The spectrum of acute pancreatitis (AP) affects between 4.9 and 73.4 patients out of 100,000 worldwide annually (Tenner, Baillie, DeWitt, & Vege, 2013). AP uses the Atlanta classification system to establish a diagnosis of mild, moderate, or severe. The American College of Gastroenterology (ACG) has established comprehensive clinical practice guidelines (CPG) for the management of AP, the most recent version published in 2013 (Tenner et al., 2013). There have been similar CPGs published internationally that integrate current evidence-based research into recommendations for practice. These guidelines along with the ACG's guidelines recommend initiating a diet for mild acute pancreatitis patients due to research findings of improved patient outcomes (i.e. reduced length of hospital stay, decreased rate of infections, and reduced mortality) (Horibe et al., 2015; Lariño-Noia et al., 2014). There is an international awareness of the need for increased CPG nutrition recommendation compliance in the practice setting as many studies have found providers prefer to keep patients nil per os (NPO) and do not adhere to CPGs (Andersson, Andrén-Sandberg, Nilsson, & Andersson, 2012; Greenberg et al., 2016; Sun et al., 2013). The purpose of this doctor of nursing practice (DNP) project is to assess providers' current nutrition therapy practice and knowledge of the ACG’s CPG nutrition recommendations for mild AP patients. The researcher conducted the assessment with a hospitalist practice at Banner University Medical Center in Phoenix, Arizona. The results of the project contribute to the current body of research on national adherence to CPGs for AP and act as a needs assessment for future projects where a nutrition protocol order set may be established. The investigation of nutrition therapy for AP patients seeks to improve and standardize the care this patient population receives while in the acute care setting.

Osteoporosis is a common health problem and it is increasing in prevalence due to the increase in the aging population. The interest to treat osteoporosis has increased in recent years, due to availability of screening modalities, advances in medications that may prevent osteoporotic fractures. Many studies have showed the high medical and economic burden of the disease on the patients, their caregivers and on the health system. Clinical practice guidelines for management of osteoporosis varied nationally and internationally, and the adherence of physicians to guidelines were always reported as suboptimal, though most studies were for after fragility fracture care gap and vert few looked at the primary screening to identify patients at risk before the occurrence of fractures. This thesis is composed of two manuscripts research project assessing the development and impact of screening for osteoporosis guidelines. The first chapter is an overview of osteoporosis, definition, risk factors, diagnosis and treatment. A follow up discussion of the literature on adherence of physicians to the osteoporosis guidelines, which ends up with the rational for this thesis. The first paper is a systematic review to identify guidelines for screening for osteoporosis from 2002-2016 (Chapter 2). We assessed the quality of these guidelines using the AGREE II and IOM standards, compared between the two tools, and assessed if the quality has changed over time. We extracted recommendations in key areas with summary of the systems that were used to assign the level of evidence and strength of recommendations. We found that the quality of guidelines has varied greatly between different countries with no significant change over time. The recommendations and systems for level of evidence were variable and all this may create confusion to clinicians. In the second paper, we used an interrupted time series design to assess the effect of three clinical practice guidelines for screening for osteoporosis in Ontario on the baseline bone mineral density (BMD) testing for older adults 65 years of age and above using administrative data by ICES from 1998-2006. All three guidelines recommend baseline BMD testing for this age population. In addition, we analyzed the pattern of repeated testing in accordance with the latest guideline. We have found low rates of baseline BMD testing with a decreasing pattern of testing. The last guideline in 2010 had gradually increased the trend of BMD testing, though it was a very small change. Stratified analyses by sex showed that the decrease in the total BMD testing is due to decrease in the testing for female population while there is an increasing trend of BMD testing in male population. CPG by Osteoporosis Canada in 2010 caused an immediate reduction in the BMD testing for female, yet, over a period of time, the guideline increased the BMD testing. For male population; the 2002 CPG had immediately increased the BMD testing, while over time this trend has decreased. Despite the low baseline BMD testing by physicians, there is an over use of repeated BMD testing in the low risk population, especially the annual and the 2 yearly BMD repeats. In conclusion: This research project found a varied quality of guideline development and reporting of guidelines for osteoporosis screening, and no improvement in the quality over time (2002-2016). Several systems were used to assign the level of evidence and strength of recommendations with conflicting recommendations between different health organizations in the same country such as in Canada. Many tools are available to appraise the quality of guidelines, however, comparing between two tools (AGREE II & IOM standards) showed that they may give conflicting results for guidelines quality. There is no effect of guidelines for screening for osteoporosis on the ordering of BMD testing to screen adults 65 years and above living in Ontario between 1998- 2016. A small increase the rate of baseline BMD testing followed the release of the 2010 guideline. For male population the 2002 guideline showed an evident immediate and gradual effect over time on the rate of baseline BMD testing ordering for male population. Despite the low baseline BMD testing rates for adults 65 years and above, there is an unnecessary repeated BMD testing for low risk population in Ontario between 2011-2016 which is not in compliance to the latest guideline for screening for osteoporosis.

