategy successfully detected several loci for the phenotypes, at genome-wide significance, using a single, modest-sized population (N = 505). The effector loci each explain 2%-10% of the measured trait variation and, taken together, the loci can account for over 25% of a trait's total population variation. A replicate population (N = 378) was used to confirm initially observed loci for one trait (femur length), and, when the two groups were merged, the combined population demonstrated increased power to detect loci. In contrast to human population studies, our mouse genome-wide searches find loci that individually explain a larger fraction of the observed variation. Also, the additive effects of our detected mouse loci more closely match the predicted genetic component of variation. The genetic loci discovered are logical candidates for components of the genetic networks having evolutionary conservation with human biology.

Association of COMT val158met and DRD2 G>T genetic polymorphisms with individual differences in motor learning and performance in female young adults.

Individuals learn new skills at different rates. Given the involvement of corticostriatal pathways in some types of learning, variations in dopaminergic transmission may contribute to these individual differences. Genetic polymorphisms of the catechol-O-methyltransferase (COMT) enzyme and dopamine receptor D2 (DRD2) genes partially determine cortical and striatal dopamine availability, respectively. Individuals who are homozygous for the COMT methionine (met) allele show reduced cortical COMT enzymatic activity, resulting in increased dopamine levels in the prefrontal cortex as opposed to individuals who are carriers of the valine (val) allele. DRD2 G-allele homozygotes benefit from a higher striatal dopamine level compared with T-allele carriers. We hypothesized that individuals who are homozygous for COMT met and DRD2 G alleles would show higher rates of motor learning. Seventy-two young healthy females (20 ± 1.9 yr) performed a sensorimotor adaptation task and a motor sequence learning task. A nonparametric mixed model ANOVA revealed that the COMT val-val group demonstrated poorer performance in the sequence learning task compared with the met-met group and showed a learning deficit in the visuomotor adaptation task compared with both met-met and val-met groups. The DRD2 TT group showed poorer performance in the sequence learning task compared with the GT group, but there was no difference between DRD2 genotype groups in adaptation rate. Although these results did not entirely come out as one might predict based on the known contribution of corticostriatal pathways to motor sequence learning, they support the role of genetic polymorphisms of COMT val158met (rs4680) and DRD2 G>T (rs 1076560) in explaining individual differences in motor performance and motor learning, dependent on task type.

Effect of body mass index on stroke rehabilitation.

OBJECTIVE: To investigate the association between body mass index (BMI) and the functional progress of patients with stroke, admitted to a rehabilitation hospital. DESIGN: A retrospective cohort study. SETTING: A freestanding university rehabilitation hospital stroke unit. PARTICIPANTS: All patients (N=819) admitted to the stroke unit of a rehabilitation hospital during the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The primary study outcome measure was the FIM efficiency of patients by BMI category. RESULTS: For the 819 patients admitted during the observation period, BMI was compared with FIM score changes per day (FIM efficiency). After adjusting for age and sex, the FIM efficiency differed by BMI. The underweight group had the lowest FIM efficiency, followed by the obese and normal-weight subgroups. The overweight group had the highest FIM efficiency (P=.05) when compared with the obese subgroup. CONCLUSIONS: Among patients admitted to an acute rehabilitation hospital for stroke rehabilitation, overweight patients had better functional progress than did patients in the other weight categories.

The Frequency of Neuropsychiatric Sequelae After Traumatic Brain Injury in the Global South: A systematic review and meta-analysis.

