What do end-users want to know about managing the performance of healthcare delivery systems? Co-designing a context-specific and practice-relevant research agenda.

BACKGROUND: Despite increasing interest in joint research priority-setting, few studies engage end-user groups in setting research priorities at the intersection of the healthcare and management disciplines. With health systems increasingly establishing performance management programmes to account for and incentivize performance, it is important to conduct research that is actionable by the end-users involved with or impacted by these programmes. The aim of this study was to co-design a research agenda on healthcare performance management with and for end-users in a specific jurisdictional and policy context. METHODS: We undertook a rapid review of the literature on healthcare performance management (n = 115) and conducted end-user interviews (n = 156) that included a quantitative ranking exercise to prioritize five directions for future research. The quantitative rankings were analysed using four methods: mean, median, frequency ranked first or second, and frequency ranked fifth. The interview transcripts were coded inductively and analysed thematically to identify common patterns across participant responses. RESULTS: Seventy-three individual and group interviews were conducted with 156 end-users representing diverse end-user groups, including administrators, clinicians and patients, among others. End-user groups prioritized different research directions based on their experiences and information needs. Despite this variation, the research direction on motivating performance improvement had the highest overall mean ranking and was most often ranked first or second and least often ranked fifth. The research direction was modified based on end-user feedback to include an explicit behaviour change lens and stronger consideration for the influence of context. CONCLUSIONS: Joint research priority-setting resulted in a practice-driven research agenda capable of generating results to inform policy and management practice in healthcare as well as contribute to the literature. The results suggest that end-users are keen to open the "black box" of performance management to explore more nuanced questions beyond "does performance management work?" End-users want to know how, when and why performance management contributes to behaviour change (or fails to) among front-line care providers.

Enabling Clinical Technologies for Hyperpolarized 129 Xenon Magnetic Resonance Imaging and Spectroscopy.

Hyperpolarization is a technique that can increase nuclear spin polarization with the corresponding gains in nuclear magnetic resonance (NMR) signals by 4-8 orders of magnitude. When this process is applied to biologically relevant samples, the hyperpolarized molecules can be used as exogenous magnetic resonance imaging (MRI) contrast agents. A technique called spin-exchange optical pumping (SEOP) can be applied to hyperpolarize noble gases such as 129 Xe. Techniques based on hyperpolarized 129 Xe are poised to revolutionize clinical lung imaging, offering a non-ionizing, high-contrast alternative to computed tomography (CT) imaging and conventional proton MRI. Moreover, CT and conventional proton MRI report on lung tissue structure but provide little functional information. On the other hand, when a subject breathes hyperpolarized 129 Xe gas, functional lung images reporting on lung ventilation, perfusion and diffusion with 3D readout can be obtained in seconds. In this Review, the physics of SEOP is discussed and the different production modalities are explained in the context of their clinical application. We also briefly compare SEOP to other hyperpolarization methods and conclude this paper with the outlook for biomedical applications of hyperpolarized 129 Xe to lung imaging and beyond.

Novel C-7 carbon substituted fourth generation fluoroquinolones targeting N. Gonorrhoeae infections.

Delafloxacin, a fourth-generation anionic fluoroquinolone (FQ) was approved in 2019 for community acquired bacterial pneumonia (CARP). It has broad spectrum activity and an improved class-related toxicity profile. However, it has recently failed a Phase 3 clinical trial for treatment of N. gonorrhoeae infections due to the lack of sufficient efficacy at the dose administered. Inspired by the microbiological and safety profile of delafloxacin, we have developed and profiled the first reported delafloxacin carbon analogue whereby a Nitrogen-for-Carbon swap has been successfully carried out at the C7 position. Not only have we shown that compounds with this modification maintain activity against N. gonorrhoeae (plus other gram-positive and gram-negative bacteria) but they also demonstrate a differentiated physicochemical profile. A zwitterionic derivative of delafloxacin was also profiled and demonstrated a superior microbiological profile against gram-negative strains, whilst maintaining favorable selected ADMET properties.

Synthesis of Urban CO2 Emission Estimates from Multiple Methods from the Indianapolis Flux Project (INFLUX).

Urban areas contribute approximately three-quarters of fossil fuel derived CO2 emissions, and many cities have enacted emissions mitigation plans. Evaluation of the effectiveness of mitigation efforts will require measurement of both the emission rate and its change over space and time. The relative performance of different emission estimation methods is a critical requirement to support mitigation efforts. Here we compare results of CO2 emissions estimation methods including an inventory-based method and two different top-down atmospheric measurement approaches implemented for the Indianapolis, Indiana, U.S.A. urban area in winter. By accounting for differences in spatial and temporal coverage, as well as trace gas species measured, we find agreement among the wintertime whole-city fossil fuel CO2 emission rate estimates to within 7%. This finding represents a major improvement over previous comparisons of urban-scale emissions, making urban CO2 flux estimates from this study consistent with local and global emission mitigation strategy needs. The complementary application of multiple scientifically driven emissions quantification methods enables and establishes this high level of confidence and demonstrates the strength of the joint implementation of rigorous inventory and atmospheric emissions monitoring approaches.

