American football and other sports injuries may cause migraine/persistent pain decades later and can be treated successfully with electrical twitch-obtaining intramuscular stimulation (ETOIMS)

Introduction

Autonomous twitch elicitation at myofascial trigger points from spondylotic radiculopathies-induced denervation supersensitivity can provide favourable pain relief using electrical twitch-obtaining intramuscular stimulation (ETOIMS).

Aim

To provide objective evidence that ETOIMS is safe and efficacious in migraine and persistent pain management due to decades-old injuries to head and spine from paediatric American football.

Methods and materials

An 83-year-old mildly hypertensive patient with 25-year history of refractory migraine and persistent pain self-selected to regularly receive fee-for-service ETOIMS 2/week over 20 months. He had 180 sessions of ETOIMS. Pain levels, blood pressure (BP) and heart rate/pulse were recorded before and immediately after each treatment alongside highest level of clinically elicitable twitch forces/session, session duration and intervals between treatments. Twitch force grades recorded were from 1 to 5, grade 5 twitch force being strongest.

Results

Initially, there was hypersensitivity to electrical stimulation with low stimulus parameters (500 µs pulse-width, 30 mA stimulus intensity, frequency 1.3 Hz). This resolved with gradual stimulus increments as tolerated during successive treatments. By treatment 27, autonomous twitches were noted. Spearman's correlation coefficients showed that pain levels are negatively related to twitch force, number of treatments, treatment session duration and directly related to BP and heart rate/pulse. Treatment numbers and session durations directly influence twitch force. At end of study, headaches and quality of life improved, hypertension resolved and antihypertensive medication had been discontinued.

Conclusions

Using statistical process control methodology in an individual patient, we showed long-term safety and effectiveness of ETOIMS in simultaneous diagnosis, treatment, prognosis and prevention of migraine and persistent pain in real time obviating necessity for randomised controlled studies.

Excited-State Studies of Polyacenes: A Comparative Picture Using EOMCCSD, CR-EOMCCSD(T), Range-Separated (LR/RT)-TDDFT, TD-PM3, and TD-ZINDO

The low-lying excited states (La and Lb) of polyacenes from naphthalene to heptacene (N = 2-7) are studied using various time-dependent computational approaches. We perform high-level excited-state calculations using equation of motion coupled cluster with singles and doubles (EOMCCSD) and completely renormalized equation of motion coupled cluster with singles, doubles, and perturbative triples (CR-EOMCCSD(T)) and use these results to evaluate the performance of various range-separated exchange-correlation functionals within linear-response (LR) and real-time (RT) time-dependent density functional theories (TDDFT). As has been reported recently, we find that the range-separated family of functionals addresses the well-documented TDDFT failures in describing these low-lying singlet excited states to a large extent and are as about as accurate as results from EOMCCSD on average. Real-time TDDFT visualization shows that the excited state charged densities are consistent with the predictions of the perimeter free electron orbital (PFEO) model. This corresponds to particle-on-a-ring confinement, which leads to the well-known red-shift of the excitations with acene length. We also use time-dependent semiempirical methods like TD-PM3 and TD-ZINDO, which are capable of handling very large systems. Once reparametrized to match the CR-EOMCCSD(T) results, TD-ZINDO becomes roughly as accurate as range-separated TDDFT, which opens the door to modeling systems such as large molecular assemblies.

Active case finding of undetected tuberculosis among chronic coughers in a slum setting in Kampala, Uganda

SETTING

Kisenyi slum in peri-urban Kampala, Uganda.

OBJECTIVES

Using chronic cough (> or = 2 weeks) inquiry as a screening tool to identify undetected smear-positive tuberculosis (TB) cases and to describe the characteristics of smear-positive TB cases detected by active case finding.

DESIGN

A house-to-house survey was conducted in five randomly selected villages in Kampala between June and August 2005. A sample of households was visited; adults aged > or = 15 years were consecutively interviewed to identify those with chronic cough. Three sputum specimens were collected and examined by smear microscopy.

RESULTS

Among 930 individuals, we identified 189 (20%) chronic coughers. Of these, we found 33 (18%) undiagnosed smear-positive cases. The newly detected cases had an even sex distribution (P = 0.47), a median age of 30 years, a median cough duration of 1 month and 55% had acid-fast bacilli 1+ sputum smear grade.

