The impact of different researchers to capture quality of life measures in a dementia randomised controlled trial.

BACKGROUND: Capturing changes in health and wellbeing within randomised controlled trials (RCTs) can be complex. The precision and accuracy of outcome scales to measure change is crucial, and therefore, consideration needs to be given to potential measurement errors when collecting these outcomes. Many RCTs use multiple researchers to collect data, which has the potential to introduce variation in measurements. This study aimed to identify if there was a measurable effect of using different researchers to collect repeated assessments of quality of life (QoL) at different time points. METHODS: A previously conducted study assessing the impact of reminiscence therapy on participants with dementia and carer (PwD-carer) dyads, 'REMCARE' (Reminiscence groups for people with dementia and their family caregivers), provided the platform for this exploratory secondary analysis. Data was categorised into two broad groups: those where the same researcher attended all assessments and those where different researchers undertook the assessments. ANCOVA (analysis of covariance) models used in the original REMCARE analysis with the addition of the 'researcher-continuity' variable were run on two QoL measures, the QoL-AD (Quality of Life in Alzheimer's Disease) and QCPR (Quality of the Caregiving Relationship). RESULTS: Three hundred thirty PwD-carer dyads were included in the analysis. For the PwD, a statistically significant effect was found on the researcher continuity variable for the QoL-AD and QCPR outcome measures at follow-up 1 but not at follow-up 2 signifying an impact of researcher attendance at the first follow-up but not follow-up 2. For the carer data, analyses revealed no statistically significant effects at follow-up 1; however, the QoL-AD measure at follow-up 2 was found to be statistically significant. CONCLUSIONS: These exploratory results indicate the possible impact of researcher continuity on QoL outcomes in dementia studies. Further research is required to explore this further and establish causality. If demonstrated, this would have implications for the planning of future empirical studies in dementia, in order to reduce this potential source of bias.

Update to the Canadian clinical practice guideline for best-practice management of breast cancer-related lymphedema: study protocol.

BACKGROUND: One of the more frequent complications following treatment for breast cancer, lymphedema is a substantial swelling of the arm, breast and chest wall that occurs on the side where lymph nodes were removed. The aim of this work is to update recommendations on the prevention, diagnosis and management of lymphedema related to breast cancer. METHODS: We present the protocol for an update of the 2001 clinical practice guideline on lymphedema from the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. We will use a patient-oriented research approach with a focus on self-management and the positive health model to inform the updated guideline development. The methods proposed will be undertaken with consideration of the standards outlined in the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. The literature will be appraised by evaluating existing guidelines from other countries, the evidence from systematic reviews and meta-analyses and direct evidence from clinical studies. We will manage competing interests according to Guidelines International Network principles. Recommendations will be presented using an actionable statement format and will be linked to the level of evidence along with any relevant considerations used in formulation. A draft of the guideline will be produced by the steering committee then sent out to international experts and stakeholder groups for feedback. INTERPRETATION: The primary benefit of this clinical guideline will be to improve the quality of care of women with breast cancer-related lymphedema. Findings will be disseminated at national and international conferences and through webinars and educational videos hosted on the websites of the supporting organizations.

A study of changes in everyday mobility during the Covid-19 pandemic: As perceived by people living in Malmö, Sweden.

Sweden's strategy to manage the spread of Covid-19 has not included any form of lockdown, in contrast to the approaches adopted by most other countries. Instead, the strategy has been largely based on strong recommendations for society. Even though Sweden has not had any form of lockdown, the Covid-19 pandemic has during a relatively short period of time brought changes for society, significantly disrupting everyday life. The pandemic poses both challenges and opportunities for sustainable future transport, not least public transport provision, supply and use. The purpose of this study is to investigate how changes for society have translated into changes for mobility as an element of everyday life during the early stages of a pandemic. This study draws on a map-based online survey (public participatory GIS) which was purposefully designed to allow people to contribute with their experiences in order to capture how the current situation has affected several different facets of people's everyday life. Results suggest that effects on mobility, such as the possibility to telework, affect different groups differently and may exacerbate existing differences in terms of gender, geography and mobility. In order to mitigate negative effects, transport policy needs to be tailored in order to take these heterogeneities into account. Both spatio-temporal adjustment and modal adjustment were dominant themes for most activities, although the dominance of these themes varied among the activities. Our findings give an indication of both the short and long-term impacts on everyday mobility in the Swedish context, for groups of inhabitants in the city of Malmö. Through deepening our understanding of the processes at play, we suggest eight possible policy responses that can be carefully tailored, both in the interim and into the future.

