Clinical Behavior Change Research Articles

Five-year follow-up of an interdisciplinary oral health education program: Clinical practice behaviors in working pediatric nurse practitioners.

Many interdisciplinary oral health education programs have been implemented for pediatric primary care providers (e.g., pediatric nurse practitioner [PNP]) to raise awareness and gain skills related to the prevention of early childhood caries (ECC). However, no studies have evaluated if these educational programs provided to PNPs during their training resulted in clinical practice behavior changes. A 33-item survey was designed on a web-based platform (Survey Monkey) and distributed to 71 PNP graduates. The survey included demographics, current clinical practice, clinical practice behaviors, and perceived barriers to practice. Descriptive statistics were used to assess the survey items and thematic analyses on the open-ended questions. The survey response rate was 70% (50/71 PNPs). Most practicing PNPs were in acute care or specialty clinics (n = 33; 66%) where oral health was not part of the focused visit. Majority used knowledge learned in assessment and anticipatory guidance skills. However, only 14% of primary care providers were applying fluoride varnish with 10% billing for this procedure. Barriers to application were time, available supplies, COVID protocols, lack of support staff, or not billing due to minimal reimbursement. Many primary care-trained PNPs were practicing in acute or subspecialty areas where prevention of ECC is not viewed as part of their focused visit. Pediatric nurse practitioners working in primary care demonstrated some clinical practice changes. However, areas for improvement are time to perform a risk assessment and application of fluoride varnish, access to these supplies, and standard billing and insurance reimbursement for these preventable services.

Successes and challenges towards improving quality of primary health care services: a scoping review

BackgroundQuality health services build communities’ and patients’ trust in health care. It enhances the acceptability of services and increases health service coverage. Quality primary health care is imperative for universal health coverage through expanding health institutions and increasing skilled health professionals to deliver services near to people. Evidence on the quality of health system inputs, interactions between health personnel and clients, and outcomes of health care interventions is necessary. This review summarised indicators, successes, and challenges of the quality of primary health care services.MethodsWe used the preferred reporting items for systematic reviews and meta-analysis extensions for scoping reviews to guide the article selection process. A systematic search of literature from PubMed, Web of Science, Excerpta Medica dataBASE (EMBASE), Scopus, and Google Scholar was conducted on August 23, 2022, but the preliminary search was begun on July 5, 2022. The Donabedian’s quality of care framework, consisting of structure, process and outcomes, was used to operationalise and synthesise the findings on the quality of primary health care.ResultsHuman resources for health, law and policy, infrastructure and facilities, and resources were the common structure indicators. Diagnosis (health assessment and/or laboratory tests) and management (health information, education, and treatment) procedures were the process indicators. Clinical outcomes (cure, mortality, treatment completion), behaviour change, and satisfaction were the common indicators of outcome. Lower cause-specific mortality and a lower rate of hospitalisation in high-income countries were successes, while high mortality due to tuberculosis and the geographical disparity in quality care were challenges in developing countries. There also exist challenges in developed countries (e.g., poor quality mental health care due to a high admission rate). Shortage of health workers was a challenge both in developed and developing countries.ConclusionsQuality of care indicators varied according to the health care problems, which resulted in a disparity in the successes and challenges across countries around the world. Initiatives to improve the quality of primary health care services should ensure the availability of adequate health care providers, equipped health care facilities, appropriate financing mechanisms, enhance compliance with health policy and laws, as well as community and client participation. Additionally, each country should be proactive in monitoring and evaluation of performance indicators in each dimension (structure, process, and outcome) of quality of primary health care services.

The ACCELERATE Plus (assessment and communication excellence for safe patient outcomes) Trial Protocol: a stepped-wedge cluster randomised trial, cost-benefit analysis, and process evaluation

