Large Quality Improvement Research Articles

TCT-851 Most Patients With Low-Gradient AS Derive Large Improvements in Quality of Life After TAVR Irrespective of Aortic Valve Calcium Score

TCT-851 Most Patients With Low-Gradient AS Derive Large Improvements in Quality of Life After TAVR Irrespective of Aortic Valve Calcium Score

Intervening to reduce sedentary behavior among African American elders: the "Stand Up and Move More" intervention.

Reducing sedentary behavior is a promising intervention target for improving health for older adults; however, few interventions include African American communities. The purpose of this research was to extend the reach of an effective sedentary behavior intervention to African American elders. Two pilot studies assessed the feasibility (retention, adherence, and safety) and acceptability (participant and leader perspectives) of a 4-wk "Stand Up and Move More" (SUMM) intervention. Sedentary behavior (self-reported and monitor-derived), function (short physical performance battery), and quality of life (SF-36) were measured at baseline (wk0), postintervention (wk4), and follow up (wk12; study 1) to examine preliminary effectiveness of the intervention. Participants (N=26) attended SUMM or an attention-matched stress management intervention (study 2). The magnitude of treatment effects were determined using Hedge's g effect size calculations [small (g=0.20 to 0.49), moderate (g=0.50 to 0.79), large (g>0.80)]. Retention and adherence rates ranged from 50%-100% and 80%-100%, respectively. There were no adverse events. Participants expressed high satisfaction, and the leader of the SUMM intervention indicated that the intervention content was beneficial. Hedges' g revealed negligible to small changes in sedentary behavior (g<0.50) following SUMM. There were moderate to large improvements in function (g=0.51-0.82) and quality of life (g=0.54-1.07) from wk0 to wk4 in study 1; and moderate to large improvements in function (g=0.51-0.88) from wk0 to wk4 in study 2. There was a moderate improvement in quality of life (SF-36 emotional role limitations g=0.54) in the SUMM group only. Given its feasibility, safety, and acceptability, SUMM may be a promising intervention to improve functioning and well-being among African American elders.

Variation in care and outcome for fragile hip fracture patients: a European multicentre study benchmarking fulfilment of established quality indicators.

Despite the availability of clinical guidelines for hip fracture patients, adherence to these guidelines is challenging, potentially resulting in suboptimal patient care. The goal of this study was (1) to evaluate and benchmark the adherence to recently established quality indicators (QIs), and (2) to study clinical outcomes, in fragile hip fracture patients from different European countries. This observational, cross-sectional multicenter study was performed in 10 hospitals from 9 European countries including data of 298 consecutive patients. A large variation both within and between hospitals were seen regarding adherence to the individual QIs. QIs with the lowest overall adherence rates were the administration of systemic steroids (5.4%) and tranexamic acid (20.1%). Indicators with the highest adherence rates (above 95%) were pre-operative (99.3%) and post-operative haemoglobin level assessment (100%). The overall median time to surgery was 22.6h (range 15.7-42.5h). The median LOS was 9.0 days (range 5.0-19.0 days). The most common complications were delirium (23.2%) and postsurgical constipation (25.2%). The present study shows large variation in the care for fragile patients with hip fractures indicating room for improvement. Therefore, hospitals should invest in benchmarking and knowledge-sharing. Large quality improvement initiatives with longitudinal follow up of both process and outcome indicators should be initiated.

Traffic Flow Optimisation for Lifelong Multi-Agent Path Finding

Multi-Agent Path Finding (MAPF) is a fundamental problem in robotics that asks us to compute collision-free paths for a team of agents, all moving across a shared map. Although many works appear on this topic, all current algorithms struggle as the number of agents grows. The principal reason is that existing approaches typically plan free-flow optimal paths, which creates congestion. To tackle this issue, we propose a new approach for MAPF where agents are guided to their destination by following congestion-avoiding paths. We evaluate the idea in two large-scale settings: one-shot MAPF, where each agent has a single destination, and lifelong MAPF, where agents are continuously assigned new destinations. Empirically, we report large improvements in solution quality for one-short MAPF and in overall throughput for lifelong MAPF.

