Search

Purpose: To describe the roles of nurse practitioners (NPs) in a novel model of healthcare delivery for patients with chronic disease: shared medical appointments (SMAs)/group visits based on the chronic care model (CCM). To map the specific skills of NPs to the six elements of the CCM: self-management, decision support, delivery system design, clinical information systems, community resources, and organizational support. Data sources: Case studies of three disease-specific multidisciplinary SMAs (diabetes, heart failure, and hypertension) in which NPs played a leadership role. Conclusions: NPs have multiple roles in development, implementation, and sustainability of SMAs as quality improvement interventions. Although the specific skills of NPsmapout all six elements of theCCM,in our context, they had the greatest role in self-management, decision support, and delivery system design. Implications for practice: With the increasing numbers of patients with chronic illnesses, healthcare systems are increasingly challenged to provide necessary care and empower patients to participate in that care. NPs can play a key role in helping to meet these challenges. [ABSTRACT FROM AUTHOR]

Assembly work and inspection and testing tasks tend to be combined nowadays in the automotive industry as a way of achieving job enrichment. Workers inspect and test parts manufactured or assembled by them. This is in addition to routine quality assurance activities. As well as introducing new sensory demands into the jobs, this integration of assembly and inspection activities also brings with it significant additional motor components, which lead to musculo-skeletal strains. No empirical studies of the superimposed stresses involved in this type of job has been performed to date in the automotive industry. A ergonomically representative sample of work at 22 work stations shows that, whilst most of the work is performed close to the body and involves a substantial proportion of standing positions and strenuous forced postures, only relatively low levels of forces have to be applied. In contrast, tasks requiring the use of testing tools have to be performed farther from the body and higher forces have to be applied. The findings reported from this study led to the design of a screening procedure for the predominantly physical stresses arising in assembly and inspection work in the automotive industry. [ABSTRACT FROM AUTHOR]

To determine whether motor development in premature infants varies according to sleep position, we evaluated 213 infants <1750 g birth weight enrolled in the Collaborative Home Infant Monitoring Evaluation (CHIME). At 56 weeks postconceptional age (PCA), sleep position was determined by maternal report, and the Bayley Scales of Infant Development 2nd Edition (BSID-II) were performed. Infants who slept supine were less likely than infants who slept prone to receive credit for maintaining the head elevated to 45 degrees (p = .021), and infants who slept nonprone were less likely than prone sleepers to receive credit for maintaining the head elevated to 90 degrees and lowering with control (p = .001). The Psychomotor and Mental Development Indices at 56 and 92 weeks PCA were not altered by usual sleep position at 56 weeks PCA. In summary, infants sleeping supine are less able to lift the head and lower with control at 56 weeks PCA, but global developmental status was unaffected. Supine sleeping has been associated with decreased risk for sudden infant death syndrome, but compensatory strategies while awake may be needed to avoid delayed acquisition of head control. [ABSTRACT FROM AUTHOR]

Secretin has been proposed as a treatment alternative for autistic spectrum disorders, but empirical support is lacking. A double-blind placebo-controlled study examined the effect of a single dose of synthetic human secretin on aberrant behavior. Parent and teacher data from the Aberrant Behavior Checklist for eight male children were analyzed for reliable change in a clinical replication series. By parent and teacher report, the majority of change occurred either on the placebo trial or reflected deterioration subsequent to secretin infusion. Repeated-measures multivariate analysis of variance results were similar. Results are consistent with other studies, suggesting that secretin may not be an effective treatment option. [ABSTRACT FROM AUTHOR]

We studied the nucleation of gold clusters on TiO2(110) surfaces in three different oxidation states by high-resolution scanning tunneling microscopy. The three TiO2(110) supports chosen were (i) reduced (having bridging oxygen vacancies), (ii) hydrated (having bridging hydroxyl groups), and (iii) oxidized (having oxygen adatoms). At room temperature, gold nanoclusters nucleate homogeneously on the terraces of the reduced and oxidized supports, whereas on the hydrated TiO2(110) surface, clusters form preferentially at the step edges. From interplay with density functional theory calculations, we identified two different gold-TiO2(110) adhesion mechanisms for the reduced and oxidized supports. The adhesion of gold clusters is strongest on the oxidized support, and the implications of this finding for catalytic applications are discussed. [ABSTRACT FROM AUTHOR]

Competing Interests: The authors declare no conflict of interest.

