Acute Spinal Cord Compression: CQI Framework Increases Resource Efficiency While Promoting Delivery of High-Quality Care

Multiple myeloma presenting with acute bony spinal cord compression and mechanical instability successfully managed nonoperatively

Background: Although continuous quality improvement (CQI) methodology is routinely used in corporate America, it has had limited application in medical education. Description: The purpose of this study was to decrease the length of time needed for submission of summative clerkship student grades and evaluations, including both the final grade and the narrative description of performance. Methods of CQI were used to define the extent of the problem regarding clerkship evaluation submission, to evaluate the cause, and to create an intervention strategy. Evaluation: Baseline data revealed that on average it took 10.1 weeks (range = 8.5� 15.2 weeks) for departments to submit clerkship evaluations. Following an in-depth prospective analysis, strategies were developed and implemented that decreased the average time to submission to 5.0 weeks (range = 4.0� 6.1 weeks). Conclusion: We conclude that CQI methodology can be used successfully in medical education.

BackgroundScaling up continuous quality improvement (CQI) processes could be key in achieving the 95:95:95 cascade and global HIV targets. This paper describes the experiences and outcomes related to implementing CQI processes to help reach these targets, with particular focus on clinical and programmatic settings in 6 countries from the global south.MethodsThe HIV program at the University of Maryland, Baltimore (UMB) implemented an adapted CQI model in Kenya, Tanzania, Botswana, Zambia, Nigeria and Rwanda that included the following steps: (1) analysing the problem to identify goals and objectives for improvement; (2) developing individual changes or ‘change packages’, (3) developing a monitoring system to measure improvements; and (4) implementing and measuring changes through continuous ‘plan-do-study-act’ (PDSA) cycles. We describe country-level experiences related to implementing this adaptive design, a collaborative learning and scale-up/sustainability model that addresses the 95:95:95 global HIV targets via a CQI learning network, and mechanisms for fostering communication and the sharing of ideas and results; we describe trends both before and after model implementation.ResultsOur selected country-level experiences based on implementing our CQI approach resulted in an increased partner testing acceptance rate from 21.7 to 48.2 % in Rwanda, which resulted in an increase in the HIV testing yield from 2.1 to 6.3 %. In Botswana, the overall linkage to treatment improved from 63 to 94 %, while in Kenya, the viral load testing uptake among paediatric and adolescent patients improved from 65 to 96 %, and the viral load suppression improved from 53 to 88 %.ConclusionsAdopting CQI processes is a useful approach for accelerating progress towards the attainment of the global 95:95:95 HIV targets. This paper also highlights the value of institutionalizing CQI processes and building the capacity of Ministry of Health (MoH) personnel in sub-Saharan Africa for the effective quality improvement of HIV programs and subsequent sustainability efforts.

PROBLEM: A need to improve service to patients by reducing the time wasted by reception staff so that the 48 hour target for processing repeat prescription requests for patient collection...

To explore the effect and underlying mechanism of decompression(DE)combined with Governor Vessel(GV)electro-acupuncture(EA) on rats with acute severe upper cervical spinal cord compression injury. Thirty SPF rats were randomly divided into 5 groups(control group A, B and experiment group C, D, E), 6 rats in each group. The model of acute severe upper cervical spinal cord compression injury were made by forcing a balloon catheter put in atlas pillow clearance. The group A was blank one, the group B put balloon catheter in atlas pillow clearance without forcing, and the group C, D, E sustained compressed for 48 h. The group C received electric acupuncture intervention, selecting the Baihui and Dazhui point, having the continuous wave and frequency of 2 Hz, with the treatment time of 15 min and continuous treatment for 14 d; the group D received methylprednisolone intervention, injected by caudal vein; the group E did not received any intervention again. The arterial blood and injured spinal cord tissue of all the rats were obtained after 14 days' treatment, and BBB score was used to evaluate the change of each group hind limbs motor function, the contents of platelet activating factor(PAF) in injured spinal cord tissue and blood serum were assess by ELISA method; the Caspase-9 expression for each group after 14 days' treatment was assess by Western blot method. BBB scores were(21.000±0.000) points at the 6 time points, that was, 1 h, 48 h after forcing in control group, 24 h, 3 d, 7 d, 14 d after treating in experiment group; the score of experimental groups (group C, D, E) were always lower than control groups(group A, B); compared with group E, group C and D were significantly higher(P<0.05); and there was no significant difference between group C and group D(P>0.05). The results of PAF by ELISA method to measure:the concentration of serum PAF, there was no statistical difference among group A, B, D, E (P>0.05), group C was lower than the other groups (P<0.05); the concentration of tissue PAF, there was no significant difference between group A and group B(P>0.05), group D was significantly higher than that of group A, B, and C(P<0.05), group E was the highest one than that of the other groups(P<0.05). Western blot med tests showed that the Caspase-9 protein expression in group A and B was similar (P>0.05), group C was higher than that of group A and B(P<0.05), group D was higher than group A, B and C(P<0.05), group E was the highest than that of group A, B, C and D (P<0.05). Decompression and Governor Vessel electro-acupuncture on acute severe upper cervical spinal cord compression injury had a better effect compare with decompression and methylprednisolone or simple decompression only, its mechanism may be related to lower the PAF levels and downregulating Caspase-9 protein expression in spinal injury tissue.