Motivational drivers for health professionals in a large quality improvement collaborative project in Brazil: a qualitative study

BackgroundThe success of collaborative quality improvement (QI) projects in healthcare depends on the context and engagement of health teams; however, the factors that modulate teams’ motivation to participate in these projects are still unclear. The objective of the current study was to explore the barriers to and facilitators of motivation; the perspective was health professionals in a large project aiming to implement evidence-based infection prevention practices in intensive care units of Brazilian hospitals.MethodsThis qualitative study was based on content analysis of semistructured in-depth interviews held with health professionals who participated in a collaborative QI project named “Improving patient safety on a large scale in Brazil”. In accordance with the principle of saturation, we selected a final sample of 12 hospitals located throughout the five regions of Brazil that have implemented QI; then, we conducted videoconference interviews with 28 health professionals from those hospitals. We encoded the interview data with NVivo software, and the interrelations among the data were assessed with the COM-B model.ResultsThe key barriers identified were belief that improvement increases workload, lack of knowledge about quality improvement, resistance to change, minimal involvement of physicians, lack of supplies, lack support from senior managers and work overload. The primary driver of motivation was tangible outcomes, as evidenced by a decrease in infections. Additionally, factors such as the active participation of senior managers, teamwork, learning in practice and understanding the reason for changes played significant roles in fostering motivation.ConclusionThe motivation of health professionals to participate in collaborative QI projects is driven by a variety of barriers and facilitators. The interactions between the senior manager, quality improvement teams, and healthcare professionals generate attitudes that modulate motivation. Thus, these aspects should be considered during the implementation of such projects. Future research could explore the cost-effectiveness of motivational approaches.

Implementation strategies for large scale quality improvement initiatives in primary care settings: a qualitative assessment

Background and objectivesThe EvidenceNOW: Advancing Heart Health in Primary Care was designed to assist primary care practices in the US in implementing evidence-based practices in cardiovascular care and building capacity for quality improvement. EvidenceNOW, NCT03054090, was registered with ClinicalTrials.gov on 15/02/2017. The goals of this study were to gain a comprehensive understanding of perspectives from research participants and research team members on the value of implementation strategies and factors that influenced the EvidenceNOW initiative in Virginia.MethodsIn 2018, we conducted 25 focus groups with clinicians and staff at participating practices, including 80 physicians, advanced practice clinicians, practice managers and other practice staff. We also conducted face-to-face and telephone interviews with 22 research team members, including lead investigators, practice facilitators, physician expert consultants, and evaluators. We used the integrated-Promoting Action on Research Implementation in the Health Services (i-PARIHS) framework in our qualitative data analysis and organization of themes.ResultsImplementation strategies valued by both practice representatives and research team members included the kick-off event, on-site practice facilitation, and interaction with physician expert consultants. Remote practice facilitation and web-based tools were used less frequently. Contextual factors that influence quality improvement efforts include leadership support, access to resources, previous quality improvement experience, and practice ownership type (independent compared to health system owned). Many clinicians and staff were overwhelmed by day-to-day activities and experience initiative fatigue, which hindered their ability to fully participate in the EvidenceNOW initiative.ConclusionsThis study provides details on how the practice environment plays an essential role in the implementation of evidence-based practices in primary care. Future efforts to improve quality in primary care practices should consider the context and environment of individual practices, with targeted implementation strategies to meet the needs of independent and health system owned practices. Future efforts to improve quality in primary care practices require strategies to address initiative fatigue among clinicians and practice staff. External support for building capacity for quality improvement could help primary care practices implement and sustain evidence-based practices and improve quality of care.Trial registrationThis project was registered with ClinicalTrials.gov on 15/02/2017 and the identifier is NCT03054090.

Relationship of Race With Functional and Clinical Outcomes With the REHAB-HF Multidomain Physical Rehabilitation Intervention for Older Patients With Acute Heart Failure.

