Inclusion of autistic students: promising modalities for supporting a school team.

PURPOSE: School staff who work with autistic students are at a high risk of exhaustion. More training and guidance are needed to enable them to respond to these students' needs. The purpose of this study was to design and evaluate a professional development program offered by an occupational therapist to help a team of school staff facilitate the participation of autistic students and their peers. METHODS: A design-based research approach guided the development and evaluation of the modalities of the program. A case study was conducted in a school with nine school staff members using individual interviews, questionnaires, and a logbook. RESULTS: The program comprised five modalities: regular presence of the occupational therapist, a needs analysis, content focused on the features of an inclusive school, individual coaching, and team coaching. The following elements emerged as particularly helpful for the participants: frequent interactions with the occupational therapist, opportunities to collaborate, personalized support, experimentation of new practices with the occupational therapist, and concrete training content that can benefit all students. CONCLUSION: The modalities of the program appear promising to help a school team facilitate the participation of all students, including those who are autistic.Implications for rehabilitationOccupational therapists can help school teams to facilitate the participation of autistic students and their peers.A combination of individual and team coaching sessions appears promising in helping school staff adopt practice changes to make their school more inclusive.Using a multi-tiered approach can help therapists collaborate with school staff members to first find solutions that will be applicable with all of their students.

User Experience of the Co-design Research Approach in eHealth: Activity Analysis With the Course-of-Action Framework.

BACKGROUND: The cocreation of eHealth solutions with potential users, or co-design, can help make the solution more acceptable. However, the co-design research approach requires substantial investment, and projects are not always fruitful. Researchers have provided guidelines for the co-design approach, but these are either applicable only in specific situations or not supported by empirical data. Ways to optimize the experience of the co-design process from the point of view of the participants are also missing. Scientific literature in the co-design field generally provides an extrinsic description of the experience of participants in co-design projects. OBJECTIVE: We addressed this issue by describing a co-design project and focusing on the participants' experiences looking at what was significant from their point of view. METHODS: We used a qualitative situated cognitive anthropology approach for this study. Data were collected on a co-design research project that aimed to support the help-seeking process of caregivers of functionally dependent older adults. The methodology was based on the perspective of experience by Dewey and used the course-of-action theoretical and methodological framework. Data collection was conducted in 2 phases: observation of participants and recording of sessions and participant self-confrontation interviews using the session recordings. We interviewed 27% (20/74) of the participants. We analyzed the data through nonexclusive emerging categorization of themes using the constant comparative method. RESULTS: In total, 5 emerging themes were identified. The perception of extrinsic constraints and the effects of the situation was central and the most important theme, affecting other themes (frustrating interactions with others, learning together, destabilization, and getting personal benefits). Co-occurrences between codes allowed for a visual and narrative understanding of what was significant for the participants during this project. The results highlighted the importance of the role of the research team in preparing and moderating the sessions. They also provided a detailed description of the interactions between participants during the sessions, which is a core aspect of the co-design approach. There were positive and negative aspects of the participants' experiences during this co-design project. Reflecting on our results, we provided potential affordances to shape the experience of participants in co-design. CONCLUSIONS: Potential users are an essential component of the co-design research approach. Researchers and designers should seek to offer these users a positive and contributory experience to encourage participation in further co-design initiatives. Future research should explore how the proposed affordances influence the success of the intervention.

Comparative educational outcomes of an active versus passive learning continuing professional development activity on self-management support for respiratory educators: A non-randomized controlled mixed-methods study.

