Minimizing the Risk of Surgical Site Infection Following Hip Fracture Operation.

Introduction: Hip fractures are the most common serious injury in the elderly, associated with disability, morbidity, and mortality. Surgical site infection (SSI) is a serious post-operative complication. This prospective cohort study outlines how our center made cumulative improvements in SSI incidence rates, reaching a 12-month average of 0.5%. Methods: All patients undergoing hip fracture operation between 2016 and 2021 were included. The primary outcome measure was confirmed SSI, according to the Public Health England definition. Results were compared with the baseline recordings by an independent SSI team in 2013. Demographic data were compared with National Hip Fracture Database records. Peri-operative infection control and wound management tactics introduced between 2014 and 2021 were collated to gain an overview care bundle. Results: Baseline recordings identified a 9.0% SSI rate in a three-month observation period. In our study, 3,138 hip fracture operative cases were completed between October 2016 and December 2021. There were 9 superficial and 32 deep infections identified, yielding an overall infection rate of 1.3%. However, when analyzing the 12-month average, there was consistent decline in SSI from the baseline 9.0% in 2013 to 0.5% in 2021 (p < 0.05). A peri-operative care bundle included pre-operative bleeding risk assessment. Intra-operatively, double preparation and draping is used for arthroplasty. Broad-spectrum antibiotic agents and tranexamic acid are administered. Meticulous hemostasis and watertight wound closure are observed. Anti-coagulated patients received negative pressure dressings. Post-operatively, a dedicated senior lead team provided daily inpatient review of patients, with urgent consultant review of all wound healing concerns. Conclusion: Patients with a hip fracture have numerous risk factors for SSI. A dedicated multi-focal tactic, adopted by a multi-disciplinary department, can yield substantial risk reduction. Each intervention is evidence based and contributes to cumulative improvement. By prioritizing infection prevention, we have minimized the need for complex infection management interventions and achieved an annual saving of £860,000 for our trust.

Trends in companion animal access to veterinary care in Canada, 2007 to 2020.

Objective: Assess trends in access to veterinary care for companion animals in Canada. Procedure: Analysis and integration of available data, 2007 to 2020. Results: Cumulative growth in the Canadian veterinary workforce was 38%, and 49% for companion animal veterinarians. Clients per companion animal veterinarian decreased 30% from 2008 to 2020. Absolute client numbers increased 1.3%, compared to pet population growth of 17%. Medicalized pets (those that had received veterinary care in the past year) increased 25%, from 9.02 million in 2007 to 11.24 million in 2020. Non-medicalized pets increased 1.8%, from 4.48 million to 4.56 million. In 2007, 33% of pets were non-medicalized, compared to 29% (15% of dogs and 42% of cats) in 2020. There was a cumulative increase of 31% for total non-medicalized dogs, and a change of -5.6% for cats. Gross and net revenues per client increased by 99 and 112%, respectively, compared to cumulative inflation of 21%. Conclusion and clinical relevance: The analysis identified a large cohort of pets that had not received veterinary care each year. The trends were fewer clients per veterinarian, each paying higher veterinary costs, and suggested a relative, rather than absolute, veterinary capacity shortage overall. Accessible care-provision models must be encouraged, regulated for, and allowed to flourish alongside traditional models.

