Factors affecting length of stay after posterior spinal fusion for adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: Determine factors that influence hospital length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. Standardized care pathways decrease variability in care, improve patient outcomes, and decrease cost. Specifically, global care pathway development using Lean process mapping for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) has been shown to lead to a significant decrease in postoperative length of stay. Assessment of variables that affect length of stay after pathway implementation may identify opportunities for additional process refinement to further decrease postoperative length of stay and improve pathway efficiency. METHODS: A standardized care pathway was implemented at our institution for all patients undergoing posterior spinal fusion for AIS. This pathway was developed using the Lean process mapping technique to create evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care. Patient and care-related variables in these time periods were assessed to determine those factors that significantly affected postoperative length of stay. RESULTS: Preoperative factors associated with a prolonged postoperative length of stay included patient ethnicity (non-Hispanic > Hispanic, p = 0.035) and gender (female > male, p = 0.039). Significant intraoperative factors included longer surgical time (p < 0.001), increased number of fusion levels (p = 0.034), and higher volume of crystalloid administered (p = 0.011). Significant postoperative factors were higher average pain scores on the first postoperative day (p < 0.001) and higher cumulative morphine use (p < 0.001). CONCLUSIONS: Use of a standardized care pathway for the treatment of patients with AIS can decrease postoperative length of stay. Despite a carefully designed pathway, variability persists in aspects of care that can impact length of stay, including surgical efficiency, intraoperative fluid and blood management, and postoperative pain management. Continued process improvement focused on these variables will likely further improve the effectiveness of standardized pathways for patients with AIS. LEVEL OF EVIDENCE: Level III.

"Reasonable adjustments" under the UK's Equality Act 2010: An enquiry into the care and treatment to patients with intellectual disabilities in acute hospital settings.

OBJECTIVES: To understand the views of qualified medical practitioners regarding "reasonable adjustments" and the quality of the care and treatment provided to adults with intellectual disabilities when admitted to acute hospitals as inpatients. METHODS: Semi-structured interviews took place with 14 medical practitioners, seven from each of two acute hospitals, with a thematic analysis of the resulting data. RESULTS: All 14 medical practitioners reported problems in the diagnosis and treatment of patients with intellectual disabilities. Most participants attributed these difficulties to communication problems and/or behaviours that, in the context of a hospital ward, were non-conforming. However, a minority reported that, because they were likely to have multiple comorbid health conditions, patients with intellectual disabilities were more complex. In addition, half of all these respondents reported making little use of "reasonable adjustments" introduced to improve the quality of the care received by this group of patients. CONCLUSIONS: Medical practitioners should make better use of the "reasonable adjustments" introduced in the UK to address inequities in care and treatment received by patients with intellectual disabilities. However, training should also focus on the biomedical complexities often presented by these men and women.

How Health Care Professionals Evaluate a Digital Intervention to Improve Medication Adherence: Qualitative Exploratory Study.

BACKGROUND: Medication nonadherence poses a serious and a hard-to-tackle problem for many chronic diseases. Electronic health (eHealth) apps that foster patient engagement and shared decision making (SDM) may be a novel approach to improve medication adherence. OBJECTIVE: The aim of this study was to investigate the perspective of health care professionals regarding a newly developed digital app aimed to improve medication adherence. Familial hypercholesterolemia (FH) was chosen as a case example. METHODS: A Web-based prototype of the eHealth app-MIK-was codesigned with patients and health care professionals. After user tests with patients, we performed semistructured interviews and user tests with 12 physicians from 6 different hospitals to examine how the functionalities offered by MIK could assist physicians in their consultation and how they could be integrated into daily clinical practice. Qualitative thematic analysis was used to identify themes that covered the physicians' evaluations. RESULTS: On the basis of the interview data, 3 themes were identified, which were (1) perceived impact on patient-physician collaboration; (2) perceived impact on the patient's understanding and self-management regarding medication adherence; and (3) perceived impact on clinical decisions and workflow. CONCLUSIONS: The eHealth app MIK seems to have the potential to improve the consultation between the patient and the physician in terms of collaboration and patient engagement. The impact of eHealth apps based on the concept of SDM for improving medication-taking behavior and clinical outcomes is yet to be evaluated. Insights will be useful for further development of eHealth apps aimed at improving self-management by means of patient engagement and SDM.

Perioperative Surgical Home in Pediatric Settings: Preliminary Results.

