Exploring the influence of context on social norms around Australian parents' food provision using story completion

OBJECTIVE

To explore the differences in social norms around parents' food provision in different provision contexts and by demographics.

DESIGN

Qualitative study using story completion methodology via an online survey in September 2021. Adults 18+ with or without children were randomised to one of three story stems focusing on food provision in different contexts; food provision at home (non-visitor), with visitors present and with the involvement of sport. Stories were coded and themed using thematic analysis. A content analysis was performed to determine count and frequency of codes in stories by participant demographics and story assumptions.

SETTING

Australia.

PARTICIPANTS

Adults (n 196).

RESULTS

Nine themes were identified from the data resulting in four social norms around providing healthy foods and justifying non-adherence to healthy eating guidelines, evolution of family life and mealtime values, the presence of others influencing how we engage with food provision and unhealthy foods used as incentives/rewards in sport. Following content analysis, no differences of themes or norms by participant demographics or story assumptions were found.

CONCLUSIONS

We identified pervasive social norms around family food provision and further identified how contextual factors resulted in variations or distinct norms. This highlights the impact context may have on the social norms parents face when providing food to their children and the opportunities and risks of leveraging these social norms to influence food choice in these contexts. Public health interventions and practitioners should understand the influence of context and social environments when promoting behaviour change and providing individualised advice. Future research could explore parents' experiences of these norms and to what extent they impact food choice.

Clinical practice guideline recommendations for the management of challenging behaviours after traumatic brain injury in acute hospital and inpatient rehabilitation settings: a systematic review

PURPOSE

Clinical practice guideline (CPG) recommendations for the management of challenging behaviours after traumatic brain injury (TBI) in hospital and inpatient rehabilitation settings are sparse. This systematic review aims to identify and appraise CPGs, and report high-quality recommendations for challenging behaviours after TBI in hospital and rehabilitation settings.

MATERIALS AND METHODS

A three-step search strategy was conducted to identify CPGs that met inclusion criteria. Two reviewers independently scored the AGREE II domains. Guideline quality was assessed based on CPGs adequately addressing four out of the six AGREE II domains. Data extraction was performed with a compilation of high-quality CPG recommendations.

RESULTS

Seven CPGs out of 408 identified records met the inclusion criteria. Two CPGs were deemed high-quality. High-quality CPG recommendations with the strongest supporting evidence include behaviour management plans; beta-blockers for the treatment of aggression; selective serotonin reuptake inhibitors for moderate agitation; adamantanes for impaired arousal/attention in agitation; specialised, multi-disciplinary TBI behaviour management services.

CONCLUSIONS

This systematic review identified and appraised the quality of CPGs relating to the management of challenging behaviours after TBI in acute hospital and rehabilitation settings. Further research to rigorously evaluate TBI behaviour management programs, investigation of evidence-practice gaps, and implementation strategies for adopting CPG recommendations into practice is needed.Implications for rehabilitationTwo clinical practice guidelines appraised as high-quality outline recommendations for the management of challenging behaviours after traumatic brain injury in hospital and inpatient rehabilitation settings.High-quality guideline recommendations with the strongest supporting evidence for non-pharmacological treatment include behaviour management plans considering precipitating factors, antecedents, and reinforcing events.High-quality guideline recommendations with the strongest supporting evidence for pharmacological management include beta blockers for aggression in traumatic brain injury.Few guidelines provide comprehensive detail on the implementation of recommendations into clinical care which may limit adoption.

Essential content for teaching implementation practice in healthcare: a mixed-methods study of teams offering capacity-building initiatives

BACKGROUND

Applying the knowledge gained through implementation science can support the uptake of research evidence into practice; however, those doing and supporting implementation (implementation practitioners) may face barriers to applying implementation science in their work. One strategy to enhance individuals' and teams' ability to apply implementation science in practice is through training and professional development opportunities (capacity-building initiatives). Although there is an increasing demand for and offerings of implementation practice capacity-building initiatives, there is no universal agreement on what content should be included. In this study we aimed to explore what capacity-building developers and deliverers identify as essential training content for teaching implementation practice.

METHODS

We conducted a convergent mixed-methods study with participants who had developed and/or delivered a capacity-building initiative focused on teaching implementation practice. Participants completed an online questionnaire to provide details on their capacity-building initiatives; took part in an interview or focus group to explore their questionnaire responses in depth; and offered course materials for review. We analyzed a subset of data that focused on the capacity-building initiatives' content and curriculum. We used descriptive statistics for quantitative data and conventional content analysis for qualitative data, with the data sets merged during the analytic phase. We presented frequency counts for each category to highlight commonalities and differences across capacity-building initiatives.

RESULTS

Thirty-three individuals representing 20 capacity-building initiatives participated. Study participants identified several core content areas included in their capacity-building initiatives: (1) taking a process approach to implementation; (2) identifying and applying implementation theories, models, frameworks, and approaches; (3) learning implementation steps and skills; (4) developing relational skills. In addition, study participants described offering applied and pragmatic content (e.g., tools and resources), and tailoring and evolving the capacity-building initiative content to address emerging trends in implementation science. Study participants highlighted some challenges learners face when acquiring and applying implementation practice knowledge and skills.

CONCLUSIONS

This study synthesized what experienced capacity-building initiative developers and deliverers identify as essential content for teaching implementation practice. These findings can inform the development, refinement, and delivery of capacity-building initiatives, as well as future research directions, to enhance the translation of implementation science into practice.

Barriers and enablers to managing challenging behaviours after traumatic brain injury in the acute hospital setting: a qualitative study

BACKGROUND

Challenging behaviours after traumatic brain injury (TBI) in the acute setting are associated with risk of harm to the patient and staff, delays in commencing rehabilitation and increased length of hospital stay. Few guidelines exist to inform practice in acute settings, and specialist services providing multi-disciplinary expertise for TBI behaviour management are predominantly based in subacute inpatient services. This study aims to investigate acute and subacute staff perspectives of barriers and enablers to effectively managing challenging behaviours after TBI in acute hospital settings.

METHODS

Qualitative focus groups were conducted with 28 staff (17 from acute setting, 11 from subacute setting) across two sites who had experience working with patients with TBI. Data were analysed using inductive-deductive reflexive thematic analysis. Data were applied to the constructs of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to generate themes representing barriers and enablers to managing challenging behaviours after TBI in the acute hospital setting.

RESULTS

Four barriers and three enablers were identified. Barriers include (1) Difficulties with clinical decision making; (2) Concerns for risks to staff and patients; (3) Hospital environment; (4) Intensive resources are required. Enablers were (1) Experienced staff with practical skills; (2) Incorporating person-centred care; and (3) Supportive teams.

CONCLUSION

These findings can inform pre-implementation planning for future improvements to TBI behaviour management in acute hospital settings. Difficulties with clinical decision making, concerns for risks of injury, the hospital environment and lack of resources are major challenges. Implementation strategies developed to address barriers will need to be trialled, with multi-disciplinary team approaches, and tailored to the acute setting.

Family experiences of the management of challenging behaviours after traumatic brain injury in the acute hospital setting

PURPOSE

This study explored experiences of the management of challenging behaviours after traumatic brain injury (TBI) in the acute hospital setting from the perspectives of family members.

