Implementation of QI Coaching Versus Physician Communication Training for Improving HPV Vaccination in Primary Care: A Randomized Implementation Trial

Purpose of study: Health departments (HDs) are at the forefront of efforts to improve HPV vaccine uptake in the US. Most notably, HD staff routinely conduct in-person quality improvement (QI) coaching to help primary care clinics improve their vaccine delivery systems. Some HDs also engage outside experts to conduct remote physician communication training to help vaccine prescribers recommend HPV vaccine more effectively. To guide future HD programming, we sought to understand the implementation strengths and challenges of QI coaching and physician communication training. Methods: In a cluster randomized trial, we allocated 855 primary care clinics in 3 geographically-diverse US states to receive: 1) QI coaching; 2) physician communication training; or 3) both interventions combined. In each arm, we assessed adoption (or the % of clinics receiving the allocated intervention out of those invited), contacts per clinic (mean number of contacts needed to successfully schedule one clinic), reach (median number of total staff and prescriber participants per clinic), and delivery cost. Results: More clinics adopted QI coaching than communication training or the combined intervention (63% vs 16% and 12%, both p<.05). Recruiting clinics into QI coaching sessions required fewer contacts than communication training or the combined intervention (mean = 4.7 vs 29.0 and 40.4, both p<.05). In contrast, communication training and the combined intervention reached more total staff per clinic than QI coaching (median = 5 and 5 vs 2, both p<.05), including more prescribers per clinic (2 and 2 vs 0, both p<.05). QI coaching cost $439 per clinic on average, including costs incurred from follow up ($129/clinic), session preparation ($73/clinic), and travel ($69/clinic). Communication training cost $1,287 per clinic, with most cost incurred from clinic recruitment ($653/clinic). Conclusions: QI coaching was lower cost and had higher adoption, but remote communication training achieved higher reach, including to highly influential vaccine prescribers. Thus, communication training is a promising intervention for improving HPV vaccine delivery, although care will be needed to overcome substantial challenges to clinic recruitment.

Radium-223 outcomes after multiple lines of metastatic castration-resistant prostate cancer therapy in clinical practice: implication of pre-treatment spinal epidural disease

BACKGROUND

Magnetic resonance imaging (MRI) is not routinely performed before initiating radium-223 to document spinal epidural disease. However, radium-223 decays to form α-particles with very short path lengths that may not reach the epidural space. Herein, we investigate the impact of baseline spinal epidural disease on metastatic castration-resistant prostate cancer (mCRPC) patients treated with radium-223.

METHODS

Between October 2013 to December 2014, 41 consecutive mCRPC patients at a large tertiary cancer center were prescribed radium-223 as part of standard of care. 29% of patients had pre-treatment epidural disease (posMRI), 27% had no epidural disease (negMRI), and 44% did not have a baseline MRI (noMRI). All patients had post-treatment spinal imaging. Actuarial survival times were calculated for overall survival (OS), spinal axis radiographic progression-free survival (spinePFS) and epidural progression-free survival (epiPFS) from time of first radium-223 treatment.

RESULTS

For patients with posMRI (n=12), noMRI (n=18) and negMRI (n=11) cumulative rates of development or worsening of epidural disease and/or high-grade cord compression at time of last follow-up were 83%, 44% and 9%, respectively (P=0.001). For the posMRI, noMRI and negMRI groups the median OS was 6.3 months, 12.6 months and not reached (P=0.01), the median spinePFS was 3.2 months, 4.8 months and not reached (P=0.01), and the median epiPFS was 3.2 months, 10.4 months and not reached (P=0.001). Completing less than six cycles of radium-223 was significantly associated with worse OS (P<0.0001), spinePFS (P=0.007) and epiPFS (P=0.01). Greater than or equal to twenty osseous lesions pre-treatment was significantly associated with worse spinePFS (P=0.001) and epiPFS (P=0.03).

CONCLUSIONS

In a heavily pre-treated small cohort, patients with baseline epidural disease frequently progressed to spinal cord compression and early cessation of radium-223 therapy. Studies are needed to determine the optimal timing of radium-223 with other mCRPC therapies given the predilection for epidural disease and treatment failure after multiple prior lines of mCRPC therapy.

Coronal oblique imaging of the knee: can it increase radiologists' confidence in diagnosing posterior root meniscal tears?

AIM

To investigate the utility of the coronal oblique sequence in the interrogation of posterior root meniscal lesions.

MATERIALS AND METHODS

Following international review board approval, 62 consecutive knee arthroscopy cases were referred to the musculoskeletal (MSK) radiologists from the same orthopaedic surgeon for imaging/surgical correlation of the posterior meniscal roots. Of 62 cases, 45 lateral and 46 medial menisci met the inclusion criteria. Imaging evaluation was performed with standard magnetic resonance imaging (MRI) sequences, including a coronal oblique proton density sequence. Two blinded fellowship-trained MSK radiologists independently evaluated the menisci on standard sequences indicating whether a tear was identified and then specifying a confidence score using a scale of 1-3 on each study interpreted. Immediately thereafter, the coronal oblique sequence was evaluated using the same method. Statistics were performed on meniscal lesions involving the posterior horn/root junction or isolated root tears comparing confidence scores.

