Drivers of COVID-19 Outcomes in Long-Term Care Facilities Using Multi-Level Analysis: A Systematic Review

This study aimed to identify the individual, organizational, and environmental factors which contributed to COVID-19-related outcomes in long-term care facilities (LTCFs). A systematic review was conducted to summarize and synthesize empirical studies using a multi-level analysis approach to address the identified influential factors. Five databases were searched on 23 May 2023. To be included in the review, studies had to be published in peer-reviewed journals or as grey literature containing relevant statistical data. The Joanna Briggs Institute critical appraisal tool was employed to assess the methodological quality of each article included in this study. Of 2137 citations identified after exclusions, 99 records met the inclusion criteria. The predominant individual, organizational, and environmental factors that were most frequently found associated with the COVID-19 outbreak comprised older age, higher dependency level; lower staffing levels and lower star and subset domain ratings for the facility; and occupancy metrics and co-occurrences of outbreaks in counties and communities where the LTCFs were located, respectively. The primary individual, organizational, and environmental factors frequently linked to COVID-19-related deaths comprised age, and male sex; higher percentages of racial and ethnic minorities in LTCFs, as well as ownership types (including private, for-profit, and chain membership); and higher occupancy metrics and LTCF's size and bed capacity, respectively. Unfolding the risk factors collectively may mitigate the risk of outbreaks and pandemic-related mortality in LTCFs during future endemic and pandemics through developing and improving interventions that address those significant factors.

"We could have used a lot more of this before…": A qualitative study understanding barriers and facilitators to implementing a provincial PPE safety coach program during the COVID-19 pandemic

BACKGROUND

A Provincial PPE Safety Coach Program was introduced to support appropriate use of personal protective equipment by health care workers. The objective was to understand barriers and facilitators to implementation.

METHODS

A qualitative study was conducted mid-2021. Participants were recruited using a purposive sampling strategy. Interviews were conducted using a guide informed by the Theoretical Domains Framework and Consolidated Framework for Implementation Research. Analysis was conducted using the Theoretical Domains Framework.

RESULTS

Prominent domains identified by staff were "social influences and skills", "environmental context and resources", "social/professional role and identity", "emotion", and "belief of consequences". Prominent domains identified by safety coaches were "knowledge", "social/professional role and identity", "environmental context and resources", and "memory". Only "environmental context and resources" and "social/professional role and identity" were similar. The main facilitators were fear of COVID-19 and leadership commitment, while the main barriers were lack of clarity and balancing the role.

DISCUSSION

Understanding the local context of a health care environment influenced the success of safety coaches. The role allowed individuals to develop leadership skills and help staff improve their perceived competence in using personal protective equipment.

CONCLUSIONS

Safety coaches were well received. Influencing factors provide a basis for strategies to embed this approach throughout a health care system.

Cultural Knowledge in Context - People Aged 50 Years and Over Make Sense of a First Fracture and Osteoporosis

Catch a Break (CaB) is a secondary fracture prevention program that uses medical understandings of osteoporosis to assess first fractures and determine appropriateness for secondary fracture prevention. In this study, we interviewed CaB program participants to identify the understandings that patients themselves used to make sense of first fractures and the osteoporosis suggestion as cause. Semi-structured interviews were conducted with female and male participants of the CaB program in Canada. An interpretive practice approach was used to analyze the data. A random sample of 20 individuals, 12 women, and eight men all aged 50 years and over participated. First fractures were produced as meaningful in the context of osteoporosis only for seniors of very advanced age, and for people of any age with poor nutrition. The trauma events that led to a first fracture were produced as meaningful only if perceived as accidents, and having an active lifestyle was produced as beneficial only for mental health and well-being unrelated to osteoporosis. Cultural knowledge shapes, but does not determine, how individuals make sense of their health and illness experiences. Risk prevention program designers should include patients on the design team and be more aware of the presumptive knowledge used to identify individuals at risk of disease.

Supporting Rehabilitation of Rural Patients Receiving Total Knee Arthroplasty Through Physical Activity: Perceptions of Stakeholder Groups

Objective

To identify how patients with osteoarthritis waiting for and recovering from total knee arthroplasty (TKA) conceptualized and participated in physical activity behaviors in their rural setting and to gather perceptions of health care professionals and rehabilitation decision‐makers on the feasibility of a remotely led physical activity coaching intervention.

Methods

Using a qualitative descriptive study, we collected data from three stakeholder groups: patients waiting for or recovering from TKA (interviews), health professionals delivering a physical activity intervention to patients in the recovering cohort (focus group), and rehabilitation leaders involved in decision‐making at the local or provincial level (interviews).

Results

A total of 38 individuals provided their perspectives (25 patients, five health professionals, eight decision‐makers). Patients waiting for and recovering from surgery described the attributes of their rural environment that supported and restricted their ability to participate in physical activities. Patients recovering from TKA appreciated support for goal‐setting and problem‐solving during their rehabilitation. Health care professionals and decision‐makers commented on the benefits of the program's innovative use of relatively simple technology to support remotely delivered, personalized rehabilitation in rural settings.

Conclusion

This study adds to the limited voice of and about patients living with osteoarthritis who reside in rural settings and identifies facilitators and barriers to TKA rehabilitation in this population. Our findings highlight that it is important to consider the local context and the resources available to patients as they navigate living well with osteoarthritis.

Molecular Determinants of Human T-cell Leukemia Virus Type 1 Gag Targeting to the Plasma Membrane for Assembly

Assembly of human T-cell leukemia virus type 1 (HTLV-1) particles is initiated by the trafficking of virally encoded Gag polyproteins to the inner leaflet of the plasma membrane (PM). Gag-PM interactions are mediated by the matrix (MA) domain, which contains a myristoyl group (myr) and a basic patch formed by lysine and arginine residues. For many retroviruses, Gag-PM interactions are mediated by phosphatidylinositol 4,5-bisphosphate [PI(4,5)P2]; however, previous studies suggested that HTLV-1 Gag-PM interactions and therefore virus assembly are less dependent on PI(4,5)P2. We have recently shown that PI(4,5)P2 binds directly to HTLV-1 unmyristoylated MA [myr(-)MA] and that myr(-)MA binding to membranes is significantly enhanced by inclusion of phosphatidylserine (PS) and PI(4,5)P2. Herein, we employed structural, biophysical, biochemical, mutagenesis, and cell-based assays to identify residues involved in MA-membrane interactions. Our data revealed that the lysine-rich motif (Lys47, Lys48, and Lys51) constitutes the primary PI(4,5)P2-binding site. Furthermore, we show that arginine residues 3, 7, 14 and 17 located in the unstructured N-terminus are essential for MA binding to membranes containing PS and/or PI(4,5)P2. Substitution of lysine and arginine residues severely attenuated virus-like particle production, but only the lysine residues could be clearly correlated with reduced PM binding. These results support a mechanism by which HTLV-1 Gag targeting to the PM is mediated by a trio engagement of the myr group, Arg-rich and Lys-rich motifs. These findings advance our understanding of a key step in retroviral particle assembly.

