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ng during affected hand movement showed decreased brain activation among participants with the BDNF val(66)met polymorphism compared with those lacking this polymorphism, especially in the ipsilesional primary sensorimotor cortex contralateral to movement. These results echo findings in healthy people and suggest that genetic factors affecting the normal brain continue to be operative after stroke. The findings suggest a potential imaging-based endophenotype for the BDNF val(66)met polymorphism's effect on the motor system that may be useful in a clinical trial setting.
A hospital-based pediatric outpatient center, wanting to weave evidence into practice, initiated an update of knowledge, skills, and documentation patterns with its staff physical therapists and occupational therapists who treat people with congenital muscular torticollis (CMT). This case report describes 2 cycles of implementation (1) the facilitators and barriers to implementation and (2) selected quality improvement outcomes aligned with published clinical practice guidelines (CPGs).
The Pediatric Therapy Services of St Joseph's Regional Medical Center in New Jersey has 4 full-time, 1 part-time, and 3 per diem staff. Chart audits in 2012 revealed variations in measurement, interventions, and documentation that led to quality improvement initiatives. An iterative process, loosely following the knowledge-to-action cycle, included a series of in-service training sessions to review the basic anatomy, pathokinesiology, and treatment strategies for CMT; reading assignments of the available CPGs; journal revilementable recommendations.
Successful implementation of both clinical and documentation practices were facilitated by a multifaceted approach to knowledge translation that included a culture supportive of evidence-based practice, administrative support for training and documentation redesign, commitment by clinicians to embrace changes aimed at improved care, and clinical guidelines that provide implementable recommendations.People with Parkinson disease (PD) who show freezing of gait also have dysfunction in cognitive domains that interact with mobility. Specifically, freezing of gait is associated with executive dysfunction involving response inhibition, divided attention or switching attention, and visuospatial function. Nimodipine cell line The neural control impairments leading to freezing of gait have recently been attributed to higher-level, executive and attentional cortical processes involved in coordinating posture and gait rather than to lower-level, sensorimotor impairments. To date, rehabilitation for freezing of gait primarily has focused on compensatory mobility training to overcome freezing events, such as sensory cueing and voluntary step planning. Recently, a few interventions have focused on restitutive, rather than compensatory, therapy. Given the documented impairments in executive function specific to patients with PD who freeze and increasing evidence of overlap between cognitive and motor function, incorporating cognitive challenges with mobility training may have important benefits for patients with freezing of gait. Thus, a novel theoretical framework is proposed for exercise interventions that jointly address both the specific cognitive and mobility challenges of people with PD who freeze.
The current state of health care demands higher-value care. Due to many barriers, clinicians routinely do not implement evidence-based care even though it is known to improve quality and reduce cost of care. The purpose of this case report is to describe a theory-based, multitactic implementation of a quality improvement process aimed to deliver higher-value physical therapy for patients with low back pain.
Patients were treated from January 2010 through December 2014 in 1 of 32 outpatient physical therapy clinics within an academic health care system. Data were examined from 47,755 patients (mean age=50.3 years) entering outpatient physical therapy for management of nonspecific low back pain, with or without radicular pain. Development and implementation tactics were constructed from adult learning and change management theory to enhance adherence to best practice care among 130 physical therapists. A quality improvement team implemented 4 tactics establish care delivery expectations, facilitate peer-leddence-based care can be overcome, creating an environment supportive of delivering higher-value physical therapy for patients with low back pain.
The correct identification of patients with Parkinson disease (PD) at risk for falling is important to initiate appropriate treatment early.
This study compared the Fullerton Advanced Balance (FAB) scale with the Mini-Balance Evaluation Systems Test (Mini-BESTest) and Berg Balance Scale (BBS) to identify individuals with PD at risk for falls and to analyze which of the items of the scales best predict future falls.
This was a prospective study to assess predictive criterion-related validity.
The study was conducted at a university hospital in an urban community.
Eighty-five patients with idiopathic PD (Hoehn and Yahr stages 1-4) participated in the study.
Measures were number of falls (assessed prospectively over 6 months), FAB scale, Mini-BESTest, BBS, and Unified Parkinson's Disease Rating Scale.