BackgroundNurses play an essential role in patient safety. Inadequate nursing physical assessment and communication in handover practices are associated with increased patient deterioration, falls and pressure injuries. Despite internationally implemented rapid response systems, falls and pressure injury reduction strategies, and recommendations to conduct clinical handovers at patients’ bedside, adverse events persist. This trial aims to evaluate the effectiveness, implementation, and cost–benefit of an externally facilitated, nurse-led intervention delivered at the ward level for core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication. We hypothesise the trial will reduce medical emergency team calls, unplanned intensive care unit admissions, falls and pressure injuries.MethodsA stepped-wedge cluster randomised trial will be conducted over 52 weeks. The intervention consists of a nursing core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication and will be implemented in 24 wards across eight hospitals. The intervention will use theoretically informed implementation strategies for changing clinician behaviour, consisting of: nursing executive site engagement; a train-the-trainer model for cascading facilitation; embedded site leads; nursing unit manager leadership training; nursing and medical ward-level clinical champions; ward nurses’ education workshops; intervention tailoring; and reminders. The primary outcome will be a composite measure of medical emergency team calls (rapid response calls and ‘Code Blue’ calls), unplanned intensive care unit admissions, in-hospital falls and hospital-acquired pressure injuries; these measures individually will also form secondary outcomes. Other secondary outcomes are: i) patient-reported experience measures of receiving safe and patient-centred care, ii) nurses’ perceptions of barriers to physical assessment, readiness to change, and staff engagement, and iii) nurses’ and medical officers’ perceptions of safety culture and interprofessional collaboration. Primary outcome data will be collected for the trial duration, and secondary outcome surveys will be collected prior to each step and at trial conclusion. A cost–benefit analysis and post-trial process evaluation will also be undertaken.DiscussionIf effective, this intervention has the potential to improve nursing care, reduce patient harm and improve patient outcomes. The evidence-based implementation strategy has been designed to be embedded within existing hospital workforces; if cost-effective, it will be readily translatable to other hospitals nationally.Trial registrationAustralian New Zealand Clinical Trials Registry ID: ACTRN12622000155796. Date registered: 31/01/2022.

Unlocking the restraint-Development of a behaviour change intervention to increase the provision of modified constraint-induced movement therapy in stroke rehabilitation.

Strong evidence supports the provision of modified constraint-induced movement therapy (mCIMT) to improve upper limb function after stroke. A service audit identified that very few patients received mCIMT in a large subacute, early-supported discharge rehabilitation service. A behaviour change intervention was developed to increase the provision of mCIMT following an unsuccessful 'education only' attempt. This paper aims to systematically document the steps undertaken and to provide practical guidance to clinicians and rehabilitation services to implement this complex, yet effective, rehabilitation intervention. This clinician behaviour change intervention was developed over five stages and led by a working group of neurological experts (n = 3). Data collection methods included informal discussions with clinicians and an online survey (n = 35). The staged process included reflection on why the first attempt did not improve the provision of mCIMT (stage 1), mapping barriers and enablers to the Theoretical Domains Framework (TDF) and behaviour change wheel (BCW) to guide the behaviour change techniques (stages 2 and 3), developing a suitable mCIMT protocol (stage 4), and delivering the behaviour change intervention (stage 5). Reflection among the working group identified the need for upskilling in mCIMT delivery and the use of a behaviour change framework to guide the implementation program. Key determinants of behaviour change operated within the TDF domains of knowledge, skills, environmental context and resources, social role and identity, and social influences. Following the development of a context-specific mCIMT protocol, the BCW guided the behaviour change intervention, which included education, training, persuasion, environmental restructuring, and modelling. This paper provides an example of using the TDF and BCW to support the implementation of mCIMT in a large early-supported discharge service. It outlines the suite of behaviour change techniques used to influence clinician behaviour. The success of this behaviour change intervention will be explored in future research.

Optimizing Best Practice Advisory alerts in electronic medical records with a multi-pronged strategy at a tertiary care hospital in Singapore.

