Identifying Quality Indicators for the Care of Hospitalized Injured Older Adults: A Scoping Review of the Literature

OBJECTIVES

Older adults represent more than 50% of trauma admissions in many high-income countries. Furthermore, they are at increased risk for complications, resulting in worse health outcomes than younger adults and a significant health care utilization burden. Quality indicators (QIs) are used to assess the quality of care in trauma systems, but few QIs reflect responses to older patients' specific needs. We aimed to (1) identify QIs used to assess acute hospital care for injured older patients, (2) assess support for identified QIs and, (3) identify gaps in existing QIs.

DESIGN

Scoping review of the scientific and gray literature.

METHODS

Selection and data extraction were performed by 2 independent reviewers. The level of support was assessed by the number of sources reporting QIs and whether they were developed according to scientific evidence, expert consensus, and patients' perspectives.

RESULTS

Of 10,855 identified studies, 167 were eligible. Among 257 different QIs identified, 52% were hip fracture specific. Gaps were identified for head injuries, rib, and pelvic ring fractures. Although 61% of QIs assessed care processes, 21% and 18% focused on structures and outcomes, respectively. Although most QIs were based on literature reviews and/or expert consensus, patients' perspective was rarely accounted for. The 15 QIs with the highest level of support included minimum time between emergency department arrival and ward admission, minimum time to surgery for fractures, assessment by a geriatrician, orthogeriatric review for hip fracture patients, delirium screening, prompt and appropriate analgesia, early mobilizations, and physiotherapy.

CONCLUSION AND IMPLICATIONS

Multiple QIs were identified, but their level of support was limited, and important gaps were identified. Future work should focus on achieving consensus for a set of QIs to assess the quality of trauma care to older adults. Such QIs could be used for quality improvement and ultimately improve outcomes for injured older adults.

Feasibility of a Hybrid Web-Based and In-Person Self-management Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma (iPACT-E-Trauma): A Pilot Randomized Controlled Trial

Objective 1) To assess the feasibility of research methods to test a self-management intervention aimed at preventing acute to chronic pain transition in patients with major lower extremity trauma (iPACT-E-Trauma) and 2) to evaluate its potential effects at three and six months postinjury. Design A pilot randomized controlled trial (RCT) with two parallel groups. Setting A supraregional level 1 trauma center. Methods Fifty-six adult patients were randomized. Participants received the intervention or an educational pamphlet. Several parameters were evaluated to determine the feasibility of the research methods. The potential efficacy of iPACT-E-Trauma was evaluated with measures of pain intensity and pain interference with activities. Results More than 80% of eligible patients agreed to participate, and an attrition rate of ≤18% was found. Less than 40% of screened patients were eligible, and obtaining baseline data took 48 hours postadmission on average. Mean scores of mild pain intensity and pain interference with daily activities (<4/10) on average were obtained in both groups at three and six months postinjury. Between 20% and 30% of participants reported moderate to high mean scores (≥4/10) on these outcomes at the two follow-up time measures. The experimental group perceived greater considerable improvement in pain (60% in the experimental group vs 46% in the control group) at three months postinjury. Low mean scores of pain catastrophizing (Pain Catastrophizing Scale score < 30) and anxiety and depression (Hospital Anxiety and Depression Scale scores ≤ 10) were obtained through the end of the study. Conclusions Some challenges that need to be addressed in a future RCT include the small proportion of screened patients who were eligible and the selection of appropriate tools to measure the development of chronic pain. Studies will need to be conducted with patients presenting more serious injuries and psychological vulnerability or using a stepped screening approach.

Feasibility of a tapering opioids prescription program for trauma patients at high risk of chronic consumption (TOPP-trauma): protocol for a pilot randomized controlled trial

BACKGROUND

Opioid use disorder (OUD) and deaths related to the chronic use of opioids have increased significantly over the last two decades. Chronic consumption of opioids has been documented in many patients with traumatic injuries. Preliminary research findings have shown that interventions using cognitive-behavioral strategies were a promising adjunct in decreasing the burden associated with opioid consumption. Accordingly, the Tapering Opioids Prescription Program in Trauma (TOPP-Trauma) was developed.