Beteendemedicin är ett paraplybegrepp där den fysioterapeutiska tillämpningen i praktik kan se ut på många olika sätt. Hur fysioterapeuter tillämpar beteendemedicin i praktiken och hur det avspeglas i den individanpassade behandlingsplanen råder det oklarheter kring. Syftet med denna studie var att undersöka fem fysioterapeuters upplevelser och erfarenheter av tillämpning av beteendemedicin inom sina respektive verksamheter i Uppsala län. Studien var av kvalitativ design. Enskilda semistrukturerade intervjuer avfem fysioterapeuter inom olika verksamheter utfördes. Databearbetning genomfördes i form av en kvalitativ innehållsanalys. Deltagarna tillämpade flertalet olika tekniker inom beteendemedicin. De upplevde även att det finns utmaningar som att det är tidskrävande, att patienten inte förstår konceptet och att teorin är lättare än tillämpningen i praktik. Alla deltagare var överens om att det finns en nytta med beteendemedicinsk tillämpning, som att bli en bättre fysioterapeut, att det ger vinst i långa loppet samt att teorin fyller en viktig funktion för praktisk tillämpning. Det föreföll sig som att fysioterapeuterna tillämpar beteendemedicin på ett annat sätt än vad de lärt sig från den teoretiska utbildningen. Fyra huvudkategorier identifierades under databearbetningen; Olika tekniker inom beteendemedicin, Utmaningar med att arbeta beteendemedicinskt, Förståelse av nyttan med beteendemedicin, Blivit en “tyst” kunskap. Deltagarna upplevde att beteendemedicin fyller en viktig funktion i den individualiserade behandlingsplanen för patienten, men upplevde även många utmaningar. Trots utmaningarna så var deltagarna överens om att beteendemedicin är ett vinnande behandlingskoncept inom fysioterapi. Detta examensarbete kan bidra till utvecklingsmöjligheter för grundutbildningen i fysioterapi. / Behavioral medicine is an umbrella concept where the physiotherapeutic application in practice can differ in many ways. There are uncertainties about how physiotherapists apply it in practice and how this is reflected in the individualized treatment plan. The aim of this study was to investigate five physiotherapists' experiences of applying behavioral medicine in clinical practice within each of their workplaces in Uppsala. This study is of a qualitative design. Individual semi-structured interviews offive physiotherapists were performed. Data processing was carried out in the form of a qualitative content analysis. The participants applied several different behavioral medicine techniques. They also experienced challenges; it is time consuming, the patient does not understand the concept and the theory is easier than the application in practice. All participants agreed that there are benefits to behavioral medicine application; becoming a better physiotherapist, it provides benefits in the long run and the theory fulfills an important function for practical application. It seemed that the physiotherapists apply behavioral medicine in a different way than what they have learned. Four main categories were identified; Different techniques in behavioral medicine, Challenges when working with behavioral medicine, Understanding the benefits of behavioral medicine, Has become a “silent” knowledge. The participants experienced that behavioral medicine fulfills an important function in individualized treatment plans for patients, but they also experienced many challenges. Despite the challenges, the participants agreed that behavioral medicine is a winning concept in physiotherapy. This degree project can contribute to development opportunities for the undergraduate education in physiotherapy.