Clinical decision support (CDS) alerts can aid in improving patient care. One CDS functionality is the Best Practice Advisory (BPA) alert notification system, wherein BPA alerts are automated alerts embedded in the hospital's electronic medical records (EMR). However, excessive alerts can change clinician behavior; redundant and repetitive alerts can contribute to alert fatigue. Alerts can be optimized through a multipronged strategy. Our study aims to describe these strategies adopted and evaluate the resultant BPA alert optimization outcomes. This retrospective single-center study was done at Jurong Health Campus. Aggregated, anonymized data on patient demographics and alert statistics were collected from January 1, 2018 to December 31, 2021. "Preintervention" period was January 1-December 31, 2018, and "postintervention" period was January 1-December 31, 2021. The intervention period was the intervening period. Categorical variables were reported as frequencies and proportions and compared using the chi-square test. Continuous data were reported as median (interquartile range, IQR) and compared using the Wilcoxon rank-sum test. Statistical significance was defined at P < .05. There was a significant reduction of 59.6% in the total number of interruptive BPA alerts, despite an increase in the number of unique BPAs from 54 to 360 from pre- to postintervention. There was a 74% reduction in the number of alerts from the 7 BPAs that were optimized from the pre- to postintervention period. There was a significant increase in percentage of overall interruptive BPA alerts with action taken (8 [IQR 7.7-8.4] to 54.7 [IQR 52.5-58.9], P-value < .05) and optimized BPAs with action taken (32.6 [IQR 32.3-32.9] to 72.6 [IQR 64.3-73.4], P-value < .05). We estimate that the reduction in alerts saved 3600 h of providers' time per year. A significant reduction in interruptive alert volume, and a significant increase in action taken rates despite manifold increase in the number of unique BPAs could be achieved through concentrated efforts focusing on governance, data review, and visualization using a system-embedded tool, combined with the CDS Five Rights framework, to optimize alerts. Improved alert compliance was likely multifactorial-due to decreased repeated alert firing for the same patient; better awareness due to stakeholders' involvement; and less fatigue since unnecessary alerts were removed. Future studies should prospectively focus on patients' clinical chart reviews to assess downstream effects of various actions taken, identify any possibility of harm, and collect end-user feedback regarding the utility of alerts.

Identification of Clinician Training Techniques as an Implementation Strategy to Improve Maternal Health: A Scoping Review.

Training is a key implementation strategy used in healthcare settings. This study aimed to identify a range of clinician training techniques that facilitate guideline implementation, promote clinician behavior change, optimize clinical outcomes, and address implicit biases to promote high-quality maternal and child health (MCH) care. A scoping review was conducted within PubMed, CINAHL, PsycInfo, and Cochrane databases using iterative searches related to (provider OR clinician) AND (education OR training). A total of 152 articles met the inclusion/exclusion criteria. The training involved multiple clinician types (e.g., physicians, nurses) and was predominantly implemented in hospitals (63%). Topics focused on maternal/fetal morbidity/mortality (26%), teamwork and communication (14%), and screening, assessment, and testing (12%). Common techniques included didactic (65%), simulation (39%), hands-on (e.g., scenario, role play) (28%), and discussion (27%). Under half (42%) of the reported training was based on guidelines or evidence-based practices. A minority of articles reported evaluating change in clinician knowledge (39%), confidence (37%), or clinical outcomes (31%). A secondary review identified 22 articles related to implicit bias training, which used other reflective approaches (e.g., implicit bias tests, role play, and patient observations). Although many training techniques were identified, future research is needed to ascertain the most effective training techniques, ultimately improving patient-centered care and outcomes.

E051 A systematic review of audit and feedback tools to reduce opioid prescribing for chronic non-cancer pain

Abstract Background/Aims Opioid prescribing has increased considerably over the 15 years for chronic non-cancer pain in the UK, including for musculoskeletal conditions. Whilst there are national and international guidelines to reduce inappropriate opioid prescribing, these are not always adhered to in practice. Audit and feedback is a common intervention for supporting clinical behaviour change. Little is known if such tools have been used to support safer opioid prescribing to date. This systematic review aimed to describe audit and feedback tools that were designed, implemented and led to changes in opioid prescribing practices. Methods A systematic review of the literature was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework (PRISMA). Both Embase and MEDLINE were searched to identify studies that included audit and feedback tools in patients prescribed opioids with chronic non-cancer pain until the 31st of May 2021. Results Of the 539 studies imported, following removal of duplicates, 497 studies were screened. Following title and abstract review 6 full-text studies were assessed for eligibility. A total of three studies were deemed to meet inclusion criteria. Approaches found included: The Controlled Medication Advisory Board (CMAB), Systems Consultation and the Opioid Safety Initiative (OSI). CMAB involved the use of a dashboard to provide feedback to clinicians on referred patients. As a result the opioid prescribing rate per 100 patient visits decreased by 31% and the rate of co-prescription of benzodiazepines and opioids decreased by 56%. Systems Consultation involved the use of audit and feedback, academic detailing and external facilitation to reduce opioid prescribing. Systems consultation resulted in a statistically significant reduction in the morphine equivalent daily doses. The OSI used automatic electronic medical records auditing to enable clinic leaders to identify physician prescribing patterns via a dashboard. OSI enabled a 9.9% reduction in opioid prescriptions from 571,476 to 514,883. Conclusion Computerised audit and feedback tools may be effective interventions to support opioid stewardship initiative and promote safer opioid prescribing. Such approaches being used internationally could pave the way for similar initiatives in the UK and future research evaluating their impact on patient safety. Disclosure J. Feldman: None. M. Jani: Grants/research support; National Institute for Health and Care Research Advanced Fellowship (NIHR301413).

