Feasibility study of microburst VNS therapy in drug-resistant focal and generalized epilepsy

BACKGROUND

Vagus nerve stimulation (VNS) at low frequencies (≤30 Hz) has been an established treatment for drug-resistant epilepsy (DRE) for over 25 years.

OBJECTIVE

To examine the initial safety and efficacy performance of an investigational, high-frequency (≥250 Hz) VNS paradigm herein called "Microburst VNS" (μVNS). μVNS consists of short, high-frequency bursts of electrical pulses believed to preferentially modulate certain brain regions.

METHODS

Thirty-three (33) participants were enrolled into an exploratory feasibility study, 21 with focal-onset seizures and 12 with generalized-onset seizures. Participants were titrated to a personalized target dose of μVNS using an investigational fMRI protocol. Participants were then followed for up to 12 months, with visits every 3 months, and monitored for side-effects at all time points. This study was registered as NCT03446664 on February 27th, 2018.

RESULTS

The device was well-tolerated. Reported adverse events were consistent with typical low frequency VNS outcomes and tended to diminish in severity over time, including dysphonia, cough, dyspnea, and implant site pain. After 12 months of μVNS, the mean seizure frequency reduction for all seizures was 61.3% (median reduction: 70.4%; 90% CI of median: 48.9%-83.3%). The 12-month responder rate (≥50% reduction) was 63.3% (90% CI: 46.7%-77.9%) and the super-responder rate (≥80% reduction) was 40% (90% CI: 25.0%-56.6%). Participants with focal-onset seizures appeared to benefit similarly to participants with generalized-onset seizures (mean reduction in seizures at 12 months: 62.6% focal [n = 19], versus 59.0% generalized [n = 11]).

CONCLUSION

Overall, μVNS appears to be safe and potentially a promising therapeutic alternative to traditional VNS. It merits further investigation in randomized controlled trials which will help determine the impact of investigational variables and which patients are most suitable for this novel therapy.

Create and Sustain a Culture of Curiosity: A Case Study of a Home Healthcare Organization in Toronto

Increased integration in the healthcare sector requires traditionally non-research-based organizations to contribute to evidence-based decision making as equal partners. This requires a culture and infrastructure that support structured inquiry to improve best practice, quality and safety. We present the roadmap used by one home healthcare organization to create an embedded research unit to drive this transformation. The use of a relevant model and a framework provided structure to guide and sustain the process. We expect that the core strategies and combination of frameworks should be transferrable to others wishing to contribute meaningfully to evidence-based health system transformation.

Construction sector joint health and safety committees: Can their effectiveness be assessed using the JHSC assessment eTool?

BACKGROUND: Joint health and safety committees (JHSCs) are a legal requirement for most Ontario workplaces. However, few evidence-based tools exist to assess JHSC effectiveness. The JHSC Assessment eTool has been developed and tested in the healthcare and education sectors with positive results. OBJECTIVE: The objective of this study is to test the usability and feasibility of the JHSC Assessment eTool in the construction sector. METHODS: Testing was carried out in two phases using a non-experimental study design. In the first phase, construction sector health and safety experts reviewed the content of the eTool to ensure that it had relevance for the sector. In phase two, a convenience sample of JHSCs from construction sector workplaces were recruited to pilot the eTool and provide feedback. RESULTS: Feedback from six constructor sector health and safety experts and six JHSC committees indicated that the eTool had value and relevance for use in the sector. Additionally, our study identified several minor areas for refinement including the addition of construction-specific resources in the final report. CONCLUSIONS: The results of our study suggest minor modifications to the eTool for use by construction sector workplaces.

Spot It, Prevent It: Evaluation of a Rapid Response Algorithm for Managing Workplace Violence Among Home Care Workers

Background:

Workplace violence incidents remain pervasive in health care. Home care workers like personal support workers (PSWs) provide services for clients with dementia, which has been identified as a risk factor for workplace violence. The objective of this study was to evaluate whether the implementation of a rapid response algorithm resolved unsafe working conditions associated with responsive behaviors and decreased perception of risk.

Methods:

A nonexperimental pre- and post-evaluation design was utilized to collect data from PSWs and supervisors. PSWs completed an online survey about their experience with workplace violence and perception of risk. Bi-weekly check-ins were conducted with supervisors to track incidents and their level of resolution in the algorithm. Semi-structured interviews were also conducted to gather in-depth feedback about the algorithm in practice.

Findings:

We found no difference in risk perception among PSWs pre- and post-implementation. However, PSWs who had been employed for less than 1 year had a significantly higher risk perception. Overall, the algorithm was found to be helpful in resolving workplace violence incidents.

Conclusion and Application to Practice:

Opportunity exists to further refine the algorithm and ongoing dissemination, and implementation of the algorithm is recommended to continually address incidents of workplace violence. Newly hired PSWs may require additional supports. Ongoing education and training were identified as key mitigation strategies.

Sources of Cannabis Information and Medical Guidance for Neurologic Use: NARCOMS Survey of People Living With Multiple Sclerosis

Background and Objectives

As cannabis products become increasingly accessible across the United States, understanding how patients obtain medical information on cannabis and view the role of their health care provider in providing information is important.

Methods

Participants with multiple sclerosis (MS) from the North American Research Committee on Multiple Sclerosis registry completed a supplemental survey on Δ⁹-tetrahydrocannabinol-containing cannabis use between March and April 2020. Participants reported dialogue with health care providers regarding cannabis use, information sources used to make product decisions, and expenditure on cannabis. Findings are reported using descriptive statistics.

