OP0209-HPR BRIDGE – A QUALITY IMPROVEMENT PROGRAM IN TEAM-BASED REHABILITATION: RESULTS FROM A MIXED METHODS STUDY

Background

There is a well-known variability in the quality of rehabilitation provided to patients with rheumatic and musculoskeletal diseases (RMDs). Elements to be improved are a higher standardization of the core content, optimal patient participation in goal setting and continuation of the process in tailored follow-up. More knowledge is needed on critical features for successful delivery of improvement programs in rehabilitation.

Objectives

To investigate how a team-based quality improvement program was implemented and how it influenced the quality in RMD rehabilitation.

Methods

This convergent mixed methods study is nested within a stepped-wedge, randomized controlled trial where providers at 8 rehabilitation-centers delivered traditional programs in the control phase (T1), and added the BRIDGE quality improvement program in the intervention phase (T2). The BRIDGE program addressed a dialog-based, multidisciplinary approach to support the patients’ self-management, comprising motivational interviewing, goal setting, plans for rehabilitation, feedback and monitoring of progress, and tailored follow up. Providers answered 19 structure indicators from a quality indicator (QI) set for RMD rehabilitation [1] at T1 and T2, and a program-fidelity checklist with 18 items at T2 (both scored 0-100%, 100=best). Qualitative data was collected in three focus groups (FG) with the BRIDGE providers, and analyzed using reflexive thematic analysis. Integration and discussion of findings from the different data sources are ongoing, in our research group.

Results

Median summary pass rate for the structure QIs for all centers increased from 53 to 90% between T1 and T2. Program-fidelity was high, with a median summary score of 94% (range 6–100%), but lowest for program-components related to follow-up and communication with external services. Themes developed from the FG interviews reflected that variations in how the program was implemented related to features of the providers and institutions. More specific; the delivery of high-quality rehabilitation depended on the degree to which the providers trained their communication skills, used available tools to support their practice, and grounded their interventions in professional reasons. Critical organisational features at the institutions were dedicated time for team-work based on the patients’ plans for self-management, and sufficient attention to needs for involvement of next of kin or external services. Additionally, better program-implementation occurred if providers experienced an institutional culture for quality improvement, such as educational initiatives from the leaders.

Preliminary integration of data is summarized in Figure 1. Congruent evidence in both quantitative and qualitative findings addressed the sustained needs for better quality in the area of follow-up across levels of care. However, the qualitative findings provided expanded insights on variability also in initial parts of the rehabilitation process. Presumably, these variations in delivery reported in interviews are important for the effectiveness of a quality improvement program, but difficult to capture in questionnaires.

Figure 1.

Complementary viewpoints on how the BRIDGE program was provided and how it influenced the quality of rehabilitation.

Conclusion

To target specific strategies for quality improvement, we suggest a combined attention not only to recommended care reflected in quality indicators and measurable aspects of fidelity, but also to contextual factors, including the providers’ confidence and skills needed to provide a high-quality delivery of all components in a rehabilitation improvement program.

References

[1]Johansen et al. A quality indicator set for use in rehabilitation team care of people with rheumatic and musculoskeletal diseases; development and pilot testing. BMC Health Serv Res. 2019;19(1).

Disclosure of Interests

None declared

Erratum to "A Novel Method for Extraction of Galegine by Molecularly Imprinted Polymer (MIP) Technique Reinforced with Graphene Oxide and Its Evaluation Using Polarography"

[This corrects the article DOI: 10.1155/2020/3646712.].