Examining the Process of Modal Choice for Everyday Travel Among Older People.

Modal choice is a prominent concept within transport studies. However, the term is often used quite loosely, with little known about the factors lying behind the choice, the alternatives available to a person, and whether the person had a 'choice' to begin with. This study draws on a travel survey among older people living in Sweden's large metropolitan regions. The questions posed as part of this survey facilitate a greater insight into the processes at play behind modal choice. An analysis of the differences between: (1) the range of modal options available to respondents and (2) the modes selected from this range (modal choice) is presented. An analysis of the respondents' reasoning for choosing the modes they did and not the others they could have chosen is also presented. It was found that more than a quarter of respondents have the option to use and actually use all modes for everyday travel. The car is more inclined to be selected among those who have a range of different modal options. Suitability and comfort are the two main reasons given for modal choice. More positive reasons are given for actively selecting walking and cycling, whereas the motives behind the selection of the car instead tend to be framed as reasons for not selecting other modes. Adaptive preference and adjustment effects are also apparent in the selection processes. This study gives us a deeper understanding of the intricate mechanisms and reasoning at play behind the process of modal choice among this group. In this way, we have a better basis for shaping and implementing measures to promote and encourage sustainable mobility, in such a way that the well-being of older people is also supported.

Plugging the patient evidence gap: what patients with swallowing disorders post-stroke say about thickened liquids.

BACKGROUND: Oropharyngeal dysphagia post-stroke is well known, with its presence increasing the risk of poor outcomes in particular aspiration and aspiration pneumonia. Management to minimize the risk of aspiration and improve swallow safety post-stroke includes the treatment of thickened liquids (TL), an established bolus modification intervention. Despite widespread use, there is a lack of robust empirical evidence and minimal patient evidence as to the experience and acceptability of using thickeners by people who experience dysphagia after a stroke. AIMS: To explore people with swallowing disorders post-stroke experiences of and acceptability regarding the bolus modification treatment of thickened liquids. METHODS & PROCEDURES: A qualitative, descriptive study exploring the experiences of individuals given TL after their stroke. A purposive sample of 14 adults was obtained with data collection and generation through the medium of individual semi-structured interviews. Inductive thematic analysis was used to analyse the data. OUTCOMES & RESULTS: Three overarching themes of 'uncertainty', 'an unpleasant experience' and 'a trade-off' were identified. These themes highlight that participants disliked TL and this dislike may have impacted clinically in terms of adherence, hydration and quality of life. Lack of sensory appeal was important in framing patient dislike. Participants' involvement in and understanding of reasons for prescription of TL was poor leading to uncertainty regarding the treatment. Notwithstanding, some participants felt it was necessary for their stroke recovery. CONCLUSIONS & IMPLICATIONS: TL can be considered a burdensome treatment from multiple perspectives including product palatability, treatment uncertainty and treatment adherence issues. Despite intensely disliking this treatment, some patients ultimately understand why the treatment is prescribed. Improvements in product palatability are required in order to improve adherence and patient quality of life. Consideration of other treatment options and newer products to manage aspiration post-stroke is also warranted.

What information is used in treatment decision aids? A systematic review of the types of evidence populating health decision aids.