Purpose: We hypothesized that clinical data from a neonatal intensive care unit (NICU) infant developmental follow-up clinic would identify early manifestations of autism spectrum disorder (ASD)., Methods: One hundred forty-four infants were identified; 72 later diagnosed with ASD and 72 controls. Retrospective chart review provided data from the Test of Infant Motor Performance (TIMP) and the Bayley Scales of Infant and Toddler Development, third edition (Bayley-III), between 8 and 26 months of age., Results: Between-group comparisons indicated no significant group difference in TIMP scores; however, Bayley-III scaled scores differed between the groups at 2 administration times. The within-group Bayley-III change scores declined significantly more for the ASD group in cognitive and communication subtests., Conclusion: High-risk neonates, due to prematurity or morbidity, later diagnosed with ASD demonstrated statistically significant differences, including a more precipitous drop in Bayley-III scores over time. Early, longitudinal developmental surveillance for neonates at risk of ASD is critical. What this adds to the evidence: Early identification of ASD is critical to optimize developmental outcomes in young children, including infants born prematurely or with neonatal morbidity, who are perceived to have an increased risk for ASD. Despite these findings, minimal research has been conducted to evaluate the utility of commonly administered norm-referenced developmental surveillance instruments to identify possible early signs of ASD in this high-risk population due to prematurity or neonatal morbidity and not familial association. The present study analyzed retrospectively collected clinical data from a NICU developmental follow-up clinic for 144 infants, 72 of which were later diagnosed with ASD and 72 sex- and gestational age-matched controls. Results demonstrated statistically significant poorer Bayley-III outcomes for the ASD group compared with controls at 2 different study time points, including a more precipitous drop in Bayley-III scaled scores over time. This study highlights the importance of early and longitudinal developmental surveillance for high-risk neonates at risk of ASD., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.)

Objectives: The 21st Century Cures Act included an "OpenNotes" mandate to foster transparent communication among patients, families, and clinicians by offering rapid electronic access to clinical notes. This article seeks to address concerns about increased documentation burden, vulnerability to patient complaints, and other unforeseen consequences of patients having near-real-time access to their records., Methods: This topical review explores both extant literature, and case examples from the authors' direct experience, about potential responses/reactions to OpenNotes., Results: The ethics of disclosing medical information calls for nuanced approaches: Although too little access can undermine a patient's autonomy and the capacity for truly egalitarian shared decision-making, unfettered access to all medical information has significant potential to harm them. Suggested strategies for mitigating risks in premature disclosure include patient and provider education and "modularizing" sensitive information in notes., Conclusion: The OpenNotes era has ushered in the possibilities of greater patient and family collaboration in shared decision-making and reduced barriers to documentation sharing. However, it has raised new ethical and clinician documentation considerations. In addition to clinician education, patients and families could benefit from education around the purpose of clinical documentation, how to utilize OpenNotes, and the benefits of engaging in dialogue regarding the content and tone of documentation., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Shared medical appointments (SMAs) offer a means for providing knowledge and skills needed for chronic disease management to patients. However, SMAs require a time and attention investment from health care providers, who must understand the goals and potential benefits of SMAs from the perspective of patients and providers. To better understand how to gain provider engagement and inform future SMA implementation, qualitative inquiry of provider experience based on a knowledge-attitude-practice model was explored. Semi-structured interviews were conducted with 24 health care providers leading SMAs for heart failure at three Veterans Administration Medical Centers. Rapid matrix analysis process techniques including team-based qualitative inquiry followed by stakeholder validation was employed. The interview guide followed a knowledge-attitude-practice model with a priori domains of knowledge of SMA structure and content (understanding of how SMAs were structured), SMA attitude/beliefs (general expectations about SMA use), attitudes regarding how leading SMAs affected patients, and providers. Data regarding the patient referral process (organizational processes for referring patients to SMAs) and suggested improvements were collected to further inform the development of SMA implementation best practices. Providers from all three sites reported similar knowledge, attitude and beliefs of SMAs. In general, providers reported that the multi-disciplinary structure of SMAs was an effective strategy towards improving clinical outcomes for patients. Emergent themes regarding experiences with SMAs included improved self-efficacy gained from real-time collaboration with providers from multiple disciplines, perceived decrease in patient re-hospitalizations, and promotion of self-management skills for patients with HF. Most providers reported that the SMA-setting facilitated patient learning by providing opportunities for the sharing of experiences and knowledge. This was associated with the perception of increased comradery and support among patients. Future research is needed to test suggested improvements and to develop best practices for training additional sites to implement HF SMA., Competing Interests: The authors have declared that no competing interests exist.

