A framework for using real-time evaluative interview feedback for health promotion program and evaluation improvement: The Check It case study.

Formative evaluation is a crucial strategy for health promotion program improvement. Early and ongoing formative evaluation can make a major impact on program outcomes; however, there are few frameworks that provide actual guidance on how programmatic or research teams can systematically perform this kind of important work. In this article we describe the use of an iterative real-time interview feedback framework we developed for Check It, a community-wide chlamydia screening and treatment program for young African American men in New Orleans, Louisiana. The framework considers the diverse and needed perspectives of multiple stakeholders, including participants, interviewers, transcribers, program staff, and lead researchers and/or administrators. Interviews were conducted with N = 15 Check It participants utilizing this approach. Employing the framework led to critical insights that resulted in several vital programmatic and evaluation improvements. Lessons learned, including strengths and challenges of utilizing the framework, are also shared so that this model can be replicated or adapted by program planning and evaluation professionals for other kinds of programs.

Encouraging family engagement in the rehabilitation process: a rehabilitation provider's development of support strategies for family members of people with traumatic brain injury.

PURPOSE: After a moderate to severe traumatic brain injury, it is widely recommended that family members be actively engaged in the client's rehabilitation journey because evidence suggests that this is associated with better outcomes. The ability of family members to fully engage in rehabilitation may be hindered by the barriers (logistical and psychological) they encounter. However, rehabilitation services can facilitate family engagement through a person-centred approach that provides support to remove barriers. Limited published guidance exists regarding practical and effective methods for delivering such support. This paper describes how one rehabilitation service has developed an eight-tiered approach. KEY MESSAGES AND IMPLICATIONS: Family support is provided by explicit structuring of services to include (i) early engagement, (ii) meeting cultural needs, (iii) keeping families together, (iv) actively listening, (v) active involvement, (vi) education, (vii) skills training, and (viii) support for community re-integration. Implementation of these support strategies are individualised based on the expressed needs of each family. Families report a high level of satisfaction with the service. CONCLUSION: A practice-based quality improvement model identified challenges, implemented changes, and observed/evaluated the results to successfully develop a multifaceted strategy for supporting families, thereby encouraging their engagement in rehabilitation. Ongoing refinements and evaluation are planned.

Neuroprotective effect of testosterone treatment on motoneuron recruitment following the death of nearby motoneurons.

Motoneuron loss is a significant medical problem, capable of causing severe movement disorders or even death. We have previously shown that motoneuron death induces marked dendritic atrophy in surviving nearby motoneurons. Additionally, in quadriceps motoneurons, this atrophy is accompanied by decreases in motor nerve activity. However, treatment with testosterone partially attenuates changes in both the morphology and activation of quadriceps motoneurons. Testosterone has an even larger neuroprotective effect on the morphology of motoneurons of the spinal nucleus of the bulbocavernosus (SNB), in which testosterone treatment can completely prevent dendritic atrophy. The present experiment was performed to determine whether the greater neuroprotective effect of testosterone on SNB motoneuron morphology was accompanied by a greater neuroprotective effect on motor activation. Right side SNB motoneurons were killed by intramuscular injection of cholera toxin-conjugated saporin in adult male Sprague-Dawley rats. Animals were either given Silastic testosterone implants or left untreated. Four weeks later, left side SNB motor activation was assessed with peripheral nerve recording. The death of right side SNB motoneurons resulted in several changes in the electrophysiological response properties of surviving left side SNB motoneurons, including decreased background activity, increased response latency, increased activity duration, and decreased motoneuron recruitment. Treatment with exogenous testosterone attenuated the increase in activity duration and completely prevented the decrease in motoneuron recruitment. These data provide a functional correlate to the known protective effects of testosterone treatment on the morphology of these motoneurons, and further support a role for testosterone as a therapeutic agent in the injured nervous system.

Successful long-term outcomes of spinal cord stimulation despite limited pain relief during temporary trialing.

Objectives. In spinal cord stimulation (SCS) therapy, limited pain relief during the temporary trial period is generally considered to be predictive of poor long-term benefit. To validate or refute this perception, the long-term outcomes of subjects who reported less than 50% pain relief during a temporary SCS trial were examined. Materials and Methods. Twelve subjects with intractable pain underwent implantation of trial SCS systems. After a trial period in which they reported less than 50% pain relief, they each received a permanent SCS implant. Pain ratings and complications were tracked for 6-18 months. Results. At the end of the temporary trial period, the average pain relief was 21%; no subject reported 50% or better pain relief. More favorable outcomes were reported after activation of the permanent system, however. At all follow-up time points, at least a third of the subjects reported better than 50% pain relief, and the average pain relief varied over time between 44% and 83%. All complications were readily resolved and no subjects withdrew from the study. Conclusions. Although SCS provided limited pain relief during the trial period, efficacy was more satisfactory after permanent implantation. Several subjects went on to experience nearly complete pain relief for up to 18 months (the maximum follow-up visit for study purposes), and no subject chose to discontinue SCS therapy. SCS appears to be a viable treatment option for patients who fail trials, raising some doubt as to the predictive sensitivity and specificity of the trial period. Thus, although outcome of a temporary trial period may be suggestive of later efficacy with SCS, it may not be the sole predictor of success. Alternatively, the arbitrary benchmark of 50% pain relief that is typically used to define the success of a temporary trial may be too stringent and unreliable.

