Starting and Sustaining an Extracorporeal Membrane Oxygenation Program.

The use of extracorporeal membrane oxygenation (ECMO) is growing rapidly in all patient populations, especially adults for both acute lung or heart failure. ECMO is a complex, high risk, resource-intense, expensive modality that requires appropriate planning, training, and management for successful outcomes. This article provides an optimal approach and the basic framework for initiating a new ECMO program, which can be tailored to meet local needs. Setting up a new ECMO program and sustaining it requires institutional commitment, physician champions, multidisciplinary team involvement, ongoing training, and education of the ECMO team personnel and a robust quality assurance program to minimize complications and improve outcomes.

Laboratory assessment of multiple myeloma.

Laboratory testing plays an essential role in the diagnosis and management of patients with multiple myeloma. A variety of chemistry and molecular assays are routinely used to monitor patient progress, response to treatment and relapse. Here, we have reviewed current literature and core guidelines on the details of laboratory testing in myeloma-related investigations. This includes the use and value of protein electrophoresis, serum free light chain and cytogenetic testing. Furthermore, we discuss other traditional chemistry assays essential to myeloma investigation, and potential interferences that may arise due to the disease nature of myeloma, that is, the presence of a monoclonal immunoglobulin. Finally, we discuss the importance of communication in protein electrophoresis results, where laboratorians are required to relate clinically relevant myeloma-relevant information to the ordering physician on the background of a complex pattern of serum or urine proteins. Laboratory testing in myeloma-related investigation relies on several traditional chemistry assays. However, we anticipate new tests and technologies to become available in the future with improved analytical sensitivity, as well as improved clinical sensitivity in identifying patients who are at high risk of progression to multiple myeloma.

Candidate recommendations for protein electrophoresis reporting from the Canadian Society of Clinical Chemists Monoclonal Gammopathy Working Group.

Protein electrophoresis is commonly used as an aid in the diagnosis of monoclonal gammopathies and is performed in many laboratories in Canada and throughout the world. However, unlike many other diagnostic tests, there is limited guidance for standardization and neither guidance nor specific recommendations for clinical reporting of serum (SPE) or urine (UPE) protein electrophoresis and immunotyping available in the literature. Therefore, a Canadian effort was undertaken to recommend standards that cover all aspects of clinical reporting with an ultimate goal towards reporting standardization. The Canadian Society of Clinical Chemists (CSCC) Monoclonal Gammopathy Interest Group (MGIG), which is composed of CSCC members with an interest in protein electrophoresis, has formed a Monoclonal Gammopathy Working Group (MGWG) to take initial steps towards standardization of SPE, UPE and immunotyping. Candidate standardization recommendations were developed, discussed and voted upon by the MGWG. Candidate recommendations that achieved 90% agreement are presented as consensus recommendations. Recommendations that did not achieve 90% consensus remain candidate recommendations and are presented with accompanying MGWG discussion. Eleven consensus recommendations along with candidate recommendations for nomenclature, protein fraction reporting, test utilization, interference handling and interpretive reporting options are presented.

A framework for developing rural academic general practices: a qualitative case study in rural Victoria.