AIM: We compared educational outcomes associated with an active vs. passive continuing professional development activity on self-management support for respiratory educators. BACKGROUND: There is a need to identify learning activities associated with the most successful continuing professional development programs for respiratory educators. DESIGN: This was a non-randomized controlled mixed-methods study recruiting respiratory educators attending a continuing professional development activity on self-management support. METHODS: In the experimental group, active learning methods (role-play simulations) were employed, whereas passive learning methods (lecture) were used in the comparison group. Educators were allocated to the comparison group (first 15 months of the study), then to the experimental group (last 17 months). Educators filled questionnaires measuring pre-/post-activity knowledge about self-management support (score 0-25) and self-reported competence (score 1-10). Scores were compared using mixed-effect models. Interviews with educators were conducted and content analysis was performed. RESULTS: We recruited 94/94 educators (active: n = 51; passive: n = 43). Knowledge scores increased to a greater extent in the active vs. passive learning group (adjusted difference-in-difference [aDID]=2.01; 95% confidence interval [95%CI]: 0.14-3.88), although competence scores increased to a greater extent in the passive learning group (aDID=-0.38; 95%CI: -1.56 to -0.04). Reflecting on their competence, educators of the active learning group identified the need to further improve their self-management support skills, whereas educators of the passive learning group did not. CONCLUSIONS: Our results show that an active learning continuing professional development activity on self-management support could help educators to better apply knowledge and appears to engage them in a process of reflection on action.

Co-Design to Support the Development of Inclusive eHealth Tools for Caregivers of Functionally Dependent Older Persons: Social Justice Design.

BACKGROUND: eHealth can help reduce social health inequalities (SHIs) as much as it can exacerbate them. Taking a co-design approach to the development of eHealth tools has the potential to ensure that these tools are inclusive. Although the importance of involving future users in the development of eHealth tools to reduce SHIs is highlighted in the scientific literature, the challenges associated with their participation question the benefits of this involvement as co-designers in a real-world context. OBJECTIVE: On the basis of Amartya Sen's theoretical framework of social justice, the aim of this study is to explore how co-design can support the development of an inclusive eHealth tool for caregivers of functionally dependent older persons. METHODS: This study is based on a social justice design and participant observation as part of a large-scale research project funded by the Ministry of Families as part of the Age-Friendly Quebec Program (Québec Ami des Aînés). The analysis was based on the method developed by Miles and Huberman and on Paillé's analytical questioning method. RESULTS: A total of 78 people participated in 11 co-design sessions in 11 Quebec regions. A total of 24 preparatory meetings and 11 debriefing sessions were required to complete this process. Co-designers participated in the creation of a prototype to support the search for formal services for caregivers. The majority of participants (except for 2) significantly contributed to the tool's designing. They also incorporated conversion factors to ensure the inclusiveness of the eHealth tool, such as an adequate level of digital literacy and respect for the caregiver's help-seeking process. In the course of the experiment, the research team's position regarding its role in co-design evolved from a neutral posture and promoting co-designer participation to one that was more pragmatic. CONCLUSIONS: The use of co-design involving participants at risk of SHIs does not guarantee innovation, but it does guarantee that the tool developed will comply with their process of help-seeking and their literacy level. Time issues interfere with efforts to carry out a democratic process in its ideal form. It would be useful to single out some key issues to guide researchers on what should be addressed in co-design discussions and what can be left out to make optimal use of this approach in a real-world context.

Integration of Conversion Factors for the Development of an Inclusive eHealth Tool With Caregivers of Functionally Dependent Older Persons: Social Justice Design.