Competing Interests: Disclosure: The authors declare no conflict of interest.

A primary goal of this research project is to better understand how shared medical appointments (SMAs) can improve the health status and decrease hospitalization and death for patients recently discharged with heart failure (HF) by providing education, disease state monitoring, medication titration, and social support to patients and their caregivers. We propose a 3-site randomized-controlled efficacy trial with mixed methods to test a SMA intervention, versus usual care. Patients within 12 weeks of a HF hospitalization will be randomized to receive either HF-SMA (intervention arm) with optional co-participation with their caregivers, versus usual care (control arm). The HF-SMA will be provided by a non-physician team composed of a nurse, a nutritionist, a health psychologist, a nurse practitioner and/or a clinical pharmacist and will consist of four sessions of 2-h duration that occur every other week for 8 weeks. Each session will start with an assessment of patient needs followed by theme-based disease self-management education, followed by patient-initiated disease management discussion, and conclude with break-out sessions of individualized disease monitoring and medication case management. The study duration will be 180 days for all patients from the day of randomization. The primary study hypothesis is that, compared with usual care, patients randomized to HF-SMA will experience better cardiac health status at 90 and 180 days follow-up. The secondary hypotheses are that, compared to usual care, patients randomized to HF-SMA will experience better overall health status, a combined endpoint of hospitalization and death, better HF self-care behavior, and lower B-type natriuretic peptide levels., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Online patient portals are not widely used, despite their advantages for efficient communication, especially for patients with chronic conditions. A hospital-based group practice of Developmental-Behavioral Pediatricians initiated this quality improvement (QI) project with a goal to increase the percentage of patients with an active MyChart (Epic Systems Corporation's patient portal) account and ultimately improve efficiency of communication between families and clinical staff., Methods: Using QI methodology, we identified staff commitment, workflow issues, and family awareness as gaps and implemented progressive Plan, Do, Study, Act cycles aimed at developing standard processes for activating families on MyChart. We tracked our project measures with statistical process control methodology and sustained our progress with improving awareness and regular feedback., Results: Patient portal activations increased from 1.8% to 30% in a 6-month time period. Highly successful interventions included development and implementation of a standard process for activation, staff education to ensure comfort and commitment, having families opt out instead of opt in, and completed activation of accounts before families leaving clinic., Conclusions: Patient portal activation can be significantly increased through systematic application of QI methodology to address staff training and workflow in a busy subspecialty clinic. Engagement of operations staff and completion of the activation process while the family is still in clinic seemed to be effective in getting families activated in MyChart. It is possible to improve patient portal activation with minimal impact to workflow.

