Defining practice variation and exploring influencing factors on needs assessment in home care nursing: A Delphi study.

AIM: To describe a Delphi study regarding practice variation in needs assessment by Dutch home care nurses, to define practice variation in home care nursing and explore which factors may have a role in this needs assessment. DESIGN: A Delphi study was conducted with the participation of home care representatives. METHOD: A Delphi questionnaire was developed, preceded by literature research and an expert meeting. The Delphi study took place between December 2020 and February 2021. The goal was to achieve a consensus level of at least 70%. RESULTS: After three rounds, 32 experts reached a consensus about definitions regarding variation in needs assessment, warranted and unwarranted variation. In total, 59 factors were determined related to (1) the client and health, (2) the clients' context, (3) nurses and (4) the nurses' context. Thirty-four factors scored warranted of influence and 18 (of 34) were client related. Most of the factors that scored unwarranted influencing needs assessment (17 of 26) were related to the home care nurses' context. CONCLUSION: Having a consensus about the definition of practice variation in needs assessment and possible influencing factors support the professionals to discuss and improve the unity and quality of their decision-making process in home care. This may contribute to more righteous care for clients in need of home care. IMPACT: Since 2015, home care nurses in the Netherlands are responsible for determining the amount, type and duration of care for clients in need of home care. This so-called needs assessment legitimizes the payment by health insurers. Signals of practice variation in needs assessment are heard in home care field. Although practice variation may be justified, it can lead to over or underuse of care, which may affect clients' outcomes. If we can identify influencing factors and find patterns that contribute to practice variation, we might gain a better understanding of the process and improve home care. PATIENT OR PUBLIC CONTRIBUTION: In this study, there was no patient or public involvement. Client representatives were included in this research as experts in the home care field, and they participated in three rounds of the Delphi study. They contributed by sharing their expert opinion on the definitions presented and the factors possibly influencing needs assessment.

Measurement of glucose metabolism in the occipital lobe and frontal cortex after oral administration of [1-13C]glucose at 9.4 T.

For the first time, labeling effects after oral intake of [1-13C]glucose are observed in the human brain with pure 1H detection at 9.4 T. Spectral time series were acquired using a short-TE 1H MRS MC-semiLASER (Metabolite Cycling semi Localization by Adiabatic SElective Refocusing) sequence in two voxels of 5.4 mL in the frontal cortex and the occipital lobe. High-quality time-courses of [4-13C]glutamate, [4-13C]glutamine, [3-13C]glutamate + glutamine, [2-13C] glutamate+glutamine and [3-13C]aspartate for individual volunteers and additionally, group-averaged time-courses of labeled and non-labeled brain glucose could be obtained. Using a one-compartment model, mean metabolic rates were calculated for each voxel position: The mean rate of the TCA-cycle (Vtca) value was determined to be 1.36 and 0.93 µmol min-1 g-1, the mean rate of glutamine synthesis (Vgln) was calculated to be 0.23 and 0.45 µmol min-1 g-1, the mean exchange rate between cytosolic amino acids and mitochondrial Krebs cycle intermediates (Vx) rate was found to be 0.57 and 1.21 µmol min-1 g-1 for the occipital lobe and the frontal cortex, respectively. These values were in agreement with previously reported data. Altogether, it can be shown that this most simple technique combining oral administration of [1-13C]Glc with pure 1H MRS acquisition is suitable to measure metabolic rates.

Phosphorus transversal relaxation times and metabolite concentrations in the human brain at 9.4 T.