The effectiveness of clinical guideline implementation strategies in oncology—a systematic review

ImportanceGuideline recommendations do not necessarily translate into changes in clinical practice behaviour or better patient outcomes.ObjectiveThis systematic review aims to identify recent clinical guideline implementation strategies in oncology and to determine their effect primarily on patient-relevant outcomes and secondarily on healthcare professionals' adherence.MethodsA systematic search of five electronic databases (PubMed, Web of Science, GIN, CENTRAL, CINAHL) was conducted on 16 december 2022. Randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) assessing the effectiveness of guideline implementation strategies on patient-relevant outcomes (overall survival, quality of life, adverse events) and healthcare professionals' adherence outcomes (screening, referral, prescribing, attitudes, knowledge) in the oncological setting were targeted. The Cochrane risk-of-bias tool and the ROBINS-I tool were used for assessing the risk of bias. Certainty in the evidence was evaluated according to GRADE recommendations. This review was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the identification number CRD42021268593.FindingsOf 1326 records identified, nine studies, five cluster RCTs and four controlled before-and after studies, were included in the narrative synthesis. All nine studies assess the effect of multi-component interventions in 3577 cancer patients and more than 450 oncologists, nurses and medical staff.Patient-levelEducational meetings combined with materials, opinion leaders, audit and feedback, a tailored intervention or academic detailing may have little to no effect on overall survival, quality of life and adverse events of cancer patients compared to no intervention, however, the evidence is either uncertain or very uncertain.Provider-levelMulti-component interventions may increase or slightly increase guideline adherence regarding screening, referral and prescribing behaviour of healthcare professionals according to guidelines, but the certainty in evidence is low. The interventions may have little to no effect on attitudes and knowledge of healthcare professionals, still, the evidence is very uncertain.Conclusions and relevanceKnowledge and skill accumulation through team-oriented or online educational training and dissemination of materials embedded in multi-component interventions seem to be the most frequently researched guideline implementation strategies in oncology recently. This systematic review provides an overview of recent guideline implementation strategies in oncology, encourages future implementation research in this area and informs policymakers and professional organisations on the development and adoption of implementation strategies.

The impact of educational whiteboard videos on healthcare providers' self-efficacy to deprescribe.

The impact of educational whiteboard videos on healthcare providers' self-efficacy to deprescribe.

A Retrospective Study of Metastatic Renal Cell Carcinoma Patients With Brain Metastases.

Metastatic renal cell carcinoma (mRCC) involving the central nervous systemis currently an excluded subgroup of patients in the systemic treatment; for this reason, there is no solid data to support the efficacy of therapies in this subgroup. That is why it is important to describe real-life experiences in order to know if there is a special change in clinical behavior or treatment response in these kinds of patients. Patients and methods A retrospective review was performed to characterize mRCC patients diagnosed with brain metastases (BrM) during treatment at the National Institute of Cancerology of Bogota, Colombia. Descriptive statistics and time-to-event methods are used to evaluate the cohort. For the descriptive measures of quantitative variables, the mean with standard deviation was taken, and the minimum and maximum values were reported. In the case of qualitative variables, absolute and relative frequencies were used. The software used was R - Project v4.1.2 (R Foundation for Statistical Computing, Vienna, Austria). Results A total of 16 patients were included with mRCC betweenJanuary 2017 to August 2022 with a median 35.1-month follow-up, 4/16 (25%) were diagnosed with BrM at the time of screening and 12/16 (75%) during treatment. The International Metastatic RCC Database Consortium risk (IMDC) was favorable for 12.5%, intermediate for 43.7%, and poor for 25%, and not classified for 18.8%, BrM involvement was multifocal in 50% of the population and localized, brain-directed therapy was done in 43.7% of patients, predominantly palliative radiotherapy. Median overall survival (OS) for all the patients regardless of the time of metastatic presentation of the disease in the central nervous system was 53.5 months (0-70.3), and OS for cases with central nervous system involvement was 10.9 months. IMDC risk did not correlate with survival (log-rank, p=0.67). The OS for the subgroup of patients who debut with metastatic disease in the central nervous system is different from the group that developed metastasis in the progression of their disease (OS of 42 vs 3.6 months, respectively). Conclusions This is the largest descriptive study in Latin America and the second in the world from one institution that admits patients with metastasic renal cell carcinoma and central nervous system metastasis. In these kinds of patients with metastatic disease or progression to the central nervous system, there is a hypothesis that shows more aggressive clinical behavior. There is limited data on locoregional intervention to metastatic disease in the nervous system drastically, but trends show this could impact overall survival outcomes.