RESULTS

Reader A identified nine posterior horn/root junction tears and 14 isolated root tears. Following the addition of the coronal oblique sequence, confidence scores increased in three of 14 (21.4%) isolated root tears. All three final reads were concordant with arthroscopy. Reader B identified 10 posterior horn/root junction tears and 19 isolated root tears. The confidence score increased in six cases: five of 19 (26.3%) isolated root tears and one of 10 (10%) posterior horn/root junction tears. All six final reads were concordant with arthroscopy. Kappa coefficients indicated near perfect agreement.

CONCLUSION

The coronal oblique sequence increased reader confidence in nearly 24% of the posterior root cases identified in this series.

Inter-organizational relationships of seven Veterans Affairs Medical Centers and their affiliated medical schools: results of a multiple-case-study investigation

PURPOSE

This study describes the costs and and value added to Veterans Affairs Medical Centers (VAMCs) through their affiliations with medical schools. The study also creates a conceptual framework for evaluating the critical dimensions across which these affiliations vary.

METHOD

Case studies of seven VAMCs' affiliations with medical schools, ranging from two highly affiliated VAMCs to one with only one funded residency position, were conducted in 1997 and 1998 using a survey and in-depth interviews with 78 key individuals at the institutions. The qualitative data were then used to develop a conceptual framework for evaluating these affiliations.

RESULTS

The results are reported in two stages. In stage one, three organizing themes emerged from the data that formed the conceptual framework for evaluating affiliations: (1) the characteristics of each VAMC and its environment, (2) the characteristics of the relationships between each VAMC and its medical school affiliates, and (3) the costs and value that medical school affiliations add to VAMCs. The affiliations that were most beneficial to VAMCs were characterized by a relationship of trust, extensively shared education and research programs, and a high degree of physician interaction. The achievement of these characteristics is influenced by the distance between the VAMCs and their affiliated medical schools, the VAMCs' levels of organizational complexity, the degree of managed care penetration, and the continuity and academic orientation of leadership at the VAMCs. In stage two, study data were used to create a conceptual framework to evaluate the characteristics of VAMCs and their affiliations with medical schools.

CONCLUSIONS

The study supplied data to construct a conceptual framework that describes many of the relationships among the different affiliations in the study. The framework offers a tool for evaluating the dimensions across which affiliations vary and how these differences influence the costs and value of medical school affiliations to VAMCs.

Open chest cardiopulmonary resuscitation in out-of-hospital cardiac arrest

Because closed chest cardiopulmonary resuscitation (CCCPR) achieve restoration of spontaneous circulation (ROSC) in less than 50% of cases, and because of the apparent physiological superiority of open-chest cardiopulmonary resuscitation (OCCPR), we evaluated OCCPR in out-of hospital cardiac arrest in cases who did not respond to standard external cardiopulmonary resuscitation with advanced life support. Over a period of 12 years, OCCPR was performed in 33 patients with out-of-hospital cardiac arrest arising from different causes, after unsuccessful attempts to achieve ROSC with CCCPR efforts over 7-121 min (median 25 min). With OCCPR, ROSC was achieved in 13/33 patients. Of these, two recovered to discharge (one with no neurological deficit and one with mild brain damage). The other 11 rearrested either in the emergency department after a median period of 70 min of resuscitation, or in the intensive care unit after a median period of 104 h. One case of iatrogenic cardiac injury was observed. The OCCPR attempts were well accepted by the public. Our data suggest that OCCPR is more effective than CCCPR in achieving ROSC outside hospital in patients with major cardiac disease and prolonged arrest. OCCPR is feasible in the out-of-hospital setting. Survival without neurological deficit cannot be expected when CCCPR with no-flow is continued beyond 25 min.

Different clinical manifestations of meningococcaemia: three patient reports

Neisseria meningitidis, a ubiquitous Gram-negative diplococcus, is responsible for a spectrum of clinical manifestations. This is illustrated by the history of three patients recently admitted to our hospital. Because of the possibly rapid and dramatic evolution, awareness for meningococcal diseases remains obligatory. Adequate antibiotic treatment instituted as soon as the diagnosis is suspected and early application of aggressive supportive care can lead to more favourable outcome.

Experimental inhibition of peroxisomal beta-oxidation in rats: influence on brain myelination

Oral administration of thioridazine, an inhibitor of peroxisomal beta-oxidation, to normal rats from weaning till day 60 causes a small increase of the very long chain fatty acid C26 in brain lipids. Myelination in the brain is decreased. In the genu of the corpus callosum the ratio of non-myelinated/myelinated axons is increased. In the commissura anterior the myelin sheaths of the axons are significantly thinner in treated than in control animals. Undernourishment caused by the drug is minimal in this experiment. Area and total DNA of glial nuclei are unaltered in both the genu and the commissura anterior of treated rats. The distribution of chromatin (texture), however, shows small differences in the corpus callosum.