Using implementation science to promote the use of the fascia iliaca blocks in hip fracture care.

PURPOSE: There is variable and suboptimal use of fascia iliaca compartment nerve blocks (FICBs) in hip fracture care. Our objective was to use an evidence-based and theory-informed implementation science approach to analyze barriers and facilitators to timely administration of FICB and select evidence-based interventions to enhance uptake. METHODS: We conducted a qualitative study at a single centre using semistructured interviews and site observations. We interviewed 35 stakeholders including health care providers, managers, patients, and caregivers. We mapped barriers and facilitators to the Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR). We compared the rate and timeliness of FICB administration before and after evidence-based implementation strategies were applied. RESULTS: The study identified 18 barriers and 11 facilitators within seven themes of influences of FICB use: interpersonal relationships between health care professionals; clinician knowledge and skills related to FICB; roles, responsibilities, and processes for delivering FICB; perceptions on using FICB for pain; patient and caregiver perceptions on using FICB for pain; communication of hip fracture care between departments; and resources for delivering FICBs. We mapped the behaviour change domains to eight implementation strategies: restructure the environment, create and distribute educational materials, prepare patients to be active participants, perform audits and give feedback, use local opinion leaders, use champions, train staff on FICB procedures, and mandate change. We observed an increase in the rates of FICBs administered (48% vs 65%) and a decrease in the median time to administration (1.63 vs 0.81 days). CONCLUSION: Our study explains why FICBs are underused and shows that the TDF and CFIR provide a framework to identify barriers and facilitators to FICB implementation. The mapped implementation strategies can guide institutions to improve use of FICB in hip fracture care.

RéSUMé: OBJECTIF: Il existe une utilisation variable et sous-optimale des blocs nerveux du compartiment fascia iliaca (FICB) dans les soins des fractures de la hanche. Notre objectif était d'utiliser une approche scientifique de la mise en œuvre fondée sur des données probantes et sur la théorie pour analyser les obstacles et les facilitateurs à l'administration opportune d'un FICB et pour sélectionner des interventions fondées sur des données probantes pour améliorer l'adoption de cette technique. MéTHODE: Nous avons mené une étude qualitative dans un seul centre à l'aide d'entrevues semi-structurées et d'observations sur place. Nous avons interviewé 35 intervenant·es, y compris des prestataires de soins de santé, des gestionnaires, des patient·es et des soignant·es. Nous avons cartographié les obstacles et les facilitateurs du cadre des domaines théoriques (Theoretical Domains Framework, TDF) et du cadre consolidé pour la recherche sur la mise en œuvre (Consolidated Framework for Implementation Research, CFIR). Nous avons comparé le taux et la rapidité d'administration d'un FICB avant et après l'application des stratégies de mise en œuvre fondées sur des données probantes. RéSULTATS: L'étude a identifié 18 obstacles et 11 facilitateurs dans sept thèmes d'influence de l'utilisation du FICB : les relations interpersonnelles entre les professionnel·les de la santé; les connaissances et les compétences des clinicien·nes liées au FICB; les rôles, responsabilités et processus d'exécution des FICB; les perceptions de l'utilisation des FICB pour soulager la douleur; les perceptions des patient·es et des soignant·es concernant l'utilisation de FICB pour soulager la douleur; la communication des soins des fractures de la hanche entre les services; et les ressources nécessaires à l'exécution des FICB. Nous avons mis en correspondance les domaines de changement de comportement avec huit stratégies de mise en œuvre : restructurer l'environnement, créer et distribuer du matériel éducatif, préparer les patient·es à participer activement, effectuer des audits et donner de la rétroaction, faire appel à des leaders d'opinion locales et locaux, utiliser des champion·nes, former le personnel sur les interventions de FICB et forcer au changement. Nous avons observé une augmentation des taux de FICB administrés (48% vs 65%) et une diminution du délai médian d'administration (1,63 vs 0,81 jour). CONCLUSION: Notre étude explique pourquoi les FICB sont sous-utilisés et montre que le TDF et le CFIR fournissent un cadre pour identifier les obstacles et les facilitateurs à la mise en œuvre des FICB. Les stratégies de mise en œuvre cartographiées peuvent aider les établissements à améliorer l'utilisation des FICB dans le traitement des fractures de la hanche.

Systemic and mucosal IgA responses are variably induced in response to SARS-CoV-2 mRNA vaccination and are associated with protection against subsequent infection.