Human Retrovirus Genomic RNA Packaging

Two non-covalently linked copies of the retrovirus genome are specifically recruited to the site of virus particle assembly and packaged into released particles. Retroviral RNA packaging requires RNA export of the unspliced genomic RNA from the nucleus, translocation of the genome to virus assembly sites, and specific interaction with Gag, the main viral structural protein. While some aspects of the RNA packaging process are understood, many others remain poorly understood. In this review, we provide an update on recent advancements in understanding the mechanism of RNA packaging for retroviruses that cause disease in humans, i.e., HIV-1, HIV-2, and HTLV-1, as well as advances in the understanding of the details of genomic RNA nuclear export, genome translocation to virus assembly sites, and genomic RNA dimerization.

Accounts of health risk assessment survey administration in the Catch a Break Program: the social construction of osteoporosis risk identification and need for intervention

Catch a Break staff conducting the organizational work of delivering secondary fracture prevention screening conversations drew on cultural and organizational resources to determine eligibility of individuals. They encountered and navigated their way through interactional troubles as they requested participation, assessed trauma risk, and provided lifestyle information.

PURPOSE

We investigated delivery of a population-based type C fracture liaison service for non-hip fractures. The purpose of this study was to examine accounts of how osteoporosis health risk screening interactions were delivered.

METHODS

A pre-determined sample of 5 organizational representatives (program staff) were interviewed by telephone. We analyzed the qualitative data through the lens of interpretive inquiry, informed by discourse analysis, to examine staff's "talk" about conducting the program risk screening conversations.

RESULTS

A dominant finding emerging from CAB staff's accounts of program delivery was the conversational work required to include only those individuals deemed appropriate for the program while managing the survey interaction. Staff talked about specific examples of interactional troubles they experienced as barriers to the smooth and successful risk screening conversation. They drew on cultural and organizational resources as interpretive frameworks to make decisions about individuals and groups at risk and in need of further investigation. They drew on larger ideas about ageism and genderism, judging as inappropriate for participation the oldest old adults, men involved in high risk occupations, and adults aged 50 to 70. Staff also employed interactional resources useful in managing problems in the conversation during the request to participate, trauma risk assessment, and lifestyle/health information provision sequences of the risk screening call.

CONCLUSION

We uncovered areas in the screening interaction that were talked about by staff as problematic to achieving the program objective of identifying and enrolling individuals in the secondary fracture prevention program. By highlighting areas for improvement in program delivery, this study may help to reduce the interactional troubles staff negotiate as they deliver this type of program.

Structural Insights into the Mechanism of Human T-cell Leukemia Virus Type 1 Gag Targeting to the Plasma Membrane for Assembly

Retroviral Gag targeting to the plasma membrane (PM) for assembly is mediated by the N-terminal matrix (MA) domain. For many retroviruses, Gag-PM interaction is dependent on phosphatidylinositol 4,5-bisphosphate (PI(4,5)P₂). However, it has been shown that for human T-cell leukemia virus type 1 (HTLV-1), Gag binding to membranes is less dependent on PI(4,5)P₂ than HIV-1, suggesting that other factors may modulate Gag assembly. To elucidate the mechanism by which HTLV-1 Gag binds to the PM, we employed NMR techniques to determine the structure of unmyristoylated MA (myr(-)MA) and to characterize its interactions with lipids and liposomes. The MA structure consists of four α-helices and unstructured N- and C-termini. We show that myr(-)MA binds to PI(4,5)P₂ via the polar head and that binding to inositol phosphates (IPs) is significantly enhanced by increasing the number of phosphate groups on the inositol ring, indicating that the MA-IP binding is governed by charge-charge interactions. The IP binding site was mapped to a well-defined basic patch formed by lysine and arginine residues. Using an NMR-based liposome binding assay, we show that PI(4,5)P₂and phosphatidylserine enhance myr(-)MA binding in a synergistic fashion. Confocal microscopy data revealed formation of puncta on the PM of Gag expressing cells. However, G2A-Gag mutant, lacking myristoylation, is diffuse and cytoplasmic. These results suggest that although myr(-)MA binds to membranes, myristoylation appears to be key for formation of HTLV-1 Gag puncta on the PM. Altogether, these findings advance our understanding of a key mechanism in retroviral assembly.

Identification of knowledge translation theories, models or frameworks suitable for health technology reassessment: a survey of international experts

OBJECTIVE

Health technology reassessment (HTR) is a field focused on managing a technology throughout its life cycle for optimal use. The process results in one of four possible recommendations: increase use, decrease use, no change or complete withdrawal of the technology. However, implementation of these recommendations has been challenging. This paper explores knowledge translation (KT) theories, models and frameworks (TMFs) and their suitability for implementation of HTR recommendations.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Purposeful sampling of international KT and HTR experts was administered between January and March 2019.

METHODS

Sixteen full-spectrum KT TMFs were rated by the experts as 'yes', 'partially yes' or 'no' on six criteria: familiarity, logical consistency/plausibility, degree of specificity, accessibility, ease of use and HTR suitability. Consensus was determined as a rating of ≥70% responding 'yes'. Descriptive statistics and manifest content analysis were conducted on open-ended comments.

RESULTS

Eleven HTR and 11 KT experts from Canada, USA, UK, Australia, Germany, Spain, Italy and Sweden participated. Of the 16 KT TMFs, none received ≥70% rating. When ratings of 'yes' and 'partially yes' were combined, the Consolidated Framework for Implementation Research was considered the most suitable KT TMF by both KT and HTR experts (86%). One additional KT TMF was selected by KT experts: Knowledge to Action framework. HTR experts selected two additional KT TMFs: Co-KT framework and Plan-Do-Study-Act cycle. Experts identified three key characteristics of a KT TMF that may be important to consider: practicality, guidance on implementation and KT TMF adaptability.

CONCLUSIONS

Despite not reaching an overall ≥70% rating on any of the KT TMFs, experts identified four KT TMFs suitable for HTR. Users may apply these KT TMFs in the implementation of HTR recommendations. In addition, KT TMF characteristics relevant to the field of HTR need to be explored further.

The Brain in Motion II Study: study protocol for a randomized controlled trial of an aerobic exercise intervention for older adults at increased risk of dementia

BACKGROUND

There remains no effective intervention capable of reversing most cases of dementia. Current research is focused on prevention by addressing risk factors that are shared between cardiovascular disease and dementia (e.g., hypertension) before the cognitive, functional, and behavioural symptoms of dementia manifest. A promising preventive treatment is exercise. This study describes the methods of a randomized controlled trial (RCT) that assesses the effects of aerobic exercise and behavioural support interventions in older adults at increased risk of dementia due to genetic and/or cardiovascular risk factors. The specific aims are to determine the effect of aerobic exercise on cognitive performance, explore the biological mechanisms that influence cognitive performance after exercise training, and determine if changes in cerebrovascular physiology and function persist 1 year after a 6-month aerobic exercise intervention followed by a 1-year behavioural support programme (at 18 months).

METHODS

We will recruit 264 participants (aged 50-80 years) at elevated risk of dementia. Participants will be randomly allocated into one of four treatment arms: (1) aerobic exercise and health behaviour support, (2) aerobic exercise and no health behaviour support, (3) stretching-toning and health behaviour support, and (4) stretching-toning and no health behaviour support. The aerobic exercise intervention will consist of three supervised walking/jogging sessions per week for 6 months, whereas the stretching-toning control intervention will consist of three supervised stretching-toning sessions per week also for 6 months. Following the exercise interventions, participants will receive either 1 year of ongoing telephone behavioural support or no telephone support. The primary aim is to determine the independent effect of aerobic exercise on a cognitive composite score in participants allocated to this intervention compared to participants allocated to the stretching-toning group. The secondary aims are to examine the effects of aerobic exercise on a number of secondary outcomes and determine whether aerobic exercise-related changes persist after a 1-year behavioural support programme (at 18 months).

