Optimizing the use of patients' individual outcome information - Development and usability tests of a Chronic Kidney Disease dashboard.

BACKGROUND: Reporting individual clinical and patient-reported outcomes to patients during consultations may add to patients' disease knowledge and activation and stimulate Shared Decision Making (SDM). These outcomes can be presented over time in a clear way by the means of dashboarding. We aimed to systematically develop a Chronic Kidney Disease (CKD) dashboard designed to support consultations, test its usability and explore conditions for optimal use in practice. METHODS: For development a participatory approach with patients and healthcare professionals (HCPs) from three hospitals was used. Working groups and patient focus groups were conducted to identify needs and inform the dashboard's design. Usability was tested in patient interviews. A focus group with HCPs was held to identify conditions for optimal use of the dashboard in daily practice. RESULTS: A dashboard was developed for CKD patients stage 3b-4 visualizing both clinical and patient-reported outcomes over time for use during consultations and accessible for patients at home. Both HCPs and patients indicated that the dashboard can: motivate patients in their treatment by providing feedback on outcomes over time; improve consultation conversations by enhanced preparation of both HCPs and patients; better inform patients, thereby facilitating shared decision making. HCPs and patients both stated that setting a topic agenda for the consultation together is important in effectively discussing the dashboard during consultations. Moreover, the dashboard should not dominate the conversation. Lastly, findings of the usability tests provided design requirements for optimal user-friendliness and clarity. CONCLUSIONS: Dashboarding can be a valuable way of reporting individual outcome information to patients and their clinicians as findings suggest it may stimulate patient activation and facilitate decision making. Co-creation with patients and HCPs was essential for successful development of the dashboard. Gained knowledge from the co-creation process can inform others wishing to develop similar digital tools for use in clinical practice.

Accuracy of pedicle localization using a 3D ultrasound navigator on vertebral phantoms for posterior spinal surgery.

Severe adolescent idiopathic scoliosis (AIS) requires surgery to halt curve progression. Accurate insertion of pedicle screws is important. This study reports a newly developed 3D ultrasound (3DUS) to localize pedicles intraoperatively and register a pre-op 3D vertebral model to the surface to be displayed for navigation. The objective was to determine speed of the custom 3DUS navigator and accuracy of pedicle probe placement. The developed 3DUS navigator integrated an ultrasound scanner with motion capture cameras. Two adolescent 3D printed spine models T2-T8 and T7-T11 were modified to include pedicle holes with known trajectory and be mounted on a high precision LEGO pegboard in a water bath for imaging. Calibration of the motion cameras and the 3DUS were conducted prior to the study. A total of 27 scans from T3 to T11 vertebrae with 3 individual scans were performed to validate the repeatability. Three accuracy tests that varied vertebral a) orientation, b) position and c) a combination of location and orientation were completed. Based on all experiments, the acquisition-to-display time was 18.9±3.1s. The repeatability of the trajectory error and positional error were 0.5±0.2° and 0.3±0.1mm, respectively. The a) center orientation, b) position and c) orientation/position on trajectory and positional error were for a) 1.4±0.9° and 0.5±0.4mm, b) 1.4±0.8° and 0.3±0.3mm and c) 2.0±0.8° and 0.5±0.5mm, respectively. These results demonstrated that a high precision real-time 3DUS navigator for screw placement in scoliosis surgery is feasible. The next step will study the effect of surrounding soft tissues on navigation accuracy.

Convergent validity, ceiling, and floor effects of the English-ISYQOL against established quality of life questionnaires (SRS-22r and SAQ) and curve angles in adolescents with idiopathic scoliosis.