Background The REHAB-HF (Rehabilitation Therapy in Older Acute Heart Failure Patients) randomized trial demonstrated that a 3-month transitional, tailored, progressive, multidomain physical rehabilitation intervention improves physical function, frailty, depression, and health-related quality of life among older adults with acute decompensated heart failure. Whether there is differential intervention efficacy by race is unknown. Methods and Results In this prespecified analysis, differential intervention effects by race were explored at 3 months for physical function (Short Physical Performance Battery [primary outcome], 6-Minute Walk Distance), cognition, depression, frailty, health-related quality of life (Kansas City Cardiomyopathy Questionnaire, EuroQoL 5-Dimension-5-Level Questionnaire) and at 6 months for hospitalizations and death. Significance level for interactions was P≤0.1. Participants (N=337, 97% of trial population) self-identified in near equal proportions as either Black (48%) or White (52%). The Short Physical Performance Battery intervention effect size was large, with values of 1.3 (95% CI, 0.4-2.1; P=0.003]) and 1.6 (95% CI, 0.8-2.4; P<0.001) in Black and White participants, respectively, and without significant interaction by race (P=0.56). Beneficial effects were also demonstrated in 6-Minute Walk Distance, gait speed, and health-related quality of life scores without significant interactions by race. There was an association between intervention and reduced all-cause rehospitalizations in White participants (rate ratio, 0.73 [95% CI, 0.55-0.98]; P=0.034) that appears attenuated in Black participants (rate ratio, 1.06 [95% CI, 0.81-1.41]; P=0.66; interaction P=0.067). Conclusions The intervention produced similarly large improvements in physical function and health-related quality of life in both older Black and White patients with acute decompensated heart failure. A future study powered to determine how the intervention impacts clinical events is required. REGISTRATION URL: https://www.clinicaltrials.gov. Identifier: NCT02196038.

48 Capabilities of Emergency Departments to Treat Alcohol Use Disorder: Assessment From a Large Quality Improvement Initiative

48 Capabilities of Emergency Departments to Treat Alcohol Use Disorder: Assessment From a Large Quality Improvement Initiative

Transcatheter Edge-to-Edge Repair in 5,000 Patients With Secondary Mitral Regurgitation: COAPT Post-Approval Study

BackgroundReal-world applicability of the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) randomized controlled trial (RCT) has been debated because of careful patient selection and the contrasting results of the MITRA-FR (Multicentre Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients with Severe Secondary Mitral Regurgitation) RCT. ObjectivesThe COAPT-PAS (COAPT Post-Approval Study) was initiated to assess the safety and effectiveness of the MitraClip in patients with secondary mitral regurgitation (SMR). MethodsCOAPT-PAS is a prospective, single-arm, observational study of 5,000 consecutive patients with SMR treated with the MitraClip at 406 U.S. centers participating in the TVT (Transcatheter Valve Therapy) registry from 2019 to 2020. The 1-year outcomes from the COAPT-PAS full cohort and the COAPT-like and MITRA-FR–like subgroups who met RCT inclusion/exclusion criteria are reported. ResultsPatients in the COAPT-PAS had more comorbidities, more severe HF and functional limitations, and less guideline-directed medical therapy than those in the COAPT or MITRA-FR RCTs. Patients in the COAPT-PAS full cohort and the COAPT-like (n = 991) and MITRA-FR–like (n = 917) subgroups achieved a 97.7% MitraClip implant rate, a similar and durable reduction of mitral regurgitation to ≤2+ at 1 year (90.7%, 89.7%, and 86.6%, respectively), a large improvement in quality of life at 1 year (Kansas City Cardiomyopathy Questionnaire +29 COAPT-PAS, +27 COAPT-like, and +33 MITRA-FR–like), faster procedure times, similar or lower clinical event rates compared with the RCTs’ MitraClip arms, and lower clinical event rates than the RCTs’ guideline-directed medical therapy only arms. One-year heart failure hospitalizations was 18.9% in COAPT-PAS, 19.7% in COAPT-like compared with 24.9% in COAPT-RCT, and 28.7% in COAPT-PAS-MITRA-FR–like compared with 47.4% in MITRA-FR-RCT. ConclusionsThis large, contemporary, real-world study reinforces the safety and effectiveness of the MitraClip System in patients with SMR, including those who met the COAPT or MITRA-FR RCT inclusion/exclusion criteria and patients excluded from the RCTs.

Does orthodontic treatment improve the Oral Health-Related Quality of Life when assessed using the Malocclusion Impact Questionnaire-a 3-year prospective longitudinal cohort study.