Bouncier Particles at Night: Biogenic Secondary Organic Aerosol Chemistry and Sulfate Drive Diel Variations in the Aerosol Phase in a Mixed Forest.

Aerosol phase state is critical for quantifying aerosol effects on climate and air quality. However, significant challenges remain in our ability to predict and quantify phase state during its evolution in the atmosphere. Herein, we demonstrate that aerosol phase (liquid, semisolid, solid) exhibits a diel cycle in a mixed forest environment, oscillating between a viscous, semisolid phase state at night and liquid phase state with phase separation during the day. The viscous nighttime particles existed despite higher relative humidity and were independently confirmed by bounce factor measurements and atomic force microscopy. High-resolution mass spectrometry shows the more viscous phase state at night is impacted by the formation of terpene-derived and higher molecular weight secondary organic aerosol (SOA) and smaller inorganic sulfate mass fractions. Larger daytime particulate sulfate mass fractions, as well as a predominance of lower molecular weight isoprene-derived SOA, lead to the liquid state of the daytime particles and phase separation after greater uptake of liquid water, despite the lower daytime relative humidity. The observed diel cycle of aerosol phase should provoke rethinking of the SOA atmospheric lifecycle, as it suggests diurnal variability in gas-particle partitioning and mixing time scales, which influence aerosol multiphase chemistry, lifetime, and climate impacts.

Signs of autonomic arousal precede tilt-induced psychogenic nonsyncopal collapse among youth.

Characterizing the physiologic changes leading up to psychogenic nonsyncopal collapse (PNSC) may help to elucidate the processes that cause paroxysmal functional neurological symptom disorders and to clinically distinguish PNSC from syncope. Thus, we aimed to characterize preictal sweat rate, heart rate, and systolic blood pressure changes among patients with tilt-induced PNSC compared to patients with tilt-induced neurally mediated syncope. The presence of increased preictal sweating was compared between groups. Heart rates and systolic blood pressures were compared from the recumbent and tilted baselines to the periods 120 s and 30 s prior to PNSC and syncope. Patients with PNSC (n = 44) were more likely than patients with syncope (n = 44) to have preictal increases in sweating, n = 31 (70.5%) versus n = 21 (47.7%), p = 0.03, although all patients with syncope eventually developed a sweat response. Comparing the recumbent baseline to the period 30 s prior to PNSC, blood pressure (112 ±â€¯9 versus 129 ±â€¯13 mmHg, p < 0.001) and heart rate (76 ±â€¯12 versus 119 ±â€¯22 bpm, p < 0.001) increased. Similarly, comparing the tilted baseline to the period 30 s prior to PNSC, blood pressure (118 ±â€¯12 versus 129 ±â€¯13 mmHg, p < 0.001) and heart rate (95 ±â€¯15 versus 119 ±â€¯22 bpm, p < 0.001) increased. Preictal blood pressure and heart rate differed significantly between patients with PNSC and patients with syncope. In conclusion, signs of autonomic arousal (increased sweating, heart rate, and blood pressure) often precede tilt-induced PNSC. Sweating prior to fainting may not be useful in distinguishing PNSC from neurally mediated syncope.

Strategies for the prevention of perinatal hepatitis B transmission in a marginalized population on the Thailand-Myanmar border: a cost-effectiveness analysis.

BACKGROUND: Data on the cost effectiveness of hepatitis B virus (HBV) screening and vaccination strategies for prevention of vertical transmission of HBV in resource limited settings is sparse. METHODS: A decision tree model of HBV prevention strategies utilised data from a cohort of 7071 pregnant women on the Thailand-Myanmar border using a provider perspective. All options included universal HBV vaccination for newborns in three strategies: (1) universal vaccination alone; (2) universal vaccination with screening of women during antenatal visits with rapid diagnostic test (RDT) plus HBV immune globulin (HBIG) administration to newborns of HBV surface antigen positive women; and (3) universal vaccination with screening of women during antenatal visits plus HBIG administration to newborns of women testing HBV e antigen positive by confirmatory test. At the time of the study, the HBIG after confirmatory test strategy was used. The costs in United States Dollars (US$), infections averted and incremental cost effectiveness ratios (ICERs) were calculated and sensitivity analyses were conducted. A willingness to pay threshold of US$1200 was used. RESULTS: The universal HBV vaccination was the least costly option at US$4.33 per woman attending the clinic. The HBIG after (RDT) strategy had an ICER of US$716.78 per infection averted. The HBIG after confirmatory test strategy was not cost-effective due to extended dominance. The one-way sensitivity analysis showed that while the transmission parameters and cost of HBIG had the biggest impact on outcomes, the HBIG after confirmatory test only became a cost-effective option when a low test cost was used or a high HBIG cost was used. The probabilistic sensitivity analysis showed that HBIG after RDT had an 87% likelihood of being cost-effective as compared to vaccination only at a willingness to pay threshold of US$1200. CONCLUSIONS: HBIG following confirmatory test is not a cost-effective strategy for preventing vertical transmission of HBV in the Thailand-Myanmar border population. By switching to HBIG following rapid diagnostic test, perinatal infections will be reduced by nearly one third. This strategy may be applicable to similar settings for marginalized populations where the confirmatory test is not logistically possible.

