Interprofessional Teams Supporting Care Transitions from Hospital to Community: A Scoping Review.

Introduction: Poor outcomes following the transition from hospital back to community living are common, especially for older adults with complex health and social care needs. Some health care systems now have multiple interprofessional teams (in hospital and community) to support care transitions. These teams will need to be well coordinated to improve care transition outcomes. Methods: We conducted a scoping review to identify and map peer-reviewed literature on how interprofessional teams are working together to support older adults transitioning from hospital back to the community. We used the six-stage framework developed by Levac and colleagues (2010). Procedures were guided by the Joanna Briggs Institute scoping review guidelines. Results: Our structured search and screening process resulted in 70 articles, published between 2000 and 2022, from 14 counties. Within these articles, 26 programs were described that used interprofessional teams in both the hospital and community. Discussion: The qualitative articles suggested that effective teamwork is very important for promoting care transition quality, but the quantitative research did not report on team-related outcomes. Quantitative research has described, but not evaluated, strategies for promoting interprofessional collaboration. Conclusion: Future research should focus on evaluating processes used to promote effective interprofessional teamwork in care transition interventions.

Primary care occupational, physical, and respiratory therapy role adaptation in the first year of the COVID-19 pandemic.

BACKGROUND: Occupational, physical and respiratory therapists are relatively new to primary care settings, and thus their roles are still emerging. The COVID-19 pandemic was a time of abrupt changes in professional roles. Professional role adaptations are integral to the ability of health care teams to respond to day-to-day care delivery challenges, such as the current physician and nurse shortage, as well as disaster situations. This study explored the role adaptation of occupational, physical, and respiratory therapists in Canadian primary care settings throughout the first year of the COVID-19 pandemic, as well as barriers and facilitators to adaptation. METHODS: This longitudinal interpretative descriptive study purposively sampled primary care occupational, physical, and respiratory therapists from two Canadian provinces (Manitoba and Ontario). We asked participants to prepare at least 10 semi-structured audio-diary entries during a 12-week period (April - Oct 2020), followed by two semi-structured interviews (Dec 2020, Apr 2021). Questions focused on changes happening in their practice over time. Analysis was iterative, including developing a individual summaries and coding data using both inductive and pre-determined codes. We then entered an immersion/crystallization process to develop key themes related to role adaptation. RESULTS: We represent our findings with the metaphor of the game of Role Adaptation Snakes and Ladders (aka Chutes and Ladders). The pandemic was certainly not a game, but this metaphor represents the tension of being a pawn to circumstance while also being expected to take control of one's professional and personal life during a disaster. The object of the game is to move through three phases of role adaptation, from Disorienting, through Coping and Waiting, to Adapting. In the Adapting phase, the therapists creatively found ways to provide vital services for the pandemic response. The therapists were influenced both negatively and positively (snakes and ladders) by their personal circumstances, and professional meso and macro contexts. Each therapist moved across the board in a unique trajectory and timeline based on these contexts. CONCLUSIONS: Rehabilitation professionals, with adequate meso and macro system supports, can maximize their role on primary care teams by adapting their services to work to their full scope of practice.

Collaborating with a Youth Council to Improve Chronic Pain Resources.

Background: There is a recognized need to involve people with lived experience of chronic pain when developing chronic pain resources. Aims: The aim of this study was to develop, implement, and evaluate a short-term youth council focused on eliciting youths' recommendations for key features of chronic pain informational resources. Methods: In this mixed methods instrumental case study, demographic data were collected via Survey Monkey®. Select Patient-Reported Outcomes Measurement Information System® brief measures were used to provide context regarding pain impact within this group. Participants completed an initial interview, which informed youth council workshop delivery. Over two youth council workshops, participants reviewed select informational resources and identified key features of chronic pain resources. Participants evaluated their involvement experience during a second interview. Qualitative data were transcribed and analyzed using directed content analysis. Member-checking occurred during a third workshop, held virtually. Results: Seven youth self-identifying as girl/woman or demi-girl participated. The youth were satisfied with the youth council experience, highlighting the importance of meeting others, a relaxed environment, and participating in valuable work. A list of youth-identified key features for informational resources was created through the workshops, which includes considerations for audience groups, content, and presentation. Conclusion: Participants' input into youth council development and meeting others with lived experience contributed to a safe and supportive involvement experience. Youth council involvement supported the development of preliminary recommendations for chronic pain informational resources.

