Purpose/Aims: The American Thoracic Society (ATS) published recommendations for alpha-1 antitrypsin deficiency (AATD) testing in 2003. This descriptive project evaluates the outcomes of ATS AATD guideline use in the setting of the pulmonary function testing (PFT) lab.The specific aims met by this descriptive project describe the prevalence of AATD cases and carriers in the sample, examine to what degree the established clinical guideline promoted accurate patient selection for the alpha-1 test in the sample, and aimed to determine whether alpha-1 antitrypsin blood levels are reduced in current smokers compared to former or never smokers.Background: Alpha-1 antitrypsin prevents lung tissue breakdown by attenuating excess elastase released from neutrophils during the inflammatory response. Smoking impairs alpha-1 antitrypsin protection at the site of lung inflammation promoting emphysema development. In the case of genetic mutation, protective alpha-1 antitrypsin levels are reduced, causing emphysema even in non-smokers. Significantly reduced protective levels of alpha-1 antitrypsin increase the odds for morbidity and early mortality from emphysema. The literature provides support for targeted testing in the population most affected.Sample/Methods: The sample population included adults 21 through 79 years completing pulmonary function testing over 18 months in a metropolitan pulmonary medicine practice and was retrospectively reviewed.Of the 521 in the sample, 190 were tested for AATD, and 24 were found to carry an abnormal genotype. However, using Table 11 from the ATS CPG failed to provide structured, consistent guidance in selecting patients for AATD testing. Still, the prevalence of the abnormal genotypes MS, MZ, SZ, and ZZ was increased in this pulmonary population compared to the published estimated prevalence for the general population.A structured decision-tree, developed from the original guideline for diagnostic testing, may provide superior guidance for AATD test patient selection in this setting. Increased case finding by targeted testing of patients in the setting of the pulmonary function lab can serve to integrate this clinical practice guideline in a consistent streamlined fashion.In this sample, no difference between AAT blood levels among ever, never, and current tobacco smokers was detected. A more powerful sample is needed.

Suicide is an issue that plagues adolescents in the United States. Suicide crosses socioeconomic, racial, and gender divides and is difficult to predict and prevent. Primary care providers (PCPs) are in a position to detect suicidality in adolescents; however, PCPs lack the knowledge and confidence necessary to accurately identify suicidal adolescents. The author conducted an extensive review of current literature (meta-analyses, systematic reviews, literature reviews, case reports, and existing clinical practice guidelines) on identification of adolescent suicidality in pediatric primary care settings. This paper provides a set of recommendations for primary care providers on how to properly identify adolescents with suicidal ideation and behavior.

Background: Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance. We sought to answer the question, “Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?” Methods: A systematic review of the literature was performed in 5 databases published after 1985 and 5 additional sources for relevant publications were searched. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case control series, and case series for human subjects, published in English. One hundred thirty-five articles were identified as relevant to this clinical practice guideline. Results/Discussion: Based on strong evidence and a preponderance of benefit over harm, clinicians should offer vestibular rehabilitation to persons with unilateral and bilateral vestibular hypofunction with impairments and functional limitations related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) as specific exercises for gaze stability. Based on moderate evidence, clinicians may offer specific exercise techniques to target identified impairments or functional limitations. Based on moderate evidence and in consideration of patient preference, clinicians may provide supervised vestibular rehabilitation. Based on expert opinion extrapolated from the evidence, clinicians may prescribe a minimum of 3 times per day for the performance of gaze stability exercises as 1 component of a home exercise program. Based on expert opinion extrapolated from the evidence (range of supervised visits: 2-38 weeks, mean = 10 weeks), clinicians may consider providing adequate supervised vestibular rehabilitation sessions for the patient to understand the goals of the program and how to manage and progress themselves independently. As a general guide, persons without significant comorbidities that affect mobility and with acute or subacute unilateral vestibular hypofunction may need once a week supervised sessions for 2 to 3 weeks; persons with chronic unilateral vestibular hypofunction may need once a week sessions for 4 to 6 weeks; and persons with bilateral vestibular hypofunction may need once a week sessions for 8 to 12 weeks. In addition to supervised sessions, patients are provided a daily home exercise program. Disclaimer: These recommendations are intended as a guide for physical therapists and clinicians to optimize rehabilitation outcomes for persons with peripheral vestibular hypofunction undergoing vestibular rehabilitation.

