Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry.

BACKGROUND: In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings. METHODS: We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use. RESULTS: We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment. CONCLUSION: In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.

Adolescent Females' Dyadic Conversations About Body, Weight, and Appearance.

Body talk among adolescent females has been associated with negative outcomes, including depressed mood, disordered eating, and body dissatisfaction. Yet, little work has investigated the manifestation of body talk in actual conversations between adolescent females or explored pathways through which body talk is spread (e.g., co-rumination). The present study examined body talk among adolescent female dyads (N = 23 dyads) ages 13 to 17 (Mage = 15.12) using an observational design. Reciprocally nominated dyads were recruited from a high school in the southeastern United States. Conversations between dyads were qualitatively coded using an applied thematic analysis approach. Identified themes were related to weight, appearance, and personality. Results provide insight into the social context in which sociocultural norms of weight stigma, body dissatisfaction, and eating-related psychopathology may be reinforced. Findings have implications for informing the development of interventions to reduce co-rumination of negative weight- and appearance-related body talk and to promote positive body image and healthy weight among adolescent girls.

Quantification of T2-FLAIR Mismatch in Nonenhancing Diffuse Gliomas Using Digital Subtraction.

BACKGROUND AND PURPOSE: The T2-FLAIR mismatch sign on MR imaging is a highly specific imaging biomarker of isocitrate dehydrogenase (IDH)-mutant astrocytomas, which lack 1p/19q codeletion. However, most studies using the T2-FLAIR mismatch sign have used visual assessment. This study quantified the degree of T2-FLAIR mismatch using digital subtraction of fluid-nulled T2-weighted FLAIR images from non-fluid-nulled T2-weighted images in human nonenhancing diffuse gliomas and then used this information to assess improvements in diagnostic performance and investigate subregion characteristics within these lesions. MATERIALS AND METHODS: Two cohorts of treatment-naïve, nonenhancing gliomas with known IDH and 1p/19q status were studied (n = 71 from The Cancer Imaging Archive (TCIA) and n = 34 in the institutional cohort). 3D volumes of interest corresponding to the tumor were segmented, and digital subtraction maps of T2-weighted MR imaging minus T2-weighted FLAIR MR imaging were used to partition each volume of interest into a T2-FLAIR mismatched subregion (T2-FLAIR mismatch, corresponding to voxels with positive values on the subtraction maps) and nonmismatched subregion (T2-FLAIR nonmismatch corresponding to voxels with negative values on the subtraction maps). Tumor subregion volumes, percentage of T2-FLAIR mismatch volume, and T2-FLAIR nonmismatch subregion thickness were calculated, and 2 radiologists assessed the T2-FLAIR mismatch sign with and without the aid of T2-FLAIR subtraction maps. RESULTS: Thresholds of ≥42% T2-FLAIR mismatch volume classified IDH-mutant astrocytoma with a specificity/sensitivity of 100%/19.6% (TCIA) and 100%/31.6% (institutional); ≥25% T2-FLAIR mismatch volume showed 92.0%/32.6% and 100%/63.2% specificity/sensitivity, and ≥15% T2-FLAIR mismatch volume showed 88.0%/39.1% and 93.3%/79.0% specificity/sensitivity. In IDH-mutant astrocytomas with ≥15% T2-FLAIR mismatch volume, T2-FLAIR nonmismatch subregion thickness was negatively correlated with the percentage T2-FLAIR mismatch volume (P < .0001) across both cohorts. The percentage T2-FLAIR mismatch volume was higher in grades 3-4 compared with grade 2 IDH-mutant astrocytomas (P < .05), and ≥15% T2-FLAIR mismatch volume IDH-mutant astrocytomas were significantly larger than <15% T2-FLAIR mismatch volume IDH-mutant astrocytoma (P < .05) across both cohorts. When evaluated by 2 radiologists, the additional use of T2-FLAIR subtraction maps did not show a significant difference in interreader agreement, sensitivity, or specificity compared with a separate evaluation of T2-FLAIR and T2-weighted MR imaging alone. CONCLUSIONS: T2-FLAIR digital subtraction maps may be a useful, automated tool to obtain objective segmentations of tumor subregions based on quantitative thresholds for classifying IDH-mutant astrocytomas using the percentage T2 FLAIR mismatch volume with 100% specificity and exploring T2-FLAIR mismatch/T2-FLAIR nonmismatch subregion characteristics. Conversely, the addition of T2-FLAIR subtraction maps did not enhance the sensitivity or specificity of the visual T2-FLAIR mismatch sign assessment by experienced radiologists.