To assess the change in Oral Health-Related Quality of Life (OHRQoL) following orthodontic treatment using the Malocclusion Impact Questionnaire (MIQ) and to test the responsiveness of MIQ to treatment-associated changes. A longitudinal prospective cohort study, in an orthodontic postgraduate centre, Kerala, India. Patients under 18 years were invited to complete the MIQ before the start of treatment (T0) and 1 month after treatment completion (T1). TheIndex of Orthodontic Treatment Need and Peer Assessment Rating (PAR) scores were assessed at both time periods as well as a global transition judgement at T1. Two hundred and ten participants were recruited and 162 completed both questionnaires (45.1% males; 54.9% females; age = 12-18 years, mean = 16.8; SD = 1.7). There was large reduction in MIQ scores from T0 (mean = 28.1, SD = 6.1) to T1 (mean = 3.7, SD = 2.6). 53% reported a large improvement in oral health and related life quality after treatment, 32% minimal change, and 15% no change. None reported worsening in OHRQoL at T1. There was a significant positive correlation between change in MIQ score and change in PAR score (r = 0.358), pretreatment aesthetic component (rho = 0.467) and dental health component (rho = 0.491) of the index of orthodontic treatment (IOTN-DHC), and treatment time (rho = 0.502). Regression analysis revealed the change in PAR score and pretreatment IOTN-DHC to be independent predictors of change in MIQ score. Standardized effect size (4.0) and standardized response mean (2.9) were large and the minimal important difference was 7.7. Receiver operating characteristic analysis reported a high diagnostic accuracy of MIQ. There was a significant improvement in OHRQoL following orthodontic treatment when assessed using a condition-specific measure for malocclusion. MIQ was found to be responsive to changes associated with orthodontic treatment.

Mesocosm studies clarify effects of external and internal phosphorus (P) loads to treatment wetlands at lower limits of P removal

This study evaluates wetland phosphorus (P) removal where P concentrations can be extremely low (∼20 μg/L or less). Stormwater Treatment Area (STAs) are large water quality improvement projects constructed for Everglades restoration, where research is underway to understand the processes that control P removal at already low P concentrations, particularly in the lower reaches of the flow-ways, upstream of the discharge structures. One concept that is being researched consists of scraping the P-enriched muck soil from the discharge region of STAs to expose the underlying limerock (LR) substrate. This has been investigated in numerous subscale platforms and results in proliferation of periphyton and submerged aquatic vegetation (SAV) communities. In principle, it also reduces internal P loads to the water column, although this point has lacked direct data support. One 40-ha field-scale periphyton-based STA (PSTA) cell has operated since 2008 and has regularly reduced ∼15 μg/L inflow TP to ∼10 μg/L (long-term flow-weighted means). This study documents two mesocosm experiments aimed at better understanding PSTA systems. The first experiment investigated the response of outflow P to external P loading rates (PLR = 0.3–1.3 g/m2/yr). Together with the field data from full-scale STAs, the results establish that PSTA systems are responsive to upstream P inputs (a reduction in external P inputs results in lower outflow P), whereas adjacent muck-based STA treatment cells receiving similar P inputs are not. The second experiment investigated differences in discharge TP and plant tissue and sediment P. Seven substrate-vegetation combinations were used: 0, 5, and 15 cm of limerock (LR) “cap” over indigenous muck with and without SAV found in the STAs; and a LR-only system inoculated with SAV but heavily dominated by periphyton. Rooted SAV produced internal P loads to the water column at a magnitude that is dependent upon access to the soil-P pool (muck only > LR cap over muck > LR only). Thus, the likely reason why PSTA achieves lower P discharges and exhibits external PLR influence is very low internal P loading rates (iPLR), where more elevated iPLR in muck-based systems appears to mask the effects of reducing external loading under low-P conditions. These results improve our understanding of external and internal P load contributions in low-P wetlands.

The Efficacy of Hypnotic Analgesic Suggestions in Chronic Nociplastic Pain: A Randomized Controlled Trial

ABSTRACT This blinded study evaluated the relative efficacy of three hypnosis sessions in 60 patients with chronic nociplastic pain allocated randomly to one of two conditions: hypnosis with analgesic suggestions, or hypnosis with nonspecific suggestions. Pain intensity, pain quality, and pain interference as outcome measures were assessed before and after treatment. A mixed-design analysis of the variance model showed no significant differences between groups. According to the adjusted model, large effect size improvements in pain intensity and pain quality emerged for both conditions but were only meaningful for patients not taking pain medications. Analgesic suggestions may not play a primary role in beneficial outcomes of hypnosis at the beginning of chronic pain management since both interventions demonstrated similar positive effects. Future studies should investigate the efficacy of the hypnosis components over longer treatment periods.

