Overall Quality Performance of Long-Term Care Homes in Ontario.

In this paper, individually reported long-term care (LTC) quality indicators have been supplemented with the composite Qindex measure and applied to 614 homes in Ontario, Canada. This study (1) describes the overall quality performance of LTC homes across five years (2012-2017) and (2) determines if organizational factors impact quality performance. The results demonstrate significant, continuous sector-wide improvement in overall quality performance (as assessed by the Qindex) over time and significant differences in quality based on home size, operator size and ownership. This paper positions the Qindex, a global metric of quality, as a valuable tool for quality measurement and management in the LTC sector.

Implementation of Behavioural Supports Ontario (BSO): An Evaluation of Three Models of Care.

Behavioural Supports Ontario (BSO) was launched to enhance the healthcare services for Ontario's seniors, their caregivers and families living and coping with responsive behaviours associated with dementia and other neurological conditions. The implementation of the program varied across and within the local health integration networks (LHINs). By 2015, there were three BSO models operating within the long-term care (LTC) home sector: in-home BSO teams, a mobile team that serves multiple LTC homes within a sub-area of a LHIN and a LHIN-wide mobile team that provides services to all homes. A survey was undertaken to identify the differences among the BSO models of care in relation to care planning, collaboration and team building and home-level resident outcomes. We found that three years after implementation, LTC staff reported that the in-home BSO model out-performs the mobile team across all key measures. There is a role for mobile teams to provide expertise and sharing of best practices across the regions, but future policy and funding should focus on supporting the development of in-home BSO teams.

Hepatocellular carcinoma detection: diagnostic performance of a simulated abbreviated MRI protocol combining diffusion-weighted and T1-weighted imaging at the delayed phase post gadoxetic acid.

PURPOSE: The purpose of this study was to evaluate the diagnostic performance of a "simulated" abbreviated MRI (AMRI) protocol using diffusion-weighted imaging (DWI) and T1-weighted (T1w) imaging obtained at the hepatobiliary phase (HBP) post gadoxetic acid injection alone and in combination, compared to dynamic contrast-enhanced (CE)-T1w imaging for the detection of hepatocellular carcinoma (HCC). METHODS: This was an IRB approved HIPAA compliant retrospective single institution study including patients with liver disease who underwent gadoxetic acid-enhanced MRI for HCC diagnosis. Three independent observers assessed 2 sets of images (full CE-set and AMRI including DWI+T1w-HBP). Diagnostic performance of T1w-HBP and DWI alone and in combination was compared to that of CE-set. All imaging sets included unenhanced T1w and T2w sequences. A preliminary analysis was performed to assess cost savings of AMRI protocol compared to a full MRI study. RESULTS: 174 patients including 62 with 80 HCCs were assessed. Equivalent per-patient sensitivity and negative predictive value (NPV) were observed for DWI (85.5% and 92.2%, pooled data) and T1w-HBP (89.8% and 94.2%) (P = 0.1-0.7), while these were significantly lower for the full AMRI protocol (DWI+T1w-HBP, 80.6% and 80%, P = 0.02) when compared to CE-set (90.3% and 94.9%). Higher specificity and positive predictive value were observed for CE-set vs. AMRI (P = 0.02). The estimated cost reduction of AMRI versus full MRI ranged between 30.7 and 49.0%. CONCLUSION: AMRI using DWI and T1w-HBP has a clinically acceptable sensitivity and NPV for HCC detection. This could serve as the basis for a future study assessing AMRI for HCC screening and surveillance.

Canadian Stroke Best Practice Recommendations: Managing transitions of care following Stroke, Guidelines Update 2016.

Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. For patients, families and caregivers, this can be a difficult time of adjustment. The 2016 update of the Canadian Managing Transitions of Care following Stroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by clinicians who provide care to patients following stroke across a broad range of settings. The focus of these recommendations is on support, education and skills training for patients, families and caregivers; effective discharge planning; interprofessional communication; adaptation in resuming activities of daily living; and transition to long-term care for patients who are unable to return to or remain at home. Unlike other modules contained in the Canadian Stroke Best Practice Recommendations (such as acute inpatient care), many of these recommendations are based on consensus opinion, or evidence level C, highlighting the absence of conventional evidence (i.e. randomized controlled trials) in this area of stroke care. The quality of care transitions between stages and settings may have a direct impact on patient and family outcomes such as coping, readmissions and functional recovery. While many qualitative and non-controlled studies were reviewed, this gap in evidence combined with the fact that mortality from stoke is decreasing and more people are living with the effects of stroke, underscores the need to channel a portion of available research funds to recovery and adaptation following the acute phase of stroke.

Lymph nodes can accurately be measured on PET-CT for lymphoma staging/restaging without a concomitant contrast enhanced CT scan.

Dual imaging with both contrast enhanced CT scan and PET-CT is recommended for evaluation of lymphoma. We compared the performance in identification and size measurements of involved lymph nodes in FDG-avid lymphomas on the low dose non-contrast enhanced CT of a PET-CT scan with those on a diagnostic contrast enhanced CT scan. The size of FDG-avid lymph nodes was measured in both the short and long axis on both the low dose non-contrast CT of the PET-CT and the contrast enhanced CT by two independent readers. A total of 307 FGD avid lymph nodes were identified in 52 patients. There was no statistically significant differences in the measured size of the nodes on the non-contrast and contrast enhanced scans (p=0.21). Baseline staging and restaging of FDG-avid lymphomas can be performed with one test, PET-CT, without an accompanying contrast enhanced CT scan, with no effect on the measured nodal size.

IVIM Diffusion-weighted Imaging of the Liver at 3.0T: Comparison with 1.5T.

PURPOSE: To compare intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) of the liver between 1.5T and 3.0 T in terms of parameter quantification and inter-platform reproducibility. MATERIALS AND METHODS: In this IRB approved prospective study, 19 subjects (17 patients with chronic liver disease and 2 healthy volunteers) underwent two repeat scans at 1.5T and 3.0T. Each scan included IVIM DWI using 16 b values from 0 to 800 s/mm2. A single observer measured IVIM parameters for each platform and estimated signal to noise ratio (eSNR) at b0, 200, 400 and 800 s/mm2. Wilcoxon paired tests were used to compare liver eSNR and IVIM parameters. Inter-platform reproducibility was assessed by calculating within-subject coefficient of variation (CV) and Bland-Altman limits of agreement. An ice water phantom was used to test ADC variability between the two MRI systems. RESULTS: The mean invitro difference in ADC between the two platforms was 6.8%. eSNR was significantly higher at 3.0T for all selected b values (p=0.006-0.020), except for b0 (p=0.239). Liver IVIM parameters were significantly different between 1.5T and 3.0T (p=0.005-0.044), except for ADC (p=0.748). The inter-platform reproducibility of true diffusion coefficient (D) and ADC were good, with mean CV of 10.9% and 11.1%, respectively. Perfusion fraction (PF) and pseudodiffusion coefficient (D*) showed more limited inter-platform reproducibility (mean CV of 22.6% for PF and 46.9% for D*). CONCLUSION: Liver D and ADC values showed good reproducibility between 1.5T and 3.0T platforms; while there was more variability in PF, and large variability in D* parameters between the two platforms. These findings may have implications for drug trials assessing the role of IVIM DWI in tumor response and liver fibrosis.

Comparison of gadoxetic acid and gadopentetate dimeglumine-enhanced MRI for HCC detection: prospective crossover study at 3 T.