Alcohol and drug use severity are independently associated with antiretroviral adherence in the current treatment era.

Substance use in people with HIV (PWH) negatively impacts antiretroviral therapy (ART) adherence. However, less is known about this in the current treatment era and the impact of specific substances or severity of substance use. We examined the associations of alcohol, marijuana, and illicit drug use (methamphetamine/crystal, cocaine/crack, illicit opioids/heroin) and their severity of use with adherence using multivariable linear regression in adult PWH in care between 2016 and 2020 at 8 sites across the US. PWH completed assessments of alcohol use severity (AUDIT-C), drug use severity (modified ASSIST), and ART adherence (visual analogue scale). Among 9400 PWH, 16% reported current hazardous alcohol use, 31% current marijuana use, and 15% current use of ≥1 illicit drugs. In multivariable analysis, current methamphetamine/crystal use, particularly common among men who had sex with men, was associated with 10.1% lower mean ART adherence (p < 0.001) and 2.6% lower adherence per 5-point higher severity of use (ASSIST score) (p < 0.001). Current and more severe use of alcohol, marijuana, and other illicit drugs were also associated with lower adherence in a dose-dependent manner. In the current HIV treatment era, individualized substance use treatment, especially for methamphetamine/crystal, and ART adherence should be prioritized.

Burnout Among Nursing Home Care Aides and the Effects on Resident Outcomes.

While burnout among health care workers has been well studied, little is known about the extent to which burnout among health care workers impacts the outcomes of their care recipients. To test this, we used a multi-year (2014-2020) survey of care aides working in approximately 90 nursing homes (NHs); the survey focused on work-life measures, including the Maslach Burnout Inventory (MBI) and work-unit identifier. Resident Assessment Instrument Minimum Data Set (RAI-MDS 2.0) data were obtained on all residents in the sampled NHs during this time and included a unit identifier for each resident. We used multi-level models to test associations between the MBI emotional exhaustion and cynicism sub-scales reported by care aides and the resident outcomes of antipsychotics without indication, depressive symptoms, and responsive behaviors among residents on units. In 2019/2020, our sample included 3,547 care aides and 10,117 residents in 282 units. The mean frequency of emotional exhaustion and cynicism across units was 43% and 50%, respectively. While residents frequently experienced antipsychotics without indication 1,852 (18.3%), depressive symptoms 2,089 (20.7%), and responsive behaviors 3,891 (38.5%), none were found to be associated with either emotional exhaustion or cynicism among care aides.

Expanded statistical analysis of squats on the Great Britain (GB) mainline network.

Squat defects are one of the most common rail surface defects. Significant research effort has gone into understand squat defects over the last 10 years which has brought about important developments in the understanding of their initiation mechanism; however, further work is still required to fully understand squat and the best methods to control them. This study considers records of squat defects over a period 9 years, considering 2600 km of track across 8 different routes on the GB mainline network. The analysis separately reviews squats on: plainline, crossings, joints and welds. Results include an overview of the main factors influencing the development of each type of squats, practical methods to immediately reduce and manage squat defects and recommends focus areas for further research to understand squat defects. Results suggest that squats on plainline, crossings, joints and welds, all correlate with different influencing factors; headcheck defects appear to significantly influence the probability of squats and how other factors influence squat development. There is a strong connection between total head wear rate (combined material removal due to traffic and grinding) and squats; 90 % of all squats appear on rail with a headwear rate of <0.2 mm/year. Overall larger section rail (60 kg/m vs 56 kg/m) and harder material (260 Brinell vs 220 Brinell) is significantly less susceptible to squat damage. Track curvature has an influence of squat development, especially in rail with no headcheck cracking, where the tightest curves are significantly more likely to sustain squat damage. The probability of squat at vertical discontinuities, i.e. joints and crossings are significantly more likely as train speed increases. Whilst squats on joints are 1000 time more likely than squats on welds.

Optimizing the design and implementation of question prompt lists to support person-centred care: A scoping review.