A Novel Method for Extraction of Galegine by Molecularly Imprinted Polymer (MIP) Technique Reinforced with Graphene Oxide and Its Evaluation Using Polarography

Galega officinalis products have been used for the control of diabetes (type 2) across the world. Experimental and clinical evaluations of galegine substance produced by a medicinal plant (Galega officinalis) provided the pharmacological and chemical basis for metformin discovery which was confirmed for diabetes therapy. In this paper, the molecularly imprinted polymer (MIP) was synthesized for galegine, using galegine as a template molecule, methacrylic acid (MAA) as a functional monomer, ethylene glycol dimethacrylate (EGDMA) as a cross-linker, azobisisobutyronitrile (AIBN) as a reaction initiator, and acetonitrile as a solvent. The assisted functional groups, morphology, topographic image of surface, and crystalline structure of synthesized MIP were characterized by FT-IR spectroscopy, field emission scanning electron microscopy (FE-SEM), atomic force microscopy (AFM) images, and XRD diffraction pattern techniques, respectively. Also, the performance of the mentioned electrode was quantified and qualified by the differential pulse voltammetry technique (DPV). The galegine amount was determined with the polarographic technique. In this research, the galegine extraction conditions were optimized and graphene nanoparticles were used to increase the adsorption. In addition, different parameters affecting extraction were investigated such as MIP adsorbent amount, pH of solution, effect of the surfactant, and ionic compound to achieve high recovery percent. The recovery percent, limit of detection (LOD), limit of quantification (LOQ), and relative standard deviation (RSD %) were 4.101 μg·mL^-1, 12.427 μg·mL^-1, and 1.199% (n = 3), respectively. The results show that the prepared MIP can be used as an effective and inexpensive adsorbent for preconcentration and galegine extraction from a natural sample. It is noteworthy that this developed method was used successfully to determine galegine extracted from Galega officinalis L.

Superadiabatic quantum heat engine with a multiferroic working medium

A quantum thermodynamic cycle with a chiral multiferroic working substance such as LiCu_{2}O_{2} is presented. Shortcuts to adiabaticity are employed to achieve an efficient, finite-time quantum thermodynamic cycle, which is found to depend on the spin ordering. The emergent electric polarization associated with the chiral spin order, i.e., the magnetoelectric coupling, renders possible steering of the spin order by an external electric field and hence renders possible an electric-field control of the cycle. Due to the intrinsic coupling between the spin and the electric polarization, the cycle performs an electromagnetic work. We determine this work's mean-square fluctuations, the irreversible work, and the output power of the cycle. We observe that the work mean-square fluctuations are increased with the duration of the adiabatic strokes, while the irreversible work and the output power of the cycle show a nonmonotonic behavior. In particular, the irreversible work vanishes at the end of the quantum adiabatic strokes. This fact confirms that the cycle is reversible. Our theoretical findings evidence the existence of a system inherent maximal output power. By implementing a Lindblad master equation we quantify the role of thermal relaxations on the cycle efficiency. We also discuss the role of entanglement encoded in the noncollinear spin order as a resource to affect the quantum thermodynamic cycle.

Hemoglobin Hakkari: an autosomal dominant form of beta thalassemia with inclusion bodies arising from de novo mutation in exon 2 of beta globin gene

Certain beta globin gene mutations produce a thalassemia major phenotype in the heterozygous state. While most such patients have thalassemia intermedia, we describe a young Guatemalan child with a de novo mutation in the beta globin gene, codon 31 T --> G (Hemoglobin Hakkari), who developed severe anemia at the age of 10 months and remains transfusion-dependent. The substitution of B13 leucine with arginine in the beta globin results in alteration of a critical heme contact point resulting in an extremely unstable variant hemoglobin and a clinical picture that is characterized by ineffective erythropoiesis and numerous intracytoplasmic inclusions within the erythrocyte precursors of the bone marrow. .