BACKGROUND: The Perioperative Surgical Home (PSH) is a patient-centered, team-based approach that aims to improve the value of perioperative care. We implemented a PSH for patients with adolescent idiopathic scoliosis who were undergoing posterior spinal fusion at Children's National Health System. We hypothesized that this PSH would improve patient surgical outcomes and reduce hospital length of stay (LOS). METHODS: A multidisciplinary group created evidence-based protocols for the preoperative, operative, postoperative, and postdischarge care of this patient population. After a 5-month design and training period, PSH for spinal fusion was implemented in March 2015, with reduction in LOS as the primary outcome measure. Anesthesia comanagement of patients additionally allowed a new pathway for patients to recover in the postanesthesia care unit and reduce intensive care unit utilization. Patients before and after the implementation of the PSH were compared on clinical and efficiency metrics. RESULTS: The spinal fusion PSH achieved the primary outcome measure by a significant reduction in LOS. Care improvement was illustrated by achievement of the secondary outcome measure of reduced perioperative transfusion. CONCLUSIONS: The PSH model presented a ready structure that proved successful at our institution for patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion.

A retrospective assessment of the use of naltrexone implants for the treatment of problematic amphetamine use.

BACKGROUND: At present there is no registered effective pharmacotherapy for the treatment of problematic amphetamine use. OBJECTIVES: This study aims to examine self-reported abstinence from amphetamines following treatment with a sustained release naltrexone preparation in patients with self and clinically identified problems with amphetamine use and the relationship between naltrexone blood levels and abstinence from amphetamines. METHODS: Forty-four patients with problematic amphetamine use, who were treated with a naltrexone implant, completed an interview evaluating self-reported reduction in amphetamine use following treatment. Additional data were collected from the patients' clinical treatment files. RESULTS: Of the 44 subjects, 29 (65.9%) interviewed reported that following treatment they ceased using and maintained abstinence from amphetamines for at least 1 month. Of these patients, 14 (48.3%) were reportedly still abstinent at 6 months. Rates of abstinence were found to be 2.27 times higher (95% CI 1.38-3.74) in patients when blood naltrexone levels were above 2 ng/ml, with rates as high as 100% and 90.9% for ≥5 and ≥2 ng/ml, respectively, compared with 42.9% for 1-2 ng/ml and 38.9% low less than 1 ng/ml. CONCLUSIONS: Although this study has several limitations, the findings provide preliminary data in support of the use of implant naltrexone for the treatment of problematic amphetamine use and suggest that naltrexone levels above 2 ng/ml should be targeted for use in patients. SCIENTIFIC SIGNIFICANCE: Data supports the use of implant naltrexone, as a treatment for problematic amphetamine use, for which there is currently no registered pharmacotherapy. However, further research is required.

Preclinical pharmacology of sugammadex.

Since the introduction of nondepolarizing neuromuscular blocking agents, acetylcholinesterase inhibitors have been used to increase the speed of recovery from neuromuscular blockade. The major disadvantages of acetylcholinesterase inhibitors are their lack of activity against profound neuromuscular blockade and their activity outside the neuromuscular junction resulting in unwanted side effects, requiring cotreatment with a muscarinic antagonist. An alternative to acetylcholinesterase inhibitors is the encapsulating agent sugammadex. This agent has been specifically designed to encapsulate the steroidal neuromuscular blocking agents rocuronium and vecuronium. This review describes the effects of sugammadex in in vitro tissue and in vivo animal experiments. The encapsulation approach allows reversal of any degree of neuromuscular blockade because the dose of sugammadex can be adjusted to encapsulate sufficient neuromuscular blocking molecules to cause effective reversal. Because this interaction is a drug-drug interaction, reversal can be achieved very fast but is limited by the circulation time. Sugammadex is also effective against neuromuscular blockade under conditions with reduced acetylcholine release, which potentiate the action of neuromuscular blocking agents. Sugammadex does not cause cholinergic side effects, preventing the need of coadministration of muscarinic antagonists. Because of these properties, sugammadex has the potential to become a very useful drug for the management of neuromuscular blockade.

Homoplasy in genome-wide analysis of rare amino acid replacements: the molecular-evolutionary basis for Vavilov's law of homologous series.

BACKGROUND: Rare genomic changes (RGCs) that are thought to comprise derived shared characters of individual clades are becoming an increasingly important class of markers in genome-wide phylogenetic studies. Recently, we proposed a new type of RGCs designated RGC_CAMs (after Conserved Amino acids-Multiple substitutions) that were inferred using genome-wide identification of amino acid replacements that were: i) located in unambiguously aligned regions of orthologous genes, ii) shared by two or more taxa in positions that contain a different, conserved amino acid in a much broader range of taxa, and iii) require two or three nucleotide substitutions. When applied to animal phylogeny, the RGC_CAM approach supported the coelomate clade that unites deuterostomes with arthropods as opposed to the ecdysozoan (molting animals) clade. However, a non-negligible level of homoplasy was detected. RESULTS: We provide a direct estimate of the level of homoplasy caused by parallel changes and reversals among the RGC_CAMs using 462 alignments of orthologous genes from 19 eukaryotic species. It is shown that the impact of parallel changes and reversals on the results of phylogenetic inference using RGC_CAMs cannot explain the observed support for the Coelomata clade. In contrast, the evidence in support of the Ecdysozoa clade, in large part, can be attributed to parallel changes. It is demonstrated that parallel changes are significantly more common in internal branches of different subtrees that are separated from the respective common ancestor by relatively short times than in terminal branches separated by longer time intervals. A similar but much weaker trend was detected for reversals. The observed evolutionary trend of parallel changes is explained in terms of the covarion model of molecular evolution. As the overlap between the covarion sets in orthologous genes from different lineages decreases with time after divergence, the likelihood of parallel changes decreases as well. CONCLUSION: The level of homoplasy observed here appears to be low enough to justify the utility of RGC_CAMs and other types of RGCs for resolution of hard problems in phylogeny. Parallel changes, one of the major classes of events leading to homoplasy, occur much more often in relatively recently diverged lineages than in those separated from their last common ancestor by longer time intervals of time. This pattern seems to provide the molecular-evolutionary underpinning of Vavilov's law of homologous series and is readily interpreted within the framework of the covarion model of molecular evolution.