Contexte: Il est largement reconnu qu'il est essentiel d'impliquer les individus ayant une expérience personnelle de la douleur chronique dans le processus de création de ressources sur la douleur chronique.Objectifs: Cette étude visait à établir, mettre en œuvre et évaluer un conseil consultatif composé de jeunes, à court terme, dans le but d'obtenir leurs recommandations concernant les caractéristiques essentielles des ressources d'information sur la douleur chronique.Méthodes: Dans le cadre de cette étude de cas instrumentale utilisant une approche mixte, des données démographiques ont été collectées via Survey Monkey®. Des mesures brèves du Système d'information sur les mesures des résultats déclarés par les patients® ont été sélectionnées pour contextualiser l'impact de la douleur au sein de ce groupe. Les participants ont ensuite complété un entretien initial, qui a servi de base pour la mise en œuvre de l'atelier du conseil des jeunes. Au cours de deux ateliers du conseil des jeunes, les participants ont examiné des ressources d'information sélectionnées et ont déterminé quelles devaient être les principales caractéristiques des ressources en matière de douleur chronique. Les participants ont évalué leur expérience de participation au cours d'un deuxième entretien. Les données qualitatives ont été transcrites et analysées à l'aide d'une analyse de contenu dirigée. Une vérification par les membres a été effectuée lors d'un troisième atelier, qui s'est tenu virtuellement.Résultats: Sept jeunes s'identifiant comme filles/femmes ou demi-filles ont participé à l'étude. Les jeunes se sont déclarés satisfaits de leur expérience au sein du conseil des jeunes, soulignant l'importance de rencontrer d'autres jeunes, d'un environnement détendu et de la participation à un travail utile. Une liste des caractéristiques clés identifiées par les jeunes pour les ressources d'information a été dressée au cours des ateliers. Celle-ci comprenait notamment des considérations relatives aux groupes cibles, au contenu et à la présentation.Conclusion: La contribution des participants à l'élaboration du conseil des jeunes et la rencontre avec d'autres personnes ayant une expérience personnelle ont contribué à une expérience de participation sûre et positive. La participation du Conseil des jeunes a contribué à l'élaboration de recommandations préliminaires concernant les ressources d'information sur la douleur chronique.

Telerehabilitation Delivery in Canada and the Netherlands: Results of a Survey Study.

BACKGROUND: Following the onset of the COVID-19 pandemic, telerehabilitation (TR) has been expanding to address the challenges and risks of in-person delivery. It is likely that a level of TR delivery will continue after the pandemic because of its advantages, such as reducing geographical barriers to service. Many pandemic-related TR initiatives were put in place quickly. Therefore, we have little understanding of current TR delivery, barriers and facilitators, and how therapists anticipate integrating TR into current practice. Knowing this information will allow the incorporation of competencies specifically related to the use and provision of TR into professional profiles and entry-to-practice education, thereby promoting high-quality TR care. OBJECTIVE: This study aimed to obtain a descriptive overview of current TR practice among rehabilitation therapists in Canada and the Netherlands and identify perceived barriers to and facilitators of practice. METHODS: A web-based cross-sectional survey was conducted with occupational, physical, and respiratory therapists and dietitians in Canada (in French and English) and the Netherlands (in Dutch and English) between November 2021 and March 2022. Recruitment was conducted through advertisements on social media platforms and email invitations facilitated by regulatory and professional bodies. The survey included demographic and practice setting information; whether respondents delivered TR, and if so, components of delivery; confidence and satisfaction ratings with delivery; and barriers to and facilitators of use. TR satisfaction and uptake were measured using the Telehealth Usability Questionnaire and modified Technology Acceptance Model. Data were first summarized descriptively, and then, comparisons were conducted between professions. RESULTS: Overall, 723 survey responses were received, mostly from Canada (n=666, 92.1%) and occupational therapists (n=434, 60%). Only 28.1% (203/723) reported receiving specific training in TR, with 1.2% (9/723) indicating that it was part of their professional education. Approximately 19.5% (139/712) reported not using TR at all, whereas most participants (366/712, 51.4%) had been using this approach for 1 to 2 years. Services delivered were primarily teleconsultation and teletreatment with individuals. Respondents offering TR were moderately satisfied with their service delivery and found it to be effective; 90.1% (498/553) indicated that they were likely to continue offering TR after the pandemic. Technology access, confidence, and setup were rated the highest as facilitators, whereas technology issues and the clinical need for physical contact were the most common barriers. CONCLUSIONS: Professional practice and experience with TR were similar in both countries, suggesting the potential for common strategic approaches. The high prevalence of current practice and strong indicators of TR uptake suggest that therapists are likely to continue TR delivery after the pandemic; however, most therapists (461/712, 64.7%) felt ill prepared for practice, and the need to target TR competencies during professional and postprofessional education is critical. Future studies should explore best practice for preparatory and continuing education.