Results

Overall, 3,249 participants responded (47% response rate), of whom 31% ever used cannabis and 20% currently used cannabis for MS. To determine presumed cannabis contents, respondents who had ever used cannabis (ever users) most often used dispensary-provided information (39%), word of mouth/dealer/friend (29%), and unregulated product labels (24%). For general information on cannabis for MS, ever users most often used dispensary staff (38%) and friends (32%). The primary source of medical guidance among ever users was most often “nobody or myself” (48%), followed by a dispensary professional (21%); only 12% relied on their MS physician, although 70% had discussed cannabis with their MS physician. Most current users (62%) typically sourced their cannabis from a dispensary. The most common factor in selecting a cannabis product was perceived quality and safety (70%).

Discussion

Participants most often received information on cannabis for MS from dispensaries, unregulated product labels, and friends; only a small proportion used health care providers. Evidence-based patient and physician education is needed.

Supporting Discovery and Inquiry: A Canadian Hospital's Approach to Building Research and Innovation Capacity in Point-of-Care Health Professionals

BACKGROUND AND OBJECTIVES

Building capacity for research and innovation among point-of-care health professionals can translate into positive outcomes from the organization, staff, and patient perspective. However, there is not a widely accepted framework in place across academic hospitals to guide this work and measure impact. This article outlines one Canadian hospital's approach and provides a blueprint with appropriate indicators as a starting point and guide for organizations looking to develop and implement a practice-based research and innovation strategy.

METHODS

An adapted framework was utilized to measure and track progress toward achievement of research and innovation strategic goals. The framework outlines key domains for research and capacity development and appropriate metrics. Data are reported from a 4-year period (2014-2018).

RESULTS

The evaluation of the practice-based research and innovation portfolio identified several important factors that contribute to the success of embedding this strategy across a large academic teaching institution. These include using a collaborative leadership model, leveraging linkages, partnerships, and collaborations, and recognizing the academic contributions of health professionals engaging in research and innovation.

CONCLUSIONS

Engaging those who provide care directly to patients and families in research and innovation is critical to ensuring high-quality health outcomes and patient experience. Creative and innovative funding models, collaborative leadership, and partnerships with key stakeholders to support research and innovation are needed to ensure sustainability.

Understanding transitional care programs for older adults who experience delayed discharge: a scoping review

Background

Many hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. However, little is known about the contextual factors (i.e., patient, staff and environmental characteristics) that may influence the implementation and outcomes of TCPs. This scoping review aims to answer: 1) What are socio-demographic and/or clinical characteristics of older patients served by TCPs?; 2) What are the core components provided by TCPs?; and 3) What patient, caregiver, and health system outcomes have been investigated and what changes in these outcomes have been reported for TCPs?

Methods

The six-step scoping review framework and PRISMA-ScR checklist were followed. Studies were included if they presented models of TCPs and evaluated them in community-dwelling older adults (65+) experiencing or at-risk for delayed discharge. The data synthesis was informed by a framework, consistent with Donabedian’s structure-process-outcome model.

Results

TCP patients were typically older women with multiple chronic conditions and some cognitive impairment, functionally dependent and living alone. The review identified five core components of TCPs: assessment; care planning and monitoring; treatment; discharge planning; and patient, family and staff education. The main outcomes examined were functional status and discharge destination. The results were discussed with a view to inform policy makers, clinicians and administrators designing and evaluating TCPs as a strategy for addressing delayed hospital discharges.

Conclusion

TCPs can influence outcomes for older adults, including returning home. TCPs should be designed to incorporate interdisciplinary care teams, proactively admit those at risk of delayed discharge, accommodate persons with cognitive impairment and involve care partners. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02099-9.

Understanding transitional care programmes for older adults who experience delayed discharge: a scoping review protocol

INTRODUCTION

Many hospitalised older adults experience delayed discharges due to increased postacute health and social support needs. Transitional care programmes (TCPs) provide short-term care to these patients to prepare them for transfer to nursing homes or back to the community with supports. There are knowledge gaps related to the development, implementation and evaluation of TCPs. The aims of this scoping review (ScR) are to identify the characteristics of older patients served by TCPs; criteria for transfer, components and services provided by TCPs; and outcomes used to evaluate TCPs.

METHODS AND ANALYSIS

The study involves six-step ScR and is informed by a collaborative/participatory approach whereby stakeholders engage in the development of the research questions, identification of literature, data abstraction and synthesis; and participation in consultation workshop. The search for scientific literature will be done in the Medline, PsychINFO, Emcare and CINAHL databases; as well, policies and reports that examined models of transitional care and the outcomes used to evaluate them will be reviewed. Records will be selected if they involve community dwelling older adults aged 65 years or older, or indigenous persons 45 years or older; and presented in English, French, Dutch and German languages. Records will be screened, reviewed and abstracted by two independent reviewers. Extracted data will be analysed using descriptive statistics and a narrative analysis, and organised according to Donabedian's model of structure (characteristics of older adults experiencing delayed discharge and served by TCPs), process (TCP components and services) and outcome.

ETHICS AND DISSEMINATION

This ScR does not require ethics approval. Dissemination activities include integrated knowledge translation (KT) (consultation with stakeholders throughout the study) and end-of-grant KT strategies (presentations at national and international conferences; and publication in peer-reviewed interdisciplinary journal).

Testing the joint health and safety committee assessment tool in the education sector

Joint Health and Safety Committee (JHSC) effectiveness has been identified as an area of concern for Ontario's education sector. The JHSC Assessment Tool has been previously tested in hospitals with positive results. This study assessed the feasibility and usability of the JHSC Assessment Tool in the education sector. Members of multi-workplace JHSCs from Ontario school boards used the tool to assess their committees' effectiveness before, during and after a committee meeting with usability testing conducted pre and post meeting. Results suggested that the JHSC Assessment Tool was feasible to use during a regular JHSC meeting, groups were able to come to consensus on the majority of items, and usability scores were high overall. Participant feedback provided insight that informed the development of a version relevant to multi-workplace committees.