Optical Properties of Secondary Organic Aerosol from cis-3-Hexenol and cis-3-Hexenyl Acetate: Effect of Chemical Composition, Humidity, and Phase.

Atmospheric aerosols play an important role in Earth's radiative balance directly, by scattering and absorbing radiation, and indirectly, by acting as cloud condensation nuclei (CCN). Atmospheric aerosol is dominated by secondary organic aerosol (SOA) formed by the oxidation of biogenic volatile organic compounds (BVOCs). Green leaf volatiles (GLVs) are a class of BVOCs that contribute to SOA, yet their role in the Earth's radiative budget is poorly understood. In this work we measured the scattering efficiency (at 450, 525, and 635 nm), absorption efficiency (between 190 and 900 nm), particle phase, bulk chemical properties (O:C, H:C), and molecular-level composition of SOA formed from the ozonolysis of two GLVs: cis-3-hexenol (HXL) and cis-3-hexenyl acetate (CHA). Both HXL and CHA produced SOA that was weakly absorbing, yet CHA-SOA was a more efficient absorber than HXL-SOA. The scatter efficiency of SOA from both systems was wavelength-dependent, with the stronger dependence exhibited by HXL-SOA, likely due to differences in particle size. HXL-SOA formed under both dry (10% RH) and wet (70% RH) conditions had the same bulk chemical properties (O:C), yet significantly different optical properties, which was attributed to differences in molecular-level composition. We have found that SOA derived from green leaf volatiles has the potential to affect the Earth's radiative budget, and also that bulk chemical properties can be insufficient to predict SOA optical properties.

Sweat patterns differ between tilt-induced reflex syncope and tilt-induced anxiety among youth.

PURPOSE: Profound sweating can occur with reflex-syncope and with emotional distress, but little is known about the similarities and differences between these sweat responses when they occur during orthostatic challenge. We sought to characterize and compare the sweat patterns related to tilt-induced syncope, presyncope, anxiety, and normal tilt testing. METHODS: In a prospective observational study, quantitative sweat rate was measured from the abdomen, forearm, ankle, and thigh during head-upright tilt. Sweat characteristics were compared across tilt diagnoses of syncope, presyncope, anxiety, and normal testing. When anxiety and syncope/presyncope occurred during the same study (separated by ≥6 min), both were diagnosed. RESULTS: Our cohort comprised150 patients (15.1 ± 2.3 years; 82.9 % female) with 156 diagnoses: 76 with reflex-syncope, 31 with presyncope, 23 with anxiety, and 26 with normal results. All syncope/presyncope patients and 20 (87 %) of the anxiety patients had corresponding sweat responses. Minimal or negligible sweating occurred among patients with normal tests. Neither basal sweat (19.4 ± 4.7 versus 18.3 ± 3.7 versus 18.5 ± 3.7 nL/min/cm(2)) nor peak sweat (171 ± 47.4 versus 149.4 ± 64.4 versus 154.4 ± 59.2 nL/min/cm(2)) differed between patients with syncope, presyncope, or anxiety, p = .32 and p = .12, respectively. However, the qualitative sweat patterns related to syncope/presyncope (diffuse, smoothly contoured, symmetrical, single peaks) differed considerably from the sweat patterns related to anxiety (heterogeneous, asymmetrical, roughly contoured single-peak, multi-peak, or progressive sweat changes). CONCLUSIONS: The sweat patterns related to syncope/presyncope are distinguishable from the sweat patterns related to anxiety. Recognition of the different sweat patterns can inform how signs and symptoms are interpreted during clinical orthostatic challenge.

Queer Youth in Family Therapy.

Trends in popular belief about same-sex relationships have undergone noteworthy change in the United States over the last decade. Yet this change has been marked by stark polarizations and has occurred at varying rates depending upon regional, community, racial, religious, and individual family context. For queer youth and their families, this cultural transformation has broadened opportunities and created a new set of risks and vulnerabilities. At the same time, youth's increasingly open and playful gender fluidity and sexual identity is complicated by unique intersections of class, race, religion, and immigration. Effective family therapy with queer youth requires practitioner's and treatment models that are sensitive to those who bear the burden of multiple oppressions and the hidden resilience embedded in their layered identities. We present case examples of our model of family therapy which addresses refuge, supports difficult dialogs, and nurtures queerness by looking for hidden resilience in the unique intersections of queer youths' lives. These intersections provide transformational potential for youth, their families and even for family therapists as we are all nurtured and challenged to think more complexly about intersectionality, sexuality, and gender.

Implementation of an agency to improve chronic kidney disease care in Ontario: lessons learned by the Ontario Renal Network.