INTRODUCTION: There is increasing pressure for Australian rural general practices to engage in educational delivery as a means of addressing workforce issues and accommodating substantial increases in learners. For practices that have now developed a strong focus on education, there is the challenge to complement this by engaging in research activity. This study develops a rural academic general practice framework to assist rural practices in developing both comprehensive educational activity and a strong research focus thus moving towards functioning as mature academic units. METHODS: A case study research design was used with the unit of analysis at the level of the rural general practice. Purposively sampled practices were recruited and individual interviews conducted with staff (supervisors, practice managers, nurses), learners (medical students, interns and registrars) and patients. Three practices hosted 'multi-level learners', two practices hosted one learner group and one had no learners. Forty-four individual interviews were conducted with staff, learners and patients. Audio recordings were transcribed for thematic analysis. After initial inductive coding, deductive analysis was undertaken with reference to recent literature and the expertise of the research team resulting in the rural academic general practice framework. RESULTS: Three key themes emerged with embedded subthemes. For the first theme, organisational considerations, subthemes were values/vision/culture, patient population and clinical services, staffing, physical infrastructure/equipment, funding streams and governance. For the second theme, educational considerations, subthemes were processes, clinical supervision, educational networks and learner presence. Third, for research considerations, there were the subthemes of attitude to research and research activity. The framework maps the development of a rural academic practice across these themes in four progressive stages: beginning, emerging, consolidating and established. CONCLUSIONS: The data enabled a framework to be constructed to map rural general practice activity with respect to activity characteristic of an academic general practice. The framework offers guidance to practices seeking to transition towards becoming a mature academic practice. The framework also offers guidance to educational institutions and funding bodies to support the development of academic activity in rural general practices. The strengths and limitations of the study design are outlined.

Dynamic biological changes in metabolic disease biomarkers in childhood and adolescence: A CALIPER study of healthy community children.

BACKGROUND: Understanding age- and sex-specific biological changes in metabolic disease biomarkers is essential for their appropriate utilization in management of children with inborn errors of metabolism (IEM). The CALIPER program aimed to establish pediatric reference values in healthy community children for common metabolic biomarkers and determine the effects of key covariates including age and sex across the pediatric age. METHODS: A cohort of 500 healthy children and adolescents from birth to 19years were initially recruited to establish pediatric reference intervals according to the CLSI C28-A3 guidelines. Serum samples were used to measure 37 amino acids by ultra-performance liquid chromatography, 32 acylcarnitines, as well as free and total carnitine by tandem mass spectrometry, and ß-hydroxybutyrate and free fatty acids using the Vitros 5.1 chemistry analyzer. P ediatric reference intervals were calculated using non-parametric statistics and partitioned based on age- and sex-distributions. RESULTS: Approximately 80% of all analytes required 2 to 4 age-dependent partitions, with over 50% of amino acids and over 70% of acylcarnitines exhibiting significant physiological changes during the neonatal period. Also, 21% of all analytes required partitioning during puberty and adolescence, half of which produced sex-specific distributions. CONCLUSIONS: A comprehensive reference interval database for metabolic disease biomarkers established in this study will improve detection of IEMs by providing appropriate age- and sex-related information in the pediatric population. It will also aid newborn screening programs and guide the management of patients with known metabolic diseases, especially pubertal and adolescent boys and girls that display sex-specific concentrations.

Evaluation of a next generation direct whole blood enzymatic assay for hemoglobin A1c on the ARCHITECT c8000 chemistry system.

BACKGROUND: The utility of HbA1c for the diagnosis of type 2 diabetes requires an accurate, precise and robust test measurement system. Currently, immunoassay and HPLC are the most popular methods for HbA1c quantification, noting however the limitations associated with some platforms, such as imprecision or interference from common hemoglobin variants. Abbott Diagnostics has introduced a fully automated direct enzymatic method for the quantification of HbA1c from whole blood on the ARCHITECT chemistry system. METHODS: Here we completed a method evaluation of the ARCHITECT HbA1c enzymatic assay for imprecision, accuracy, method comparison, interference from hemoglobin variants and specimen stability. This was completed at three independent clinical laboratories in North America and Europe. RESULTS: The total imprecision ranged from 0.5% to 2.2% CV with low and high level control materials. Around the diagnostic cut-off of 48 mmol/mol, the total imprecision was 0.6% CV. Mean bias using reference samples from IFCC and CAP ranged from -1.1 to 1.0 mmol/mol. The enzymatic assay also showed excellent agreement with HPLC methods, with slopes of 1.01 and correlation coefficients ranging from 0.984 to 0.996 compared to Menarini Adams HA-8160, Bio-Rad Variant II and Variant II Turbo instruments. Finally, no significant effect was observed for erythrocyte sedimentation or interference from common hemoglobin variants in patient samples containing heterozygous HbS, HbC, HbD, HbE, and up to 10% HbF. CONCLUSIONS: The ARCHITECT enzymatic assay for HbA1c is a robust and fully automated method that meets the performance requirements to support the diagnosis of type 2 diabetes.