Despite their medical training, record of military service, and the unmet needs within the health care sector, numerous challenges face veterans who seek to leverage their health care skills for employment after leaving the military. Creative solutions are necessary to successfully leverage these skills into jobs for returning medics that also meet the needs of health care systems. To achieve this goal, we created a novel ambulatory care health technician position on the basis of existing literature and modeled after a program which incorporates former military medics in emergency departments. Through a quality improvement approach, a position description, interview process, training program with clinical competencies, and team integration plan were developed and implemented. To date, two medics have been hired, successfully trained on relevant skill sets, and are currently caring for medical outpatients (under the supervision of licensed clinical personnel) as crucial interdisciplinary team members. Taken together, a multifaceted approach is required to effectively harness military medics' skills and experiences to meet identified health delivery needs., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

People with autism spectrum disorder (ASD) and other developmental disabilities have poorer health and face unique barriers to health care compared to people without disabilities. These health disparities can be partially attributed to physicians' limited knowledge about caring for patients with developmental disabilities. The purpose of this study was to determine the effectiveness of ASD training for medical students. Our training included a lecture and a panel presentation that featured people with ASD and family members. Students reported improved knowledge, skills, confidence, and comfort in caring for patients with ASD.

Objective: The prevalence of autism spectrum disorder is steadily increasing and placing more demands on already overburdened diagnostic and treatment systems. A thoughtful, systematic reorganization of autism service delivery may reduce delays and better meet the growing need., Methods: Two clinical centers in the Autism Intervention Research Network on Physical Health, Cincinnati Children's Hospital Medical Center (CCHMC) and Nationwide Children's Hospital (NCH), undertook a year-long access improvement project to reduce delays to care by using system analysis to identify sources of delay and to target changes by using a set of defined access principles. Although both sites addressed access, they focused on slightly different targets (reducing number of patients with autism spectrum disorders waiting for follow-up appointments at NCH and reducing delay to new diagnosis at CCHMC)., Results: Both sites achieved dramatic improvements in their complex, multidisciplinary systems. A 94% reduction in number of patients on the waitlist from 99 to 6 patients and a 22% reduction in median delay for a new ongoing care appointment were realized at NCH. A 94% reduction in third next available appointment for new physician visits for children 3 to 5 years old was realized at CCHMC., Conclusions: This article demonstrates that 2 different clinical systems improved access to care for autism diagnosis and follow-up care by identifying sources of delay and using targeted changes based on a set of access change principles. With appropriate guidance and data analysis, improvements in access can be made., (Copyright © 2016 by the American Academy of Pediatrics.)

Selective eating is common in children with autism spectrum disorder (ASD), but it is not yet well understood. The objectives of this study were to examine a new definition of selective eating, compare behavioral measures between children with ASD and selective eating and those without selective eating, and determine relationships among behavioral measures and measures of selective eating. Participants were assigned to groups on the basis of number of foods eaten compared with a population-based sample. Results of one-way multivariate analysis of variance indicated no overall effect of group for challenging behaviors, sensory reactivity, or repetitive behaviors. Between-participant tests indicated that scores for compulsive behaviors were significantly lower (p = .036) for the selective eating group. Correlations were moderately strong among variables relating to food intake and behavioral variables, but were not significant between selective eating and behavioral variables. Further research is needed to validate the definition of selective eating and to identify targets for intervention., (Copyright © 2015 by the American Occupational Therapy Association, Inc.)

Unlabelled: Whether provider education changes practice for HF has not been reported. (NHeFT)™ uses didactic and experiential training of primary care providers (PCP) to optimize treatment of HF. We randomized PCP's in the Cleveland VA clinics to training (T) vs control (C)., Endpoints: Primary - the number of patients with EF < 40% treated with ACEI/ARB and Beta Blocker, +/- diuretic post T vs pre T; Secondary - the number of patients with increase in ACEI/ARB or a decrease in diuretic post T vs. pre T. Of 641 patients, 216 (85 C,131 T) had EF < 40%; 188 (85%) did not meet the primary endpoint at baseline. After T, a similar proportion (64.2% C, 74.4%,T) met the endpoint at end of study (P = 0.14). The odds of a patient meeting the primary endpoint by care of a T provider, was not significantly higher than C (OR 1.496, 95% CI (0.751, 2.982)). Patients seen by T were more likely to have the diuretic dose decreased vs patients under C, without increases in ACEI or ARB (P < 0.03). Thus, a didactic program of HF plus a preceptorship changed practice modestly. Studies should address provider readiness of change and self efficacy to adhere to evidenced-based care., (© 2012 Wiley Periodicals, Inc.)