MATERIALS AND METHODS

A qualitative, interpretive phenomenological approach was adopted involving semi-structured interviews with 10 family members. Interviews were transcribed and analysed using thematic analysis, with Ecological Systems Theory applied as a guiding framework to discuss findings and implications for practice.

RESULTS

Four primary themes were identified: 1) The hospital environment; 2) Hospital staffing; 3) Identifying and preventing triggers, and 4) Family support and information.

CONCLUSIONS

This qualitative study highlights the need for further information, education, and support to families of patients with TBI in the acute setting. Further research investigating the implementation of best practice approaches for managing challenging behaviours practice in acute settings is needed to overcome the barriers of the hospital environment, inexperienced and inconsistent staffing, and difficulties identifying triggers within the acute hospital setting, experienced by families. Approaches for family involvement in behaviour management strategies, and facilitation of communication for people with TBI in the acute setting requires exploration.

'I wasn't made to feel like a nut case after all': A qualitative story completion study exploring healthcare recipient and carer perceptions of good professional caregiving relationships

BACKGROUND

Professional caregiving relationships are central to quality healthcare but are not always developed to a consistently high standard in clinical practice. Existing literature on what constitutes high-quality relationships and how they should be developed is plagued by dyadic conceptualisations; discipline, context and condition-specific research; and the absence of healthcare recipient and informal carer voices. This study aimed to address these issues by exploring how healthcare recipients and carers conceptualise good professional caregiving relationships regardless of discipline, care setting and clinical condition.

DESIGN

A qualitative story completion approach was used. Participants completed a story in response to a hypothetical stem that described a healthcare recipient (and, in some instances, carer) developing a good relationship with a new healthcare provider. Stories were analysed using reflexive thematic analysis.

PARTICIPANTS

Participants were 35 healthcare recipients and 37 carers (n = 72 total).

RESULTS

Participants' stories were shaped by an overarching discourse that seeking help from new providers can elicit a range of unwanted emotions for both recipients and carers (e.g., anxiety, fear, dread). These unwanted emotions were experienced in relation to recipients' presenting health problems as well as their anticipated interactions with providers. Specifically, recipient and carer characters were fearful that providers would dismiss their concerns and judge them for deciding to seek help. Good relationships were seen to develop when healthcare providers worked to relieve or minimise these unwanted emotions, ensuring healthcare recipients and carers felt comfortable and at ease with the provider and the encounter. Participants positioned healthcare providers as primarily responsible for relieving recipients' and carers' unwanted emotions, which was achieved via four approaches: (1) easing into the encounter, (2) demonstrating interest in and understanding of recipients' presenting problems, (3) validating recipients' presenting problems and (4) enabling and respecting recipient choice. Participants' stories also routinely oriented to temporality, positioning relationships within recipients' and carers' wider care networks and biographical and temporal contexts.

CONCLUSION

The findings expand our understanding of professional caregiving relationships beyond dyadic, static conceptualisations. Specifically, the findings suggest that high-quality relationships might be achieved via a set of core healthcare provider behaviours that can be employed across disciplinary, context and condition-specific boundaries. In turn, this provides a basis to support interprofessional education and multidisciplinary healthcare delivery, enabling different healthcare disciplines, specialties, and teams to work from the same understanding of what is required to develop high-quality relationships.

PATIENT OR PUBLIC CONTRIBUTION

The findings are based on stories from 72 healthcare recipient and carer participants, providing rich insight into their conceptualisations of high-quality professional caregiving relationships.

Exploring the role of a facilitator in supporting family carers when embedding the iSupport for Dementia programme in care services: A qualitative study

AIMS

To explore stakeholders' perceptions of a facilitator's role in supporting carers when embedding iSupport for Dementia psychoeducation program, in care services.

METHODS

A qualitative descriptive study design was applied. Data were collected from workshops and interviews with carers of people living with dementia (PLWD)and with health and social care professionals from two tertiary hospitals and two community aged care organisations across three Australian states between October 2021 and March 2022. A thematic analysis was used to analyse data. The COREQ guideline was followed to report our findings.

RESULTS

A total of 30 family carers and 45 health and social care professionals participated in the study. Three main themes and seven subthemes were identified from the data. We described the main themes as (1) the facilitator's role at the time of dementia diagnosis, (2) the facilitator's role throughout the everyday dementia care journey and (3) the facilitator's role during transition moments.

CONCLUSIONS

Caring for family members with dementia is demanding and stressful for carers. Embedding a facilitator-enabled iSupport for Dementia program in hospital and community aged care settings has the potential to mitigate sources of stress associated with care recipient factors, carer factors and care service factors, and improve the health and well-being of carers and those for whom they care.

RELEVANCE TO CLINICAL PRACTICE

Our findings will inform the establishment of iSupport facilitators appointed by dementia care providers in hospital and community care settings and help determine their roles and responsibilities in delivering the iSupport program. Our findings relate to nurse-led and coordinated dementia care in hospital and community aged care settings.

PATIENT OR PUBLIC CONTRIBUTION

This study was co-designed with stakeholders from two aged care organisations and two tertiary hospitals. The study participants were staff employed by these organisations and carers of PLWD who were service users.

Wicked problems in a post-truth political economy: a dilemma for knowledge translation

The discipline of knowledge translation (KT) emerged as a way of systematically understanding and addressing the challenges of applying health and medical research in practice. In light of ongoing and emerging critique of KT from the medical humanities and social sciences disciplines, KT researchers have become increasingly aware of the complexity of the translational process, particularly the significance of culture, tradition and values in how scientific evidence is understood and received, and thus increasingly receptive to pluralistic notions of knowledge. Hence, there is now an emerging view of KT as a highly complex, dynamic, and integrated sociological phenomenon, which neither assumes nor creates knowledge hierarchies and neither prescribes nor privileges scientific evidence. Such a view, however, does not guarantee that scientific evidence will be applied in practice and thus poses a significant dilemma for KT regarding its status as a scientific and practice-oriented discipline, particularly within the current sociopolitical climate. Therefore, in response to the ongoing and emerging critique of KT, we argue that KT must provide scope for relevant scientific evidence to occupy an appropriate position of epistemic primacy in public discourse. Such a view is not intended to uphold the privileged status of science nor affirm the "scientific logos" per se. It is proffered as a counterbalance to powerful social, cultural, political and market forces that are able to challenge scientific evidence and promote disinformation to the detriment of democratic outcomes and the public good.

Family Life During and Beyond COVID-19: The Impact of Relationship Quality on Caregivers’ Management of Paid Work, Caregiving, and Self-Care

This multi-method project examined how Australian caregivers navigated family life during the COVID-19 pandemic in 2020 and subsequent impact on family health behaviours. Participants were invited to complete all three phases. In phase 1, 115 caregivers completed an online survey, focussed on 2020 experiences of COVID-19. In phase 2, 96 of the participants completed a use-of-time recall and 80 completed a dietary recall examining participants’ health behaviours including how they spent their time, their physical activity, and diet quality. Phase 3 involved 24 of the participants completing an online story completion task, focussed on understanding participants’ sense-making of COVID-19. Through triangulating analyses of the three phases, this project identified how poor relationship quality negatively affected families’ experiences of significant disruptions and transitions. This project provides a nuanced picture of how COVID-19 in 2020 impacted family life and highlights the importance of caregiver relationship quality for family health and wellbeing.

