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1. Many migratory species are in decline across their geographical ranges. Single-population studies can provide important insights into drivers at a local scale, but effective conservation requires multi-population perspectives. This is challenging because relevant data are often hard to consolidate, and state-of- the-art analytical tools are typically tailored to specific datasets. 2. We capitalized on a recent data harmonization initiative (SPI-Birds) and linked it to a generalized modelling framework to identify the demographic and environmental drivers of large-scale population decline in migratory pied flycatchers (Ficedula hypoleuca) breeding across Britain. 3. We implemented a generalized integrated population model (IPM) to estimate age-specific vital rates, including their dependency on environmental conditions, and total and breeding population size of pied flycatchers using long-term (34–64 years) monitoring data from seven locations representative of the British breeding range. We then quantified the relative contributions of different vital rates and population structure to changes in short-and long-term population growth rate using transient life table response experiments (LTREs). 4. Substantial covariation in population sizes across breeding locations suggested that change was the result of large-scale drivers. This was supported by LTRE analyses, which attributed past changes in short-term population growth rates and long-term population trends primarily to variation in annual survival and dispersal dynamics, which largely act during migration and/or nonbreeding season. Contributions of variation in local reproductive parameters were small in comparison, despite sensitivity to local temperature and rainfall within the breeding period. 5. We show that both short-and long-term population changes of British breeding pied flycatchers are likely linked to factors acting during migration and in nonbreeding areas, where future research should be prioritized. We illustrate the potential of multi-population analyses for informing management at (inter)national scales and highlight the importance of data standardization, generalized and accessible analytical tools, and reproducible workflows to achieve them. annual survival, comparative analysis, environmental effects, full annual cycle, integrated population model, LTRE, multi-population, pied flycatcher

Background: Previously, we reported on an opioid receptor quantitative systems pharmacology (QSP) model to evaluate naloxone dosing. Methods: In this study we extended our model to include higher systemic levels of fentanyl (up to 100 ng/ml) and the newly approved 8mg IN naloxone dose (equivalent to 4 mg)Results : As expected, at the lower peak fentanyl concentrations (25 ng/ml and 50 ng/ml), the simulations predicted that 2 mg, 4 mg, 5 mg, and 10 mg IM doses of naloxone displaced fentanyl and reached below the 50% receptor occupancy within 10 minutes. However, at the concentration of 75 ng/ml, the simulation predicted that the 2 mg dose of naloxone failed to reach below the 50% occupancy within 10 minutes. Interestingly, at the highest peak concentration of fentanyl studied (100 ng/ml), the model predicted that the 4 mg of naloxone IM (equivalent to 8 mg IN) failed to reach below the threshold of 50 % occupancy within 10 minutes or even within 15 minutes (Data not shown). In contrast, the model predicted successful reversals when 5 and 10 mg IM doses were utilized. Conclusion:These results support the notion that acutely administered higher doses of naloxone are needed for rapid and adequate clinical reversal, particularly when higher systemic exposure of the potent synthetic opioids occur.

Approximately 100,000 primary knee replacements are performed in the UK each year. There has been increasing focus on enhanced recovery after surgery (ERAS) programmes aimed at reducing complications and improving patient functional outcomes, with a consequent reduction in length of stay. Management of patients expectations preoperatively have been shown to be very important in providing better improvement of pain and function postoperatively. As part of ERAS programmes, management of postoperative pain control is essential to help promote early mobilization, compliance in rehabilitation with physiotherapists and minimizing the risk of venous thromboembolism (VTE). We focus this review on VTE prophylaxis, perioperative management of anticoagulation, rehabilitation and follow-up. In conclusion, success in ERAS programmes is heavily reliant on strong collaboration within the multidisciplinary team consisting of orthopaedic surgeons, anaesthetists, physiotherapists, nurses and occupational therapists. All of the above provide simultaneous patient-centred care.

