Building immunization decision-making capacity within the World Health Organization European Region

A National Immunization Technical Advisory Group (NITAG) is a multi-disciplinary body of national experts that provides evidence-based recommendations to policy-makers, assisting them in making sound immunization policy and programme decisions. The World Health Organization (WHO) Regional Office for Europe is working to strengthen the capacity of newly-established NITAGs and has targeted efforts on low- and middle-income countries. The Regional Office, in collaboration with WHO Headquarters and USA Centers for Disease Control and Prevention (CDC), developed a new training strategy and held training workshops to improve NITAGs’ functioning and ability to make evidence-based recommendations. Feedback from countries that participated in trainings indicated that the updated training materials and interactive approach with follow-up technical support enabled them to align their NITAG charters and processes with WHO recommendations. To ensure continued progress, global and regional partners such as WHO and CDC should continue providing technical support to recently established NITAGs.     

Impact of serial gait analyses on long-term outcome of hippotherapy in children and adolescents with cerebral palsy

The aim of this study was to obtain data of gait parameters on predicting long-term outcome of hippotherapy. In 20 participants (4–19 years; GMFCS levels I to III) with cerebral palsy (CP), gait and balance abilities were examined after 10-m walking test using a portable motion recorder. Hippotherapy was associated with increased Gross Motor Function Measure (GMFM)-66 at 1 year from the baseline (P < 0.001). Hippotherapy increased stride length, walking speed, and mean acceleration and decreased horizontal/vertical displacement ratio over time (P < 0.05). Stride length and mean acceleration at 6 weeks predicted the elevation of GMFM-66 score. These data suggest that 1-year outcome of hippotherapy on motor and balance functions can be assessed from the early phase by serial monitoring of the gait parameters.     

The Sensational Hand: Clinical Assessment after Nerve Repair

Following the transection and repair of major nerve trunks in the forearm, the functional outcome is influenced by mechanisms in the peripheral, as well as in the central nervous system. In the present thesis the interest is focused on assessment of the outcome after nerve repair, central nervous factors influencing the outcome, and sense substitution to compensate for sensory loss. A new model instrument for routine documentation of the outcome after repair of a peripheral nerve is identified. The model includes assessments reflecting sensory, motor and pain/discomfort domains. Investigations of frequently used assessment instruments led to the construction and evaluation of a new test instrument for assessment of discriminative sensibility (tactile gnosis) to fit in the model. The summarised outcome, calculated from the model instrument and with a numerical scoring system, conforms well with the patient's opinion on the influence on activities of daily living resulting from the nerve injury, and demonstrates good reliability and validity. A reference interval for the outcome is presented, with the estimated 95% predicted values for the outcome up to five years after the nerve repair. Brain plasticity is a factor sensibility - tactile gnosis - in the adaptive process after a nerve injury, when the mind has to interpret new signal patterns, when objects are touched. For better understanding of the sensory outcome after nerve repair, central nervous factors were examined. Specific cognitive capacities, such as verbal learning and visuo-spatial logic capacity could be identified as being of importance for recovery of tactile gnosis. For patients with temporary or permanent sensory loss, a new principle for artificial sensibility based on sense substitution is presented. The hearing sense substitutes the sense of touch. The resemblance in perceptual experience between sound and touch is bridged by the stereophonic friction sound generated by touching objects, which is then amplified and transmitted to earphones. The delicate capacity of the sense of hearing to discriminate between the complex pattern of frequencies makes it reasonable to assume that hearing is able to take over functions normally devoted to touch. This is demonstrated in the thesis.     

Clinical implementation of systematic medication reconciliation and review as part of the Lund Integrated Medicines Management model – impact on all‐cause emergency department revisits