No description available.

Background: Analytical frameworks (AF) are graphical representation of the key questions answered by a systematic review and can support the development of guideline recommendations. Our objectives are to a) conduct a systematic review to identify, describe and compare all AFs published as part of a systematic and guideline development process related to colorectal cancer (CRC); and b) to use this case study to develop guidance on how to conduct systematic reviews of AFs. Methods: We conducted a systematic review and searched Medline and Embase from 1996 until December 2020. We also manually searched guideline databases and websites. We identified all guidelines in CRC that utilized an AFs and all systematic reviews in primary prevention, screening, and diagnosis of CRC that used AFs. We assessed quality of the guidelines using the Appraisal of Guidelines for Research and Evaluation II tool. The systematic review was registered in PROSPERO, registration CRD42020172117. Results: We screened 34,505 records and identified 1166 guidelines on CRC and 3127 systematic reviews, of which 5 met our inclusion criteria identifying a total of 4 AFs in colorectal cancer. We describe our search strategy and methods for conducting systematic reviews for AFs. Conclusion: Few guidelines and systematic reviews are utilizing AFs in the development of recommendations. We developed methods for conducting a systematic review on AF / Thesis / Master of Science (MSc) / Analytical frameworks are graphical diagrams that represent key questions with flow of resining from population to outcome. We conducted a systematic review to identify all analytical frameworks in colorectal cancer and in the process we developed guidance on how to conduct a systematic review for analytical frameworks. We identified four analytical frameworks, one in primary prevention, and three in screening of colorectal cancer. We found only a few clinical practice guidelines that utilized analytical frameworks in the development of the recommendations. We developed methods for conducting a systematic review of analytical frameworks.

Clostridium difficile infection (CDI) prevention is of high priority. We reviewed clinical practice guidelines (CPGs), and conducted an individual participant data meta-analysis (IPMDA) of randomized controlled trials (RCTs) to assess effectiveness and safety of probiotic prophylaxis. For CPGs, we rated quality, summarized recommendations with their strength and author-reported evidence, then re-evaluated evidence. For the IPDMA, we pooled RCTs investigating probiotics versus control for CDI prevention among antibiotic consumers, using generalized linear mixed models. Our outcomes were CDI and serious adverse events (SAEs). We adjusted for age, sex, hospitalization status, and exposure to high risk antibiotics. We assessed study risk of bias and confidence in estimates of effect. Five international guidelines were evaluated, and all scored poorly for applicability, stakeholder involvement, and rigor of development. Recommendations were not always linked to evidence, and guideline authors were not transparent about how evidence limitations impacted their decisions. None of the guidelines recommended probiotics. Fourteen studies contributed data, with one pending. Probiotics reduced CDI among all studies and the adjusted model. No covariates were significantly associated with CDI. Subgroups suggested that high incidence did not affect probiotic effectiveness, and high-dose, multi-strain probiotics were more beneficial. Our estimate was robust to sensitivity analyses. Probiotics did not significantly affect SAE odds among all studies and the adjusted model. Increasing age was a significantly associated with SAEs. No SAEs were reportedly probiotics-related. For both outcomes, estimates were similar from data of obtained and not obtained studies. Confidence in estimates was moderate for both outcomes, due to low event rates. Current guidelines on CDI prevention did not adhere well to validated standards for development and reporting, most notably due to insufficient links between recommendations and supporting evidence. Our preliminary analysis suggests that probiotic prophylaxis is useful and safe for CDI prevention. / Thesis / Master of Science (MSc) / Clostridium difficile infection (CDI) is a common hospital-associated infection, and prevention is of high priority. We reviewed clinical practice guidelines on CDI prevention to summarize their recommendations, and assess the quality of guideline development and reporting. Furthermore, we analysed patient data from randomized clinical trials to obtain an overall estimate (meta-analysis) of whether using a novel strategy, probiotic prophylaxis, is effective and safe. The guidelines had several limitations, importantly that authors were not transparent about how recommendation were developed, and recommendations were not always linked to evidence. Although no guideline recommended using probiotics to prevent CDI, our advanced analysis of previously conducted trials suggested that it was an effective intervention, reducing infections by approximately 76%, and was not associated with differences in serious adverse events compared to participants not receiving probiotics. In summary, guidelines on CDI prevention should be improved, and probiotics may be considered as an additional strategy.