Immuno-oncology (IO) is a fast-expanding field due to recent success using IO therapies in treating cancer. As IO therapies do not directly kill tumor cells but rather act upon the patients' own immune cells either systemically or in the tumor microenvironment, new and innovative approaches are required to inform IO therapy research and development. Quantitative systems pharmacology (QSP) modeling describes the biological mechanisms of disease and the mode of action of drugs with mathematical equations, which has significant potential to address the big challenges in the IO field, from identifying patient populations that respond to different therapies to guiding the selection, dosing, and scheduling of combination therapy. To assess the perspectives of the community on the impact of QSP modeling in IO drug development and to understand current applications and challenges, the IO QSP working group-under the QSP Special Interest Group (SIG) of the International Society of Pharmacometrics (ISoP)-conducted a survey among QSP modelers, non-QSP modelers, and non-modeling IO program stakeholders. The survey results are presented here with discussions on how to address some of the findings. One of the findings is the differences in perception among these groups. To help bridge this perception gap, we present several case studies demonstrating the impact of QSP modeling in IO and suggest actions that can be taken in the future to increase the real and perceived impact of QSP modeling in IO drug research and development.

This paper outlines the development of one integrated ITE programme that leads to two QTS pathways: Primary Post-Graduate Certificate in Education with Secondary Enrichment; and Secondary Post-Graduate Certificate in Education with Primary Enrichment. The integrated ITE programme AberTeach + enables student teachers to 'Teach beyond boundaries for an all-through experience'. This paper reviews the programme's conceptual framework and learning philosophy and in so doing, considers the core principles that influenced the design of the programme, as follows: Inclusive Partnership; Effective Pedagogy; Integrated Pedagogy; Specialised and Enriched Pedagogy; Shared and Reflective Pedagogy; Truly Collaborative Research Culture, Democratic Accountability and the eight principles of the Learning Philosophy. The paper proceeds to explain how the integrated programme is delivered via a cluster hub approach across 5 hub regions in Mid-Wales. In doing so, it outlines the role of the University staff and Lead and Partner school mentors as well as the minimum expectations for student teachers whilst on school experience. Consideration is also given to Welsh-medium provision and support as well as the centrality of research within the ITE Partnership as a whole. The paper closes by considering what is innovative about the programme and the benefits that student teachers gain from undertaking the programme.

Smjernice za prevenciju tromboembolijskih incidenata prilikom ortopedskih zahvata na kuku i koljenu.

ObjectivesTo evaluate whether a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty offers superior outcomes to traditional outpatient physiotherapy.DesignA prospective, single-blind, two-arm randomised controlled superiority trial.Setting14 National Health Service physiotherapy departments in the UK.Participants621 participants identified at high risk of a poor outcome after knee arthroplasty using a bespoke screening tool.InterventionsA multicomponent home-based rehabilitation programme delivered by rehabilitation assistants with supervision from qualified therapists versus usual care outpatient physiotherapy.Main outcome measuresThe primary outcome was the Late-Life Function and Disability Instrument (LLFDI) at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function), Knee injury and Osteoarthritis Outcome Score Quality of Life subscale, Physical Activity Scale for the Elderly, 5 dimension, 5 level version of Euroqol (EQ-5D-5L) and physical function assessed using the Figure of 8 Walk test, 30 s Chair Stand Test and Single Leg Stance.Results621 participants were randomised between March 2015 and January 2018. 309 were assigned to CORKA (Community Rehabilitation after Knee Arthroplasty) home-based rehabilitation, receiving a median five treatment sessions (IQR 4–7). 312 were assigned to usual care, receiving a median 4 sessions (IQR 2–6). The primary outcome, LLFDI function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference=0.49 points; 95% CI −0.89 to 1.88; p=0.48). There were no statistically significant differences between the groups on any of the patient-reported or physical secondary outcome measures at 6 or 12 months.There were 18 participants in the intervention group reporting a serious adverse event (5.8%), only one directly related to the intervention, all other adverse events recorded throughout the trial related to underlying chronic medical conditions.ConclusionsThe CORKA intervention was not superior to usual care. The trial detected no significant differences, clinical or statistical, between the two groups on either primary or secondary outcomes. CORKA offers an evaluation of an intervention utilising a different service delivery model for this patient group.Trial registration numberISRCTN13517704.