DISCUSSION

This study will address knowledge gaps regarding the underlying mechanisms of the pro-cognitive effects of exercise by examining the potential mediating factors, including cerebrovascular/physiological, neuroimaging, sleep, and genetic factors that will provide novel biologic evidence on how aerobic exercise can prevent declines in cognition with ageing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03035851 . Registered on 30 January 2017.

Transforming primary care for older Canadians living with frailty: mixed methods study protocol for a complex primary care intervention

INTRODUCTION

Older Canadians living with frailty are high users of healthcare services; however, the healthcare system is not well designed to meet the complex needs of many older adults. Older persons look to their primary care practitioners to assess their needs and coordinate their care. They may need care from a variety of providers and services, but often this care is not well coordinated. Older adults and their family caregivers are the experts in their own needs and preferences, but often do not have a chance to participate fully in treatment decisions or care planning. As a result, older adults may have health problems that are not properly assessed, managed or treated, resulting in poorer health outcomes and higher economic and social costs. We will be implementing enhanced primary healthcare approaches for older patients, including risk screening, patient engagement and shared decision making and care coordination. These interventions will be tailored to the needs and circumstances of the primary care study sites. In this article, we describe our study protocol for implementing and testing these approaches.

METHODS AND ANALYSIS

Nine primary care sites in three Canadian provinces will participate in a multi-phase mixed methods study. In phase 1, baseline information will be collected through questionnaires and interviews with patients and healthcare providers (HCPs). In phase 2, HCPs and patients will be consulted to tailor the evidence-based interventions to site-specific needs and circumstances. In phase 3, sites will implement the tailored care model. Evaluation of the care model will include measures of patient and provider experience, a quality of life measure, qualitative interviews and economic evaluation.

ETHICS AND DISSEMINATION

This study has received ethics clearance from the host academic institutions: University of Calgary (REB17-0617), University of Waterloo (ORE#22446) and Université Laval (#MP-13-2019-1500 and 2017-2018-12-MP). Results will be disseminated through traditional means, including peer-reviewed publications and conferences and through an extensive network of knowledge user partners.

TRIAL REGISTRATION NUMBER

NCT03442426;Pre-results.

Characteristics of knowledge translation theories, models and frameworks for health technology reassessment: expert perspectives through a qualitative exploration

BACKGROUND

Health Technology Reassessment (HTR) is a process that systematically assesses technologies that are currently used in the health care system. The process results in four outputs: increase use or decrease use, no change, or de-adoption of a technology. Implementation of these outputs remains a challenge. The Knowledge Translation (KT) field enables to transfer/translate knowledge into practice. KT could help with implementation of HTR outputs. This study sought to identify which characteristics of KT theories, models, and frameworks could be useful, specifically for decreased use or de-adoption of a technology.

METHODS

A qualitative descriptive approach was used to ascertain the perspectives of international KT and HTR experts on the characteristics of KT theories, models, and frameworks for decreased use or de-adoption of a technology. One-to-one semi-structured interviews were conducted from September to December 2019. Interviews were audio recorded and transcribed verbatim. Themes and sub-themes were deduced from the data through framework analysis using five distinctive steps: familiarization, identifying an analytic framework, indexing, charting, mapping and interpretation. Themes and sub-themes were also mapped to existing KT theories, models, and frameworks.

RESULTS

Thirteen experts from Canada, United States, United Kingdom, Australia, Germany, Spain, and Sweden participated in the study. Three themes emerged that illustrated the ideal traits: principles that were foundational for HTR, levers of change, and steps for knowledge to action. Principles included evidence-based, high usability, patient-centered, and ability to apply to the micro, meso, macro levels. Levers of change were characterized as positive, neutral, or negative influences for changing behaviour for HTR. Steps for knowledge to action included: build the case for HTR, adapt research knowledge, assess context, select interventions, and assess impact. Of the KT theories, models, and frameworks that were mapped, the Consolidated Framework for Implementation Research had most of the characteristics, except ability to apply to micro, meso, macro levels.

CONCLUSIONS

Characteristics that need to be considered within a KT theory, model, and framework for implementing HTR outputs have been identified. Consideration of these characteristics may guide users to select relevant KT theories, models, and frameworks to apply to HTR projects.

Effect of a multimethod quality improvement intervention on antipsychotic medication use among residents of long-term care

BACKGROUND

Antipsychotic medications are used to address neuropsychiatric symptoms associated with dementia. Evidence suggests that among older adults with dementia, their harms outweigh their benefits. A quality improvement initiative was conducted to address inappropriate antipsychotic medication use in long-term care (LTC) in the province of Alberta.

METHODS

We conducted a multimethod evaluation of the provincial implementation of the project in 170 LTC sites over a 3-year project period incorporating a quasi-experimental before-after design. Using a three-component intervention of education and audit and feedback delivered in a learning workshop innovation collaborative format, local LTC teams were supported to reduce the number of residents receiving antipsychotic medications in the absence of a documented indication. Project resources were preferentially allocated to supporting sites with the highest baseline antipsychotic medication use. Changes in antipsychotic medication use, associated clinical and economic outcomes, and the effects of the project on LTC staff, physicians, leaders and administrators, and family members of LTC residents were assessed at the conclusion of the implementation phase.

RESULTS

The province-wide initiative was delivered with a 75% implementation fidelity. Inappropriate antipsychotic medication use declined from 26.8% to 21.1%. The decrease was achieved without unintended consequences in other outcomes including physical restraint use or aggressive behaviours. The project was more expensive but resulted in less inappropriate use of antipsychotics than the pre-project period (incremental cost per inappropriate antipsychotic avoided of $5 678.71). Accounts from family, organisational leaders, and LTC staff were supportive of the project activities and outcomes.

CONCLUSION

This quality improvement initiative was successfully delivered across an entire delivery arm of the continuing care sector. Quality of care in LTC was improved.

Identifying what matters most for the health of older adults in Alberta: results from a James Lind Alliance Research Priority Setting Partnership

BACKGROUND

As the number of older adults continues to increase, addressing their health becomes increasingly important for both the population and the health care system. The aim of this priority setting partnership was to use direct engagement with older adults, caregivers and health care providers to identify and prioritize the most important topics on the health of older adults that should be addressed by future research.

METHODS

We followed the James Lind Alliance method. We conducted an initial online and paper survey from Jan. 22 to May 2, 2018, with older adults in Alberta aged 65 years and older to identify what respondents saw as being most important for the health of older adults. We formed responses into summary questions and checked them against existing evidence. We administered a second survey (July 3 to Aug. 2, 2018) to shortlist summary questions and held an in-person workshop (Aug. 30, 2018) to rank the list through discussion and shared decision-making.