Neonatal abstinence syndrome (NAS) refers to the withdrawal symptoms experienced when an infant has been exposed to certain substances (e.g., opioids) in-utero, resulting in health challenges for infants. Previous studies have reported substantial variations in the clinical management of NAS, suggesting that some infants may not be receiving optimal care. High-quality clinical practice guidelines are crucial to support optimal patient outcomes and standardize care. In response, I conducted a systematic review and quality appraisal of available NAS guidelines and recommendations using the AGREE-II and AGREE-REX tools. I also developed and piloted a tool to measure family-centred care in guidelines. Most guidelines received low-quality appraisal scores on the AGREE-II and the AGREE-REX appraisals (16/20 and 10/20, respectively) and have conflicting pharmacological recommendations. Findings will improve clinicians’ awareness of the variation in the quality of guidelines and assist them to make care decisions that are from the best available evidence and family-centred.

This research was undertaken to study the impact of single and multicomponent knowledge translation interventions (KTIs) on barriers to the integration of Clinical Practice Guidelines (CPG) into Clinical Decision Making (CDM) in the context of physical therapists (PTs) and find out which of the two KTIs was more effective. A literature review showed that research knowledge (e.g. CPG) in the field of PT (Physical Therapy) is not being integrated in to clinical practice (e.g. CDM), thus leading to a research-practice (R-P) gap in other words CPG-CDM gap. It is suggested in the literature that the management and behavioural aspects of PTs might be acting as barriers hindering the integration of the research knowledge into clinical practice consequently affecting the delivery of optimum patientcare. Remedial measures, namely KTIs, are suggested to address those barriers and to bridge the R-P gap. However, the phenomenon of the R-P gap, the causes of it and the possible interventions are not well understood concepts in the literature, particularly in the context of PTs. CPG for Venous Thromboembolism (VTE) in PT was chosen as the example of research knowledge. It was argued that barriers have the potential to affect CDM which in turn can affect the CPG-CDM gap. Lack of knowledge about CPG-CDM gap is a major limitation in the literature that is affecting the integration of CPG into CDM. Other gaps found in the literature that have the potential to affect CPG-CDM gap include management and behavioural variables as probable causes of CPG-CDM gap (or barriers), use of KTIs to bridge the CPG-CDM gap and, KTIs. Furthermore, lack of knowledge about relationship between barriers and CPG-CDM gap, KTIs and barriers, KTIs and CPG-CDM gap and the impact of KTIs (effectiveness) in bridging CPG-CDM gap were the other gaps found in the literature that had potential implications to CPG-CDM gap. These gaps were addressed in this research to some extent. Relationships between the independent variables (lack of knowledge of PTs in CPG, lack of favourable attitude of PTs towards CPG and lack of self-efficacy and motivation of PTs to integrate CPG into CDM) and the dependent variables (CDM and CPG-CDM gap) were defined and models were proposed. Further, it was posited that KTIs could impact barriers based on theories and models found in the literature that provided some basis to create the linkage between KTIs and management and behavioural barriers. Education material (EM) and virtual communities of practice (VCoP) were chosen as of the KTIs in this study. The models of Cabana et al. (1999) and Fischer et al. (2016), primarily, were used to ground the conceptual models represented by figures and equations. Methodologically, a positivist approach with an objective ontological stance was employed and a deductive approach and quantitative research method were used to address the research gaps. The research design included a longitudinal element and survey questionnaire. The target population was licensed PTs in the USA. Random sampling was used. Two groups of PTs were identified namely EM-group and VCoP group. Data was collected from the groups before and after administering the KTIs. The results showed that single and multicomponent KTIs impacted barriers in different ways. EM impacted lack of favourable attitude of PTs towards CPG, and lack of self-efficacy and motivation of PTs to integrate CPG into CDM as barriers and narrow the CPG-CDM gap. VCoP was found to impact the combination of four barriers and narrow CPG-CDM gap. In addition, barriers in groups of two were also impacted by VCoP and narrowed the CPG-CDM gap. Furthermore, a CPG knowledge score card and a corresponding CDM score card developed by the researcher were used to test the change behaviour of PTs in integrating CPG into CDM. This experiment showed that barriers existed and caused CPG-CDM gap and KTIs could narrow the CPG-CDM gap. The findings indicate that this research has contributed to knowledge in many ways, including unearthing the relationship between CPG-CDM gap and barriers, better understanding of KTIs, their relationship with CPG-CDM gap and barriers, gaining knowledge about the impact of single and multicomponent KTIs on single and multiple barriers and identification of methods to bridge the CPG-CDM gap.