Long-term safety and efficacy of cannabidiol in children and adults with treatment resistant Lennox-Gastaut syndrome or Dravet syndrome: Expanded access program results

BACKGROUND

Since 2014, patients with severe treatment-resistant epilepsies (TREs) have been receiving add-on cannabidiol (CBD) in an ongoing, expanded access program (EAP), which closely reflects clinical practice. We conducted an interim analysis of long-term efficacy and tolerability in patients with Lennox-Gastaut syndrome (LGS) or Dravet syndrome (DS) who received CBD treatment through December 2016.

METHODS

Children and adults with LGS/DS taking stable doses of antiepileptic drugs (AEDs) at baseline were included from 25 EAP sites across the United States. During the 4-week baseline period, parents/caregivers kept diaries of all countable seizure types. Patients received a pharmaceutical formulation of highly purified CBD (Epidiolex®; 100 mg/mL) in oral solution at 2-10 mg/kg/day, titrated until tolerability limit or a maximum dose of 25-50 mg/kg/day. Patient visits were every 2-4 weeks. The percentage change from baseline in median monthly convulsive (ie, major motor) and total seizures was evaluated at 12-week intervals through 96 weeks. The percentages of patients who had ≥50%, ≥75%, and 100% reduction in monthly seizures relative to the baseline period were also evaluated. Adverse events (AEs) were monitored and summarized for the safety analysis set (SAS) through 144 weeks.

RESULTS

Of the 607 patients in the SAS, 58 had DS and 94 had LGS (N = 152); 455 patients had other TREs. Twenty-eight percent of LGS/DS patients withdrew, primarily owing to lack of efficacy (20%). LGS/DS patients were taking a median of 3 (0-10) concomitant AEDs. Median treatment duration was 78.3 (range, 4.1-146.4) weeks. Between weeks 12 and 96, median CBD dose ranged from 21 to 25 mg/kg/day. At 12 weeks, add-on CBD reduced median monthly major motor seizures by 50% and total seizures by 44%, with consistent reductions in both seizure types through 96 weeks. At 12 weeks, the proportions of patients with ≥50%, ≥75%, and 100% reductions in major motor seizures were 53%, 23%, and 6%; the proportions with corresponding reductions in total seizures were 46%, 26%, and 5%. Responder rates for both seizure types were consistent through 96 weeks. CBD had an acceptable safety profile; the most common AEs were somnolence (30%) and diarrhea (24%).

CONCLUSIONS

Results from this interim analysis support add-on CBD as an effective long-term treatment option in LGS or DS.

Implementing Practice Guides to Improve Cancer Symptom Management in Homecare: A Comparative Case Study

Symptoms experienced by clients with cancer often occur at home and can become life-threatening, posing serious safety concerns. This study evaluated implementation of evidence-informed symptom practice guides to enhance quality of cancer symptom support by homecare nurses. A comparative case study was conducted using the Knowledge to Action Framework. Case were created for each of six agencies providing nursing care within a regional homecare authority. A team of researchers and knowledge users (e.g., managers, educators, family member): (1) assessed factors influencing practice guide use (survey, interviews) at six agencies, (2) adapted 15 practice guides for local use, (3) implemented with interventions to address barriers, and (4) monitored use. Analysis was within and across cases. Of six nursing agencies, one withdrew and five participated. In the baseline survey, 51% of nurses reported using guidelines but nurses did not describe using them in their current practice during the interviews. To overcome barriers, 489 nurses in five agencies were trained in how to use the practice guides, principles were established for documenting cancer symptom management, and practice guides were made available in various formats. Success with implementation varied across the participating cases. Chart audits conducted in three agencies revealed evidence of practice guide use for 16%, 22%, and 70% client visits, respectively. Implementation of evidence-informed practice guides in nursing required an approach tailored for each agency. Training, integration in documentation, and easy access to practice guides increased use for some nurses but ongoing support and reinforcement from nurse leaders is required.

Testing the Hand Dermatitis Screening Tool in the Home Health Care Sector

Workers exposed to wet work are at an increased risk for occupational contact dermatitis and may benefit from screening to detect early disease. The objective of this study was to assess the prevalence of hand dermatitis in home care workers, identify factors that influence presence of disease, and explore feasibility and importance of workplace screening in the home care sector. Following institutional ethics approval, nurses, personal support workers, and rehab therapists at one large home care provider in Ontario, Canada, self-screened for hand dermatitis using the Hand Dermatitis Screening Tool and accompanying photo guide and completed a short feasibility evaluation. Of the 220 participants, 18% had a positive screen for hand dermatitis and 77% reported exposure to wet work. In all, 93% of participants reported using the tool took less than 2 minutes and 84% reported screening for hand dermatitis is important. In conclusion, prevalence of hand dermatitis in home care workers is higher than reported in the general population. Workplace screening for hand dermatitis was deemed important, and the tool was feasible to use in the home care sector.

