The Knowledge Broker Mentoring Program: Developing capacity for evidence-informed decision making

Background

Evidence-informed decision making (EIDM) is important to ensure that practice is evidence-informed and resources are used efficiently and effectively. However, public health professionals can face barriers to EIDM. Knowledge Brokers can support and champion EIDM within an organization. The National Collaborating Centre for Methods and Tools (NCCMT) developed a Knowledge Broker (KB) Mentoring program, a hands-on mentorship program to develop capacity for evidence-informed decision making.

Objectives

The objectives of the KB Mentoring program are to build individual and organizational capacity for evidence-informed decision making. The program takes place over 20 months and includes an organizational assessment, nine face-to-face workshop days, monthly webinars, completion of a rapid review, and a period post-program to connect with mentors. Participating cohorts are evaluated qualitatively.

Results

To date, two cohorts of five organizations each have completed the program (n = 56 participants). At the individual level, participants reported increased: confidence; EIDM knowledge and skills; and interpersonal connections. At the organizational level, the groups reported conducting rapid reviews, critically appraising evidence, and using evidence in program planning decisions. Additionally, organizations have put in place ongoing supports to build EIDM capacity. Participants noted that they would like more support both before and after the program. This recommendation was put in place for the third cohort, currently in progress.

Conclusions

Participants indicated the KB mentoring program was high quality and increased EIDM capacity and behaviour in their organizations. This innovative program is important across settings and countries as public health continues to face changes to public health practice. In order to scale up the program to diverse geographic settings, an online KB mentoring program is currently in development.

Key messages

Knowledge Broker mentoring supports public health practitioners to use evidence in practice. Knowledge broker mentoring raises the confidence, knowledge, skills, and connections of participants.

A new tool to assess community-level evidence to inform public health decision making

Background

As public health responds to evolving challenges around the globe, it is critical to draw on community-level evidence to inform decisions on emerging needs. There are existing tools for assessing the quality of research evidence, but none that explicitly focus on quality assessment of evidence from community sources, including local health status and ever-changing community and political preferences and actions.

Methods

The National Collaborating Centre for Methods and Tools (NCCMT) in Canada has developed new tools, called Quality Assessment of Community Evidence (QACE), to help public health decision makers assess the quality of community evidence. The QACE tools were drafted through extensive review of existing frameworks, tools and measures for appraising population health and community evidence, and diverse key informants. We identified three consistent themes that became the core dimensions in these tools. By using the QACE tools, practitioners can answer the question: “Is the quality of this evidence about local context, community needs and political preferences good enough to influence decision making?”

Results

The QACE tools provide probing questions for each of three dimensions: relevant, trustworthy and equity-informed. Supplementary resources help users delve more deeply into different aspects of quality assessment. The QACE tools are intended for public health practitioners who provide and use evidence to support or make decisions about public health practice and policy, including public health practitioners, senior leaders, policy makers and funders.

Conclusions

The QACE tool is a new addition to the public health toolbox for evidence-informed decision making, providing questions to ask about evidence from community sources. By using the tool as part of a decision-making process, public health practitioners can be assured that their decisions are based on the best-available evidence for their communities.

Key messages

The new Quality Assessment of Community Evidence (QACE) tools fill the gap in assessing quality of community-level evidence for public health decision-makers. Community evidence, including local health status and needs and community and political preferences and actions, should be assessed for quality in three critical domains.

The National Collaborating Centre for Methods and Tools: Supporting evidence-informed decision making

Background

Public health continuously evolves to address an uncertain future, and public health professionals must effectively and efficiently adapt to changes. Evidence-informed decision making (EIDM) is one way to adapt to change. The National Collaborating Centre for Methods and Tools (NCCMT) provides high quality resources, training and mentorship to support the EIDM process through both in-person and distance-based formats. Freely accessible resources including online training opportunities can help public health professionals globally put evidence into practice and be ready to respond to change.

Objectives

The NCCMT's work is driven by the belief that everyone deserves optimal health and well-being and this can be achieved by using the best available evidence in practice. Our training and education resources include thirteen online learning modules, an EIDM skills assessment, video series, a rapid review guidebook and regular webinars, amongst others. These resources are self-paced and they can be accessed when and where it is most convenient for public health professionals.

Results

The NCCMT's resources are highly accessed, with over 320, 000 visits to the NCCMT website from around the world from April 2018-March 2019. There were also over 42,000 downloads of knowledge products in the same time period. The NCCMT's resources have been integrated into public health organizations and curriculum in public health postsecondary programs in Canada. We are continuously evolving by engaging our users. We will be launching an updated version of our Learning Centre in April 2020.

