Designing an implementation strategy to improve interprofessional shared decision making in sciatica: study protocol of the DISC study

ABSTRACT: BACKGROUND: Sciatica is a common condition worldwide that is characterized by radiating leg pain and regularly caused by a herniated disc with nerve root compression. Sciatica patients with persisting leg pain after six to eight weeks were found to have similar clinical outcomes and associated costs after prolonged conservative treatment or surgery at one year follow-up. Guidelines recommend that the team of professionals involved in sciatica care and patients jointly decide about treatment options, so-called interprofessional shared decision making (SDM). However, there are strong indications that SDM for sciatica patients is not integrated in daily practice. We designed a study aiming to explore the barriers and facilitators associated with the everyday embedding of SDM for sciatica patients. All related relevant professionals and patients are involved to develop a tailored strategy to implement SDM for sciatica patients. METHODS: The study consists of two phases: identification of barriers and facilitators and development of an implementation strategy. First, barriers and facilitators are explored using semi-structured interviews among eight professionals of each (para)medical discipline involved in sciatica care (general practitioners, physical therapists, neurologists, neurosurgeons, and orthopedic surgeons). In addition, three focus groups will be conducted among patients. Second, the identified barriers and facilitators will be ranked using a questionnaire among a representative Dutch sample of 200 GPs, 200 physical therapists, 200 neurologists, all 124 neurosurgeons, 200 orthopedic surgeons, and 100 patients. A tailored team-based implementation strategy will be developed based on the results of the first phase using the principles of intervention mapping and an expert panel. DISCUSSION: Little is known about effective strategies to increase the uptake of SDM. Most implementation strategies only target a single discipline, whereas multiple disciplines are involved in SDM among sciatica patients. The results of this study can be used as an example for implementing SDM in other patient groups receiving multidisciplinary complex care (e.g., elderly) and can be generalized to other countries with similar context, thereby contributing to a worldwide increase SDM in preference sensitive choices.     

Implementing international osteoarthritis treatment guidelines in primary health care: study protocol for the SAMBA stepped wedge cluster randomized controlled trial

Background

Previous research indicates that people with osteoarthritis (OA) are not receiving the recommended and optimal treatment. Based on international treatment recommendations for hip and knee OA and previous research, the SAMBA model for integrated OA care in Norwegian primary health care has been developed. The model includes physiotherapist (PT) led patient OA education sessions and an exercise programme lasting 8–12 weeks. This study aims to assess the effectiveness, feasibility, and costs of a tailored strategy to implement the SAMBA model.

Methods/design

A cluster randomized controlled trial with stepped wedge design including an effect, process, and cost evaluation will be conducted in six municipalities (clusters) in Norway. The municipalities will be randomized for time of crossover from current usual care to the implementation of the SAMBA model by a tailored strategy. The tailored strategy includes interactive workshops for general practitioners (GPs) and PTs in primary care covering the SAMBA model for integrated OA care, educational material, educational outreach visits, feedback, and reminder material. Outcomes will be measured at the patient, GP, and PT levels using self-report, semi-structured interviews, and register based data. The primary outcome measure is patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire) at 6-month follow-up. Secondary outcomes include referrals to PT, imaging, and referrals to the orthopaedic surgeon as well as participants’ treatment satisfaction, symptoms, physical activity level, body weight, and self-reported and measured lower limb function. The actual exposure to the tailor made implementation strategy and user experiences will be measured in a process evaluation. In the economic evaluation, the difference in costs of usual OA care and the SAMBA model for integrated OA care will be compared with the difference in health outcomes and reported by the incremental cost-effectiveness ratio (ICER).

Discussion

The results from the present study will add to the current knowledge on tailored strategies, which aims to improve the uptake of evidence-based OA care recommendations and improve the quality of OA care in primary health care. The new knowledge can be used in national and international initiatives designed to improve the quality of OA care.