PURPOSE

To assess the feasibility of the TOPP-Trauma intervention and its research methods; and explore the potential efficacy of TOPP-Trauma in reducing opioid consumption.

METHODS

A 2-arm pilot randomized controlled trial (RCT) will be conducted in patients presenting a high risk for chronic opioid consumption. Fifty participants at high risk for chronic consumption of opioid will receive either TOPP-Trauma or an educational pamphlet. The feasibility assessment of TOPP-Trauma will be based on the ability to provide its components as initially planned. Several parameters will be evaluated to determine the feasibility of the research methods, including the adequacy of the sampling pool, the dropout rate, and the ease of data collection. The morphine equivalent dose (MED) per day between both groups will be measured at 6 and 12 weeks. Pain intensity and pain interference with activities will also be evaluated at the same time points.

DISCUSSION

This study will provide evidence on the feasibility of a preventive program aimed at reducing chronic opioid use in high risk trauma patients. Information will also be gathered on the methods that should be used to test the efficacy of such programs.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN): 40263056. Registered 26 May 2018.

The effect of tailored Web-based interventions on pain in adults: a systematic review protocol

BACKGROUND

Information technologies can facilitate the implementation of health interventions, especially in the case of widespread conditions such as pain. Tailored Web-based interventions have been recognized for health behavior change among diverse populations. However, none of the systematic reviews looking at Web-based interventions for pain management has specifically addressed the contribution of tailoring.

METHODS

The aims of this systematic review are to assess the effect of tailored Web-based pain management interventions on pain intensity and physical and psychological functions. Randomized controlled trials including adults suffering from any type of pain and involving Web-based interventions for pain management, using at least one of the three tailoring strategies (personalization, feedback, or adaptation), will be considered. The following types of comparisons will be carried out: tailored Web-based intervention with (1) usual care (passive control group), (2) face-to-face intervention, and (3) standardized Web-based intervention. The primary outcome will be pain intensity measured using a self-report measure such as the numeric rating scale (e.g., 0-10) or visual analog scale (e.g., 0-100). Secondary outcomes will include pain interference with activities and psychological well-being. A systematic review of English and French articles using MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library will be conducted from January 2000 to December 2015. Eligibility assessment will be performed independently in an unblinded standardized manner by two reviewers. Extracted data will include the following: sample size, demographics, dropout rate, number and type of study groups, type of pain, inclusion and exclusion criteria, study setting, type of Web-based intervention, tailoring strategy, comparator, type of pain intensity measure, pain-related disability and psychological well-being outcomes, and times of measurement. Disagreements between reviewers at the full-text level will be resolved by consulting a third reviewer, a senior researcher.

DISCUSSION

This systematic review is the first one looking at the specific ingredients and effects of tailored and Web-based interventions for pain management. Results of this systematic review could contribute to a better understanding of the mechanisms by which Web-based interventions could be helpful for people facing pain problems.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015027669.

Impact of a preventive programme on the occurrence of incidents during the transport of critically ill patients

OBJECTIVE

Incidents related to transport of critically ill patients have been extensively reported. The objective of this study was to determine the effect of an interdisciplinary preventive programme used by all intensive care unit team members involved in patients' transport on the rate of these incidents.

METHODS

A clinical quality improvement audit using a prospective pre and post intervention design was performed among medical and surgical patients hospitalised in intensive care who required intra or inter-hospital transport.

RESULTS

A total of 180 transports occurred in the pre-implementation phase of the study and 187 transports in the post-implementation phase. A 20% absolute reduction of incidents was observed (57.2% vs. 37.4%, p<0.001). Statistically significant reductions were obtained for the technical problems category of incidents (25% vs. 7.5%, p<0.001) as well as the problems related to patient's mobilisation category (14.4% vs. 7.5%, p=0.05). Clinically significant trends were also observed for the clinical deterioration (24.4% vs. 17.1%, p=0.11) and undesired delay before test (23.9% vs. 17.6%, p=0.14) categories but did not reach statistical significance.