Acute compression of the spinal cord is a devastating but treatable disorder. Diseases that cause acute spinal cord compression constitute a special category because they originate in the spinal column and narrow the spinal canal. This review addresses the disorders that account for most instances of acute spinal cord compression: trauma, tumor, epidural abscess, and epidural hematoma. The pathophysiological features and management of these disorders are similar to those of other acute and serious spinal conditions. The medical context of spinal cord compression determines the diagnosis and directs treatment. Traumatic cord compression is often self-evident. Cord compression in patients with . . .

Spinal cord evoked potentials and peripheral nerve evoked potentials after spinal cord stimulation were recorded under acute spinal cord compression in 19 cats. To investigate the effects of acute compression upon grey matter and white matter by comparing both potentials. We compared peripheral nerve evoked potentials, recorded at the biceps brachii branch of the musculocutaneous nerve, with descending spinal cord evoked potentials, recorded from the lumbar spinal cord, by stimulation to the C2 level, under compression of the C6 segment. The amplitude of both potentials decreased with increased compression. The second wave of peripheral nerve evoked potentials, which are motor fibre action potentials, decreased sooner than those of the spinal cord evoked potentials. These findings indicate that peripheral nerve evoked potentials are sensitive to acute damage of the segmented compression. This suggests that grey matter is more vulnerable to compression than white matter.

The Liaison Committee on Medical Education now expects all allopathic medical schools to develop and adhere to a documentable continuous quality improvement (CQI) process. Medical schools must consider how to establish a defensible process that monitors compliance with accreditation standards between site visits. The purpose of this descriptive study is to detail how ten schools in the Association of American Medical Colleges' (AAMC) Southern Group on Educational Affairs (SGEA) CQISpecial Interest Group (SIG) are tackling practical issues of CQI development including establishing a CQI office, designating faculty and staff, charging a CQI committee, choosing software for data management, if schools are choosing formalized CQI models, and other considerations. The information presented is not meant to certify that any way is the correct way to manage CQI, but simply present some schools' models. Future research should include defining commonalities of CQI models as well as seeking differences. Furthermore, what are components of CQI models that may affect accreditation compliance negatively? Are there "worst practices" to avoid? What LCME elements are most commonly identified for CQI, and what are the successes and struggles for addressing those elements? What are identifiable challenges relating to use of standard spreadsheet software and engaging information technology for support? How can students be more engaged and involved in the CQI process? Finally, how do these major shifts to a formalized CQI process impact the educational experience?

The 2010 Affordable Care Act provided for evidence-based home visiting and an accompanying continuous quality improvement (CQI) process in all states and territories. This is an organizational-level study of one state's qualitative approach to CQI during early implementation, when data system infrastructure and local agency capacity were still developing. We examined the CQI topics created by local agencies and operationalized through a qualitative, strength-based CQI process. During the first 18 months, state and local site teams (n = 21) participated in 150 CQI teleconferences. We used qualitative content analysis of teleconference notes to identify issues important to sites and that could be addressed through a qualitative CQI process. Seven categories of CQI topics emerged: participant enrollment and retention; administrative infrastructure and capacity; programmatic resources and practices; community advisory boards; home visitor skill development; systems integration and strategic partnerships; and hiring home visiting staff. Sites added local nuances to frame and address CQI topics. When local sites identify their own CQI topics in early implementation, they addressed program need at multiple levels of influence. A few sites addressed individually focused topics traditional to CQI. Most often, sites engaged with institution- or community-focused topics atypical for CQI but nonetheless essential to launching a program: building skills and capacity for administrative and program implementation, and engaging with the local system of services. Oversight agencies should be prepared to address program, organization, partner or system level issues through CQI to foster program establishment. A site-centered, strength-based approach can support programs even when quantitative data are limited.

