Key components of external facilitation in an acute stroke quality improvement collaborative in the Veterans Health Administration

Background Facilitation is a key component for successful implementation in several implementation frameworks; however, there is a paucity of research specifying this component. As part of a stroke quality improvement intervention in the Veterans Health Administration (VHA), facilitation plus data feedback was compared to data feedback alone in 11 VA medical facilities. The objective of this study was to elucidate upon the facilitation components of the stroke quality improvement. Methods We conducted a secondary evaluation of external facilitation using semi-structured interviews. Five facilitators and two program directors were interviewed. Qualitative analysis was performed on transcribed interviews to gain an understanding of the role and activities of external facilitators during the on-site and telephone facilitation. Quantitative frequencies were calculated from the self-reported time spent in facilitation tasks by facilitators. Results The external facilitators saw their role as empowering the clinical teams to take ownership of the process changes at the clinical sites to improve their performance quality. To fulfill this role, they reported engaging in a number of core tasks during telephone and on-site visits including: assessing the context in which the teams were currently operating, guiding the clinical teams through their planned changes and use of process improvement tools, identifying resources and making referrals, holding teams accountable for plan implementation with on-site visits, and providing support and encouragement to the teams. Time spent in facilitation activities changed across time from guiding change (early) to supporting efforts made by the clinical teams (later). Facilitation activity transitioned to more monitoring, problem solving, and intentional work to hand over the clinical improvement process to the site teams with the coach’s role being increasingly that of a more distant consultant. Overall, this study demonstrated that external facilitation is not an event but rather a process where relationships and responsibilities evolve over time. Conclusions This study shows that external facilitation involves core elements related to communication, relationship building, methods training, monitoring performance over time, and facilitating team-based problem solving. Importantly, this work demonstrates the fluid nature of external facilitation over time, as teams learn, grow, change, and experience changing contexts

Motor unit potential morphology differences in individuals with non-specific arm pain and lateral epicondylitis

<p>Abstract</p> <p>Background</p> <p>The pathophysiology of non-specific arm pain (NSAP) is unclear and the diagnosis is made by excluding other specific upper limb pathologies, such as lateral epicondylitis or cervical radiculopathy. The purpose of this study was to determine: (i) if the quantitative parameters related to motor unit potential morphology and/or motor unit firing patterns derived from electromyographic (EMG) signals detected from an affected muscle of patients with NSAP are different from those detected in the same muscle of individuals with lateral epicondylitis (LE) and/or control subjects and (ii) if the quantitative EMG parameters suggest that the underlying pathophysiology in NSAP is either myopathic or neuropathic in nature.</p> <p>Methods</p> <p>Sixteen subjects with NSAP, 11 subjects with LE, eight subjects deemed to be at-risk for developing a repetitive strain injury, and 37 control subjects participated. A quantitative electromyography evaluation was completed using decomposition-based quantitative electromyography (DQEMG). Needle- and surface-detected EMG signals were collected during low-level isometric contractions of the extensor carpi radialis brevis (ECRB) muscle. DQEMG was used to extract needle-detected motor unit potential trains (MUPTs), and needle-detected motor unit potential (MUP) and surface detected motor unit potential (SMUP) morphology and motor unit (MU) firing rates were compared among the four groups using one-way analysis of variance (ANOVA). Post hoc analyses were performed using Tukey's pairwise comparisons.</p> <p>Results</p> <p>Significant group differences were found for all MUP variables and for MU firing rate (<it>p</it> < 0.006). The post-hoc analyses revealed that patients with NSAP had smaller MUP amplitude and SMUP amplitude and area compared to the control and LE groups (<it>p </it>< 0.006). MUP duration and AAR values were significantly larger in the NSAP, LE and at-risk groups compared to the control group (<it>p </it>< 0.006); while MUP amplitude, duration and AAR values were smaller in the NSAP compared to the LE group. SMUP duration was significantly shorter in the NSAP group compared to the control group (<it>p </it>< 0.006). NSAP, LE and at-risk subjects had lower mean MU firing rates than the control subjects (<it>p </it>< 0.006).</p> <p>Conclusion</p> <p>The size-related parameters suggest that the NSAP group had significantly smaller MUPs and SMUPs than the control and LE subjects. Smaller MUPs and SMUPs may be indicative of muscle fiber atrophy and/or loss. A prospective study is needed to confirm any causal relationship between smaller MUPs and SMUPs and NSAP as found in this work.</p