BACKGROUND: eHealth can help reduce social health inequalities (SHIs); at the same time, it also has the potential to increase them. Several conversion factors can be integrated into the development of an eHealth tool to make it inclusive: (1) providing physical, technical, and financial access to eHealth; (2) enabling the integration of people at risk of SHIs into the research and development of digital projects targeting such populations (co-design or participatory research); (3) promoting consistency between the digital health literacy level of future users (FUs) and the eHealth tool; (4) developing an eHealth tool that is consistent with the technological skills of FUs; (5) ensuring that the eHealth tool is consistent with the help-seeking process of FUs; (6) respecting the learning capacities of FUs; and (7) being sensitive to FUs' cultural context. However, only little empirical evidence pointing out how these conversion factors can be integrated into an effective eHealth tool is available. OBJECTIVE: On the basis of Amartya Sen's theoretical framework of social justice, the objective of this study was to explore how these 7 conversion factors can be integrated into an eHealth tool for caregivers of functionally dependent older persons. METHODS: This study was based on a social justice design and participant observation as part of a large-scale research project funded by the Ministère de la Famille through the Quebec Ami des Aînés Program. Data were collected by recording the preparation sessions, the co-design and advisory committee sessions, as well as the debriefing sessions. The results were analyzed using Miles and Huberman's method. RESULTS: A total of 78 co-designers participated in 11 co-design sessions, 24 preparation sessions, and 11 debriefing sessions. Of the 7 conversion factors, 5 could be explored in this experiment. The integration of conversion factors has been uneven. The participation of FUs in the development of the tool supports other conversion factors. Respecting the eHealth literacy level of FUs means that their learning abilities and technological skills are also respected because they are closely related to one another and are therefore practically difficult to be distinguished. CONCLUSIONS: Conversion factors can be integrated into the development of eHealth tools that are intended to be inclusive and contribute to curbing SHIs by integrating FU participation into the tool design process.

COPD-Specific Self-Management Support Provided by Trained Educators in Everyday Practice is Associated with Improved Quality of Life, Health-Directed Behaviors, and Skill and Technique Acquisition: A Convergent Embedded Mixed-Methods Study.

BACKGROUND: There is a necessity to better document the effect of continuing education activities targeted at respiratory educators providing self-management support for patients with chronic obstructive pulmonary disease (COPD). We therefore sought to describe real-life COPD-specific self-management support delivered by respiratory educators who participated in a lecture-based continuing education activity and assess the outcomes of patients with COPD. METHODS: We conducted a convergent embedded mixed-methods study. Respiratory educators attended a 7-h, lecture-based continuing education activity on self-management support held in Québec, Canada. Four months after the continuing education activity, in their professional practice, trained educators provided self-management support to patients with COPD. One month later, to describe the components of self-management support provided, individual telephone interviews were conducted with educators. Interviews were transcribed verbatim and were qualitatively analyzed. Before self-management support and 6 months afterwards, we assessed the following clinical outcomes of patients with COPD: (1) quality of life (St. George's Respiratory Questionnaire for COPD patients, Impact domain; score 0-100; minimal clinically important difference = - 4; telephone administered); (2a) whether patients had one or more unscheduled doctor visit, (2b) one or more emergency room visit, and (2c) one or more hospitalization in the 6 preceding months (Survey on Living with Chronic Diseases in Canada; telephone administered); and (3a) health-directed behaviors and (3b) skill and technique acquisition (Health Education Impact Questionnaire; score 1-4; self-administered at home). We used mixed models to estimate mean differences and prevalence ratios, with associated 95% confidence intervals. RESULTS: Trained respiratory educators (nurse: n = 1; respiratory therapist: n = 3; ≥ 15 years of experience of care with patients with chronic disease) invited 75 patients with COPD to participate in the study. Fifty-four individuals with COPD (age, mean ± standard deviation: 68 ± 8 years; men: n = 31) were enrolled and received self-management support. Qualitative analyses revealed that self-management support consisted of one to two visits that included: (1) provision of information on COPD; (2) training in inhalation technique; and (3) smoking cessation advice. No educator reported implementing two or more follow-up visits because of a lack of time and human resources in their work setting. Among patients with COPD, improvements in quality of life were clinically important (adjusted mean difference = - 12.75; 95% confidence interval - 18.79 to - 6.71; p = 0.0001). Health-resource utilization was not different over time (all p values > 0.05). Improvements in health-directed behaviors and skill and technique acquisition were statistically significant (health-directed behaviors: adjusted mean difference = 0.50; 95% confidence interval 0.23-0.77; p = 0.0005; skill and technique acquisition: adjusted mean difference = 0.12; 95% confidence interval 0.01-0.23; p = 0.0293). CONCLUSIONS: Following a 7-h, lecture-based continuing education activity on COPD-specific self-management support, respiratory educators with significant experience of care provided self-management support that included provision of information, inhalation technique training, and smoking cessation advice. This resulted in enhanced patient quality of life, health-directed behaviors, and skill and technique acquisition. To decrease health resource utilization, the training could employ active learning methods. More time and resources could also be devoted to implementing regular follow-up visits. CLINICAL TRIALS REGISTRATION NO: NCT02870998.