Tendances en matière d'accès des animaux de compagnie aux soins vétérinaires au Canada, 2007 à 2020. Objectif: Évaluer les tendances en matière d'accès aux soins vétérinaires pour les animaux de compagnie au Canada. Procédure: Analyse et intégration des données disponibles, 2007 à 2020. Résultats: La croissance cumulative de la main-d'œuvre vétérinaire canadienne était de 38 %, et de 49 % pour les médecins vétérinaires d'animaux de compagnie. Le nombre de clients par vétérinaire pour animaux de compagnie a diminué de 30 % entre 2008 et 2020. Le nombre absolu de clients a augmenté de 1,3 %, comparé à une croissance de la population d'animaux de compagnie de 17 %. Les animaux de compagnie médicalisés (ceux qui ont reçu des soins vétérinaires au cours de l'année écoulée) ont augmenté de 25 %, passant de 9,02 millions en 2007 à 11,24 millions en 2020. Les animaux de compagnie non médicalisés ont augmenté de 1,8 %, passant de 4,48 millions à 4,56 millions. En 2007, 33 % des animaux de compagnie étaient non médicalisés, contre 29 % (15 % des chiens et 42 % des chats) en 2020. Il y a eu une augmentation cumulée de 31 % pour le total des chiens non médicalisés, et une variation de ­5,6 % pour les chats. Les revenus bruts et nets par client ont augmenté respectivement de 99 et 112 %, par rapport à une inflation cumulée de 21 %. Conclusion et pertinence clinique: L'analyse a identifié chaque année une large cohorte d'animaux de compagnie qui n'avaient pas reçu de soins vétérinaires. Les tendances étaient moins de clients par vétérinaire, chacun payant des frais vétérinaires plus élevés, et suggéraient une pénurie globale de capacité vétérinaire relative plutôt qu'absolue. Les modèles de prestation de soins accessibles doivent être encouragés, réglementés et autorisés à prospérer aux côtés des modèles traditionnels.(Traduit par Dr Serge Messier).

Further variation of the adulticide protocol for the treatment of canine heartworm infection: can it be even shorter and cost less?

BACKGROUND: This retrospective study evaluated modified three-dose melarsomine treatment protocols in a shelter setting and compared them to the American Heartworm Society (AHS)-recommended protocol. METHODS: As compared with the AHS protocol, the shelter protocols utilized doxycycline 10 mg/kg once daily (SID) or twice daily (BID), and varied the time from initiation of doxycycline (day 1) to the first melarsomine injection (M1). Dogs were retrospectively grouped based on the shelter's current protocol (M1 on day 14; Group A) and the AHS protocol (M1 on day 60; Group C), allowing a week on either side of the target M1 day. Treatments that fell outside these ranges formed two additional treatment groups (Groups B and D). Respiratory complications were defined as respiratory signs requiring additional treatment, and were statistically compared for Groups A and C. New respiratory signs and gastrointestinal (GI) signs were compared between dogs receiving SID or BID doxycycline. RESULTS: One hundred fifty-seven dogs with asymptomatic or mild heartworm disease at presentation were included. All dogs survived to discharge. There was no statistically significant difference between Groups A (n = 79) and C (n = 27) for new respiratory signs post-melarsomine (P = 0.73). The time to M1 for 14 dogs that developed new respiratory signs was a median of 19 days, compared with 22 days for 143 dogs without new respiratory signs (P = 0.2). Respiratory complications post-melarsomine were uncommon. New respiratory signs post-melarsomine occurred in 10/109 (9.2%) dogs receiving SID doxycycline and 4/48 (8.3%) dogs receiving BID doxycycline (P > 0.999). GI signs prior to M1 were recorded for 40/109 (36.7%) dogs receiving SID doxycycline and 25/48 (52.1%) receiving BID doxycycline (P = 0.08). Forty-four follow-up antigen test results were available; all tests performed > 3 months after the third melarsomine injection were negative. CONCLUSIONS: This study provided support for initiating melarsomine after 14 days of doxycycline and for a lower doxycycline dose. Shorter and less expensive treatment protocols can increase lifesaving capacity and improve quality of life for shelter dogs by reducing the duration of exercise restriction and length of stay.

Clinical outcomes after total excision of transobturator tape inserted for treatment of stress urinary incontinence.