Muscle Sympathetic Nerve Activity Is Related to a Surrogate Marker of Endothelial Function in Healthy Individuals

BACKGROUND: Evidence from animal studies indicates the importance of an interaction between the sympathetic nervous system and the endothelium for cardiovascular regulation. However the interaction between these two systems remains largely unexplored in humans. The aim of this study was to investigate whether directly recorded sympathetic vasoconstrictor outflow is related to a surrogate marker of endothelial function in healthy individuals. METHODS AND RESULTS: In 10 healthy normotensive subjects (3 f/7 m), (age 37+/-11 yrs), (BMI 24+/-3 kg/m(2)) direct recordings of sympathetic action potentials to the muscle vascular bed (MSNA) were performed and endothelial function estimated with the Reactive Hyperaemia- Peripheral Arterial Tonometry (RH-PAT) technique. Blood samples were taken and time spent on leisure-time physical activities was estimated. In all subjects the rate between resting flow and the maximum flow, the Reactive Hyperemic index (RH-PAT index), was within the normal range (1.9-3.3) and MSNA was as expected for age and gender (13-44 burst/minute). RH-PAT index was inversely related to MSNA (r = -0.8, p = 0.005). RH-PAT index and MSNA were reciprocally related to time (h/week) spent on physical activity (p = 0.005 and p = 0.006 respectively) and platelet concentration (PLT) (p = 0.02 and p = 0.004 respectively). CONCLUSIONS: Our results show that sympathetic nerve activity is related to a surrogate marker of endothelial function in healthy normotensive individuals, indicating that sympathetic outflow may be modulated by changes in endothelial function. In this study time spent on physical activity is identified as a predictor of sympathetic nerve activity and endothelial function in a group of healthy individuals. The results are of importance in understanding mechanisms underlying sympathetic activation in conditions associated with endothelial dysfunction and emphasise the importance of a daily exercise routine for maintenance of cardiovascular health

Genome-wide association studies identify 137 genetic loci for DNA methylation biomarkers of aging

Background Biological aging estimators derived from DNA methylation data are heritable and correlate with morbidity and mortality. Consequently, identification of genetic and environmental contributors to the variation in these measures in populations has become a major goal in the field. Results Leveraging DNA methylation and SNP data from more than 40,000 individuals, we identify 137 genome-wide significant loci, of which 113 are novel, from genome-wide association study (GWAS) meta-analyses of four epigenetic clocks and epigenetic surrogate markers for granulocyte proportions and plasminogen activator inhibitor 1 levels, respectively. We find evidence for shared genetic loci associated with the Horvath clock and expression of transcripts encoding genes linked to lipid metabolism and immune function. Notably, these loci are independent of those reported to regulate DNA methylation levels at constituent clock CpGs. A polygenic score for GrimAge acceleration showed strong associations with adiposity-related traits, educational attainment, parental longevity, and C-reactive protein levels. Conclusion This study illuminates the genetic architecture underlying epigenetic aging and its shared genetic contributions with lifestyle factors and longevity.</p

Comparison of two approaches to screen for dysphagia among acute ischemic stroke patients: Nursing admission screening tool versus National Institutes of Health Stroke Scale

This study assessed the positive and negative predictive values and the sensitivity and specificity of a nursing dysphagia screening tool and the National Institutes of Health Stroke Scale (NIHSS) for the identification of dysphagia for veterans hospitalized with ischemic stroke. A secondary objective of this study was to evaluate the speech-language pathology consult rate before and after the nursing admission dysphagia screening tool. This retrospective cohort study evaluated veterans admitted to one Department of Veterans Affairs medical center with ischemic stroke during the 6 months both before and after the implementation of a nursing dysphagia screening tool, which was part of the admission nursing template. Stroke severity was measured with the use of the retrospective NIHSS. Dysphagia diagnosis was based on speech-language pathology evaluations. Dysphagia was present in 38 of 101 patients (38%) with ischemic stroke. The nursing dysphagia screening tool had a positive predictive value of 50% and a negative predictive value of 68%, with a sensitivity of 29% and specificity of 84%. The use of the NIHSS to identify dysphagia risk had a positive predictive value of 60% and a negative predictive value of 84%. The NIHSS had better test characteristics in predicting dysphagia than the nursing dysphagia screening tool. Future research should evaluate the use of the NIHSS as a screening tool for dysphagia

