All hands on deck: The multidisciplinary rehabilitation assessment and management of hand function in persons with neuromuscular disorders.

Hand function is important in every aspect of our lives. Across a wide range of neuromuscular disorders-inherited ataxias, motor neuron diseases, polyneuropathies, and myopathies-people can experience losses in hand strength, tone, movement, dexterity, joint range, and sensation. Such changes can adversely affect function and independence in daily activities, reducing participation and quality of life. People with neuromuscular disorders (pwNMD) known to involve the hand should be assessed at regular intervals for changes both clinically and using impairment, performance, function, and patient-reported outcome measures as appropriate. A patient-centered approach to management is recommended, with clinicians partnering with the individual, their caregivers and the interprofessional teams to create personalized solutions that can overcome barriers to participation and best meet the goals of individuals affected by neuromuscular disorders. Management strategies should be multifaceted, and may include exercise, orthoses, assistive devices, technological solutions, environmental or task adaptations, medications, and/or surgery. Exercise recommendations and orthoses should be individualized and evolve based on disease progression, impairments, and functional limitations. While medications and surgery have a small role for specific clinical situations, there is a plethora of assistive and technological solutions to assist with basic and instrumental activities of daily living, work/education, and leisure for pwNMD with reduced hand function. In addition, clinicians should advocate for appropriate accommodations for reduced hand function at work/school, and the development of and adherence to legislation supporting accessibility and inclusion.

Musculoskeletal mimics of lumbosacral radiculopathy.

Electrodiagnostic evaluations are commonly requested for patients with suspected radiculopathy. Understanding lower extremity musculoskeletal conditions is essential for electrodiagnostic medicine specialists, as musculoskeletal disorders often mimic or coexist with radiculopathy. This review delineates radicular pain from other types originating from the lumbosacral spine and describes musculoskeletal conditions frequently mimicking radiculopathy, such as those that cause radiating pain and sensorimotor dysfunction. In clinical evaluation, a history of pain radiating along a specific dermatomal territory with associated sensory disturbance suggests radiculopathy. Physical examination findings consistent with radiculopathy include myotomal weakness, depressed or absent muscle stretch reflexes, focal atrophy along a discrete nerve root territory, and potentially positive dural tension maneuvers like the straight leg raise. However, electrodiagnostic medicine specialists must be knowledgeable of musculoskeletal mimics, which may manifest as incomplete radiation within or beyond a dermatomal territory, non-radiating pain, tenderness, and give-way weakness, in the context of a normal neurological examination. A systematic approach to musculoskeletal examination is vital, and this review focuses on high-yield physical examination maneuvers and diagnostic investigations to differentiate between musculoskeletal conditions and radiculopathy. This approach ensures accurate diagnoses, promotes resource stewardship, enhances patient satisfaction, and optimizes care delivery. Musculoskeletal conditions resembling L1 to S4 radiculopathy are reviewed, emphasizing their distinctive features in history, physical examination, and diagnostic investigation. Among the more than 30 musculoskeletal disorders reviewed are hip and knee osteoarthritis, lumbar facet syndrome, myofascial pain syndrome, greater trochanteric pain syndrome, and plantar fasciitis.

Defoliation, trampling and nutrient return differentially influence grassland productivity by modulating trait-dependent plant community composition: insights from a simulated grazing experiment.