This study aimed to assess the prevalence of neuropsychiatric sequelae following traumatic brain injury (TBI) among the Western Asian, South Asian and African regions of the global south. All studies on psychiatric disturbances or cognitive impairment following TBI conducted (until August 2021) in the 83 countries that constitute the aforementioned regions were reviewed; 6 databases were selected for the literature search. After evaluating the articles using the Joanna Briggs Institute guidelines, the random effects model was used to estimate the prevalence of depression, anxiety, post-traumatic stress disorder (PTSD), TBI-related sleep disturbance (TBI-SD), obsessive-compulsive disorder (OCD) and cognitive impairment. Of 56 non-duplicated studies identified in the initial search, 27 were eligible for systematic review and 23 for meta-analysis. The pooled prevalence of depression in 1,882 samples was 35.35%, that of anxiety in 1,211 samples was 28.64%, that of PTSD in 426 samples was 19.94%, that of OCD in 313 samples was 19.48%, that of TBI-SD in 562 samples was 26.67% and that of cognitive impairment in 941 samples was 49.10%. To date, this is the first critical review to examine the spectrum of post-TBI neuropsychiatric sequelae in the specified regions. Although existing studies lack homogeneous data due to variability in the diagnostic tools and outcome measures utilised, the reported prevalence rates are significant and comparable to statistics from the global north.

Types and sociodemographic correlates of complementary and alternative medicine (CAM) use among people with epilepsy in Oman.

Nonpharmacological treatment strategies that originate from sociocultural teachings and are beyond the scope of allopathic medicine are commonly used among people with epilepsy (PWE) in many parts of the world. The present study explored the types and sociodemographic correlates of complementary and alternative medicine (CAM) use among PWE in Oman among attendees of a neurological unit at a tertiary care center. Data on the types of CAM were gathered from telephone interviews. The relevant demographic and clinical characteristics of the participants were obtained from electronic medical records. Of the total of 101 participants, 73.3% were CAM users. The majority of these participants have not disclosed their CAM use to their allopathic health-care providers. The most common types of CAM reported were those falling under the 'mind-body' type (incantations and fumigation) and biologically based (herbal concoctions) or a combination of them. Compared to non-CAM users, a significant and greater proportion of CAM users attributed the etiology of their illness to nonbiomedical factors such as 'evil eyes' (P=0.04). The multivariate logistic regression model indicated that the use of CAM was highly associated with age of <30years (OR=3.09; 95% CI: 1.10, 5.46), unemployment (OR=2.04; 95% CI: 1.15, 6.39), having basic school education (OR=2.21; 95% CI: 0.83, 5.18), low family income (OR=1.52; 95% CI: 0.91, 2.11), and the presence of hypersalivation (OR=2.20; 95% CI: 1.01, 4.39). Further studies are needed to harmonize these two healing practices. On the whole, this study indicates that among attendees of tertiary care utilization, CAM is common among PWE in Oman. The most utilized type of CAM falls under the umbrella of mind-body practice.

Ancestral heterogeneity in a biethnic stroke population.

To test for and characterize heterogeneity in ancestral contributions to individuals among a population of Mexican American (MA) and non-Hispanic white (NHW) stroke/transient ischemic attack (TIA) cases, data from a community-based stroke surveillance study in south Texas were used. Strokes/TIA cases were identified (2004-2006) with a random sample asked to provide blood. Race-ethnicity was self-reported. Thirty-three ancestry informative markers were genotyped and individual genetic admixture estimated using maximum likelihood methods. Three hypotheses were tested for each MA using likelihood ratio tests: (1) H(0) : µi = 0 (100% Native American), (2) H(0) : µi = 1.00 (100% European), (3) H(0) : µi = 0.59 (average European). Among 154 self-identified MAs, estimated European ancestry varied from 0.26 to 0.98, with an average of 0.59 (SE = 0.014). We rejected hypothesis 1 for every MA and rejected hypothesis 2 for all but two MAs. We rejected hypothesis 3 for 40 MAs (20 < 59%, 20 > 59%). Among 84 self-identified NHWs, the estimated fraction of European ancestry ranged from 0.83 to 1.0, with an average of 0.97 (SE = 0.014). Self-identified MAs, and to a lesser extent NHWs, from an established bi-ethnic community were heterogeneous with respect to genetic admixture. Researchers should not use simple race-ethnic categories as proxies for homogeneous genetic populations when conducting gene mapping and disease association studies in multi-ethnic populations.

Post-Stroke Psychiatric and Cognitive Symptoms in West Asia, South Asia and Africa: A Systematic Review and Meta-Analysis.