Application of an expanded multiplex genotyping assay for the simultaneous detection of Hemoglobin Constant Spring and common deletional alpha-thalassemia mutations

Hemoglobin Constant Spring (HbCS) is the most common nondeletional alpha-thalassemia variant causing HbH disease, making its detection crucial in populations at risk. Universal newborn screening for HbH is carried out in California. Identification of alpha-thalassemia genotypes responsible for HbH and HbH-CS requires rapid, accurate and cost-effective genotyping methods suitable for population screening. We incorporated the HbCS mutation into our existing seven-plex genotyping assay for common alpha-thalassemia deletions. To assess the feasibility and diagnostic utility of this expanded multiplex gap-PCR assay, we determined genotypic frequencies of HbCS in samples referred for alpha-thalassemia testing between 1 January 2006 and 31 December 2008. During the 3-year study period, 1436 samples were genotyped for alpha-thalassemia. HbH-CS accounted for 23 (13%) of the 176 cases of HbH disease identified. In a subset of 145 newborns referred by the California NBS program with an elevated Hb Bart's level at birth, HbH disease was confirmed in 134 (93%) and HbH-CS identified in 13 (10%) of these. This expanded genotyping assay has proven to be a rapid, reliable and clinically useful diagnostic tool for the detection of HbH-CS disease.

Application of flow cytometry-based genotyping for rapid detection of hemoglobin variants

The hemoglobinopathies represent a genetically heterogeneous group of disorders. Clinically important hemoglobin variants have been increasingly reported in the USA. Consequently, rapid and accurate testing methods are needed to address the growing diagnostic challenges of identifying these variants. To evaluate the utility of the Luminex LabMAP system for hemoglobinopathy testing, we adapted single base primer extension (SBPE) to this platform to detect 11 clinically important hemoglobin variants. Clinical samples from 11 individuals were tested for five beta-globin mutations (C-Harlem, D-Iran, Fannin-Lubbock and Hope) and six alpha-globin mutations (J-Toronto, Hasharon, G-Philadelphia, G-Norfolk, Constant-Spring and Quong-Sze). Two separate multiplexed SBPE assays were developed. Biotinylated amplification products were hybridized to fluorescent microspheres tagged with allele-specific capture probes and analyzed by flow cytometry on the Luminex100 instrument. The median fluorescent intensity (MFI) ranged from 1255 to 7478 fluorescence units (FU) and from 282 to 2609 FU above background for all positive beta-globin and alpha-globin alleles, respectively. Using the highest background MFI + 3 SD as a conservative threshold, MFI values uniformly discriminated wild type from mutant alleles, and genotypes were correctly identified in all samples tested. This pilot study demonstrates the potential application of the Luminex LabMAP genotyping platform to newborn screening for definitive hemoglobinopathy testing.

Universal newborn screening for Hb H disease in California

Newborn screening is an accepted public health measure to ensure that appropriate health care is provided in a timely manner to infants with hereditary/metabolic disorders. Alpha-thalassemia is a common hemoglobin (Hb) disorder, and causes Hb H (beta4) disease, and usually fatal homozygous alpha(0)-thalassemia, also known as Hb Bart's (gamma4) hydrops fetalis syndrome. In 1996, the State of California began to investigate the feasibility of universal newborn screening for Hb H disease. Initial screening was done on blood samples obtained by heel pricks from newborns, and stored as dried blood spots on filter paper. Hb Bart's levels were measured as fast-moving Hb by automated high-performance liquid chromatography (HPLC) identical to that currently used in newborn screening for sickle cell disease. Subsequent confirmation of Hb H disease was done by DNA-based diagnostics for alpha-globin genotyping. A criterion of 25% or more Hb Bart's as determined by HPLC detects most, if not all cases of Hb H disease, and few cases of alpha-thalassemia trait. From January, 1998, through June, 2000, 89 newborns were found to have Hb H disease. The overall prevalence for Hb H disease among all newborns in California is approximately 1 per 15,000. Implementation of this program to existing newborn hemoglobinopathy screening in populations with significant proportions of southeast Asians is recommended. The correct diagnosis would allow affected infants to be properly cared for, and would also raise awareness for the prevention of homozygous alpha(0)-thalassemia or Hb Bart's hydrops fetalis syndrome.