Scoliosis significantly impacts Quality of Life (QOL). Current quality of life questionnaires for adolescents with idiopathic scoliosis (AIS) have limitations. A new questionnaire for measuring QOL in AIS called the Italian Spine Youth Quality of Life (ISYQOL) has been developed to address these limitations but the English translation has not yet been validated. To determine the ceiling and floor effects, and the convergent validity of the ISYQOL questionnaire against established QOL questionnaires and Cobb angle in AIS. One hundred consecutive females with AIS, (10-18 years old), treated non-operatively. The English translation of the ISYQOL was compared to the following established questionnaires: Scoliosis Research Society-22r and the Spinal Appearance Questionnaire. The participants were 100 females (13.89+/-1.8 years) with 28.75+/-13.9° curve angles. The convergent validity of the ISYQOL score (60.3+/-12.44) was supported by significant correlation with the SRS-22r total score, function, pain, self-image, and mental health scores (r = 0.70, 0.54, 0.57, 0.52 and 0.50, respectively), and with the SAQ general, waist, and expectations domains (r = -0.6. -.52, and -0.56, respectively). Correlation with the Cobb angle was (r = -.37)(see Table 1). No ceiling effect was observed in the ISYQOL. Ceiling effects were observed for the SRS-22r and the SAQ. The ISYQOL demonstrated evidence of convergent validity. This study supports its suitability for QOL research in AIS. ISYQOL appears more likely to detect changes in evaluative studies than the SRS- 22r and the SAQ.

Asymmetric mass ratios for bright double neutron-star mergers.

The discovery of a radioactively powered kilonova associated with the binary neutron-star merger GW170817 remains the only confirmed electromagnetic counterpart to a gravitational-wave event1,2. Observations of the late-time electromagnetic emission, however, do not agree with the expectations from standard neutron-star merger models. Although the large measured ejecta mass3,4 could be explained by a progenitor system that is asymmetric in terms of the stellar component masses (that is, with a mass ratio q of 0.7 to 0.8)5, the known Galactic population of merging double neutron-star systems (that is, those that will coalesce within billions of years or less) has until now consisted only of nearly equal-mass (q > 0.9) binaries6. The pulsar PSR J1913+1102 is a double system in a five-hour, low-eccentricity (0.09) orbit, with an orbital separation of 1.8 solar radii7, and the two neutron stars are predicted to coalesce in [Formula: see text] million years owing to gravitational-wave emission. Here we report that the masses of the pulsar and the companion neutron star, as measured by a dedicated pulsar timing campaign, are 1.62 ± 0.03 and 1.27 ± 0.03 solar masses, respectively. With a measured mass ratio of q = 0.78 ± 0.03, this is the most asymmetric merging system reported so far. On the basis of this detection, our population synthesis analysis implies that such asymmetric binaries represent between 2 and 30 per cent (90 per cent confidence) of the total population of merging binaries. The coalescence of a member of this population offers a possible explanation for the anomalous properties of GW170817, including the observed kilonova emission from that event.

Physiotherapeutic scoliosis-specific exercises for adolescents with idiopathic scoliosis.

The use of exercises for the treatment of Adolescents with Idiopathic Scoliosis is controversial. Whilst exercises are routinely used in a number of central and southern European countries, most centres in the rest of the world (mainly in Anglo-Saxon countries), do not advocate its use. One of the reasons for this is that many health care professionals are usually not conversant with the differences between generalised physiotherapy exercises and physiotherapeutic scoliosis-specific exercises (PSSE): while the former are generic exercises usually consisting of low-impact stretching and strengthening activities like yoga, Pilates and the Alexander technique, PSSE consist of a program of curve-specific exercise protocols which are individually adapted to a patients' curve site, magnitude and clinical characteristics. PSSEs are performed with the therapeutic aim of reducing the deformity and preventing its progression. It also aims to stabilise the improvements achieved with the ultimate goal of limiting the need for corrective braces or the necessity of surgery. This paper introduces the different 'Schools' and approaches of PSSE currently practiced (Scientific Exercise Approach to Scoliosis - SEAS, Schroth, Barcelona Scoliosis Physical Therapy School - BSPTS, Dobomed, Side Shift, Functional Individual Therapy of Scoliosis - FITS and Lyon) and discusses their commonalities and differences.

Treating diabetes with islet transplantation: lessons from the past decade in Lille.