Conclusions

The NCCMT houses useful resources for all public health professionals to learn about finding, understanding, and using evidence. Public health professionals from around the world have used the NCCMT's educational resources to put evidence into practice. The NCCMT is committed to working with global organizations to support them to achieve their EIDM goals.

Key messages

The NCCMT supports public health professionals to use the best available evidence in practice. The NCCMT offers high quality resources, training and mentorship to public health professionals.

Using theory of change to assess impact of knowledge translation initiatives

Issue

The National Collaborating Centre for Methods and Tools (NCCMT) offers high quality supports to public health professionals on evidence-informed decision making (EIDM). We developed a theory of change evaluation framework to guide evaluations of our programs and services to ensure that the NCCMT's resources and training continue to be high quality and meet the needs of public health professionals globally.

Description of the Problem

Our objective was to develop an evaluation framework that illustrates our reach, quality, and impact. The NCCMT contracted an external program evaluation expert to assist in developing a revised framework to better capture these aspects. An inductive approach was used to identify evaluation themes through internal document review, and a review of applicable program evaluation literature.

Results

A revised evaluation framework, influenced by theory of change, was developed and is being implemented at the NCCMT. The theory of change visualizes how the NCCMT influences EIDM and public health practice through four stages that progress from creation of products and services, to knowledge and awareness, to engagement and capacity development, and finally to policy and practice changes embedded within organizational structures. Specific outcome indicators include: public health professionals' confidence, knowledge, and skills; improved public health programs; organizational support for evidence-informed decision making; and workforce engagement and competence.

Lessons

This innovative evaluation framework informed by a theory of change resulted in significant streamlining of the centre's evaluation activities, and has provided clearer direction with respect to the purpose of evaluation, as well as enhanced ability to capture the centre's reach, quality and impact. The lessons of the importance of using theory of change to underpin evaluation activities can be applied to other public health organizations globally.

Key messages

Applying an evaluation framework supports effective and efficient programming. The evaluation framework demonstrates the NCCMT’s impact and reach in public health.

Key Aspects of Neurovascular Control Mediated by Specific Populations of Inhibitory Cortical Interneurons

Inhibitory interneurons can evoke vasodilation and vasoconstriction, making them potential cellular drivers of neurovascular coupling. However, the specific regulatory roles played by particular interneuron subpopulations remain unclear. Our purpose was therefore to adopt a cell-specific optogenetic approach to investigate how somatostatin (SST) and neuronal nitric oxide synthase (nNOS)-expressing interneurons might influence the neurovascular relationship. In mice, specific activation of SST- or nNOS-interneurons was sufficient to evoke hemodynamic changes. In the case of nNOS-interneurons, robust hemodynamic changes occurred with minimal changes in neural activity, suggesting that the ability of blood oxygen level dependent functional magnetic resonance imaging (BOLD fMRI) to reliably reflect changes in neuronal activity may be dependent on type of neuron recruited. Conversely, activation of SST-interneurons produced robust changes in evoked neural activity with shallow cortical excitation and pronounced deep layer cortical inhibition. Prolonged activation of SST-interneurons often resulted in an increase in blood volume in the centrally activated area with an accompanying decrease in blood volume in the surrounding brain regions, analogous to the negative BOLD signal. These results demonstrate the role of specific populations of cortical interneurons in the active control of neurovascular function.

Investigating the effects of tDCS on Visual Orientation Discrimination Task Performance: 'The possible influence of placebo'

The non-invasive neuromodulation technique tDCS offers the promise of a low cost tool for both research and clinical applications in psychology, psychiatry and neuroscience. However, findings regarding its efficacy are often equivocal. A key issue is that the clinical and cognitive applications studied are often complex and thus effects of tDCS are difficult to predict given its known effects on the basic underlying neurophysiology, namely alterations in cortical inhibition-excitation balance. As such, it may be beneficial to assess the effects of tDCS in tasks whose performance has a clear link to cortical inhibition-excitation balance such as the visual orientation discrimination task (ODT). In prior studies in our laboratory no practise effects were found during 2 consecutive runs of the ODT, thus in the current investigation, to examine the effects of tDCS, subjects received 10 minutes of 2mA occipital tDCS (sham, anode, cathode) between a first and second run of ODT. Surprisingly, subjects' performance significantly improved in the second run of ODT compared to the first one regardless of the tDCS stimulation type they received (anodal, cathodal, or sham-tDCS). Possible causes for such an improvement could have been due to either a generic 'placebo' effect of tDCS (as all subjects received some form of tDCS) or an increased delay period between the two runs of ODT of the current study compared to our previous work (10 minutes duration required to administer tDCS as opposed to ~2 minutes in previous studies as a 'break'). As such, we tested these two possibilities with a subsequent experiment in which subjects received 2 minutes or 10 minutes delay between the 2 runs (with no tDCS) or 10 minutes of sham-tDCS. Only sham-tDCS resulted in improved performance thus these data add to a growing literature suggesting that tDCS has powerful placebo effect that may occur even in the absence of active cortical modulation.