Ungulate grazing involves multiple components, including defoliation, dung and urine return, and trampling, which supply offsetting or synergistic effects on plant community composition and productivity (ANPP), but these effects have not been fully studied. Plant functional traits may reflect the response of plants to disturbance and their impact on ecosystem functions. Species turnover and intraspecific trait variation (ITV) are important drivers of community trait composition. We conducted a simulated grazing experiment in a steppe grassland in northern China to examine the effects of defoliation, dung and urine return, and trampling on community-weighted mean (CWM), functional diversity (FD) and ANPP, and to disentangle the roles of species turnover and ITV in driving these changes. We found that defoliation had a dominant effect on CWMs and FDs of all four traits through species turnover and ITV, respectively, resulting in a convergence of traits towards as more resource-acquisitive strategy. Dung-urine return resulted in more resource-acquisitive community traits mainly through ITV, whereas there were no significant effects on FDs except for leaf C/N. Trampling increased CWM of leaf dry matter content primarily driven by ITV, and had no significant effect on FDs. Furthermore, our simulated grazing positively affected ANPP, primarily due to nutrient additions from dung and urine, and ITV largely explained the variation in ANPP. These findings highlight the multifaceted effects of grazing components on community structure and ANPP, and the significance of ITV in shaping grassland plant communities and productivity.

Adverse events associated with the delivery of telerehabilitation: A scoping review protocol.

OBJECTIVE: This scoping review aims to map the existing research on adverse events during the delivery of telerehabilitation. INTRODUCTION: Telerehabilitation, a subset of telemedicine, has gained traction during the COVID-19 pandemic as a means to deliver rehabilitation services remotely. However, there exists a research gap as there has yet to be any scoping review, systematic review, or meta-analysis published to identify and summarize the current primary research on adverse events related to telerehabilitation as a whole. It is important to understand how adverse events, such as falls during physiotherapy or aspiration pneumonia during speech language pathology sessions, are associated with telerehabilitation delivery. This will help to identify key limitations for optimizing telerehabilitation delivery by allowing for the development of key risk-mitigation measures and quality indicators. It can also help improve the uptake of telerehabilitation among clinicians and patients. This review aims to fill this research gap by conducting a search of published literature on adverse events in telerehabilitation. Anticipated key findings of this scoping review include identifying the characteristics and frequencies of adverse events during telerehabilitation, the patient populations and types of telerehabilitation associated with the most adverse events, and the quality of reporting of adverse events. METHODS: The review follows the Joanna Briggs Institute (JBI) methodological framework and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. The review protocol has been registered and published on Open Science Framework. A comprehensive search strategy was implemented across multiple databases (MEDLINE ALL, EMBASE, APA PsycINFO, CENTRAL, and CINAHL). All stages (screening, extraction, and synthesis) will be conducted in duplicate and independently, with data extraction following the TIDieR framework, along with authors, year of publication (before or after COVID), population and sample size, and specific mode/s of telerehabilitation delivery. For synthesis, data will be summarized quantitatively using numerical counts and qualitatively via content analysis. The data will be grouped by intervention type and by type of adverse event. INCLUSION CRITERIA: This scoping review will include qualitative and quantitative studies published between 2013 and 2023, written in English, and conducted in any geographic area. All modes of telerehabilitation delivery (asynchronous, synchronous, or hybrid) will be included. Systematic reviews, meta-analyses, commentaries, protocols, opinion pieces, conference abstracts, and case series with fewer than five participants will be excluded.

Serum Ferritin and Non-alcoholic Fatty Liver Disease: A Meta-analysis and Systematic Review.

BACKGROUND/AIMS: Previous studies have shown that hyperferritinemia is a common phenomenon in non-alcoholic fatty liver dis- ease patients. We aim to further explore the relationship between serum ferritin levels and non-alcoholic fatty liver disease using a meta-analysis. MATERIALS AND METHODS: Four Library databases were electronically searched from inception until December 2021 to find prospective cohort or case-control studies examining the relationship between serum ferritin levels and non-alcoholic fatty liver disease, and all kinds of literature were screened according to the inclusion and exclusion criteria. The odds ratio and other related data were extracted, and a meta-analysis was performed. RESULTS: Eleven studies examining the relationship between serum ferritin levels and non-alcoholic fatty liver disease were included. The serum ferritin levels in the non-alcoholic fatty liver disease group were significantly higher than those without non-alcoholic fatty liver disease group (1.54 ng/mL, 95% CI: 0.85-2.23, P < .001). Serum ferritin levels were significantly associated with the risk of non-alcoholic fatty liver disease in both men and women (odds ratio = 2.36, 95% CI: 1.41-3.93, P = .001 and odds ratio = 2.93, 95% CI: 1.83-4.69, P < .001, respectively), and after adjusting for the parameters, the relationships were still shown to be significant in men and women (odds ratio = 2.24, 95% CI: 1.64-3.05, P < .001 and odds ratio = 3.30, 95% CI: 2.13-5.11, P < .001, respectively). CONCLUSION: Serum ferritin levels were higher in patients with non-alcoholic fatty liver disease than in those without non-alcoholic fatty liver disease and were associated with the risk of non-alcoholic fatty liver disease in both men and women.