Many physicians use surveillance questions to assess development; the American Academy of Pediatrics recommends screening at 9-, 18-, and 24-month health supervision visits (HSVs). There are no studies directly comparing surveillance with screening. The authors directly compared systematic surveillance with standardized screening using a cross-sectional observational study of children with no known delays. Surveillance questions were completed at each HSV. The Ages and Stages Questionnaire (ASQ) was administered following the 9-, 18-, or 24-month HSV. The authors compared detection of delays by surveillance with ASQ screening. Using surveillance, 11/95 subjects were identified as delayed. Using the ASQ, 15/95 subjects scored fail; 28/95 scored monitor. Among the 11 delayed surveillance subjects, 5 scored fail on the ASQ and 5 scored monitor. Ten of the 15 subjects scoring fail on the ASQ were not identified by surveillance. The study's findings support the American Academy of Pediatrics recommendations for periodic formal screening in addition to continued surveillance.

Upper limbs repetitive tasks are one of the main sources of risk for the workers of the manufacturing industries and the standards ISO 11228-3 and EN 1005-5 addressed this issue since 2007. EAWS (European Assembly Worksheet) is a 1st level ergonomic risk assessment method and it provides in its 4th section a score to measure the load level for the upper limbs based on a traffic light scheme. According to the relevant ISO/CEN standards, the OCRA Index is the preferred system to refer to in the evaluation of the biomechanical stress of hand-harm-shoulder system. This correlation study is based on a 45 workstations sample coming from the automobile manufacturing industry. According to the results, EAWS4 shows an excellent correlation with OCRA index (Spearman's rho correlation index 0.95). Being EAWS based on biometric statistical data distribution, its typical application is the process design phase, but adopting a conservative approach in the interpretation of EAWS4 score for risk mapping purposes, it provides an equivalent "reaction" pattern (countermeasures to be taken in the production phase) with respect of OCRA Index with an Odds Ratio ranging from 0.89 (OR-matched) to 1.00 (OR-conservative).

Background: Interprofessional practice has increasingly been recognized as important for chronic illness care. Recently, several health care professional-accrediting bodies have called for integration of interprofessional care and education. The shared medical appointment (SMA) is an interprofessional practice model that provides an educational opportunity., Objective: A description of this innovative educational model, the challenges associated with the implementation, and the evaluation are presented., Method: Mixed quantitative and qualitative analysis were utilized., Results: Preliminary evaluation suggests that SMAs promote improved trainee/student understanding of both the complexity of diabetes care and the seriousness of the illness, along with an increased confidence in the ability to communicate with providers from other disciplines., Conclusion: Further research to determine the efficacy of SMAs as an interprofessional training venue is needed that focuses on comprehensive assessment, necessary dose of exposure, and identification of barriers to overcome operational issues.

Purpose: To describe the roles of nurse practitioners (NPs) in a novel model of healthcare delivery for patients with chronic disease: shared medical appointments (SMAs)/group visits based on the chronic care model (CCM). To map the specific skills of NPs to the six elements of the CCM: self-management, decision support, delivery system design, clinical information systems, community resources, and organizational support., Data Sources: Case studies of three disease-specific multidisciplinary SMAs (diabetes, heart failure, and hypertension) in which NPs played a leadership role., Conclusions: NPs have multiple roles in development, implementation, and sustainability of SMAs as quality improvement interventions. Although the specific skills of NPs map out all six elements of the CCM, in our context, they had the greatest role in self-management, decision support, and delivery system design., Implications for Practice: With the increasing numbers of patients with chronic illnesses, healthcare systems are increasingly challenged to provide necessary care and empower patients to participate in that care. NPs can play a key role in helping to meet these challenges.