Type 1 diabetes (T1D) is due to the loss of both beta-cell insulin secretion and glucose sensing, leading to glucose variability and a lack of predictability, a daily issue for patients. Guidelines for the treatment of T1D have become stricter as results from the Diabetes Control and Complications Trial (DCCT) demonstrated the close relationship between microangiopathy and HbA1c levels. In this regard, glucometers, ambulatory continuous glucose monitoring, and subcutaneous and intraperitoneal pumps have been major developments in the management of glucose imbalance. Besides this technological approach, islet transplantation (IT) has emerged as an acceptable safe procedure with results that continue to improve. Research in the last decade of the 20th century focused on the feasibility of islet isolation and transplantation and, since 2000, the success and reproducibility of the Edmonton protocol have been proven, and the mid-term (5-year) benefit-risk ratio evaluated. Currently, a 5-year 50% rate of insulin independence can be expected, with stabilization of microangiopathy and macroangiopathy, but the possible side-effects of immunosuppressants, limited availability of islets and still limited duration of insulin independence restrict the procedure to cases of brittle diabetes in patients who are not overweight or have no associated insulin resistance. However, various prognostic factors have been identified that may extend islet graft survival and reduce the number of islet injections required; these include graft quality, autoimmunity, immunosuppressant regimen and non-specific inflammatory reactions. Finally, alternative injection sites and unlimited sources of islets are likely to make IT a routine procedure in the future.

Identifying the best surface topography parameters for detecting idiopathic scoliosis curve progression.

There is no consensus on which surface topography (ST) parameters may be used to detect scoliosis progression. The sensitivity to change of common ST parameters has not yet been compared. The goal of this study was to determine which ST parameters are most sensitive to scoliosis progression in patients with adolescent idiopathic scoliosis (AIS) receiving conservative treatment. Fifty-eight subjects with AIS were included whose Cobb angle had progressed by at least 5 degrees during a 1 year interval. All had had ST scans and frontal radiographs at a 12 month interval at our clinic. Commonly used back-only ST parameters and contributing scores were derived by one evaluator. Standardized response mean (SRM) and 95% confidence intervals (CI) were calculated using the absolute value of the changes between baseline and follow-up to reflect change in deformity, independent of direction. Decompensation, cosmetic score, Deformity in the Axial Plane Index (DAPI), trunk rotation, Hump Sum, and lordosis angle were highly sensitive to scoliosis progression (SRM>0.8). Cosmetic score, Posterior Trunk Symmetry Index (POTSI), and kyphosis angle had significantly poorer SRM values than the Cobb angle. All other ST parameters had SRM estimates that did not differ significantly from the Cobb angle, suggesting that they have a similar ability to detect progression The ST measures that were most sensitive to detection of scoliosis progression in the frontal, transverse, and sagittal planes were decompensation, trunk rotation, and lordosis angle, respectively. Absolute changes in surface parameters representing either worsening or improvement externally could reflect worsening of the internal deformity. The majority of ST parameters are potentially sensitive to scoliosis progression.

Can future back pain in AIS subjects be predicted during adolescence from the severity of the deformity?

Back pain is frequently reported as a symptom of adolescent idiopathic scoliosis (AIS). Prediction of pain in adulthood would be useful to identify subjects requiring follow-up. The aim is to determine adolescent predictors of adult back pain. This study is a retrospective review of 27 females with AIS who attended our pediatric scoliosis clinic and later completed the SRS-22 questionnaire as young adults (range 18-25 years). Subjects with surgery at baseline (age 14-16 years) were excluded. The relationships between largest curve size, decompensation and trunk twist at baseline and pain as measured by the SRS-22 pain domain as young adults were studied. At baseline, subjects had a largest curve of 47+/-15 degrees , decompensation of 18+/-14 mm and trunk twist of 14+/-6 degrees . At follow-up, 5.3+/-1.9 years later, the total SRS-22 score was 3.9+/-0.3 and the pain domain score was 3.9+/-0.7. Pearson correlations between the SRS-22 pain domain and largest curve, decompensation and trunk twist were 0.17, -0.11 and -0.25, respectively (p>0.05). Individual questions within the pain domain had similar correlations. Even though the sample represented a wide range of scoliosis severity at baseline and a wide range of pain scores (2.4 to 5) at follow-up, baseline scoliosis deformity parameters of largest curve size, decompensation and trunk twist did not predict scoliosis-related pain in young adulthood.

Preliminary validation of curve progression model for brace treatment.