Although SARS-CoV-2 infects the upper respiratory tract, we know little about the amount, type, and kinetics of antibodies (Ab) generated in the oral cavity in response to COVID-19 vaccination. We collected serum and saliva samples from participants receiving two doses of mRNA COVID-19 vaccines and measured the level of anti-SARS-CoV-2 Ab. We detected anti-Spike and anti-Receptor Binding Domain (RBD) IgG and IgA, as well as anti-Spike/RBD associated secretory component in the saliva of most participants after dose 1. Administration of a second dose of mRNA boosted the IgG but not the IgA response, with only 30% of participants remaining positive for IgA at this timepoint. At 6 months post-dose 2, these participants exhibited diminished anti-Spike/RBD IgG levels, although secretory component-associated anti-Spike Ab were more stable. Examining two prospective cohorts we found that participants who experienced breakthrough infections with SARS-CoV-2 variants had lower levels of vaccine-induced serum anti-Spike/RBD IgA at 2-4 weeks post-dose 2 compared to participants who did not experience an infection, whereas IgG levels were comparable between groups. These data suggest that COVID-19 vaccines that elicit a durable IgA response may have utility in preventing infection. Our study finds that a local secretory component-associated IgA response is induced by COVID-19 mRNA vaccination that persists in some, but not all participants. The serum and saliva IgA response modestly correlate at 2-4 weeks post-dose 2. Of note, levels of anti-Spike serum IgA (but not IgG) at this timepoint are lower in participants who subsequently become infected with SARS-CoV-2. As new surges of SARS-CoV-2 variants arise, developing COVID-19 booster shots that provoke high levels of IgA has the potential to reduce person-to-person transmission.

Evaluation of the SARS-CoV-2 Antibody Response to the BNT162b2 Vaccine in Patients Undergoing Hemodialysis.

Importance: Patients undergoing hemodialysis have a high mortality rate associated with COVID-19, and this patient population often has a poor response to vaccinations. Randomized clinical trials for COVID-19 vaccines included few patients with kidney disease; therefore, vaccine immunogenicity is uncertain in this population. Objective: To evaluate the SARS-CoV-2 antibody response in patients undergoing chronic hemodialysis following 1 vs 2 doses of BNT162b2 COVID-19 vaccination compared with health care workers serving as controls and convalescent serum. Design, Setting, and Participants: A prospective, single-center cohort study was conducted between February 2 and April 17, 2021, in Toronto, Ontario, Canada. Participants included 142 patients receiving in-center hemodialysis and 35 health care worker controls. Exposures: BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine. Main Outcomes and Measures: SARS-CoV-2 IgG antibodies to the spike protein (anti-spike), receptor binding domain (anti-RBD), and nucleocapsid protein (anti-NP). Results: Among the 142 participants undergoing maintenance hemodialysis, 94 (66%) were men; median age was 72 (interquartile range, 62-79) years. SARS-CoV-2 IgG antibodies were measured in 66 patients receiving 1 vaccine dose following a public health policy change, 76 patients receiving 2 vaccine doses, and 35 health care workers receiving 2 vaccine doses. Detectable anti-NP suggestive of natural SARS-CoV-2 infection was detected in 15 of 142 (11%) patients at baseline, and only 3 patients had prior COVID-19 confirmed by reverse transcriptase polymerase chain reaction testing. Two additional patients contracted COVID-19 after receiving 2 doses of vaccine. In 66 patients receiving a single BNT162b2 dose, seroconversion occurred in 53 (80%) for anti-spike and 36 (55%) for anti-RBD by 28 days postdose, but a robust response, defined by reaching the median levels of antibodies in convalescent serum from COVID-19 survivors, was noted in only 15 patients (23%) for anti-spike and 4 (6%) for anti-RBD in convalescent serum from COVID-19 survivors. In patients receiving 2 doses of BNT162b2 vaccine, seroconversion occurred in 69 of 72 (96%) for anti-spike and 63 of 72 (88%) for anti-RBD by 2 weeks following the second dose and median convalescent serum levels were reached in 52 of 72 patients (72%) for anti-spike and 43 of 72 (60%) for anti-RBD. In contrast, all 35 health care workers exceeded the median level of anti-spike and anti-RBD found in convalescent serum 2 to 4 weeks after the second dose. Conclusions and Relevance: This study suggests poor immunogenicity 28 days following a single dose of BNT162b2 vaccine in the hemodialysis population, supporting adherence to recommended vaccination schedules and avoiding delay of the second dose in these at-risk individuals.

Less approach, more avoidance: Response inhibition has motivational consequences for sexual stimuli that reflect changes in affective value not a lingering global brake on behavior.

Response inhibition negatively impacts subsequent hedonic evaluations of motivationally relevant stimuli and reduces the behavioral incentive to seek and obtain such items. Here we expand the investigation of the motivational consequences of inhibition by presenting sexually appealing and nonappealing images in a go/no-go task and a subsequent image-viewing task. Each initially obscured image in the viewing task could either be made more visible or less visible by repeatedly pressing different keys. Fewer key presses were made to obtain better views of preferred-sex images when such images had previously been inhibited as no-go items than when previously encountered as noninhibited go items. This finding replicates prior results and is consistent with the possibility that motor-response suppression has lingering effects that include global reductions in all behavioral expression. However, for nonpreferred images, prior inhibition resulted in more key presses to obscure their visibility than when such images had not been inhibited. This novel finding suggests that the motivational consequences of response inhibition are not due to a global brake on action but are instead linked to negative changes in stimulus value that induce corresponding increases in avoidance and decreases in approach.