Trial registration

ClinicalTrials.gov NCT02333656

     

Evidence of mesenchymal stromal cell adaptation to local microenvironment following subcutaneous transplantation

Subcutaneous transplantation of mesenchymal stromal cells (MSC) emerged as an alternative to intravenous administration because it avoids the pulmonary embolism and prolongs post‐transplantation lifetime. The goal of this study was to investigate the mechanisms by which these cells could affect remote organs. To this aim, murine bone marrow–derived MSC were subcutaneously transplanted in different anatomical regions and the survival and behaviour have been followed. The results showed that upon subcutaneous transplantation in mice, MSC formed multicellular aggregates and did not migrate significantly from the site of injection. Our data suggest an important role of hypoxia‐inducible signalling pathways in stimulating local angiogenesis and the ensuing modulation of the kinetics of circulating cytokines with putative protective effects at distant sites. These data expand the current understanding of cell behaviour after subcutaneous transplantation and contribute to the development of a non‐invasive cell‐based therapy for distant organ protection.     

Barriers and facilitators to implement shared decision making in multidisciplinary sciatica care: a qualitative study

Background

Venous thromboembolism (VTE) is a common preventable cause of mortality in hospitalized medical patients. Despite rigorous randomized trials generating strong recommendations for anticoagulant use to prevent VTE, nearly 40% of medical patients receive inappropriate thromboprophylaxis. Knowledge-translation strategies are needed to bridge this gap.

Methods

We conducted a 16-week pilot cluster randomized controlled trial (RCT) to determine the proportion of medical patients that were appropriately managed for thromboprophylaxis (according to the American College of Chest Physician guidelines) within 24 hours of admission, through the use of a multicomponent knowledge-translation intervention. Our primary goal was to determine the feasibility of conducting this study on a larger scale. The intervention comprised clinician education, a paper-based VTE risk assessment algorithm, printed physicians’ orders, and audit and feedback sessions. Medical wards at six hospitals (representing clusters) in Ontario, Canada were included; three were randomized to the multicomponent intervention and three to usual care (i.e., no active strategies for thromboprophylaxis in place). Blinding was not used.

Results

A total of 2,611 patients (1,154 in the intervention and 1,457 in the control group) were eligible and included in the analysis. This multicomponent intervention did not lead to a significant difference in appropriate VTE prophylaxis rates between intervention and control hospitals (appropriate management rate odds ratio = 0.80; 95% confidence interval: 0.50, 1.28; p = 0.36; intra-class correlation coefficient: 0.022), and thus was not considered feasible. Major barriers to effective knowledge translation were poor attendance by clinical staff at education and feedback sessions, difficulty locating preprinted orders, and lack of involvement by clinical and administrative leaders. We identified several factors that may increase uptake of a VTE prophylaxis strategy, including local champions, support from clinical and administrative leaders, mandatory use, and a simple, clinically relevant risk assessment tool.

Conclusions

Hospitals allocated to our multicomponent intervention did not have a higher rate of medical inpatients appropriately managed for thromboprophylaxis than did hospitals that were not allocated to this strategy.     

Cloning and characterization of three hypothetical secretion chaperone proteins from Xanthomonas axonopodis pv. citri

Xanthomonas axonopodis pv. citri (Xac) causes citrus canker in plantations around the world and is of particular significance in Brazil where its incidence has risen exponentially over the past decade. Approximately one third of the predicted Xac open reading frames show no homology, or homology with very low score with that of known sequences. It is believed that Xac utilizes secretion systems to transfer virulence proteins into susceptible eukaryotic cells. This process is assisted by secretion chaperones that maintain virulence proteins partly or completely unfolded during translocation. We have cloned three of these hypothetical secretion chaperones: XAC0419 and XAC1346 from type III secretion system (TTSS) and XACb0033 from type IV secretion system (TFSS). All proteins were cloned in a pET23a vector (Novagen), expressed at 37 degrees C using a BL21(DE3)pLysS Escherichia coli strain and purified by ion exchange and gel-filtration chromatographic methods. Pure proteins were characterized using spectroscopic measurements: circular dichroism, and both static and lifetime emission fluorescence in the case of XACb0033. The analyzed proteins are stable at elevated temperatures (up to 65 degrees C) and exhibit alpha-helix content from approximately 30% (XACb003) to approximately 87% (XAC1346). XACb0033 exhibits lifetimes in the fluorescence experiments that indicate different neighborhoods for its tryptophan residues. These chaperones have the characteristics of TTSS and TFSS: all are small, with a high alpha-helix content, and without ATP-binding or ATP-hydrolyzing activity.     