Understand me: Youth with chronic pain on how knowledge gaps influence their pain experience.

Background: There is a perceived lack of readily available resources to support self-management skills in youth living with chronic pain. The perspectives of youth regarding information gaps may improve the effectiveness of resources developed for them. Aim: The aim of this study was to explore the perspectives of youth living with chronic pain on the interactions among their pain experiences, chronic pain resources and research. Methods: Using an interpretive paradigm, we interviewed seven participants (age range 12-19 years) diagnosed with chronic pain. Two frameworks for meaningful engagement of citizens in research and policy informed the interview guide. Data were analyzed inductively using content analysis approaches to examine patterns and develop themes. Results: The participants' perceptions were captured by the overarching theme of "understand me." Four subthemes elaborate on the relationship between the participants' experiences and how their lives could be enhanced through research and knowledge mobilization. In the subtheme "my unique pain experience," the participants help us understand them by chronicling the variation in presentation of their chronic pain. The subtheme "people don't know it's a thing" emphasizes that there is general misunderstanding of chronic pain by the public and in the participants' support systems. The first two subthemes influence the third, which describes how the pain "kind of stops you from living." The fourth subtheme, "knowledge offers hope," offers a solution to dismantling misunderstanding of youth living with chronic pain. Conclusion: Future work needs to focus on embedding health literacy and knowledge mobilization into health and education structures to promote developmentally relevant self-management skills.

Contexte: Il y a un manque perçu de ressources facilement disponibles pour soutenir les compétences d'auto-prise en charge chez les jeunes vivant avec de la douleur chronique. Les points de vue des jeunes sur les lacunes en matière d'information peuvent améliorer l'efficacité des ressources mises au point pour eux.Objectif: Le but de cette étude était d'explorer les perspectives des jeunes vivant avec de la douleur chronique sur les interactions entre leurs expériences de douleur, leurs ressources de douleur chronique et leurs recherches.Méthodes: À l'aide d'un paradigme d'interprétation, nous avons interrogé sept participants (âgés de 12 à 19 ans) qui avaient reçu un diagnostic de douleur chronique. Deux cadres pour une participation significative des citoyens à la recherche et aux politiques ont éclairé le guide d'entrevue. Les données ont été analysées par induction à l'aide d'approches d'analyse du contenu afin d'examiner les modèles et développer des thèmes.Résultats: Le thème général de « comprenez-moi ¼ reflète bien les perceptions des participants. Quatre sous-thèmes approfondissent la relation entre les expériences des participants et la façon dont leur vie pourrait être améliorée par la recherche et la mobilisation des connaissances. Dans le sous-thème « mon expérience de douleur unique ¼, les participants nous aident à les comprendre en racontant les variations dans la façon dont leur douleur chronique se présente. Le sous-thème « les gens ne savent pas que ça existe ¼ souligne qu'il y a une incompréhension générale de la douleur chronique par le public et dans les systèmes de soutien des participants. Les deux premiers sous-thèmes influencent le troisième, qui décrit comment la douleur « vous empêche de vivre en quelque sorte. ¼ Le quatrième sous-thème, « les connaissances apportent de l'espoir ¼, offre une solution pour démanteler l'incompréhension des jeunes vivant avec la douleur chronique.Conclusion: Les travaux futurs doivent se concentrer sur l'intégration de la littératie en santé et de la mobilisation des connaissances dans les structures de santé et d'éducation afin de promouvoir des compétences d'auto-prise en charge pertinentes sur le plan du développement.

Interprofessional Collaborative Relationship-Building Model in Action in Primary Care: A Secondary Analysis.