A method to estimate phosphorus (31 P) transversal relaxation times (T2 s) of coupled spin systems is demonstrated. Additionally, intracellular and extracellular pH and relaxation-corrected metabolite concentrations are reported. Echo time (TE) series of 31 P metabolite spectra were acquired using stimulated echo acquisition mode (STEAM) localization. Spectra were fitted using LCModel with accurately modeled Versatile Simulation, Pulses and Analysis (VeSPA) basis sets accounting for J-evolution of the coupled spin systems. T2 s were estimated by fitting a single exponential two-parameter model across the TE series. Fitted inorganic phosphate frequencies were used to calculate pH, and estimated relaxation times were used to determine the relaxation-corrected brain metabolite concentrations on an assumption of 3 mM γ-ATP. The method was demonstrated in healthy human brain at a field strength of 9.4 T. T2 times of ATP and nicotinamide adenine dinucleotide (NAD) were shortest between 8 and 20 ms, followed by T2 s of inorganic phosphate between 25 and 50 ms, and phosphocreatine with a T2 of 100 ms. Phosphomonoesters and phosphodiesters had the longest T2 s of about 130 ms. The measured T2 s are comparable with literature values and fit in a decreasing trend with increasing field strengths. Calculated pHs and metabolite concentrations are also comparable with literature values.

Simultaneous detection of metabolite concentration changes, water BOLD signal and pH changes during visual stimulation in the human brain at 9.4T.

This study presents a method to directly link metabolite concentration changes and BOLD response in the human brain during visual stimulation by measuring the water and metabolite signals simultaneously. Therefore, the metabolite-cycling (MC) non-water suppressed semiLASER localization technique was optimized for functional 1H MRS in the human brain at 9.4 T. Data of 13 volunteers were acquired during a 26:40 min visual stimulation block-design paradigm. Activation-induced BOLD signal was observed in the MC water signal as well as in the NAA-CH3 and tCr-CH3 singlets. During stimulation, glutamate concentration increased 2.3 ± 2.0% to a new steady-state, while a continuous increase over the whole stimulation period could be observed in lactate with a mean increase of 35.6 ± 23.1%. These increases of Lac and Glu during brain activation confirm previous findings reported in literature. A positive correlation of the MC water BOLD signal with glutamate and lactate concentration changes was found. In addition, a pH decrease calculated from a change in the ratio of PCr to Cr was observed during brain activation, particularly at the onset of the stimulation.

ProFit-1D-A 1D fitting software and open-source validation data sets.

PURPOSE: Accurate and precise MRS fitting is crucial for metabolite concentration quantification of 1 H-MRS spectra. LCModel, a spectral fitting software, has shown to have certain limitations to perform advanced spectral fitting by previous literature. Herein, we propose an open-source spectral fitting algorithm with adaptive spectral baseline determination and more complex cost functions. THEORY: The MRS spectra are characterized by several parameters, which reflect the environment of the contributing metabolites, properties of the acquisition sequence, or additional disturbances. Fitting parameters should accurately describe these parameters. Baselines are also a major contributor to MRS spectra, in which smoothness of the spline baselines used for fitting can be adjusted based on the properties of the spectra. Three different cost functions used for the minimization problem were also investigated. METHODS: The newly developed ProFit-1D fitting algorithm is systematically evaluated for simulations of several types of possible in vivo parameter variations. Although accuracy and precision are tested with simulated spectra, spectra measured in vivo at 9.4 T are used for testing precision using subsets of averages. ProFit-1D fitting results are also compared with LCModel. RESULTS: Both ProFit-1D and LCModel fitted the spectra well with induced parameter and baseline variations. ProFit-1D proved to be more accurate than LCModel for simulated spectra. However, LCModel showed a somewhat increased precision for some spectral simulations and for in vivo data. CONCLUSION: The open-source ProFit-1D fitting algorithm demonstrated high accuracy while maintaining precise metabolite concentration quantification. Finally, through the newly proposed cost functions, new ways to improve fitting were shown.

3D 31 P MRSI of the human brain at 9.4 Tesla: Optimization and quantitative analysis of metabolic images.

PURPOSE: To present 31 P whole brain MRSI with a high spatial resolution to probe quantitative tissue analysis of 31 P MRSI at an ultrahigh field strength of 9.4 Tesla. METHODS: The study protocol included a 31 P MRSI measurement with an effective resolution of 2.47 mL. For SNR optimization, the nuclear Overhauser enhancement at 9.4 Tesla was investigated. A sensitivity correction was achieved by applying a low rank approximation of the γ-adenosine triphosphate signal. Group analysis and regression on individual volunteers were performed to investigate quantitative concentration differences between different tissue types. RESULTS: Differences in gray and white matter tissue 31 P concentrations could be investigated for 12 different 31 P resonances. In addition, the first highly resolved quantitative MRSI images measured at B0 = 9.4 Tesla of 31 P detectable metabolites with high SNR could be presented. CONCLUSION: With an ultrahigh field strength B0 = 9.4 Tesla, 31 P MRSI moves further toward quantitative metabolic imaging, and subtle differences in concentrations between different tissue types can be detected.