In 2009, Ontario's Ministry of Health and Long-Term Care initiated the transfer of oversight and coordination of chronic kidney disease (CKD) care to the Ontario Renal Network (ORN) under the auspices of Cancer Care Ontario (CCO). The aim was to replicate the quality improvement and change management practices used for cancer control within CKD. Much of the ORN's first three years were dedicated to building the infrastructure necessary to bridge the gap between provincial policy and clinical practice. This article explores the accomplishments, challenges and lessons learned over that period. The results, which are applicable to the management of chronic diseases in Ontario, Canada, and internationally, confirm that sustainable change takes time and requires strong leadership, transparency, accountability and communication, supported by a solid foundation of data and evidence.

The hard Test Your Memory. Evaluation of a short cognitive test to detect mild Alzheimer's disease and amnestic mild cognitive impairment.

OBJECTIVE: The aim of this study is the evaluation of a novel cognitive test, the hard Test Your Memory (H-TYM), in the detection of mild Alzheimer's disease (AD) and amnestic mild cognitive impairment (aMCI). METHODS: This paper uses a prospective study in an outpatient memory clinic. We recruited 97 patients with a diagnosis of mild AD or aMCI aged between 50 and 80 years. All scored 20 or more on the mini mental state examination (MMSE). We recruited 200 controls from a similar background. The patients were given a novel short cognitive test (H-TYM) designed to test recall of newly learnt visual and verbal material together with the Addenbrooke's Cognitive Assessment Revised, MMSE, and TYM test. RESULTS: Alzheimer's disease/aMCI patients completed the H-TYM with an average recall score of 6.69 (SD 3.45); control participants scored an average of 20.4 (SD 4.54). The H-TYM detected 95% of cases of mild AD/aMCI on the basis of an optimum cutoff point. The area under the receiver operating characteristic for the H-TYM ratio was calculated to be 0.989 with a 95% confidence interval of 0.980-0.997. CONCLUSIONS: The H-TYM test has an excellent ability to discriminate between AD/aMCI cases and healthy controls. The H-TYM is a useful tool for the detection of mild AD/aMCI, and it detects AD/aMCI in the majority of patients who "pass" the MMSE and Addenbrooke's Cognitive Assessment Revised.

Maximizing Student Outcomes in Schools: Data-Driven Individualized Education Program Goals and Objectives Aligned to the Standards.

PURPOSE: Federal and state laws require schools to be accountable for student performance on measures of academic achievement in literacy, mathematics, and science skills; monitor high school graduation rates; and track student growth and academic progression throughout the grade levels. Success on these measures gives students pathways to postsecondary options in the workforce, technical education, or college/university education. Speech-language pathologists (SLPs) can utilize existing data sources in the school in conjunction with their knowledge of diagnostics and treatment of cognition, language, and culture to maximize student outcomes beyond the therapy room and in the curriculum standards. METHOD: This clinical focus article will review methods of data collection from existing sources in the students' grade level and academic content curriculum. Utilization of information and input from parents, teachers, paraprofessionals, and others who support the student's academic endeavors will be discussed for Individualized Education Program Present Levels of Academic Achievement and Functional Performance and goal development. Procedures for the SLP to collect independent data aligned to standards-based curriculum will be explored. Consideration will be given for utilizing data to develop future goals and objectives. The benefits of data collection for monitoring student progress and success in the grade-level or alternate standards will be highlighted through case examples. Techniques for classroom-based services, model lessons, coaching, and co-teaching will be presented. CONCLUSIONS: SLPs are recognized as specialized instructional support personnel who have unique knowledge and expertise for diagnosing and treating speech/language impairments (S/LI) disabilities. By understanding how they can use existing data and apply it to developing intervention plans, SLPs can ensure students with S/LI disabilities experience the maximum potential for outcomes in academic and functional success. Data-driven tools and methods aligned to the grade-level standards and curriculum are one of the most powerful tools in an SLP's toolbox. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24869592.

Post-diagnostic support for adults diagnosed with autism in adulthood in the UK: A systematic review with narrative synthesis.

LAY ABSTRACT: More adults than ever before are seeking an autism diagnosis in adulthood. While receiving a diagnosis may be beneficial, many autistic people struggle to navigate their new diagnosis, and require support. This study conducted a systematic review of previous research on the support available after diagnosis (post-diagnostic support) for autistic adults without intellectual disability who were diagnosed in adulthood in the UK. A systematic review is a pre-planned method of searching for all relevant studies, before combining these to answer a larger question. The study aimed to investigate the availability of such support and its effectiveness, and to explore autistic adults' experiences of accessing support. We also used publicly available information to create a map of the post-diagnostic support services currently available across the UK. A systematic search of seven databases was conducted, to identify UK-based studies published after 2012. Nineteen studies were eligible to be included in the study. Although some form of post-diagnostic support is available across most areas in the UK, this mostly consists of providing information and 'signposting' the person to other services. These options may not meet the needs of autistic people, who want services such as psychoeducation (therapy whereby an individual receives education about their diagnosis to improve understanding and self-management), and peer support. Findings highlight the need for adequate support to alleviate the post-diagnostic challenges autistic adults face. The study could not evaluate the effectiveness of support options in the UK due to a lack of information about this in published research. Research shows that autistic adults would like low-level support services, psychoeducation, and peer support, and may also prefer autistic-led support. Further research is required to develop and evaluate post-diagnostic support programmes which include these elements.