RESULTS

We recruited 670 participants (32.7% older adults, 19.7% caregivers, 46.9% health and social care workers) in the initial survey to tell us what topics on the health of older adults mattered most to them. Over 3000 responses generated 101 summary questions, of which only 4 were completely answered by existing evidence. The second prioritization survey was completed by 232 participants (28.4% older adults, 24.6% care partners, 47.0% health and social care workers) to produce a shortlist of 22 high priority questions. Twenty-two attendees participated in the summary workshop to create a prioritized list of 10 questions for future research that address aspects of the health system, provision of care and living well in older adulthood.

INTERPRETATION

Older adults, caregivers and clinicians collectively produced a prioritized list of questions that matter most to older adults' health in Alberta. Provincial researchers and research funders should consider these unmet knowledge needs of end-users in future endeavours.

Return on Investment of the Primary Health Care Integrated Geriatric Services Initiative Implementation

BACKGROUND

Since June 2017, the Primary Health Care Integrated Geriatric Services Initiative (PHC IGSI) has been implemented in Alberta, Canada to, among other aims, reduce costs of unplanned health service utilization while maximizing the utilization of available community resources to support people living with dementia living in communities.

AIM OF THE STUDY

We performed an economic evaluation of this initiative to inform policy regarding sustainability, scale up and spread.

METHODS

We used a cohort design together with a difference-in-difference approach and a propensity score matching technique to calculate impacts of the intervention on patient's health service utilization, including inpatient, outpatient and physician services, as well as prescription drugs. We then used a decision tree to compare between benefits and costs of the intervention and reported net benefits (NB) and return on investment ratios (ROI). We used a health system perspective and a time horizon of 1 year. Both deterministic and probabilistic sensitivity analyses were performed for the uncertainty of parameters. We analyzed real-world data extracted from the Alberta Health Administrative Databases. All costs/savings were inflated to 2019 CAD (CAD 1 \sim = USD 0.75) using the Canadian Consumer Price Index.

RESULTS

The intervention reduced the use of hospital (inpatient, emergency, and outpatient) services by increasing the use of community services (physician and prescription drug). As hospital services are expensive, the PHC IGSI community intervention resulted in a NB from CAD 554 to 4,046 per patient-year for the health system, and a ROI from 1.3 to 3.1 meaning that every CAD invested in PHC IGSI would bring CAD 1.3 to 3.1 in return. The probability of PHC IGSI to be cost-saving was 56.4% to 69.3%.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

The PHC IGSI is cost-effective in Alberta.

IMPLICATIONS FOR HEALTH POLICY

The savings would be larger if the initiative is sustained, scaled up and spread because of not only a reduced cost of intervention in the sustainability phase, but also because of the increased number of patients that would be impacted.

IMPLICATIONS FOR FURTHER RESEARCH

Future studies taking a societal perspective to also include costs for families and health and social sectors at the community level, would be desirable. Additionally, future works to determine how wellbeing is impacted by the PHC IGSI as vertical and horizontal integration interventions are implemented at the community level, are essential to undertake. Finally, in addition to people living with dementia, the PHC IGSI also supports people living in the community with frailty and other geriatric syndromes, therefore, the cost-savings estimated in this study are likely underestimated.

Implementation of an in-patient hip fracture liaison services to improve initiation of osteoporosis medication use within 1-year of hip fracture: a population-based time series analysis using the RE-AIM framework

A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was effective for improving initiation of osteoporosis medication following hip fracture.

PURPOSE

To examine implementation of an in-patient hip fracture liaison service (H-FLS) to improve osteoporosis medication use after hip fracture using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance).

METHODS

Using population-based administrative data from 7 quarters before and up to 7 quarters after H-FLS implementation, we examined new starts, continued use, and overall use (new starts + continued use) of osteoporosis medication after hip fracture. A total of 1427 patients 50 years and older that underwent hip fracture surgery at 1 of 2 tertiary hospitals in a Canadian province and survived to 12 months post-fracture were included. We also compared treatment initiation rates by sex and hospital.

RESULTS

Of the 1427 patients, 1002 (70.2%) were female (mean age = 79.3 ± 11.9 years) and 425 (29.8%) were male (mean age = 73.8 ± 13.8 years). Based on pre-fracture residence within the health zone, 1101 (69%) were considered eligible (Reach). New starts of osteoporosis medication increased from 24.7% pre- to 43.9% post-implementation of the H-FLS (p < 0.001) (effectiveness). The proportion of patients prescribed osteoporosis medication prior to a hip fracture remained consistent (15.1% pre-; 14.7% post-implementation; p = 0.88) with a resultant improvement in overall medication use from 39.8% pre- to 58.6% post-implementation (p < 0.001). Both sites significantly improved medication initiation (site 1: 27.9% pre- to 40.3% post-implementation; site 2: 19.6% pre- to 50.0% post-implementation; p < 0.001 for both) (adoption). Medication initiation in females improved from 26.0% pre- to 43.4% post-implementation while initiation in males improved from 21.7% pre- to 45.1% post-implementation (p < 0.001[females]; p = 0.001[males]) (implementation). Post-implementation, elevated initiation rates were retained over the 7 quarters (p = 0.81) (maintenance).

CONCLUSIONS

An H-FLS based in two tertiary hospital sites significantly improved use of osteoporosis medications after hip fracture in both males and females.

A scoping review of full-spectrum knowledge translation theories, models, and frameworks

Background

Application of knowledge translation (KT) theories, models, and frameworks (TMFs) is one method for successfully incorporating evidence into clinical care. However, there are multiple KT TMFs and little guidance on which to select. This study sought to identify and describe available full-spectrum KT TMFs to subsequently guide users.

Methods

A scoping review was completed. Articles were identified through searches within electronic databases, previous reviews, grey literature, and consultation with KT experts. Search terms included combinations of KT terms and theory-related terms. Included citations had to describe full-spectrum KT TMFs that had been applied or tested. Titles/abstracts and full-text articles were screened independently by two investigators. Each KT TMF was described by its characteristics including name, context, key components, how it was used, primary target audience, levels of use, and study outcomes. Each KT TMF was also categorized into theoretical approaches as process models, determinant frameworks, classic theories, implementation theories, and evaluation frameworks. Within each category, KT TMFs were compared and contrasted to identify similarities and unique characteristics.

Results

Electronic searches yielded 7160 citations. Additional citations were identified from previous reviews (n = 41) and bibliographies of included full-text articles (n = 6). Thirty-six citations describing 36 full-spectrum were identified. In 24 KT TMFs, the primary target audience was multi-level including patients/public, professionals, organizational, and financial/regulatory. The majority of the KT TMFs were used within public health, followed by research (organizational, translation, health), or in multiple contexts. Twenty-six could be used at the individual, organization, or policy levels, five at the individual/organization levels, three at the individual level only, and two at the organizational/policy level. Categorization of the KT TMFs resulted in 18 process models, eight classic theories, three determinant frameworks, three evaluation frameworks, and four that fit more than one category. There were no KT TMFs that fit the implementation theory category. Within each category, similarities and unique characteristics emerged through comparison.

Conclusions

A systematic compilation of existing full-spectrum KT TMFs, categorization into different approaches, and comparison has been provided in a user-friendly way. This list provides options for users to select from when designing KT projects and interventions.

Trial registration

A protocol outlining the methodology of this scoping review was developed and registered with PROSPERO (CRD42018088564).