New facial measurement used in the determination of palatine index and thickness of the mandibular body index

Measurements of the height of the mandibular body and the length of the palate rest on the assumption that the alveolar parts of the mandible and maxilla are not altered. Unfortunately, in the skeletal remains of the past population most of the molar teeth are often antemortem lost and this tooth loss is followed by resorption of the alveolar ridge. A new method of taking mandibular and palate measurements, which could be used in these cases is proposed in the study.     

Bioassay-guided fractionation of pterocarpans from roots of Harpalyce brasiliana Benth

Pterocarpans, a special kind of isoflavonoids possessing two contiguous benzofuran and benzopyran rings, have been reported as possessing several biological activities. In order to isolate and identify the active principles possibly responsible for the stronger activity of the EtOH extract from roots of Harpalyce brasiliana on the antimitotic assay using sea urchin egg development, a bioassay-guided fractionation was performed. Six bioactive pterocarpan derivatives: 4'-dehydroxycabenegrin A-I, leiocarpin, medicarpin, cabenegrins A-I and A-II, and maackiain were isolated from the chloroform fraction of H. brasiliana extract. Leiocarpin was the most active on the sea urchin egg assay with IC(50) values ranging from 0.1 to 1.2 microg/mL, followed by 4'-dehydroxycabenegrin A-I. The isolated compounds were also tested for cytotoxicity against tumor cell lines in cultures, where 4'-dehydroxycabenegrin A-I was the most active, followed by leiocarpin. Additionally, some studies on the structure-activity relationship of these pterocarpans are suggested.     

CT reconstruction of the Glabellar bone

During systematic archaelogical excavations of the early medieval kingdom of Serbia, and adult male skull belonging to the skeleton of a Roman individual was unearthed at Babrež site in the Ras region. A supernumerary bone was found interposed between the frontal bones of the skull and the facial skeleton. Paleopathological investigation and CT reconstruction proved that this skull had been deformed during foetal development due to a disorder or disease affecting the mother. This probably led to the formation of the supernumerary Glabellar bone in the frontal region. This is the first case of Os Glabellae recorded so far.     

Most Important Factors for the Implementation of Shared Decision Making in Sciatica Care: Ranking among Professionals and Patients

Introduction

Due to the increasing specialization of medical professionals, patients are treated by multiple disciplines. To ensure that delivered care is patient-centered, it is crucial that professionals and the patient together decide on treatment (shared decision making (SDM)). However, it is not known how SDM should be integrated in multidisciplinary practice. This study determines the most important factors for SDM implementation in sciatica care, as it is known that a prior inventory of factors is crucial to develop a successful implementation strategy.

Methods

246 professionals (general practitioners, physical therapists, neurologists, neurosurgeons, orthopedic surgeons) (30% response) and 155 patients (96% response) responded to an internet-based survey. Respondents ranked barriers and facilitators identified in previous interviews, on their importance using Maximum Difference Scaling. Feeding back the personal top 5 most important factors, each respondent indicated whether these factors were barriers or facilitators. Hierarchical Bayes estimation was used to estimate the relative importance (RI) of each factor.

Results

Professionals assigned the highest importance to: quality of professional-patient relationship (RI 4.87; CI 4.75–4.99); importance of quick recovery of patient (RI 4.83; CI 4.69–4.97); and knowledge about treatment options (RI 6.64; CI 4.53–4.74), which were reported as barrier and facilitator. Professionals working in primary care had a different ranking than those working in hospital care. Patients assigned the highest importance to: correct diagnosis by professionals (barrier, RI 8.19; CI 7.99–8.38); information provision about treatment options and potential harm and benefits (RI 7.87; CI 7.65–8.08); and explanation of the professional about the care trajectory (RI 7.16; CI 6.94–7.38), which were reported as barrier and facilitator.

Conclusions

Knowledge, information provision and a good relationship are the most important conditions for SDM perceived by both patients and professionals. These conditions are not restricted to one specific disease or health care system, because they are mostly professional or patient dependent and require healthcare professional training.