CONCLUSIONS

A preventive programme applied by all care providers involved in transport of critically ill patients was associated with a reduction of incidents. The application of such a programme should be acknowledged as a standard of care considering the risks inherent to the transportation of ICU patients.

Tumorigenicity of the mixed spindle-epithelioid SP6.5 and epithelioid TP17 uveal melanoma cell lines is differentially related to alpha5beta1 integrin expression

PURPOSE

It has been suggested that the epithelioid morphology and high aggressiveness that is typical of the uveal melanoma cell line TP17 is dependent on the loss of alpha5beta1 integrin expression at the cell surface. The purpose of the current study was to test this hypothesis in the TP17 cell line and investigate the role this integrin may play in the tumorigenicity of the SP6.5 cells, a mixed spindle-epithelioid culture-type human uveal melanoma that shows tumorigenic properties clearly distinct from that of TP17 cells.

METHODS

Expression of the alpha5 integrin subunit was restored in the alpha5-TP17 cell line by stably transfecting the cells with a recombinant plasmid encoding the integrin subunit. Flow cytometry and adhesion assays on fibronectin (FN)-coated culture plates were used to monitor alpha5 expression in the cells. The effect of alpha5 expression on both tumorigenicity and cell proliferation was evaluated in vivo in nude mice. In vitro growth properties of the alpha5(+) TP17 cells was evaluated by cell counting and compared with that of the alpha5 parental TP17 cell line. The influence exerted by the alpha5 integrin subunit on the tumorigenic and proliferative properties of the SP6.5 cells was evaluated in vivo in nude mice by exposing the cells to increasing doses of a blocking antibody directed against the alpha5-subunit before subcutaneous injection, and compared with the results obtained with untreated SP6.5 cells.

RESULTS

Expression of the alpha5 integrin subunit in the alpha5-TP17 cells was successfully achieved, as evidenced by both flow cytometry and adhesion assays on FN-coated culture plates. Restoring expression of alpha5 in TP17 cells enhanced epithelioid cell morphology and increased the growth properties of this cell line in vivo. The ability of the SP6.5 cells to yield subcutaneous tumors was found to be concentration dependent and was reduced in a dose-dependent manner when the cells were exposed to the anti-alpha5 blocking antibody.

CONCLUSIONS

Restoring expression of alpha5 in the alpha5-negative TP17 uveal melanoma cell line influenced the proliferative properties of these cells but did not alter its tumorigenic potential. In contrast, the ability of the SP6.5 cells to yield tumors in vivo in nude mice appeared to be related to expression of this integrin.

Expression of integrin alpha5beta1 and MMPs associated with epithelioid morphology and malignancy of uveal melanoma

PURPOSE

Altered expression of the alpha5beta1 integrin and matrix metalloproteinases (MMPs) is recognized as a hallmark of invasive tumor cells. The purpose of the present study was to investigate the expression of integrin subunit alpha5, its corresponding ligand fibronectin (FN), and the expression pattern for MMPs in four highly proliferative human choroidal melanomas (TP17, TP31, SP8.0, and SP6.5) to evaluate whether any correlation can be established between these markers and cell tumorigenicity.

METHODS

Cell tumorigenicity was evaluated by subcutaneous injection of uveal melanoma cell lines in immunodeficient nude mice. Anchorage dependency was evaluated by growth assays in soft agar. The invasive ability of each cell type was also determined using a modified Boyden chamber. Expression of both the alpha5 integrin subunit and FN was determined at the mRNA level by RT-PCR. The protein level (for alpha5) was determined by flow cytometry and inhibition of adhesion assays by using an antibody directed against the alpha5 subunit. Expression of MMPs was determined by standard gelatin zymography.

RESULTS

Assays in nude mice provided evidence that the cell lines possess a range of tumorigenic ability of TP17>TP31>SP8.0>SP6.5. Antibody inhibition of cell adhesion and flow cytometry demonstrated that TP17 cells have no detectable membrane-bound alpha5beta1, whereas low levels are found in primary cultured melanocytes, as well as in SP6.5, SP8.0, and TP31 cells. RT-PCR analyses provided evidence that both FN and alpha5 expression may be regulated at the transcriptional level. Gelatin zymography revealed that all cell lines, as well as normal melanocytes, express MMP-2 at varying levels but that only the highly invasive TP17 cell line secretes a distinctive MMP with a high molecular weight of 117 kDa.