Introduction: Team-based care has been integrated into primary care (PC) across Canada because it improves patient safety, effectiveness, efficiency, person-centredness, and equity. However, this integration in and of itself may not lead to improved patient care without effective interpersonal relationships amongst team members. Currently, teams have few tools to guide the development of collaborative relationships. The Interprofessional Collaborative Relationship-building Model (ICRB) was developed to be a tool for understanding the stages of development of the interprofessional team's relationship-building. Purpose: This qualitative secondary data analysis illuminates a PC team's experiences of their developing interprofessional relationships with occupational therapists and physical therapists who joined the PC team. Method: Eleven team member interviews of one primary care team from a family medicine teaching clinic affiliated with a training university and the health region in central Canada were analyzed using secondary data analysis. The team included family physicians (n = 4), nurses (n = 2), a social worker (n = 1), a mental health counselor (n = 1), occupational therapists (n = 2), and a physical therapist (n = 1). We used the ICRB for directed content analysis using the phased approach that includes the three main steps of data preparation, data organization and data presentation. Results: This team experienced the ICRB stages of Looking For Help, Fitting-In, and Growing Reciprocity thereby learning about one another to better understand what OT and PT may bring to the PC setting. However, contrary to the ICRB, co-location, was the context within which the collaborative relationship-building took place rather than a distinct developmental stage. Although team members did experience some level of Growing Reciprocity, this developing team had not yet established collaborative leadership processes. As the ICRB originally posited, communication and patient focus facilitated all stages of the relationship-building process and helped the team develop shared values and role clarity that establish how different team members contribute to improving quality care. Conclusions: The context of co-location with a patient focus and open communication facilitated the team's development with the occupational therapists and physical therapist. Collaborative leadership is a worthy goal for future research and clinical focus as it has implications for improving overall patient quality care and team member work satisfaction.

A comparison of the COVID-19 response for urban underserved patients experiencing healthcare transitions in three Canadian cities.

OBJECTIVES: The COVID-19 pandemic and response has highlighted existing strengths within the system of care for urban underserved populations, but also many fault lines, in particular during care transitions. The objectives of this study were to describe COVID-19 response policies for urban underserved populations in three Canadian cities; examine how these policies impact continuity of care for urban underserved populations; determine whether and how urban underserved community members were engaged in policy processes; and develop policy and operational recommendations for optimizing continuity of care for urban underserved populations during public health crises. METHODS: Using Walt & Gilson's Policy Triangle framework as a conceptual guide, 237 policy and media documents were retrieved. Five complementary virtual group interview sessions were held with 22 front-line and lived-experience key informants to capture less well-documented policy responses and experiences. Documents and interview transcripts were analyzed inductively for policy content, context, actors, and processes involved in the pandemic response. RESULTS: Available documents suggest little focus on care continuity for urban underserved populations during the pandemic, despite public health measures having disproportionately negative impacts on their care. Policy responses were largely reactive and temporary, and community members were rarely involved. However, a number of community-based initiatives were developed in response to policy gaps. Promising practices emerged, including examples of new multi-level and multi-sector collaboration. CONCLUSION: The pandemic response has exposed inequities for urban underserved populations experiencing care transitions; however, it has also exposed system strengths and opportunities for improvement to inform future policy direction.

RéSUMé: OBJECTIFS: La pandémie et la riposte au COVID-19 ont mis en évidence les forces existantes au sein du système de soins pour les populations urbaines mal desservies, mais aussi de nombreuses faillites, en particulier lors des transitions de soins. Les objectifs de cette étude étaient de décrire les politiques de réponse au COVID-19 pour les populations urbaines mal desservies dans trois villes canadiennes; examiner l'impact de ces politiques sur la continuité des soins pour les populations urbaines mal desservies; déterminer si et comment les membres de la communauté urbaine mal desservie ont été impliqués dans les processus politiques; et développer des recommandations politiques et opérationnelles pour optimiser la continuité des soins pour les populations urbaines mal desservies pendant les crises de santé publique. MéTHODES: Utilisant le cadre Policy Triangle de Walt et Gilson comme guide conceptuel, 237 documents politiques et des médias ont été récupérés. Cinq séances d'entrevues de groupe virtuelles complémentaires ont été organisées avec 22 informateurs clés de première ligne et d'expérience vécue pour saisir des réponses et des expériences politiques moins bien documentées. Les documents et les transcriptions des entrevues ont été analysés de manière inductive pour le contenu politique, le contexte, les acteurs et les processus impliqués dans la riposte à la pandémie. RéSULTATS: Les documents disponibles suggèrent que l'accent est peu mis sur la continuité des soins pour les populations urbaines mal desservies pendant la pandémie, malgré les mesures de santé publique ayant des impacts négatifs disproportionnés sur leurs soins. Les réponses politiques étaient en grande partie réactives et temporaires, et les membres de la communauté étaient rarement impliqués. Cependant, un certain nombre d'initiatives communautaires ont été élaborées en réponse aux lacunes des politiques. Des pratiques prometteuses ont émergé, y compris des exemples de nouvelles collaborations multiniveaux et multisectorielles. CONCLUSION: La réponse à la pandémie a révélé des inégalités pour les populations urbaines mal desservies qui subissent des transitions de soins, mais elle a également exposé les forces du système et les possibilités d'amélioration pour éclairer l'orientation future des politiques.