Managing Symptoms During Cancer Treatments: Barriers and Facilitators to Home Care Nurses Using Symptom Practice Guides

Nurses are instrumental in helping clients safely manage at home and triage potentially life-threatening symptoms from cancer. The purpose of this study was to assess factors influencing home care nurses’ use of 15 evidence-informed symptom practice guides for providing telephone or in-home nursing services to clients with cancer. A mixed-methods descriptive study was guided by the Knowledge-to-Action Framework. All six nursing agencies within a regional home care authority participated. Data collection included retrospective audit of symptom management in 50 patient records, 14 interviews, and barriers survey from 150 of 243 (61.7%) registered nurses and registered practical nurses providing cancer symptom support in home care. Chart audit revealed more than 80% of clients were on chemotherapy and common symptoms were nausea/vomiting (44%), constipation (32%), fatigue (32%), loss of appetite (32%), and pain (20%). Nurses had positive intentions ( M = 5.4 out of 7; SD = 1.3) and felt capable of using the symptom practice guides ( M = 5.4; SD = 1.0), held strong beliefs about the consequences ( M = 5.8; SD = 1.1) and moral norms of using them ( M = 5.7; SD = 1.1), and identified neutral to low social influence ( M = 3.0; SD = 1.6). Common barriers were inadequate time in practice, learning curve, need to integrate into documentation, and competing system changes. Common facilitators were being comprehensive, an evidence-based resource for use in practice, and having consistent symptom management guides across settings. Overall, the symptom guides were well received by the nurses. Interventions nurses identified to overcome barriers were education, clear organizational mandate for implementation, and integration with documentation.

The development and testing of a tool to assess joint health and safety committee functioning and effectiveness

BACKGROUND

Concern regarding functioning and effectiveness of joint health and safety committees (JHSCs) in Ontario hospitals was raised following the Severe Acute Respiratory Syndrome outbreak in 2003. A subsequent literature review revealed a lack of studies focused within the healthcare sector.

METHODS

A tool to measure JHSC effectiveness was developed by a panel of occupational health and safety experts based on a framework from the healthcare sector. Usability testing was conducted in two phases with members of five hospital JHSCs before, during and after a committee meeting.

RESULTS

Usability of the tool was scored high overall with an average of > 4 on a 5 point scale across twelve items. Downward adjustment of self-assessment scores was reported following JHSC meetings.

CONCLUSION

Findings demonstrated that the tool was easy to use, effective in supporting discussion and in assisting participants in reaching consensus on rating a large number of JHSC characteristics. Am. J. Ind. Med. 60:368-376, 2017. © 2017 Wiley Periodicals, Inc.

Joint health and safety committees - What is their impact in the acute care hospital?

BACKGROUND

There is very little in the literature on the effectiveness of Joint Health and Safety Committees (JHSCs) in the healthcare sector and a paucity of information on how JHSCs are perceived in the workplace.

OBJECTIVE

This study was carried out to explore hospital worker, hospital management, and healthcare sector stakeholder views on the effectiveness of JHSCs in the acute healthcare setting.

METHODS

The study used a qualitative descriptive design with: (1) nineteen focus groups and twenty two individual interviews in three hospitals of different sizes; and (2) eight individual interviews with external stakeholders.

RESULTS

Study findings showed gaps in awareness and understanding of the role and responsibilities of the Joint Health and Safety Committee. Some participants indicated that JHSCs lacked profile and had low visibility in the organization. Facilitators and barriers to JHSC effectiveness were investigated and measures to assess effectiveness identified. The attributes of a "gold standard" JHSC were outlined by respondents and can be used to develop an evidence-driven assessment tool to evaluate JHSCs.

CONCLUSIONS

The results of this study indicate both a continuing need for education and training related to JHSCs and the need to develop better tools to assess JHSC functioning and effectiveness.

Cancer symptom management in the home: A scoping review

The aim of this scoping review was to examine interventions used by nurses in the home setting for symptom management of adults with cancer. Databases were searched (CINAHL, Medline, PubMed, EBM Reviews, Joanna Briggs Institute EBP) with key words cancer, home, nursing, symptom, and protocol. Out of 390 identified citations, five met the inclusion criteria. Studies were conducted from 1989 to 2009. Findings revealed that home care nursing services improved symptom management, promoted independence, maintained quality of life, and decreased use of health care services. Two studies used evidence-based guidelines for cancer symptom management. Although few studies have explored nursing interventions for cancer symptom management in the home setting, their evidence suggests some improved client- and system-level outcomes.

Knowledge Tools for Cancer Treatment–Related Symptom Management by Home Care Nurses

A mixed methods descriptive study explored 38 nurses’ perceptions of usability and factors influencing the use of 13 symptom management protocols when caring for patients with cancer in the home. Descriptive analysis of the usability survey revealed protocols had high readability, right amount of information, appropriate terms, and were self-evident to complete. Thematic analysis of transcripts identified barriers to using the protocols including lack of time, paper-based documentation systems, and length of the protocols. Facilitating factors included high usability of the protocols, integration of a remote symptom support nursing role, and the usefulness for education and training. In summary, the protocols were described as a useful resource and beneficial for nursing orientation but required support to overcome some barriers and improve fit with clinical workflow.

Form and function of joint health and safety committees in Ontario acute care hospitals

Even though joint health and safety committees (JHSCs) have been in existence in Ontario workplaces for almost 30 years and healthcare workers are at high risk for workplace injury, there has been little research done related to JHSC functioning in Ontario's healthcare sector. In his recent review of the 2003 outbreak of severe acute respiratory syndrome in Toronto, Justice Archie Campbell found that JHSCs in Ontario hospitals were not fulfilling their intended roles and responsibilities. The objective of this study was to gain a deeper understanding of the role, resources, structure and functioning of JHSCs in Ontario hospitals.

Barriers to the Adoption of Safety-Engineered Needles Following a Regulatory Standard: Lessons Learned from Three Acute Care Hospitals

BACKGROUND

A number of jurisdictions have introduced regulation to accelerate the adoption of safety-engineered needles (SENs). This study examined the transition to SENs in three acute care hospitals prior to and following the implementation of a regulatory standard in Ontario. This paper focuses on the ongoing barriers to the prevention of needlestick injuries among healthcare workers.