INTRODUCTION: Midurethral tapes (MUTs) were the most common surgical treatment for stress urinary incontinence (SUI) between 2008 and 2017. Transobturator tapes were introduced as a novel way to insert MUTs. Some women have experienced life-changing complications, and opt to undergo a total excision of transobturator tape (TETOT). There is a paucity in evidence about the outcomes of TETOT, which is a complex operation. This study aims to report clinical outcomes of all women who underwent TETOT in a specialist mesh center. METHODS: All women between 2017 and 2022 who underwent TETOT in one mesh center were reviewed. Background demographics and preoperative symptoms were recorded retrospectively. Outcome data were collected using patient global impression of improvement (PGI-I) scales via telephone review and analyzed using SPSS 25. RESULTS: Forty-five women underwent telephone review in May 2022, on average 27.9 months (range: 3-60) after TETOT. Mean age was 55 and body mass index (BMI): 30; 82% were postmenopausal, 20% were smokers, and 73.3% had recurrent SUI before excision. Indications for excision were infection (4%), vaginal exposure (24%), urethral perforation (9%), and chronic pain not associated with other complications (60%). Two women with recurrent SUI opted for a concomitant fascial sling; both reported a PGI of "very much improved" regarding SUI postoperatively. Only 12 women (26.5%) did not have SUI before excision; of these 9 (75%) reported new SUI postoperatively. Pain improved for 57.8%, but worsened for 24.4%. Although not statistically significant (p = 0.055), more women who underwent TETOT for pain alone reported worsening pain than those with pain with an additional complication (37% vs. 5.55%). Overall, 62.2% women felt "better" after their excision, 17.8% felt "worse." DISCUSSION: After TETOT, 62% of women felt better. Improvement in pain was reported by 58%-those with chronic pain without another complication reported improvement in pain less frequently (48% vs. 72%) and worsening pain more frequently (37% vs. 6%). Existing SUI worsened in 65% of women and 75% developed new SUI. There appears to be discordance between reporting global improvement with worsening of commonly measured clinical outcomes. CONCLUSION: Outcome data are important for counseling women about the risks and benefits of TETOT. Women and clinicians may have different attitudes to the possible benefits of TETOT, as evidenced by women reporting feeling better despite continuing pain or SUI. Conventional outcome measures do not adequately capture all outcomes that are important to patients.

Flavan-3-ol-methylxanthine interactions: Modulation of flavan-3-ol bioavailability in volunteers with a functional colon and an ileostomy.

Flavan-3-ols, including the flavan-3-ol monomer (-)-epicatechin, are dietary bioactives known to mediate beneficial cardiovascular effects in humans. Recent studies showed that flavan-3-ols could interact with methylxanthines, evidenced by an increase in flavan-3-ol bioavailability with a concomitant increase in flavan-3-ol intake-mediated vascular effects. This study aimed at elucidating flavan-3-ol-methylxanthine interactions in humans in vivo by evaluating the specific contributions of theobromine and caffeine on flavan-3-ol bioavailability. In ileostomists, the effect of methylxanthines on the efflux of flavan-3-ol metabolites in the small intestine was assessed, a parameter important to an understanding of the pharmacokinetics of flavan-3-ols in humans. In a randomized, controlled, triple cross-over study in volunteers with a functional colon (n = 10), co-ingestion of flavan-3-ols and cocoa methylxanthines, mainly represented by theobromine, increased peak circulatory levels (Cmax) of flavan-3-ols metabolites (+21 ± 8%; p < 0.05). Conversely, caffeine did not mediate a statistically significant effect on flavan-3-ol bioavailability (Cmax = +10 ± 8%, p = n.s.). In a subsequent randomized, controlled, double cross-over study in ileostomists (n = 10), cocoa methylxanthines did not affect circulatory levels of flavan-3-ol metabolites, suggesting potential differences in flavan-3-ol bioavailability compared to volunteers with a functional colon. The main metabolite in ileal fluid was (-)-epicatechin-3'-sulfate, however, no differences in flavan-3-ol metabolites in ileal fluid were observed after flavan-3-ol intake with and without cocoa methylxanthines. Taken together, these results demonstrate a differential effect of caffeine and theobromine in modulating flavan-3-ol bioavailability when these bioactives are co-ingested. These findings should be considered when comparing the effects mediated by the intake of flavan-3-ol-containing foods and beverages and the amount and type of methylxanthines present in the ingested matrixes. Ultimately, these insights will be of value to further optimize current dietary recommendations for flavan-3-ol intake. CLINICAL TRIAL REGISTRATION NUMBER: This work was registered at clinicaltrials.gov as NCT03526107 (study part 1, volunteers with functional colon) and NCT03765606 (study part 2, volunteers with an ileostomy).