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Childhood bullying can lead to adverse physical and mental health outcomes for both the victim and the bully. Risk factors for bullying can be related to gender, race, sexual preference, and having any type of disability. A pediatric primary care clinic in a large, metropolitan area, the focus for this project, did not have an evidenced-based clinical practice guideline (CPG) for providers to facilitate the management of children who presented with reported bullying. The project, guided by the Tanner'€™s integrated model of clinical judgement, addressed the question whether a CPG would facilitate the early recognition and treatment of bullying in the pediatric clinical site. Using a literature search, a CPG was developed with evidence that included 6 recommendations ranging from clinical assessment and screening to advocacy. The CPG was then evaluated by 4 expert panelists using the AGREE II tool. Panelists included 2 pediatric medical doctors, 1 pediatric school nurse, and 1 mental health nurse practitioner. The panel evaluation results revealed a score of 81 out of a possible 100, where a score of 71 was the standard for acceptable results for the 6 recommendations. Results from the expert panel were used to modify the CPG, after which the guideline was presented to the panel for final approval. One final recommendation of the panel was to include a provision for referral and follow up for children identified with bullying. The finalized CPG was presented to the medical director of the pediatric clinic for implementation. The implications of the project for positive social change include decreased variations in clinical practice, early detection and intervention of bullying, improved effectiveness and quality of care, and decreased costly and preventable adverse events.

Reviews the book, Complementary medicine and clinical practice edited by David P. Rakel and Nancy Faass (2006). Complementary and alternative medicine, or CAM, as it is known, has been an important and controversial topic for allopathic medicine. Although the majority of the patients in this country will use one or more forms of complementary medicine, and spend more out-of-pocket money on CAM techniques and practitioners than on allopathic ones, there is still a great deal of uncertainty among practicing physicians about what exactly CAM consists of. This book goes a long way toward helping to clarify this diverse and changing topic. Overall, each of the topics in the book emphasizes a refreshing focus on health compared with the antidisease focus of many more traditional medical articles and books. Each of the chapters integrates the technique and philosophy of the topic explored into an overall health-oriented approach to patient care. Rakel and Faass's book creates a template for a new model of medicine. Given its broad scope, it is ideal for family physicians to consider as we envision the evolution of our practices.

Health care changes, including increased hospital admissions, an aging population and the chronicity of diseases and conditions have led to increased collaboration with unregulated professionals. Within the professions of occupational therapy and physiotherapy, there is a paucity of literature that addresses the perceptions of Occupational Therapist Assistants and Physiotherapist Assistants (OTAs and PTAs) with respect to their competence in clinical practice. This research study investigates the perceptions of clinical competence of OTA and PTA graduates from one Ontario community college. A phenomenological theoretical framework was used to explore the participants’ lived experiences. Eight individual in-depth interviews were used to gather data representing the graduate OTAs and PTAs’ perspectives. In addition, the viewpoints from a stakeholder focus group of eight participants comprised of occupational therapists, physiotherapists, and administration personnel from one Ontario hospital were used to triangulate the data.. Four themes emerged: 1) employing effective communication, 2) emerging knowledge, skills and competencies in clinical practice, 3) transitioning into clinical practice, and 4) developing confidence as an OTA and PTA. The Person Environment Occupation (PEO) model (Law et al., 1996) was used to organize the themes and to assist in determining the optimal fit between the themes. Confidence was articulated as a continuous concept that facilitated the graduates’ competence in their clinical skills. Proficiency in their roles, a supportive transition, and demonstrated competence were the presenting factors that empowered the graduate OTAs and PTAs to affirm their competence in clinical practice. This research study is foundational for future research related to OTAs and PTAs in the areas related to use of title, educational credentialing, and collaborative competency documentation. / Thesis / Master of Science (MSc) / Currently, there are changes in health care services that require modifications to the delivery of the treatment. Occupational Therapist Assistants and Physiotherapist Assistants (OTAs and PTAs) work within patient rehabilitation; however, their perceptions of competence have not been assessed. This study reviews the perceptions of the OTAs and PTAs when completing their role with patients by interviewing them and interviewing the staff that work with them. The data from this thesis will provide us with an enhanced understanding of the perceptions of OTAs and PTAs and the supports they believe enable them to be competent and confident health care professionals. This information will facilitate the identification of the next steps in research specific to OTAs and PTAs in the areas of competency and educational programs.