Hepatocyte senescence predicts progression in non-alcohol-related fatty liver disease.

BACKGROUND & AIMS: Models of non-alcohol-related fatty liver disease (NAFLD) reveal features of accelerated ageing, such as impaired regeneration, and an increased risk of hepatocellular carcinoma. The relation between accelerated ageing, disease progression and clinical outcome has not been previously investigated and is the subject of the current study. METHODS: Liver sections from 70 patients with NAFLD (105 biopsies) and 60 controls were studied for telomere length, nuclear area, DNA damage and cell cycle phase markers, using quantitative fluorescent in situ hybridization and immunohistochemistry. RESULTS: Hepatocyte telomeres were shorter in NAFLD than controls (p <0.0001). Hepatocytes in NAFLD demonstrated lack of cell cycle progression beyond G1/S phase and high-level expression of p21, the universal cell cycle inhibitor (p=0.001). γ-H(2)AX expression increased with steatosis (p=0.01), indicating DNA damage, and was associated with shorter hepatocyte telomeres (p <0.0001). Hepatocyte p21 expression correlated with fibrosis stage and diabetes mellitus, independently (p <0.001 and p=0.002, respectively). Further analysis revealed that an adverse liver-related outcome was strongly associated with higher hepatocyte p21 expression and greater hepatocyte nuclear area (p=0.02 and p=0.006), but not with telomere length. In paired biopsies, changes in hepatocyte p21 expression and nuclear area mirrored changes in fibrosis stage (p=0.01 and p=0.006, respectively). CONCLUSIONS: These findings are consistent with hepatocyte senescence and permanent cell cycle arrest in NAFLD. Hepatocyte senescence correlated closely with fibrosis stage, diabetes mellitus, and clinical outcome. Hepatocyte p21 expression could be used as a prognostic marker and for stratification in clinical studies.

To Pack a Nose: High-Fidelity Epistaxis Simulation Using 3D Printing Technology.

BACKGROUND: Initial management and stabilization of epistaxis is managed by a diverse offset of clinical providers with variable levels of training. OBJECTIVE: To determine the anatomic and clinical fidelity and ease of use of a novel simulator for the training and assessment of epistaxis management skills. STUDY DESIGN: Qualitative Research Study using expert questionnaire's for validation of a newly developed simulator. METHODS: We performed a quasi-experimental intervention with 22 otolaryngology faculty and 10 trainees who independently evaluated the simulator. Data were collected in three phases: phase 1 (preliminary evaluation), phase 2 (final expert evaluation), and phase 3 (trainee evaluation). We designed a three-dimensional (3D) printed model from a de-identified patient computed tomography scan. Artificial blood was circulated through catheters to simulate bleeding from three distinct sites (sphenopalatine, Kiesselbach's plexus, and anterior ethmoid). Four domains were assessed: "Physical and anatomic attributes," "Realism of experience," "Ability to perform tasks," and "Value and clinical relevance." Internal structure and validity were measured with Cronbach's alpha and item outfit mean-square statistics. RESULTS: Results from otolaryngology faculty showed very high median ratings for "Value of the simulator as a training tool" (4.0/4) and high ratings for "Relevance to practice" (4.0/4), and realism of experience (4.0/4). Responses from otolaryngology trainees demonstrated high value for clinical training (4.0/4) and high likelihood to recommend use for future trainees (4.0/4). Confidence in managing epistaxis before (1.0/4) and after (3.0/4) simulator use was statistically improved (P = .03). CONCLUSIONS: Using 3D printing technology, we created a novel simulator for epistaxis management. Preliminary evidence suggests the model is cost-effective, anatomically realistic, relevant to trainees' educational needs, and valuable as a training tool. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:747-753, 2022.

Defining the Scope of Knowledge Translation Within a National, Patient-Oriented Kidney Research Network.