Seizing the opportunity to improve patient care: pelvic floor services in 2021 and beyond.

Patients requiring pelvic floor and functional urological, gynaecological and coloproctological surgery were viewed as a low priority even before COVID-19. A consensus report outlines recommendations to improve care and encourage clinicians to help bring about positive changes for patients with pelvic floor problems.

Prevalence of heartworm in relocated, local and outreach clinic dogs: A Canadian sheltering perspective.

This study reports heartworm (Dirofilaria immitis) prevalence in dogs tested by an animal shelter located in a low-prevalence region of Ontario, Canada. From 2015-2018, 4567 unique dogs were tested. The prevalence of heartworm was 3.9 %, with sub-prevalence of 0.3 % (2/662) for dogs surrendered within the Greater Toronto Area (both dogs were originally imported from the US); 6.6 % (130/1,981) for dogs relocated from beyond the Greater Toronto Area; 0% (0/1,668) for dogs tested at the shelter's public veterinary services clinic and 18.4 % (47/256) for owned dogs tested at outreach clinics at a First Nations community in south-eastern Ontario. More than half (54.7 %) of the heartworm-positive dogs originated from Canada. Most heartworm-positive dogs from the US (72/80; 90 %) were transferred from Texas and Georgia. Ninety-three heartworm-positive Canadian dogs were from Ontario, 4 from Manitoba and 1 from Quebec. Most (83/98, 84.7 %) were from four First Nations communities. The prevalence in homeless dogs from one First Nations community in south-western Ontario was 36.5 % (31/85). For 140 shelter dogs with at least one positive test result, there was 91 % concordance between shelter and reference laboratory antigen tests and poor agreement between antigen tests and microfilarial tests (approximately 50 %). Results of historical tests and post-relocation antigen tests were discordant in 28.2 % (shelter point-of-care tests) and 36.2 % (reference laboratory tests) of cases. This was most commonly due to negative historical results followed by positive results after relocation. Microfilarial filtration tests were positive for 77.1 % antigen-positive dogs from First Nations communities, compared with 37.1 % of dogs from other sources. Microfilarial counts were significantly higher for dogs from First Nations communities. This study demonstrated endemic and hyperendemic foci of heartworm within Canada, which were presumed to be associated with limited access to veterinary care. The results support recommendations to retest previously negative animals after relocation.

Laparoscopic sacrocolpopexy (LSCP) using an ultra-lightweight polypropylene mesh.

OBJECTIVES: Since 2005 the preferred method for surgical treatment of vaginal vault prolapse within the department has been laparoscopic sacrocolpopexy with an ultra-lightweight polypropylene mesh. The study aimed to explore the functional and anatomical outcomes and mesh adverse events of women following this procedure. STUDY DESIGN: All women who had a Laparoscopic Sacrocolpopexy (LSCP) using an ultra-lightweight (19 g/m2) polypropylene mesh in two units in the North West of England between March 2005 and January 2013 (n = 238) were invited to participate in the study.Functional outcome data was collected using the Patient Global Impression Questionnaire (PGI-I), the Pelvic Floor Distress Inventory (PFDI-20) and the Electronic Personal Assessment Questionnaire (EPAQ) post-operatively. Anatomical outcome was assessed by Pelvic Organ Prolapse Quantification System (POP-Q) measurement. A mesh palpability assessment was performed and any mesh complications were recorded using the International Continence Society/International Urogynecology Association (ICS/IUGA) classification system. The results were compared to those in our previously published series using the same surgical technique but a standard weight mesh (82.5 g/m2). RESULTS: 89% of participants reported that they felt their post-operative condition had improved. POP-Q results revealed that the median position of C changed from -3 pre-op to -7 post-operatively. Mesh was palpable during vaginal examination in only 3 women (3%). No mesh extrusion was identified during the study. CONCLUSIONS: The study demonstrates that LSCP performed with an ultra-lightweight polypropylene mesh improves women's functional and anatomical symptoms and appears to have a low risk of mesh extrusion.