INTRODUCTION: Question prompt lists (QPLs) are lists of questions that patients may want to discuss with clinicians. QPLs support person-centred care and have been associated with many beneficial outcomes including improved patient question-asking, and the amount and quality of the information provided by clinicians. The purpose of this study was to review published research on QPLs to explore how QPL design and implementation can be optimized. METHODS: We performed a scoping review by searching MEDLINE, EMBASE, Scopus, CINAHL, Cochrane Library and Joanna Briggs Database from inception to 8 May 2022, for English language studies of any design that evaluated QPLs. We used summary statistics and text to report study characteristics, and QPL design and implementation. RESULTS: We included 57 studies published from 1988 to 2022 by authors in 12 countries on a range of clinical topics. Of those, 56% provided the QPL, but few described how QPLs were developed. The number of questions varied widely (range 9-191). Most QPLs were single-page handouts (44%) but others ranged from 2 to 33 pages. Most studies implemented a QPL alone with no other accompanying strategy; most often in a print format before consultations by mail (18%) or in the waiting room (66%). Both patients and clinicians identified numerous benefits to patients of QPLs (e.g., increased patient confidence to ask questions, and patient satisfaction with communication or care received; and reduced anxiety about health status or treatment). To support use, patients desired access to QPLs in advance of clinician visits, and clinicians desired information/training on how to use the QPL and answer questions. Most (88%) studies reported at least one beneficial impact of QPLs. This was true even for single-page QPLs with few questions unaccompanied by other implementation strategies. Despite favourable views of QPLs, few studies assessed outcomes amongst clinicians. CONCLUSION: This review identified QPL characteristics and implementation strategies that may be associated with beneficial outcomes. Future research should confirm these findings via systematic review and explore the benefits of QPLs from the clinician's perspective. PATIENT/PUBLIC CONTRIBUTION: Following this review, we used the findings to develop a QPL on hypertensive disorders of pregnancy and interviewed women and clinicians about QPL design including content, format, enablers and barriers of use, and potential outcomes including beneficial impacts and possible harms (will be published elsewhere).

Vaporized nicotine use among patients in HIV care who smoke tobacco: perceived health effects and effectiveness as a smoking cessation tool.

Evidence suggests adverse health effects from vaporized nicotine (VN) use, such as electronic "e" cigarettes, and limited efficacy to aid tobacco cessation. People with HIV (PWH) smoke tobacco at higher rates than the general population, with greater morbidity, highlighting the necessity of effective tobacco cessation tools. PWH may be more vulnerable to adverse effects of VN. Using semi-structured 1:1 interviews, we examined health beliefs regarding VN, patterns of use, and perceived effectiveness for tobacco cessation among PWH in HIV care at three geographically diverse U.S. sites. PWH (n = 24) had limited understanding of VN product content or health effects, presuming VN less harmful than tobacco cigarettes (TC). VN failed to adequately replicate the psychoactive effects or desired ritual of smoking TC. Concurrent TC use, and continuous VN use throughout the day, was common. Satiety using VN was elusive, and consumption quantity was difficult to track. VN had limited desirability and durability as a TC cessation tool among the interviewed PWH.

Artificial intelligence (AI)-based decision support improves reproducibility of tumor response assessment in neuro-oncology: An international multi-reader study.

BACKGROUND: To assess whether artificial intelligence (AI)-based decision support allows more reproducible and standardized assessment of treatment response on MRI in neuro-oncology as compared to manual 2-dimensional measurements of tumor burden using the Response Assessment in Neuro-Oncology (RANO) criteria. METHODS: A series of 30 patients (15 lower-grade gliomas, 15 glioblastoma) with availability of consecutive MRI scans was selected. The time to progression (TTP) on MRI was separately evaluated for each patient by 15 investigators over two rounds. In the first round the TTP was evaluated based on the RANO criteria, whereas in the second round the TTP was evaluated by incorporating additional information from AI-enhanced MRI sequences depicting the longitudinal changes in tumor volumes. The agreement of the TTP measurements between investigators was evaluated using concordance correlation coefficients (CCC) with confidence intervals (CI) and P-values obtained using bootstrap resampling. RESULTS: The CCC of TTP-measurements between investigators was 0.77 (95% CI = 0.69,0.88) with RANO alone and increased to 0.91 (95% CI = 0.82,0.95) with AI-based decision support (P = .005). This effect was significantly greater (P = .008) for patients with lower-grade gliomas (CCC = 0.70 [95% CI = 0.56,0.85] without vs. 0.90 [95% CI = 0.76,0.95] with AI-based decision support) as compared to glioblastoma (CCC = 0.83 [95% CI = 0.75,0.92] without vs. 0.86 [95% CI = 0.78,0.93] with AI-based decision support). Investigators with less years of experience judged the AI-based decision as more helpful (P = .02). CONCLUSIONS: AI-based decision support has the potential to yield more reproducible and standardized assessment of treatment response in neuro-oncology as compared to manual 2-dimensional measurements of tumor burden, particularly in patients with lower-grade gliomas. A fully-functional version of this AI-based processing pipeline is provided as open-source (https://github.com/NeuroAI-HD/HD-GLIO-XNAT).