© 2020 IEEE. AI has powerful capabilities in prediction, automation, planning, targeting, and personalisation. Generally, it is assumed that AI can enable machines to exhibit human-like intelligence, and is claimed to benefit to different areas of our lives. Since AI is fueled by data and is a distinct form of autonomous and self-learning agency, we are seeing increasing ethical concerns related to AI uses. In order to mitigate various ethical concerns, national and international organisations including governmental organisations, private sectors as well as research institutes have made extensive efforts by drafting ethical principles of AI, and having active discussions on ethics of AI within and beyond the AI community. This paper investigates these efforts with a focus on the identification of fundamental ethical principles of AI and their implementations. The review found that there is a convergence around limited principles and the most prevalent principles are transparency, justice and fairness, responsibility, non-maleficence, and privacy. The investigation suggests that ethical principles need to be combined with every stages of the AI lifecycle in the implementation to ensure that the AI system is designed, implemented and deployed in an ethical manner. Similar to ethical framework used in biomedical and clinical research, this paper suggests checklist-style questionnaires as benchmarks for the implementation of ethical principles of AI.

Mae'r papur hwn yn amlinellu datblygiad un rhaglen AGA integredig sy'n arwain at ddau lwybr SAC: Tystysgrif Addysg i Raddedigion Cynradd gyda Chyfoethogi Uwchradd; a Thystysgrif Addysg i Raddedigion Uwchradd gyda Chyfoethogi Cynradd. Mae rhaglen AGA integredig Dysgu Aber+ yn galluogi athrawon i 'addysgu y tu hwnt i'r ffiniau ar gyfer profiad cyfannol'. Mae'r papur yn adolygu fframwaith cysyniadol y rhaglen a'i hathroniaeth ddysgu ac wrth wneud hynny mae'n ystyried yr egwyddorion craidd a ddylanwadodd ar gynllun y rhaglen, fel a ganlyn: Partneriaeth Gynhwysol; Addysgeg Effeithiol; Addysgeg Integredig; Addysgeg Arbenigol ac wedi'i Chyfoethogi; Addysgeg a Rennir ac Adfyfyriol; Diwylliant Ymchwil Gwirioneddol Gydweithredol, Atebolrwydd Democrataidd ac wyth egwyddor yr Athroniaeth Ddysgu. Mae'r papur yn mynd ymlaen i esbonio sut mae'r rhaglen integredig yn cael ei chyflwyno drwy gyfrwng dull hwb clwstwr ar draws 5 rhanbarth hwb yng Nghanolbarth Cymru. Wrth wneud hyn, mae'n amlinellu rôl staff y Brifysgol a Phrif fentoriaid a mentoriaid Ysgolion Partner yn ogystal ag isafswm y gofynion ar gyfer athrawon dan hyfforddiant tra'u bod ar brofiad yn yr ysgol. Mae ystyriaeth hefyd yn cael ei rhoi i ddarpariaeth a chefnogaeth cyfrwng Cymraeg yn ogystal â rôl ganolog ymchwil o fewn y Bartneriaeth AGA gyfan. Mae'r papur yn cloi drwy ystyried beth sy'n arloesol am y rhaglen a'r manteision sy'n dod i'r athrawon dan hyfforddiant wrth ddilyn y rhaglen.

Purpose Results of a pilot project to improve the safety and efficiency of the discharge process by adding daily pharmacist review and preparation of discharge medication orders to an existing discharge medication reconciliation workflow are reported. Summary Due to patient capacity issues, the pharmacy department of a large tertiary medical center implemented changes to the existing medication discharge workflow. A steering committee was established, with subgroups responsible for workflow development, electronic medical record enhancement, and data collection designated. Patients admitted to 5 hospitalist services, 1 otolaryngology service, and 1 gynecology service were included in pilot testing of a new discharge workflow over a 7-week period. The new workflow included pharmacist daily prospective preparation of discharge medication orders by “pending” (i.e., managing all aspects of) orders for providers to sign. After implementation, a 22% relative reduction ( p = 0.046) in pharmacist-identified medication-related problems was documented. Additionally, the proportion of discharges occurring before noon was increased on all services involved in the pilot project, including a significant increase (from 19% to 23%, p = 0.001) on the hospitalist services. Challenges identified during the pilot project included suboptimal initial provider acceptance and added pharmacist workload. On average, an additional 16.2 minutes of pharmacist time per patient was required for ordering of discharge medications throughout a patient stay. Conclusion Implementation of a discharge process that incorporated pharmacist pending of discharge medication orders throughout the patient stay improved measures of safety and efficiency of the discharge process.