D2 Dopamine Receptor G Protein-Biased Partial Agonists Based on Cariprazine.

Functionally selective G protein-coupled receptor ligands are valuable tools for deciphering the roles of downstream signaling pathways that potentially contribute to therapeutic effects versus side effects. Recently, we discovered both Gi/o-biased and ß-arrestin2-biased D2 receptor agonists based on the Food and Drug Administration (FDA)-approved drug aripiprazole. In this work, based on another FDA-approved drug, cariprazine, we conducted a structure-functional selectivity relationship study and discovered compound 38 (MS1768) as a potent partial agonist that selectively activates the Gi/o pathway over ß-arrestin2. Unlike the dual D2R/D3R partial agonist cariprazine, compound 38 showed selective agonist activity for D2R over D3R. In fact, compound 38 exhibited potent antagonism of dopamine-stimulated ß-arrestin2 recruitment. In our docking studies, compound 38 directly interacts with S1935.42 on TM5 but has no interactions with extracellular loop 2, which appears to be in contrast to the binding poses of D2R ß-arrestin2-biased ligands. In in vivo studies, compound 38 showed high D2R receptor occupancy in mice and effectively inhibited phencyclidine-induced hyperlocomotion.

Laparoscopic sacrocolpopexy posthysterectomy: intraoperative feasibility and safety in obese women compared with women of normal weight.

INTRODUCTION AND HYPOTHESIS: Our aim was to determine the intraoperative feasibility and complication rate of laparoscopic sacrocolpopexy (LSC) in overweight and obese women compared with women of normal weight. METHODS: This was a retrospective observational cohort study (Canadian Task Force classification II-2) conducted at a tertiary urogyaenocology unit evaluating 119 women who underwent LSC between March 2005 and January 2013. RESULTS: Body mass index (BMI) was classified as normal (22.89 ± 1.55), overweight (27.12 ± 1.40) and obese (33.47 ± 3.26) according to the World Health Organisation (WHO) classification. There was no difference in intraoperative complication rates for bladder, bowel, ureteric or vascular injury; haemorrhage; conversion to laparotomy; or anaesthetic complications for normal weight, overweight or obese women. Similarly there was no difference in operating time, duration of anaesthetic or hospital stay between BMI class (p = 0.070, p = 0.464, p = 0.898, respectively) postoperative or mesh complication rates. At 6-months' follow-up, there was no difference in Patient Global Impression of Improvement scale (PGI-I) (defined as very much better or much better) between normal weight, overweight and obese women (76.9, 72 and 65.4%, p = .669) or objective cure using the Pelvic Organ Prolapse Quantification (POP-Q) examination (p = 0.402). CONCLUSIONS: LSC is feasible, with equivalent intraoperative complication rates for normal weight, overweight and obese women when performed by experienced laparoscopic urogynaecologists. Given the benefits of a laparoscopic approach in obese women, the authors suggest they should be offered LSC as an option to treat vault prolapse when surgical management is being considered.

Challenges in reducing TIA clinic waiting times from 9 to 3 days in an acute Welsh hospital.