Objective: Transforming growth factor-beta (TGF-beta), the central cytokine responsible for the development of diabetic nephropathy, is usually secreted as a latent procytokine complex that has to be activated before it can bind to its receptors. Recent studies by our group demonstrated that thrombospondin-1 (TSP-1) is the major activator of latent TGF-beta in experimental glomerulonephritis in the rat, but its role in diabetic nephropathy in vivo is unknown., Research Design and Methods: Type 1 diabetes was induced in wild-type (n = 27) and TSP-1-deficient mice (n = 36) via streptozotocin injection, and diabetic nephropathy was investigated after 7, 9.5, and 20 weeks. Renal histology, TGF-beta activation, matrix accumulation, and inflammation were assessed by immunohistology. Expression of fibronectin and TGF-beta was evaluated using real-time PCR. Furthermore, functional parameters were examined., Results: In TSP-1-deficient compared with wild-type mice, the amount of active TGF-beta within glomeruli was significantly lower, as indicated by staining with specific antibodies against active TGF-beta or the TGF-beta signaling molecule phospho-smad2/3 or the typical TGF-beta target gene product plasminogen activator inhibitor-1. In contrast, the amount of glomerular total TGF-beta remained unchanged. The development of diabetic nephropathy was attenuated in TSP-1-deficient mice as demonstrated by a significant reduction of glomerulosclerosis, glomerular matrix accumulation, podocyte injury, renal infiltration with inflammatory cells, and renal functional parameters., Conclusions: We conclude that TSP-1 is an important activator of TGF-beta in diabetic nephropathy in vivo. TSP-1-blocking therapies may be considered a promising future treatment option for diabetic nephropathy.

Purpose: To evaluate the yield of genetic testing in children with autism spectrum disorders., Methods: We performed a retrospective chart review of 71 unrelated patients with a diagnosis of an isolated autism spectrum disorder seen in a genetics clinic over a period of 14 months. For most, referrals occurred after evaluation by a developmental pediatrician and/or psychologist to establish the diagnosis. Tiered laboratory testing for the majority of the patients followed a guideline that was developed in collaboration with clinicians at The Autism Center at Children's Hospital, Columbus, OH., Results: The patients included 57 males and 14 females; 57 met DSM-IV criteria for autism, with the rest being Asperger or pervasive developmental disorder not otherwise specified. Macrocephaly [head circumference (HC) >or=95%] was present in 19 (27%). Two children had visible chromosome abnormalities (47,XYY; 48,XY + 2mar/49,XY + 3mar). Two patients with autism and macrocephaly had heterozygous mutations in the PTEN tumor suppressor gene. Three females had Rett syndrome, each confirmed by DNA sequencing of the MECP2 gene. Extensive metabolic testing produced no positive results, nor did fragile X DNA testing., Conclusion: The overall diagnostic yield was 10% (7/71). PTEN gene sequencing should be considered in any child with macrocephaly and autism or developmental delay. Metabolic screening may not be warranted in autism spectrum disorders without more specific indications or additional findings.

Previous trials of secretin for the treatment of autism have utilized a single or double dose administered intravenously. This is a report of a double-blind, randomized, controlled crossover trial of transdermally applied secretin in 15 children diagnosed with autism or pervasive developmental delay. Secretin or placebo was applied daily, in ointment form, to the backs of the children in randomized, successive 4 week periods with an intermediate 6 week washout period. Behavioral outcomes were measured by parents and teachers using the Autism Treatment Evaluation Checklist. Overall, there were no statistically significant differences in speech, sociability, sensory, and health scores for treatment versus placebo periods. In addition, there were no differences in such scores for children with a history of diarrhea. Severity of autism was significantly greater at baseline in children receiving concomitant medications. Improvement in speech was found during the treatment phase of the trial (p=0.0479 for secretin versus placebo) only in children not using other medications.