The prescription rate of antipsychotics in patients with dementia varies between 20% and 50% for the common and troubling neuropsychiatric symptoms experienced by patients with dementia. The use of these antipsychotic medications has been linked with increased risk of morbidity and mortality due to associated Parkinsonism, over sedation, gait disturbances, cognitive decline, and cardiovascular adverse events. The purpose of this project was to assess whether development of an evidence-based clinical practice guideline (CPG) for a long-term care facility would increase awareness about issues that govern the safe use of antipsychotic medications. The conceptual framework for the project was Watson's model of caring. The Fineout-Overholt tool was used to rank and score information retrieved following an extensive literature review. An expert panel made up of 2 medical doctors and 4 nurse practitioners had 100% agreement that objectives were clear; content was relevant and easy to understand; the CPG was well-organized and easy to follow; and knowledge learned would be used in practice. From 66.6% to 83.3% agreed that the CGP led to an improved understanding of dementia, neuropsychiatric symptoms, medication adverse events, and nonpharmacologic interventions. The expert panel agreed to launch the CPG upon implementation of an educational program for frontline nursing staff and a behavioral log to track occurrence and frequency of behaviors and the use of nonpharmacologic interventions and their effectiveness in managing behaviors. Safe implementation of this CPG might be adapted to other long-term facilities to optimize dementia care, which would bring about a positive social change.

Organizational learning through experience has been found to be associated with enhanced firm performance. Organizational experiments are a method of experiential learning that enable organizations to learn from experience and gain context-specific knowledge of how and why to implement new knowledge. Pilot projects, a type of organizational experiment, involve making intentional, systematic efforts to gather and analyze feedback in order to accurately assess the action-outcome relationships of adopting new knowledge prior to embarking on full-scale implementation. Despite the popularity of pilot projects used to test products, programs, and services as well as reports on the outcomes of such experiments, there is a dearth of research focusing on how organizational learning occurs during organizational experiments, and on the processes and structural mechanisms of organizational experiments that contribute to organizational learning. A qualitative, multiple-case study of eight pilot projects was carried out within nursing units across five acute health care organizations during Fall 2008. Interviews were conducted with 32 individuals, including pilot project leaders, nursing program managers and direct care nurses. An inductive approach to data analysis was applied and themes identified. Results were compared to 14 propositions that were developed based on the knowledge transfer, innovation diffusion, and organizational learning literature, and which were bracketed before data analysis to allow findings to emerge from the data. The findings advance existing organizational learning, innovation diffusion, and knowledge transfer models by illuminating the complexity of organizational learning processes. Several processes and structural mechanisms of organizational experiments were found to facilitate single-loop organizational learning, leading to incremental changes to meet existing goals and objectives. Although double-loop organizational learning, which may result in fundamental changes in an organization’s assumptions, norms, policies, goals and objectives was not observed, the study revealed a number of processes and structural mechanisms that have the potential to encourage this type of learning. Studies of organizational experiments are rare. Future directions for research and theory development are suggested to build on the findings of this study. Practical implications are offered to organizations in any industry interested in realizing the potential that organizational experiments have for double-loop learning and enhanced organizational performance.