Brace treatment is the most commonly used non-surgical treatment for adolescent idiopathic scoliosis (AIS). A brace compliance monitoring system consisting of a microcomputer and a force transducer was used to monitor how brace candidates used their braces during daily activates. A prediction model of the brace treatment outcome was developed based on 20 AIS subjects. Six subjects (1M, 5F) with AIS who had worn their braces for six weeks participated into this study. One month data was recorded during the study period. Knowing the risk progression at the beginning of brace treatment plus how brace subjects used their braces in terms of brace tightness and wear time during brace treatment yielded a predicted outcome which was compared to the final treatment outcomes with 2 years followed-up. This preliminary result demonstrated that the prediction model was able to predict the treatment outcome within +/-3.5 degrees.

Validity and reliability of active shape models for the estimation of Cobb angles in adolescent idiopathic scoliosis.

Choosing the most suitable treatment for scoliosis relies heavily on accurate and reproducible Cobb angle measurement from successive radiographs. The objective is to reduce variability of Cobb angle measurement by reducing user intervention and bias. Custom software to automate Cobb angle measurement from posteroanterior radiographs was developed using active shape models. Validity and reliability of the automated system against a manual and semi-automated measurement method was conducted by two examiners each performing measurements on 3 occasions from a test set (N=22). A training set (N=47) of radiographs representative of curves seen in a scoliosis clinic was used to train the software to recognize vertebrae from T4 to L4. Images with a maximum Cobb angle between 20 degrees and 50 degrees, excluding surgical cases, were selected for training and test sets. Automated Cobb angles were calculated using best-fit slopes of the detected vertebrae endplates. Intra-class correlation coefficient (ICC) and standard error of measurement (SEM) showed high intra-examiner (ICC > 0.90, SEM 2-3 degrees) and inter-examiner (ICC > 0.82, SEM 2-4 degrees), but poor inter-method reliability (ICC=0.30, SEM 8-9 degrees). The automated method underestimated large curves. The reliability improved (ICC = 0.70, SEM 4-5 degrees) with exclusion of the 4 largest curves (>40 degrees) in the test set. The automated method was reliable for moderate sized curves, but did not properly detect vertebrae in larger curves. Optimization of constraints on scaling, rotation, translation, and iteration may improve reliability with larger curves.

Associations between quality-of-life and internal or external spinal deformity measurements in adolescent with idiopathic scoliosis (AIS).

In theory, quality-of-life measures should correlate with impairments such as spinal deformity. The goal was to determine the ability of the SRS-22 and surface topography measures to predict internal deformity. Data from 227 females with AIS were collected. Correlations and regression were used to predict Cobb angle or category. In subjects treated conservatively, the Cobb angle correlated with pain, self-image, satisfaction and total score. Only self-image correlated with surface topography. In subjects having had surgery, Cobb angle correlated with self-image, mental health, satisfaction and total scores. The cosmetic score was the only external deformity measure to correlate with the SRS-22. Function, self-image and trunk-twist predicted subjects within 3 categories (Cobb <30 degrees , 30-50 degrees , >50 degrees) with 57% accuracy compared to 53% when using self-image only. Accuracy in predicting subjects with curves smaller or larger than 50 degrees was 79% (using self-image, trunk-twist) or 72% (self-image only). Correlations between quality-of-life and deformity measures were low. However, it was possible to predict subjects within clinically meaningful categories of internal deformity using SRS-22 scores.

Recurrent nonmenstrual toxic shock syndrome: clinical manifestations, diagnosis, and treatment.

We report 3 cases of recurrent nonmenstrual toxic shock syndrome (TSS) and review the clinical manifestations, diagnosis, and treatment. The primary sites of infection were the genital tract (in a patient who underwent cesarean delivery), the upper respiratory tract, and a breast abscess. In all 3 patients, the initial illness was not recognized to be TSS; only after development of recurrent illness with desquamation was this diagnosis entertained. Strains of Staphylococcus aureus that were isolated from 2 patients produced TSS toxin-1, whereas the third strain produced staphylococcal enterotoxin B. All 3 patients lacked antibody to the implicated toxins at the time of presentation with recurrent illness. Nonmenstrual TSS can occur in a variety of clinical settings and may be recurrent. The presence of desquamation during a febrile, multisystem illness could suggest this diagnosis and should prompt the clinician to obtain appropriate cultures for S. aureus.

Feasibility of an eight-week dance-based exercise program and its effects on locomotor ability of persons with functional class III rheumatoid arthritis.