PURPOSE OF PROGRAM: Integrated knowledge translation (IKT) is a collaborative approach whereby knowledge created through health research is utilized in ways that are relevant to the needs of all stakeholders. However, research teams have limited capacity and know-how for achieving IKT, resulting in a disconnect between the generation and application of knowledge. The goal of this report is to describe how IKT research was achieved across a large-scale, patient-oriented research network, Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD). SOURCES OF INFORMATION: Resources to facilitate knowledge translation (KT) planning across the network were developed by the Can-SOLVE CKD Knowledge User/Knowledge Translation Committee with reference to established Canadian KT and patient engagement tools and frameworks, review of the published and gray literature, and expertise of committee members. METHODS: The Can-SOLVE CKD Knowledge User/Knowledge Translation Committee consisting of patient partners, health care providers, policymakers, and researchers provided oversight of the development and implementation of the network's IKT initiatives. Guided by its strategic framework, the committee developed KT planning templates and review checklists to assist network projects with preparing for dissemination, implementation, and scale and spread of their interventions. The committee has acted in a consultative capacity to facilitate IKT across network initiatives and has supported capacity building through KT activities aimed at network membership and knowledge users more broadly. KEY FINDINGS: The Can-SOLVE CKD Knowledge User/Knowledge Translation Committee established a nation-wide strategy for KT infrastructure and capacity building. Acting as a knowledge intermediary, the committee has connected research teams with knowledge users across Canada to support practices and policies informed by evidence generated by the network. The committee has developed KT initiatives, including a Community of Practice, whereby participants across different regions and disciplines convene regularly to share health research knowledge and communications strategies relevant to the network. Critically, patients are engaged and contribute throughout the research process. Examples of IKT activities from select projects are provided, as well as ways for sustaining the network's KT platform. LIMITATIONS: The KT resources developed by the committee were adapted from other established resources to meet the needs of the network and have not undergone formal evaluation in this context. Given the broad scope of the network, resources to facilitate implementation and knowledge user engagement may not meet the needs of all initiatives and must be tailored accordingly. Knowledge barriers, including a lack of information and skills related to conceptual and practical aspects of KT, among network members provided a rationale for various KT capacity-building initiatives. IMPLICATIONS: The approach described here offers a practical method for achieving IKT, including how to plan, implement, and sustain initiatives across large-scale health research networks. Within the context of Can-SOLVE CKD, these efforts will shorten knowledge-practice gaps through producing and applying relevant research to improve the lives of people living with kidney disease.

OBJECTIF DU PROGRAMME: L'application intégrée des connaissances (AIC) est une approche collaborative à répondre aux besoins de tous les intervenants. Les équipes de recherche ont cependant une capacité et un savoir-faire limités pour réaliser l'AIC, ce qui entraîne un décalage entre la production et l'application des connaissances. L'objectif de cet article est de décrire comment la recherche sur l'AIC a été réalisée dans le cadre d'un vaste réseau de recherche axée sur le patient, le réseau CAN-SOLVE CKD (Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease). SOURCES: Les ressources visant à faciliter la planification de l'application des connaissances (AC) dans l'ensemble du réseau ont été élaborées par le Comité des utilisateurs/de l'application des connaissances (Knowledge User/Knowledge Translation Committee) de Can-SOLVE CKD en se référant à des outils et des cadres d'AC et de participation des patients établis au Canada, à l'examen de la documentation publiée et de la littérature grise et à l'expertise des membres du comité. MÉTHODOLOGIE: Le Comité des utilisateurs/de l'application des connaissances de CAN-SOLVE, constitué de partenaires patients, de fournisseurs de soins, de décideurs et de chercheurs, a supervisé le développement et la mise en œuvre des initiatives d'AIC du réseau. Guidé par son cadre stratégique, le comité a élaboré des modèles de planification pour l'AC et des listes de vérification pour aider les projets du réseau à se préparer à la diffusion et à la mise en œuvre de leurs interventions, de même qu'à leur élargissement et leur diffusion. Le comité a agi à titre consultatif pour faciliter l'AIC dans l'ensemble des initiatives du réseau, et a appuyé le renforcement des capacités par le biais d'activités d'AC destinées aux membres du réseau et, plus largement, aux utilisateurs des connaissances. PRINCIPAUX RÉSULTATS: Le Comité des utilisateurs/de l'application des connaissances de CAN-SOLVE a établi une stratégie nationale pour l'infrastructure et le renforcement des capacités en matière d'AC. En tant qu'intermédiaire, le comité a mis en relation des équipes de recherche et des utilisateurs des connaissances partout au Canada afin d'appuyer les pratiques et les politiques fondées sur les données probantes produites par le réseau. Le comité a élaboré des initiatives d'AC, notamment une communauté de pratique où les participants des différentes régions et disciplines se réunissent sur une base régulière pour partager les connaissances générées en recherche et les stratégies de communication pertinentes pour le réseau. Il est essentiel que les patients s'engagent et contribuent tout au long du processus de recherche. Des exemples d'activités d'AIC tirés de projets sélectionnés sont fournis, de même que des moyens de maintenir la plateforme d'AC du réseau. LIMITES: Les ressources d'AC développées par le comité ont été adaptées à partir de ressources établies pour répondre aux besoins du réseau et, dans ce contexte, n'ont pas fait l'objet d'une évaluation officielle. Compte tenu de la vaste portée du réseau, les ressources destinées à faciliter la mise en œuvre et la participation des utilisateurs des connaissances pourraient ne pas répondre aux besoins de toutes les initiatives et devraient être adaptées en conséquence. Les freins à la connaissance parmi les membres du réseau, notamment le manque d'information et de compétences liées aux aspects conceptuels et pratiques de l'AC, ont servi de justification à diverses initiatives de renforcement des capacités en matière d'AC. CONCLUSION: L'approche décrite offre une méthode pratique pour parvenir à l'AIC, notamment dans la façon de planifier, de mettre en œuvre et d'appuyer des initiatives dans les réseaux de recherche d'envergure. Dans le contexte de CAN-SOLVE CKD, ces efforts permettront de réduire les écarts entre les connaissances et les pratiques, en produisant et en appliquant des recherches visant l'amélioration de la vie des personnes atteintes de néphropathies.

