Organizational model and process for clinical best practice in rehabilitation and complex continuing care

Toronto Rehabilitation Institute developed its Clinical Best Practice Model and Process (TR-CBPMP) to facilitate a systematic and consistent approach to best practice with the goal of shortening the path between best knowledge and clinical care and linking this process to patient needs and outcomes. The TR-CBPMP guides clinicians, inter-professional teams, administrators and leaders in identifying patient needs, reviewing present practice, determining best practice priorities, analyzing gaps, preparing for and implementing best practice, evaluating patient-based outcomes and sustaining the best practice. The TR-CBPMP has been used successfully to develop program-specific, profession-specific and organization-wide best practices.     

Bed-rest exercise, activity restriction, and high-risk pregnancies: a feasibility study

This feasibility study investigated the response of maternal heart rate, blood pressure, and uterine contractions to a 30-min bed-rest exercise session (while listening to music) in hospitalized women with varying diagnoses of high-risk pregnancy. Eleven antenatal women who were hospitalized for activity restriction were assigned randomly to either a bed-rest exercise and music group (n = 6) or a bed-rest and music group (n = 5) that involved no exercise. The key findings were that there were no changes in maternal blood pressure or in the number of uterine contractions following the exercise intervention. A supervised bed-rest exercise intervention may, therefore, provide minimal risks and help alleviate the physiological effects of hospital activity restriction.     

Is Weight-Based Adjustment of Automatic Exposure Control Necessary for the Reduction of Chest CT Radiation Dose?

Objective

To assess the effects of radiation dose reduction in the chest CT using a weight-based adjustment of the automatic exposure control (AEC) technique.

Materials and Methods

With Institutional Review Board Approval, 60 patients (mean age, 59.1 years; M:F = 35:25) and 57 weight-matched patients (mean age, 52.3 years, M:F = 25:32) were scanned using a weight-adjusted AEC and non-weight-adjusted AEC, respectively on a 64-slice multidetector CT with a 0.984:1 pitch, 0.5 second rotation time, 40 mm table feed/rotation, and 2.5 mm section thickness. Patients were categorized into 3 weight categories; < 60 kg (n = 17), 60-90 kg (n = 52), and > 90 kg (n = 48). Patient weights, scanning parameters, CT dose index volumes (CTDIvol) and dose length product (DLP) were recorded, while effective dose (ED) was estimated. Image noise was measured in the descending thoracic aorta. Data were analyzed using a standard statistical package (SAS/STAT) (Version 9.1, SAS institute Inc, Cary, NC).

Results

Compared to the non-weight-adjusted AEC, the weight-adjusted AEC technique resulted in an average decrease of 29% in CTDIvol and a 27% effective dose reduction (p < 0.0001). With weight-adjusted AEC, the CTDIvol decreased to 15.8, 15.9, and 27.3 mGy for the < 60, 60-90 and > 91 kg weight groups, respectively, compared to 20.3, 27.9 and 32.8 mGy, with non-weight-adjusted AEC. No significant difference was observed for objective image noise between the chest CT acquired with the non-weight-adjusted (15.0 ± 3.1) and weight-adjusted (16.1 ± 5.6) AEC techniques (p > 0.05).

Conclusion

The results of this study suggest that AEC should be tailored according to patient weight. Without weight-based adjustment of AEC, patients are exposed to a 17 - 43% higher radiation-dose from a chest CT.     

Semi-quantitative analysis of Ruminococcus flavefaciens, Fibrobacter succinogenes and Streptococcus bovis in the equine large intestine using real-time polymerase chain reaction

There is a need to further our understanding of the role that the equine hindgut ecosystem plays in digestive processes and diseases. The aim of the present study was to utilise the real-time PCR technique to determine the abundance of candidate cellulolytic (Ruminococcus flavefaciens; Fibrobacter succinogenes) and non-cellulolytic (Streptococcus bovis) bacteria in lumen contents from the caecum, ventral and dorsal colon, and rectum of healthy horses (n 14). Total DNA was extracted from frozen and lyophilised lumen contents, and PCR primers and Taqman probes were designed based on 16S rDNA sequences for specific detection of candidate bacterial species. Overall, in frozen and lyophilised digesta, there were significantly (P F. succinogenes > S. bovis (P < 0.05), while in lyophilised digesta R. flavefaciens was present in significantly (P < 0.05) greater amounts than F. succinogenes and S. bovis. R. flavefaciens and F. succinogenes were abundant at significantly (P < 0.05) greater levels in lyophilised digesta v. frozen digesta, with no difference in S. bovis levels. These data indicate that for these bacteria at least, faeces are a suitable model for studying the bacterial ecosystem within the equine colon. The present study also indicates that the preservation method of digesta affects levels of bacteria detected.     