BACKGROUND: Patient decision aids (DAs) are support tools designed to provide patients with relevant information to help them make informed decisions about their healthcare. While DAs can be effective in improving patient knowledge and decision quality, it is unknown what types of information and evidence are used to populate such decision tools. METHODS: Systematic methods were used to identify and appraise the relevant literature and patient DAs published between 2006 and 2015. Six databases (Academic Search Complete, AMED, CINAHL, Biomedical Reference Collection, General Sciences and MEDLINE) and reference list searching were used. Articles evaluating the effectiveness of the DAs were appraised using the Cochrane Risk of Bias tool. The content, quality and sources of evidence in the decision aids were evaluated using the IPDASi-SF and a novel classification system. Findings were synthesised and a narrative analysis was performed on the results. RESULTS: Thirteen studies representing ten DAs met the inclusion criteria. The IPDASI-SF score ranged from 9 to 16 indicating many of the studies met the majority of quality criteria. Sources of evidence were described but reports were sometimes generic or missing important information. The majority of DAs incorporated high quality research evidence including systematic reviews and meta-analyses. Patient and practice evidence was less commonly employed, with only a third of included DAs using these to populate decision aid content. The quality of practice and patient evidence ranged from high to low. Contextual factors were addressed across all DAs to varying degrees and covered a range of factors. CONCLUSIONS: This is an initial study examining the information and evidence used to populate DAs. While research evidence and contextual factors are well represented in included DAs, consideration should be given to incorporating high quality information representing all four pillars of evidence based practice when developing DAs. Further, patient and expert practice evidence should be acquired rigorously and DAs should report the means by which such evidence is obtained with citations clearly provided.

The Family Medicine Integrated Clinical Pathways Project (FM ICliP): Methods of development and implementation

Continuing care in family and community medicine is a dynamic process that requires regular patient assessments and adjustments of treatment strategies as the patient goes through the wellness and disease process. Family and community physicians need to be aware of any changes in the patient's clinical condition and re-assess therapeutic interventions when such changes occur. The use of clinical pathways can optimize the management of patients with a given disorder in our setting. The overall goal of the project is to improve the quality of health care in Philippine family and community medicine practice.Clinical pathway is defined as a "tool to guide family and community medicine practitioners to implement evidence- based care and holistic interventions to specific group of patients and populations within a specific timeframe adjusted for acceptable variations that may be due to patient and practice setting characteristics designed to achieve optimum health outcome for the patient and community and efficient use of health care resources." In this definition, holistic interventions refer to interventions directed to the individual patient within the context of the family and community. In this context the PAFP Clinical Pathways Project will be developed to promote and implement the clinical pathways in family and community medicine. The PAFP Clinical Pathways Project will be implemented by a group who will review published medical literature to identify, summarize and operationalize the clinical content of diagnostics, interventions and clinical indicators or outcomes to develop an evidence-based clinical pathway in family medicine practice. The group will also identify processes and indicators to measure the effect of implementation of clinical pathways. Linear time-related representations of patient care processes, in terms of assessments, pharmacologic and non-pharmacologic interventions as well as social and community strategies to prevent complications and maintain wellness will be developed. The clinical pathways will be disseminated to the general PAFP membership and other stakeholders for consensus development. We hope that with this process, family and community medicine practitioners will be dedicated to a common goal and overcome organizational, personal, and professional perspectives barriers to the implementation of the clinical pathway.The implementation of the clinical pathways to be adopted by the PAFP will include a nation-wide dissemination, education, quality improvement initiatives and feedback. Dissemination will be in a form of publication in the Family Filipino Physician Journal, conference presentations and focused group discussions. Quality improvement activities will be in a form of patient record reviews, audit and feedback. Audit standards will be the assessment and intervention recommendations in the clinical pathway. Variations will be discussed in focused group meeting and feedback sessions. The clinical pathways recommendations may also be revised if the variations are justified. Quality improvement activities will also be used to identify barriers in the implementation of clinical pathway. An electronic medical information system may also be used to facilitate the implementation.To monitor the implementation of clinical pathways the PAFP need to select, define and use outcomes and impact to monitor the success of implementation. Outcomes and impact will be at the practice level and the organizational level. Practice level can be a simple count of family and community medicine practice using and applying the clinical pathways. Patient outcomes will also be measured based on quality improvement reports. Organizational outcomes can be activities of the PAFP devoted to the promotion, development, dissemination and implementation of clinical pathways.