CONCLUSIONS

Among the four melanoma cell lines selected for the completion of this study, TP17 exhibited the most aggressive phenotype, which also correlated with the mostly epithelioid morphology of these cells. The cell morphology of the TP17 cell line could be related to the loss of alpha5beta1, whereas its invasive properties are more likely related to the expression of the 117-kDa MMP.

Molecular phylogenetic examination of the delphinoidea trichotomy: congruent evidence from three nuclear loci indicates that porpoises (Phocoenidae) share a more recent common ancestry with white whales (Monodontidae) than they do with true dolphins (Delphinidae)

Porpoises (Phocoenidae), dolphins (Delphinidae), and the two species of Monodontidae (beluga and narwhal) together constitute the superfamily Delphinoidea. Although there is extensive evidence supporting the monophyly of this superfamily, previous studies involving morphology, as well as sequence analysis of mitochondrial genes, have failed to yield a clear picture of the relative relationships within the group. Here we present the first examination of this issue from the perspective of single-copy nuclear genes at the DNA sequence level. The data involve three such loci: von Willebrand factor (vWF), interphotoreceptor retinoid binding protein (IRBP), and lactalbumin. The vWF and IRBP data sets consist of protein-coding fragments, whereas the sequenced lactalbumin fragment is predominately intronic. All phylogenetic analyses involving at least one representative from each of the three Delphinoidea families congruently support a beluga/porpoise clade. The levels of sequence divergence for most of these data appear to roughly concur with a paleontological date for the radiation of the Delphinoidea at 11-15 MYA but, in agreement with mitochondrial DNA sequence analyses, suggest that the extant major groups of cetaceans radiated approximately 25 MYA, 10 million years later than inferred from paleontological data.

Multiple levels of single-strand slippage at cetacean tri- and tetranucleotide repeat microsatellite loci

Between three and six tri- and tetranucleotide repeat microsatellite loci were analyzed in 3720 samples collected from four different species of baleen whales. Ten of the 18 species/locus combinations had imperfect allele arrays, i.e., some alleles differed in length by other than simple integer multiples of the basic repeat length. The estimate of the average number of alleles and heterozygosity was higher at loci with imperfect allele arrays relative to those with perfect allele arrays. Nucleotide sequences of 23 different alleles at one tetranucleotide repeat microsatellite locus in fin whales, Balaenoptera physalus, and humpback whales, Megaptera novaeangliae, revealed sequence changes including perfect repeats only, multiple repeats, and partial repeats. The relative rate of the latter two categories of mutation was estimated at 0.024 of the mutation rate involving perfect repeats only. It is hypothesized that single-strand slippage of partial repeats may provide a mechanism for counteracting the continuous expansion of microsatellite loci, which is the logical consequence of recent reports demonstrating directional mutations. Partial-repeat mutations introduce imperfections in the repeat array, which subsequently could reduce the rate of single-strand slippage. Limited computer simulations confirmed this predicted effect of partial-repeat mutations.

Level of suspicion of a mammographic lesion: use of features defined by BI-RADS lexicon and correlation with large-core breast biopsy

OBJECTIVE

To determine whether the categories defined in the Breast Imaging Reporting and Data System (BI-RADS) are useful predictors of malignancy and to assess their positive predictive value.

PATIENTS AND METHODS

A retrospective study was undertaken from July 1, 1994, to June 30, 1995. Of 568 abnormal mammograms for which largecore biopsy was recommended, 495 were available for review. The mammographic features of the lesions, as defined by the BI-RADS lexicon, were used to assess the level of suspicion. The lesions were classified as "probably benign," "suspicious" or "highly suggestive of malignancy." These diagnostic impressions were then correlated with the histologic diagnosis made after core biopsy.

RESULTS

The diagnostic impressions before core biopsy were as followed: 16 (3%) benign lesions, 397 (80%) suspicious lesions and 82 (17%) lesions highly suggestive of malignancy. All benign lesions remained in the same category after core biopsy, whereas, of the suspicious lesions, 91% were diagnosed as benign, only 4% as malignant, and the other 5% as atypical hyperplasia. Among the lesions highly suggestive of malignancy according to the BI-RADS lexicon, 54% were found to be malignant at core biopsy.