1077-P: A Multicenter Initiative to Improve Care in Cardiometabolic Disease—Initial Report From Cardiometabolic Center Alliance (CMCA)

Background: Despite high risk, minority of individuals with Type 2 diabetes (T2D) and cardiovascular or chronic kidney disease (CVD/CKD) receives optimal guideline directed medical therapy (GDMT). Professional societies advocate for collaborative, team-based models to improve care in this group but successful multicenter implementation efforts are lacking. Methods: CMCA is a non for profit organization that seeks to transform care and outcomes in individuals with cardiometabolic disease. CMCA assists members in implementing team-based, coordinated care models (Cardiometabolic Centers) and GDMT driven pathways. Quality of care and outcomes are monitored via multicenter registry. Since launch in 2020, 14 US organizations joined CMCA. This initial report includes sites with data reported for ≥30 participants (each with ≥ 2 visits). Results: In total 606 individuals with T2D and CVD/CKD from 6 sites were evaluated (age 64 years, 44% women, 78% white, median follow up 6 months). After initiation of care at CMCA sites, large improvements in GDMT and reductions in weight, HbA1c, blood pressure, total/LDL cholesterol, triglycerides, and insulin requirements were observed (Figure panels 1 and 2; p&amp;lt; 0.001 for all). Conclusion: CMCA directed implementation of coordinated team-based care produced rapid and large improvements in GDMT and quality of care across multiple sites. Disclosure M.N.Kosiborod: Consultant; Alnylam Pharmaceuticals, Inc., Amgen Inc., Applied Therapeutics Inc., AstraZeneca, Bayer Inc., Boehringer Ingelheim Inc., Cytokinetics Inc., Dexcom, Inc., Eli Lilly and Company, ESPERION Therapeutics, Inc., Janssen Pharmaceuticals, Inc., Lexicon Pharmaceuticals, Inc., Merck &amp; Co., Inc., Novo Nordisk, Pharmacosmos A/S, Pfizer Inc., Sanofi, Vifor Pharma Management Ltd., Youngene Therapeutics, Other Relationship; AstraZeneca, Research Support; AstraZeneca, Boehringer Ingelheim Inc. E.Fryoux: None. L.Harness: None. R.Heath: None. K.A.Miller: None. I.Neeland: Consultant; Nestlé Health Science, Speaker's Bureau; Boehringer Ingelheim and Eli Lilly Alliance, Bayer Inc. S.Patel: None. J.Plutzky: Advisory Panel; ESPERION Therapeutics, Inc., Consultant; Amgen Inc., Merck &amp; Co., Inc., Novo Nordisk, Research Support; Boehringer Ingelheim Inc. R.K.Saalfeld: None. A.Stafos: None. S.Rajagopalan: Advisory Panel; Novartis, Novo Nordisk, Speaker's Bureau; Novo Nordisk. M.L.Magwire: Consultant; AstraZeneca, Novo Nordisk. D.S.Aistrope: None. E.Andaya: None. J.Butler: Consultant; Abbott,, Amgen, Applied Therapeutics, Array, Astra Zeneca, Bayer,, Boehringer Ingelheim, Bristol Myers Squibb, CVRx, G3 Pharma,, Impulse Dynamics, Innolife, Janssen, LivaNova, Luitpold, Medtronic, Merck, Novartis, NovoNordisk, Relypsa, Roche, Sequana Medical, Vifor, Speaker's Bureau; Novartis, Boehringer Ingelheim-Lilly, Astra Zeneca, Janssen. K.Cummings: None. L.Davis: Speaker's Bureau; Amgen Inc. R.H.Eckel: Advisory Panel; Amarin Corporation, 89bio, Inc., Novo Nordisk, Weight Watchers International, Board Member; Lexicon Pharmaceuticals, Inc., Consultant; Amgen Inc., Better Therapeutics, Inc, The Healthy Aging Company, Other Relationship; Arrowhead Pharmaceuticals, Inc. J.A.Fialkow: Speaker's Bureau; Amgen Inc., ESPERION Therapeutics, Inc., Amarin Corporation. Funding AstraZeneca; Boehringer Ingelheim; Novo Nordisk, Amgen Inc.; Eli Lilly and Company; Novartis

The effectiveness of non-pharmacological sleep interventions for improving inpatient sleep in hospital: A systematic review and meta-analysis

