Models, strategies, and tools. Theory in implementing evidence-based findings into health care practice

This paper presents a case for careful consideration of theory in planning to implement evidence-based practices into clinical care. As described, theory should be tightly linked to strategic planning through careful choice or creation of an implementation framework. Strategies should be linked to specific interventions and/or intervention components to be implemented, and the choice of tools should match the interventions and overall strategy, linking back to the original theory and framework. The thesis advanced is that in most studies where there is an attempt to implement planned change in clinical processes, theory is used loosely. An example of linking theory to intervention design is presented from a Mental Health Quality Enhancement Research Initiative effort to increase appropriate use of antipsychotic medication among patients with schizophrenia in the Veterans Health Administration.     

Weight maintenance: challenges,tools and strategies for primary care physicians

Obesity is recognized as a chronic disease and one of the major healthcare challenges facing us today. Weight loss can be achieved via lifestyle, pharmacological and surgical interventions, but weight maintenance remains a lifetime challenge for individuals with obesity. Guidelines for the management of obesity have highlighted the role of primary care providers (PCPs). This review examines the long‐term outcomes of clinical trials to identify effective weight maintenance strategies that can be utilized by PCPs. Because of the broad nature of the topic, a structured PubMed search was conducted to identify relevant research articles, peer‐reviewed reviews, guidelines and articles published by regulatory bodies. Trials have demonstrated the benefit of sustained weight loss in managing obesity and its comorbidities. Maintaining 5–10% weight loss for ≥1 year is known to ameliorate many comorbidities. Weight maintenance with lifestyle modification – although challenging – is possible but requires long‐term support to reinforce diet, physical activity and behavioural changes. The addition of pharmacotherapy to lifestyle interventions promotes greater and more sustained weight loss. Clinical evidence and recently approved pharmacotherapy has given PCPs improved strategies to support their patients with maintenance of weight loss. Further studies are needed to assess the translation of these strategies into clinical practice.     

Rapid prototyping to create vascular replicas from CT scan data: making tools to teach, rehearse, and choose treatment strategies.

Our goal was to develop and prove the accuracy of a system that would allow us to re-create live patient arterial pathology. Anatomically accurate replicas of blood vessels could allow physicians to teach and practice dangerous interventional techniques and might also be used to gather basic physiologic information. The preparation of replicas has, until now, depended on acquisition of fresh cadaver material. Using rapid prototyping, it should be able to replicate vascular pathology in a live patient. We obtained CT angiographic scan data from two patients with known arterial abnormalities. We took such data and, using proprietary software, created a 3D replica using a commercially available rapid prototyping machine. From the prototypes, using a lost wax technique, we created vessel replicas, placed those replicas in the CT scanner, then compared those images with the original scans. Comparison of the images made directly from the patient and from the replica showed that with each step, the relationships were maintained, remaining within 3% of the original, but some smoothing occurred in the final computer manipulation. From routinely obtainable CT angiographic data, it is possible to create accurate replicas of human vascular pathology with the aid of commercially available stereolithography equipment. Visual analysis of the images appeared to be as important as the measurements. With 64 and 128 slice detector scanners becoming available, acquisition times fall enough that we should be able to model rapidly moving structures such as the aortic root.     

In-training gastrointestinal endoscopy competency assessment tools: Types of tools,validation and impact

The ability to perform endoscopy procedures safely, effectively and efficiently is a core element of gastroenterology practice. Training programs strive to ensure learners demonstrate sufficient competence to deliver high quality endoscopic care independently at completion of training. In-training assessments are an essential component of gastrointestinal endoscopy education, required to support training and optimize learner's capabilities. There are several approaches to in-training endoscopy assessment from direct observation of procedural skills to monitoring of surrogate measures of endoscopy skills such as procedural volume and quality metrics. This review outlines the current state of evidence as it pertains to in-training assessment of competency in performing gastrointestinal endoscopy as part of an overall endoscopy quality and skills training program.     

Models, Strategies, and Tools

This paper presents a case for careful consideration of theory in planning to implement evidence-based practices into clinical care. As described, theory should be tightly linked to strategic planning through careful choice or creation of an implementation framework. Strategies should be linked to specific interventions and/or intervention components to be implemented, and the choice of tools should match the interventions and overall strategy, linking back to the original theory and framework. The thesis advanced is that in most studies where there is an attempt to implement planned change in clinical processes, theory is used loosely. An example of linking theory to intervention design is presented from a Mental Health Quality Enhancement Research Initiative effort to increase appropriate use of antipsychotic medication among patients with schizophrenia in the Veterans Health Administration.     