Comparative impact of two continuing education activities targeted at COPD educators on educational outcomes: protocol for a non-randomized controlled study using mixed methods.

BACKGROUND: Therapeutic patient education (TPE) improves quality of life and reduces health care utilization among patients with chronic obstructive pulmonary disease (COPD). However, benefits from TPE might depend on the performance of the educators and training is needed to ensure the effective delivery of TPE interventions. Based on the framework by Moore et al. (J Contin Educ Health Prof 29:1-15, 2009), we will compare the impact of two continuing education (CE) activities on TPE in regard to the following educational outcomes: (1) learning, (2) self-report of competence, (3) performance of the educators, and (4) outcomes of COPD patients who will meet the newly trained educators for TPE. METHODS: We will conduct a non-randomized controlled study using mixed methods. Educators will first participate in a CE activity on TPE that will include a role-playing simulation (experimental group) or in a lecture on TPE (comparison group) and then will perform TPE in COPD patients. Among educators, we will assess: (1) learning, by measuring knowledge about TPE, and (2) self-report of competence using self-administered questionnaires before and after the activity. Then, after the CE activity, we will assess (3) educators' performance levels in delivering TPE by rating a videotaped TPE intervention. In COPD patients who will meet the newly trained educators for TPE after either CE activity, we will assess (4) quality of life and resource utilization using interviewer-administered questionnaires, before and after TPE. Statistical analyses will compare the experimental group against the comparison group using multivariate models. Using a semi-structured interview guide, we will conduct interviews with educators and perform content analysis. Results will be integrated in order that qualitative results further explain the quantitative ones. DISCUSSION: To the best of our knowledge, this is the first controlled mixed methods study to compare the impact of two CE activities on TPE in regard to four educational outcomes. We believe this study will serve as a model for evaluating CE activities on TPE. Results from this study could increase educators' performance levels in delivering effective TPE interventions, and, in turn, COPD patient outcomes. TRIAL REGISTRATION: The study was registered on https://clinicaltrials.gov/ ( NCT02870998 ) on March 15, 2016.

Social Health Inequalities and eHealth: A Literature Review With Qualitative Synthesis of Theoretical and Empirical Studies.

BACKGROUND: eHealth is developing rapidly and brings with it a promise to reduce social health inequalities (SHIs). Yet, it appears that it also has the potential to increase them. OBJECTIVES: The general objective of this review was to set out how to ensure that eHealth contributes to reducing SHIs rather than exacerbating them. This review has three objectives: (1) identifying characteristics of people at risk of experiencing social inequality in health; (2) determining the possibilities of developing eHealth tools that avoid increasing SHI; and (3) modeling the process of using an eHealth tool by people vulnerable to SHI. METHODS: Following the EPPI approach (Evidence for Policy and Practice of Information of the Institute of Education at the University of London), two databases were searched for the terms SHIs and eHealth and their derivatives in titles and abstracts. Qualitative, quantitative, and mixed articles were included and evaluated. The software NVivo (QSR International) was employed to extract the data and allow for a metasynthesis of the data. RESULTS: Of the 73 articles retained, 10 were theoretical, 7 were from reviews, and 56 were based on empirical studies. Of the latter, 40 used a quantitative approach, 8 used a qualitative approach, 4 used mixed methods approach, and only 4 were based on participatory research-action approach. The digital divide in eHealth is a serious barrier and contributes greatly to SHI. Ethnicity and low income are the most commonly used characteristics to identify people at risk of SHI. The most promising actions for reducing SHI via eHealth are to aim for universal access to the tool of eHealth, become aware of users' literacy level, create eHealth tools that respect the cultural attributes of future users, and encourage the participation of people at risk of SHI. CONCLUSIONS: eHealth has the potential to widen the gulf between those at risk of SHI and the rest of the population. The widespread expansion of eHealth technologies calls for rigorous consideration of interventions, which are not likely to exacerbate SHI.