The Family Medicine Integrated Clinical Pathways Project (FM ICliP): Methods of development and implementation

@#<p style="text-align: justify;">Continuing care in family and community medicine is a dynamic process that requires regular patient assessments and adjustments of treatment strategies as the patient goes through the wellness and disease process. Family and community physicians need to be aware of any changes in the patient's clinical condition and re-assess therapeutic interventions when such changes occur. The use of clinical pathways can optimize the management of patients with a given disorder in our setting. The overall goal of the project is to improve the quality of health care in Philippine family and community medicine practice.<br />Clinical pathway is defined as a "tool to guide family and community medicine practitioners to implement evidence- based care and holistic interventions to specific group of patients and populations within a specific timeframe adjusted for acceptable variations that may be due to patient and practice setting characteristics designed to achieve optimum health outcome for the patient and community and efficient use of health care resources." In this definition, holistic interventions refer to interventions directed to the individual patient within the context of the family and community. In this context the PAFP Clinical Pathways Project will be developed to promote and implement the clinical pathways in family and community medicine. The PAFP Clinical Pathways Project will be implemented by a group who will review published medical literature to identify, summarize and operationalize the clinical content of diagnostics, interventions and clinical indicators or outcomes to develop an evidence-based clinical pathway in family medicine practice. The group will also identify processes and indicators to measure the effect of implementation of clinical pathways. Linear time-related representations of patient care processes, in terms of assessments, pharmacologic and non-pharmacologic interventions as well as social and community strategies to prevent complications and maintain wellness will be developed. The clinical pathways will be disseminated to the general PAFP membership and other stakeholders for consensus development. We hope that with this process, family and community medicine practitioners will be dedicated to a common goal and overcome organizational, personal, and professional perspectives barriers to the implementation of the clinical pathway.<br />The implementation of the clinical pathways to be adopted by the PAFP will include a nation-wide dissemination, education, quality improvement initiatives and feedback. Dissemination will be in a form of publication in the Family Filipino Physician Journal, conference presentations and focused group discussions. Quality improvement activities will be in a form of patient record reviews, audit and feedback. Audit standards will be the assessment and intervention recommendations in the clinical pathway. Variations will be discussed in focused group meeting and feedback sessions. The clinical pathways recommendations may also be revised if the variations are justified. Quality improvement activities will also be used to identify barriers in the implementation of clinical pathway. An electronic medical information system may also be used to facilitate the implementation.<br />To monitor the implementation of clinical pathways the PAFP need to select, define and use outcomes and impact to monitor the success of implementation. Outcomes and impact will be at the practice level and the organizational level. Practice level can be a simple count of family and community medicine practice using and applying the clinical pathways. Patient outcomes will also be measured based on quality improvement reports. Organizational outcomes can be activities of the PAFP devoted to the promotion, development, dissemination and implementation of clinical pathways.</p>

Avian influenza rapidly induces antiviral genes in duck lung and intestine.

Ducks are the natural reservoir of influenza A and survive infection by most strains. To characterize the duck immune response to influenza, we sought to identify innate immune genes expressed early in an infection. We used suppressive subtractive hybridization (SSH) to construct 3 libraries enriched in differentially expressed genes from lung RNA of a duck infected with highly pathogenic avian influenza virus A/Vietnam/1203/04 (H5N1), or lung and intestine RNA of a duck infected with low pathogenic avian influenza A/mallard/BC/500/05 (H5N2) compared to a mock-infected duck. Sequencing of 1687 clones identified a transcription profile enriched in genes involved in antiviral defense and other cellular processes. Major histocompatibility complex class I (MHC I), interferon induced protein with tricopeptide repeats 5 (IFIT5), and 2'-5' oligoadenylate synthetase-like gene (OASL) were increased more than 1000-fold in relative transcript abundance in duck lung at 1dpi with highly pathogenic VN1203. These genes were induced much less in lung or intestine following infection with low pathogenic BC500. The expression of these genes following infection suggests that ducks initiate an immediate and robust response to a potentially lethal influenza strain, and a minimal response to a low pathogenic strain.