Physician engagement in organisational patient safety through the implementation of a Medical Safety Huddle initiative: a qualitative study.

BACKGROUND: Efforts to increase physician engagement in quality and safety are most often approached from an organisational or administrative perspective. Given hospital-based physicians' strong professional identification, physician-led strategies may offer a novel strategic approach to enhancing physician engagement. It remains unclear what role medical leadership can play in leading programmes to enhance physician engagement. In this study, we explore physicians' experience of participating in a Medical Safety Huddle initiative and how participation influences engagement with organisational quality and safety efforts. METHODS: We conducted a qualitative study of the Medical Safety Huddle initiative implemented across six sites. The initiative consisted of short, physician focused and led, weekly meetings aimed at reviewing, anticipating and addressing patient safety issues. We conducted 29 semistructured interviews with leaders and participants. We applied an interpretive thematic analysis to the data using self-determination theory as an analytic lens. RESULTS: The results of the thematic analysis are organised in two themes, (1) relatedness and meaningfulness, and (2) progress and autonomy, representing two forms of intrinsic motivation for engagement that we found were leveraged through participation in the initiative. First, participation enabled a sense of community and a 'safe space' in which professionally relevant safety issues are discussed. Second, participation in the initiative created a growing sense of ability to have input in one's work environment. However, limited collaboration with other professional groups around patient safety and the ability to consistently address reported concerns highlights the need for leadership and organisational support for physician engagement. CONCLUSION: The Medical Safety Huddle initiative supports physician engagement in quality and safety through intrinsic motivation. However, the huddles' implementation must align with the organisation's multipronged patient safety agenda to support multidisciplinary collaborative quality and safety efforts and leaders must ensure mechanisms to consistently address reported safety concerns for sustained physician engagement.

Psychosocial Factors Associated with Prolonged Length of Stay in Acquired Brain Injury Rehabilitation: A Retrospective Cohort Study.

OBJECTIVE: In a climate of rising healthcare costs and increasing pressure to reduce inpatient length of stay, hospitals must balance their role as care providers with that as resource stewards. There is a need to understand what factors are associated with patients staying beyond rehabilitation length of stay targets. The aim of this study was to determine psychosocial patient factors that are identifiable on admission that influence length of stay targets in acquired brain injury rehabilitation. METHODS: A retrospective case series of 167 inpatients with acquired brain injury was conducted at an urban, academic rehabilitation hospital. A total of 29 factors were used for data analysis. Logistic and multiple linear regression analysis was utilized to determine if any patient factors were associated with patients exceeding their length of stay targets. RESULTS: Premorbid communal living status (e.g. group home) was associated with an odds ratio of 14.67 of exceeding length of stay target. Patients who did not drive prior to their admission had an odds ratio of 2.63 of exceeding their length of stay target. CONCLUSION: Premorbid communal living and premorbid non-driving status are predictors of patients with acquired brain injuries exceeding target rehabilitation length of stay. These findings may help acquired brain injury rehabilitation programmes plan for the needs of and advocate for patients.

Clinicians' Experiences of Implementing a Telerehabilitation Toolkit During the COVID-19 Pandemic: Qualitative Descriptive Study.