Amine-weighted chemical exchange saturation transfer magnetic resonance imaging in brain tumors.

Amine-weighted chemical exchange saturation transfer (CEST) magnetic resonance imaging (MRI) is particularly valuable as an amine- and pH-sensitive imaging technique in brain tumors, targeting the intrinsically high concentration of amino acids with exchangeable amine protons and reduced extracellular pH in brain tumors. Amine-weighted CEST MRI contrast is dependent on the glioma genotype, likely related to differences in degree of malignancy and metabolic behavior. Amine-weighted CEST MRI may provide complementary value to anatomic imaging in conventional and exploratory therapies in brain tumors, including chemoradiation, antiangiogenic therapies, and immunotherapies. Continual improvement and clinical testing of amine-weighted CEST MRI has the potential to greatly impact patients with brain tumors by understanding vulnerabilities in the tumor microenvironment that may be therapeutically exploited.

Nurses' work, work psychology, and the evolution & devolution of care provision in nursing homes: A scoping review.

Background: Societal aging is exerting profound impacts on providers of long-term care. Nurses provide much of the direct care in the long-term care sector, and they increasingly provide unit- and facility-level leadership and fill top administrative and clinical roles.The work health and quality of work life of long-term care nurses are emergent concerns and the foci of research across multiple disciplines. Objectives: To enhance our understanding of factors influencing long-term care nurses' work health and quality of work life, we summarize the findings of disparate studies across diverse disciplines, time, and jurisdictions. Eligibility criteria: No restrictions were placed on study date, design, or country. Searches were restricted to English language only or translated studies. Included studies reported associations and relationships between/amongst nurses' work (role and work design), work environments, work attitudes, and work outcomes. Published peer-reviewed studies and reviews were included, as were reports. Editorials and opinion pieces were excluded. The search included publications up to March 2022. Sources of evidence: Medline, CINAHL, PsychINFO, EMBASE, Scopus, PSNet. Charting methods: Data abstraction from full-text articles. Results: The evolution of long-term care nurses' work to include both medical and administrative responsibilities has generally not been managed well, resulting in persistent role ambiguity, job dissatisfaction, and burnout. Nurses are concerned about their capacity to provide resident care and the adequacy of their preparation. Their work environments are under-resourced, and they are at high risk for workplace injury or violence. Supervisory and organizational support can be protective of negative aspects of nurses' work environments. Supervisory support can improve the immediate work environment, assist nurses in fulfilling their roles, and afford greater role clarity, and supervisors can influence their nursing staff's perceptions of the work safety and the value that their organization places on them. Organizational support can reduce work stress, enhance feelings of self-worth, and mitigate some of the self-stigmatization that influences long-term care nurses' attitudes toward themselves and their work, which influences work outcomes, including job performance and quality of resident care. Conclusions: Work stress, burnout, increased turnover, decreased morale and work motivation, increased health and safety concerns, and decreases in job satisfaction accompanied by self-stigmatization are all indicators of a system that has failed nurses, other long-term care staff, and nursing home residents. We consider the implications of our findings for enhancing the work health and quality of life of nurses working in long-term care and identify gaps in knowledge about their psychological health that merit future study. Tweetable Abstract: The long-term care sector is failing nurses globally. This review is a step toward understanding how we can improve the work psychology, including work-related psychological health, of nurses in long-term care.

Implementing a complex hospital innovation: conceptual underpinnings, program design and implementation of a complex innovation in an international multi-site hospital trial.

BACKGROUND: Designing implementation programs that effectively integrate complex healthcare innovations into complex settings is a fundamental aspect of knowledge translation. We describe the development of a conceptually grounded implementation program for a complex healthcare innovation and its subsequent application in pediatric hospital settings. METHODS: We conducted multiple case observations of the application of the Phased Reciprocal Implementation Synergy Model (PRISM) framework in the design and operationalization of an implementation program for a complex hospital wide innovation in pediatric hospital settings. RESULTS: PRISM informed the design and delivery of 10 international hospital wide implementations of the complex innovation, BedsidePEWS. Implementation and innovation specific goals, overarching implementation program design principles, and a phased-based, customizable, and context responsive implementation program including innovation specific tools and evaluation plans emerged from the experience. CONCLUSION: Theoretically grounded implementation approaches customized for organizational contexts are feasible for the adoption and integration of this complex hospital-wide innovation. Attention to the fitting of the innovation to local practices, setting, organizational culture and end-user preferences can be achieved while maintaining the integrity of the innovation.