Benefits and challenges of multi-level learner rural general practices--an interview study with learners, staff and patients.

BACKGROUND: General practices vary in the provision of training and education. Some practices have training as a major focus with the presence of multi-level learners and others host single learner groups or none at all. This study investigates the educational benefits and challenges associated with 'multi-level learner' practices. METHODS: This paper comprised three case studies of rural general practices with multiple levels of learners. Qualitative data were collected from 29 interviews with learners (n = 12), staff (n = 12) and patients (n = 5). Interviews were initially analyzed using open and axial coding and thematic analysis. RESULTS: Thematic analysis showed 'multi-level learning' in general practices has benefits and challenges to learners and the practice. Learner benefits included knowledge exchange, the opportunity for vertical peer learning, a positive learning environment and the development of a supportive network. The presence of multi-level learners promoted sharing of knowledge with all staff, a sense of community, an increase in patient services and enthused supervisors. Challenges for learners included perception of decreased access to supervisors, anxiety with peer observation, reduced access to patient presentations and patient reluctance to be seen by a learner. Practice challenges were administration requirements, high learner turnover, infrastructure requirements and the requirement for supervisors to cater to a range of learner level needs. CONCLUSIONS: The presence of medical students, interns and registrars in general practice has educational benefits to the learners extending to the other stakeholders (staff and patients). Multi-level learners present challenges to the learners and the practice by increasing pressures on resources, staff (administrative and supervisors) and infrastructure.

The DREEM, part 1: measurement of the educational environment in an osteopathy teaching program.

BACKGROUND: Measurement of the educational environment has become more common in health professional education programs. Information gained from these investigations can be used to implement and measure changes to the curricula, educational delivery and the physical environment. A number of questionnaires exist to measure the educational environment, and the most commonly utilised of these is the Dundee Ready Educational Environment Measure (DREEM). METHODS: The DREEM was administered to students in all year levels of the osteopathy program at Victoria University (VU), Melbourne, Australia. Students also completed a demographic survey. Inferential and correlational statistics were employed to investigate the educational environment based on the scores obtained from the DREEM. RESULTS: A response rate of 90% was achieved. The mean total DREEM score was 135.37 (+/- 19.33) with the scores ranging from 72 to 179. Some subscales and items demonstrated differences for gender, clinical phase, age and whether the student was in receipt of a government allowance. CONCLUSIONS: There are a number of areas in the program that are performing well, and some aspects that could be improved. Overall students rated the VU osteopathy program as more positive than negative. The information obtained in the present study has identified areas for improvement and will enable the program leaders to facilitate changes. It will also provide other educational institutions with data on which they can make comparisons with their own programs.

Approach to low back pain - osteopathy.

Case A man aged 42 years, who works as a police officer, presented with severe lower back pain, which he had experienced for 24 hours after spending the previous day helping his brother to move house. He had difficulty ambulating and most movements aggravated the pain. There were no lower limb symptoms and no red flags present on history or examination. He was otherwise well and was not taking any regular medications.

Pediatric reference value distributions for vitamins A and E in the CALIPER cohort and establishment of age-stratified reference intervals.