The FAB scale, Mini-BESTest, and BBS showed similar accuracy to predict future falls, with values for area under the curve (AUC) of the receiver operating characteristic (ROC) curve of 0.68, 0.65, andf the 3 scales contribute to the detection of future falls. Clinicians should particularly focus on the item "tandem stance" along with the items "one-leg stance," "rise to toes," "compensatory stepping backward," "turning 360°," and "placing foot on stool" when analyzing postural control deficits related to fall risk. Future research should analyze whether balance training including the aforementioned items is effective in reducing fall risk.The NADPH-dependent human carbonyl reductase 1 (hCBR1), a member of the short-chain dehydrogenase/reductase protein family, plays an important role in the ubiquitous metabolism of endogenous and xenobiotic carbonyl containing compounds. Glutathione (GSH) is also a cofactor of hCBR1, however, its role in the carbonyl reductase function of the enzyme is still unclear. In this study, we presented the crystal structure of hCBR1 in complex with GSH, in the absence of its substrates or inhibitors. Interestingly, we found that the GSH molecule presents in a configuration quite different from that was previously reported when substrate is binding to hCBR1. Our structure indicates that GSH contributes to the substrate selectivity of hCBR1 and protects the catalytic center of hCBR1 through a switch-like mechanism. The isothermal titration calorimetry and enzymology data shows that GSH directly binding with hCBR1 when there's no substrate exist. The enzymology data also shows GSH protects NADPH being attacked by oxidative small molecules. This is the first time that GSH is found to demonstrate such functions as a co-enzyme. Our crystal structure succeeds in providing critical insights into the substrate selectivity of hCBR1 and the interaction between hCBR1 and GSH.
Most strategies used to help improve the patient experience of care and ease emergency department (ED) crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both.
To compare the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) on the patient experience of care in a medium-size safety net ED.
This paper describes a study of a single ED wherein the department first undertook a physical expansion (2006 Q2 to 2007 Q2) followed by a reorganization of patient flow and establishment of an RAU (2009 Q2) by the use of an interrupted time series analysis.
In the time period after ED expansion, significant negative trends were observed decreasing Press Ganey percentiles (-4.1 percentile per quarter), increasing door-to-provider time (+4.9 minutes per quarter), increasing duration of stay (+13.2 minutes per quarter), and increasing percent of patients leaving without being seen (+0.11 per quarter). After the RAU was established, significant immediate impacts were observed for door-to-provider time (-25.8 minutes) and total duration of stay (-66.8 minutes). The trends for these indicators further suggested the improvements continued to be significant over time. Furthermore, the negative trends for the Press Ganey outcomes observed after ED expansion were significantly reversed and in the positive direction after the RAU.
Our results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion.
Our results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion.We sought to determine temporal changes in COD and identify COD-specific risk factors in pediatric primary HTx recipients. Using the ISHLT registry, time-dependent hazard of death after pediatric HTx, stratified by COD, was analyzed by multiphasic parametric hazard modeling with multivariable regression models for risk factor analysis. The proportion of pediatric HTx deaths from each of cardiovascular cause, allograft vasculopathy, and malignancy increased over time, while all other COD decreased post-HTx. Pre-HTx ECMO was associated with increased risk of death from graft failure (HR 2.43; p less then 0.001), infection (HR 2.85; p less then 0.001), and MOF (HR 2.22; p = 0.001), while post-HTx ECMO was associated with death from cerebrovascular events/bleed (HR 2.55; p = 0.001). CHD was associated with deaths due to pulmonary causes (HR 1.78; p = 0.007) or infection (HR 1.72; p less then 0.001). Non-adherence was a significant risk factor for all cardiac COD, notably graft failure (HR 1.66; p = 0.001) and rejection (HR 1.89; p less then 0.001). Risk factors related to specific COD are varied across different temporal phases post-HTx. Increased understanding of these factors will assist in risk stratification, guide anticipatory clinical decisions, and potentially improve patient survival.
Associations between patient-reported outcomes and mucosal healing have not been established in ulcerative colitis (UC).
To evaluate relationships of rectal bleeding and stool frequency with mucosal healing and quality of life (QoL) in patients with UC in two Phase 3 studies (ULTRA 1 and 2).
Associations of patient-reported rectal bleeding and stool frequency subscores with mucosal healing (Mayo endoscopy subscore=0 or 0/1) and QoL [inflammatory bowel disease questionnaire (IBDQ)] were assessed in adalimumab-randomised patients (160/80mg at Weeks 0/2 followed by 40mg biweekly or weekly) at Weeks 8 (n=433) and 52 (n=299), and in patients with mucosal healing [endoscopy subscore=0 (n=17); 0/1 (n=52)] at Weeks 8 and 52.
At Week 8, the positive predictive values (PPVs) of rectal bleeding subscore=0, stool frequency subscore=0 or both scores=0 for endoscopy subscore=0/1 were 69%, 84% and 90% respectively; all proportions increased at Week 52. Equivalent PPVs for these subscores in patients with endoscopy subscore=0 were 26%, 37% and 46% respectively.
