Understanding How Newly Implemented Rehabilitation Best Practices Are Sustained: A Realist Review

ObjectiveWe conducted a realist review to understand how (mechanism) and in what circumstances (context) evidence-based practices are sustained in rehabilitation (outcome).Data SourcesMEDLINE, Embase, reference lists, and targeted websites.Study SelectionTwo independent reviewers calibrated study selection; then 1 reviewer screened all titles and abstracts, while the second reviewer screened a random 20%. We repeated this process for full texts. We included 115 documents representing 61 implementation projects (8.9% of identified documents). Included documents described implementation projects in which physical therapists, occupational therapists, and/or speech-language pathologists were the target users of an evidence-based practice.Data ExtractionTwo reviewers repeated the independent process described in study selection to extract basic study and sustainability characteristics as well as context, mechanism, outcome, and strategy text.Data SynthesisUsing basic numerical analyses, we found that only 54% of evidence-based practices in rehabilitation are sustained. Furthermore, while authors who reported sustainability planning sustained the practice 94% of the time, sustainability planning in rehabilitation is rare (only reported 26% of the time). Extracted text was synthesized using the realist technique of inductive and deductive retroduction in which context, mechanism, outcome, and strategy text are combined into narrative explanations of how sustainability works. To inform these explanations, we applied normalization process theory and the theory of planned behavior. Collectively, the 52 identified narratives provide evidence for 3 patterns: (1) implementation and sustainability phases are interconnected, (2) continued use of the evidence-based practice can be interpreted as the ultimate sustainability outcome, and (3) intermediate sustainability outcomes (ie, fit/alignment, financial support, benefits, expertise) can become contextual features influencing other sustainability outcomes.ConclusionsImplementation teams can use the narrative explanations generated in this review to optimize sustainability planning. This can sustain practice changes and improve quality of care and patient outcomes. Future research should seek to iteratively refine the proposed narrative explanations.     

Addressing the ethical grey zone in surgery: a framework for identification and safe introduction of novel surgical techniques and procedures

While the introduction of new surgical techniques can radically improve patient care, they may equally expose patients to unforeseen harms associated with untested procedures. The enthusiastic uptake of laparoscopic cholecystectomy in the early 1990s saw a dramatic increase in the rate of common bile duct injuries, and was described by Alfred Cuschieri as ‘the biggest unaudited free‐for‐all in the history of surgery’ due to ‘a lack of effective centralised control’. Whether a new surgical intervention is considered an acceptable ‘minor’ variation of an established procedure, or is sufficiently ‘novel’ to constitute experimentation on human subjects is often unclear. Furthermore, once a new technique is identified as experimental, there is no agreed protocol for safety evaluation in a first‐in‐human setting. In phase I (first‐in‐human) pharmacological trials only small, single arm cohorts of highly selected patients are enrolled in order to establish the safety profile of a new drug. This exposes only a small number of patients to the unknown or unforeseen risks that may be associated with a new agent, in a highly regulated and scientifically rigorous manner. There is no equivalent study design for the introduction of new and experimental surgical procedures. This article proposes a practical stepwise approach to the safe introduction of new surgical procedures that surgeons and surgical departments can adopt. It includes criteria for new surgical techniques which require formal prospective ethical evaluation, and a novel study design for conducting a safety evaluation at the ‘first in human’ stage.     

Adapting Gerontechnological Development to Hospitalized Frail Older People: Implementation of the ALLEGRO Hospital-Based Geriatric Living Lab

Gerontechnology aims at improving the functioning of older people and their carers in their daily lives as well as improving gerontological practices. To promote gerontechnology innovation in the hospital and bridge the gap between gerontechnology developers and hospitalized frail older patients, our objective was to create and implement a hospital-based geriatric living lab. We designed a hospital-based living lab, providing reflexive workshops bringing around the table gerontechnology users and developers, supplemented with an experimental hospital room receiving both the users and the devices to be tested. Three different types of users were distinguished: seriously ill older inpatients, professional hospital caregivers, and informal carers. Three different kinds of devices were also distinguished: prototypes under development, new services and/or care organizations, and new uses. Finally, we were able to open in 2018 the Angers Living Lab En GéRiatrie hOspitalière (ALLEGRO) hospital-based geriatric living lab. ALLEGRO offers the organization of "idea incubator workshops" for users and developers, together with one “experimental hospital room” equipped with validated devices to provide reference measures used as a standard to test the diagnostic efficacy of prototypes. The room is intended to accommodate one older inpatient with severe acute organic failures. No patient selection is planned at admission, apart from consent to research. Until now, no refusal to participate in a study was noted. In conclusion, we offer a new and unprecedented hospital-based geriatric living lab to improve hospital care for older inpatients and to promote successful aging through gerontechnology.     