Recent research has shown that the prevalence of stroke incidents and the number of survivors in developing countries surpass those from developed countries. This study aimed to enumerate the prevalence of post-stroke psychiatric and cognitive symptoms among stroke survivors from West and South Asia and Africa through a systematic review and meta-analysis. Data from each country was systematically acquired from five major databases (PsycINFO, Web of Science, Scopus, PubMed/Medline, and Google Scholar (for any missing articles and grey literature)). Meta-analytic techniques were then used to estimate the prevalence of various post-stoke psychiatric and cognitive symptoms. A total of 36 articles were accrued from 11 countries, of which 25 were evaluated as part of the meta-analysis. The pooled prevalence of post-stroke depression as per the Hospital Anxiety and Depression Scale (HADS), Hamilton Depression Rating Scale, Patient Health Questionnaire, Schedules for Clinical Assessment in Neuropsychiatry (SCAN), Geriatric Depression Scale, and the Montgomery-Asberg Depression Rating Scale ranged from 28.00 to 50.24%. Pooled prevalence of post-stroke anxiety based on the HADS and SCAN was 44.19% and 10.96%, respectively. The pooled prevalence of post-stroke cognitive impairment as per the Mini-Mental Status Examination was 16.76%. This present review has suggested that both psychiatric and cognitive symptoms are common among stroke survivors. Concerted efforts are needed to institute robust studies using culturally sensitive measures to contemplate mechanisms that address the unmet needs of this vulnerable population.

The Effect of Body Mass Index on Pulmonary Related Debility Rehabilitation.

BACKGROUND: Obesity is a known factor for the development of abnormal respiratory physiology. However, several studies have found that obesity does not hinder functional recovery in patients hospitalized for postacute care following a stroke or cardiovascular event. This study was designed to determine the effect of overweight and obesity on patients with acute pulmonary disease, hospitalized in an inpatient rehabilitation facility (IRF). OBJECTIVE: To investigate the impact of body mass index (BMI) on indices of function, specifically, the functional independence measure (FIM) among patients with pulmonary related debility admitted to a rehabilitation hospital. DESIGN: Retrospective cohort study. SETTING: Pulmonary unit in an acute freestanding rehabilitation hospital. PATIENTS: All patients admitted to an IRF with a diagnosis of pulmonary related debility over a 6-year period. METHODS: The data used in the study included the patient height and weight (measured on admission) and FIM (scored on admission and discharge). MAIN OUTCOME MEASURES: The primary study outcome measure was the change in FIM per day by the patients' BMI category. RESULTS: For the 381 patients admitted during the observation period, BMI was compared with FIM score changes per day (FIM efficiency). After adjusting for age and sex, the FIM efficiency only slightly differed by BMI, failing to reach statistical significance. However, age did significantly influence the outcome (P = .05). CONCLUSION: This study demonstrates that among a large group of patients with a pulmonary related debility, there was no statistically significant correlation between BMI and FIM efficiency. The overweight patients were similar in progression to those who were underweight, normal weight, and obese. However, this study found that increased age adversely affected the outcome of rehabilitation. LEVEL OF EVIDENCE: III.

Peritonitis secondary to the migration of a trans-hepatically-placed percutaneous endoscopic gastrostomy tube: a case report.

Enteral feeding by percutaneous endoscopic gastrostomy (PEG) tube has become a commonly used method of supplying nutrition to patients with impaired neurologic function. In this case study we describe a 33-year-old brain-injured patient whose PEG insertion was complicated by inadvertent malpositioning and subsequent infection. After initially being placed through the liver, the PEG tube migrated out several weeks later, resulting in intra-abdominal feed collection, peri-hepatic abscess formation, and peritonitis. Physicians should be aware of the potential for inadvertent positioning through other viscera, and consider optimal methods of intraprocedural monitoring and post placement verification.

Effect of amantadine on the sleep-wake cycle of an inpatient with brain injury.