Trustworthy clinical practice guidelines assist health care professionals in selecting the management options that optimize patient health outcomes. The development of trustworthy guidelines requires the consideration of many aspects and the involvement of multiple contributors, often working in groups. The guideline panel plays the key role in the development process as it is responsible for prioritizing topics that should be covered as part of the guideline effort, formulating questions, reviewing the evidence, developing and agreeing on the recommendations, and endorsing the final guideline document. Ensuring transparency throughout the process by appropriately organizing and documenting panel activities is an essential standard that is used to assess the credibility of a developed guideline and its resulting recommendations. The adoption of conceptual frameworks that systematically guides panel members in their decision-making process (e.g. the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks) can aid in the formulation of methodologically sound recommendations. In this dissertation, I used the example of a guideline on diagnosis and treatment of autism spectrum disorders to describe how rigorous research methods can support guideline panels in the development process from early stages to the formulation of recommendations. In another prominent guideline development effort with the American Society of Hematology, I have identified two steps in the process where panel members may benefit from further support and addressed these gaps by conceptualizing and developing novel approaches. The first approach comprises modelling baseline risk estimates for patient-important outcomes when only surrogate data is available. The second approach proposes a method to estimate decision thresholds for judgments on health benefits and harms using the GRADE EtD framework. While these approaches are tailored to address specific guideline panel needs, guideline methodologists could use the underlying concepts to find solutions to aid guideline panels in other steps of the development process. / Thesis / Doctor of Philosophy (PhD) / Clinical practice guidelines assist health care professionals in selecting management options that can best improve the health outcomes of their patients. The development of trustworthy guidelines is a complex process that requires the contribution of several entities. The guideline panel, which typically comprises different experts (clinicians, patient representatives, experts in research methodologies) plays the key role in this process as it is responsible for selecting the most important questions to address in the guideline, reviewing the evidence supporting an option, agreeing on the recommendations, and endorsing the final guideline document. To ensure that the process of developing guidelines is transparent and that the recommendations are credible, it is important that panel activities are well documented and follow rigorous methods. Structured frameworks, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) approach, have been developed to systematically guide the panel members and to minimize the error that could be introduced while making decisions. In this thesis, I describe the development of an approach and its application for comprehensive guideline development by the Italian National Health Institute, to describe rigorous guideline development and propose two novel approaches to further assist panel members in enhancing their guideline development. The first of these two enhancements to guideline development describes how to derive a modelled estimate of the risk of having certain health conditions when this data is not directly available in the medical literature. The second of the two enhancements is a method to support guideline panels in judging how substantial the desirable and undesirable effects of health interventions are. Both approaches were tailored to fit specific needs but can be adapted to inform the improvement of other steps in the guideline development process.