Mobilising Implementation of i-PARIHS (Mi-PARIHS): development of a facilitation planning tool to accompany the Integrated Promoting Action on Research Implementation in Health Services framework

BACKGROUND

Facilitation makes the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework a popular framework in the field of implementation science. Facilitation allows for flexible application of the i-PARIHS framework by encouraging the iterative tailoring of implementation strategies to a dynamic context. However, successfully harnessing this flexibility can be challenging to navigate, particularly for novice facilitators. Therefore, to support and promote more widespread use of the i-PARIHS framework, and to make it easier for people who are already using i-PARIHS, we have undertaken the Mi-PARIHS Project-Mobilising Implementation of i-PARIHS, focused on developing a suite of practical and pragmatic i-PARIHS resources.

METHODS

Through a co-design approach drawing on end-users' experiences, we developed the Mi-PARIHS Facilitation Planning Tool, and this article reports on the final end-user feedback via an online survey.

RESULTS

A total of 58 participants completed the online survey. The survey focused on participants' previous experiences with i-PARIHS, their feedback on the background information provided with the Mi-PARIHS Tool, and their feedback on the tool itself (e.g. clarity, use, satisfaction, improvements). This feedback resulted in the development of a comprehensive 34-item Mi-PARIHS Facilitation Planning Tool that supports i-PARIHS users in their (1) assessment of the i-PARIHS framework's innovation, context, and recipient constructs; (2) development of a tailored facilitation plan; and (3) repeated use over time to evaluate the effectiveness of facilitation strategies.

CONCLUSIONS

The Mi-PARIHS Facilitation Planning Tool makes framework-guided implementation more accessible and reliable to a wider range of systems and stakeholders, thereby contributing to more consistent implementation of evidence-based practices and other innovations. It addresses the challenge of systematically assessing core constructs of the i-PARIHS framework to develop tailored facilitation strategies. The Mi-PARIHS Facilitation Planning Tool is freely available for use at the website https://www.flinders.edu.au/caring-futures-institute/Mi-PARIHS-tool .

"You Are By No Means Alone": A Netnographic Study of Self-Care Support in an Online Community for Older Adults

Online peer-to-peer communities provide environments in which people with similar health concerns can interact and exchange information that can support self-care of long-term conditions. However, current theories have not adequately accounted for how self-care support is enacted in online communities. We conducted an observational netnography to identify and analyze posts in a publicly accessible online community (discussion forum boards) designed for older people. A Straussian grounded theory approach was used to examine 659 posts in health-related message boards. Self-care support involved the construction of three interrelated identities: (1) the support seeking self, in which members described problems and requested information; (2) the empathizing self, in which they described similar experiences and offered support; and (3) the influencing self, in which they provided information or advice. Online communities appear to be an important source of peer support and information and may be a cost-effective approach to supplement standard care.

Implementing a behavior management approach in the hospital setting for individuals with challenging behaviors during acute traumatic brain injury

PRIMARY OBJECTIVE

This study aimed to determine if implementing a clinically pragmatic behavior management approach for challenging behaviors during acute TBI reduces use of restraints, security incidences, acute length of stay admission and cost, thereby improving progress to rehabilitation.

RESEARCH DESIGN

This pilot study involved a behavior management group (n = 27), compared with a historical control group (n = 74).

METHOD AND PROCEDURES

The behavior management group received care following the implementation of a behavior management approach for challenging behaviors during acute TBI at two hospitals in South Australia.

MAIN OUTCOMES AND RESULTS

Fidelity results demonstrated high level of adherence to the implemented behavior management approach. The behavior management group had significant lower use of mechanical restraints (p = 0.03), and significantly lower acute admission costs (p = 0.034). Trends in lower pharmacological restraint usage, lower acute hospital length of stay and time from admission to rehabilitation acceptance were recorded.

CONCLUSIONS

These pilot results contribute to improving quality of health care but methodological limitations make outcomes difficult to interpret as a direct result of the intervention. Future studies are required to investigate evidence-based behavior management interventions for acute TBI patients using more rigorous knowledge translation implementation designs.

Exploring the social norms regarding parents' food provision in Australia using story completion methodology

Children's diets are not aligned with dietary guidelines, with the social context including social norms being one factor influencing parents' food provision. Little is known about social norms in broad society that parents face when providing food to children. We aimed to determine the social norms surrounding family food provision from the perspectives of Australian adults. This qualitative study used story completion methodology via an online survey to gather hypothetical stories from adults (≥18 years). Participants were presented with a story stem focusing on home food provision. Stories (i.e. data) were coded and analysed using thematic analysis. Five themes were identified from the data (N = 75); 1. Providing a healthy snack, 2. Providing justification for the provision of unhealthy convenience foods, 3. Increasing child autonomy in food provision, 4. Mealtimes are a social occasion, and 5. Contextual factors influencing food provision and social norms. From these themes, social norms were identified around providing healthy foods and justifying non-adherence to healthy eating guidelines and evolution of family life and mealtime values. This study provides new knowledge that there are social norms around parents providing healthy foods and needing to justify non-adherence to healthy eating guidelines, as well as the norm that family life and mealtime values are evolving. This highlights the need to consider the broader context that influences food choices. Furthermore, this study highlights the utility of novel methods in this field.

Lessons Learned from the Preimplementation Phase of an Oral Health Care Project

KNOWLEDGE TRANSFER STATEMENT

This commentary highlights that effective implementation of best-practice oral health care in acute geriatric units is built on the time and relationship building invested in the preimplementation phase.

Incerto-thalamic modulation of fear via GABA and dopamine

Fear generalization and deficits in extinction learning are debilitating dimensions of Post-Traumatic Stress Disorder (PTSD). Most understanding of the neurobiology underlying these dimensions comes from studies of cortical and limbic brain regions. While thalamic and subthalamic regions have been implicated in modulating fear, the potential for incerto-thalamic pathways to suppress fear generalization and rescue deficits in extinction recall remains unexplored. We first used patch-clamp electrophysiology to examine functional connections between the subthalamic zona incerta and thalamic reuniens (RE). Optogenetic stimulation of GABAergic ZI → RE cell terminals in vitro induced inhibitory post-synaptic currents (IPSCs) in the RE. We then combined high-intensity discriminative auditory fear conditioning with cell-type-specific and projection-specific optogenetics in mice to assess functional roles of GABAergic ZI → RE cell projections in modulating fear generalization and extinction recall. In addition, we used a similar approach to test the possibility of fear generalization and extinction recall being modulated by a smaller subset of GABAergic ZI → RE cells, the A13 dopaminergic cell population. Optogenetic stimulation of GABAergic ZI → RE cell terminals attenuated fear generalization and enhanced extinction recall. In contrast, optogenetic stimulation of dopaminergic ZI → RE cell terminals had no effect on fear generalization but enhanced extinction recall in a dopamine receptor D1-dependent manner. Our findings shed new light on the neuroanatomy and neurochemistry of ZI-located cells that contribute to adaptive fear by increasing the precision and extinction of learned associations. In so doing, these data reveal novel neuroanatomical substrates that could be therapeutically targeted for treatment of PTSD.