BACKGROUND: Gadoxetic acid and gadopentetate dimeglumine are gadolinium-based contrast agents (GBCAs) with an established role in HCC detection and characterization. PURPOSE: To compare gadopentetate dimeglumine and gadoxetic acid-enhanced magnetic resonance imaging (MRI) for image quality and hepatocellular carcinoma (HCC) detection/conspicuity. MATERIAL AND METHODS: In this IRB approved cross-over pilot prospective study, 12 patients (all men; mean age, 56 years) with chronic liver disease at risk of HCC underwent two repeat MRI examinations using gadopentetate dimeglumine and gadoxetic acid (mean interval between studies, 5 days). Two independent observers analyzed images for image quality and HCC detection/conspicuity. Per-lesion sensitivity, positive predictive value, quantitative enhancement, and lesion-to-liver contrast ratio were calculated for both contrast agents. RESULTS: There was no significant difference in image quality scores between both GBCAs (P = 0.3). A total of 20 HCCs were identified with reference standard in 12 patients (mean size 2.6 cm, range, 1.0-5.0 cm). Higher sensitivity was seen for observer 1 for gadoxetic acid-set in comparison with gadopentetate dimeglumine-set (sensitivity increased from 85.7% to 92.8%), while no difference was noted for observer 2 (sensitivity of 78.5%). Lesion conspicuity was significantly higher on hepatobiliary phase (HBP) images compared to arterial phase images with both GBCAs for both observers (P < 0.05). Lesion-to-liver contrast ratios were significantly higher for HBP compared to all dynamic phases for both agents (P < 0.05). CONCLUSION: Our initial experience suggests that gadoxetic acid-set was superior to gadopentetate dimeglumine-set in terms of HCC detection for one observer, with improved lesion conspicuity and liver-to-lesion contrast on HBP images.

Quantification of hepatic blood flow using a high-resolution phase-contrast MRI sequence with compressed sensing acceleration.

OBJECTIVE. The objective of our study was to evaluate the performance of a high-spatial-resolution 2D phase-contrast (PC) MRI technique accelerated with compressed sensing for portal vein (PV) and hepatic artery (HA) flow quantification in comparison with a standard PC MRI sequence. SUBJECTS AND METHODS. In this prospective study, two PC MRI sequences were compared, one with parallel imaging acceleration and low spatial resolution (generalized autocalibrating partial parallel acquisition [GRAPPA]) and one with compressed sensing acceleration and high spatial resolution (sparse). Seventy-six patients were assessed, including 37 patients with cirrhosis. Two observers evaluated PC image quality. Quantitative analyses yielded a mean velocity, flow, and vessel area for the PV and HA and an arterial fraction. The PC techniques were compared using the paired Wilcoxon test and Bland-Altman statistics. The sensitivity of the flow parameters to the severity of cirrhosis was also assessed. RESULTS. Vessel delineation was significantly improved using the PC sparse sequence (p < 0.034). For both in vitro and in vivo measurements, PC sparse yielded lower estimates for vessel area and flow, and larger differences between PC GRAPPA and PC sparse were observed in the HA. PV velocity and flow were significantly lower in patients with cirrhosis on both PC sparse (p < 0.001 and p = 0.042, respectively) and PC GRAPPA (p < 0.001 and p = 0.005, respectively). PV velocity correlated negatively with Child-Pugh class (r = -0.50, p < 0.001), whereas the arterial fraction measured with PC sparse was higher in patients with Child-Pugh class B or C disease than in those with Child-Pugh class A disease, with a trend toward significance (p = 0.055). CONCLUSION. A high-spatial-resolution highly accelerated compressed sensing technique (PC sparse) allows total hepatic blood flow measurements obtained in 1 breath-hold, provides improved delineation of the hepatic vessels compared with a standard PC MRI sequence (GRAPPA), and can potentially be used for the noninvasive assessment of liver cirrhosis.

Hepatocellular carcinoma: short-term reproducibility of apparent diffusion coefficient and intravoxel incoherent motion parameters at 3.0T.