Diary-interview studies: longitudinal, flexible qualitative research design.

Diary-interview studies are a longitudinal qualitative approach that allows both participants and researchers to explore participants' experiences and sense-making in relation to life situations. The purpose of this Methods Brief is to introduce readers to the diary-interview method and highlight methodological decisions researchers need to make when using this type of qualitative approach to generating data. We will introduce each of these decisions in turn, then detail the methodological options. To further exemplify, we describe our 2020­2021 diary-interview study of Canadian primary care clinicians navigating the first year of the pandemic.

Comparative Studies of Renin-Null Zebrafish and Mice Provide New Functional Insights.

BACKGROUND: The renin-angiotensin system is highly conserved across vertebrates, including zebrafish, which possess orthologous genes coding for renin-angiotensin system proteins, and specialized mural cells of the kidney arterioles, capable of synthesising and secreting renin. METHODS: We generated zebrafish with CRISPR-Cas9-targeted knockout of renin (ren-/-) to investigate renin function in a low blood pressure environment. We used single-cell (10×) RNA sequencing analysis to compare the transcriptome profiles of renin lineage cells from mesonephric kidneys of ren-/- with ren+/+ zebrafish and with the metanephric kidneys of Ren1c-/- and Ren1c+/+ mice. RESULTS: The ren-/- larvae exhibited delays in larval growth, glomerular fusion and appearance of a swim bladder, but were viable and withstood low salinity during early larval stages. Optogenetic ablation of renin-expressing cells, located at the anterior mesenteric artery of 3-day-old larvae, caused a loss of tone, due to diminished contractility. The ren-/- mesonephric kidney exhibited vacuolated cells in the proximal tubule, which were also observed in Ren1c-/- mouse kidney. Fluorescent reporters for renin and smooth muscle actin (Tg(ren:LifeAct-RFP; acta2:EGFP)), revealed a dramatic recruitment of renin lineage cells along the renal vasculature of adult ren-/- fish, suggesting a continued requirement for renin, in the absence of detectable angiotensin metabolites, as seen in the Ren1YFP Ren1c-/- mouse. Both phenotypes were rescued by alleles lacking the potential for glycosylation at exon 2, suggesting that glycosylation is not essential for normal physiological function. CONCLUSIONS: Phenotypic similarities and transcriptional variations between mouse and zebrafish renin knockouts suggests evolution of renin cell function with terrestrial survival.

Facilitators and Barriers to Becoming Age-Friendly: A Review.

This interpretive review examined the empirical evidence of the factors that facilitate or hinder the implementation of age-friendly community and city (AFCC) initiatives. Thirteen studies were included in the review. Findings show three themes: enablers (consisting of the subthemes of multilevel leadership and a common vision, effective governance and management, and diverse partnerships); process-related factors (e.g., linking to other strategies); and contextual factors (e.g., rural/urban). Moreover, several underlying influencers intersect with these themes, such as how age-friendliness is conceptualized. This review shows that there is a need for more process evaluations. The AFCC movement would also benefit from drawing on other relevant work, such as literature in the areas of coalitions, public administration, and political studies.

Measuring Processes of Integrated Care for Hospital to Home Transitions.

BACKGROUND: Integrated care is a promising approach to improve transitions from hospital for older adults. Measures of integrated care tend to be survey-based or outcomes focused. This study determined the feasibility of using hospital chart data to measure integrated processes of care. METHODS: This paper reports on two objectives: 1) the development of an integrated care transition framework and associated features of care; 2) a pilot study to test if the features could be applied to 214 hospital patient charts. RESULTS: Twenty-four features were tested, and fifteen features could be reliably measured using chart review. Of these, the percent of patients classified as receiving integrated care varied widely across the items, from 0.05% to 84.1%. DISCUSSION: The framework presented in this paper can guide measurement of system and clinical delivery of integrated care transitions. In combination with other tools, chart review can provide perspective on day-to-day care delivery not otherwise accessible, and highlight areas requiring practice change. CONCLUSION: Multiple measurement perspectives are needed to improve our understanding of how integrated care is being implemented. While chart review cannot address the full breadth of integrated care, it can help understand how processes of care are being implemented in routine daily care.

scRNA Transcription Profile of Adult Zebrafish Podocytes Using a Novel Reporter Strain.