BACKGROUND: Although the COVID-19 pandemic resulted in a rapid implementation and scale-up of telehealth for patients in need of rehabilitation, an overall slower scaling up to telerehabilitation has been documented. OBJECTIVE: The purpose of this study was to understand experiences of implementing telerehabilitation during the COVID-19 pandemic as well as using the Toronto Rehab Telerehab Toolkit from the perspective of rehabilitation professionals across Canada and internationally. METHODS: The study adopted a qualitative descriptive approach that consisted of telephone- or videoconference-supported interviews and focus groups. Participants included rehabilitation providers as well as health care leaders who had used the Toronto Rehab Telerehab Toolkit. Each participant took part in a semi-structured interview or focus group, lasting approximately 30-40 minutes. Thematic analysis was used to understand the barriers and enablers of providing telerehabilitation and implementing the Toronto Rehab Telerehab Toolkit. Three members of the research team independently analyzed a set of the same transcripts and met after each set to discuss their analysis. RESULTS: A total of 22 participants participated, and 7 interviews and 4 focus groups were included. The data of participants were collected from both Canadian (Alberta, New Brunswick, and Ontario) and international sites (Australia, Greece, and South Korea). A total of 11 sites were represented, 5 of which focused on neurological rehabilitation. Participants included health care providers (ie, physicians, occupational therapists, physical therapists, speech language pathologists, and social workers), managers and system leaders, as well as research and education professionals. Overall, 4 themes were identified including (1) implementation considerations for telerehabilitation, encompassing 2 subthemes of "infrastructure, equipment, and space" and "leadership and organizational support"; (2) innovations developed as a result of telerehabilitation; (3) the toolkit as a catalyst for implementing telerehabilitation; and (4) recommendations for improving the toolkit. CONCLUSIONS: Findings from this qualitative study confirm some of the previously identified experiences with implementing telerehabilitation, but from the perspective of Canadian and international rehabilitation providers and leaders. These findings include the importance of adequate infrastructure, equipment, and space; the key role of organizational or leadership support in adopting telerehabilitation; and availing resources to implement it. Importantly, participants in our study described the toolkit as an important resource to broker networking opportunities and highlighted the need to pivot to telerehabilitation, especially early in the pandemic. Findings from this study will be used to improve the next iteration of the toolkit (Toolkit 2.0) to promote safe, accessible, and effective telerehabilitation to those patients in need in the future.

In defence of falling: the onomastics and ethics of "therapeutic" falls in rehabilitation.

Aim: Despite efforts towards a more just culture, rehabilitation providers still experience shame and trauma when their patients fall. This paper proposes a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls in rehab are not seen as something to be avoided at all costs, but rather as part of the recovery journey for some patients.Methods: Patients who understand and are willing to take on the risks of falling are more likely to collaborate with their care team to practice higher-risk activities, such as walking to the bathroom independently at night, as part of their recovery. If a fall takes place in this context, we argue that it should be considered a "therapeutic" fall.Results: This paper details some of the clinical and ethical approaches to supporting a care environment where values-and potential conflicts-about the benefits and challenges of risk-taking are recognized. An expanded concept of a therapeutic fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Conclusion: The goal of this work is to offer rehabilitation patients greater opportunities to make autonomous decisions about their mobility, and lay the groundwork for a more successful transition home.IMPLICATIONS FOR REHABILITATIONDespite best efforts, patients are often less active than they or their rehabilitation team might wish them to be.An expanded concept of a "therapeutic" fall may help patients and providers take a more balanced and nuanced approach to promoting safety while maximising independence.Rehabilitation is the right environment to support shared decision-making about risk that better prepares patients and families for the often challenging transition back to community living.This works represents a shift in philosophy in how we classify, communicate and learn from falls, and joins the growing literature in which falls are not something to be avoided at all costs, but can instead be part of the journey to recovery.

Protocol for a stepped wedge cluster randomized quality improvement project to evaluate the impact of medical safety huddles on patient safety.