Barriers and facilitators to diagnosing and managing apathy in Parkinson's disease: a qualitative study

BACKGROUND

Apathy is a prominent non-motor symptom in Parkinson's disease (PD). People with apathy show a lack of emotion, passion, and motivation. Between 17 and 70% of persons with PD have apathy; the extreme heterogeneity in these estimates is due to limited heterogeneous knowledge concerning how to diagnose PD. The lack of a widely utilized diagnostic process limits understandings on how to treat and manage apathy in PD. A scoping review of apathy in PD identified only one qualitative study investigating this symptom. It was our objective to assess perceived barriers and facilitators to diagnosing, treating, and managing apathy in PD, as described by key stakeholders.

METHODS

This research applied qualitative methodology, utilizing focus groups and interviews with health care practitioners (HCPs), persons with PD, and caregivers. Evidence gathered from a scoping review on apathy in PD informed discussions that took place with participants. Data collection and analysis was conducted using framework analysis, applying the Theoretical Domains Framework and Behaviour Change Wheel.

RESULTS

Eleven HCPs and five persons with PD/caregivers participated. Themes included interdisciplinary teams and communication with family to facilitate diagnosis and treatment, and the use of education and increased awareness of apathy to facilitate management. Themes surrounding barriers included lack of initiative and motivation to maintain treatment plans, and a lack of evidence for apathy specific interventions. While a key barrier identified was the lack of information HCPs have access to, persons with PD and caregivers would prefer to receive a diagnosis of apathy even with limited management methods. Thus, education and awareness were noted as two of the most important facilitators, overall.

CONCLUSION

These findings suggest that diagnosing, treating, and managing apathy in PD requires interdisciplinary teams, that include family and caregivers. We identified that where HCPs perceive lack of knowledge as a barrier to diagnosis, persons with PD and caregivers find being given a diagnosis facilitates understanding. These findings highlight the importance of qualitative research involving persons with PD and apathy, caregivers, and HCPs who aid in management of this symptom. Barriers reported suggest future research must aim to identify apathy specific treatments, both pharmacologic and non-pharmacologic.

Human T-cell leukemia virus type 1 Gag domains have distinct RNA-binding specificities with implications for RNA packaging and dimerization

Human T-cell leukemia virus type 1 (HTLV-1) is the first retrovirus that has conclusively been shown to cause human diseases. In HIV-1, specific interactions between the nucleocapsid (NC) domain of the Gag protein and genomic RNA (gRNA) mediate gRNA dimerization and selective packaging; however, the mechanism for gRNA packaging in HTLV-1, a deltaretrovirus, is unclear. In other deltaretroviruses, the matrix (MA) and NC domains of Gag are both involved in gRNA packaging, but MA binds nucleic acids with higher affinity and has more robust chaperone activity, suggesting that this domain may play a primary role. Here, we show that the MA domain of HTLV-1, but not the NC domain, binds short hairpin RNAs derived from the putative gRNA packaging signal. RNA probing of the HTLV-1 5' leader and cross-linking studies revealed that the primer-binding site and a region within the putative packaging signal form stable hairpins that interact with MA. In addition to a previously identified palindromic dimerization initiation site (DIS), we identified a new DIS in HTLV-1 gRNA and found that both palindromic sequences bind specifically the NC domain. Surprisingly, a mutant partially defective in dimer formation in vitro exhibited a significant increase in RNA packaging into HTLV-1-like particles, suggesting that efficient RNA dimerization may not be strictly required for RNA packaging in HTLV-1. Moreover, the lifecycle of HTLV-1 and other deltaretroviruses may be characterized by NC and MA functions that are distinct from those of the corresponding HIV-1 proteins, but together provide the functions required for viral replication.

Classification schemes for knowledge translation interventions: a practical resource for researchers

BACKGROUND

As implementation science advances, the number of interventions to promote the translation of evidence into healthcare, health systems, or health policy is growing. Accordingly, classification schemes for these knowledge translation (KT) interventions have emerged. A recent scoping review identified 51 classification schemes of KT interventions to integrate evidence into healthcare practice; however, the review did not evaluate the quality of the classification schemes or provide detailed information to assist researchers in selecting a scheme for their context and purpose. This study aimed to further examine and assess the quality of these classification schemes of KT interventions, and provide information to aid researchers when selecting a classification scheme.

METHODS

We abstracted the following information from each of the original 51 classification scheme articles: authors' objectives; purpose of the scheme and field of application; socioecologic level (individual, organizational, community, system); adaptability (broad versus specific); target group (patients, providers, policy-makers), intent (policy, education, practice), and purpose (dissemination versus implementation). Two reviewers independently evaluated the methodological quality of the development of each classification scheme using an adapted version of the AGREE II tool. Based on these assessments, two independent reviewers reached consensus about whether to recommend each scheme for researcher use, or not.

RESULTS

Of the 51 original classification schemes, we excluded seven that were not specific classification schemes, not accessible or duplicates. Of the remaining 44 classification schemes, nine were not recommended. Of the 35 recommended classification schemes, ten focused on behaviour change and six focused on population health. Many schemes (n = 29) addressed practice considerations. Fewer schemes addressed educational or policy objectives. Twenty-five classification schemes had broad applicability, six were specific, and four had elements of both. Twenty-three schemes targeted health providers, nine targeted both patients and providers and one targeted policy-makers. Most classification schemes were intended for implementation rather than dissemination.

CONCLUSIONS

Thirty-five classification schemes of KT interventions were developed and reported with sufficient rigour to be recommended for use by researchers interested in KT in healthcare. Our additional categorization and quality analysis will aid in selecting suitable classification schemes for research initiatives in the field of implementation science.

Facilitators and barriers of change toward an elder-friendly surgical environment: perspectives of clinician stakeholder groups

BACKGROUND

Current acute care surgical practices do not focus on the unique needs of older adults. Adverse outcomes in older patients result from a complex interrelationship between baseline vulnerability and insults experienced during hospitalization. The purpose of this study is to assess the organizational readiness and the barriers and facilitators for the implementation of elder-friendly interventions in the acute care of unplanned abdominal surgery patients.

METHODS

This cross-sectional mixed methods study included a convenience sample of clinician stakeholder groups. Eight focus groups were conducted with 33 surgical team members including: 10 health care aides, 6 licensed practical nurses, 6 registered nurses, 4 nurse managers and 7 surgeons, to identify barriers and facilitators to the implementation of an elder-friendly surgical unit. Audio recordings of the focus groups were transcribed verbatim and analysed using interpretive description techniques. Transcripts were coded along with explanatory memos to generate a detailed description of participant experiences. Themes were identified followed by refining the codes. Participants also completed the Organizational Readiness for Implementing Change questionnaire. Differences in organizational readiness scores across clinician stakeholder groups were assessed using Kruskal-Wallice tests. Mann-Whitney tests (Bonferroni's corrections for multiple comparisons) were conducted to assess pair-wise relationships.

RESULTS

The focus group data were conceptualized to represent facilitators and barriers to change at two levels of care delivery. Readiness to change at the organizational level was evident in five categories that reflected the barriers and facilitators to implementing an elder-friendly surgical unit. These included education, environment, staffing, policies and other research projects. At the individual level barriers and facilitators were apparent in staff members' acceptance of new roles and duties with other staff, family and patients. Examples of these included communication, teamwork and leadership. The mean change commitment and change efficacy scores on the Organizational Readiness for Implementing Change Questionnaire were 3.7 (0.8) and 3.5 (0.9) respectively. No statistically significant differences were detected between the stakeholder groups.