METHODS

Information from document review and 30 informant interviews were used to prepare three case studies detailing each organization's implementation activities and outcomes.

RESULTS

All three hospitals responded to the regulatory requirements with integrity and needlestick injuries declined. However, needlestick injuries continued to occur during the activation of safety devices, during procedures and during instrument disposal. The study documented substantial barriers to further progress in needlestick injury prevention.

CONCLUSIONS

Healthcare organizations should focus on understanding their site-specific challenges that contribute to ongoing injury risk to better understand issues related to product limitations, practice constraints and the work environment.

Hospital unit safety climate: relationship with nurses' adherence to recommended use of facial protective equipment

Background

Despite the existence of formal guidelines for the acute health care sector, nurses' adherence to recommended use of facial protective equipment (FPE) to prevent occupational transmission of communicable respiratory disease remains suboptimal. In addition to individual factors such as knowledge and education, group factors such as shared perceptions of organizational support for safety may influence adherence. These group safety climate perceptions can differ depending on the pace and type of work, local leadership, and organizational structure of each unit.

Methods

An analysis of a data set from a cross-sectional survey of 1,074 nurses in 45 units of 6 acute care hospitals was conducted. Variance components analysis was performed to examine the variance in perceptions of safety climate and adherence between units. Hierarchical linear modeling using unit-level safety climate dimensions was conducted to determine if unit-level safety climate dimensions were predictors of nurses' adherence to FPE.

Results

Findings revealed statistically significant unit variances in adherence and 5 of the 6 unit-level safety climate dimensions (P < .05). Furthermore, a hierarchical model suggested that tenure and unit-level communication were significantly associated with increased adherence to FPE (P < .05).

Conclusion

Unit-level safety climate measures varied significantly between units. Strategies to improve unit-level communication regarding safety should assist in improving adherence to FPE.

Clobazam and its active metabolite N-desmethylclobazam display significantly greater affinities for α₂- versus α₁-GABA(A)-receptor complexes

Clobazam (CLB), a 1,5-benzodiazepine (BZD), was FDA-approved in October 2011 for the adjunctive treatment of seizures associated with Lennox-Gastaut syndrome (LGS) in patients 2 years and older. BZDs exert various CNS effects through allosteric modulation of GABA_A receptors. The structurally distinct, 1,4-BZD clonazepam (CLN) is also approved to treat LGS. The precise mechanisms of action and clinical efficacy of both are unknown. Data show that the GABA_A α₁-subunit–selective compound zolpidem [ZOL] exhibits hypnotic/sedative effects. Conversely, data from knock-in mice carrying BZD binding site mutations suggest that the α₂ subunit mediates anticonvulsant effects, without sedative actions. Hence, the specific pattern of interactions across the GABA_A receptor complexes of BZDs might be reflected in their clinical efficacies and adverse effect profiles. In this study, GABA_A-receptor binding affinities of CLB, N-desmethylclobazam (N-CLB, the major metabolite of CLB), CLN, and ZOL were characterized with native receptors from rat-brain homogenates and on cloned receptors from HEK293 cells transfected with combinations of α (α₁, α₂, α₃, or α₅), β₂, and γ₂ subtypes. Our results demonstrate that CLB and N-CLB have significantly greater binding affinities for α₂- vs. α₁-receptor complexes, a difference not observed for CLN, for which no distinction between α₂ and α₁ receptors was observed. Our experiments with ZOL confirmed the high preference for α₁ receptors. These results provide potential clues to a new understanding of the pharmacologic modes of action of CLB and N-CLB.

Evaluating the implementation of health and safety innovations under a regulatory context: a collective case study of Ontario's safer needle regulation

Background

Implementation effectiveness models have identified important factors that can promote the successful implementation of an innovation; however, these models have been examined within contexts where innovations are adopted voluntarily and often ignore the socio-political and environmental context. In the field of occupational health and safety, there are circumstances where organizations must adopt innovations to comply with a regulatory standard. Examining how the external environment can facilitate or challenge an organization’s change process may add to our understanding of implementation effectiveness. The objective of this study is to describe implementation facilitators and barriers in the context of a regulation designed to promote the uptake of safer engineered medical devices in healthcare.

Methods

The proposed study will focus on Ontario’s safer needle regulation (2007) which requires healthcare organizations to transition to the use of safer engineered medical devices for the prevention of needlestick injuries. A collective case study design will be used to learn from the experiences of three acute care hospitals in the province of Ontario, Canada. Interviews with management and front-line healthcare workers and analysis of supporting documents will be used to describe the implementation experience and examine issues associated with the integration of these devices. The data collection and analysis process will be influenced by a conceptual framework that draws from implementation science and the occupational health and safety literature.

Discussion

The focus of this study in addition to the methodology creates a unique opportunity to contribute to the field of implementation science. First, the study will explore implementation experiences under circumstances where regulatory pressures are influencing the organization's change process. Second, the timing of this study provides an opportunity to focus on issues that arise during later stages of implementation, a phase during the implementation cycle that has been understudied. This study also provides the opportunity to examine the relevance and utility of current implementation science models in the field of occupational health where the adoption of an innovation is meant to enhance the health and safety of workers. Previous work has tended to focus almost exclusively on innovations that are designed to enhance an organization’s productivity or competitive advantage.

Behind the mask: Determinants of nurse's adherence to facial protective equipment

BACKGROUND

As the predominant occupation in the health sector and as the health worker with the most patient interaction, nurses are at high risk for occupational transmission of communicable respiratory illness. The use of facial protective equipment (FPE) is an important strategy to prevent occupational transmission.