多层次创新人才培养教学基地的建立

建立培养多层次创新人才标准化的教学基地。根据需求制定科学合理的培训方案,制定多层次创新人才的培养机制SOP,选用合适的教材和优秀的带教老师,依托先进实验室培训教学平台建设,实施激励约束和考核制度。建立了一整套多层次创新人才的培养制度,确立了多层次、多方向、多学科的带教老师。十年来培养应用型和研究型人才1197人,合格率100%,发表专业学术论文114篇。加强输血医学专业人才的培养至关重要,有必要在血液中心层建立多层次创新人才的培养机制和实施方法,需要与时创新,不断改进我们的模式和方法,为输血医学人才的培养提供有力的教学资源保证和优良的平台。     

PBL与思维导图相结合教学模式在临床教学中的应用

目的探讨PBL与思维导图相结合教学模式在临床教学中的应用。方法本文研究对象为在我院见习的临床本科生,为大理大学2015级一个班级,共55名学生,数据收集时间为2019年1月;按照授课方式的差异将学生分为实验班与对照班,实验班27名学生,对照班28名学生;对照班实施常规教学法,实验班实施PBL与思维导图相结合教学法。结果实验班教学结束测试得分为(85.60±3.46)分,对照班教学结束测试得分为(77.48±3.12)分,差异具有统计学意义(P<0.05);实验班教学方式满意度评分为(90.35±4.12)分,对照班教学方式满意度评分为(80.25±4.05)分,差异具有统计学意义(P<0.05)。结论在临床教学中采用PBL与思维导图相结合教学模式,能够提高学生的专业知识掌握水平与对教学模式的认可度。     

科技期刊嵌入的多重复合科技创新生态系统研究

【目的】 深入探究科技期刊和科技创新生态系统的关系,为科技期刊响应国家号召,高质量、可持续地服务科技创新提供参考。【方法】 基于生态隐喻和模型构建法,构造出科技期刊嵌入的多重复合科技创新生态系统模型,理顺期刊创新运作机制和复合系统构建路径。【结果】 科技期刊被嵌入科技创新生态系统后,形成身兼二任的次生生态,不仅是创新成果作者与多种科技创新主体的接口,而且上下联通不同层级创新生态圈,还衍生出动态自调节、协同共生、交互作用机制。【结论】 科技期刊强力嵌入并高效发挥主观能动性,为科技期刊服务国家科技创新提供全新理论和实践动力,并丰富科技创新生态系统层次、内涵。     

Clermont-Ferrand versus Vectec uterine manipulator for total laparoscopic hysterectomy

Objective: To compare the operation time and performance of two uterine manipulators used for total laparoscopic hysterectomy (TLH).

Material and methods: Design: Retrospective cohort analysis. Design classification: Canadian Task Force Classification II-2. Setting: Tertiary-care university-based teaching hospital and academic affiliated private hospital. Patients: All consecutive patients who underwent for TLH between January 2014 and June 2017. All operations were performed by two expert endoscopic surgeons using one of the following uterine manipulators depending on surgeon preferences: Clermont-Ferrand (CF) or Vectec (VT) MAUT60. Patients were excluded if additional surgeries such as urogynecological procedures were performed, TLH was converted to laparotomy prior to colpotomy, and when their operation records could not be obtained. A total of 169 patients were added to final analysis. Operation time, colpotomy time and the subjective performance of manipulators such as movement of the uterus, visualization of the vaginal fornices, and maintenance of pneumoperitoneum were evaluated by watching un-edited operation videos.

Results: A total of 169 patients (83 patients in CF group; 86 patients in VT group) were included in the final analysis. Patients’ baseline characteristics were comparable between groups. Operation time and time required for colpotomy were significantly shorter in the VT group. Lateral movements of the manipulators and elevation of the uterus were better with VT compared to CF (p?=?.001 for both). Compared to the CF, VT was superior for visualization of the vaginal fornices (p?=?.004) and maintenance of pneumoperitoneum (p?<?.001). Both surgeons had perfect agreement on the performance grading of manipulators (p?<?.001, Kappa values were between 0.86–0.92). There was no difference between groups in estimated blood loss and duration of hospital stay. Reinsertion or the need to change the manipulator was not required in either group. No pelvic or vaginal abscess, cuff cellulitis, dehiscence, or hematoma formations were noted.

Conclusion: Laparoscopic hysterectomy assisted with the VT uterine manipulator is associated with shorter operation and colpotomy time. Furthermore, the movements of uterus, visualization of the vaginal fornices, and maintenance of pneumoperitoneum were significantly better with VT compared to the CF manipulator.     

Predefined vs data-guided training prescription based on autonomic nervous system variation: A systematic review

Monitoring variations in the functioning of the autonomic nervous system may help personalize training of runners and provide more pronounced physiological adaptations and performance improvements. We systematically reviewed the scientific literature comparing physiological adaptations and/or improvements in performance following training based on responses of the autonomic nervous system (ie, changes in heart rate variability) and predefined training. PubMed, SPORTDiscus, and Web of Science were searched systematically in July 2019. Keywords related to endurance, running, autonomic nervous system, and training. Studies were included if they (a) involved interventions consisting predominantly of running training; (b) lasted at least 3 weeks; (c) reported pre- and post-intervention assessment of running performance and/or physiological parameters; (d) included an experimental group performing training adjusted continuously on the basis of alterations in HRV and a control group; and (e) involved healthy runners. Five studies involving six interventions and 166 participants fulfilled our inclusion criteria. Four HRV-based interventions reduced the amount of moderate- and/or high-intensity training significantly. In five interventions, improvements in performance parameters (3000 m, 5000 m, Loadmax, Tlim) were more pronounced following HRV-based training. Peak oxygen uptake () and submaximal running parameters (eg, LT1, LT2) improved following both HRV-based and predefined training, with no clear difference in the extent of improvement in . Submaximal running parameters tended to improve more following HRV-based training. Research findings to date have been limited and inconsistent. Both HRV-based and predefined training improve running performance and certain submaximal physiological adaptations, with effects of the former training tending to be greater.