CONCLUSIONS

Staff are interested in contributing to improved care for elderly surgical patients; however, opportunities were identified to enhance facilitators and reduce barriers in advance of implementing the elder-friendly surgical unit intervention.

APOBEC3B lysine residues are dispensable for DNA cytosine deamination, HIV-1 restriction, and nuclear localization

The APOBEC3 DNA cytosine deaminase family comprises a fundamental arm of the innate immune response and is best known for retrovirus restriction. Several APOBEC3 enzymes restrict HIV-1 and related retroviruses by deaminating viral cDNA cytosines to uracils compromising viral genomes. Human APOBEC3B (A3B) shows strong virus restriction activities in a variety of experimental systems, and is subjected to tight post-translational regulation evidenced by cell-specific HIV-1 restriction activity and active nuclear import. Here we ask whether lysines and/or lysine post-translational modifications are required for these A3B activities. A lysine-free derivative of human A3B was constructed and shown to be indistinguishable from the wild-type enzyme in DNA cytosine deamination, HIV-1 restriction, and nuclear localization activities. However, lysine loss did render the protein resistant to degradation by SIV Vif. Taken together, we conclude that lysine side chains and modifications thereof are unlikely to be central to A3B function or regulation in human cells.

Incontinence and Nocturia in Older Adults After Hip Fracture: Analysis of a Secondary Outcome for a Parallel Group, Randomized Controlled Trial

Objective: To test the effect of a follow-up clinic on urinary incontinence (UI) and nocturia among older adults with hip fracture. Method: Fifty-three older adults (≥65 years) 3 to 12 months following hip fracture were enrolled and randomized to receive usual care plus the intervention (B4), or usual care (UC) only. The B4 group received management by health professionals, with need-based referrals. UI, nocturia, and quality of life were measured with questionnaires at baseline, 6 months, and 12 months. Results: There were 48 participants included in this analysis, and at baseline, 44% of study participants self-reported UI. At final assessment, six out of 24 B4 participants and 12 out of 24 UC participants reported UI. Four out of five study participants reported nocturia at baseline; this did not decrease during the study. Discussion: Following hip fracture, many older adults report UI and most report nocturia. Health professionals should be aware of the high occurrence of urinary symptoms among older adults post hip fracture.

Reflections on Hip Fracture Recovery From Older Adults Enrolled in a Clinical Trial

This study describes patients' perspectives on recovery during participation in a randomized controlled trial that tested a postoperative hip fracture management program (B4 Clinic), compared with usual care, on mobility. Semistructured qualitative interviews were conducted with 50 older adults with hip fracture (from both groups) twice over 12 months. A total of 32 women (64%) and 18 men (36%) participated in the study with a mean age at baseline of 82 (range = 65-98) years. A total of 40 participants reported recovery goals at some point during their recovery from hip fracture but only 18 participants realized their goals within 12 months. Recovering mobility, returning to prefracture activities, and obtaining stable health were the most commonly reported goals. Participants described good social support, access to physiotherapy, and positive perspective as most important to recovery. These factors were influenced by participants' knowledge, resources, and monthly contact with study staff (perceived as a form of social support). The most frequently reported barriers to participants' recovery were the onset of complications, pain, and limited access to physiotherapy. Potential implications of these findings include design and modification of new or preexisting fracture programs, prioritizing patient engagement and enhanced knowledge for future clinical research in hip fracture recovery.

A Critical Discussion of Patient Engagement in Research

Patients are increasingly expected to take a more involved role in research. Funding for some projects now requires incorporating patients' viewpoints or involvement in research processes. While intended to achieve commendable goals, it is important to critically assess the means used to achieve these aims. Presently, there may be issues of valuing only certain epistemologies, failing to evaluate existing programs and their impacts, marginalizing less "engaged" patients, and promoting only tokenism. These are areas that require exploration and reflection before assuming that patient engagement approaches are sufficient or the only means of incorporating patient perspectives into research.

Gait Speed and Variability for Usual Pace and Pedestrian Crossing Conditions in Older Adults Using the GAITRite Walkway

Objectives: To determine gait characteristics of community-dwelling older adults at different speeds and during a crosswalk simulation. Methods: Twenty-two older adults completed walking trials at self-selected slow, usual, and fast paces, and at a crosswalk simulation, using the GAITRite walkway. These objective measures were complemented by self-report health and mobility questionnaires. Results: Gait speeds at self-selected slow, usual, and fast paces were 98.7 (18.1) cm/s, 140.9 (20.4) cm/s, and 174.0 (20.6) cm/s, respectively, and at simulated crosswalk conditions was 144.2 (22.3) cm/s. For usual pace, right step length variability was 2.0 (1.4) cm and step time variability was 13.6 (7.2) ms, compared with 2.4 (1.3) cm and 17.3 (9.7) ms, respectively, for crosswalk conditions. Discussion: Our sample of healthy older adults walked at a speed exceeding standards for crossing urban streets; however, in response to a crosswalk signal, participants adopted a significantly faster and more variable gait.

Exploring older adults' patterns and perceptions of exercise after hip fracture

PURPOSE

To identify exercise patterns and perceived barriers, enablers, and motivators to engaging in exercise for older adults following hip fracture.

METHOD

Telephone interviews were conducted with older adults (aged 62-97 y) within 1 year after hip fracture. Participants were asked about basic demographic information; level of mobility before hip fracture; current level of mobility; and barriers, enablers, and motivators to participating in exercise.

RESULTS

A total of 32 older adults successfully recovering after hip fracture completed the telephone interviews. Participants reported few problems with their mobility, and all were engaging in exercise. There were few reported barriers to exercise; the most common were health-related concerns (pain, fatigue, illness, or injury). The most frequently reported enablers were intrinsic factors (determination, seeing improvements, and making exercise part of their daily routine); in particular, the most common motivator to exercise was recovery of function to improve mobility and complete daily and leisure activities.

CONCLUSIONS

This study highlights the responses of a group of older adults recovering well after hip fracture. Older adults engage in exercise despite the potential limitations associated with a hip fracture. Participants' responses underscore the importance of intrinsic factors and suggest avenues for future investigation.

Concept mapping applied to the intersection between older adults' outdoor walking and the built and social environments

OBJECTIVE

For older adults, the ability to navigate walking routes in the outdoor environment allows them to remain active and socially engaged, facilitating community participation and independence. In order to enhance outdoor walking, it is important to understand the interaction of older adults within their local environments and the influence of broader stakeholder priorities that impact these environments. Thus, we aimed to synthesize perspectives from stakeholders to identify elements of the built and social environments that influence older adults' ability to walk outdoors.

METHOD

We applied a concept mapping approach with the input of diverse stakeholders (N=75) from British Columbia, Canada in 2012.

RESULTS

A seven-cluster map best represented areas that influence older adults' outdoor walking. Priority areas identified included sidewalks, crosswalks, and neighborhood features.

CONCLUSION

Individual perceptions and elements of the built and social environments intersect to influence walking behaviors, although targeted studies that address this area are needed.