BACKGROUND/AIMS: The role of podocytes is well conserved across species from drosophila to teleosts, and mammals. Identifying the molecular markers that actively maintain the integrity of the podocyte will enable a greater understanding of the changes that lead to damage. METHODS: We generated transgenic zebrafish, expressing fluorescent reporters driven by the podocin promoter, for the visualization and isolation of podocytes. We have conducted single cell RNA sequencing (scRNA-seq) on isolated podocytes from a zebrafish reporter line. RESULTS: We demonstrated that the LifeAct-TagRFP-T fluorescent reporter faithfully replicated podocin expression in vivo. We were also able to show spontaneous GCaMP6s fluorescence using light sheet (single plane illumination) microscopy. We identified many podocyte transcripts, encoding proteins related to calcium-binding and actin filament assembly, in common with those expressed in human and mouse mature podocytes. CONCLUSION: We describe the establishment of novel transgenic zebrafish and their use to identify and isolate podocyte cells for the preparation of a scRNA-seq library from normal podocytes. The scRNA-seq data identifies distinct populations of cells and potential gene switching between clusters. These data provide a foundation for future comparative studies and for exploiting the zebrafish as a model for kidney development, disease, injury and repair.

Comparison of Hands-On Versus Online Learning in Teaching Ultrasound Skills for Achilles Tendon Rupture: A Pilot Study.

Introduction In the emergency department, the diagnosis of an Achilles tendon rupture (ATR) is reportedly missed in greater than 20% of cases. A limited number of studies evaluate the use of cadaver models as a potential ultrasound teaching and training modality. We hypothesize that emergency medicine residents can effectively utilize point-of-care ultrasound (POCUS) on cadaver models and a focused teaching intervention to assess their ability to detect ATRs. Methods A prospective study of 23 EM residents was performed. All participants in the study were divided into two learner groups: (a) independent and (b) hands-on. The independent learner group received a 30-minute online didactic lecture demonstrating how to diagnose ATRs. The hands-on learner group received direct instruction on cadaver lower leg models with a ruptured and normal Achilles tendon (AT). Both groups then participated in identifying either normal or ruptured ATs on six cadaver lower leg models. Results The sensitivity and specificity were 89% and 82% in the independent learner group 96% and 100% in the hands-on learner group, respectively. The overall sensitivity and specificity were 91% and 88%, respectively. There was a trend toward successful identification with increased years of residency training. Conclusions In this study, lower leg and ankle cadaver models were found to be as effective as an independent learner model for potential POCUS teaching and training modality in both novice and more advanced trainees.

Pregnancy and Delivery Outcomes Following Benzodiazepine Exposure: A Systematic Review and Meta-analysis.

OBJECTIVE: Understanding the effects of benzodiazepines (BZDs) on maternal/fetal health remains incomplete despite their frequent use. This article quantifies the effects of antenatal BZD exposure on delivery outcomes. DATA SOURCES: Medline, PsycINFO, CINAHL, Embase, and the Cochrane Library were searched till June 30, 2018. STUDY SELECTION: English-language cohort studies comparing antenatal BZD exposure to an unexposed group on any delivery outcome were eligible. In all, 23,909 records were screened, 56 studies were assessed, and 14 studies were included. DATA EXTRACTION: Two reviewers independently assessed quality and extracted data. Estimates were pooled using random effects meta-analysis. Sub-analyses examined several potential moderators including timing of exposure. RESULTS: There were 9 outcomes with sufficient data for meta-analysis. Antenatal BZD exposure was significantly associated with increased risk of 6 outcomes initially: spontaneous abortion (pooled odds ratio = 1.86; 95% confidence interval [CI], 1.43 to 2.42), preterm birth (1.96; 95% CI, 1.25 to 3.08), low birth weight (2.24; 95% CI, 1.41 to 3.88), low Apgar score (2.19; 95% CI, 1.94 to 2.47), Neonatal Intensive Care Unit (NICU) admission (2.61; 95% CI, 1.64 to 4.14), and induced abortion (2.04; 95% CI, 1.23 to 3.40). There was significant heterogeneity between studies for most outcomes without consistent moderators. Birth weight (mean difference [MD]: -151.35 g; 95% CI, -329.73 to 27.03), gestational age (-0.49 weeks; 95% CI, -1.18 to 0.19), and small for gestational age (SGA; 1.42; 95% CI, 1.00 to 2.01) did not show significant associations although after adjusting for publication bias, gestational age, and SGA became significant, totaling 8 significant outcomes. CONCLUSIONS: Antenatal BZD exposure appears to be statistically associated with increased risk of several adverse perinatal outcomes. Although confounds cannot be ruled out, NICU admission does appear clinically relevant and consistent with the antidepressant literature.