OBJECTIVES: Vitamin A (retinol) and vitamin E (α-tocopherol) are fat soluble micronutrients most commonly measured in the pediatric population to monitor deficiencies due to malabsorption secondary to gastrointestinal (GI) disorders. One of the major challenges of vitamin A and E testing is the lack of reliable pediatric reference intervals which limits accurate interpretation of results. Here we report new pediatric reference intervals (RI) for both vitamins as part of the Canadian Laboratory Initiative for Pediatric Reference Intervals (CALIPER). DESIGN AND METHODS: A total of 342 blood samples were collected from healthy children 1 day to 19 years of age recruited from the community. Retinol and α-tocopherol were extracted from serum using hexane before concentrations were measured with high-performance liquid chromatography (HPLC). Age and sex-specific RI were calculated with guidance from CLSI C28-A2. Non-parametric and robust methods were used to calculate the 95th percentile ranges of the reference intervals along with the 90% confidence intervals. RESULTS: Vitamin A demonstrated increasing levels with age necessitating four distinct age stratifications. Vitamin E levels peaked within the first year of life requiring only 2 age partitions. Ratios of vitamin E to cholesterol and triglyceride were also calculated, and correlated well to vitamin E levels. Sex-specific differences were not observed. CONCLUSIONS: This study establishes pediatric RI for vitamins A and E in a healthy population of children from neonates to early adulthood. These values will be beneficial in assessing accurate vitamin status when monitoring children with GI disorders or malnutrition.

Key challenges in simulated patient programs: an international comparative case study.

BACKGROUND: The literature on simulated or standardized patient (SP) methodology is expanding. However, at the level of the program, there are several gaps in the literature. We seek to fill this gap through documenting experiences from four programs in Australia, Canada, Switzerland and the United Kingdom. We focused on challenges in SP methodology, faculty, organisational structure and quality assurance. METHODS: We used a multiple case study method with cross-case synthesis. Over eighteen months during a series of informal and formal interactions (focused meetings and conference presentations) we documented key characteristics of programs and drew on secondary document sources. RESULTS: Although programs shared challenges in SP methodology they also experienced differences. Key challenges common to programs included systematic quality assurance and the opportunity for research. There were differences in the terminology used to describe SPs, in their recruitment and training. Other differences reflected local conditions and demands in organisational structure, funding relationships with the host institution and national trends, especially in assessments. CONCLUSION: This international case study reveals similarities and differences in SP methodology. Programs were highly contextualised and have emerged in response to local, institutional, profession/discipline and national conditions. Broader trends in healthcare education have also influenced development. Each of the programs experienced challenges in the same themes but the nature of the challenges often varied widely.

Initial development of a work-related assessment of dysexecutive syndrome: the Complex Task Performance Assessment.

UNLABELLED: This article describes the initial development of the Complex Task Performance Assessment (CTPA) as a work-related assessment of dysexecutive syndrome. METHODS: A cross-sectional case-control pilot study using the Complex Task Performance Assessment (CTPA) and a neuropsychological battery consisting of subtests from the Delis Kaplan Executive Function System (DKEFS) were used with a population of adults with mild stroke and a control group of healthy community participants (n = 9). RESULTS: A correlation matrix between the DKEFS and the CTPA found no significant relationships between overall performance efficiency on the CTPA compared to the DKEFS scaled scores. In contrast, four of the six variables tested on the CTPA were found to have significant differences between the mild stroke group and the controls (p < 0.05). CONCLUSION: The sensitivity of the CTPA in this pilot sample justifies future study to provide a link between traditional neuropsychological assessment and rehabilitation professionals' observation of performance related to return to work. Neuroperformance assessment such as the CTPA will provide clinicians with a way to identify dysexecutive syndrome and higher-level cognitive processing deficits in the context of care.

Reliability, validity, and clinical utility of the Executive Function Performance Test: a measure of executive function in a sample of people with stroke.

This study examined the reliability and validity of the Executive Function Performance Test (EFPT). The EFPT assesses executive function deficits in the performance of real-world tasks. It uses a structured cueing and scoring system to assess higher-level cognitive functions, specifically initiation, organization, sequencing safety and judgment, and task completion. Seventy-three participants with mild to moderate stroke and 22 age- and education-matched controls completed the 4 EFPT tasks (cooking, using the telephone, managing medications, and paying bills). Significant differences were found between participants with mild and moderate stroke and healthy control participants. The EFPT can help occupational therapists determine the level of support needed by people with cognitive impairments to perform complex instrumental tasks. Objective information derived from this assessment is an essential part of the process of determining whether the person can live independently and helping families understand how to support the performance of their family members at home.