A state-wide review of hospital postnatal care in Victoria, Australia: the views and experiences of midwives

OBJECTIVE: to describe midwives' views and experiences of the provision and organisation of hospital-based postnatal care. DESIGN: semi-structured interviews with key informants who provide hospital-based postnatal care. SETTING: public hospitals in Victoria, Australia. PARTICIPANTS: clinical midwives and midwifery managers (n=33). FINDINGS: midwives remain positive about working in hospital-based postnatal care; however, their satisfaction is influenced by barriers to effective care beyond their control, which specifically limit the time available to spend with women. They described many constraints on their practice, including the length of hospital stay, inadequate midwife-to-woman ratios, the busyness of postnatal units, and the effect of visitors. Midwives viewed the aims of postnatal care to include education and support of women with breastfeeding and parenting skills, and helping in women's physical recovery after pregnancy and birth. Midwives' perceptions of the factors that influence women's satisfaction with postnatal care are consistent with what we know are women's views: continuity of care, individualised unrushed care, and flexibility in routine practices. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: midwives' views and experiences of hospital-based postnatal care are in accordance with women's views and experiences. They are less than satisfied with hospital-based postnatal care, and they perceive a need for individualised, unrushed, flexible care. With evidence from both providers and women about the unsatisfactory nature of the current provision and organisation of hospital-based postnatal care, new approaches to this episode of care need to be explored.     

Genomic Profiling Reveals Differences in Primary Central Nervous System Lymphoma and Large B-Cell Lymphoma,With Subtyping Suggesting Sensitivity to BTK Inhibition

BackgroundB-cell primary central nervous system (CNS) lymphoma (PCL) is diffuse large B-cell lymphoma (DLBCL) confined to the CNS. Less than 50% of patients with PCL achieve complete remission with current therapies. We describe the findings from comprehensive genomic profiling (CGP) of a cohort of 69 patients with PCL, 36 cases of secondary CNS lymphoma (SCL), and 969 cases of DLBCL to highlight their differences and characterize the PCL cohort. In addition, we highlight the differences in frequency of germinal center B-cell like (GCB) and non-GCB subtypes and molecular subtypes, particularly MCD and EZH subtypes, between PCL and DLBCL.Materials and MethodsSixty-nine cases of B-cell PCL, 36 cases of secondary CNS lymphoma (SCL), and 969 cases of DLBCL were evaluated by CGP of 405 genes via DNAseq and 265 genes via RNAseq for fusions (FoundationOne Heme). Tumor mutational burden (TMB) was calculated from 1.23 Mb of sequenced DNA.ResultsGenomic alterations with significant differences between PCL and DLBCL included MYD88, ETV6, PIM1, PRDM1, CXCR4, TP53, and CREBBP, while only MYD88 was significantly different between SCL and DLBCL. PCL cases were significantly enriched for the MCD molecular subtypes, which have an excellent response to BTKi. We report a patient with a durable complete response to BTKi consistent with their genomic profile. EBV status, CD274 amplification, and TMB status suggest that 38% of PCL patients may benefit from ICPI; however further study is warranted.ConclusionCGP of PCLs reveals biomarkers, genomic alterations, and molecular classifications predictive of BTKi efficacy and potential ICPI efficacy. Given the limitations of standard of care for PCL, CGP is critical to identify potential therapeutic approaches for patients in this rare form of lymphoma.     

Structural Bridging Network Position is Associated with HIV Status in a Younger Black Men Who Have Sex with Men Epidemic

Younger Black men who have sex with men (BMSM) ages 16–29 have the highest rates of HIV in the United States. Despite increased attention to social and sexual networks as a framework for biomedical intervention, the role of measured network positions, such as bridging and their relationship to HIV risk has received limited attention. A network sample (N = 620) of BMSM respondents (N = 154) and their MSM and transgendered person network members (N = 466) was generated through respondent driven sampling of BMSM and elicitation of their personal networks. Bridging status of each network member was determined by a constraint measure and was used to assess the relationship between this bridging and unprotected anal intercourse (UAI), sex-drug use (SDU), group sex (GS) and HIV status within the network in South Chicago. Low, moderate and high bridging was observed in 411 (66.8 %), 81 (13.2 %) and 123 (20.0 %) of the network. In addition to age and having sex with men only, moderate and high levels of bridging were associated with HIV status (aOR 3.19; 95 % CI 1.58–6.45 and aOR 3.83; 95 % CI 1.23–11.95, respectively). Risk behaviors observed including UAS, GS, and SDU were not associated with HIV status, however, they clustered together in their associations with one another. Bridging network position but not risk behavior was associated with HIV status in this network sample of younger BMSM. Socio-structural features such as position within the network may be important when implementing effective HIV prevention interventions in younger BMSM populations.