PURPOSE: To evaluate short-term test-retest and interobserver reproducibility of IVIM (intravoxel incoherent motion) diffusion parameters and ADC (apparent diffusion coefficient) of hepatocellular carcinoma (HCC) and liver parenchyma at 3.0T. MATERIALS AND METHODS: In this prospective Institutional Review Board (IRB)-approved study, 11 patients were scanned twice using a free-breathing single-shot echo-planar-imaging, diffusion-weighted imaging (DWI) sequence using 4 b values (b = 0, 50, 500, 1000 s/mm(2)) and IVIM DWI using 16 b values (0-800 s/mm(2)) at 3.0T. IVIM parameters (D: true diffusion coefficient, D*: pseudodiffusion coefficient, PF: perfusion fraction) and ADC (using 4 b and 16 b) were calculated. Short-term test-retest and interobserver reproducibility of IVIM parameters and ADC were assessed by measuring correlation coefficient, coefficient of variation (CV), and Bland-Altman limits of agreements (BA-LA). RESULTS: Fifteen HCCs were assessed in 10 patients. Reproducibility of IVIM metrics in HCC was poor for D* and PF (mean CV 60.6% and 37.3%, BA-LA: -161.6% to 135.3% and -66.2% to 101.0%, for D* and PF, respectively), good for D and ADC (CV 19.7% and <16%, BA-LA -57.4% to 36.3% and -38.2 to 34.1%, for D and ADC, respectively). Interobserver reproducibility was on the same order of test-retest reproducibility except for PF in HCC. Reproducibility of diffusion parameters was better in liver parenchyma compared to HCC. CONCLUSION: Poor reproducibility of D*/PF and good reproducibility for D/ADC were observed in HCC and liver parenchyma. These findings may have implications for trials using DWI in HCC.

Simultaneous measurement of hepatic and splenic stiffness using MR elastography: preliminary experience.

PURPOSE: To compare MR elastography (MRE) using a single and a dual driver excitation for the quantification of hepatic and splenic stiffness (HS and SS), and to investigate the performance of HS and SS measured with single or dual driver excitation for the detection of liver cirrhosis in subjects with liver disease. PATIENTS AND METHODS: This prospective HIPAA compliant and IRB approved study involved 49 subjects who underwent MRE at 3.0T, comparing three different acquisition methods (single driver on the liver, single driver on the spleen and dual driver acoustic excitation). A Mann-Whitney test was used to assess changes in stiffness values. Bland-Altman analysis was used to compare single and dual driver configurations for each organ. Performance for detection of liver cirrhosis was assessed using ROC analysis. Pearson correlation was used to estimate the dependence of HS and SS on spleen size. RESULTS: There were 40 noncirrhotic and 9 cirrhotic patients. There was good agreement between stiffness values measured with a single or a dual driver (Bland-Altman limits of agreement -14.3 % to 18.9 % and -18.1 % to 29.7 %, CV 6.4 % and 9.4 %, for HS and SS. respectively). HS and SS were higher in subjects with liver cirrhosis (p < 0.001), with excellent detection performance (AUROC range 0.87-0.93). SS correlated strongly with spleen size (r = 0.69, p < 0.001), while HS showed weak correlation (r = 0.38, p = 0.006). CONCLUSION: Using a dual acoustic driver configuration, hepatic and splenic stiffness can be simultaneously estimated with good concordance with single driver measurement.

Template-based Intensity-Modulated Radiation Therapy: A Cost-effective Intensity-Modulated Radiation Therapy Planning Procedure for Prostate Cancer.

INTRODUCTION: Intensity-modulated radiation therapy (IMRT) has been widely accepted for the treatment of prostate cancer. In comparison with traditional three-dimensional conformal radiation therapy (3D-CRT), it improves local control while minimizing side effects. However, IMRT comes at a significantly higher cost. In this report, we describe the development of template-based IMRT (TB-IMRT) planning for prostate cancer that does not require additional resources above 3D-CRT. METHODS: Twenty patients previously treated using 3D-CRT were retrospectively planned using the TB-IMRT planning technique. Planning target volume coverage, dose to organs at risk, and resource usage were compared between 3D-CRT and TB-IMRT techniques. RESULTS: All 3D-CRT and TB-IMRT plans met the planning guidelines. TB-IMRT compared better than 3D-CRT in terms of the homogeneity index (0.039 ± 0.007 vs. 0.052 ± 0.008) and conformity index (0.866 ± 0.024 vs. 0.752 ± 0.054). TB-IMRT also provided better sparing of organs at risk. Planning times were significantly less for TB-IMRT (average 13.43 ± 2.18 minutes) compared with conventional plans (45.4 ± 17.0 minutes). Times required for patient-specific quality assurance were similar between TB-IMRT and 3D-CRT. CONCLUSIONS: The TB-IMRT technique for prostate allows for all the potential benefits of IMRT without any additional resources above conventional 3D-CRT.