What is known and objective: Interventions involving medication reconciliation and review by clinical pharmacists can reduce drug‐related problems and improve therapeutic outcomes. The objective of this study was to examine the impact of routine admission medication reconciliation and inpatient medication review on emergency department (ED) revisits after discharge. Secondary outcomes included the combined rate of post‐discharge hospital revisits or death. Methods: This prospective, controlled study included all patients hospitalized in three internal medicine wards in a university hospital, between 1 January 2006 and 31 May 2008. Medication reconciliation on admission and inpatient medication review, conducted by clinical pharmacists in a multiprofessional team, were implemented in these wards at different times during 2007 and 2008 (intervention periods). A discharge medication reconciliation was undertaken in all the study wards, during both control and intervention periods. Patients were included in the intervention group (n = 1216) if they attended a ward with medication reconciliation and review, whether they had received the intervention or not. Control patients (n = 2758) attended the wards before implementation of the intervention. Results and Discussion: No impact of medication reconciliation and reviews on ED revisits [hazard ratio (HR), 0·95; 95% confidence interval (CI), 0·86–1·04]or event‐free survival (HR, 0·96; 95% CI, 0·88–1·04) was demonstrated. In the intervention group, 594 patients (48·8%) visited the ED, compared with 1416 (51·3%) control patients. In total, 716 intervention (58·9%) and 1688 (61·2%) control patients experienced any event (ED visit, hospitalization or death). Because the time to a subsequent ED visit was longer for the control as well as the intervention groups in 2007 than in 2006 (P < 0·05), we re‐examined this cohort of patients; the proportion of patients revisiting the ED was similar in both groups in 2007 (P = 0·608). What is new and conclusion: Routine implementation of medication reconciliation and reviews on admission and during the hospital stay did not appear to have any impact on ED revisits, re‐hospitalizations or mortality over 6‐month follow‐up.     

Baseline Serum 25-Hydroxyvitamin D Levels in Men Undergoing Radical Prostatectomy: Is There An Association With Adverse Pathologic Features?

Introduction/BackgroundThe purpose of this study was to evaluate the prevalence of vitamin D (VitD) deficiency in men undergoing radical prostatectomy and determine whether an association exists between preoperative VitD levels and adverse pathologic features.Patients and MethodsPatients scheduled to undergo radical prostatectomy for clinically localized disease from January to August 2012 were prospectively followed and those with available preoperative serum 25-hydroxyvitamin D levels were included. Men with a known diagnosis of VitD deficiency or taking VitD supplementation were excluded. Cox regression analysis was performed to determine whether preoperative VitD level is predictive of adverse pathologic outcomes.ResultsOne hundred consecutive men were included. Mean age was 62 (range, 42-79) years and mean VitD level was 26 (range, 6-57) ng/mL. Overall, 65 men (65%) had suboptimal levels of VitD (< 30 ng/mL), and 32 (32%) had deficiency (< 20 ng/mL). There was no significant correlation between VitD and age (P = .5). In logistic regression analysis, VitD level was not predictive of pathologic Gleason (P = .11), pathologic stage (P = .7), or positive margin status (P = .8).ConclusionThe association between VitD and prostate cancer has been controversial and data suggesting an increased risk of aggressive cancer in men with low levels of VitD have been inconsistent. We found that baseline preoperative VitD level was not associated with any adverse pathologic features. However, VitD deficiency is a common finding in this population, although unrelated to patient age. These results represent the first time the correlation between VitD and prostate cancer has been evaluated in a cohort of men undergoing radical prostatectomy.     

Predictors of early vs. late permanent shunt insertion after aneurysmal subarachnoid hemorrhage

Objective: Numerous studies have identified different predictors for secondary hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH), although predictors regarding timing of the shunt operation have never been reported. Predictors for an early shunt, which was defined as a shunt operation performed ≤30 days after SAH onset, and for a late shunt, performed at >40 days, were investigated.

Methods: A total of 735 consecutive SAH patients admitted to our hospital between 2003 and 2014 who underwent surgery for ruptured aneurysms within five days of onset were retrospectively assessed.

Results: Secondary hydrocephalus developed in 225 patients, including 70 with an early shunt and 96 with a late shunt. Multivariate analysis showed that predictors for secondary hydrocephalus were age ≥70 years, World Federation of Neurosurgical Society (WFNS) grade IV-V, Fisher grade 3–4, intraventricular hemorrhage, anterior cerebral artery aneurysms, and external drainage for acute hydrocephalus (p < 0.05). In the early and late shunt groups, multivariate analysis indicated that early shunt was significantly associated with coil embolization, and late shunt was correlated with middle cerebral artery aneurysms and cerebral infarction due to vasospasm (p < 0.05).

Discussion: The difference in the predictors between the early and late shunts implied that the mechanisms of secondary hydrocephalus differed between the early and late shunt groups. Knowledge of the associated risk factors might help to predict the timing of the shunt operation for early rehabilitation planning in the future.