Collaboration to transform care.

Transforming Care is an improvement initiative introduced at Betsi Cadwaladr University Health Board in October 2010. The health board collaborated with a university to develop a degree module to support its implementation. This article describes the delivery and evaluation of the module, and how Transforming Care is helping to unite a newly formed organisation.

Pulmonary embolism presenting as non-ST elevation myocardial infarction: a case report.

We describe a case which highlights the difficulties in diagnosing pulmonary embolism as it can mimic other conditions. In a patient with chest pain with raised troponin, a diagnosis of pulmonary embolism should also be considered as well if the clinical picture does not fit with myocardial infarction. Otherwise, the diagnosis of pulmonary embolism can be easily missed and patients may not receive appropriate treatment resulting in increased mortality.

Changes in information behavior in clinical teams after introduction of a clinical librarian service.

OBJECTIVES: The eighteen-month evaluation of a clinical librarian project (October 2003-March 2005) conducted in North Wales, United Kingdom (UK) assessed the benefits of clinical librarian support to clinical teams, the impact of mediated searching services, and the effectiveness of information skills training, including journal club support. METHODS: The evaluation assessed changes in teams' information-seeking behavior and their willingness to delegate searching to a clinical librarian. Baseline (n = 69 responses, 73% response rate) and final questionnaire (n = 57, 77% response rate) surveys were complemented by telephone and face-to-face interviews (n = 33) among 3 sites served. Those attending information skills training sessions (n = 130) completed evaluations at the session and were surveyed 1 month after training (n = 24 questionnaire responses, n = 12 interviews). RESULTS: Health professionals in clinical teams reported that they were more willing to undertake their own searching, but also more willing to delegate some literature searching, than at the start of the project. The extent of change depended on the team and the type of information required. Information skills training was particularly effective when organized around journal clubs. CONCLUSIONS: Collaboration with a clinical librarian increased clinician willingness to seek information. Clinical librarian services should leverage structured training opportunities such as journal clubs.

Neuroimaging of NREM sleep in primary insomnia: a Tc-99-HMPAO single photon emission computed tomography study.

STUDY OBJECTIVES: The objectives of this study were to: 1) demonstrate the feasibility of combining polysomnography and SPECT neuroimaging to study NREM sleep in primary insomnia and 2) evaluate possible functional CNS abnormalities associated with insomnia. DESIGN: Patients with insomnia and good sleeper controls were studied polysomnographically for three nights with a whole brain SPECT Scan of NREM sleep on Night 3. Groups were screened for medical/psychiatric history, substance use, and matched on age, body mass index, and education. SETTING: Sleep Research Laboratory and Nuclear Medicine Center PARTICIPANTS: Nine females, 5 patients with chronic psychophysiologic insomnia and 4 healthy good sleepers (mean age 36 years, SD 12, range 27-55). INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Tomographs of regional cerebral blood flow during the 1st NREM sleep cycle were successfully obtained. Contrary to our expectations, patients with insomnia showed a consistent pattern of hypoperfusion across all 8 pre-selected regions of interest, with particular deactivation in the basal ganglia (p=.006). The frontal medial, occipital, and parietal cortices also showed significant decreases in blood flow compared to good sleepers (p<.05). Subjects with insomnia had decreased activity in the basal ganglia relative to the frontal lateral cortex, frontal medial cortex, thalamus, occipital and parietal cortices (p<.05). CONCLUSIONS: This study demonstrated the feasibility of combining neuroimaging and polysomnography to study cerebral activity in chronic insomnia. These preliminary results suggest that primary insomnia may be associated with abnormal central nervous system activity during NREM sleep that is particularly linked to basal ganglia dysfunction.