Implementation Science: Application of Evidence-Based Practice Models to Improve Healthcare Quality

BACKGROUND

Translating research into practice is complex for clinicians, yet essential for high quality patient care. The field of implementation science evolved to address this gap by developing theoretical approaches to guide adoption and sustained implementation of practice changes. Clinicians commonly lack knowledge, time, and resources of how evidence-based practice (EBP) models can guide implementation, contributing to the knowledge-to-practice gap.

AIM

This paper aimed to equip clinicians and other healthcare professionals with implementation science knowledge, confidence, and models to facilitate EBP change in their local setting and ultimately improve healthcare quality, safety, and population health outcomes.

METHODS

The field of implementation science is introduced, followed by application of three select models. Models are applied to a clinical scenario to emphasize contextual factors, process, implementation strategies, and outcome evaluation. Key attributes, strengths, opportunities, and utilities of each model are presented, along with general resources for selecting and using published criteria to best fit clinical needs. Partnerships between implementation scientists and clinicians are highlighted to facilitate the uptake of evidence into practice.

LINKING EVIDENCE TO ACTION

Knowledge of implementation science can help clinicians adopt high-quality evidence into their practices. Application-oriented approaches can guide clinicians through the EBP processes. Clinicians can partner with researchers in advancing implementation science to continue to accelerate the adoption of evidence and reduce the knowledge-to-action gap.

How nursing leaders promote evidence-based practice implementation at point-of-care: A four-country exploratory study

AIMS

To describe strategies nursing leaders use to promote evidence-based practice implementation at point-of-care using data from health systems in Australia, Canada, England and Sweden.

DESIGN

A descriptive, exploratory case-study design based on individual interviews using deductive and inductive thematic analysis and interpretation.

METHODS

Fifty-five nursing leaders from Australia, Canada, England and Sweden were recruited to participate in the study. Data were collected between September 2015 and April 2016.

RESULTS

Nursing leaders both in formal managerial roles and enabling roles across four country jurisdictions used similar strategies to promote evidence-based practice implementation. Nursing leaders actively promote evidence-based practice implementation, work to influence evidence-based practice implementation processes and integrate evidence-based practice implementation into everyday policy and practices.

CONCLUSION

The deliberative, conscious strategies nursing leaders used were consistent across country setting, context and clinical area. These strategies were based on a series of activities and interventions around promoting, influencing and integrating evidence-based practice implementation. We conjecture that these three key strategies may be linked to two overarching ways of demonstrating effective evidence-based practice implementation leadership. The two overarching modes are described as mediating and adapting modes, which reflect complex, dynamic, relationship-focused approaches nursing leaders take towards promoting evidence-based practice implementation.

IMPACT

This study explored how nursing leaders promote evidence-based practice implementation. Acknowledging and respecting the complex work of nursing leaders in promoting evidence-based practice implementation through mediating and adapting modes of activity is necessary to improve patient outcomes and system effectiveness.

Introducing an interactional approach to exploring facilitation as an implementation intervention: examining the utility of Conversation Analysis

BACKGROUND

The widely adopted integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework identifies facilitation as a 'core ingredient' for successful implementation. Indeed, most implementation scientists agree that a certain degree of facilitation is required to translate research into clinical practice; that is, there must be some intentional effort to assist the implementation of evidence-based approaches and practices into healthcare. Yet understandings of what constitutes facilitation and how to facilitate effectively remain largely theoretical and, therefore, provide scant practical guidance to ensure facilitator success. Implementation Science theories and frameworks often describe facilitation as an activity accomplished in, and through, formal and informal communication amongst facilitators and those involved in the implementation process (i.e. 'recipients'). However, the specific communication practices that constitute and enable effective facilitation are currently inadequately understood.

AIM

In this debate article, we argue that without effective facilitation-a practice requiring significant interactional and interpersonal skills-many implementation projects encounter difficulties. Therefore, we explore whether and how the application of Conversation Analysis, a rigorous research methodology for researching patterns of interaction, could expand existing understandings of facilitation within the Implementation Science field. First, we illustrate how Conversation Analysis methods can be applied to identifying what facilitation looks like in interaction. Second, we draw from existing conversation analytic research into facilitation outside of Implementation Science to expand current understandings of how facilitation might be achieved within implementation.

CONCLUSION

In this paper, we argue that conversation analytic methods show potential to understand and refine facilitation as a critical, and inherently interactional, component of implementation efforts. Conversation analytic investigations of facilitation as it occurs in real-time between participants could inform mechanisms to (1) improve understandings of how to achieve successful implementation through facilitation, (2) overcome difficulties and challenges in implementation related to interpersonal communication and interaction, (3) inform future facilitator training and (4) inform refinement of existing facilitation theories and frameworks (e.g. i-PARIHS) currently used in implementation interventions.

Experiences of using the i-PARIHS framework: a co-designed case study of four multi-site implementation projects

BACKGROUND

The integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework is an implementation framework that has been developed and refined over the last 20 years. Its underlying philosophy is that implementing research into healthcare practice is complex, unpredictable and non-linear which therefore requires a flexible and responsive approach to implementation. Facilitation is recognized as the central ingredient of this approach, and i-PARIHS now provides a Facilitation Guide with associated tools. This multiple case study of four implementation projects explored how the i-PARIHS framework has been practically operationalized by diverse implementation project teams.

METHODS

A co-design approach was used to elicit the experiences of four implementation project teams who used the i-PARIHS framework to guide their implementation approach. We conducted the established co-design steps of (i) setting up for success, (ii) gathering the experience, and (iii) understanding the experience. In particular we explored teams' approaches to setting up their projects; why and how they used the i-PARIHS framework and what they learnt from the experience.

RESULTS

We found both commonalities and differences in the use of i-PARIHS across the four implementation projects: (i) all the projects used the Facilitation Checklist that accompanies i-PARIHS as a starting point, (ii) the projects differed in how facilitation was carried out, (iii) existing tools were adapted for distinct phases: pre-implementation, during implementation, and post-implementation stages; and (iv) project-specific tools were often developed for monitoring implementation activities and fidelity.

CONCLUSIONS

We have provided a detailed overview of how current users of i-PARIHS are operationalising the framework, which existing tools they are using or adapting to use, and where they have needed to develop new tools to best utilise the framework. Importantly, this study highlights the value of existing tools from the published i-PARIHS Facilitation Guide and provides a starting point to further refine and add to these tools within a future Mobilising Implementation of i-PARIHS (or "Mi-PARIHS") suite of resources. Specifically, Mi-PARIHS might include more explicit guidance and/or tools for developing a structured implementation plan and monitoring fidelity to the implementation plan, including recording how strategies are tailored to an evolving context.