Reduction in epistaxis and emergency department visits in patients taking warfarin after implementation of an education program.

BACKGROUND: Anticoagulated patients are often seen unnecessarily in the emergency department (ED) for epistaxis, leading to increased healthcare costs. Patients are often unaware of preventative and management techniques for handling epistaxis in the home. METHODS: In 2016, the Michigan Anticoagulation Quality Improvement Initiative (MAQI2), a Blue Cross Blue Shield of Michigan-sponsored consortium of 6 anticoagulation clinics in Michigan, implemented an epistaxis-management educational program for warfarin-treated patients with the goal of reducing unnecessary ED visits. A pre-implementation cohort (2014-2015) consisted of patients who did not receive epistaxis-related educational materials. A post-implementation cohort (2017-2018) received epistaxis educational materials covering home treatment and prevention strategies. Patient characteristics and outcomes (rates of epistaxis and epistaxis ED visits) were compared using Chi-square, Poisson regression, and t-tests. RESULTS: Of the 4473 patients included, 2634 (58.9%) initiated warfarin in the pre-implementation phase and 1839 (41.1%) initiated warfarin in the post-implementation phase. The post-implementation cohort had a lower overall epistaxis rate (13.4 vs 10.4 per 100 patient-year, pre- vs. post-implementation; p = 0.029), a lower epistaxis-related ED visit rate (5.6 vs. 3.1 per 100 patient-year; p = 0.003), and a lower proportion of nosebleeds that led to an ED visit (42% vs. 30%; p = 0.032). After controlling for antiplatelet use, renal disease, and time in therapeutic range, both cohorts were equally likely to have nosebleeds (RR 0.77, 95% CI: 0.58-1.02); however, the post-implementation cohort was less likely to visit the ED for epistaxis (RR 0.52, 95% CI: 0.32-0.84). CONCLUSION: An epistaxis education program was associated with a reduction in epistaxis-related ED visits among warfarin-treated patients.

Perceived mechanisms of change in therapeutic yoga targeting psychological distress.

INTRODUCTION: This study was designed to investigate yoga teachers' and yoga therapists' perceptions of the ways yoga is applied to treat symptoms of psychological distress, and identify the defining features, main components, and mechanisms of change in therapeutic practice. METHODS: A qualitative design was employed. Six yoga teachers who had specific training and experience in teaching therapeutic yoga or practicing 'yoga therapy' took part in one-to-one interviews during which they gave accounts of their experiences of helping people cope with psychological distress through yoga. Participants' interviews were transcribed verbatim and were analysed using an integrative inductive-deductive thematic analysis. RESULTS: Four key themes were identified in relation to the benefits of therapeutic yoga: Awareness, Choice, Relationships, and Tailoring. CONCLUSIONS: The findings support previous research which suggests that individualised yoga therapy is a promising intervention, and may help to form a theoretical rationale for the future treatment of psychological distress with yoga.

Canadian Senior Renal Leaders Community of Practice: Vulnerable Populations With Chronic Kidney Disease-Evidence to Inform Policy.

PURPOSE: Low socioeconomic status, race, ethnicity, and rural/remote populations are all associated with disparities in access, care, and outcomes for chronic kidney disease (CKD). There have been different interventions supported by Canadian renal programs to address these disparities. This article reviews the evidence for impact of strategies to reduce inequities experienced by vulnerable populations living with or at risk of CKD and to collate and share interprovincial targeted interventions through the newly formed "Canadian Senior Renal Leaders Community of Practice" focused on translating evidence into clinical practice and policy. SOURCE OF INFORMATION: A literature search of Medline, CINAHL, PubMed, and Google Scholar from 2008 to 2018 identified 13 reports of processes and interventions that have been implemented in Australia, Canada, and the United States to reduce inequities in CKD care and can be categorized into 3 broad areas: (1) early screening and prevention, (2) disease management and dialysis, and (3) pretransplant. Web sites from each Canadian jurisdiction and from Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) Network were used to assess the current state of Canadian initiatives. METHODS: Reviews were completed to gather information on renal initiatives for vulnerable populations, including (1) identification of populations that experience disparities in access to care or in outcomes in the context of CKD prevention and treatment and (2) interventions that have been implemented to reduce disparities in access, care, and outcomes for vulnerable populations with CKD. A current state summary of Canadian initiatives related to vulnerable populations was conducted through a review of publicly available information, including a review of renal program Web sites and a review of current projects related to vulnerable populations that are part of Can-SOLVE CKD. Can-SOLVE CKD is a Canadian Institutes of Health Research Strategy for Patient-Oriented Research (CIHR-SPOR) funded research network to transform the care of people affected by kidney disease. KEY FINDINGS: Interventions to improve inequities in access to CKD screening, disease management, and care are successful when developed with community engagement, provided to the patient in their own environment, and tailored to specific populations. Many provincial renal programs have implemented initiatives to support vulnerable populations with or at risk of CKD. Current projects funded through CIHR SPOR focus on underserved populations and involve partnerships with Indigenous populations. Many renal programs in Canada had or were in the process of implementing interventions to support vulnerable populations with CKD; however, information about the initiatives were not readily available online despite a strong interest and opportunity to support interprovincial knowledge sharing. Despite this common interest, little information is systematically shared between Canadian jurisdictions to support interprovincial sharing to promote evidence-informed policy and program development. Efforts will be made through the newly formed Canadian Senior Renal Leaders Community of Practice to collaborate and share learnings to inform future program and policy development, implementation, and evaluation. LIMITATIONS: As this was not a systematic review, literature search only encompassed studies published in English between 2008 and 2018. It is possible that populations and interventions were overlooked during the search and through the screening process. Furthermore, the controversial definition of "vulnerable" and literature that only came from Canada, the United States, and Australia limits the generalizability of this review.