Overexpression of the EphA2 tyrosine kinase in prostate cancer

BACKGROUND

Molecules that are highly expressed by human prostate cancers may serve as therapeutically relevant targets or tumor markers. Tyrosine kinases are frequently overexpressed in metastatic tumor cells and this prompted us to screen for tyrosine kinases that are overexpressed in prostate cancer cells.

METHODS

Expression levels of the EphA2 receptor tyrosine kinase were determined by Western blot analysis in canine and human prostate cancer cell lines and in immortalized and transformed variants of 267B1 prostatic epithelial cells. EphA2 levels in benign human prostate and prostate cancers were also determined in formalin-fixed, paraffin-embedded tissues using immunohistochemical staining.

RESULTS

Metastatic prostate cancer cells overexpressed EphA2 by 10-100 fold as compared with non-invasive prostatic epithelial cells. EphA2 immunoreactivity in vivo was also significantly greater in human prostate cancers as compared with benign prostate epithelium.

CONCLUSIONS

The EphA2 receptor tyrosine kinase is differentially expressed in human and canine prostate cancer cell lines and overexpressed in human prostate cancers as compared with benign prostate tissues. Metastasis-derived canine prostate carcinoma cell lines overexpress EphA2 and may provide pre-clinical models to further evaluate the role of EphA2 in prostate carcinogenesis. Further investigations are needed to determine the utility of EphA2 as a tumor marker and a novel target in human prostate cancer.

E-cadherin regulates the function of the EphA2 receptor tyrosine kinase

EphA2 is a member of the Eph family of receptor tyrosine kinases, which are increasingly understood to play critical roles in disease and development. We report here the regulation of EphA2 by E-cadherin. In nonneoplastic epithelia, EphA2 was tyrosine-phosphorylated and localized to sites of cell-cell contact. These properties required the proper expression and functioning of E-cadherin. In breast cancer cells that lack E-cadherin, the phosphotyrosine content of EphA2 was decreased, and EphA2 was redistributed into membrane ruffles. Expression of E-cadherin in metastatic cells restored a more normal pattern of EphA2 phosphorylation and localization. Activation of EphA2, either by E-cadherin expression or antibody-mediated aggregation, decreased cell-extracellular matrix adhesion and cell growth. Altogether, this demonstrates that EphA2 function is dependent on E-cadherin and suggests that loss of E-cadherin function may alter neoplastic cell growth and adhesion via effects on EphA2.

Syntheses and calcium channel antagonist activity of nifedipine analogues with methylsulfonylimidazolyl substituent

Various diester analogues of nifedipine in which the ortho nitrophenyl group at position 4 is replaced by 1-methyl-2-methylsulfonyl-5-imidazolyl substituent, were synthesized and evaluated as calcium channel antagonists on guinea-pig ileal smooth muscle. Nifedipine was used as a standard. Compound 6n was found to be the most active.

Distortion in diffraction tomography caused by multiple scattering

In this paper, we have first presented a new computational procedure for the calculation of the "true" forward scattered fields of a multicomponent object. By "true" we mean fields that are not limited by the first-order approximations, such as those used in the first-order Born and Rytov calculations. Although the results shown will only include the second-order fields for a multicomponent object, the computational procedure can easily be generalized for higher order scattering effects. Using this procedure we have shown by computer simulation that even when each component of a two-component object is weakly scattering, the multiple scattering effects become important when the components are blocking each other. We have further shown that when strongly scattering components that are large compared to a wavelength are not blocking each other, the scattering effects can be ignored. Both these conclusions agree with intuitive reasoning. Since all the currently available diffraction tomography algorithms are based on the assumption that the object satisfies the first-order scattering assumption, it is interesting to test them under conditions when this assumption is violated. We have used the scattered fields obtained with the new computational procedure to test these algorithms, and shown the resulting artifacts. Our main conclusion drawn from this computer simulation study is that even when object inhomogeneities are as small as 5 percent of the background, multiple scattering can introduce severe distortions in multicomponent objects.