Optimizing neuromuscular blockade management for improving patient safety and peri-operative outcomes: a pilot phase of a quality improvement initiative.

Although quantitative monitoring of neuromuscular blockade (NMB) is recommended, it is not routinely used in daily practice. The optimizing NMB management to improve patient safety and perioperative outcomes (OBISPO) quality improvement (QI) initiative intends to address this issue and change clinicians' behaviors. A pilot phase of the prospective QI intervention was conducted. The primary objective was implement clinical practice change that emphasizes improving NMB monitoring in patients undergoing elective cardiac surgery who are eligible for fast-track extubation between February 2021 and December 2021. The secondary objective was to reduce the train-of-four ratio (TOFR) < 0.9 incidence before tracheal extubation to less than 20%. The intervention included educational sessions for teams. A total of 859 patients underwent elective cardiac surgery, 40% were eligible for fast-track extubation. From our cohort of fast-track cardiac cases, 69% had reported TOFR; 47% of them had residual paralysis (TOFR < 0.9) on arrival to PACU, 22% persisted with residual paralysis after extubation, and 27% were extubated without monitoring. The survey identified cognitive biases, knowledge gaps, unfamiliarity, and lack of trust in quantitative monitoring devices. Workflow disruptions imposed by COVID and changes in NMB monitoring devices have negatively affected our initiative. Our study showed that changes in clinician behavior are among the most challenging issues in perioperative medicine. Continuous teaching and QI initiatives, focused on quantitative NMB monitors and adequate reversal agent use, are mandatory to improve perioperative outcomes. Therefore, new proposals are required to promote changes in current practices.

Systematic Review of the Effectiveness of Allied Health Clinical Education Programs.

Continuing allied health professional (AHP) clinical education is essential to ensure high-quality patient care; however, the effectiveness of current education programs is unclear. This review aimed to determine whether AHP education programs improve the knowledge of AHPs, change their clinical practice behavior, and/or improve patient-related clinical outcome and to identify important components of these programs. Four electronic databases were searched. Controlled clinical trials investigating the effectiveness of clinical education programs were included. Education programs were diverse, varying in design, delivery mode, and intensity. Only therapy-specific AHPs were included. Effectiveness was determined by differences in group outcomes in the domains of AHP knowledge, AHP clinical practice behavior, and patient-related clinical outcomes. Forty-four studies were identified, of which 26 included physiotherapists only. Most control groups were waitlist, passive dissemination of information, or usual care, limiting comparisons between programs. Changes in AHP knowledge was investigated in 20 trials, with 13 showing an improvement. Thirty studies investigated changes in AHP clinical practice behavior, with half demonstrating a difference between groups. Seventeen studies investigated a patient-related clinical outcome, with five finding a difference between groups. Where improvements in outcomes were demonstrated, programs tended to incorporate self-selection and cater to the learner's contextual needs. AHP knowledge is effectively improved through targeted education programs. To change AHP behavior and patient outcomes, it seems important to incorporate self-selection for the program and consider the learner's individual needs and contexts through mentoring, outreach visits, reflection, and incorporating patient participation in the learning.