Structures of a pan-specific antagonist antibody complexed to different isoforms of TGFß reveal structural plasticity of antibody-antigen interactions.

Various important biological pathways are modulated by TGFß isoforms; as such they are potential targets for therapeutic intervention. Fresolimumab, also known as GC1008, is a pan-TGFß neutralizing antibody that has been tested clinically for several indications including an ongoing trial for focal segmental glomerulosclerosis. The structure of the antigen-binding fragment of fresolimumab (GC1008 Fab) in complex with TGFß3 has been reported previously, but the structural capacity of fresolimumab to accommodate tight interactions with TGFß1 and TGFß2 was insufficiently understood. We report the crystal structure of the single-chain variable fragment of fresolimumab (GC1008 scFv) in complex with target TGFß1 to a resolution of 3.00 Å and the crystal structure of GC1008 Fab in complex with TGFß2 to 2.83 Å. The structures provide further insight into the details of TGFß recognition by fresolimumab, give a clear indication of the determinants of fresolimumab pan-specificity and provide potential starting points for the development of isoform-specific antibodies using a fresolimumab scaffold.

Role of nitric oxide and protein kinase C in the tachyphylaxis to vasopressin in rat aortic rings.

The contribution of endothelium-derived mediators and protein kinase C in the tachyphylaxis to arginine vasopressin (AVP) was assessed in the rat aorta. Endothelium-intact (E+) and denuded rings (E-) obtained from the rat thoracic aorta were exposed to three administrations of a supramaximal concentration of AVP (100 nM), lasting 20 min and 45 min apart. N-Omega-nitro-L-arginine (NNLA), a non-selective inhibitor of all isoforms of NO synthase, and AMT, a selective inhibitor for the inducible (iNOS) and neuronal (nNOS) isoforms, diminished the tachyphylaxis to AVP significantly in both E+ and in E- rings. No iNOS could be detected by Western blots in freshly isolated rings or in rings exposed to AVP, despite a strong signal in rings isolated from LPS-treated rats, while nNOS could be constitutively detected. Inhibition of prostaglandins or epoxyeicosatrienoic acids (EETs) synthesis by diclofenac or clotrimazole, respectively, had no effect on tachyphylaxis while combination of these agents diminished tachyphylaxis in E+ only. Combination of NNLA, diclofenac and clotrimazole blocked completely the tachyphylaxis. Inhibition of PKC by either chelerythrine or bisindolylmaleimide I-HCl (BisI) led to a significant diminution of AVP tachyphylaxis only in E-. Activation of PKC with phorbol-12-myristate-13-acetate (PMA) simulated tachyphylaxis to AVP in E- only, effect blocked by the NO donor, SNP. In conclusion, NO produced from constitutive nNOS present in vascular smooth muscle cells participates in tachyphylaxis to AVP. PKC is involved in this tachyphylaxis only in E- rings, the presence of NO probably diminishing the effects of this kinase.

Quantification of total mitochondrial DNA and the 4977-bp common deletion in Pearson's syndrome lymphoblasts using a fluorogenic 5'-nuclease (TaqMan) real-time polymerase chain reaction assay and plasmid external calibration standards.