Does an 'activity-permissive' workplace change office workers' sitting and activity time?

Introduction

To describe changes in workplace physical activity, and health-, and work-related outcomes, in workers who transitioned from a conventional to an ‘activity-permissive’ workplace.

Methods

A natural pre-post experiment conducted in Vancouver, Canada in 2011. A convenience sample of office-based workers (n=24, 75% women, mean [SD] age = 34.5 [8.1] years) were examined four months following relocation from a conventional workplace (pre) to a newly-constructed, purpose-built, movement-oriented physical environment (post). Workplace activity- (activPAL3-derived stepping, standing, and sitting time), health- (body composition and fasting cardio-metabolic blood profile), and work- (performance; job satisfaction) related outcomes were measured pre- and post-move and compared using paired t-tests.

Results

Pre-move, on average (mean [SD]) the majority of the day was spent sitting (364 [43.0] mins/8-hr workday), followed by standing (78.2 [32.1] mins/8-hr workday) and stepping (37.7 [15.6] mins/8-hr workday). The transition to the ‘activity-permissive’ workplace resulted in a significant increase in standing time (+18.5, 95% CI: 1.8, 35.2 mins/8-hr workday), likely driven by reduced sitting time (-19.7, 95% CI: -42.1, 2.8 mins/8-hr workday) rather than increased stepping time (+1.2, 95% CI: -6.2, 8.5 mins/8-hr workday). There were no statistically significant differences observed in health- or work-related outcomes.

Discussion

This novel, opportunistic study demonstrated that the broader workplace physical environment can beneficially impact on standing time in office workers. The long-term health and work-related benefits, and the influence of individual, organizational, and social factors on this change, requires further evaluation.

Stakeholders' perceptions of programme sustainability: findings from a community-based fall prevention programme

OBJECTIVES

Sustainability of health promotion and injury prevention programmes is a goal of practitioners and an increasingly common requirement of funding bodies. However, less is known about the views held by individual stakeholders involved in such programmes regarding their perceptions of facilitators and barriers to achieving sustainability. This paper aims to share the perceptions of programme sustainability held by key stakeholders involved in a community-based fall prevention programme in three Ontario demonstration communities in Canada.

STUDY DESIGN

A qualitative case study research design.

METHOD

A holistic multiple case study method was employed. In total, 45 stakeholders involved in various aspects of the project participated from three demonstration sites. Stakeholders' perceptions were gathered on the individual actions they took in an effort to promote sustainability, and the barriers they perceived as preventing or limiting sustainability.

RESULTS

Stakeholders reported taking a number of actions to aid programme sustainability, with some actions deemed to be more functional in aiding sustainability than others. Common actions reported by stakeholders included partnership formation, networking and increasing community capacity. Stakeholders also perceived a number of barriers to achieving sustainability, including insufficient human and financial resources, lack of co-ordination and buy-in, heavy reliance on volunteers and an inability to mobilize physicians. Stakeholders' perceptions of sustainability were used to develop recommendations for sustainability for both communities and funding bodies.

CONCLUSION

The views and experiences shared by the stakeholders in this project can serve as lessons learnt to aid in the sustainability of other health promotion and injury prevention programmes in the future.

Post-discharge management following hip fracture--get you back to B4: a parallel group, randomized controlled trial study protocol

Background

Fall-related hip fractures result in significant personal and societal consequences; importantly, up to half of older adults with hip fracture never regain their previous level of mobility. Strategies of follow-up care for older adults after fracture have improved investigation for osteoporosis; but managing bone health alone is not enough. Prevention of fractures requires management of both bone health and falls risk factors (including the contributing role of cognition, balance and continence) to improve outcomes.

Methods/Design

This is a parallel group, pragmatic randomized controlled trial to test the effectiveness of a post-fracture clinic compared with usual care on mobility for older adults following their hospitalization for hip fracture. Participants randomized to the intervention will attend a fracture follow-up clinic where a geriatrician and physiotherapist will assess and manage their mobility and other health issues. Depending on needs identified at the clinical assessment, participants may receive individualized and group-based outpatient physiotherapy, and a home exercise program. Our primary objective is to assess the effectiveness of a novel post-discharge fracture management strategy on the mobility of older adults after hip fracture.

We will enrol 130 older adults (65 years+) who have sustained a hip fracture in the previous three months, and were admitted to hospital from home and are expected to be discharged home. We will exclude older adults who prior to the fracture were: unable to walk 10 meters; diagnosed with dementia and/or significant comorbidities that would preclude their participation in the clinical service.

Eligible participants will be randomly assigned to the Intervention or Usual Care groups by remote allocation. Treatment allocation will be concealed; investigators, measurement team and primary data analysts will be blinded to group allocation. Our primary outcome is mobility, operationalized as the Short Physical Performance Battery at 12 months. Secondary outcomes include frailty, rehospitalizations, falls risk factors, quality of life, as well as physical activity and sedentary behaviour. We will conduct an economic evaluation to determine health related costs in the first year, and a process evaluation to ascertain the acceptance of the program by older adults, as well as clinicians and staff within the clinic.

Trial registration number

ClinicalTrials.gov: NCT01254942

Broadening our understanding: approaching falls as a stigmatizing topic for older adults

This theoretical paper aims to demonstrate that our current understanding of falls in older adulthood can be improved by viewing falls as a stigmatizing topic. Existing empirical research alludes to the stigmatization of falls for older adults, but until now the explicit link between the study of falls and stigma has not been made. After applying the concepts of identity threat, modified labeling theory, and attribution theory, the research implications of stigma on an older adult's willingness to report and discuss falls will be outlined. As many research investigations use the number of prior falls to assign individuals to study groups, the influence of stigma may be widespread and confounding research findings. By better recognizing and understanding the contribution of stigma to the willingness of older adults to report and discuss falls, we will be better able to mitigate its effects.

Defining program sustainability: differing views of stakeholders

OBJECTIVES

Sustainability is a highly desired outcome of health promotion programs, yet it often eludes program planners looking to achieve it. This study aimed to uncover how the goal of program sustainability was interpreted by key stakeholders from three fall prevention program demonstration sites.

METHOD

Collected as part of a larger study on program sustainability that made use of a multiple case study methodology, semi-structured interviews were conducted with key informants involved in a wide range of program initiatives throughout the two-year funding period.

RESULTS

Forty participants across the three sites provided definitions of sustainability. Most stakeholders reported that it was some version of the general fall prevention program that should be sustained. Fewer stakeholders reported that it was the successful elements or solutions to the program goals that should be sustained. The most common suggestions reported by stakeholders for how sustainability should be achieved were awareness raising and securing new funding sources. Although a number of key elements emerged, there were significant differences in stakeholders' definitions of sustainability, both within and between demonstration sites.

CONCLUSION

This research provided insight into the unique meanings of sustainability held by different stakeholders during their involvement in a fall prevention program. The array of definitions held by stakeholders demonstrates how easily the efforts of those involved can become fragmented and, therefore, less effective in reaching the end goal of program sustainability when the project team is not working from the same definition of what that goal means.