Interactive workshop to develop implementation framework (i-PARIHS) resources to support practice facilitation

BACKGROUND

Practice facilitation is a method used to address the complexity associated with implementation of innovations into primary care. To provide support, we propose that the i-PARIHS (Integrated Promoting Action on Research Implementation in Health Services) framework could support practice facilitators. The i-PARIHS framework positions facilitation as a core element for successful implementation. Therefore, the aim of this study was to provide support to practice facilitators whilst simultaneously gaining feedback on what facilitators in practice need in regard to support with operationalising the i-PARIHS framework in practice.

METHODS

This study involved the delivery of a 1-h workshop on the i-PARIHS framework at the 2018 International Conference on Practice Facilitation. The authors provided an overview of the i-PARIHS framework, how it can be used to support the facilitation of innovations into practice, and finally, attendees worked through facilitation scenarios and applied an i-PARIHS resource. At the end of the workshop, attendees were invited to participant in the research component, by completing a post-workshop survey on the workshop content and the i-PARIHS resource.

RESULTS

Participants were highly engaged and enthusiastic about the workshop. Participants reported that an introduction to implementation frameworks was valuable and the example of how the i-PARIHS framework had been used in a previous project was helpful. Overall, this study identifies how framework informed facilitation helped participants feel more equipped to conduct systematic facilitation and that the development of i-PARIHS resources would be helpful in their everyday work.

CONCLUSIONS

This study demonstrates that the existence of implementation frameworks is not sufficient to provide support to those who facilitate in the real world. The current study introduced practice facilitators to the i-PARIHS framework, and the findings demonstrate the need to develop and refine existing i-PARIHS resources to support facilitation. Specifically, the next steps stemming from this study will be to (i) continue to utilize workshops for sharing and refining tools, (ii) allocate development efforts to tools that assist with planning, (iii) focus on tool provision mechanisms that keep user-friendliness in mind, and (iv) translate the i-PARIHS facilitation checklist from academic language into more practical and user-friendly language.

Proximate causes and consequences of intergenerational influences of salient sensory experience

Salient sensory environments experienced by a parental generation can exert intergenerational influences on offspring. While these data provide an exciting new perspective on biological inheritance, questions remain about causes and consequences of intergenerational influences of salient sensory experience. We previously showed that exposing male mice to a salient olfactory experience, like olfactory fear conditioning, resulted in offspring demonstrating a sensitivity to the odor used to condition the paternal generation and possessing enhanced neuroanatomical representation for that odor. In this study, we first injected RNA extracted from sperm of male mice that underwent olfactory fear conditioning into naïve single-cell zygotes and found that adults that developed from these embryos had increased sensitivity and enhanced neuroanatomical representation for the odor (Odor A) with which the paternal male had been conditioned. Next, we found that female, but not male offspring sired by males conditioned with Odor A show enhanced consolidation of a weak single-trial Odor A + shock fear conditioning protocol. Our data provide evidence that RNA found in the paternal germline after exposure to salient sensory experiences can contribute to intergenerational influences of such experiences, and that such intergenerational influences confer an element of adaptation to the offspring. In so doing, our study of intergenerational influences of parental sensory experience adds to existing literature on intergenerational influences of parental exposures to stress and dietary manipulations and suggests that some causes (sperm RNA) and consequences (behavioral flexibility) of intergenerational influences of parental experiences may be conserved across a variety of parental experiences.

Reversing Behavioral, Neuroanatomical, and Germline Influences of Intergenerational Stress

BACKGROUND

Stressors affect populations exposed to them as well as offspring. Strategies preventing the intergenerational propagation of effects of stress would benefit public health. Olfactory cue-based fear conditioning provides a framework to address this issue.

METHODS

We 1) exposed adult male mice to an odor, acetophenone (Ace) or Lyral (parental generation [F0]-Exposed), 2) trained mice to associate these odors with mild foot shocks (F0-Trained), and 3) trained mice to associate these odors with mild foot shocks and then extinguished their fear toward these odors with odor-only presentations (F0-Extinguished). We then examined sensitivity of future generation (F1) offspring to these odors, expression of M71 odorant (Ace-responsive) and MOR23 odorant (Lyral-responsive) receptor-expressing cell populations in F1 offspring, and DNA methylation at genes encoding the Ace- (Olfr151, Olfr160) and Lyral- (Olfr16) responsive receptors in F0 sperm.

RESULTS

Extinguishing fear toward Ace or Lyral of F0 male mice (F0-Extinguished) that had been fear conditioned with Ace or Lyral, respectively, results in F1-Extinguished offspring that do not demonstrate behavioral sensitivity to Ace or Lyral, respectively, and do not have enhanced representation for M71 or MOR23 odorant receptors in the olfactory system, as is observed in F1-Trained-Ace or F1-Trained-Lyral cohorts, respectively. The promoters of genes encoding Olfr151 and Olfr160 receptors are less methylated in F0-Trained-Ace sperm compared with F0-Exposed-Ace sperm. The Olfr16 promoter is less methylated in F0-Trained-Lyral sperm compared with F0-Exposed-Lyral sperm, and F0-Extinguished-Lyral sperm have methylation levels comparable to F0-Exposed-Lyral sperm.

CONCLUSIONS

Our study demonstrates the potential of using extinction-based behavioral strategies to reverse influences of parental stress in offspring and in the parental germline.

"There is nothing so practical as a good theory": a pragmatic guide for selecting theoretical approaches for implementation projects

BACKGROUND

A multitude of theories, models and frameworks relating to implementing evidence-based practice in health care exist, which can be overwhelming for clinicians and clinical researchers new to the field of implementation science. Clinicians often bear responsibility for implementation, but may be unfamiliar with theoretical approaches designed to inform or understand implementation.

MAIN TEXT

In this article, a multidisciplinary group of clinicians and health service researchers present a pragmatic guide to help clinicians and clinical researchers understand what implementation theories, models and frameworks are; how a theoretical approach to implementation might be used; and some prompts to consider when selecting a theoretical approach for an implementation project. Ten commonly used and highly cited theoretical approaches are presented, none of which have been utilised to their full potential in the literature to date. Specifically, theoretical approaches tend to be applied retrospectively to evaluate or interpret findings from a completed implementation project, rather than being used to plan and design theory-informed implementation strategies which would intuitively have a greater likelihood of success. We emphasise that there is no right or wrong way of selecting a theoretical approach, but encourage clinicians to carefully consider the project's purpose, scope and available data and resources to allow them to select an approach that is most likely to "value-add" to the implementation project.

CONCLUSION

By assisting clinicians and clinical researchers to become confident in selecting and applying theoretical approaches to implementation, we anticipate an increase in theory-informed implementation projects. This then will contribute to more nuanced advice on how to address evidence-practice gaps and ultimately to contribute to better health outcomes.

"There is nothing so practical as a good theory": a pragmatic guide for selecting theoretical approaches for implementation projects

Background

A multitude of theories, models and frameworks relating to implementing evidence-based practice in health care exist, which can be overwhelming for clinicians and clinical researchers new to the field of implementation science. Clinicians often bear responsibility for implementation, but may be unfamiliar with theoretical approaches designed to inform or understand implementation.