Objectives: The incidence of fractured neck of femur (FNOF) is increasing yearly. Many of these patients undergo hip hemiarthroplasty. High dose dual-antibiotic cement (HDDAC) has been shown to reduce rates of deep surgical site infection (SSI) when compared to the current standard low dose single-antibiotic cement (LDSAC) in a quasi-randomised controlled trial. Some concerns exist regarding the use of HDDAC and the development of antibiotic resistance. We reviewed cases of infection in LDSAC and HDDAC bone cement with regard to causative organism and resistance profile.Methods: A retrospective analysis was undertaken of all hemiarthroplasties within our trust from April 2008 to December 2014. We identified all patients in this time period who acquired a deep SSI. The infecting organisms and susceptibility patterns were collated for each cement.Results: We identified 1941 hemiarthroplasties. There were 38 deep surgical site infections representing an infection rate of 3.4% in LDSAC patients and 1.2% in HDDAC patients. The majority of infections were polymicrobial. Staphylococcus epidermidis was the most commonly isolated organism. It accounted for a larger proportion of HDDAC than LDSAC infections (pCorynebacterium species and S. aureus, including MRSA, was eradicated completely with the use of HDDAC. There was no significant change in the proportion of Gram negative and Gram positive infections between the two cements. In Gram positive organisms, there was no significant change in resistance to most antibiotics. Although fewer resistant infections overall, there were significant increases in the proportion of resistance to ciprofloxacin and clindamycin with HDDAC. We observed no resistance to daptomycin or linezolid in either cement and levels of resistance remained low to rifampicin and teicoplanin. In Gram negative organisms, no significant change in resistance was observed.Conclusions: We observed a significantly lower infection rate with the use of HDDAC compared to LDSAC. Such was this reduced infection rate that there was a trend to a lower rate of resistance with the use of HDDAC. However, there were increases in the proportion of resistant cases, most notably to clindamycin and ciprofloxacin in Gram positive organisms, possibly reflecting the higher number of S. epidermidis in the HDDAC group. Whilst the differences in our study were not found to be statistically significant, it is reassuring for teams using HDDAC to prevent SSI in hip hemiarthroplasty.

We have measured the activity patterns of wintering Green Sandpipers before and after they were fitted with geolocators attached using leg loop harnesses and compared these with a control group of untagged birds. The geolocators and harnesses represented 1.4–1.6% of the body mass of the birds. Although the proportion of time the birds spent feeding increased over the course of the winter, we found no significant effect of tagging. Tagged birds spent significantly more time preening than untagged birds (6.3% overall compared with 4.6% for untagged birds) but the effect decreased with days after tagging. There was no evidence that this small increase in preening activity led to lower survival of the birds or changes in their migration timetable.