Introduction: Physician engagement is crucial for furthering patient safety and quality improvement within healthcare organizations. Medical Safety Huddles, which are physician-specific huddles, is a novel way to engage physicians with patient safety and may reduce adverse events experienced by patients. We plan to conduct a multi-center quality improvement (QI) initiative to implement and evaluate Medical Safety Huddles. The primary objective is to determine the impact of the huddles on adverse events experienced by patients. Secondary objectives include assessing the impact of the huddles on patient safety culture and physician engagement, and a process evaluation to assess the fidelity of implementation. Methods: This stepped wedge cluster randomized study will be conducted at four academic inpatient hospitals over 19 months. Each site will adapt Medical Safety Huddles to its own practice context to best engage physicians. We will review randomly selected patient charts for adverse events. Generalized linear mixed effects regression will be used to estimate the overall intervention effect on adverse events. Process measures such as physician attendance rates and number of safety issues raised per huddle will be tracked to monitor implementation adherence. Conclusion: Medical Safety Huddles may help healthcare organizations and medical leaders to better engage physicians with patient safety. The project results will assess the fidelity of implementation and determine the impact of Medical Safety Huddles on patient safety.

The incidence and nature of adverse events in rehabilitation inpatients with acquired brain injuries.

BACKGROUND: Patient safety is important in all healthcare settings. Few studies have examined the state of patient safety in rehabilitation and none have examined patient safety in the setting of acquired brain injury (ABI) rehabilitation. OBJECTIVES: To determine the incidence, most common types, and severities of adverse events among inpatients undergoing ABI rehabilitation. DESIGN: Retrospective case series descriptive study. SETTING: The inpatient ABI rehabilitation program at an academic, tertiary rehabilitation hospital in Canada. PARTICIPANTS: One hundred eight consecutive inpatients with acquired brain injuries. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Patient charts and incident reports from the hospital's voluntary reporting system were reviewed by three board-certified physiatrists to determine the incidence, type, severity and preventability of adverse events. Adverse events were identified and classified for severity and type using the World Health Organization (WHO) International Classification for Patient Safety. Preventability was rated on a six-point Likert scale. RESULTS: During the study period, the incidence of adverse events was 17.42 ± 3.86 per 1000 patient days. Adverse events affected 52.8% of patients. Most adverse events identified were mild in severity (81.6%) and the rest were of moderate severity. The two most common types of adverse events were (1) patient incidents (50%) such as falls, pressure ulcers and skin tears and (2) patient behaviors such as missing patient, assault, or sexual behaviors (14.5%). Of the 76 adverse events identified in the study, 44.8% were preventable. The hospital's voluntary reporting system did not capture 57.9% of the adverse events identified. CONCLUSIONS: Future efforts to improve patient safety in ABI rehabilitation should focus on reducing falls, skin injuries and behaviors, and removing barriers to voluntary incident reporting. Detection of adverse events through chart reviews provides a more complete understanding of patient safety risks in ABI rehab than relying on incident reporting alone.

Sleep disturbance and length of stay in the setting of acquired brain injury rehabilitation.

OBJECTIVE: The objective of this study was to investigate the impact and prevalence of sleep-wake disturbances among adult patients admitted for inpatient acquired brain injury rehabilitation. METHOD: This was a retrospective cohort study involving all adults admitted for inpatient ABI neurocognitive rehabilitation at UHN-Toronto Rehabilitation Institute over a 12-month period (n = 165). The primary endpoint of the study was the comparison of functional independent measure efficiency and hospital length of stay between patients reporting sleep disturbance (e.g. increased sleep latency, obstructive sleep apnea [OSA], sleep maintenance insomnia) versus those with normal sleep. RESULTS: We found that more than half (58.2%) of patients experienced sleep disturbance based on a combination of self-report and clinical documentation. The most common sleep disturbance was increased sleep onset latency (28.5%), followed by mixed sleep onset/maintenance insomnia (14.5%) and obstructive sleep apnea (8.5%). Notably, OSA was associated with longer length of hospital stay and reduced functional independence measure (FIM) efficiency in the cognitive domain after accounting for age and number of medical comorbidities. IMPLICATIONS: The results of this investigation underscore the importance of screening patients with brain injury for sleep disturbances due to its high prevalence and impact on rehabilitation efficiency.