Christie Gardens Apartments and Care Inc. and the Ontario Long Term Care Association: long term care recruitment and retention project.

In 2008, the Ontario Long Term Care Association was awarded funding from HealthForceOntario to assist with its nursing recruitment strategy based on research it had initiated in 2007. The research goal was to understand the career motivations and perceptions of students enrolled in registered nursing (RN) and registered practical nursing (RPN) programs in Ontario to develop and test a message to support recruitment.

Getting a bigger bang for your buck: a collaborative approach to enhancing dementia education planning in long-term care homes.

A collaborative of Ontario-based long-term care associations, researchers, clinicians and educators representing various education initiatives related to dementia care and challenging behaviours used existing research evidence on adult learning principles, knowledge transfer and performance improvement to develop an evidence-based approach to support practice change and improvement in long-term care. The collaborative was led by the two provincial long-term care associations with no external funds to support its activities. This effort illustrates how people with common challenges, visions and goals can work together to share their intellectual and physical resources to address pervasive problems.

Space optimizing methods for laboratory rearing of Aedes aegypti.

Methods used to rear Aedes aegypti larvae were modified to maximize production under limited space requirements. Traditionally, 150 larvae were reared in 25 x 42 x 5-cm pans containing 1 liter of water. It was noticed, however, that the larvae congregated during development and did not utilize the entire rearing environment. Two new rearing methods were investigated to partition larval populations within the rearing space and thus increase rearing efficiency. The 2 methods separated groups of 50 larvae into each of either six 500-ml cylindrical cups or twelve 400-ml rectangular bins, each containing approximately 450 or 400 ml of water, respectively, and occupying approximately the same amount of shelf space as the 25 x 42 cm pans. The cup and bin protocols multiplied rearing potential by 2 and 4, respectively, under the same space constraints. A preliminary experiment was conducted to compare larval development and adult body size (using wing length as a surrogate) of mosquitoes reared in partitioned containers with those reared in the traditional open pan method. Results indicated that the pan and bin partition methods produced adults that were significantly larger than pan-reared adults, yet develop to 4th stage at a significantly slower and less synchronized rate.

Culture-based literacy and Aboriginal health.

This is a summary report of the Aboriginal content of the Language and Culture theme at the Canadian Public Health Association's Second Canadian Conference on Literacy and Health. Our key premise is that Indigenous conceptualizations of literacy need to build on Indigenous understandings and perspectives. We support this premise through a review of the relevant literature in the disciplines of Aboriginal literacy, Indigenous education, health literacy, health promotion, and knowledge translation and our synthesis of the presentations, workshops, and discussions at the meeting. Key emergent themes include: the unique and culturally determined ways in which Aboriginal peoples and their languages conceptualize learning, education, and health; and the recognition that self-determination of language and learning are human rights. Aboriginal concepts of and approaches to literacy naturally link to and overlap with Aboriginal concepts of and approaches to health. The paper includes an overview of gaps in the field and an example of the way that research and practice can be brought together in the context of one First Nations community.

Quantification of uric acid, xanthine and hypoxanthine in human serum by HPLC for pharmacodynamic studies.

A simple HPLC method was developed and validated for the determination of uric acid (UA), xanthine (X) and hypoxanthine (HX) concentrations in human serum to support pharmacodynamic (PD) studies of a novel xanthine oxidase inhibitor during its clinical development. Serum proteins were removed by ultrafiltration. The hydrophilic analytes and the I.S. were eluted by 100% aqueous phosphate buffer mobile phase. The hydrophobic matrix components (late peaks) were eluted with a step gradient of a higher organic mobile phase. Validation on linearity, sensitivity, precision, accuracy, stability, and robustness of the method for PD biomarkers (UA, X, and HX) was carried out in a similar manner to that for pharmacokinetic (PK) data where applicable. Issues of selectivity for endogenous biomarker analytes and individual concentration variations were addressed during method validation. Standards were prepared in analyte-free phosphate buffer. Quality control samples were prepared in control serum from individuals not dosed with the xanthine oxidase inhibitor. The method was simple and robust with good accuracy and precision for the measurement of serum UA, X, and HX concentrations.