METHODS

A 2-phased study was conducted to examine nurse's adherence to recommended use of FPE. Phase 1 was a cross-sectional survey of nurses in selected units of 6 acute care hospitals in Toronto, Canada. Phase 2 was a direct observational study of critical care nurses.

RESULTS

Of the 1,074 nurses who completed surveys (82% response rate), 44% reported adherence to recommended use of FPE. Multivariable analysis revealed 6 predictors of adherence: unit type, frequency of equipment use, equipment availability, training, organizational support, and communication. Following the survey, 100 observations in 14 intensive care units were conducted that revealed a 44% competence rate with proper use of N95 respirators and knowledge as a significant predictor of competence.

CONCLUSION

Whereas increasing knowledge should enhance competence, strategies to improve adherence to recommended use of FPE in a busy and complex health care setting should focus on ready availability of equipment, training and fit testing, organizational support for worker health and safety, and good communication practices.

Cardiovascular fitness is associated with altered cortical glucose metabolism during working memory in ɛ4 carriers

BACKGROUND

The possibility that ɛ4 may modulate the effects of fitness in the brain remains controversial. The present exploratory FDG-PET study aimed to better understand the relationship among ɛ4, fitness, and cerebral metabolism in 18 healthy aged women (nine carriers, nine noncarriers) during working memory.

METHODS

Participants were evaluated using maximal level of oxygen consumption, California Verbal Learning Test, and FDG-PET, which were collected at rest and during completion of the Sternberg working memory task.

RESULTS

Resting FDG-PET did not differ between carriers and noncarriers. Significant effects of fitness on FDG-PET during working memory were noted in the ɛ4 carriers only. High fit ɛ4 carriers had greater glucose uptake in the temporal lobe than the low fit ɛ4 carriers, but low fit ɛ4 carriers had greater glucose uptake in the frontal and parietal lobes.

CONCLUSIONS

We demonstrate that fitness differentially affects cerebral metabolism in ɛ4 carriers only, consistent with previous findings that the effects of fitness may be more pronounced in populations genetically at risk for cognitive decline.

Exercise improves cognition and hippocampal plasticity in APOE epsilon4 mice

BACKGROUND

Human studies on exercise, cognition, and apolipoprotein E (APOE) genotype show that epsilon4 carriers may benefit from regular physical activity.

METHODS

We examined voluntary wheel-running, memory, and hippocampal plasticity in APOE epsilon3 and APOE epsilon4 transgenic mice at 10-12 months of age.

RESULTS

Sedentary epsilon4 mice exhibited deficits in cognition on the radial-arm water maze (RAWM), a task dependent on the hippocampus. Six weeks of wheel-running in epsilon4 mice resulted in improvements on the RAWM to the level of epsilon3 mice. Hippocampal brain-derived neurotrophic factor (BDNF) levels were similar in epsilon3 and epsilon4 mice, and after exercise BDNF was similarly increased in both epsilon3 and epsilon4 mice. In sedentary epsilon4 mice, tyrosine kinase B (Trk B) receptors were reduced by 50%. Exercise restored Trk B in epsilon4 mice to the level of epsilon3 mice, and in epsilon4 mice, exercise dramatically increased synaptophysin, a marker of synaptic function.

CONCLUSIONS

Our results support the hypothesis that exercise can improve cognitive function, particularly in epsilon4 carriers.

The individual, environmental, and organizational factors that influence nurses' use of facial protection to prevent occupational transmission of communicable respiratory illness in acute care hospitals

BACKGROUND

Communicable respiratory illness is an important cause of morbidity among nurses. One of the key reasons for occupational transmission of this illness is the failure to implement appropriate barrier precautions, particularly facial protection. The objectives of this study were to describe the factors that influence nurses' decisions to use facial protection and to determine their relative importance in predicting compliance.

METHODS

This cross-sectional survey was conducted in 9 units of 2 urban hospitals in which nursing staff regularly use facial protection.

RESULTS

A total of 400 self-administered questionnaires were provided to nurses, and 177 were returned (44% response rate). Less than half of respondents reported compliance with the recommended use of facial protection (eye/face protection, respirators, and surgical masks) to prevent occupational transmission of communicable respiratory disease. Multivariate analysis showed 5 factors to be key predictors of nurses' compliance with the recommended use of facial protection. These factors include full-time work status, greater than 5 years tenure as a nurse, at least monthly use of facial protection, a belief that media coverage of infectious diseases impacts risk perception and work practices, and organizational support for health and safety.

CONCLUSION

Strategies and interventions based on these findings should result in enhanced compliance with facial protection and, ultimately, a reduction in occupational transmission of communicable respiratory illness.

Macrolide resistance mechanisms among Streptococcus pneumoniae isolated over 6 years of Canadian Respiratory Organism Susceptibility Study (CROSS) (1998 2004)

BACKGROUND

Resistance to macrolides in Streptococcus pneumoniae arises primarily due to Erm(B) or Mef(A). Erm(B) typically confers high-level resistance to macrolides, lincosamides and streptogramin B (MLS(B) phenotype), whereas Mef(A) confers low-level resistance to macrolides only (M phenotype). The purpose of this study was to investigate the incidence of macrolide resistance mechanisms in Canadian isolates of S. pneumoniae obtained between 1998 and 2004. Furthermore, the genetic relatedness, serotype distribution and antibiotic susceptibility profile among S. pneumoniae isolates with dual erythromycin ribosomal methylase [Erm(B)] and efflux pump [Mef(A)] were analysed.

