A description of a knowledge broker role implemented as part of a randomized controlled trial evaluating three knowledge translation strategies

<p>Abstract</p> <p>Background</p> <p>A knowledge broker (KB) is a popular knowledge translation and exchange (KTE) strategy emerging in Canada to promote interaction between researchers and end users, as well as to develop capacity for evidence-informed decision making. A KB provides a link between research producers and end users by developing a mutual understanding of goals and cultures, collaborates with end users to identify issues and problems for which solutions are required, and facilitates the identification, access, assessment, interpretation, and translation of research evidence into local policy and practice. Knowledge-brokering can be carried out by individuals, groups and/or organizations, as well as entire countries. In each case, the KB is linked with a group of end users and focuses on promoting the integration of the best available evidence into policy and practice-related decisions.</p> <p>Methods</p> <p>A KB intervention comprised one of three KTE interventions evaluated in a randomized controlled trial.</p> <p>Results</p> <p>KB activities were classified into the following categories: initial and ongoing needs assessments; scanning the horizon; knowledge management; KTE; network development, maintenance, and facilitation; facilitation of individual capacity development in evidence informed decision making; and g) facilitation of and support for organizational change.</p> <p>Conclusion</p> <p>As the KB role developed during this study, central themes that emerged as particularly important included relationship development, ongoing support, customized approaches, and opportunities for individual and organizational capacity development. The novelty of the KB role in public health provides a unique opportunity to assess the need for and reaction to the role and its associated activities. Future research should include studies to evaluate the effectiveness of KBs in different settings and among different health care professionals, and to explore the optimal preparation and training of KBs, as well as the identification of the personality characteristics most closely associated with KB effectiveness. Studies should also seek to better understand which combination of KB activities are associated with optimal evidence-informed decision making outcomes, and whether the combination changes in different settings and among different health care decision makers.</p

Post-intervention Status in Patients With Refractory Myasthenia Gravis Treated With Eculizumab During REGAIN and Its Open-Label Extension

OBJECTIVE: To evaluate whether eculizumab helps patients with anti-acetylcholine receptor-positive (AChR+) refractory generalized myasthenia gravis (gMG) achieve the Myasthenia Gravis Foundation of America (MGFA) post-intervention status of minimal manifestations (MM), we assessed patients' status throughout REGAIN (Safety and Efficacy of Eculizumab in AChR+ Refractory Generalized Myasthenia Gravis) and its open-label extension. METHODS: Patients who completed the REGAIN randomized controlled trial and continued into the open-label extension were included in this tertiary endpoint analysis. Patients were assessed for the MGFA post-intervention status of improved, unchanged, worse, MM, and pharmacologic remission at defined time points during REGAIN and through week 130 of the open-label study. RESULTS: A total of 117 patients completed REGAIN and continued into the open-label study (eculizumab/eculizumab: 56; placebo/eculizumab: 61). At week 26 of REGAIN, more eculizumab-treated patients than placebo-treated patients achieved a status of improved (60.7% vs 41.7%) or MM (25.0% vs 13.3%; common OR: 2.3; 95% CI: 1.1-4.5). After 130 weeks of eculizumab treatment, 88.0% of patients achieved improved status and 57.3% of patients achieved MM status. The safety profile of eculizumab was consistent with its known profile and no new safety signals were detected. CONCLUSION: Eculizumab led to rapid and sustained achievement of MM in patients with AChR+ refractory gMG. These findings support the use of eculizumab in this previously difficult-to-treat patient population. CLINICALTRIALSGOV IDENTIFIER: REGAIN, NCT01997229; REGAIN open-label extension, NCT02301624. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that, after 26 weeks of eculizumab treatment, 25.0% of adults with AChR+ refractory gMG achieved MM, compared with 13.3% who received placebo

Minimal Symptom Expression' in Patients With Acetylcholine Receptor Antibody-Positive Refractory Generalized Myasthenia Gravis Treated With Eculizumab

The efficacy and tolerability of eculizumab were assessed in REGAIN, a 26-week, phase 3, randomized, double-blind, placebo-controlled study in anti-acetylcholine receptor antibody-positive (AChR+) refractory generalized myasthenia gravis (gMG), and its open-label extension

Demographic shifts in eastern US forests increase the impact of late‐season drought on forest growth