Do Not Waste a Crisis: Physician Engagement during the COVID-19 Pandemic.

Physician engagement is an important factor in improving care quality and patient safety, but engaging physicians is not easy. Winston Churchill's famous assertion about never wasting a crisis has defined the approach taken by many leaders during the COVID-19 pandemic. This paper describes three case studies of successful physician engagement across the continuum of acute care, chronic care and primary care settings during the pandemic. These examples offer insights on physician engagement within unique settings by leveraging intrinsic motivators and Spurgeon's model of medical engagement.

The influence of molecular alignment and orientation in the ground state and excited state on the resonance-enhanced multi-photon ionization dynamics.

We explore the influence of molecular alignment and orientation in the ground and excited states on the ionization probability, photoelectron angular distribution (PAD), energy-resolved photoelectron energy spectrum (PES) and two-dimensional momentum spectrum in the resonance-enhanced multiphoton ionization (REMPI) process. The calculated results for the LiH molecule show that molecular pre-alignment and -orientation have different effects on molecular photoionization. The ionization probability and energy-resolved photoelectron spectrum are associated with molecular pre-alignment. The angular distribution of photoelectrons and angular distribution of the momentum spectra are closely dependent on molecular pre-orientation. The ionization probability is also related to the center time and overlap area of the pump and probe pulses.

Full-Length Transcriptome Survey and Expression Analysis of Parasitoid Wasp Chouioia cunea upon Exposure to 1-Dodecene.

Chouioia cunea (Yang) is an endoparasitic wasp which parasitizes pupae and thus plays an important role in the biological control of the fall webworm (Hyphantria cunea Drury), an important quarantine pest in the entire world and a major invasive pest in China. For the purposes of investigating which proteins are involved in the response of C. cunea to 1-Docecene, one of the chemical compounds of pupae of H. cunea with a significant attracting action to mated female C. cunea, 11.5 Gb transcriptome data was sequenced on the PacBio RS II platform from 1-day old C. cunea adults to generate a reference assembly. Afterwards, 46.88 Gb of clean RNA-Seq data were obtained to assess the transcriptional response of these insects before and after the stimulation with 1-Docecene. After removing redundancy using CD-HIT, a sequence structure analysis predicted 29,105 complete coding sequence (CDS) regions, 51,458 single-sequence repeats (SSRs), and 2,375 long non-coding RNAs. Based on the early transcriptome sequencing in our laboratory, we revealed some new sequences corresponding to chemosensory genes such as odorant binding proteins (OBPs), odorant receptor (OR), gustatory receptors(GRs). Results of quantitative real-time PCR experiments revealed that CcOBP7, CcOBP18, CcCSP4, CcOR2, and CcGR18 were up-regulated after 1-Dodecene stimulation. In addition, the expression of 31 genes, including 1 gene related to phospholipid biosynthesis and 2 genes related to transmembrane transport were up-regulated after 1-Dodecene stimulation; meanwhile, the expression of 22 genes, including 5 genes related to protein phosphorylation and protein serine/threonine kinase activity were significantly down-regulated after 1-Dodecene stimulation. These results suggest that the attraction of adult C. cunea to 1-dodecane is associated with the transmembrane signal transduction and dephosphorylation of some proteins. Our findings will provide useful targets for further studies on the molecular mechanism of host recognition in C. cunea.

Increasing the use of home medication lists in an outpatient neurorehabilitation clinic.