Main text

In this article, a multidisciplinary group of clinicians and health service researchers present a pragmatic guide to help clinicians and clinical researchers understand what implementation theories, models and frameworks are; how a theoretical approach to implementation might be used; and some prompts to consider when selecting a theoretical approach for an implementation project. Ten commonly used and highly cited theoretical approaches are presented, none of which have been utilised to their full potential in the literature to date. Specifically, theoretical approaches tend to be applied retrospectively to evaluate or interpret findings from a completed implementation project, rather than being used to plan and design theory-informed implementation strategies which would intuitively have a greater likelihood of success. We emphasise that there is no right or wrong way of selecting a theoretical approach, but encourage clinicians to carefully consider the project’s purpose, scope and available data and resources to allow them to select an approach that is most likely to “value-add” to the implementation project.

Conclusion

By assisting clinicians and clinical researchers to become confident in selecting and applying theoretical approaches to implementation, we anticipate an increase in theory-informed implementation projects. This then will contribute to more nuanced advice on how to address evidence-practice gaps and ultimately to contribute to better health outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3671-z) contains supplementary material, which is available to authorized users.

Genetic and biochemical basis for alternative routes of tocotrienol biosynthesis for enhanced vitamin E antioxidant production

Vitamin E tocotrienol synthesis in monocots requires homogentisate geranylgeranyl transferase (HGGT), which catalyzes the condensation of homogentisate and the unsaturated C20 isoprenoid geranylgeranyl diphosphate (GGDP). By contrast, vitamin E tocopherol synthesis is mediated by homogentisate phytyltransferase (HPT), which condenses homogentisate and the saturated C20 isoprenoid phytyl diphosphate (PDP). An HGGT-independent pathway for tocotrienol synthesis has also been shown to occur by de-regulation of homogentisate synthesis. In this paper, the basis for this pathway and its impact on vitamin E production when combined with HGGT are explored. An Arabidopsis line was initially developed that accumulates tocotrienols and homogentisate by co-expression of Arabidopsis hydroxyphenylpyruvate dioxygenase (HPPD) and Escherichia coli bi-functional chorismate mutase/prephenate dehydrogenase (TyrA). When crossed into the vte2-1 HPT null mutant, tocotrienol production was lost, indicating that HPT catalyzes tocotrienol synthesis in HPPD/TyrA-expressing plants by atypical use of GGDP as a substrate. Consistent with this, recombinant Arabidopsis HPT preferentially catalyzed in vitro production of the tocotrienol precursor geranylgeranyl benzoquinol only when presented with high molar ratios of GGDP:PDP. In addition, tocotrienol levels were highest in early growth stages in HPPD/TyrA lines, but decreased strongly relative to tocopherols during later growth stages when PDP is known to accumulate. Collectively, these results indicate that HPPD/TyrA-induced tocotrienol production requires HPT and occurs upon enrichment of GGDP relative to PDP in prenyl diphosphate pools. Finally, combined expression of HPPD/TyrA and HGGT in Arabidopsis leaves and seeds resulted in large additive increases in vitamin E production, indicating that homogentisate concentrations limit HGGT-catalyzed tocotrienol synthesis.

Vitamin E biosynthesis: functional characterization of the monocot homogentisate geranylgeranyl transferase

The biosynthesis of the tocotrienol and tocopherol forms of vitamin E is initiated by prenylation of homogentisate. Geranylgeranyl diphosphate (GGDP) is the prenyl donor for tocotrienol synthesis, whereas phytyl diphosphate (PDP) is the prenyl donor for tocopherol synthesis. We have previously shown that tocotrienol synthesis is initiated in monocot seeds by homogentisate geranylgeranyl transferase (HGGT). This enzyme is related to homogentisate phytyltransferase (HPT), which catalyzes the prenylation step in tocopherol synthesis. Here we show that monocot HGGT is localized in the plastid and expressed primarily in seed endosperm. Despite the close structural relationship of monocot HGGT and HPT, these enzymes were found to have distinct substrate specificities. Barley (Hordeum vulgare cv. Morex) HGGT expressed in insect cells was six times more active with GGDP than with PDP, whereas the Arabidopsis HPT was nine times more active with PDP than with GGDP. However, only small differences were detected in the apparent Km values of barley HGGT for GGDP and PDP. Consistent with its in vitro substrate properties, barley HGGT generated a mixture of tocotrienols and tocopherols when expressed in the vitamin E-null vte2-1 mutant lacking a functional HPT. Relative levels of tocotrienols and tocopherols produced in vte2-1 differed between organs and growth stages, reflective of the composition of plastidic pools of GGDP and PDP. In addition, HGGT was able to functionally substitute for HPT to rescue vte2-1-associated phenotypes, including reduced seed viability and increased fatty acid oxidation of seed lipids. Overall, we show that monocot HGGT is biochemically distinct from HPT, but can replace HPT in important vitamin E-related physiological processes.

Enhancing vitamin E in oilseeds: unraveling tocopherol and tocotrienol biosynthesis

Naturally occurring vitamin E, comprised of four forms each of tocopherols and tocotrienols, are synthesized solely by photosynthetic organisms and function primarily as antioxidants. These different forms vary in their biological availability and in their physiological and chemical activities. Tocopherols and tocotrienols play important roles in the oxidative stability of vegetable oils and in the nutritional quality of crop plants for human and livestock diets. The isolation of genes for nearly all the steps in tocopherol and tocotrienol biosynthesis has facilitated efforts to alter metabolic flux through these pathways in plant cells. Herein we review the recent work done in the field, focusing on branch points and metabolic engineering to enhance and alter vitamin E content and composition in oilseed crops.

Regulation of spinach chloroplast acetyl-CoA carboxylase

We have investigated several factors which influence acetyl-CoA carboxylase (ACCase) activity in lysed spinach chloroplasts. (1) When assayed after rapid lysis of light-incubated chloroplasts, ACCase activity was 2-fold higher than activity from dark-incubated chloroplasts. Within 5 min after lysis, activity from dark-incubated chloroplasts increased, suggesting a transient inactivation or inhibition of ACCase in the dark. (2) When lysed chloroplast suspensions were incubated with 30 to 100 microM acetyl-CoA before starting assays, activity was 4-fold higher than if suspensions were not preincubated with acetyl-CoA. CoA, malonyl-CoA, propionyl-CoA, and butyryl-CoA also activated ACCase. Full acetyl-CoA activation required MgATP and was essentially complete after 8 min. ACCase activity decreased upon removal of acetyl-CoA by gel filtration and was partially restored by readdition of acetyl-CoA. Thus, ACCase activation by acetyl-CoA was reversible. (3) Dithiothreitol and thioredoxin stimulated ACCase activity, but only in preparations where ACCase activity was low. (4) ACCase was assayed in concentrations of ATP, ADP, NADPH, NADP+, Mg2+, and CO2/HCO-3, which are estimated to occur in the stroma of chloroplasts under illumination or darkness. ACCase activity from lysed chloroplast suspensions was 10-fold higher when illuminated conditions were used. However, this activity was still 5-fold to 10-fold lower than the rates required to sustain known in vivo rates of fatty acid synthesis and in vitro rates achieved under optimum assay conditions with saturating substrates.