Spinal cord stimulation has comparable efficacy in common pain etiologies.

Objectives. The probability of success with spinal cord stimulation (SCS) depends largely on appropriate patient selection. Here, we have assessed the predictive value of pain etiology as it relates to pain relief with SCS as part of a prospective multicenter clinical trial. Methods. Sixty-five subjects with chronic and intractable pain tested an epidural SCS system. Subjects reported pain ratings (visual analog scale) with stimulation off and stimulation on at scheduled follow-up visits for up to 18 months after activation of the system. Visual analog scale scores were averaged and stratified by dominant pain etiologies, comprising failed back surgery syndrome, complex regional pain syndrome, and a subgroup of subjects with miscellaneous other pain etiologies. Results. More than 70% of subjects in each subgroup had successful outcomes during the temporary trial period and similar percentages of subjects from each etiology subgroup subsequently went on to permanent implantation. After permanent implantation, all subgroups reported more than 50% pain relief, on average, at each follow-up time point. No predictive value of pain etiology was observed. Conclusions. Spinal cord stimulation is an effective therapy for neuropathic pain arising from a variety of causes. Failed back surgery syndrome, complex regional pain syndrome, and pain of other etiologies responded equally well to SCS.

A new spinal cord stimulation system effectively relieves chronic, intractable pain: a multicenter prospective clinical study.

Objectives. A prospective, open label, multicenter clinical trial confirmed the functionality of a new spinal cord stimulation (SCS) system for the treatment of chronic, intractable pain of the trunk and/or limbs. Materials and Methods. Sixty-five subjects tested a rechargeable 16-channel SCS system with individual current control of each contact on one or two percutaneous eight-contact epidural leads. After baseline measurements, subjects were tracked on pain ratings and complication rates for up to 18 months. Results. After a trial period, 75% of subjects underwent permanent implantation of the entire SCS system. More than one-half the implanted subjects experienced 50% or greater relief of pain after permanent implantation; some subjects reported relief of 90% or more of their pain. The most common complications after permanent implantation were lead migration, uncomfortable stimulation, and component failure; most resolved after reprogramming or device replacement. Conclusions. The new SCS system provided good pain relief to a majority of subjects, and the results confirm a favorable safety and efficacy profile for the SCS system.

Hormone sensitivity of muscle activation in the sexually dimorphic SNB/BC neuromuscular system of the rat.

Rat penile reflexes are mediated in part by motoneurons in the sexually dimorphic spinal nucleus of the bulbocavernosus (SNB) and a muscle it innervates, the bulbocavernosus (BC). Recruitment in the M-wave component of electromyographic recording in the SNB/BC neuromuscular circuit is sensitive to testosterone and estradiol. To localize the site of the hormonal effect, we recorded muscle activity in a reduced preparation that isolated the peripheral structures involved in generating an M-wave. Castration reduced recruitment amplitude and increased response latency, and treatment with estradiol or the non-aromatizable androgen dihydrotestosterone prevented these changes. Dihydrotestosterone, but not estradiol, maintained BC muscle mass. These results indicate that functional changes in the SNB/BC circuit can result in part from hormonal sensitivity in the neuromuscular periphery and are independent of muscle mass.

Estrogen alters excitability but not morphology of a sexually dimorphic neuromuscular system in adult rats.

In rats, motoneurons of the spinal nucleus of the bulbocavernosus (SNB) innervate the bulbocavernosus (BC) muscle, which surrounds the base of the penis. The SNB/BC is a sexually dimorphic, steroid-sensitive neuromuscular system, which is critically important in male reproductive behavior. Androgens are necessary for the development, morphology, and function of the SNB/BC system. However, estradiol (E) is also necessary for the development of the SNB/BC system, and E is capable of maintaining BC EMG activity in adulthood. In this study, we used electrophysiological and anatomical methods to examine estrogenic effects on BC EMG activity. We used a modified H-reflex testing method to investigate polysynaptic reflex characteristics in intact males, castrates, and castrates treated short term with estradiol benzoate (EB). Measures of EMG activity, response latency, and spike count were altered in castrates, but maintained in EB-treated castrates to the levels of intact males. Furthermore, estrogenic effects were found in EMG activity that could be isolated to the periphery of the SNB/BC system. BC NMJ size and muscle fiber area have been demonstrated to be hormone sensitive, and we examined these for possible correlates of E's effects on BC EMG activity. BC muscles of intact males, castrates, and short-term EB-treated castrates were fixed and stained with zinc iodide and osmium tetroxide. NMJ size and muscle fiber area did not differ between groups. Together, these data suggest that E treatment results in changes in the neuromuscular periphery that maintain BC EMG activity, but this effect cannot be accounted for by changes in NMJ size or muscle fiber area.