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

Introduction Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare. Methods We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. s and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes. Results Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples. Discussion Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

Novel recombinant protein flagellin A N/C attenuates experimental autoimmune encephalomyelitis by suppressing the ROS/NF-κB/NLRP3 signaling pathway

Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease characterized by demyelination and neurodegeneration, for which traditional treatment offers limited relief. Microglial/macrophage modulation plays a critical role in the pathogenesis of MS. Oxygen free radical accumulation can induce axonal and nerve cell damage, and further promote MS development. We created a new recombinant protein based on flagellin from Legionella pneumophila named flagellin A with linked C- and N-terminal ends (FLaAN/C), which is an independent intellectual property of our team. We previously showed that FLaAN/C might mitigate radiation-induced damage by inhibiting inflammatory responses and oxidative stress. However, whether FLaAN/C protects against MS remains unknown. Here, we investigated the anti-inflammatory effects of FLaAN/C on mice with experimental autoimmune encephalomyelitis (EAE) induced by oligodendrocyte glycoprotein peptide 35-55 (MOG35-55). The mice were injected intraperitoneally with FLaAN/C after the onset of clinical symptoms, then clinical behavior scores and changes in body weight were recorded daily. The spinal lumbar spine in model mice was enlarged and accompanied by inflammatory cell infiltration and demyelination that were reversed by FLaAN/C. FLaAN/C also induced microglia/macrophages to generate less pro-inflammatory (CD86, iNOS, and TNF-α), and more anti-inflammatory (CD206, IL-10, and Arginase-1) cytokines. These findings suggesting that FLaAN/C promoted microglial/macrophages polarization from the inflammatory M1 to the anti-inflammatory M2 phenotype. Moreover, FLaAN/C inhibited release of the inflammatory cytokines, TNF-α, IL-8, IL-6, IL-17, and IFN-γ. These results indicated that the anti-inflammatory effect of FLaAN/C was associated with the inhibited generation of reactive oxygen species. FLaAN/C downregulated the expression of phosphorylated NF-κB-p65 and prevented downstream NLRP3 inflammasome-mediated pyroptosis. Collectively, these results indicated that FLaAN/C prevents pyroptosis by inhibiting the ROS/NF-κB/NLRP3 signaling pathway, and promotes the microglial/macrophage M1/M2 polarization that significantly alleviated inflammation in mouse models of EAE. Our findings suggested that FLaAN/C could be a promising candidate for MS therapy.

Intoxicación por Dieffenbachia picta schott en un perro: Reporte de caso

Poisoning by ornamental plants is a situation commonly found in the routine of care in the medical clinic of small animals, but with difficult diagnosis. Poisoning by Dieffenbachia ssp (with-no-one- can) a plant easily found in home residences, has the toxic principle based on calcium oxalate leading to gastrointestinal and even neurological clinical picture. Thus, the present article has as objective to report the occurrence of the clinical picture of Dieffenbachia ssp poisoning (with me-no-can) in dogs. For this, a canine, female, Lhasa Apso, 9 months old, weighing 5.8 kg, arrived at the clinical emergency room presenting vomiting, intense sialorrhea, nystagmus and behavior change aimed at aggressiveness, later intake of the plant with me-no-nobody-can, according to information from its responsible. The patient presented with altered clinical parameters due to the clinical picture of intoxication, which was possible to observe aquipnea, shorty, increased capillary filling time, intense abdominal algia, among others. Due to the patient's clinical urgency and aggressiveness, intramuscular acepromazine and methadone-based sedation was performed, with subsequent venous access and initiation of clinical control therapy based on fluid therapy, antibiotic therapy, antiemetics and diuretics. The monitoring of clinical parameters and installed therapy was performed during the next 48 hours with satisfactory patient evolution and subsequent clinical release, absent from neurological clinical signs and control of gastrointestinal condition. Thus, it can be concluded that the clinical picture was an oral intoxication by ornamental plant Dieffenbachia ssp known as with meno-can.