Physical preparation and return to sport of the football player with a tibia-fibula fracture: applying the 'control-chaos continuum'

Contact in elite football can result in severe injury such as traumatic fracture. Limited information exists regarding the rehabilitation and return to sport (RTS) of these injuries especially in elite football. We outline the RTS of an elite English Premier League footballer following a tibia-fibula fracture including gym-based physical preparation and the use of 'control-chaos continuum' as a framework for on-pitch sport-specific conditioning, development of technical skills while returning the player to pre-injury chronic running loads considering the qualitative nature of movement in competition. Strength and power diagnostics were used to back up clinical reasoning and decision-making throughout rehabilitation and the RTS process. The player returned to full team training after 7.5 months, completed 90 min match-play after 9 months and remains injury-free 11 months post-RTS.

Associations of Type 1 diabetes mellitus, maternal vascular disease and complications of pregnancy

BACKGROUND

Maternal diabetes increases the risk of pre-eclampsia and abnormalities of fetal growth. We studied the additional impact of maternal vascular disease on these risks.

METHODS

The first viable (> 23 weeks) pregnancies of 138 women with Type 1 diabetes mellitus (Type 1 DM), delivered between 1994 and 2003 at the Queen's Medical Centre, Nottingham, UK were studied. Women were divided into groups with and without vascular disease (retinopathy and/or nephropathy and/or pre-existing hypertension). Primary outcomes were pre-eclampsia and fetal customized birthweight percentile (cbp) (adjusted for maternal weight, height, parity, ethnicity, gestational age and gender). Secondary outcomes were perinatal outcome (miscarriage, intrauterine or neonatal death), preterm birth, birth asphyxia, neonatal hypoglycaemia and delivery mode.

RESULTS

Women with vascular disease were more likely to develop pre-eclampsia (OR 3.5; CI 1.28-9.53) and deliver infants with lower cbp (median 89.0, range 0-100 vs. 98.0, range 0-100; P < or = 0.005). Infants were less likely to be macrosomic (OR 0.46; CI 0.224-0.928) but more likely to have intrauterine growth restriction (IUGR; OR 6.0; CI 1.54-23.33). Women with vascular disease had higher Caesarean section rates (90 vs. 56%, P < or = 0.001).

CONCLUSIONS/INTERPRETATION

Women with Type 1 DM and vascular disease are at greater risk of pre-eclampsia and pathological fetal growth. This should influence counselling and merit increased pregnancy surveillance.

The actions of nickel on membrane currents activated by hyperpolarisation in single cells from the rabbit atrioventricular node

1. The atrioventricular node (AVN) is vital for cardiac function as it normally provides the only conduction route for the cardiac impulse from atria to ventricles and can act as a pacemaker for the ventricles if the sinoatrial node (SAN) fails. We have shown previously that whilst 80-90% of AVN myocytes do not possess If (we have termed these type 1 cells), a small proportion (10-20%) of AVN cells (type 2) do exhibit If. 2. The present study describes the effects of the divalent cation nickel (Ni) on membrane currents activated by hyperpolarising voltage clamps from -40/mV in type 1 and type 2 cells at 35 degrees C, using the whole cell patch clamp technique. In type 2 cells 5 mM Ni enhanced the amplitude of If. At -120 mV the mean Ni-activated If was -1.85 +/- 0.28 pA/pF (mean +/- SEM; n = 5). Ni significantly enhanced If at -70 mV and at all potentials negative to this (p < 0.05 at -70, -80, -90 and -110 mV; 0.05 < p < 0.1 at -100 mV; p < 0.005 at -120 mV). 3. In type 1 cells, which exhibit a small time-independent inward current on hyperpolarisation there was no activation of If by Ni (p > 0.1 at all potentials between -40 mV and -120 mV). 4. In type 1 cells 5 mM Ni significantly reduced the time-independent inward current activated by a hyperpolarising pulse to -120 mV (p < 0.02) and had a smaller effect at -110 and -100 mV (0.05 < p < 0.1 at these potentials). With pulses to less negative potentials there was no significant alteration of the time-independent current. 5. An additional observation was that the fast sodium current activated on repolarisation of the membrane potential to -40 mV after a hyperpolarising voltage clamp appeared to be blocked by Ni. However, this apparent blockade reflected a positive shift in the activation threshold for INa, since a repolarising step to -30 mV could still elicit INa. 6. Ni is known to block sarcolemmal Na/Ca exchange in cardiac cells, and one possible mechanism for the enhancement of If by Ni in type 2 cells is increased intracellular Ca via Na/Ca exchange blockade increasing If. The reduction in end pulse current in type 1 cells is also consistent with Na/Ca exchange current blockade. A second possibility of the enhanced If in type 2 cells with Ni is a positive shift of the activation curve for If in the presence of an increased concentration of external divalent cations.