Induction of mitochondrial dysfunction as a strategy for targeting tumour cells in metabolically compromised microenvironments

Abnormal vascularization of solid tumours results in the development of microenvironments deprived of oxygen and nutrients that harbour slowly growing and metabolically stressed cells. Such cells display enhanced resistance to standard chemotherapeutic agents and repopulate tumours after therapy. Here we identify the small molecule VLX600 as a drug that is preferentially active against quiescent cells in colon cancer 3-D microtissues. The anticancer activity is associated with reduced mitochondrial respiration, leading to bioenergetic catastrophe and tumour cell death. VLX600 shows enhanced cytotoxic activity under conditions of nutrient starvation. Importantly, VLX600 displays tumour growth inhibition in vivo. Our findings suggest that tumour cells in metabolically compromised microenvironments have a limited ability to respond to decreased mitochondrial function, and suggest a strategy for targeting the quiescent populations of tumour cells for improved cancer treatment

Improving Work Ability and Return to Work among Women on Long-term Sick Leave

The overall aim of this thesis was to gain new knowledge of factors and interventions that improve work ability and return to work (RTW) among women on long-term sick leave from human service organizations (HSOs). The specific aims of the studies were: to evaluate the associations between the self-rated Work Ability Index (WAI) and Work Ability Score (WAS), and the relationship with prospective sick leave, symptoms, and health (Paper I); to investigate whether intervention with myofeedback training or intensive muscular strength training could decrease pain and increase work ability among women with neck pain (Paper II); to examine the associations between workplace rehabilitation and the combination of supportive conditions at work with work ability and RTW over time (Paper III); and to explore experiences, views, and strategies in the rehabilitation process for RTW (Paper IV). This thesis is based on a prospective cohort study (n=324) and a randomized controlled study (RCT) (n=60, participants with neck pain). Both quantitative and qualitative methods were used. The data collection consisted of questionnaires, laboratory-observed data, register-based data, and interviews. The results showed a very strong association between WAI and WAS, and results predicted future sick leave degree, health-related quality of life, vitality, neck pain, self-rated general health, self-rated mental health, behavioral stress, and current stress (Paper I). In the RCT (Paper II), individuals in the myofeedback intervention group increased their vitality and work ability over time and individuals in the intensive musculoskeletal strength training group increased their WAI, WAS, and mental health over time. WAI, WAS, and RTW increased over time among individuals provided with workplace rehabilitation and supportive conditions at work (Paper III) such as a sense of feeling welcome back at work, influence at work, possibilities for development, degree of freedom at work, meaning of work, quality of leadership, social support, sense of community, and work satisfaction. Women described (Paper IV) how they were striving to work and how they had different views, strategies, and approaches in the rehabilitation process for RTW. They expressed a desire to work, their goals for work, and their wishes for work. In the rehabilitation process for RTW they described their interaction with stakeholders as either controlling the interaction or struggling in the interaction. They described strategies to cope with RTW in terms of yo-yo (fluctuating) working: yo-yo working as a strategy or yo-yo working as a consequence. This thesis identifies factors of importance in improving work ability and RTW among women on long-term sick leave from HSOs. For women with neck pain, the intervention study showed feasibility of the intervention and demonstrated improved work ability and decreased pain (Paper II). The intensive muscular strength training program, which is easy for the individual to learn and perform at home, was associated with increased work ability. The results regarding rehabilitation highlight the importance of integrating workplace rehabilitation with supportive conditions at work to increase work ability and improve RTW (Paper III). Women expressed that they were striving to work and that they wanted to work (Paper IV). These women were “going in and out” of work participation (yo-yo working) as a way to handle the rehabilitation process. For assessing the status and progress of work ability among women on long-term sick leave, the single-question WAS may be used as a compliment to the full WAI as a simple indicator (Paper I)