Implementation and expansion of inpatient and ambulatory pharmacist credentialing and privileging at an academic medical center.

PURPOSE: This article highlights one academic medical center's effort to implement a complete credentialing and privileging (C&P) process for both inpatient and ambulatory clinical pharmacists. SUMMARY: The C&P process offers a recognized method to advance pharmacy practice. Credentialing is defined as a process whereby an individual is deemed qualified in a specific subject matter area. Privileging is the process whereby an institution grants authority to an individual to perform services based on credentials. Federal guidelines permit pharmacists to obtain the same level of privileges as professional medical staff, such as physicians, if relevant state laws allow for the corresponding pharmacist scope of practice. States establish laws and regulations that specify the scope of practice for various types of licensed healthcare professionals, including pharmacists. Many health systems have attempted pharmacist C&P practices in both the inpatient and ambulatory care setting with varying degrees of success and reach. Privileged pharmacists provide established benefits and value to other members of the healthcare team. Oregon Health & Science University (OHSU) pursued C&P for both inpatient and ambulatory clinical pharmacists. Initiation and implementation processes were complex and accompanied by a variety of challenges. CONCLUSION: OHSU operates with advanced pharmacy practice integrated into the interdisciplinary patient care team. Pharmacist C&P allows pharmacists to demonstrate significant clinical benefits and quality improvement in patient care delivery in both inpatient and ambulatory settings.

The TeMPO trial (treatment of meniscal tears in osteoarthritis): rationale and design features for a four arm randomized controlled clinical trial.

BACKGROUND: Meniscal tears often accompany knee osteoarthritis, a disabling condition affecting 14 million individuals in the United States. While several randomized controlled trials have compared physical therapy to surgery for individuals with knee pain, meniscal tear, and osteoarthritic changes (determined via radiographs or magnetic resonance imaging), no trial has evaluated the efficacy of physical therapy alone in these subjects. METHODS: The Treatment of Meniscal Tear in Osteoarthritis (TeMPO) Trial is a four-arm multi-center randomized controlled clinical trial designed to establish the comparative efficacy of two in-clinic physical therapy interventions (one focused on strengthening and one containing placebo) and two protocolized home exercise programs. DISCUSSION: The goal of this paper is to present the rationale behind TeMPO and describe the study design and implementation strategies, focusing on methodologic and clinical challenges. TRIAL REGISTRATION: The TeMPO Trial was first registered at clinicaltrials.gov with registration No. NCT03059004 . on February 14, 2017.

The "3-Pack" Examination Is Critical for Comprehensive Evaluation of the Biceps-Labrum Complex and the Bicipital Tunnel: A Prospective Study.

PURPOSE: To determine the diagnostic value of the 3-Pack examination for biceps-labrum complex (BLC) disease, assess interobserver reliability, and generate an evidence-based diagnostic and therapeutic algorithm. METHODS: A total of 145 consecutive patients were enrolled in this prospective comparative study. The study included 116 chronically symptomatic patients indicated for arthroscopic subdeltoid transfer of the long head of the biceps tendon to the conjoint tendon and 29 asymptomatic comparison subjects. Each patient underwent examination that included the 3-Pack (active compression test [O'Brien sign], throwing test, and bicipital tunnel palpation) and traditional examination (Speed test; Yergason test; full can test; empty can test) in a blinded, randomized fashion by 3 investigators. Intraoperative BLC disease was prospectively categorized by location (inside, junctional, or bicipital tunnel). RESULTS: 3-Pack tests were highly sensitive (73% to 98%), but less specific (46% to 79%) for BLC in all 3 locations than some of the traditional tests, which were less sensitive (20% to 67%), but more specific (83% to 100%) for BLC disease in all 3 locations. With regard to hidden bicipital tunnel lesions, palpation and O'Brien sign were highly sensitive (97.8% and 95.7% respectively) and revealed high negative predictive value (NPV, 96.4% and 92.6% respectively). Speed and Yergason tests, conversely, were poorly sensitive but had high specificities (86.7% and 97.9%, respectively) and positive predictive value (76% and 92.3%, respectively). Inter-rater reliabilities were substantial to almost perfect for the 3-Pack examination (kappa 70% to 85%) and fair to moderate for the 4 traditional examinations (kappa 25% to 56%). CONCLUSIONS: The 3-Pack has excellent inter-rater reliability, sensitivity, and NPV and is a critical screening tool for BLC disease in all zones. Hidden extra-articular bicipital tunnel disease can reliably be excluded based on negative tenderness to palpation or a negative O'Brien sign (NPV 93% to 96%). LEVEL OF EVIDENCE: Level III, case control study.

Evaluation of Hip Internal and External Rotation Range of Motion as an Injury Risk Factor for Hip, Abdominal and Groin Injuries in Professional Baseball Players.