Administration of propofol by target-controlled infusion in patients undergoing coronary artery surgery

OBJECTIVES

To study the predictive performance of a target-controlled infusion (TCI) system of propofol in patients undergoing coronary bypass graft (CABG) surgery, using a referenced pharmacokinetic set derived from healthy patients. Also, to determine the propofol concentrations required for clinically acceptable induction and maintenance of anesthesia when combined with midazolam as premedication and a continuous alfentanil infusion and to study the hemodynamic stability of this technique.

DESIGN

Prospective noncomparative study analysis.

SETTING

Operating room at a university hospital.

PARTICIPANTS

Twenty-on patients with good left ventricular function undergoing coronary artery surgery.

INTERVENTIONS

Patients were anesthetized using a continuous infusion of alfentanil (mean infusion rate: 1 microgram/kg/min) and propofol administered by TCI.

MEASUREMENTS AND MAIN RESULTS

The predictive performance of the TCI system (212 arterial samples) was measured at specified time points before, during, and after bypass. The TCI system underestimated the measured blood propofol concentrations with a bias of +21.2% and +9.6% during the prebypass and the bypass periods, respectively. The predictive inaccuracy, expressed by the median absolute prediction error, was 23% and 18.5%, respectively. Mean target propofol concentrations required to induce and maintain anesthesia before bypass were 0.92 microgram/mL and 3.64 micrograms/mL, respectively. In the period during and after bypass, the mean target concentrations required to maintain anesthesia was 2.22 micrograms/mL. The administration of propofol by TCI was still associated with some short episodes of hemodynamic instability that were easily controlled by adjusting the target concentration in the majority of the patients. Therefore, the overall quality and ease of control of anesthesia were considered as being good or adequate.

CONCLUSIONS

In this group of patients undergoing CABG surgery, the TCI system used underestimated the measured propofol concentrations. However, the predictive performance of the selected mean pharmacokinetic parameters derived from healthy patients was acceptable during the whole surgical procedure.

Total intravenous anaesthesia with propofol or inhalational anaesthesia with isoflurane for major abdominal surgery. Recovery characteristics and postoperative oxygenation--an international multicentre study

Two hundred and ten adult patients undergoing open cholecystectomy, vagotomy or gastrectomy were included in a randomised multicentre study to compare postoperative nausea and vomiting, oxygen saturations for the first three postoperative nights, time to return of gastrointestinal function, mobilisation, and discharge from the hospital following induction and maintenance of anaesthesia with propofol and alfentanil or with thiopentone, nitrous oxide, isoflurane and alfentanil. Recovery from anaesthesia was significantly faster in the propofol group (mean (SD) times to eye opening and giving correct date of birth of 14.0 (SD 13.8) and 25.5 (SD 29.5) minutes, and 18.5 (SD 14.8) and 35.5 (SD 37.2) minutes in the propofol and isoflurane groups respectively). There was significantly less nausea in the propofol group (15.4%) than in the isoflurane group (33.7%) in the first two postoperative hours (p < 0.003) but not thereafter. There were no significant differences between the groups in any other recovery characteristics. The incidence of hypoxaemia (arterial oxygen saturation less than 93%) was close to 70% in both groups for the first three postoperative nights, indicating the need for oxygen therapy after major abdominal surgery.

Manual compared with target-controlled infusion of propofol

We studied 160 ASA I-II patients, anaesthetized with propofol by infusion, using either a manually controlled or target-controlled infusion system. Patients were anaesthetized by eight consultant anaesthetists who had little or no previous experience of the use of propofol by infusion. In addition to propofol, patients received temazepam premedication, a single dose of fentanyl and 67% nitrous oxide in oxygen. Each consultant anaesthetized 10 patients in sequential fashion with each system. Use of the target-controlled infusion resulted in more rapid induction of anaesthesia and allowed earlier insertion of a laryngeal mask airway. There was a tendency towards less movement in response to the initial surgical stimulus and significantly less movement during the remainder of surgery. Significantly more propofol was administered during both induction and maintenance of anaesthesia with the target-controlled system. This was associated with significantly increased end-tidal carbon dioxide measurements during the middle period of maintenance only, but recovery from anaesthesia was not significantly prolonged in the target-controlled group. With the exception of a clinically insignificant difference in heart rate, haemodynamic variables were similar in the two groups. Six of the eight anaesthetists found the target-controlled system easier to use, and seven would use the target-controlled system in preference to a manually controlled infusion. Anaesthetists without prior experience of propofol infusion anaesthesia quickly became familiar with both manual and target-controlled techniques, and expressed a clear preference for the target-controlled system.

The biomechanics of the knee during the parachute landing fall

Because anterior knee pain syndrome is common in young paratroopers, we studied the role of the extensor mechanism in deceleration during the parachute landing fall (PLF) and the extent of knee flexion resulting from use of proper and variant landing styles. The subjects were novice paratroopers. Data were gathered by electromyography and by cinematography. At impact, a period of myoelectric silence was found that increased during training. Knee flexion angles varied from 130 degrees in the proper PLF to a low of 110 degrees in the toes-knees-nose PLF and to a high of 160 degrees in the hypergenuflexion PLF. The improper PLFs had a duration of deceleration shorter than that of a proper PLF, with maximal knee flexion occurring later in the landing act. Our results give direction to more specific lower-body training.

Acute rupture of the tibialis anterior tendon: a case report

Acute rupture of tendons on the dorsum of the foot is rare and the diagnosis can be difficult. We present the case of a 51-year-old man who sustained an acute rupture of the tibialis anterior tendon. Pain about the medial aspect of the midfoot and ambulation with a steppage gait were the keys to formulating a correct diagnosis. The tendon was repaired primarily 10 days after injury. At his final follow-up examination 6 months after surgery, the patient was asymptomatic and ambulated with a normal gait.

Prevention and treatment of overuse tendon injuries

Overuse injuries are common in recreational and competitive sports as well as in day-to-day activities. The musculotendinous unit comprises the tissue most frequently involved: structural damage to the tendon occurs from repetitive strain and loading, from either endurance or skill activities that require technique and power. The potential for injury is enhanced by a great variety of predisposing intrinsic or extrinsic factors. Tendinous tissue will become fatigued as its basal reparative ability is overwhelmed by repetitive dysfunctional and microtraumatic processes. Tendinitis is the earliest recognisable manifestation of overuse injury: as damage progresses, partial tears and complete ruptures may ensue. The diagnosis of overuse injury rests with identification not only of the affected tendinous unit, but also of the underlying predisposing condition or conditions. Treatment can then proceed with elimination or correction, if possible, of these conditions, together with control of inflammation and programmes of modalities designed to restore the structural and functional integrity of the tendon. Knowledge of overuse problems has grown exponentially in the past 3 decades, as evidenced by the outpouring of scientific and medical literature. Sophisticated analytical techniques, supplementing a sound history and physical examination, have greatly facilitated the diagnosis of overuse problems and allowed the application of scientific therapeutic principles. As the number of participants in recreational activities continues to grow, the application of these techniques in ever more innovative ways holds the greatest promise for the prevention of overuse tendon injuries.