Launching an innovative educational model addressing substance use disorders and dental pain management (Project ECHO® in dentistry)

BackgroundUninformed opioid prescribing by dentists has contributed to the current opioid crisis. This report describes the development and implementation of an innovative, interactive, multidisciplinary, and participant-centric telementoring program “Pain Management and Substance Use Disorders Dental ECHO (Extension for Community Health Care Outcomes)”. We disseminated information to dentists about appropriate opioid prescribing practices and engaged them with a focus on pain management and substance use disorders. The objective of this study was to assess the effectiveness of this program for self-reported: (1) change in knowledge and confidence related to clinical skills for dental pain management of patients with substance use disorders; (2) change in clinical behavior of dentists for safe opioids prescribing; and (3) change in clinic policies regarding safe opioids prescribing.MethodsAn interdisciplinary panel of experts in medicine, pharmacy, social work, and dentistry designed and led the “Pain Management and Substance Use Disorders Dental ECHO” for invited dental care providers and dental students. Six cohorts each consisting of six, 1-h-long sessions were conducted via the Zoom videoconference platform in years 2020 and 2021. Each session included a didactic expert presentation, a participant-presented patient case and discussion. Each participant completed pre- and post-program surveys to assess the program’s influence on participant knowledge, clinical confidence and behavior change.ResultsThe participants (N = 151) were dentists (n = 109), dental faculty (n = 15), dental residents (n = 6), dental hygienists/assistants (n = 13) and nurses and clinic administrators (n = 8). Self-reported perceived medication knowledge, confidence in identification, treatment and willingness to engage with substance use disorders patients, and reported compliance with Prescription Drug Monitoring Program (PDMP) checks increased significantly from before to after the sessions (p < 0.001). Overall, participants expressed high levels of satisfaction with the content and reported that the sessions provided high benefit.ConclusionThe Project ECHO model is effective in rapidly disseminating evidence-based information. Dentists viewed this model as having a high degree of benefit for the optimal management of dental pain and the recognition and treatment of substance use disorders.

Barriers and facilitators to clinical behaviour change by primary care practitioners: a theory-informed systematic review of reviews using the Theoretical Domains Framework and Behaviour Change Wheel

BackgroundUnderstanding the barriers and facilitators to behaviour change by primary care practitioners (PCPs) is vital to inform the design and implementation of successful Behaviour Change Interventions (BCIs), embed evidence-based medicine into routine clinical practice, and improve quality of care and population health outcomes.MethodsA theory-led systematic review of reviews examining barriers and facilitators to clinical behaviour change by PCPs in high-income primary care contexts using PRISMA. Embase, MEDLINE, PsychInfo, HMIC and Cochrane Library were searched. Content and framework analysis was used to map reported barriers and facilitators to the Theoretical Domains Framework (TDF) and describe emergent themes. Intervention functions and policy categories to change behaviour associated with these domains were identified using the COM-B Model and Behaviour Change Wheel (BCW).ResultsFour thousand three hundred eighty-eight reviews were identified. Nineteen were included. The average quality score was 7.5/11. Reviews infrequently used theory to structure their methods or interpret their findings. Barriers and facilitators most frequently identified as important were principally related to ‘Knowledge’, ‘Environmental context and resources’ and ‘Social influences’ TDF domains. These fall under the ‘Capability’ and ‘Opportunity’ domains of COM-B, and are linked with interventions related to education, training, restriction, environmental restructuring and enablement. From this, three key areas for policy change include guidelines, regulation and legislation. Factors least frequently identified as important were related to ‘Motivation’ and other psychological aspects of ‘Capability’ of COM-B. Based on this, BCW intervention functions of persuasion, incentivisation, coercion and modelling may be perceived as less relevant by PCPs to change behaviour.ConclusionsPCPs commonly perceive barriers and facilitators to behaviour change related to the ‘Capability’ and ‘Opportunity’ domains of COM-B. PCPs may lack insight into the role that ‘Motivation’ and aspects of psychological ‘Capability’ have in behaviour change and/or that research methods have been inadequate to capture their function. Future research should apply theory-based frameworks and appropriate design methods to explore these factors. With no ‘one size fits all’ intervention, these findings provide general, transferable insights into how to approach changing clinical behaviour by PCPs, based on their own views on the barriers and facilitators to behaviour change.Systematic review registrationA protocol was submitted to the London School of Hygiene and Tropical Medicine via the Ethics and CARE form submission on 16.4.2020, ref number 21478 (available on request). The project was not registered on PROSPERO.