Relapse patterns and radiation dose exposure in IDH wild-type glioblastoma at first radiographic recurrence following chemoradiation.

PURPOSE: To quantify the radiation dose distribution and lesion morphometry (shape) at baseline, prior to chemoradiation, and at the time of radiographic recurrence in patients with glioblastoma (GBM). METHODS: The IMRT dose distribution, location of the center of mass, sphericity, and solidity of the contrast enhancing tumor at baseline and the time of tumor recurrence was quantified in 48 IDH wild-type GBM who underwent postoperative IMRT (2 Gy daily for total of 60 Gy) with concomitant and adjuvant temozolomide. RESULTS: Average radiation dose within enhancing tumor at baseline and recurrence was ≥ 60 Gy. Centroid location of the enhancing tumor shifted an average of 11.3 mm at the time of recurrence with respect to pre-IMRT location. A positive correlation was observed between change in centroid location and PFS in MGMT methylated patients (P = 0.0007) and Cox multivariate regression confirmed centroid distance from baseline was associated with PFS when accounting for clinical factors (P = 0.0189). Lesion solidity was higher at recurrence compared to baseline (P = 0.0118). Tumors that progressed > 12 weeks after IMRT were significantly more spherical (P = 0.0094). CONCLUSION: Most GBMs recur local within therapeutic IMRT doses; however, tumors with longer PFS occurred further from the original tumor location and were more solid and/or nodular.

The (After)life of a Trial: Biocommunicability of an At-Risk Pregnancy.

The publication of A Randomized Trial of Induction Versus Expectant Management (ARRIVE), conducted in the United States in 2018, heralded a paradigm shift within the obstetrical management of term pregnancy among people who have not previously given birth. ARRIVE finds its home among other canonical - and controversial - randomized controlled trials (RCTs) within obstetrics. We argue that RCTs have their own (after)life, both creating new subjects for biomedical intervention and recalibrating who reproductive health practitioners consider to be at risk of adverse health outcomes. These data have important consequences for medical social scientific engagement with RCTs to further interrogate the questions of risk and intervention within reproductive health.

What Is Old Is New Again: Global Issues Influencing Workers and Their Work in Long-Term Care.

We offer a broad understanding of contemporary issues relevant to the long-term care (LTC) sector and its workers, globally, and the concurrent evolution and involution of these workers' roles, their work and policy environments. While contemporary, most issues are also longstanding and fall into two broad categories: issues relating to the work environments in LTC, including resource availability and worker support, and issues relating to the changing nature of LTC work. We identify five key challenges that relate to the system structures of the LTC sector.

Characterization of Cognitive Function in Survivors of Diffuse Gliomas Using Morphometric Correlation Networks.

This pilot study investigates structural alterations and their relationships with cognitive function in survivors of diffuse gliomas. Twenty-four survivors of diffuse gliomas (mean age 44.5 ± 11.5), from whom high-resolution T1-weighted images, neuropsychological tests, and self-report questionnaires were obtained, were analyzed. Patients were grouped by degree of cognitive impairment, and interregional correlations of cortical thickness were computed to generate morphometric correlation networks (MCNs). The results show that the cortical thickness of the right insula (R2 = 0.3025, p = 0.0054) was negatively associated with time since the last treatment, and the cortical thickness of the left superior temporal gyrus (R2 = 0.2839, p = 0.0107) was positively associated with cognitive performance. Multiple cortical regions in the default mode, salience, and language networks were identified as predominant nodes in the MCNs of survivors of diffuse gliomas. Compared to cognitively impaired patients, cognitively non-impaired patients tended to have higher network stability in network nodes removal analysis, especially when the fraction of removed nodes (among 66 nodes in total) exceeded 55%. These findings suggest that structural networks are altered in survivors of diffuse gliomas and that their cortical structures may also be adapting to support cognitive function during survivorship.

A qualitative descriptive study of the role of nurse, allied health and physician middle managers who function as knowledge brokers in hospitals.