METHODS

A total of 865 macrolide-resistant (erythromycin MIC > or = 1 mg/L) S. pneumoniae isolates were collected from the Canadian Respiratory Organism Susceptibility Study (CROSS) from 1998 to 2004. The presence of erm(B) and mef(A) was determined for each isolate by PCR; mutations in the genes coding for L4 and L22 ribosomal proteins and for 23S rRNA were identified by DNA sequencing. Each isolate containing both erm(B)- and mef(A)-mediated macrolide resistance was genotyped by PFGE and serotyped using the Quellung reaction with antisera.

RESULTS

Of the 865 isolates studied, 404 (46.7%) were mef(A)-positive, 371 (42.9%) were erm(B)-positive, 50 (5.8%) were positive for both mef(A) and erm(B) and 40 (4.6%) were negative for both mef(A) and erm(B). Of the macrolide-resistant isolates negative for both mef(A) and erm(B), 22 (2.5%) contained 23S rRNA A2058G, A2059G or A2059C mutations, 7 (0.8%) contained 23S rRNA A2058G or A2059G mutations along with an S20N mutation in L4 ribosomal protein, and 1 isolate contained an E30K ribosomal protein mutation alone. Of the macrolide-resistant strains positive for both mef(A) and erm(B), 36 (72%) were multidrug-resistant (macrolide-, penicillin- and trimethoprim/sulfamethoxazole-resistant), 39 (78%) isolates belonged to serotype 19A or 19F and 36 (72%) belonged to one clonal complex (> or =80% genetic relatedness) genetically related to the Taiwan 19F-14 clone.

CONCLUSIONS

The prevalence of efflux-based macrolide resistance in S. pneumoniae in Canada remained steady between 1998 and 2004. Macrolide resistance due to erm(B) decreased over the same time period, with a rapid increase in isolates with both erm(B) and mef(A) macrolide resistance.

Genomic context drives SCA7 CAG repeat instability, while expressed SCA7 cDNAs are intergenerationally and somatically stable in transgenic mice

Spinocerebellar ataxia type 7 (SCA7) is an autosomal dominant cerebellar ataxia caused by a CAG repeat expansion in the ataxin-7 gene. In humans, SCA7 is characterized by marked anticipation due to intergenerational repeat instability with a bias toward expansion, and is thus regarded as the most unstable of the polyglutamine diseases. To study the molecular basis of CAG/CTG repeat instability and its pathological significance, we generated lines of transgenic mice carrying either a SCA7 cDNA construct or a 13.5 kb SCA7 genomic fragment with 92 CAG repeats. While the cDNA transgenic mice showed little intergenerational repeat instability, the genomic fragment transgenic mice displayed marked intergenerational instability with an obvious expansion bias. We then went on to generate additional lines of genomic fragment transgenic mice, and observed that deletion of the 3' genomic region significantly stabilized intergenerational transmission of the SCA7 CAG92 repeat. These results suggest that cis-information present on the genomic fragment is driving the instability process. As the SCA7 genomic fragment contains a large number of replication-associated motifs, the presence of such sequence elements may make the SCA7 CAG repeat region more susceptible to instability. Small-pool and standard PCR analysis of tissues from genomic fragment mice revealed large repeat expansions in their brains and livers, but no such changes were found in any tissues from cDNA transgenic mice that have been shown to undergo neurodegeneration. As large somatic repeat expansions are absent from the brains of SCA7 cDNA mice, our results indicate that neurodegeneration can occur without marked somatic mosaicism, at least in these mice.

Macrolide-resistant Streptococcus pneumoniae in Canada during 1998-1999: prevalence of mef(A) and erm(B) and susceptibilities to ketolides

In this study (1998-1999), we collected 215 macrolide-resistant Streptococcus pneumoniae isolates from an ongoing Canadian Respiratory Organism Surveillance Study involving 23 centers representing all regions of Canada. The prevalence of erythromycin-resistant S. pneumoniae was 8% (215 of 2,688). Of the 215 isolates, 48.8% (105 of 215) were PCR positive for mef(A) and 46.5% (100 of 215) were PCR positive for erm(B). The ketolides telithromycin and ABT-773 demonstrated excellent activity against both mef(A) (MIC for 90% of strains [MIC(90)], 0.06 and 0.03 microg/ml, respectively) and erm(B) (MIC(90), 0.06 and 0.03 microg/ml, respectively) strains of S. pneumoniae.

Improving residents' compliance with standards of ambulatory care: results from the VA Cooperative Study on Computerized Reminders

CONTEXT

Computerized systems to remind physicians to provide appropriate care have not been widely evaluated in large numbers of patients in multiple clinical settings.

OBJECTIVE

To examine whether a computerized reminder system operating in multiple Veterans Affairs (VA) ambulatory care clinics improves resident physician compliance with standards of ambulatory care.

DESIGN, SETTING, AND PARTICIPANTS

A total of 275 resident physicians at 12 VA medical centers were randomly assigned in firms or half-day clinic blocks to either a reminder group (n = 132) or a control group (n = 143). During a 17-month study period (January 31, 1995-June 30, 1996), the residents cared for 12,989 unique patients for whom at least 1 of the studied standards of care (SOC) was applicable.

MAIN OUTCOME MEASURES

Compliance with 13 SOC, tracked using hospital databases and encounter forms completed by residents, compared between residents in the reminder group vs those in the control group.

RESULTS

Measuring compliance as the proportion of patients in compliance with all applicable SOC by their last visit during the study period, the reminder group had statistically significantly higher rates of compliance than the control group for all standards combined (58.8% vs 53.5%; odds ratio [OR], 1.24; 95% confidence interval [CI], 1.08-1.42; P =.002) and for 5 of the 13 standards examined individually. Measuring compliance as the proportion of all visits for which care was indicated in which residents provided proper care, the reminder group also had statistically significantly higher rates of compliance than the control group for all standards combined (17.9% vs 12.2%; OR, 1.57; 95% CI, 1.45-1.71; P<.001) and for 9 of the 13 standards examined individually. The benefit of reminders, however, declined throughout the course of the study, even though the reminders remained active.