Development of a real time reverse transcriptase polymerase chain reaction for the detection of bovine respiratory syncytial virus in clinical samples and its comparison with immunohistochemistry and immunofluorescence antibody testing.

Bovine respiratory syncytial virus is an agent involved in calf pneumonia complex, a disease of significant economic importance. Accurate diagnosis of the agents involved on farm premises is important when formulating disease control measures, including vaccination. We have developed a real time reverse transcriptase polymerase chain reaction (rtRT-PCR) and compared it with the diagnostic tests currently available in the United Kingdom: immunohistochemistry (IHC) and immunofluorescence antibody test (IFAT). The rtRT-PCR had a detection limit of 10 gene copies and was 96% efficient. Recent UK isolates and clinical samples were tested; the rtRT-PCR was more sensitive than both conventional tests.

Health facilitation in primary care seen from practice and education.

'Valuing People: A New Strategy for Learning Disability for the 21st Century' (Department of Health, 2001a,b) aimed to introduce 'health facilitation' to improve the identification of health needs and access to appropriate care for people with learning disabilities. One London Borough took a leading role in implementing this new function, in the form of dedicated, full-time health facilitators. The authors examined the implementation and its impact, employing an innovative collaboration between professionals from practice, education and research. The clinical nurse involved was observed during her first year of health facilitation. The authors evaluated her impact on professionals, people with learning disabilities and the wider system of health. In some areas (for example, information technology) the health facilitator could make little progress in one year. However, she connected with a widening circle of local people and services, for example, in introducing health action plans for adults with a learning disability. Across the Borough some professionals became more aware of specific health issues in their local population.

Preliminary nanopore cheminformatics analysis of aptamer-target binding strength.

BACKGROUND: Aptamers are nucleic acids selected for their ability to bind to molecules of interest and may provide the basis for a whole new class of medicines. If the aptamer is simply a dsDNA molecule with a ssDNA overhang (a "sticky" end) then the segment of ssDNA that complements that overhang provides a known binding target with binding strength adjustable according to length of overhang. RESULTS: Two bifunctional aptamers are examined using a nanopore detector. They are chosen to provide sensitive, highly modulated, blockade signals with their captured ends, while their un-captured regions are designed to have binding moieties for complementary ssDNA targets. The bifunctional aptamers are duplex DNA on their channel-captured portion, and single-stranded DNA on their portion with binding ability. For short ssDNA, the binding is merely to the complementary strand of DNA, which is what is studied here - for 5-base and 6-base overhangs. CONCLUSION: A preliminary statistical analysis using hidden Markov models (HMMs) indicates a clear change in the blockade pattern upon binding by the single captured aptamer. This is also consistent with the hypothesis that significant conformational changes occur during the annealing binding event. In further work the objective is to simply extend this ssDNA portion to be a well-studied approximately 80 base ssDNA aptamer, joined to the same bifunctional aptamer molecular platform.

Selective relaxant binding agents for reversal of neuromuscular blockade.

Traditionally, reversal of neuromuscular blockade during anaesthesia was achieved by increasing the acetylcholine concentration in the neuromuscular junction using acetylcholinesterase inhibitors. However, this is ineffective against profound blockade. Furthermore, the increase in acetylcholine level is not limited to the neuromuscular junction, resulting in unwanted side effects requiring co-treatment with muscarinic antagonists. Selective relaxant binding agents offer a new approach for the reversal of neuromuscular blockade: encapsulation of the neuromuscular blocking agent, resulting in inactivation. As part of this new approach, cyclodextrin molecules have been designed that selectively encapsulate steroidal neuromuscular blocking agents. Both animal and human experiments have demonstrated that fast, effective and complete recovery from both normal and profound neuromuscular blockade is now possible. Furthermore, these cyclodextrin derivatives do not have the unwanted side effects of acetylcholinesterase inhibitors.