BACKGROUND: Knowledge brokers (KB) are increasingly being employed in health care to implement evidence-based practice and improve quality of care. Middle managers (MMs) may play a KB role in the implementation of an innovative or evidence-based practice in hospitals. However, how MMs' broker knowledge in hospitals and their impact on practice has not been adequately studied. AIM: To describe the role that MMs play in brokering knowledge in hospitals and their impact. METHOD: A qualitative descriptive study was conducted to generate a detailed description of MM experiences as KBs in hospitals. Data were collected using semi-structured telephone interviews with MMs in Ontario, Canada. Participants were purposively sampled to ensure variation in MM characteristics and a diverse representation of perspectives. Data were collected and analyzed concurrently using an inductive constant comparative approach. RESULTS: Twenty-one MMs from teaching and non-teaching hospitals participated. MMs described 10 roles and activities they enacted in hospitals that aligned with published KB roles. We found differences across professional groups and hospital type. Teaching status emerged as a potential factor relating to how MM KBs were able to function within hospitals. MMs reported enhanced patient, provider, and organizational outcomes. LINKING EVIDENCE TO ACTION: Middle managers may play an important KB role in the implementation of evidence-based practice in hospitals. An improved understanding of the KB roles that MMs play may be important in boosting evidence base practice in health care to ultimately improve quality of care. Administrators need a better understanding of the current KB roles and activities MMs enact as this may lead to more organizational structures to support MM KBs in health care.

Influences of post-implementation factors on the sustainability, sustainment, and intra-organizational spread of complex interventions.

BACKGROUND: Complex interventions are increasingly applied to healthcare problems. Understanding of post-implementation sustainment, sustainability, and spread of interventions is limited. We examine these phenomena for a complex quality improvement initiative led by care aides in 7 care homes (long-term care homes) in Manitoba, Canada. We report on factors influencing these phenomena two years after implementation. METHODS: Data were collected in 2019 via small group interviews with unit- and care home-level managers (n = 11) from 6 of the 7 homes using the intervention. Interview participants discussed post-implementation factors that influenced continuing or abandoning core intervention elements (processes, behaviors) and key intervention benefits (outcomes, impact). Interviews were audio-recorded, transcribed verbatim, and analyzed with thematic analysis. RESULTS: Sustainment of core elements and sustainability of key benefits were observed in 5 of the 6 participating care homes. Intra-unit intervention spread occurred in 3 of 6 homes. Factors influencing sustainment, sustainability, and spread related to intervention teams, unit and care home, and the long-term care system. CONCLUSIONS: Our findings contribute understanding on the importance of micro-, meso-, and macro-level factors to sustainability of key benefits and sustainment of some core processes. Inter-unit spread relates exclusively to meso-level factors of observability and practice change institutionalization. Interventions should be developed with post-implementation sustainability in mind and measures taken to protect against influences such as workforce instability and competing internal and external demands. Design should anticipate need to adapt interventions to strengthen post-implementation traction.

Diagnostic and Prognostic Value of pH- and Oxygen-Sensitive Magnetic Resonance Imaging in Glioma: A Retrospective Study.

Characterization of hypoxia and tissue acidosis could advance the understanding of glioma biology and improve patient management. In this study, we evaluated the ability of a pH- and oxygen-sensitive magnetic resonance imaging (MRI) technique to differentiate glioma genotypes, including isocitrate dehydrogenase (IDH) mutation, 1p/19q co-deletion, and epidermal growth factor receptor (EGFR) amplification, and investigated its prognostic value. A total of 159 adult glioma patients were scanned with pH- and oxygen-sensitive MRI at 3T. We quantified the pH-sensitive measure of magnetization transfer ratio asymmetry (MTRasym) and oxygen-sensitive measure of R2' within the tumor region-of-interest. IDH mutant gliomas showed significantly lower MTRasym × R2' (p < 0.001), which differentiated IDH mutation status with sensitivity and specificity of 90.0% and 71.9%. Within IDH mutants, 1p/19q codeletion was associated with lower tumor acidity (p < 0.0001, sensitivity 76.9%, specificity 91.3%), while IDH wild-type, EGFR-amplified gliomas were more hypoxic (R2' p = 0.024, sensitivity 66.7%, specificity 76.9%). Both R2' and MTRasym × R2' were significantly associated with patient overall survival (R2': p = 0.045; MTRasym × R2': p = 0.002) and progression-free survival (R2': p = 0.010; MTRasym × R2': p < 0.0001), independent of patient age, treatment status, and IDH status. The pH- and oxygen-sensitive MRI is a clinically feasible and potentially valuable imaging technique for distinguishing glioma subtypes and providing additional prognostic value to clinical practice.