OBJECTIVES: The main objectives of this experimental case series were to evaluate the feasibility of a modified dance-based exercise program with low ground impacts in persons with rheumatoid arthritis (RA) functional class III and to describe its effects on locomotor ability. The relationship between 3 locomotor tests and their responsiveness also were addressed. METHODS: Ten female subjects participated in an 8-week exercise program. Locomotor ability was measured before and after the program using the 50-foot test of walking time, the 6-minute test of walking distance, and the locomotion biomechanical analysis. RESULTS: All subjects showed a high compliance (92.5% presence at sessions) over the 8 weeks of exercise without any aggravation in disease status. They were able to train efficiently at moderate intensity up to 25 minutes. Significant improvements were found in locomotor ability, with a higher responsiveness measured by the locomotion biomechanical analysis, followed by the 6-minute gait test and the 50-foot gait test. Inconsistent relationships between tests suggested that different locomotor abilities are required during tests. CONCLUSION: These results support the feasibility of a modified dance-based exercise program for persons with severe RA. With high levels of responsiveness, the detailed biomechanical analysis and the 6-minute gait test are recommended for the assessment of locomotor ability.

Quality of care for elderly patients hospitalized with heart failure.

BACKGROUND: There is increasing interest in the development of explicit criteria to evaluate the quality of care for patients with heart failure. However, despite this interest, there is a paucity of information about the care of these patients in actual clinical practice across diverse sites. METHODS: We conducted a retrospective medical record review across 9 acute care hospitals in Connecticut. We selected 200 random admissions from each hospital with a principal discharge diagnosis of heart failure in 1994. Hospitals with fewer than 200 cases had 100% of cases selected. Patients with heart failure secondary to severe aortic stenosis, mitral stenosis, or medical illness were excluded. We evaluated the percentage of patients receiving appropriate treatments and interventions as defined by quality-of-care indicators derived from the Agency for Health Care Policy and Research Clinical Practice Guidelines. RESULTS: Data were abstracted from 1623 hospitalizations and the presence of heart failure was validated by chart review in 1535 (95%). In cohorts of ideal candidates for specific interventions, 832 (75%) of 1110 had a left ventricular ejection fraction documented or measured; 346 (86%) of 401 received angiotensin-converting enzyme inhibitors; 38 (14%) of 271 received target doses of angiotensin-converting enzyme inhibitors; 1359 (97%) of 1400 had counseling about medications documented; 90 (6%) of 1400 had counseling about weight documented; 980 (70%) of 1400 had counseling about diet documented; 856 (61%) of 1400 had counseling about exercise and activity documented; and 14 (11%) of 128 smokers had counseling about cessation documented. CONCLUSIONS: These data demonstrate that the documentation of left ventricular systolic function and counseling for diet, weight, activity, and smoking may provide the best opportunities to improve the hospital care of elderly patients with heart failure. The use of angiotensin-converting enzyme inhibitors in appropriate patients is relatively high, indicating successful translation of trial results into clinical practice at these hospitals.

Dance-based exercise program in rheumatoid arthritis. Feasibility in individuals with American College of Rheumatology functional class III disease.

Many studies have demonstrated that aerobic exercise training is beneficial to prevent physical deconditioning in persons with rheumatoid arthritis (RA) without inducing adverse effects on individual's joints and general health. After significant results in individuals with RA (Functional Class I and II), the present study was conducted to demonstrate the feasibility of a modified dance-based exercise program to improve the physical fitness and psychological state of persons with RA (Class III). Ten (10) female subjects (mean age, 54 +/- 10 years) participated in an eight-week exercise program (twice weekly). Health status, use of medication, joint pain and swelling, cardiorespiratory fitness, activity of daily living, and psychological state were assessed before and after the training program. A high level of participation has been maintained by the participants (mean = 14.8/16 sessions). Most of them were able to perform a maximal exercise test on treadmill and reached 90% of the predicted heart rate at maximal exercise. No significant gain in aerobic power was observed for the group as a whole, but four subjects showed improvements of between 10% and 20% of their cardiorespiratory fitness. Positive changes in depression, anxiety, fatigue, and tension were observed after the eight-week exercise program. No deleterious effect on the health status was observed. These findings provide some evidences as to the feasibility of submitting individuals with RA to a modified dance-exercise program. Further studies, however, are required to determine the long-term effect of weight-bearing exercise on the health status of individuals with RA.