High school football injuries: identifying the risk factors

This epidemiologic survey of the literature on the factors contributing to the high number of high school football injuries consolidates the current information on the characteristics and risk factors associated with these injuries. To reduce the incidence of knee sprains and strains, the most common injuries to this population, the following preventive recommendations are presented: 1) optimum maintenance of playing fields; 2) use of the soccer-style shoe; 3) noncontact and controlled activities in practice sessions; and 4) increased vigilance over technique during injury-prone preseason practices. The authors conclude that more research into factors such as exposure time and activity at injury will further reduce the risk to the high school football player.

High school football injuries: evaluation

An epidemiologic survey of the literature on high school football injuries revealed methodologic problems. These numerator-denominator inconsistencies and other confounding factors are discussed. The authors suggest a more reliable system of reporting these parameters to further reduce the risk of high school football injuries.

High school football injuries: identifying the risk factors

This epidemiologic survey of the literature on the factors contributing to the high number of high school football injuries consolidates the current information on the characteristics and risk factors associated with these injuries. To reduce the incidence of knee sprains and strains, the most common injuries to this population, the following preventive recommendations are presented: 1) optimum maintenance of playing fields; 2) use of the soccer-style shoe; 3) noncontact and controlled activities in practice sessions; and 4) increased vigilance over technique during injury-prone preseason practices. The authors conclude that more research into factors such as exposure time and activity at injury will further reduce the risk to the high school football player.

The chronically inflamed tendon

The cause, diagnosis, and treatment of some of the chronic tendonitides are discussed in this article. Most tendon injuries are "overuse syndromes" and treatment involves the use of combined modalities and exercise. Preventive measures are emphasized.

High school football injuries: evaluation

An epidemiologic survey of the literature on high school football injuries revealed methodologic problems. These numerator-denominator inconsistencies and other confounding factors are discussed. The authors suggest a more reliable system of reporting these parameters to further reduce the risk of high school football injuries.

Surgical repair of Achilles tendon ruptures

We evaluated the surgical results of 42 consecutive patients with spontaneous rupture of the Achilles tendon treated from 1973 to 1984 to determine the causes of rupture and to evaluate our treatment methods. Patients were divided into early and late repair groups and their charts reviewed to determine common clinical features. A new method of repair with early functional range of motion exercises before casting was used and compared to other techniques in common use. Thirty-one patients were contacted for long-term followup (average, 4.7 years). Twenty-three of these patients returned for intensive reevaluation and Cybex testing. We found a high incidence of gout (14.3%) and previous steroid injections (7.1%) in our patients. Good results were obtained from the four surgical methods used. There were no reruptures and only 7% of the patients experienced minor wound problems. Patients treated with early functional range of motion exercises averaged 12.5 degrees more dorsiflexion at the time of cast removal and did not require adjunctive protective devices. Long-term results, however, revealed equilibration of range of motion and near normal function in all repair techniques with 88% of all patients returning to preinjury activity levels.

Southern hip exposure

The efficacy of the posterior approach to the hip was analyzed in a retrospective study of 168 consecutive procedures performed by the author. Surgical technique is redefined historically and described in detail. Results are studied in two subgroups of hip surgery patients: endoprosthetic replacement (98) and total joint replacement (70). The factors evaluated were surgical time and blood loss, morbidity (dislocation, infection, pain, and limp), mortality, and complications of surgery. The posterior approach to the hip allowed excellent exposure without transecting tissue planes and creating dead spaces. Operative time averaged less than one hour for all cases, and blood loss, less than 500 cc. The four dislocations that occurred postoperatively were in patients with pre-existing flexion contractures. One superficial infection was noted but there was no increase in morbidity due to pain, limp, or loss of motion. Two total joint replacements were complicated by hematoma formation but occurred in patients who had extensive capsule resection and acetabuloplasty. Excellent and rapid exposure with minimal soft tissue destruction or blood loss coupled with few postoperative complications should encourage orthopedic surgeons to include the posterior approach in their treatment of hip problems.

Pharmacology of an emulsion formulation of ICI 35 868

Studies with an emulsion formulation of ICI 35 868 (2,6- diisopropylphenol ) indicate that this new formulation has anaesthetic properties in rats and mice, and haemodynamic effects in the mini-pig which are similar to those of the previously available Cremophor formulation. Administration of the emulsion formulation to dogs produced no untoward effect, whereas the Cremophor formulation produced a marked increase in plasma histamine concentration. In the mini-pig, no adverse response was produced by the repeated administration of the emulsion formulation of ICI 35 868, whereas the Cremophor formulation produced anaphylactoid responses when a second injection was given 1 week after an uneventful first exposure to this formulation. Behavioural responses in the rat suggest that the emulsion formulation may produce less discomfort on i.v. injection.

A modified anaesthetic vapour extraction system

A number of design modifications have been made to an extraction system for use with inhalation anaesthesia techniques in rats and other small laboratory animals. These changes necessitated a re-evaluation of the effectiveness of this equipment in limiting the operator's exposure to the anaesthetic vapours used. With a given fresh gas flow, the halothane vapour concentration in the operator's breathing zone was dependent on the design of the oronasal mask. With the optimum configuration the atmospheric concentration of halothane was less than 1 ppm.

Performance measurement and percent body fat in the high school athlete

Standards for performance have been derived from the preseason assessment of the high school athlete. The performance of 3,174 athletes during five performance tests was measured. The tests included dips, sit-ups, and pull-ups, in addition to grip strength measurement and vertical jump capability. Measurements were converted to the amount of work done or force developed. Nondimensional ratios were determined using the tables and empirical equations presented in this paper. These quantities were then compared to the percent body fat. The average performance of the athletes as determined by the testing procedures described herein decreases dramatically as the body fat increases above 10% in males and 19% in females.

Disruption of the vastus medialis obliquus with medial knee ligament injuries

We reviewed the clinical records of 189 consecutive surgically treated acute ligamentous injuries of the medial compartment of the knee to determine the prevalence of disruptions of the vastus medialis obliquus muscle and to document the results of simultaneous repair of the disruption. Forty knees (40 patients) demonstrated a vastus medialis muscle disruption at the time of surgical repair for the medial ligamentous disruption. All were surgically corrected and the sites of tearing were documented. The vastus medialis obliquus muscle was ruptured from the adductor tubercle in 31 (78%) knees. Of these, the tibial collateral ligament was torn from its femoral attachment in 19 (61%) knees and the meniscofemoral portion of the capsular ligament ligament was torn from its femoral attachment in 23 (74%) knees. The vastus medialis obliquus muscle was ruptured from the patella in seven (18%) knees and was ruptured interstitially in nine (23%) knees. Each of the 40 patients returned for objective, subjective, and functional follow-up evaluation (average, 39 months). At follow-up examination, 88% of the 40 knees were rated as good subjectively, 90% objectively, and 93% functionally. A high correlation exists between tears of the vastus medialis obliquus muscle from its femoral attachment and tears of the medial compartment ligaments from their respective femoral attachments. Surgical repair of disruptions of the vastus medialis obliquus muscle at the time of primary repair of injury to the ligaments of the medial compartment of the knee can prevent subsequent disorder of the extensor mechanism and can produce an objectively, subjectively, and functionally stable knee.