A patient impact project which successfully reduced the transient ischaemic attack (TIA) clinic waiting time from 9 to 3 days in an acute Welsh hospital, revealing the challenges faced and how alternative thinking and team work improved care given to our service users. Evaluating current situation, careful planning with multiple brainstorming meetings, 4 N chart and driver diagram with change ideas laid the foundation for this service improvement. Run charts, statistical process control and Pareto charts helped to identify the issues that are hindering the progress, which when rectified, reduced the clinic waiting times. Avoiding clinic cancellations by cross covering TIA clinics with mutual agreement among consultants and redeployment of ward staff to support clinics resulted in a positive impact to the patients. The average waiting time to see a patient in TIA clinic dropped from 9 days to just 3 days as a result of this, reflecting the hard-working and proactive nature of a team following a collaborative leadership journey. The service improvement initiative for 'avoiding clinic cancellations' was implemented in January 2017 and has reduced our waiting times by three times. Repeat analysis by six monthly Plan Do Study Act cycles revealed that this improvement is sustained.

Responsiveness of a parent-reported outcome measure to evaluate AAC interventions for children and youth with complex communication needs.

Evaluation of the effectiveness of augmentative and alternative communication (AAC) interventions requires reliable measures that are responsive to change. The aim of this study was to explore the potential of the Family Impact of Assistive Technology Scale for AAC (FIATS-AAC) to detect functional change in children and youth with AAC needs, aged 3-17 years, and their families, 6 and 12 weeks after receiving a graphic-based, speech-generating device (SGD). Parents whose children were awaiting a SGD as part of their regular AAC service participated in the study. In all, 45 parents completed the FIATS-AAC during each of three phone interviews: at the time of device delivery, and then 6 weeks and 12 weeks after receiving the device. Children and youth were aged 3-16 years (M = 7.8, SD = 3.3) and were mostly context-dependent communicators. Paired t-tests indicated statistically significant gains in functioning from baseline to both 6 and 12 weeks after receiving the AAC device. Effect sizes were 0.41 and 0.38, respectively. This study provides initial support for the ability of the FIATS-AAC to detect functional changes in children and youth and their families after receiving a graphic-based SGD.

Amino acid racemization and its relation to geochronology and archaeometry.

Amino acid racemization, used as a method of relative and quantitative dating of fossils, evaluates the degree of postmortem conversion of l to d amino acid enantiomers. While extensively utilized, this method has garnered confusion due to controversial age estimates for human fossils in North America in the 1970s. This paper explains the age controversy and aftermath, current chromatographic methods used in research, mathematical calibration models, and a short synopsis of other dating techniques in geochronology and archaeometry.

Nursing Student Perceptions of Structural Empowerment.

To meet role expectations for nurses, nurses must feel empowered. Faculty contributions to the learning environment for nursing students are critical. A descriptive analysis of student perceptions of empowerment within the learning environment was conducted using a form of Kanter's Conditions of Work Effectiveness Questionnaire; 203 participants from schools in 17 different states completed surveys. Subjects demonstrated moderate degrees of structural empowerment in their learning environment. This positive finding can be further investigated and used to fully prepare future nurses.

Protocol for a multicentre study to assess feasibility, acceptability, effectiveness and direct costs of TRIumPH (Treatment and Recovery In PsycHosis): integrated care pathway for psychosis.

INTRODUCTION: Duration of untreated psychosis (time between the onset of symptoms and start of treatment) is considered the strongest predictor of symptom severity and outcome. Integrated care pathways that prescribe timeframes around access and interventions can potentially improve quality of care. METHODS AND ANALYSIS: A multicentre mixed methods study to assess feasibility, acceptability, effectiveness and analysis of direct costs of an integrated care pathway for psychosis. A pragmatic, non-randomised, controlled trial design is used to compare the impact of Treatment and Recovery In PsycHosis (TRIumPH; Intervention) by comparison between NHS organisations that adopt TRIumPH and those that continue with care as usual (Control). Quantitative and qualitative methods will be used. We will use routinely collected quantitative data and study-specific questionnaires and focus groups to compare service user outcomes, satisfaction and adherence to intervention between sites that adopt TRIumPH versus sites that continue with usual care pathways. SETTING: 4 UK Mental health organisations. Two will implement TRIumPH whereas two will continue care as usual. PARTICIPANTS: Staff, carers, individuals accepted to early intervention in psychosis teams in participating organisations for the study period. INTERVENTION: TRIumPH-Integrated Care Pathway for psychosis that has a holistic approach and prescribes time frames against interventions; developed using intelligence from data; co-produced with patients, carers, clinicians and other stakeholders. OUTCOMES: Feasibility will be assessed through adherence to the process measures. Satisfaction and acceptability will be assessed using questionnaires and focus groups. Effectiveness will be assessed through data collection and evaluation of patient outcomes, including clinical, functional and recovery outcomes, physical health, acute care use. Outcome measures will be assessed at baseline, 12 and 24 months to measure whether there is an effect and if so, whether this is sustained over time. Outcomes measures at the adopter sites will be compared to their own baseline and against comparator sites. ETHICS AND DISSEMINATION: Ethics approval was obtained from East of Scotland Research Ethics Service (REC Ref no: LR/15/ES/0091). The results will be disseminated through publications, conference presentations, reports to the organisation. STUDY REGISTRATION: UK Clinical Research Network Portfolio: 19187.