Readmission after hospitalization for congestive heart failure among Medicare beneficiaries.

BACKGROUND: Congestive heart failure is the most common discharge diagnosis for Medicare beneficiaries. While several single-center studies have suggested that these patients are particularly vulnerable to readmission, no recent study, to our knowledge, has reported the readmission rates for a large number of elderly patients with congestive heart failure across a diverse spectrum of hospitals. OBJECTIVES: To define the readmission rate for elderly patients discharged after an episode of congestive heart failure. To determine the spectrum of diagnoses that are responsible for readmissions among patients with congestive heart failure. To identify patient and hospital characteristics associated with a higher likelihood of readmission. METHODS: This observational study, using Medicare administrative files, evaluated readmission and death among all survivors of a hospitalization in Connecticut for congestive heart failure from fiscal year 1991 through fiscal year 1994. RESULTS: There were 17448 survivors of a hospitalization for congestive heart failure during the study period. In the 6 months following the index admission, 7596 patients (44%) were readmitted to a hospital at least once. Congestive heart failure was the most frequent reason for readmission among study patients, accounting for 18% of all readmissions. In the multivariable analysis, significant predictors of readmission included male sex (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.05-1.20), at least 1 prior admission within 6 months of the index admission (OR, 1.64; 95% CI, 1.53-1.77), Deyo comorbidity score of more than 1 (OR, 1.56; 95% CI, 1.45-1.68), and length of stay in the index hospitalization of more than 7 days (OR, 1.32; 95% CI, 1.24-1.41). While age was not a significant predictor of readmission, it became significant in a model with the combined outcome of readmission or death as the dependent variable. CONCLUSION: Readmission after a hospitalization for congestive heart failure is common among Medicare beneficiaries, with almost half of the patients readmitted within 6 months. This striking rate of readmission in a common diagnosis demands efforts to further clarify the determinants of readmission and develop strategies to prevent this adverse outcome.

Effect of hylan on cartilage and chondrocyte cultures.

The protective role of hylan, a hyaluronan [hyaluronic acid (HA)] derivative, was studied in explanted bovine cartilage and isolated chondrocytes. Cartilage and chondrocytes were exposed to degradative enzymes (lysate from activated polymorphonuclear leukocytes), oxygen-derived free radicals (ODFR), conditioned media from mononuclear cells (MCCM), and interleukin-1 (IL-1), in the presence and absence of hylan. The effect of HA was also studied. In cartilage explants susceptibility to pertubation was evaluated in terms of 35S release and proteoglycan depletion and was compared to control cultures; high viscosity hylan was found to reduce 35S release in cartilage explants caused by degradative enzymes, ODFR, MCCM, and IL-1. The hylan effect was reversible and viscosity-dependent. In chondrocyte cultures, high viscosity hylan was effective in reducing cell injury caused by degradative enzymes and ODFR. The data suggest that the glycosaminoglycan hylan, as well as native HA, may mediate exposure to and/or response to stimuli associated with initiation of degenerative processes in cartilage tissues.

Hylan gel composition for percutaneous embolization.

Viscoelastic, pseudoplastic, radiopaque injectable hylan gel for percutaneous embolization was developed and evaluated by in vitro and in vivo tests. The embolization gel is composed of cross-linked hylan (hyaluronan, hyaluronate), tantalum, microcrystalline cellulose, hexamethonium chloride, and thrombin. Upon delivery through small-lumen catheters to the appropriate vascular site, the gel induces formation of a solid blood/gel coagulum. Results from animal studies (rat aorta, rabbit auricular artery) demonstrate that formation of complete and long-lasting arterial blockage is readily achievable without complications due to blood flow, partial vessel obstruction, uncontrolled polymerization, or movement of the gel or its components (specifically thrombin and hexamethonium chloride) into the circulation. Microscopic evaluation indicates that arterial occlusion initially occurs as a result of the injected gel and formed fibrin; at 7 weeks and beyond, arteries are occluded by injected gel, inflammatory cells and fibrosis (scar tissue).