The use of chemotherapy for extraocular retinoblastoma

Among the 114 children with retinoblastoma seen at St. Jude Children's Research Hospital 1962-1984, 11 have received treatment with chemotherapy for measurable extraocular disease which was present at diagnosis (seven patients) or developed later during the subsequent course of their disease (four patients). Metastatic disease involved the brain and spinal fluid of four persons, the orbit of five, the bone marrow of five, lymph nodes of four, and soft tissues of three individuals at the time of their treatments. Single agents or combinations were used. Two patients with orbital extension of primary retinoblastoma developed complete responses following chemotherapy and subsequently received orbital irradiation, and have had long-term disease-free survival. Additional responses developed in patients who received vincristine, cyclophosphamide, adriamycin, cisplatin, VM-26, and ifosfamide, singly or in combination. With future identification of effective chemotherapy, new studies may be focused upon patients with localized disease to reduce radiation dosage or the need for immediate surgical resection of all involved eyes.

Stage-related combined modality treatment of retinoblastoma. Results of a prospective study

Forty-two consecutive patients with retinoblastoma were evaluated by a new staging system and combined modality therapy instituted according to stage. Nineteen patients had bilateral tumors and 23 had unilateral tumors. The staging system was effective in identifying subpopulations of patients and successfully predicted those at greater risk of recurrence or death. Thirty-nine of 42 patients survive (Median survival time, 42 months). Two of 4 children with tumor extension beyond the eye died while 37 of 38 children with tumor presumed confined to the eye survive. Toxicity of the chemotherapy was mild. Radiation therapy of intraocular tumor was associated with cataract formation but most children had satisfactory vision after extraction and the use of corrective lenses. Ophthalmologic findings did not always correlate with histologic extent of tumor and both should be used in planning and evaluating treatment. Recommendations are made on the role of chemotherapy and the need to reduce the morbidity of treatment.

High-dose methotrexate used alone and in combination for measurable primary or metastatic osteosarcoma

High-dose methotrexate with leucovorin rescue was used alone or in combination with Adriamycin and cyclophosphamide for the treatment of 27 osteosarcoma patients with measurable indicators of disease. Three patients developed complete responses of measurable lesions, two had partial responses, two had static disease, one had symptomatic improvement, and one had return to normal of physical findings following treatment of a flat bone primary osteosarcoma. While the doses and frequency of administration of high-dose methotrexate differed from those used by previous investigators, these results suggest that aggressive treatment with high-dose methotrexate must be attempted to further evaluate its efficacy as single-agent therapy for osteosarcoma patients not eligible for adjuvant chemotherapy trials.

Familial erythrocytosis

Erythrocytosis was found in 3 generations of an English family. The red cell mass was only moderately increased in some of the affected members but was accompanied by an unusually low plasma volume. Oxygen affinity of Hb was normal. Changes in serum and urinary erythropoietin showed an essentially normal pattern throughout a series of venesections. Venesection produced some transient clinical benefit in the older patient but there was no obvious change in the younger ones.

Phase I study of neocarzinostatin in children with cancer

Twenty-three children with advanced cancer refractory to conventional therapy received weekly iv doses of neocarzinostatin for 5 weeks. Doses were escalated from 500 to 6750 units/m2/week. Four types of toxic manifestations occurred: acute reactions consisting of shaking chills with or without fever and cyanosis (rigor), hypersensitivity, vomiting, and marrow depression. Evidence of oncolytic activity was limited to patients with acute leukemia in whom phase II trials at doses between 3000 and 4500 units/m2 appear warranted.

Colorectal carcinoma in adolescents implications regarding etiology

Between October, 1974 and December, 1976, 13 adolescent patients with far-advanced, poorly differentiated colorectal carcinoma had been referred to a pediatric cancer center. All patients received chemotherapy with vincristine, methyl-CCNU and 5-fluorouracil. Five of 13 patients are living, one of whom remains disease-free after 12 months of chemotherapy. Four of the patients were from urban areas and nine from rural areas. One of four from urban areas had intimate exposure to chemicals used in the production of cotton and soy beans. Eight of nine patients from rural areas also had exposure to farm or agricultural chemicals, and three of these patients were intimately involved with the spraying operations. Suggestions regarding etiology and causative factors for the development of carcinoma of the colon in adults have previously been advanced. Results of these studies suggest that alternate etiologies must be suggested for adolescent colorectal carcinoma.