Diabetes and disabilities: assistive tools, services, and information

The purpose of this guide is to provide diabetes educators with a comprehensive list of assistive tools, services, and information for diabetes self-management for people with visual, manual, and hearing disabilities. A list of tools and products has been compiled by members of the Disabilities Specialty Practice Group (DSPG) and is updated periodically. The original list was assembled in 1988 with the support of a grant from the Diabetes Research and Education Foundation, Bridgewater, New Jersey. The last revised list was titled "Diabetes Aids and Products for People With Visual or Physical Impairment" and was published in Diabetes Educ. 1992;18:121-138. In addition to tools and products, organizations that provide services and information for people with disabilities are provided to diabetes educators.     

Models, standards, guidelines

This article reviews the current illness experience for elders, highlights key issues that cause suffering and affect the quality of life of elders in our society, and reviews the definition and the process for providing palliative care. A consensus-building process is described, which any hospice or palliative care organization can use to adapt existing consensus and evidence-based models, standards of practice, and preferred practice guidelines and engage all staff and stakeholders in the development of an organizational model to guide day-to-day practices and improve the quality of all its activities.     

Oxidative damage,aging and anti-aging strategies

The last two decades brought remarkable insight into the nature of normal aging in multicellular organisms. However, we are still far away from realizing extension of maximum lifespan in humans. An important modulator of lifespan is oxidative damage induced by reactive species, such as reactive oxygen species (ROS). Studies from yeast, Caenorhabditis and Drosophila primarily focused on (1) reduced generation or (2) elimination of ROS but have two principal shortcomings: (1) dietary restriction and single gene mutations are often associated with physiological impairments and (2) overexpression of components of the antioxidant system extend lifetime only under stress-induced conditions. Recent results from Drosophila indicate the involvement of an endogenous repair and elimination system for oxidatively damaged proteins in the process of aging. This system includes methionine sulfoxide reductase A (MSRA) and the carbonyl reductase Sniffer, the protein-ubiquitin ligase Parkin and the chaperone Hsp22. In this review we summarize different anti-aging strategies and discuss a synergistic interaction between protection against free radicals and specific repair/elimination of oxidative damage in lifespan extension primarily using the model system Drosophila. To achieve lifespan extension, available experiments are often methodically grouped into (1) caloric restriction, (2) single gene mutation, and (3) overexpression of genes. Here we summarize different strategies by a more causal classification: (1) prevention of ROS generation, (2) reducing free ROS level, and (3) repair and elimination of ROS-damaged proteins.     

Phaeochromocytoma, new genes and screening strategies

Following recent advances in the genetics of phaeochromocytomas and paragangliomas, the members of the European Network for the Study of Adrenal Tumours (ENS@T) Phaeochromocytoma Working Group have decided to share their genotyping data and to propose European recommendations for phaeochromocytoma/functional paraganglioma (PH/FPGL) genetic testing. Germline DNA from 642 patients was analysed by ENS@T teams. In 166 patients (25.9%) the disease was familial and caused by germline mutations in VHL (56), SDHB (34), SDHD (31), RET (31) or NF1 (14), causing von Hippel-Lindau disease, SDHB- or SDHD-PH/FPGL syndromes, multiple endocrine neoplasia type 2 (MEN 2) and type 1 neurofibromatosis (NF1), respectively. In almost 60% of inherited cases it was possible to formulate a probable genetic diagnosis based on family history and/or typical syndromic presentation. Genetic testing revealed mutations in 12.7% of cases with an apparently sporadic presentation. Several clinical characteristics, such as young age at onset, the presence of bilateral, extra-adrenal or multiple tumours or a malignant tumour, should be seen as indications for genetic testing. The ENS@T Phaeochromocytoma Working Group recommends the genetic testing of all patients with PH and FPGL and suggests a practice algorithm for the management of their exploration.     

Animal Models,Prophylaxis, and Therapeutics for Arenavirus Infections

Arenaviruses are enveloped, bipartite negative single-stranded RNA viruses that can cause a wide spectrum of disease in humans and experimental animals including hemorrhagic fever. The majority of these viruses are rodent-borne and the arenavirus family can be divided into two groups: the Lassa-Lymphocytic choriomeningitis serocomplex and the Tacaribe serocomplex. Arenavirus-induced disease may include characteristic symptoms ranging from fever, malaise, body aches, petechiae, dehydration, hemorrhage, organ failure, shock, and in severe cases death. Currently, there are few prophylactic and therapeutic treatments available for arenavirus-induced symptoms. Supportive care and ribavirin remain the predominant strategies for treating most of the arenavirus-induced diseases. Therefore, efficacy testing of novel therapeutic and prophylactic strategies in relevant animal models is necessary. Because of the potential for person-to-person spread, the ability to cause lethal or debilitating disease in humans, limited treatment options, and potential as a bio-weapon, the development of prophylactics and therapeutics is essential. This article reviews the current arenavirus animal models and prophylactic and therapeutic strategies under development to treat arenavirus infection.