Medication reconciliation in ambulatory care settings helps prevent adverse drug events. Patient involvement in the process is crucial, as clinicians must verify the reported medication history with other sources such as home medication lists or brown-bagged home medications provided by patients. However, only 47.8% of brain injury and stroke adult outpatients at Toronto Rehabilitation Institute, an academic rehabilitation hospital, bring their medications/medication lists to clinic visits. In turn, missing medication information impacts the clinic by causing delays in treatment and interrupted clinic flow. This project aimed to increase the percentage of patients who bring their medications/medication lists to 80% and decrease the impact on clinic visits caused by missing medication information to 10%. This was a controlled before-after study, with the outpatient rehabilitation assessment (OPRA) clinic as the intervention and the spasticity clinic as the control. The model for improvement was used as the project framework. Process mapping, Ishikawa diagrams, driver diagrams and patient surveys generated the change ideas. Verbal reminders during confirmation phone calls, written reminders and medication list templates were implemented. Data were collected on a biweekly basis and analysed using statistical control charts. After six Plan-Do-Study-Act cycles conducted over 49 weeks, both project aims were achieved. The percentage of OPRA clinic patients who brought medications/medication lists was 81.8% and the impact on clinic visits caused by missing medication information was 9.1% of clinic visits. Special cause variation was detected on the statistical control charts. Conversely, there was no special cause variation for the spasticity clinic (the control) for either aim. Lessons learnt include the importance of prolonged data collection when implementing interventions with long lag time, and that verbal reminders may not be effective for patients with cognitive impairments. Future efforts may focus on implementing the bundle of project interventions for the spasticity clinic.

MiR-503 suppresses cell proliferation and invasion of gastric cancer by targeting HMGA2 and inactivating WNT signaling pathway.

BACKGROUND: Abnormal expression of microRNAs (miRNAs) is related to human carcinogenesis. Although previous studies have shown that miR-503 expression in gastric cancer (GC) is downregulated, however, the underlying molecular mechanism for miR-503 involved in gastric cancer development is still largely unknown. METHODS: The relative expression of miR-503 in GC tissues and adjacent normal tissues was examined using quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) analyses. In vitro, cell proliferation and invasion were evaluated by using CCK8, cell colony and transwell invasion assays. In vivo, xenograft tumor model was constructed to assess miR-503 expression whether affects tumor growth or not. Luciferase reporter assay, qRT-PCR and western blot assay were used to demonstrate HMGA2 is a target of miR-503. RESULTS: We demonstrated that miR-503 expression was significantly downregulated in GC tissues and cell lines compared to adjacent normal tissues and normal gastric mucosa cell lines, respectively. Lower miR-503 expression associated with tumor size, lymph node metastasis, and predicted a poor overall survival (OS) time in GC patients. Subsequently, in vitro, gain-function and loss-function assays confirmed that miR-503 overexpression significantly suppressed GC cell proliferation, colony formation and cell invasion, while decreased miR-503 expression had an adverse effect in GC cells. Furthermore, we found that miR-503 specifically targeted the 3'-UTR regions of HMGA2 mRNA and suppressed its protein expression. Overexpression of HMGA2 could reverse the miR-503 mediated inhibition of GC cell proliferation and invasion. In vivo, miR-503 overexpression dramatically reduced tumor growth. Moreover, we demonstrated that miR-503 suppressed WNT/ß-catenin signaling by elevating GSK-3ß and p-ß-catenin expression, but decreased p-GSK-3ß and ß-catenin expression in GC cells. CONCLUSION: These results provide that miR-503 expression acts as a predictor for GC prognosis and may have a potential application in GC therapy.

Quality Improvement in Rehabilitation: A Primer for Physical Medicine and Rehabilitation Specialists.

Physiatrists in all practice settings can improve the care of rehabilitation patients through the rigorous application of quality improvement (QI) methodology. This primer provides a step-by-step guide to QI in rehabilitation settings for academic and community physiatrists, using the Model for Improvement. Key concepts discussed include Plan-Do-Study-Act cycles, setting optimal aim statements and measures, involving the rehabilitation team, diagnostic tools to understand root causes of quality problems, selection of change concepts and ideas, and utilizing run charts for data analysis. A QI project focused on the secondary prevention of vascular complications in amputees with diabetes admitted to inpatient rehabilitation is used as an illustrative example throughout the primer.