CONCLUSIONS

Our data indicate that reminder systems installed at multiple sites can improve residents' compliance to multiple SOC. The benefits of such systems, however, appear to deteriorate over time. Future research needs to explore methods to better sustain the benefits of reminders. JAMA. 2000;284:1411-1416.

Frequency of p53 mutations in breast carcinomas from Ashkenazi Jewish carriers of BRCA1 mutations

BACKGROUND

Breast carcinomas occurring in carriers of BRCA1 gene mutations may have a distinctly different pathway of molecular pathogenesis from those occurring in noncarriers. Data from murine models implicate loss of p53 (also known as TP53) gene function as a critical early event in the malignant transformation of cells with a BRCA1 mutation. Therefore, breast tumors from BRCA1 mutation carriers might be expected to exhibit a high frequency of p53 mutations. This study examined the frequency of p53 mutations in the breast tumors of Ashkenazi Jewish carriers and noncarriers of BRCA1 mutations.

METHODS

Tumor DNA from carriers and noncarriers of BRCA1 mutations was screened for mutations in exons 4 through 10 of the p53 gene by use of the polymerase chain reaction and single-strand conformation polymorphism (SSCP) analysis of the amplified DNA. Direct sequencing was performed on gene fragments that showed altered mobility in SSCP analysis.

RESULTS

Mutations in the p53 gene were detected in 10 of 13 tumors from BRCA1 mutation carriers versus 10 of 33 tumors from non-carriers (two-sided P = .007). The p53 mutations were distributed throughout exons 4 through 10 and included both protein-truncating and missense mutations in both groups.

CONCLUSIONS

A statistically significantly higher frequency of p53 mutations was found in breast tumors from carriers of BRCA1 mutations than from noncarriers, which adds to the accumulating evidence that loss of p53 function is an important step in the molecular pathogenesis of BRCA1 mutation-associated breast tumors. This finding may have implications for understanding phenotypic differences and potential prognostic differences between BRCA1 mutation-associated hereditary breast cancers and sporadic cancers.

Life without huntingtin: normal differentiation into functional neurons

Huntington disease (HD) is a neurodegenerative disorder associated with polyglutamine expansion in a recently identified protein, huntingtin. Huntingtin is widely expressed and plays a crucial role in development, because gene-targeted HD-/- mouse embryos die early in embryogenesis. To analyze the function of normal huntingtin, we have generated HD-/- embryonic stem (ES) cells and used an in vitro model of ES cell differentiation to analyze their ability to develop into neuronal cells. Expression analysis of wild-type ES cells revealed that huntingtin is expressed at all stages during ES cell differentiation with high expression in neurons. Expression levels increased with the maturation of differentiating neurons, demonstrating that expression of huntingtin is developmentally regulated in cell culture and resembles the pattern of expression observed in differentiating neurons in the mouse brain. It is interesting that HD-/- ES cells could differentiate into mature postmitotic neurons that expressed functional voltage- and neurotransmitter-gated ion channels. Moreover, both excitatory and inhibitory spontaneous postsynaptic currents were observed, indicating the establishment of functional synapses in the absence of huntingtin. These results demonstrate that huntingtin is not required for the generation of functional neurons with features characteristic of postmitotic neurons in the developing mouse brain.

A yeast artificial chromosome-based physical map of the juvenile amyotrophic lateral sclerosis (ALS2) critical region on human chromosome 2q33-q34

The autosomal recessive form of juvenile amyotrophic lateral sclerosis (ALS2; RFALS Type 3) has previously been mapped to the 8-cM interval flanked by D2S115 and D2S155 on human chromosome 2q33-q34. We have established a yeast artificial chromosome (YAC) contig spanning an approximately 8-Mb region of the ALS2 candidate region and mapped 52 transcribed DNA sequences including 13 known genes and 39 expressed sequenced tags within this YAC contig. The establishment of a YAC contig and transcript map that spans the region containing the ALS2 mutation is an essential step in the identification of the ALS2 gene.

Cytotoxicity of advanced glycation endproducts is mediated by oxidative stress

Non-enzymatic glycation of proteins with reducing sugars and subsequent transition metal catalysed oxidations leads to the formation of protein bound "advanced glycation endproducts" (AGEs). They accumulate on long-lived proteins and are for example structural components of the beta-amyloid plaques in Alzheimer's disease. Since the oxidation of glycated proteins as well as the interaction of AGEs with cell surface receptors produces superoxide radicals, it was tested in BHK 21 hamster fibroblast cells and SH-SY5Y human neuroblastoma cells if AGEs can exert cytotoxic effects on cells. Cell viability was assessed with three independent tests: MTT-assay (activity of the mitochondrial respiratory chain), lactate dehydrogenase assay (release of cytoplasmatic enzymes, membrane integrity) and Neutral Red assay (active uptake of a hydrophilic dye). Two model AGEs, chicken egg albumin-AGE and BSA-AGE, both caused significant cell death in a dose-dependent manner. The cytotoxic effects of AGEs could be attenuated by alpha-ketoglutarate and pyruvate, by antioxidants such as thioctic acid and N-acetylcysteine, and by aminoguanidine, an inhibitor of nitric oxide synthase. This suggests that reactive oxygen species as well as reactive nitrogen species contribute to AGE mediated cytotoxicity. Since AGEs accumulate on beta-amyloid plaques in AD over time, they may additionally contribute to oxidative stress, cell damage, functional loss and even neuronal cell death in the Alzheimer's disease brain.