109 Mutations in the T-cell receptor antigen-binding region of malignant cells in mycosis fungoides coincide with clinical and histological progression

Chronic T-cell antigen stimulation has long been suggested to contribute to carcinogenesis in mycosis fungoides (MF), but evidence of this phenomenon is lacking at the genetic level. Furthermore, mutations that alter malignant T-cells’ antigen specificities have not been previously described in MF. Here, we report evidence from two patients whereby the presence of single base substitutions (SBS) in the antigen-binding regions of the malignant clones’ T-cell receptors (TCR) coincide with changes in clinical behavior.

Seroprevalence of SARS-CoV-2 in Client-Owned Cats from Portugal.

Simple SummaryDomestic cats are highly susceptible to SARS-CoV-2. The close contact between humans and cats raises concerns about virus transmission from humans to cats. Thus, this study aims to investigate the presence of antibodies against SARS-CoV-2 in client-owned cats from Portugal, which is an indicator of exposure to the virus. A total of 176 cats, belonging to 94 households, were sampled, and cat owners answered an online questionnaire. Twenty households reported at least one confirmed human COVID-19 case. Forty cats belonged to COVID-19-positive and 136 to COVID-19-negative households. The percentages of cats exhibiting antibodies against SARS-CoV-2 from COVID-19-positive and -negative households were 5.0% and 0.7%, respectively. The two positive cats from COVID-19-positive households had an indoor lifestyle, and their owners maintained a close and frequent contact with them, even after being diagnosed with COVID-19, pointing towards human-to-cat transmission. The positive cat from the COVID-19-negative household had a mixed indoor/outdoor lifestyle and chronic diseases. Owners of the three positive cats did not notice clinical signs or behavior changes. This study highlights the low risk of SARS-CoV-2 transmission from humans to cats, even in a context of close and frequent contact.The close contact between humans and domestic cats raises concerns about the potential risks of SARS-CoV-2 transmission. Thus, this study aims to investigate anti-SARS-CoV-2 seroprevalence in client-owned cats from Portugal and evaluate the infection risk of cats that maintain contact with human COVID-19 cases. A total of 176 cats, belonging to 94 households, were sampled. Cat owners answered an online questionnaire, and cats were screened for antibodies against SARS-CoV-2 using a commercial ELISA. Twenty (21.3%) households reported at least one confirmed human COVID-19 case. Forty cats (22.7%) belonged to a COVID-19-positive and 136 (77.3%) to a COVID-19-negative household. The seroprevalences of cats from COVID-19-positive and -negative households were 5.0% (2/40) and 0.7% (1/136). The two SARS-CoV-2-seropositive cats from COVID-19-positive households had an indoor lifestyle, and their owners stated that they maintained a close and frequent contact with them, even after being diagnosed with COVID-19, pointing towards human-to-cat transmission. The SARS-CoV-2-seropositive cat from the COVID-19-negative household had a mixed indoor/outdoor lifestyle and chronic diseases. Owners of the three SARS-CoV-2-seropositive cats did not notice clinical signs or behavior changes. This study highlights the low risk of SARS-CoV-2 transmission from COVID-19-positive human household members to domestic cats, even in a context of close and frequent human–animal contact.

Understanding the Role of Clinical Champions and Their Impact on Clinician Behavior Change: The Need for Causal Pathway Mechanisms.

The clinical champion approach is a highly utilized implementation strategy used to mitigate barriers and improve outcomes of implementation efforts. Clinical champions are particularly effective at addressing provider-level barriers and promoting provider-behavior change. Yet, the specific causal pathways that explain how clinical champions impact provider behavior change have not been well-explicated. The current paper applies behavior change models to develop potential causal pathway mechanisms. The proposed mechanisms are informed by previous literature involving clinical champions and empirically supported behavior change models. These models are applied to link specific attributes to different stages of behavior change and barriers for providers. Two unique pathway mechanisms were developed, one that explicates how providers develop intention to use EBPs, while the other explicates how providers transition to EBP use and sustainment. Clinical champions may promote intention development through behavioral modeling and peer buy-in. In contrast, champions promote behavioral enactment through skill building and peer mentorship. Clinical champions likely play a critical role in reducing provider implementation barriers for providers across various phases of behavior change. The proposed pathways provide potential explanations for how clinical champions promote provider behavior change. Future research should prioritize empirically testing causal pathway mechanisms.