Cellular plasticity: A mechanism for homeostasis in the kidney.

Cellular plasticity is a topical subject with interest spanning a wide range of fields from developmental biology to regenerative medicine. Even the nomenclature is a subject of debate, and the underlying mechanisms are still under investigation. On top of injury repair, cell plasticity is a constant physiological process in adult organisms and tissues, in response to homeostatic challenges. In this review we discuss two examples of plasticity for the maintenance of homeostasis in the renal system-namely the renin-producing juxtaglomerular cells (JG cells) and cortical collecting duct (CCD) cells. JG cells show plasticity through recruitment mechanisms, answering the demand for an increase in renin production. In the CCD, cells appear to have the ability to transdifferentiate between principal and intercalated cells to help maintain the highly regulated solute transport levels of that segment. These two cases highlight the complexity of plasticity processes and the role they can play in the kidney.

Benzodiazepine Use During Pregnancy Alone or in Combination With an Antidepressant and Congenital Malformations: Systematic Review and Meta-Analysis.

OBJECTIVE: To summarize the effects of antenatal benzodiazepine exposure as monotherapy and in combination with antidepressants on the risk of congenital malformations. DATA SOURCES: MEDLINE, PsycINFO, CINAHL, Embase, and the Cochrane Library were searched from inception to June 30, 2018, using controlled vocabulary and keywords (eg, prenatal, benzodiazepines, malformation). STUDY SELECTION: English-language cohort studies with prospectively collected data on the risk of malformations in benzodiazepine-exposed and -unexposed offspring were evaluated. 23,909 records were screened, 56 studies were assessed for eligibility, and 8 studies were included. DATA EXTRACTION: Quality was assessed by 2 independent reviewers and data extracted. Random-effects models were used for outcomes (≥ 3 studies). Subanalyses examined effect of potential moderators including study quality and timing of exposure, among others. RESULTS: Prenatal benzodiazepine use was not associated with an increased risk of congenital malformations (odds ratio [OR] = 1.13; 95% CI, 0.99 to 1.30, 8 studies, n = 222/5,195 exposed and 64,335/2,082,467 unexposed), including with first trimester exposure specifically (OR = 1.08; 95% CI, 0.93 to 1.25, P = .33; 5 studies, n = 181/4,331 exposed and 64,308/2,081,463 unexposed). There was no significant association with cardiac malformation following exposure (OR = 1.27; 95% CI, 0.98 to 1.65, P = .07; 4 studies, n = 61/4,414 exposed and 19,260/2,033,402 unexposed). However, concurrent use of benzodiazepine and antidepressants during pregnancy was associated with a significantly increased risk of congenital malformations (OR = 1.40; 95% CI, 1.09 to 1.80, P = .008; 3 studies). CONCLUSIONS: Benzodiazepine exposure during pregnancy does not appear to be associated with congenital malformations or with cardiac malformations specifically. There may be an increased risk of congenital malformations when benzodiazepines are used in conjunction with antidepressants, suggesting that caution with this combination is warranted.

Health, Social, and Functional Characteristics of Older Adults With Continuing Care Needs: Implications for Integrated Care.

Objective: To identify older adults who could benefit from integrated care, we examined (a) health, social, and functional characteristics of older, hospitalized adults who required continuing care on discharge and (b) associations between these characteristics and potentially unnecessary health care use. Method: Personal characteristics were extracted from patient charts (N = 214) and examined in relation to three outcomes: discharge to institutional care, unnecessary hospital stay (alternative level of care), and long hospital stay. Results: Twenty-nine percent of the sample was discharged to an institution, 32.7% was coded as alternate level of care, and 27.6% had a long length of stay. Independent predictors of potentially avoidable health care use were mental and behavioral issues, living alone, functional status, and preadmission concerns about the patient managing in the community. Discussion: High users of health care services were identifiable prior to hospital admission, supporting the use of community-based integrated care approaches.

The use of cadaver models to diagnose rib fractures: A pilot study.