Background: Delivering high quality health care requires an ongoing effort at all levels of the health system to adopt new knowledge in routine practice, to identify and resolve persistent quality problems, and to meet the evolving needs of populations. Continuous quality improvement (CQI) is among the most promising approaches for tackling these challenges in primary care. CQI brings teams of health professionals together to develop and test changes to the systems and processes used to deliver care. The result is expected to be substantial and sustained improvement in healthcare quality. Yet limited research on how (and indeed if) CQI works creates uncertainty over its true value and weakens our ability to predict the circumstance in which CQI will be effective. Aims The overarching aim of this thesis is to examine what we know about the effectiveness of CQI in primary care and develop a framework to strengthen future research. More specifically, the aims are to: (1) synthesise existing research on the effects, and factors that modify the effects, of CQI in primary care, (2) support the design of CQI research by developing a framework intended to help evaluators identify and measure factors salient to our understanding of CQI in primary care, and (3) guide selection of the best available instruments for measuring factors in the framework. Methods Three types of research synthesis methods were used in this thesis. Systematic review methods and metaanalysis of randomised trials were used to evaluate the effectiveness of CQI. Qualitative synthesis of prevailing concepts of CQI and factors thought to influence its effectiveness was used to develop a theorybased framework for evaluating CQI. Systematic review methods were used to identify and evaluate the measurement properties of quantitative self-report instruments suitable for measuring factors in the developed framework. Framework-based synthesis methods were used to categorise instrument content in a taxonomy designed to enable direct comparison of instruments and illustrate coverage of the framework. Results Based on existing evidence from randomised trials, the effects of CQI on health professional performance and patient outcomes in primary care are uncertain. AnalysiS of more than 170 papers contributed to development of the lnforming Q!!ality Improvement Research (InQuiRe) framework. InQuiRe covers four domains (CQI process, implementation approaches, enabling context, outcomes) and includes (1) a -taxonomy of factors thought relevant to understanding and predicting the process and outcomes of CQI, (2) definition of these factors, and (3) description of the mechanism by which CQI process and context are thought to interact to yield improvements in health care. Content analysis of 319 instruments identified 160 instruments measuring factors in the InQuiRe framework, 78 of which are suitable for primary care. Conclusions Despite an expansive literature, existing evidence is yet to address important policy and practice questions about how best to implement and ensure the success of CQI in different contexts. Addressing these questions will require evaluations that examine the interplay between CQI process, context, and outcomes. The InQuiRe framework provides a tool and suite of instruments to support the design of such evaluations.

Spinal cord compression secondary to spinal extradural myeloid sarcoma in acute myeloid leukaemia: A case report and literature review

Case report. To describe the radiographic features and management of spinal brown tumor and to document tumor mineralization after parathyroidectomy. Brown tumors are classic skeletal manifestations of hyperparathyroidism usually seen in severe forms. They are increasingly rare because hyperparathyroidism is now diagnosed and treated at an early stage. A case of brown tumor of the spine in a 37-year-old woman on chronic hemodialysis is described. The imaging findings before and after parathyroidectomy are discussed. In a woman on chronic hemodialysis, a brown tumor of T8 caused acute spinal cord compression with paraplegia. Magnetic resonance imaging provided an accurate evaluation of the lesion, and needle biopsy confirmed the diagnosis. Emergent surgery was needed to relieve the spinal compression and stabilize the spine. The vertebral lesion underwent remineralization after parathyroidectomy. Brown tumor is a benign tumor that resolves after parathyroidectomy. When brown tumor arises in the spine, surgery may be needed to preserve neurologic function.

Vertebral hemangioma is common, benign lesion that occurs mostly in the body of vertebral bones and is mostly asymptomatic although they may occasionally extend into the posterior elements. An isolated location in the neural arch of vertebrae is extremely rare. An acute spinal cord compression by an exceptional hemangioma involving spinous process of the seventh thoracic vertebra and respecting vertebral body in a 40-year-old woman is reported. On magnetic resonance imaging of the spine, the lesion was hypointense on T1-weighted image, hyperintense on T2-weited image, and enhancing avidly, causing compression of spinal cord. Our case is exceptional by the rapidly character of symptom installation and by atypical and elective involvement of spinous process.

Acute spinal cord compression with myelopathy is a neurologic emergency. Recognition of spinal cord compression, timely imaging, and treatment are important to restore and preserve neurologic function. This chapter reviews the causes and clinical approach to spinal cord compression. Traumatic and nontraumatic causes of spinal cord compression are addressed together because of their overlapping symptoms and management. The chapter concludes with a brief discussion of peripheral nerve injury.

The aim of this study was to investigate whether or not conductive spinal cord evoked potentials and spinal cord function change correspondingly with each other. The relationship between conductive spinal cord evoked potentials and locomotor function during acute spinal cord compression in animals was investigated. In decerebrate cats, controlled locomotion can be induced by electrical stimuli in the mesencephalic locomotor region. Conductive spinal cord evoked potentials were recorded at the L3 level of the spinal cord and stimuli were given at the T4 segment. The locomotor function was evaluated through electromyograms of the hind limbs. By compressing the spinal cord at L1, both the conductive spinal cord evoked potentials and the locomotor function gradually decreased. When the first negative potential amplitude of conductive spinal cord evoked potentials was decreased to half the level found in normal cats, locomotor function was injured irreversibly. These results showed that changes in the conductive spinal cord evoked potentials were related to changes in locomotor function. The 50% level of the first negative potential amplitude was considered to be the critical level at which irreversible spinal cord paralysis occurred in the cats.