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS

Background Musculoskeletal ultrasound (MSUS) has assumed a prominent role in rheumatological practice as both a diagnostic and monitoring tool.1 It has utility in excluding and quantifying active synovitis and can be used to guide adjustments of therapies.2,3 Objectives We aimed to observe impacts on clinical practice of utilising ultrasound (US) scanners in outpatient clinics in a district general rheumatology service. We were particularly interested to see if this affected treatment choices, follow-up plans and referrals for radiological investigations. Methods US scanners were obtained and used by 2 rheumatology consultants with previous ultrasound training. Scanning was performed during standard 20 minute appointments within general rheumatology outpatient clinics. No extra time was allocated. Over 8 weeks, we completed questionnaires for each scan and assessed the impact on management decisions. Results Over 8 weeks, data was collected for 36 consecutive patients scanned. Commonly imaged joints were hands (81%,n=29), wrists (75%, n=27), feet (19%, n=7), and ankles (14%, n=5). Most common patient diagnoses were osteoarthritis (n=13, 36%), rheumatoid arthritis (n=10, 28%) and psoriatic arthropathy (n=6, 17%). The remaining patients had diagnostic labels including undifferentiated inflammatory arthritis or no formal diagnosis. Abnormalities suggesting active inflammation were seen in 42%. In 33% osteoarthritic changes were observed, erosions were seen in 5%. 20% scans were normal. US altered the management in 58% (n=21/36) of cases. These alterations to management included: drug added(n=5), drug stopped(n=3), dose increase (n=1), joint injection (n=3), intramuscular injection (n=2). Of the medications added, 3 were DMARDs, 1 was a biologic therapy and one case was not specified. The medications stopped were all DMARDS. US use in clinic prevented radiological investigation in 72% (26/36) of cases. These were radiology ultrasound (n=23) and MRI (n=3). Hands and wrists scans accounted for 86% of these. US altered the follow up in 56% (20/36) of cases. Of these, 40% (8/20) were reviewed earlier, and 40% (8/20) of patients were discharged based on ultrasound information. In 16/36 patients, US did not alter management. The average time taken to scan in clinic was 7 minutes per patient. The median time was 5 minutes, with the average skewed due to a few prolonged scans of multiple anatomical areas. Conclusion This audit has demonstrated that US use has impacted on our clinical practice. We identified patients to be seen earlier and altered management based on US findings. US use also prevented radiological investigations in 72% of cases. This has positive impacts on staffing, finances, radiology department capacity and patient convenience. Furthermore, we were able to discharge 40% of patients who otherwise would have been recalled. Overall, we believe this audit shows positive impacts of MSUS on patient care. Challenges include time pressures of scanning in clinic, time and cost implications of ultrasound training and the need to standardise and record ultrasound methods and findings consistently. Costs are offset by savings to radiology resources and increased discharges. We plan to expand ultrasound usage and train our colleagues to employ ultrasound for our patients. References [1] Moller I, Janta I, Backhaus M, et al. The 2017 EULAR standardised procedures for ultrasound imaging in rheumatology Annals of the Rheumatic Diseases 2017;76:1974-1979. [2] Alivernini S, et al. Tapering and discontinuation of TNF-alpha blockers without disease relapse using ultrasonography as a tool to identify patients with rheumatoid arthritis in clinical and histological remission. Arthritis Res Ther18:39. [3] Bawa S, Todd M, France J SAT0203 Optimization of biologic tapering using ultrasound in ra patients Annals of the Rheumatic Diseases 2018;77:962. Disclosure of Interests Andrew Wilkinson: None declared, Mike Reed Speakers bureau: Paid to speak at meeting by Novartis, Sara Else Consultant for: Contributed to advisory boards for: Abbvie, Norartis, Roche and Chungai Pharma., Speakers bureau: Paid to organise and chair meetings, and speak at educational events by following companies: BMS, Celegene, Grifols, Jansess, MSD, Novartis, UCB.

—Angler harvest and population characteristics of Smallmouth Bass Micropterus dolomieu were assessed through electrofishing surveys and tagging 3,027 fish with reward tags at six sites on five Ozark streams. Growth, exploitation, and mortality were estimated for each site. Predicted population responses to higher length limits were simulated using Fishery Analysis and Modeling Simulator software. Tag return rates ranged between 37% and 64%, angler release rates ranged between 63% and 94%, and annual exploitation ranged between 5% and 26%. The median time at-large for tags returned within one year of tagging ranged from 22 to 47 d of the tagging date. Growth rates were relatively slow, as mean time to reach 305 mm was 4.9 years and mean time to reach 381 mm was 7.8 years. Total annual mortality estimates ranged from 37% to 55%. Annual natural mortality estimates ranged from 13% to 33%. Predicted responses to higher length limits varied considerably by site because of differences in estimated rate functions. Although simulations predicted small increases (0.54–2.73 fish/100 recruits >381 mm) in the number of larger fish with the 381-mm length limit at five of six sites, predicted increases were substantial (17 fish/100 recruits >381 mm) and yield increased 6% at the Current River-Powder Mill site. Individuals in the Current River-Powder Mill site were not reaching their full growth potential due to growth overfishing, while simulations of the remaining five populations indicated no growth overfishing under current conditions and regulations. The combined effects of natural mortality and slow growth limited the effectiveness of higher length limits. Under most conditions, the statewide length limit of 305 mm was adequate to balance the desire of quality fishing and harvest opportunities on most Ozark streams. Our study indicates that fisheries at select stream reaches may be improved by higher length limits where exploitation is high, growth is adequate, and natural mortality is low.

Older adults as well as other vulnerable patients are particularly susceptible to the deleterious effects of polypharmacy and related inappropriate prescribing practices common in contemporary medicine. This chapter provides an overview of prescribing practices for the older adult, emphasizes selected classes of medications commonly encountered in physiatric practice, and outlines strategies for rational medication management. It describes the clinical appropriateness of specific medications and the interactions of multiple medications in the face of rapidly aging population. Rehabilitation physicians frequently manage complex patients with several comorbid conditions and on multiple medications. When caring for older patients, the changes in physiology and drug metabolism are important to keep in mind and consider in the context of each prescription, as well as comprehensive medication list assessments. The variety of commonly used pain medications ranges from topical analgesics to intravenous opioids.