BackgroundSleep disturbance is common in hospital. The hospital environment can have a negative impact on sleep quality, through factors such as noise, light, temperature, and nursing care disruptions. Poor sleep can lead to delays in recovery, wound healing, and increase risk of post-operative infection. MethodsWe conducted a systematic review evaluating the effectiveness of non-pharmacological sleep interventions for improving inpatient sleep. The primary outcome was sleep quality, the secondary outcome was length of hospital stay, the harm outcome was adverse events. MEDLINE, Embase, CINAHL, PsycINFO and the Cochrane Library were searched from inception to 17th February 2022. Meta-analysis was conducted using a fixed effects model, with narrative synthesis for studies with no useable data. Risk of bias was assessed with the Cochrane tool. Results76 studies identified with 5375 people randomised comparing 85 interventions. Interventions focused on physical sleep aids (n = 26), relaxation (n = 25), manual therapy (n = 12), music (n = 9), psychological therapy (n = 5), light therapy (n = 3), sleep protocols (n = 2), milk and honey (n = 1), exercise (n = 1), and nursing care (n = 1). In meta-analysis, medium to large improvements in sleep quality were noted for sleep aids, relaxation, music, and manual therapies. Results were generally consistent in studies at lower risk of bias. Length of hospital stay and adverse events were reported for some studies, with benefit in some trials but this was not consistent across all interventions. ConclusionsPhysical sleep aids, relaxation, manual therapy and music interventions have a strong evidence base for improving inpatient sleep quality. Research is needed to evaluate how to optimise interventions into routine care.

Blood culture procedures and practices in the neonatal intensive care unit: A survey of a large multicenter collaborative in California.

To describe variation in blood culture practices in the neonatal intensive care unit (NICU). Survey of neonatal practitioners involved with blood culturing and NICU-level policy development. We included 28 NICUs in a large antimicrobial stewardship quality improvement program through the California Perinatal Quality Care Collaborative. Web-based survey of bedside blood culture practices and NICU- and laboratory-level practices. We evaluated adherence to recommended practices. Most NICUs did not have a procedural competency (54%), did not document the sample volume (75%), did not receive a culture contamination report (57%), and/or did not require reporting to the provider if <1 mL blood was obtained (64%). The skin asepsis procedure varied across NICUs. Only 71% had a written procedure, but ≥86% changed the needle and disinfected the bottle top prior to inoculation. More than one-fifth of NICUs draw a culture from an intravascular device only (if present). Of 13 modifiable practices related to culture and contamination, NICUs with nurse practitioners more frequently adopted >50% of practices, compared to units without (92% vs 50% of units; P < .02). In the NICU setting, recommended practices for blood culturing were not routinely performed.

Home-based respiratory muscle training on quality of life and exercise tolerance in long-term post-COVID-19: Randomized controlled trial.

To evaluate the effects of a home-based respiratory muscle training programme (inspiratory [IMT] or inspiratory/expiratory muscles [RMT]) supervised by telerehabilitation on quality of life and exercise tolerance in individuals with long-term post-COVID-19 symptoms. The secondary objective was to evaluate the effects of these programmes on respiratory muscle function, physical and lung function, and psychological state. 88 individuals with long-term symptoms of fatigue and dyspnoea after COVID-19 diagnosis were randomly (1:1 ratio) assigned to IMT, IMTsham, RMT or RMTsham groups for an 8-week intervention (40min/day, 6 times/week). Primary outcomes were quality of life (EuroQol-5D questionnaire) and exercise tolerance (Ruffier test). Secondary outcomes were respiratory muscle function (inspiratory/expiratory muscle strength; inspiratory muscle endurance), physical function (lower and upper limb strength [1-min Sit-to-Stand and handgrip force]), lung function (forced spirometry), and psychological status (anxiety/depression levels and post-traumatic stress disorder). All outcomes were measured pre-, intermediate- (4th week), and post-intervention. At post-intervention, there was a statistically significant and large (d>0.90) improvement in quality of life, but not in exercise tolerance, in the RMT group compared with the RMTsham group. Both of the real training groups produced a statistically significant and large increase in inspiratory muscle strength and endurance (d≥0.80) and in lower limb muscle strength (d≥0.77) compared with the 2 sham groups. Expiratory muscle strength and peak expiratory flow showed a statistically significant and large (d≥0.87) increase in the RMT group compared with the other 3 groups. Only an 8-week supervised home-based RMT programme was effective in improving quality of life, but not exercise tolerance, in individuals with long-term post-COVID-19 symptoms. In addition, IMT and RMT programmes were effective in improving respiratory muscle function and lower limb muscle strength, but had no impact on lung function and psychological status.

Making more nurses, one minute at a time: an efficiency and quality improvement project in emergency triage.