CONCLUSION

These findings suggest that active case finding could supplement DOTS to yield additional smear-positive TB cases, lead to early diagnosis and thus shorten the duration of infectiousness before effective chemotherapy is initiated. In communities such as Kisenyi, this is a feasible strategy that may prove useful for TB control, but its cost-effectiveness needs to be evaluated. Early health care seeking for cough should be emphasized.

Daniel: using the bible to teach quality improvement methods

Most of what I need to know about clinical research methods, I learned from the Bible.

A survey of 92 quality improvement projects

BACKGROUND

Studies focusing on the impact of improvement efforts on the organization have yielded mixed results, which has increased interest in comparing the processes of improvement used. Data for a convenience sample of 92 quality improvement (QI) projects in 32 organizations were gathered from interviews and self-reported surveys from 1998 to 2000. A self-administered questionnaire was developed to measure 70 characteristics of improvement projects.

RESULTS

Most (80%) of the improvement projects were conducted by hospitals or clinics affiliated with hospitals. The projects took an average of 13 months from the team's first meeting to the end of the pilot study. Project teams met 14 times (approximately once a month) and spent 1.5 hours per meeting. Some projects did not measure the impact, others did not intend to have a specific impact, and still others measured but did not achieve the planned impact.

DISCUSSION

Patients and employees may be benefitting from improvement projects, but organizations may not be leveraging these improvements to reduce cost of delivery or increase market share. Considerable variation in the projects' impact raises the question of the need to improve the improvement methods. Generalization from this study should be made with caution, as data were based on a self-selected convenience sample of organizations. Furthermore, respondents did not complete all items, and missing information may affect the conclusions. The data on current improvement practices that are provided in this study can serve as baseline data against which rapid improvement efforts can be judged.

Public and private providers' quality of care for tuberculosis patients in Kampala, Uganda

SETTING

The role of the private sector in tuberculosis treatment in developing countries in sub-Saharan Africa is largely unknown. In recent years, many fee-for-service clinics have opened up in Kampala, Uganda. Little is known about the tuberculosis caseload seen in private clinics or the standard of care provided to the patients.

OBJECTIVE

To compare the appropriateness of tuberculosis care in private and public clinics, and the extent of the tuberculosis burden handled in the private sector.

DESIGN

Cross-sectional survey in private and public clinics treating tuberculosis patients in Kampala, Uganda, during June to August 1999.

MEASUREMENTS

Clinics were evaluated for appropriateness of care. This was defined as provision of proper diagnosis (sputum smear microscopy as the primary means of diagnosis), treatment (short-course chemotherapy, with or without directly observed therapy), outcome evaluation (smear microscopy at 6 or 7 months) and case notification in accordance with the Uganda National Tuberculosis and Leprosy Programme.

RESULTS

A total of 114 clinics (104 private, 10 public) were surveyed. Forty-one per cent of the private clinics saw three or more new tuberculosis patients each month. None of the public or private clinics met all standards for appropriate tuberculosis care. Only 24% of all clinics adhered to WHO-recommended treatment guidelines. Public clinics, younger practitioners and practitioners with advanced degrees were most likely to provide appropriate care for tuberculosis.

CONCLUSION

The private sector cares for many tuberculosis cases in Kampala; however, a new programme that offers continuing medical education is needed to improve tuberculosis care and to increase awareness of national guidelines for tuberculosis care.

Continuous self improvement to reduce stress levels: developing an individualized model of health

Personal quality improvement applies quality improvement tools and thinking to help a person improve some aspect of his or her personal life. A workbook has been developed and this approach has been used to teach health professions students about both quality improvement and the difficulties of changing health-related habits. This article describes how an interactive process was used to create and test a statistical model of her stress and its variation using correlations and a regression equation. The results of this process include a unique personal quantitative stress model that was developed and tested. Of the 16 variables, only two were correlated with the student's stress and the regression model showed that 20% of the variance in stress could be explained. This general approach could be applied to other health conditions such as diabetes and hypertension. However, the approach is now costly in terms of statistical consultation and if it is ever to find wide application, it must be automated.