Comparison of four 31P single-voxel MRS sequences in the human brain at 9.4 T.

PURPOSE: In this study, different single-voxel localization sequences were implemented and systematically compared for the first time for phosphorous MRS (31 P-MRS) in the human brain at 9.4 T. METHODS: Two multishot sequences, image-selected in vivo spectroscopy (ISIS) and a conventional slice-selective excitation combined with localization by adiabatic selective refocusing (semiLASER) variant of the spin-echo full intensity-acquired localized spectroscopy (SPECIAL-semiLASER), and two single-shot sequences, semiLASER and stimulated echo acquisition mode (STEAM), were implemented and optimized for 31 P-MRS in the human brain at 9.4 T. Pulses and coil setup were optimized, localization accuracy was tested in phantom experiments, and absolute SNR of the sequences was compared in vivo. The SNR per unit time (SNR/t) was derived and compared for all four sequences and verified experimentally for ISIS in two different voxel sizes (3 × 3 × 3 cm3 , 5 × 5 × 5 cm3 , 10-minute measurement time). Metabolite signals obtained with ISIS were quantified. The possible spectral quality in vivo acquired in clinically feasible time (3:30 minutes, 3 × 3 × 3 cm3 ) was explored for two different coil setups. RESULTS: All evaluated sequences performed with good localization accuracy in phantom experiments and provided well-resolved spectra in vivo. However, ISIS has the lowest chemical shift displacement error, the best localization accuracy, the highest SNR/t for most metabolites, provides metabolite concentrations comparable to literature values, and is the only one of the sequences that allows for the detection of the whole 31 P spectrum, including ß-adenosine triphosphate, with the used setup. The SNR/t of STEAM is comparable to the SNR/t of ISIS. The semiLASER and SPECIAL-semiLASER sequences provide good results for metabolites with long T2 . CONCLUSION: At 9.4 T, high-quality single-voxel localized 31 P-MRS can be performed in the human brain with different localization methods, each with inherent characteristics suitable for different research issues.

Double-tuned 31 P/1 H human head array with high performance at both frequencies for spectroscopic imaging at 9.4T.

PURPOSE: To develop a robust design of a human head double-tuned 31 P/1 H array, which provides good performance at both 31 P and 1 H frequencies for MR spectroscopic imaging at 9.4T. METHODS: Increasing the number of surface loops in a human head array improves the peripheral signal-to-noise ratio (SNR), while the central SNR doesn't substantially change. High peripheral SNR can contaminate MR spectroscopic imaging data at both 1 H and 31 P frequency. To minimize this effect, we limited the number of elements in the 31 P array to 10, i.e., 8 transceiver surface loops circumscribing the head and 2 receive "vertical" loops placed at the superior location. The 1 H-portion of the array also consists of 10 elements, i.e., 8 transceiver surface loops circumscribing the head and 2 transceiver "vertical" loops at the superior location of the head. Both the 31 P array and 1 H array are placed in a single layer at the same distance to the head, which provides high loading and, thus, a good performance for both arrays. RESULTS: Transmit efficiency of the 1 H-portion of the double-tuned array was very similar to that of the single-tuned arrays of similar size. Also, addition of the cross-loops substantially improved the brain coverage. CONCLUSION: We developed a novel 31 P/1 H double-tuned array for MR spectroscopic imaging of a human brain at 9.4T. Placing both 31 P and 1 H loops in a single layer provides for high transmit efficiency at both frequencies without compromising SNR near the brain center at the 31 P-frequency. Addition of the cross-loops at the superior location improves the brain coverage.