CONCLUSION

The BI-RADS lexicon is helpful in discriminating between lesions that are probably benign and probably malignant from the mammographic features. However, the rate of malignancy in the "suspicious" category is low.

Population genetic structure of North Atlantic, Mediterranean Sea and Sea of Cortez fin whales, Balaenoptera physalus (Linnaeus 1758): analysis of mitochondrial and nuclear loci

Samples were collected from 407 fin whales, Balaenoptera physalus, at four North Atlantic and one Mediterranean Sea summer feeding area as well as the Sea of Cortez in the Pacific Ocean. For each sample, the sex, the sequence of the first 288 nucleotides of the mitochondrial (mt) control region and the genotype at six microsatellite loci were determined. A significant degree of divergence was detected at all nuclear and mt loci between North Atlantic/Mediterranean Sea and the Sea of Cortez. However, the divergence time estimated from the mt sequences was substantially lower than the time elapsed since the rise of the Panama Isthmus, suggesting occasional gene flow between the North Pacific and North Atlantic ocean after the separation of the two oceans. Within the North Atlantic and Mediterranean Sea, significant levels of heterogeneity were observed in the mtDNA between the Mediterranean Sea, the eastern (Spain) and the western (the Gulf of Maine and the Gulf of St Lawrence) North Atlantic. Samples collected off West Greenland and Iceland could not be unequivocally assigned to either of the two areas. The homogeneity tests performed using the nuclear data revealed significant levels of divergence only between the Mediterranean Sea and the Gulf of St Lawrence or West Greenland. In conclusion, our results suggest the existence of several recently diverged populations in the North Atlantic and Mediterranean Sea, possibly with some limited gene flow between adjacent populations, a population structure which is consistent with earlier population models proposed by Kellogg, Ingebrigtsen, and Sergeant.

Genetic tagging of humpback whales

The ability to recognize individual animals has substantially increased our knowledge of the biology and behaviour of many taxa. However, not all species lend themselves to this approach, either because of insufficient phenotypic variation or because tag attachment is not feasible. The use of genetic markers ('tags') represents a viable alternative to traditional methods of individual recognition, as they are permanent and exist in all individuals. We tested the use of genetic markers as the primary means of identifying individuals in a study of humpback whales in the North Atlantic Ocean. Analysis of six microsatellite loci among 3,060 skin samples collected throughout this ocean allowed the unequivocal identification of individuals. Analysis of 692 'recaptures', identified by their genotype, revealed individual local and migratory movements of up to 10,000 km, limited exchange among summer feeding grounds, and mixing in winter breeding areas, and also allowed the first estimates of animal abundance based solely on genotypic data. Our study demonstrates that genetic tagging is not only feasible, but generates data (for example, on sex) that can be valuable when interpreting the results of tagging experiments.

Identification of sex in cetaceans by multiplexing with three ZFX and ZFY specific primers

We sequenced 540 nucleotides of the last exon in the ZFY/ZFX gene in two males and two females for eight cetacean species; four odontocetes (toothed whales) and four mysticetes (baleen whales). Based upon the obtained nucleotide sequences, we designed two sets of oligonucleotide primers for specific amplification of the ZFX and the ZFY sequence in odontocetes and mysticetes, respectively. Each primer set consisted of three oligonucleotides; one forward-orientated primer, which anneals to the ZFY as well as the ZFX sequence, and two reverse-orientated primers that anneal to either the ZFX or or the ZFY sequence. The resulting two amplification products (specific for the ZFY and ZFX sequences) can be distinguished by gel-electrophoresis through 2% NuSieve(TM). The accuracy of the technique was tested by determination of gender in 214 individuals of known sex. Finally we applied the technique to determine the sex of 3570 cetacean specimens; 2284 humpback whales, 315 fin whales, 37 blue whales, 7 minke whales, as well as 592 belugas, 335 narwhals and 25 harbour porpoises.