Emergency triage is a short-duration, high-volume process so small reductions in the time taken to triage one patient can have large repercussions on the total amount of triage time. At the emergency department of a large inner-city hospital, an efficiency and quality improvement project was undertaken to reduce the time taken to safely triage patients and optimise the use of triage nurses' time. The project involved removing processes that did not contribute to the primary aim of triage, supporting individual triage nurses to improve their performance where needed, and optimising the triage process. A 44% reduction in mean triage episode time was seen, equating to 18,000 minutes of triage nurses' time saved every month. This near doubling of triage capacity was associated with an improvement in triage accuracy. The article describes the project, which used lean management principles and statistical process control methods, and discusses its implications for emergency triage.

Large Improvements in Health-Related Quality of Life and Physical Fitness during Multidisciplinary Inpatient Rehabilitation for Pediatric Cancer Survivors.

Simple SummaryAfter cancer treatment, children often suffer from various health problems. Rehabilitation can improve their quality of life. We present data for 236 children and 478 parents who filled out questionnaires before and after inpatient rehabilitation. In our sample, both children and parents reported that the quality of life of the children had substantially improved during rehabilitation, especially their physical and psychosocial quality of life. Children also improved in physical exercises and their functional status. Parents and children showed better agreement regarding the child’s health status after rehabilitation than before. A specific method of statistical analysis (performance score) helped to reduce disagreement between parents and children. We therefore conclude that inpatient rehabilitation is effective for children after cancer treatment and that the performance score should be used in research on rehabilitation for children after cancer treatment to have the most accurate results.Rehabilitation is a key element in improving health-related quality of life (HRQOL) for pediatric cancer survivors. The aim of this study was to present data from a multidisciplinary inpatient rehabilitation treatment. Children took part in a four-week multidisciplinary family-oriented inpatient rehabilitation. A total of 236 children (>5–21 years) and 478 parents routinely completed electronic patient-reported outcomes (ePROs), performance-based assessments, and clinician-rated assessments before (T1) and at the end (T2) of rehabilitation. HRQOL was assessed with the PedsQL generic core and PedsQL cancer module. Data were analyzed using repeated measures analysis of variance (ANOVA). Statistically significant improvements with medium to large effect sizes were observed for most HRQOL scales (η2 = 0.09–0.31), as well as performance-based and clinician-rated assessments for physical activity and functional status (η2 > 0.28). Agreement between children’s PROs and parents’ proxy ratings was lower before (rICC = 0.72) than after (rICC = 0.86) rehabilitation. While the concordance between children and parents’ assessment of changes during rehab was low to moderate (r = 0.19–0.59), the use of the performance score led to substantially increased scores (r = 0.29–0.68). The results of this naturalistic observational study thus highlight the benefits of multidisciplinary pediatric inpatient rehabilitation for childhood cancer survivors. The use of the performance score is recommended in this field.

Observation of interfacial strain relaxation and electron beam damage thresholds in Al0.3In0.7N/GaN heterostructures by transmission electron microscopy

The structural quality of indium-rich Al0.3In0.7N grown by metal modulated epitaxy (MME), previously demonstrating x-ray diffraction (XRD) figures of merit ∼11 times better than the previous literature is investigated to explain the origin of such a large quality improvement. Four-dimensional scanning transmission electron microscope was used to map the lattice parameter near the AlInN/GaN heterojunction and indicate a 5.4% lattice constant change, suggesting 75% relaxation within ∼2 nm from the interface. Cross-sectional TEM Moiré fringes are observed at the AlInN/GaN heterointerface, indicating that there are misfit dislocations between AlInN and GaN which, while rare, have been observed for other highly mismatched In-rich III-Nitrides. The TEM measurements show regions of contrast indicating larger scale variations in strain, but defect contrast associated with dislocations and/or intrinsic basal stacking faults was minimal, indicating a good quality AlInN film and confirming prior XRD results. Significant electron beam induced damage can occur and depended strongly on operational conditions. The damage threshold current density was estimated using time-dependent TEM to be ∼5.7 A/cm2, significantly lower than from prior studies of InGaN. Damage also strongly depends on the thickness of the TEM foil examined and occurred at thicknesses greater than found for InGaN. The present study suggests that the MME technique is an excellent candidate for growing high-quality indium-rich AlInN films as compared to the traditional molecular beam epitaxy or metal organic chemical vapor deposition techniques.

Pulmonary rehabilitation versus usual care for adults with asthma.

Pulmonary rehabilitation versus usual care for adults with asthma.