CONTEXTE ET OBJECTIFS: En contexte d'insuffisance rénale chronique (IRC), le faible statut socioéconomique du patient, sa race, son origine ethnique et le fait d'habiter une région rurale/éloignée sont associés à des iniquités dans l'accès et la qualité des soins et dans les résultats de santé. Ces disparités ont d'ailleurs fait l'objet de différentes interventions de la part des programmes rénaux canadiens. Cet article explore les données probantes sur l'effet de ces stratégies de réduction des inégalités subies par les populations vulnérables atteintes ou susceptibles de développer une néphropathie chronique. L'article vise également à colliger et à partager les interventions ciblées entre les provinces par le biais de la toute nouvelle « Communauté de pratique des hauts dirigeants en néphrologie au Canada ¼, laquelle est axée sur la transposition des données probantes en politiques et pratiques cliniques. SOURCES: Une recherche sur Medline, CINAHL, PubMed et Google Scholar de la littérature publiée entre 2008 et 2018 a permis de répertorier 13 rapports faisant état d'interventions mises en œuvre en Australie, au Canada et aux États-Unis pour réduire les iniquités de soins en IRC. Ces interventions ont été classées selon trois thèmes: 1) prévention et dépistage précoce, 2) prise en charge et dialyse, et 3) pré-transplantation. Les sites Web du réseau Can-SOLVE CKD (Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease) et de chaque province et territoire canadiens ont été consultés pour dresser l'état actuel des stratégies canadiennes. MÉTHODOLOGIE: La revue de la littérature a permis de recenser les populations subissant des inégalités quant à l'accès aux soins ou aux résultats en contexte de prévention et de traitement de l'IRC, et de recueillir de l'information sur les interventions mises en œuvre pour réduire ces inégalités pour les populations vulnérables atteintes d'IRC. Un résumé des stratégies canadiennes actuelles a été rédigé à partir des informations accessibles au public sur les sites Web des différents programmes rénaux et des projets de Can-SOLVE CKD visant les populations vulnérables. Can-SOLVE CKD est un réseau de recherche financé par la Stratégie de recherche axée sur le patient des Instituts de recherche en santé du Canada (SRAP-IRSC) dont l'objectif est de transformer les soins destinés aux personnes atteintes de néphropathie. PRINCIPAUX RÉSULTATS: Les interventions visant à réduire les iniquités dans l'accès au dépistage, à la prise en charge et aux soins en IRC sont efficaces lorsqu'elles sont élaborées avec la participation de la communauté, prodiguées au patient dans son milieu de vie et adaptées en fonction de la population visée. Plusieurs programmes rénaux provinciaux ont déployé des stratégies pour venir en aide aux populations vulnérables atteintes ou susceptibles de développer une IRC. Les projets actuels financés par la SRAP-IRSC se concentrent sur les populations mal desservies et impliquent des partenariats avec les communautés autochtones. Plusieurs programmes rénaux canadiens disposent ou s'affairent à implanter des stratégies pour aider les populations vulnérables atteintes d'IRC. Par contre, malgré un grand intérêt et la possibilité de soutenir un partage interprovincial des connaissances, l'information concernant ces initiatives demeure difficilement accessible en ligne. De même, malgré l'intérêt, peu d'information est partagée systématiquement entre les provinces canadiennes pour soutenir l'élaboration de politiques et de programmes fondés sur les données probantes. La toute nouvelle « Communauté de pratique des hauts dirigeants canadiens en néphrologie ¼ s'efforcera donc de collaborer et de partager l'information afin d'éclairer l'élaboration, la mise en œuvre et l'évaluation des futurs programmes et politiques. LIMITES: Cette étude n'est pas une revue systématique; elle ne visait que les articles publiés en anglais entre 2008 et 2018. Ainsi, certaines populations ou interventions pourraient avoir été mises de côté lors de la recherche et de la sélection des articles. De plus, la définition controversée du terme « vulnérable ¼ et le fait que les articles retenus ne provenaient que du Canada, des États-Unis et de l'Australie rendent nos résultats difficilement généralisables.