Analytical derivation of interference dips in molecular absorption spectra: molecular properties and relationships to Fano's antiresonance

An analytical expression is derived for the decrease in the absorption cross section that occurs when two molecular electronic states are coupled by spin-orbit coupling. The loss of intensity, or interference dip, is common in the spectra of metal compounds. The derivation is based on a coupling of a single forbidden donor state to a broadened harmonic acceptor potential, and leads to simple analytical expressions. The new expressions give line shape functions different from those in the commonly used Fano antiresonance interpretation and are based on interpretable molecular properties.

Continuous quality improvement and the process of writing for academic publication

OBJECTIVE

To improve their academic publication productivity by understanding the process of writing and setting long-run productivity goals.

METHODS

We used the thinking and methods of continuous quality improvement and a national survey of associate professors of Family Medicine about their level of productivity at the time of their promotion to Associate Professor.

RESULTS

Barriers to writing vary. The process from idea to publication takes well over a year on average. The average number of publications associated with successful promotion in Family Medicine ranges from 10 to 14 with substantial variation.

CONCLUSION

Knowing the time until the promotion decision, the expected level of productivity, the death rates of started papers, and the duration of time between start to publication allows one to develop a long-range plan for publication productivity.

Continuous self-improvement: systems thinking in a personal context

BACKGROUND

Continuous quality improvement (CQI) thinking and tools have broad applicability to improving people's lives--in continuous self-improvement (CSI). Examples include weight loss, weight gain, increasing exercise time, and improving relationship with spouse. In addition, change agents, who support and facilitate organizational efforts, can use CSI to help employees understand steps in CQI. A STEP-BY-STEP APPROACH: Team members should be involved in both the definition of the problem and the search for the solution. How do everyday processes and routines affect the habit that needs to change? What are the precursors of the event? Clients list possible solutions, prioritize them, and pilot test the items selected. One needs to change the daily routines until the desired behavior is accomplished habitually and with little external decision.

DISCUSSION

CSI is successful because of its emphasis on habits embedded in personal processes. CSI organizes support from process owners, buddies, and coaches, and encourages regular measurement, multiple small improvement cycles, and public reporting.

Patient attitudes and preferences regarding treatment: GH therapy for childhood short stature

This paper examines the role of parents' attitudes and preferences regarding growth hormone therapy for childhood short stature. Four main questions are addressed. First, what are the demographic characteristics of families seeking medical advice for their child's short stature? Second, what are parents' attitudes towards short stature? Third, what are parents' treatment preferences (i.e. what characteristics of growth treatments are important to parents)? Finally, how do the attitudes of parents affect physician decision making? Several studies are reviewed and data are presented to answer these questions.

The effect of public accountability on hospital performance: trends in rates for cesarean sections and vaginal births after cesarean section in Cleveland, Ohio

The article reports a study that was designed to identify whether hospitals in the Cleveland, Ohio area have responded to public concern about improving their cesarean section and vaginal birth after cesarean section (VBAC) rates. A 14-item survey based on the Joint Commission on Accreditation of Healthcare Organizations' 1997 Codman Quality Award was administered to 20 hospitals. Respondents self-scored the survey based on a 5-point Likert scale. Three hospitals provided a detailed description of their efforts. Results showed that all hospitals are at various stages of the process to improve their cesarean section and VBAC rates. From this, it is proposed that public accountability encourages quality improvement.

Collaborating for improvement in health professions education

Continual improvement efforts have been slower in health professions education than in health care delivery. This article identifies the lessons learned by teams working in an Interdisciplinary Professional Education Collaborative in overcoming barriers to carrying out continual improvement efforts in these educational organizations.

Using PDSA (Plan-Do-Study-Act) to establish academic-community partnerships: the Cleveland experience

The Schools of Medicine and Nursing at Case Western Reserve University and the Program in Health Administration at Cleveland State University have created an interdisciplinary course in continuous improvement that emphasizes learning through experience, accommodates a large number of students, and has created new partnerships with Cleveland area health care organizations. An approach that respects these partners as customers and refines the relationships with serial tests of change (e.g., PDSA) has contributed significantly to this program's success.