BACKGROUND: In the emergency department, rib fractures are a common finding in patients who sustain chest trauma. Rib fractures may be a sign of significant, underlying pathology, especially in the elderly patients where rib fractures are associated with significant morbidity and mortality. To date, no studies have evaluated the ability of ultrasound to detect rib fractures using cadaver models and subsequently use this model as a teaching tool. OBJECTIVES: The purpose of this study was to determine if it is possible to generate rib fractures on cadaver models which could be accurately identified using ultrasound. METHODS: This was a cross-sectional study performed during one session at a cadaver lab. A single hemithorax from four adult cadavers were used as models. Single rib fractures on each of rib five through eight were created. Four subjects, blinded to the normal versus fractured ribs, were asked to identify the presence of a fracture on each rib. RESULTS: A total of 8 of 16 potential ribs had fractured induced by study staff. Mean accuracy was 55% for all subjects. The overall sensitivity and specificity for detecting rib fractures was 50% (CI: 31.89-68.11) and 59.38% (CI: 35.69-73.55) respectively. The overall PPV and NPV was 55.17% and 54.29% respectively. CONCLUSIONS: In this pilot study, subjects were not able to detect induced rib fractures using ultrasound on cadaver models. The use of this model as a teaching tool in the detection of rib fractures requires further investigation.

A systematic review and meta-analysis of the effects of antenatal anxiety on postpartum outcomes.

To systematically review and meta-analyze research investigating the association between maternal anxiety during pregnancy and outcomes for mother and baby following the immediate delivery period. MEDLINE, Medline In-Process & Other Non-Indexed Citations, PsycINFO, Embase, CINAHL, and the Cochrane library were searched. English-language, prospective studies providing data on outcomes following delivery in women with and without antenatal anxiety (defined by clinical diagnosis or score on validated scale) were included. Three-hundred-fifty-eight articles were retrieved and 13 were included. Titles and abstracts were screened; two reviewers independently reviewed full text articles, conducted quality assessments, extracted, and checked the data. Where available for > 2 studies, random effect meta-analysis was conducted and heterogeneity was quantified. Subanalyses explored moderators, regardless of heterogeneity, including type of anxiety assessment and timing, among others. There were two outcomes that were amenable to meta-analysis. Antenatal anxiety was significantly associated with postpartum depression (PPD) measured within 6 months postpartum (pooled odds ratio [OR] = 2.64, 95% CI 2.02-3.46; 8 studies), regardless of restricting analyses to those studies controlling for prenatal depression (2.45, 1.77-3.39; 6 studies). Associations were also significant when PPD was measured at 1-3 months (2.57, 1.94-3.40; 7 studies) and 6-10 months (4.42, 1.45-13.49; 3 studies). Maternal anxiety was also associated with reduced odds of breastfeeding (0.63, 0.53-0.74; 5 studies). Antenatal anxiety is associated with PPD up to the first 10 months, independent of prenatal depression, and with lower odds of breastfeeding.

Maternal Anxiety During Pregnancy and the Association With Adverse Perinatal Outcomes: Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review and meta-analysis examined the association between maternal antenatal anxiety (AA) and a range of perinatal outcomes. DATA SOURCES: Ovid MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, PsycINFO, CINAHL, Embase, and the Cochrane Library were searched to May 31, 2016, using controlled vocabulary and keywords (eg, prenatal, anxiety, preterm). STUDY SELECTION: Perinatal outcomes of women with and without AA (diagnosed or self-reported using validated scale) derived from English language, prospectively collected data were included. 1,458 abstracts were reviewed, 306 articles were retrieved, and 29 articles were included. DATA EXTRACTION: Two independent reviewers extracted data and assessed quality. Random-effects models were utilized for outcomes (≥ 3 studies). Subanalyses examined potential effect moderators including study quality and diagnostic versus self-reported anxiety among others. RESULTS: Antenatal anxiety was associated with increased odds for preterm birth (pooled odds ratio [OR] = 1.54; 95% confidence interval [CI], 1.39 to 1.70, 16 studies) and spontaneous preterm birth (OR = 1.41; 95% CI, 1.13 to 1.75), lower mean birth weight (mean difference = -55.96 g; 95% CI, -93.62 to -18.31 g), increased odds for low birth weight (OR = 1.80; 95% CI, 1.48 to 2.18), earlier gestational age (mean difference = -0.13 wk; 95% CI, -0.22 to -0.04 wk), increased odds for being small for gestational age (OR = 1.48; 95% CI, 1.26 to 1.74), and smaller head circumference (mean difference = -0.25 cm; 95% CI, -0.45 to -0.06 cm). Heterogeneity between studies was not significant for most outcomes. Subanalyses for birth weight found women with diagnosed anxiety had infants with significantly lower birth weight (P < .03) compared to those identified with rating scales (although both subanalyses were significant [P < .01]). Associations between anxiety and preeclampsia, cesarean delivery, and Apgar scores were nonsignificant. CONCLUSIONS: Antenatal anxiety is associated with multiple adverse perinatal outcomes and is not benign. The impact of treating anxiety on these associations is unknown.