Normal hip range of motion (ROM) is essential in running and transfer of energy from lower to upper extremities during overhead throwing. Dysfunctional hip ROM may alter lower extremity kinematics and predispose athletes to hip and groin injuries. The purpose of this study is characterize hip internal/external ROM (Arc) and its effect on the risk of hip, hamstring, and groin injuries in professional baseball players. Bilateral hip internal and external ROM was measured on all baseball players (N=201) in one professional organization (major and minor league) during spring training. Players were organized according to their respective positions. All injuries were documented prospectively for an entire MLB season (2010 to 2011). Data was analyzed according to position and injuries during the season. Total number of players (N=201) with an average age of 24±3.6 (range=17-37). Both pitchers (N=93) and catchers (N=22) had significantly decreased mean hip internal rotation and overall hip arc of motion compared to the positional players (N=86). Players with hip, groin, and hamstring injury also had decreased hip rotation arc when compared to the normal group. Overall, there is a correlation between decreased hip internal rotation and total arc of motion with hip, hamstring, and groin injuries.

Variability in knee laxity in anterior cruciate ligament deficiency using a mechanized model.

PURPOSE: To establish normative values for the magnitude of anterior tibial translation (ATT) in the Lachman and pivot shift tests in the intact and anterior cruciate ligament (ACL)-deficient states, and to explore whether a correlation in ATT magnitude exists between the Lachman and pivot shift tests. METHODS: Twenty-six fresh frozen cadaveric hip-to-toe specimens were used. Mechanized testing was performed to simulate both a Lachman and pivot shift test with the ACL intact. Tests were repeated after sectioning the ACL. ATT was recorded using a computer navigation system. Difference in ATT after sectioning was calculated for each specimen. RESULTS: For the Lachman, mean lateral compartment ATT in the intact knee was 5.3 mm (SD = 2.8 mm). After sectioning the ACL, translation increased to 11.4 mm (SD = 3.9 mm; P < 0.05). For the mechanized pivot shift, mean lateral compartment ATT in the intact knee was -0.2 mm (SD = 2.6 mm). After sectioning the ACL, translation increased to 8.2 mm (SD = 3.1 mm; P < 0.05). No correlation in the magnitude of ATT was found between the intact and ACL-deficient knees for either the Lachman or pivot shift tests, or between both tests (Cronbach's α < 0.7). CONCLUSIONS: No correlation was found between the Lachman and pivot shift test in both the intact and ACL-deficient knee. This suggests that the Lachman cannot be used as a surrogate for the pivot shift as the magnitude of the Lachman did not predict the magnitude of the pivot shift.

Fascial augmentation tenorrhaphy for extensor tendon lacerations in the forearm.

Proximal lacerations of the extensor tendon apparatus can pose a surgical challenge, especially when located at the musculotendinous junction or in patients presenting late. We describe a technique to augment the suture repair of these injuries utilizing local harvested strips of dorsal forearm fascia.

Open lateral retinacular closure surgery for treatment of anterolateral knee pain and disability after arthroscopic lateral retinacular release.

BACKGROUND: Although lateral retinacular release (LR) surgery has historically been one of the most commonly used arthroscopic procedures for the treatment of patellar instability and anterior knee pain, it may be associated with complications and poor functional outcome measures. PURPOSE: To examine the clinical efficacy of open lateral retinacular closure (LRC), a novel but technically simple procedure in the treatment of disabling anterolateral knee pain, tenderness, and positive medial patellar apprehension testing in patients who have undergone prior arthroscopic LR surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The records of 22 patients who had previously undergone an arthroscopic LR and underwent a diagnostic arthroscopy and LRC were reviewed. Physical examination findings and symptoms after prior LR surgery, duration between LR and LRC surgeries, and arthroscopic findings immediately before LRC were analyzed. Preoperative and postoperative Lysholm knee scores and activity levels were compared, and subjective satisfaction ratings assessed. RESULTS: Average follow-up after LRC was 3.2 years. Mean preoperative Lysholm knee score was 46.5 (range, 25-90), which improved postoperatively to a mean score of 86 (range, 48-100). Fourteen percent of patients subjectively rated their preoperative function as fair and 86% as poor. Postoperatively, 82% rated themselves as good or excellent and 18% as fair, with all patients improving from the LRC procedure. All patients stated that they would have the procedure again for the same problem. CONCLUSION: Open LRC provides significant pain relief and improvement in functional knee outcome scores in patients with persistent pain and tenderness at the site of a previous lateral release and a positive medial patellar apprehension test. Lateral release procedures should be considered with caution. For patients with anterolateral knee pain and symptoms of medial patellar instability after lateral release, LRC may provide symptomatic relief and functional improvement.

Staged description of the Finkelstein test.

We have revisited the original description of the Finkelstein test and review the reasons for its subsequent erroneous description. We have also outlined a staged description of this test, which we have found to be reliable and minimally painful for the diagnosis of de Quervain's tendonitis within our clinical practice.