© 2017 Elsevier Ltd Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63–1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06–3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [

Preoperative anemia in patients undergoing elective hip and knee arthroplasty is associated with increased postoperative morbidity and mortality, red blood cell (RBC) transfusion, and length of stay (LOS). The aim of this study was to assess the effect of optimizing hemoglobin (Hb) levels before elective primary hip and knee arthroplasty.This is a prospective comparative cohort study of patients who underwent elective hip and knee arthroplasty before (control) and after (intervention) the launch of a Hb optimization program. Patients with anemia followed an agreed upon algorithm dependent on their medical history and blood variables taken on listing for surgery. The primary outcome for this study was the requirement for allogenic RBC transfusion. Secondary outcomes included hospital LOS, admission to critical care, readmission, medical complications, incidence of thromboembolic events, mortality, and costs.A total of 1814 control patients operated between February 2012 and February 2013 were compared to 1622 intervention patients operated between February 2013 and May 2014. In the intervention group transfusion was significantly reduced (108 [6%] vs. 63 [4.1%], p = 0.005) as well as readmission (81 [4.5%] vs. 48 [2.3%], p= 0.020) and critical care admission (23 [1.3%] vs. 9 [0.5%], p = 0.030). LOS was significantly reduced from 3.9 days to 3.6 days (p = 0.017). The saving for the cohort was £263,000 ($342,000).Algorithm-led preoperative anemia screening and management in elective arthroplasty was associated with reduced RBC transfusion, readmission, critical care admission, LOS, and costs.

Surgical antibiotic prophylaxis remains a challenge, with a reported 30% of prescribing for this indication being inappropriate. The process of providing prophylaxis is a complex one—giving therapy only when indicated and using the right drug at the right dose at the right time and for the right duration (usually a single dose)—thus it is difficult to optimise. Additional challenges in this area include: lack of awareness of the impact of overuse of antimicrobials, anxiety about post-operative infections, suboptimal monitoring of infection rates, and the lack of an evidence base for prophylaxis in many procedures. This chapter discusses optimization of surgical prophylaxis and provides examples of successful quality improvement programmes that have overcome the challenges mentioned.

Introduction/Background Opioids are important for pain management during inpatient rehabilitation facility (IRF) stays, but are potentially overprescribed. Previously, we performed a prospective study utilizing an opioid reduction protocol to significantly reduce the opioid burden in patients admitted to an IRF. This study retrospectively analyzed patient pain satisfaction survey scores to determine the effect of the opioid reduction protocol on patient pain satisfaction. Material and method We included all patients admitted to an IRF at an academic institution during a two-month period in 2016 and calculated the Morphine Equivalent Dose (MED) for admission and discharge. We delivered informative lectures to prescribers regarding CDC recommendations, posted MED charts, calculated weekly MED scores and repeated MED calculations for all admissions and discharges over the following two months. Satisfaction surveys were sent to all patients upon discharge, with pain scored 0 to 5 (0-not controlled, 5-extremely well controlled). Results Surveys were obtained from 34 of 75 patients in the pre-intervention group and 41 of 87 in the post-intervention group. There was no statistical difference in pain satisfaction between the two groups (P = 0.38) with an average satisfaction of 3.68 and 3.32 for the pre and post-interventional groups, respectively. MED was decreased from admission to discharge in the pre-intervention group by an average of 17.79, a 44% decrease, while the post-interventional group MED decreased on average by 24.08, a 49% decrease. These findings are an important, since the primary study showed dramatic reductions in MED between pre and post intervention groups, reducing the percent of patients whose MED was greater than 50 by nearly half (23% to 12%). Conclusion This study demonstrates a method of tracking patient pain satisfaction whilst reducing opioid utilization in an IRF setting, and provides evidence that opioid weaning by tracking MED calculations does not negatively influence patient pain control satisfaction.

Item does not contain fulltext BACKGROUND: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture. METHODS: Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older. RESULTS: The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%). CONCLUSIONS: The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations. CLINICAL RELEVANCE: The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.