Glottal characteristics of male speakers: acoustic correlates and comparison with female data

Acoustic measurements believed to reflect glottal characteristics were made on recordings collected from 21 male speakers. The waveforms and spectra of three nonhigh vowels (/ae, lambda, epsilon/) were analyzed to obtain acoustic parameters related to first-formant bandwidth, open quotient, spectral tilt, and aspiration noise. Comparisons were made with previous results obtained for 22 female speakers [H. M. Hanson, J. Acoust. Soc. Am. 101, 466-481 (1997)]. While there is considerable overlap across gender, the male data show lower average values and less interspeaker variation for all measures. In particular, the amplitude of the first harmonic relative to that of the third formant is 9.6 dB lower for the male speakers than for the female speakers, suggesting that spectral tilt is an especially significant parameter for differentiating male and female speech. These findings are consistent with fiberscopic studies which have shown that males tend to have a more complete glottal closure, leading to less energy loss at the glottis and less spectral tilt. Observations of the speech waveforms and spectra suggest the presence of a second glottal excitation within a glottal period for some of the male speakers. Possible causes and acoustic consequences of these second excitations are discussed.

Glottal characteristics of female speakers: acoustic correlates

The aim of the research reported in this paper is to formulate a set of acoustic parameters of the voicing source that reflect individual differences in the voice qualities of female speakers. Theoretical analysis and observations of experimental data suggest that a more open glottal configuration results in a glottal volume-velocity waveform with relatively greater low-frequency and weaker high-frequency components, compared to a waveform produced with a more adducted glottal configuration. The more open glottal configuration also leads to a greater source of aspiration noise and larger bandwidths of the natural frequencies of the vocal tract, particularly the first formant. These different attributes of the glottal waveform can be measured directly from the speech spectrum or waveform. A set of acoustic parameters that are likely to indicate glottal characteristics is described. These parameters are measured in the speech of a group of female speakers, and the glottal configurations of the speakers are hypothesized. This research contributes to the description of normal variations of voicing characteristics across speakers and to a continuing effort to improve the analysis and synthesis of female speech. It may also have applications in clinical settings.

In vivo pharmacology of L-364,718, a new potent nonpeptide peripheral cholecystokinin antagonist

The in vivo pharmacological activity of L-364,718, a new, potent peripheral cholecystokinin (CCK) antagonist, was characterized in several species using assay systems that measure various well known actions of CCK upon the gastrointestinal system. Administered p.o., L-364,178 was highly potent in antagonizing cholecystokinin octapeptide (CCK-8)-induced inhibition of gastric emptying in mice (ED50 = 38 micrograms/kg), rats (ED50 = 140 micrograms/kg) and dogs (ED50 = 91 micrograms/kg) as well as CCK-8-induced reduction in food consumption in rats (ED50 = 321 micrograms/kg). Administered i.v., L-364,718 effectively antagonized the contractile effects of CCK on the colon in rabbits (ED50 = 34 micrograms/kg) and the gallbladder in cats (ED50 = 210 micrograms/kg). Secretion of pancreatic protein and amylase elicited by CCK in cats was also antagonized by L-364,718 (ED50 less than 1.0 mg/kg i.v.). The CCK antagonism produced by L-364,718 in all species persisted for at least 2 to 5 hr. In the absence of exogenously administered CCK-8, L-364,718 per se had no effect in any of the assay systems studied, indicating a lack of CCK-like agonist properties. Specificity for CCK was demonstrated by the inability of L-364,718 (1.0-5.0 mg/kg) to antagonize either amino acid- or atropine-induced inhibition of gastric emptying in rats and dogs, respectively. L-364,718 also did not antagonize motilin-induced gallbladder contractions or secretin-induced pancreatic secretion in cats.(ABSTRACT TRUNCATED AT 250 WORDS)

Anorexigenic and ancillary actions of MK-212 (6-chloro-2-(1-piperazinyl)-pyrazine; CPP)

In rats allowed to eat for 2 h/day and injected i.p. 30 min before feeding, MK-212, ED50 = 1.5 mg/kg, was two times more potent as an anorexigen than fenfluramine. However, the compounds were equiactive in the rat following p.o. administration 1.5 or 3 h before the test, while fenfluramine was more potent if the interval was extended to 6 h. In cats permitted to eat for 3 h/day, the ED50 dose (mg/kg p.o.) for MK-212 determined at 0.5, 1 and 3 h after feeding was, respectively, 15, 10, and 3 times less than that of fenfluramine. Emesis and diarrhea were frequently observed ancillary effects in cats treated with fenfluramine, whereas apparent sedation and salivation were commonly detected in animals after MK-212. In rats or cats pretreated with methergoline, the decrease in food consumption elicited by MK-212 was markedly inhibited, suggesting that the mechanism of action involves a serotoninlike effect. Compared with the marked stimulant action of amphetamine, MK-212 had only a minor and inconsistent effect on motor activity in rats and mice. Similar results were obtained with fenfluramine. MK-212 was not self-administered by rats, while the self-administration of amphetamine and morphine were demonstrated using the same experimental protocol.

Effect of cage size on patterns of activity and health of beagle dogs

Thirty-two male beagle dogs were assigned at random, 16 to standard size cages (30 X 30 X 30 inches) and 16 to large cages (90 X 30 X 30 inches) for a period of 13 weeks, and then were "crossed-over" for an additional period of 13 weeks. The dogs were observed daily and weighed weekly. Electrocardiographic and ophthalmologic examinations were made once and hematologic and biochemical measurements were made twice during the control period and at monthly intervals during the study. Photographs were taken of each dog every 60 seconds, 7 days a week, for about 8.5 hours each day. The film was processed and analyzed for the acf standing sitting, lying, or sleeping. In addition, dogs in the large cages were scored for the region (front, middle, or back) occupied. No statistically significant differences were found between dogs in the standard or large cages with respect to weight gain, percent of time standing, and percent of time sleeping. Statistically significant (p less than 0.05) differences were found for percent of time sitting (standard cages 12.7%; large cages 9.4%) and percent of time lying (standard cages 6.6%; large cages 8.3%); however, the differences were not large enough to be of any practical concern. Transient patterns of response over 13-week periods of the study were essentially the same (statistically verified) for dogs in either size cage. Also statistical results showed that there was no significant carryover (residual) effect associated with any of the parameters measured. No beneficial or adverse effects were noted that could be related to the size of the two cages. The size of the standard cage appeared adequate for laboratory beagle dogs and no advantage was found when the dogs were in larger cages with respect to behavior, patterns of activity, or health.

Psychophysical evaluation of toxic effects on sensory systems

Toxic effects on sensory systems have rarely been evaluated by psychophysical methods. As examples of possible applications four studies are described. Sodium salicylate and kanamycin, both reported to produce hearing deficits in man, have also been demonstrated to affect auditory thresholds in monkeys. With the latter drug the deficits measured were found to be correlated with specific loss of receptor cells in the cochlea. Pheniprazine, known to induce red-green color blindness, was found to disrupt a wavelength discrimination in pigeons. Trans 11-amino-10,11-dihydro-5-(3-dimethylaminopropyl)-5,10-expoxy-5H-dibenzo[a,d]-cycloheptene dihydrochloride, which was found to bleach the tapidum lucidum in dogs when given subacutely, was found to decrease sensitivity to light. The loss in sensitivity measured by behavioral techniques was correlated with the loss of coloration of the tapidum. Monkeys, not having a tapidum, did not show a similar effect.