This study describes a multiplex real-time polymerase chain reaction (PCR) assay that quantifies total mitochondrial DNA (mtDNA(total)) and mtDNA bearing the 4977-base pair 'common deletion' (deltamtDNA4977) in lymphoblasts derived from an individual diagnosed with Pearson's syndrome. The method is unique in its use of plasmids as external quantification standards and its use of multiplex conditions. Standards are validated by comparison with purified mtDNA amplification curves and by the fact that curves are largely unaffected by nuclear DNA (nucDNA). Finally, slopes of standard curves and unknowns are shown to be similar to each other and to theoretical predictions. From these data, mtDNA(total) in these cells is calculated to be 3258 (+723/-592) copies per cell while deltamtDNA4977 averages 232 (+136/-86) copies per cell or 7% (+4.65/-2.81).

Biological dosimetry using human interphase peripheral blood lymphocytes.

Conventional metaphase-spread chromosome-aberration-based biodosimetry techniques for radiation dose assessment, although robust, are laborious and time consuming. The molecular cytogenetic laboratory of the Armed Forces Radiobiology Research Institute is developing simple and rapid interphase-based cytological assays that will be applicable to a broad range of radiation exposure scenarios. These assays include analysis of chromosome aberrations (premature chromosome condensation-fluorescence in situ hybridization assay) and mitochondrial DNA mutations (mtDNA4977 deletion assay) using resting human peripheral blood lymphocytes. The dose-effect relationship for radiation-induced aberrations involving chromosome 1 after 24 hours of repair at 37 degrees C in resting human peripheral blood lymphocytes was studied using fluorescence in situ hybridization after chemical induction of premature chromosome condensation as previously explained. In the present study, we examined whether gamma irradiation in the range of 0 to 7.5 Gy induces a dose-dependent increase in aberrations manifested as "excess spots." The number of excess spots per cell, reflecting aberrations involving chromosome 1, increased from 0.035 at 0.5 Gy to 0.236 at 7.5 Gy. This observed dose-effect relationship was fit with a nonlinear power model. This technique may be extended to the study of radiation-induced translocations in interphase cells for retrospective dose reconstruction. With a recently developed in situ polymerase chain reaction method to detect and quantify mtDNA deletion in interphase cells after radiation exposure in cultured human peripheral blood lymphocytes, 90% to 95% of cells are analyzable. We discuss the potential use of the mtDNA deletion assay in biological dosimetry applications. Interphase-based cytological assays may eliminate some inherent problems associated with metaphase-spread-based assays. These problems involve (1) the limited number of analyzable cells containing chromosome aberrations, which is due to various factors including radiation-induced cell death and delay in cell cycle progression into mitosis, and (2) the requirements for radiation cytogenetics expertise and tedious labor to manually score chromosome aberrations.

Nucleic acid molecular biomarkers for diagnostic biodosimetry applications: use of the fluorogenic 5'-nuclease polymerase chain reaction assay.

A reliable, relatively easy method for diagnostic assessment of radiation exposure is needed to support the triage of radiation casualties and medical treatment decisions in military defense operations. Our strategy is to identify radiation-responsive DNA mutations and gene expression targets that can be analyzed using polymerase chain reaction (PCR) assays and an existing fluorescence-based nucleic acid analysis system designed for forward-deployable laboratory applications. Using an in vitro model system of human peripheral blood lymphocytes, we identified a candidate nucleic acid biomarker (i.e., gene expression target) that is responsive to ionizing radiation. In this report, we describe our preliminary Haras gene expression findings. A dose-dependent elevation in Haras gene expression levels was demonstrated using Northern-blot analysis 17 hours after exposure to a 250-kVp dose of X-rays (25-100 cGy, 1 Gy/minute); c-Haras expression levels at 100 cGy were ninefold higher than those of controls. An alternative protocol to quantify the Haras cDNA target, using the rapid, real-time reverse transcriptase fluorogenic 5'-nuclease PCR assay, is described, along with a preliminary characterization of the dynamic range for detection. Our research shows that the analysis of multitarget nucleic acid biomarkers, using the multiplex fluorogenic 5'-nuclease PCR assay, has beneficial applications in radiation epidemiology, radiation therapy, and biodosimetry.