This study retrospectively evaluated patient records from two cardiac rehabilitation (CR) service centers located in large urban hospitals using a Process Evaluation System (PES) recently developed through a collaborative project of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), Madison, WI, and the Center for Clinical Quality Evaluation (CCQE), Washington, DC. The major aims were to: 1) evaluate the utility of the PES as an audit instrument for assessment of adherence to the 24 quality process criteria that comprised the PES; and 2) determine whether adherence to the PES criteria resulted in different patient outcomes for those cases where intervention need was documented at patient admission. Using the data abstraction manual and audit procedures developed by AACVPR/CCQE, a trained medical technician audited 150 CR records for consecutively treated outpatients who typically received 36 sessions of treatment in either Moses H. Cone Memorial Hospital, N.C. Heart Institute, Greensboro, NC, or Carolinaà ­s Medical Center, Charlotte, NC, covering a calendar period between 1995-97. The data were pooled from both sites for analyses and included patients with one or more of the following diagnoses: MI (37%), angina (14%), coronary revascularization (76%), and other (18%). The cost of utilizing the PES was assessed by evaluating the technician time required to abstract a patient record and this was observed to improve over the course of the review period, i.e., mean abstraction time for initial versus final 20 records = 13.2 min. and 4.6 min., respectively. Experience with the PES suggested areas where instrument revision should be considered, e.g., the operational guidelines for extracting acceptable markers were not always clear enough or sufficiently flexible to allow determination of adherence of a record to the 24 quality process criteria. Adherence to the PES was determined, case by case, for each of the 24 criteria. In 129 cases (86% of the sample), complete adherence was found, i.e. 100% adherence to all 24 criteria that included indicators of key clinical steps for patient intake, treatment planning, and follow-up. The remaining 21 records (14%) showed adherence to at least 21 of the 24 criteria (87.5%). Given the uniformly high levels of adherence to the PES documented by these two program sites, the data could not resolve the question of whether patient outcome effects were different between cases of high versus low adherence to PES. Nonetheless, outcome data were examined to evaluate achievement levels in four different areas widely considered by clinicians as important to treatment success: blood cholesterol, smoking status, exercise tolerance, and body mass index (BMI). Of the study patients diagnosed with dyslipidemia 12 of 27 (44%) had levels < 200 mg/dl by exit. Seven of 14 documented smokers (50%) reported quitting at exit from treatment. Forty-nine patients of 117 (42%) who initially could only maintain treadmill walking for 10 min. at levels below 4 METs, were able to exceed this level by treatment end. Six of 104 (6%) with BMI values > 24.9 kg/m2 had a documented decrease in this indicator of overweight by treatment end. The threshold levels for outcome criteria used here to describe achievement levels in this data set are somewhat arbitrary. However, the criteria are reflective of the standards typically suggested as meaningful for effective secondary risk reduction in CR programs (Franklin et al., 1996). The PES system was developed to audit the quality of CR process in treatment centers, as standardized by a consensus panel to reflect the content of the evidenced-based CR guideline recently published by the US Agency for Health Care Policy and Research (Cardiac Rehabilitation as Secondary Prevention: #17, 1995). The findings of this study suggest that the content markers of quality process in the PES are relevant and the instrument is efficient to administer. When field tested against two urban centers in North Carolina where state statutes require program certification for CR treatment centers, these centers demonstrated uniformly high adherence to the PES and a pattern of good achievement for several patient outcome measures accepted as relevant to evaluation of treatment success for individual patients. / Master of Science

Yes / Binocularity in the human visual system poses two interesting and extremely challenging questions. The first, and perhaps most obvious stems from the singularity of perception even though the neural images we see originate as two separate images in the right and left eyes. Mechanistically we can ask how and where do we convert two images into one? The second question is more of a “why” question. By converting lateral eyes with their inherent panoramic visual field into frontal eyes with overlapping binocular visual fields, primates have developed an extremely large blind region (the half of the world behind us). We generally accept that this sacrifice in visual field size was driven by the potential benefit of extracting information about the 3rd dimension from overlapping right and left eye visual fields. For some people, both of these core processes of binocularity fail: a single fused binocular image is not achieved (when diplopia or suppression is present), and the ability to accurately represent the 3rd dimension is lost (stereo-blindness). In addition to these failures in the core functions of the human binocular system, early imbalances in the quality of right and left eye neural images (e.g. due to anisometropia, monocular deprivation, and/or strabismus), can precipitate profound neurological changes at a cortical level which can lead to serious vision loss in one eye (amblyopia). Caring for patients with malfunctioning binocular visual systems is a core therapeutic responsibility of the eye care professions (optometry, ophthalmology and orthoptics) and significant advances in patient care and subsequent visual outcomes will be gained from a deeper understanding of how the human brain accomplishes full binocular integration. This feature issue on binocular vision brings together original articles and reviews from leading groups of neuroscientists, psychophysicists and clinical scientists from around the world who embrace the multidisciplinary nature of this topic. Our authors have taken on the big issues facing the research community tasked with understanding how binocular vision is meant to work, how it fails, and how to better treat those with compromised binocularity. These studies address deep issues about how the human brain functions and how it fails, as well as how it can be altered by therapy.