Phosphodiesterase 10A Inhibition Improves Cortico-Basal Ganglia Function in Huntington's Disease Models.

Huntington's disease (HD) symptoms are driven to a large extent by dysfunction of the basal ganglia circuitry. HD patients exhibit reduced striatal phoshodiesterase 10 (PDE10) levels. Using HD mouse models that exhibit reduced PDE10, we demonstrate the benefit of pharmacologic PDE10 inhibition to acutely correct basal ganglia circuitry deficits. PDE10 inhibition restored corticostriatal input and boosted cortically driven indirect pathway activity. Cyclic nucleotide signaling is impaired in HD models, and PDE10 loss may represent a homeostatic adaptation to maintain signaling. Elevation of both cAMP and cGMP by PDE10 inhibition was required for rescue. Phosphoproteomic profiling of striatum in response to PDE10 inhibition highlighted plausible neural substrates responsible for the improvement. Early chronic PDE10 inhibition in Q175 mice showed improvements beyond those seen with acute administration after symptom onset, including partial reversal of striatal deregulated transcripts and the prevention of the emergence of HD neurophysiological deficits. VIDEO ABSTRACT.

Intermittent daytime mouthpiece ventilation successfully augments nocturnal non-invasive ventilation, controlling ventilatory failure and maintaining patient independence.

A 53-year-old woman with spinal muscular atrophy and a 7-year history of nocturnal non-invasive ventilation (NIV) use via nasal mask and chinstrap was admitted electively. Outpatient review suggested symptomatic hypercapnia and hypoxaemia. Use of her usual NIV resulted in early morning respiratory acidosis due to excess mouth leak, and continuous face mask NIV was instigated while in hospital. Once stabilised, she elected to return to nasal ventilation. At outpatient review, respiratory acidosis reoccurred despite diurnal use of NIV. Using the patient's routine ventilator and a novel mouthpiece and trigger algorithm, intermittent daytime mouthpiece ventilation (MPV) was introduced alongside overnight NIV. Control of respiratory failure was achieved and, vitally, independent living maintained. Intermittent MPV was practicable and effective where the limits of ventilator tolerance had otherwise been reached. MPV may reduce the need for tracheostomy ventilation and this case serves as a reminder of the increasing options routinely available to NIV clinicians.

Towards Advancing Knowledge Translation of AAC Outcomes Research for Children and Youth with Complex Communication Needs.

The production of new knowledge in augmentative and alternative communication (AAC) requires effective processes to leverage the different perspectives of researchers and knowledge users and improve prospects for utilization in clinical settings. This article describes the motivation, planning, process, and outcomes for a novel knowledge translation workshop designed to influence future directions for AAC outcomes research for children with complex communication needs. Invited knowledge users from 20 pediatric AAC clinics and researchers engaged in the collaborative development of research questions using a framework designed for the AAC field. The event yielded recommendations for research and development priorities that extend from the early development of language, communication, and literacy skills in very young children, to novel but unproven strategies that may advance outcomes in transitioning to adulthood.