BACKGROUND: A previous study suggested that the routine use of drugs intended to improve attention and arousal, such as methylphenidate, tend to have a variable but not significant effect on sleep-wake cycles. As amantadine is a frequently employed drug in brain injury rehabilitation, with known effects on fatigue and motor processing speed, this study examined the effect of amantadine on the sleep-wake behaviour of patients with brain injury undergoing rehabilitation. METHOD: This was a naturalistic observation using an observationally defined sleep-wake distribution for a total of 43 subjects with brain injury. Identified patients were observed for a full 24 hours a day 2 weeks before and 2 weeks after starting amantadine. Some of these patients (n = 12) had been administered amantadine on clinical grounds and, for this paper, served as the experimental group, while the drug naive (n = 31) served as a control. Three outcome measures were operationalized: hours of sleep in 24 hours, hours of sleep during daytime and hours of sleep during night-time. RESULT: The average number of hours of sleep during a 24-hour period was not significantly different for the two cohorts. Similarly hours of sleep during daytime and hours of sleep during night-time were on average the same for the two groups. The data suggest that amantadine has no direct bearing on sleep/wake cycles using these parameters. CONCLUSION: This study fails to demonstrate that the use of amantadine on an inpatient brain injury population will affect sleep/wake quantity.

The Effect of Body Mass Index on the Functional Prognosis of Traumatic Brain Injury Patients.

BACKGROUND: Although many studies have demonstrated that obesity is correlated with an increased risk of chronic disease, some have reported a paradox by which those in the higher weight categories actually recover better during hospitalization. This study was designed to determine whether this obesity paradox is also reflected in the recovery of patients with traumatic brain injury (TBI) undergoing care in a rehabilitation hospital. OBJECTIVE: To investigate the association between body mass index (BMI) and the functional progress of patients with TBI, admitted to a rehabilitation hospital. DESIGN: Retrospective cohort study. METHODS: The study included all patients admitted to the brain injury unit of a rehabilitation hospital over a 6-year period. The data used for this study included patient height and weight (measured on admission) and functional independence measurements (scored on admission and discharge). MAIN OUTCOME MEASURES: Functional independence measure (FIM) change per day, BMI category. RESULTS: For the 444 patients admitted, the overall FIM efficiency did not differ significantly by BMI (P = .93). After adjusting for age and gender, overweight and obese patients had the lowest FIM efficiency (1.04 for both groups), followed by the underweight and normal weight groups (1.11 and 1.26, respectively). CONCLUSION: This study demonstrated that higher BMI was not significantly correlated with the rate of functional recovery among patients admitted to a rehabilitation hospital for TBI. LEVEL OF EVIDENCE: III.

The Effect of Body Mass Index on Functional Outcome of Patients With Knee Replacement.

OBJECTIVE: To investigate the effects of body mass index (BMI) on the rehabilitation process in patients with a recent knee replacement. DESIGN: This retrospective cohort study included all patients admitted to a rehabilitation hospital, with a recent diagnosis of knee replacement and available hospital admission data including height and weight, between 2014 and 2017. SETTING: Rehabilitation hospital. PARTICIPANTS: Study participants included patients who had undergone knee replacement surgery (N=742), with available BMI data. INTERVENTIONS: None. MAIN OUTCOME MEASURES: FIM scores, including FIM change per day (FIM efficiency) by BMI category. RESULTS: The chart review identified 742 patients who had undergone knee replacement surgery, with available BMI data. The identified patients ranged in age from 58 to 85 years, with a mean age of 70 years. Of the patients included in the study, 24 were male, 49 were female, 73 were within the normal weight class, 180 in the overweight class, 189 in the obese class I, 143 in the obese class II, and 157 patients were classified as obese class III. The mean FIM efficiency was highest in the obese class II category (3.96). In a multivariate analysis after controlling for age, obese classes II and III had significantly better FIM efficiency. CONCLUSION: This study did not demonstrate that obesity adversely affects the rate of recovery during hospitalization after knee replacement surgery.

Mammalian mRNA splice-isoform selection is tightly controlled.

Post-transcriptional RNA processing is an important regulatory control mechanism for determining the phenotype of eukaryotic cells. The processing of a transcribed RNA species into alternative splice isoforms yields products that can perform different functions. Each type of cell in a multi-cellular organism is presumed to actively control the relative quantities of alternative splice isoforms. In this study, the alternatively spliced isoforms of five mRNA transcription units were examined by quantitative reverse transcription-PCR amplification. We show that interindividual variation in splice-isoform selection is very highly constrained when measured in a large population of genetically diverse mice (i.e., full siblings; N = 150). Remarkably, splice-isoform ratios are among the most invariant phenotypes measured in this population and are confirmed in a second, genetically distinct population. In addition, the patterns of splice-isoform selection show tissue-specific and age-related changes. We propose that splice-isoform selection is exceptionally robust to genetic and environmental variability and may provide a control point for cellular homeostasis. As a consequence, splice-isoform ratios may be useful as a practical quantitative measure of the physiological status of cells and tissues.

Quantitative trait loci modulate vertebral morphology and mechanical properties in a population of 18-month-old genetically heterogeneous mice.

The aim of this study was to examine effects of polymorphic genes on vertebral bone morphology and mechanical properties. Genotypes from 525 18-month-old female mice were compared to geometric traits obtained from micro-computed tomography and mechanical properties from compression testing. Genetic markers were associated with traits on at least 13 different chromosomes, demonstrating the complexity of genetic control over vertebral form, function and aging.

A comparison of functional outcomes in hypoxia and traumatic brain injury: a pilot study.

We present our experience with 30 patients on functional outcomes of patients with anoxic brain injury (ABI, n=15) due to cardiac etiologies from freestanding inpatient rehabilitation hospital. A convenience sample of patient with traumatic brain injury (TBI, n=15) with similar demographic characteristic to ABI was used for comparison on indices of activity of daily living, cognition, mobility as well as other indices of functional prognosis such as hospital length of stay, cost and discharge predisposition. No statistical significant differences were found between the two groups on the presently employed outcome measures. This investigation supports the positive impact of inpatient rehabilitation for individuals with hypoxia of cardiac etiology. Future research comparing outcomes of ABI to TBI with larger, controlled trials is warranted.

Human iris three-dimensional imaging at micron resolution by a micro-plenoptic camera.

A micro-plenoptic system was designed to capture the three-dimensional (3D) topography of the anterior iris surface by simple single-shot imaging. Within a depth-of-field of 2.4 mm, depth resolution of 10 µm can be achieved with accuracy (systematic errors) and precision (random errors) below 20%. We demonstrated the application of our micro-plenoptic imaging system on two healthy irides, an iris with naevi, and an iris with melanoma. The ridges and folds, with height differences of 10~80 µm, on the healthy irides can be effectively captured. The front surface on the iris naevi was flat, and the iris melanoma was 50 ± 10 µm higher than the surrounding iris. The micro-plenoptic imaging system has great potential to be utilized for iris disease diagnosis and continuing, simple monitoring.

Three-locus and four-locus QTL interactions influence mouse insulin-like growth factor-I.

A previous analysis of serum insulin-like growth factor I (IGF-I) levels in a mouse population (n = 961) derived from a cross of (BALB/cJ x C57BL/6J) F1 females and (C3H/HeJ x DBA/2J) F1 males documented quantitative trait loci (QTL) on chromosomes 1, 10, and 17. We employed a newly developed, random walk-based method to search for three- and four-way allelic combinations that might influence IGF-I levels through nonadditive (conditional or epistatic) interactions among 185 genotyped biallelic loci and with significance defined by experiment-wide permutation (P < 0.05). We documented a three-locus combination in which an epistatic interaction between QTL on paternal-derived chromosomes 5 and 18 had an opposite effect on the phenotype based on the allele inherited at a third locus on maternal-derived chromosome 17. The search also revealed three four-locus combinations that influence IGF-I levels through nonadditive genetic interactions. In two cases, the four-allele combinations were associated with animals having high levels of IGF-I, and, in the third case, a four-allele combination was associated with animals having low IGF-I levels. The multiple-locus genome scan algorithm revealed new IGF-I QTL on chromosomes 2, 4, 5, 7, 8, and 12 that had not been detected in the single-locus genome search and showed that levels of this hormone can be regulated by complex, nonadditive interactions among multiple loci. The analysis method can detect multilocus interactions in a genome scan experiment and may provide new ways to explore the genetic architecture of complex physiological phenotypes.