While forest communities are changing as a result of global environmental change, the impacts of tree species shifts on ecosystem services such as carbon storage are poorly quantified. In many parts of the eastern United States (US), more xeric‐adapted oak‐hickory dominated stands are being replaced with mesic beech‐maple assemblages. To examine the possible impacts of this ongoing change in forest composition, we investigated how two wide‐ranging and co‐occurring eastern US species – Acer saccharum (sugar maple) and Quercus alba (white oak) – respond to interannual climate variability. Using 781 tree cores from 418 individual trees at 18 locations, we found late‐growing season drought reduced A. saccharum growth more than that of Q. alba. A gradient in the growth reduction across latitude was also found in A. saccharum, where southern populations of A. saccharum experienced greater reductions in growth during drought. Drought had a legacy effect on growth for both species, with drought occurring later in the growing season having a larger legacy effect. Consequently, as forests shift from oak to maple dominance, drought in the later part of the growing season is likely to become an increasingly important control on forest productivity. Thus, our findings suggest that co‐occurring species are responding to environmental conditions during different times in the growing season and, therefore, the timing of drought conditions will play an important role in forest productivity and carbon sequestration as forest species composition changes. These findings are particularly important because the projected increases in potential evapotranspiration, combined with possible changes in the seasonality of precipitation could have a substantial impact on how tree growth responds to future climatic change

A Century of Reforestation Reduced Anthropogenic Warming in the Eastern United States

Abstract Restoring and preserving the world's forests are promising natural pathways to mitigate some aspects of climate change. In addition to regulating atmospheric carbon dioxide concentrations, forests modify surface and near‐surface air temperatures through biophysical processes. In the eastern United States (EUS), widespread reforestation during the 20th century coincided with an anomalous lack of warming, raising questions about reforestation's contribution to local cooling and climate mitigation. Using new cross‐scale approaches and multiple independent sources of data, we uncovered links between reforestation and the response of both surface and air temperature in the EUS. Ground‐ and satellite‐based observations showed that EUS forests cool the land surface by 1–2°C annually compared to nearby grasslands and croplands, with the strongest cooling effect during midday in the growing season, when cooling is 2–5°C. Young forests (20–40 years) have the strongest cooling effect on surface temperature. Surface cooling extends to the near‐surface air, with forests reducing midday air temperature by up to 1°C compared to nearby non‐forests. Analyses of historical land cover and air temperature trends showed that the cooling benefits of reforestation extend across the landscape. Locations surrounded by reforestation were up to 1°C cooler than neighboring locations that did not undergo land cover change, and areas dominated by regrowing forests were associated with cooling temperature trends in much of the EUS. Our work indicates reforestation contributed to the historically slow pace of warming in the EUS, underscoring reforestation's potential as a local climate adaptation strategy in temperate regions

Higher CO 2 Concentrations and Lower Acidic Deposition Have Not Changed Drought Response in Tree Growth But Do Influence iWUE in Hardwood Trees in the Midwestern United States

Several important environmental influences of tree growth and carbon sequestration have changed over the past several decades in eastern North America, specifically, more frequent pluvial conditions, increased carbon dioxide (CO2) concentrations, and decreased acidic deposition. These factors could lead to changes in the relationship between tree growth and water availability, and perhaps even decouple the two, having large implications on how future climate change will impact forest productivity and carbon sequestration. Here, we examine the concurrent influence of the climatic water balance (precipitation minus potential evapotranspiration), CO2 concentrations, and sulfate and nitrogen deposition on radial tree growth, carbon isotopes, and intrinsic water‐use efficiency (iWUE) for several hardwood tree species in the Midwestern United States. We found that when considering the simultaneous influence of these factors, the climatic water balance is the dominant influence on annual growth. Therefore, the recent pluvial period is the primary cause of the weakening relationship between radial growth and water availability. Even during pluvial periods, water availability is the primary control on growth, with increasing CO2 concentrations and decreased SO4 deposition being secondary factors. Importantly, the weakening in the climate‐growth relationship is species specific, with Acer species having stable relationships with the climatic water balance, Liriodendron tulipifera showing a strengthening relationship, and Quercus species and Populus grandidentata exhibiting weakening. Thus, interannual variations in soil moisture unevenly impact tree growth and carbon sequestration. Our findings suggest that, despite recent pluvial conditions, increasing CO2 concentrations and decreasing acidic deposition have not buffered the impact of water availability on tree growth and carbon sequestration

Durability of the Rituximab Response in Acetylcholine Receptor Autoantibody-Positive Myasthenia Gravis

IMPORTANCE: Myasthenia gravis (MG), an autoimmune disorder of neuromuscular transmission, is treated by an array of immunotherapeutics, many of which are nonspecific. Even with current therapies, a subset of patients has medically refractory MG. The benefits of B-cell-targeted therapy with rituximab have been observed in MG; however, the duration of these benefits after treatment is unclear. OBJECTIVE: To evaluate the durability of response to rituximab in the treatment of acetylcholine receptor autoantibody-positive (AChR+) generalized MG. DESIGN, SETTING AND PARTICIPANTS: This retrospective case series study included 16 patients with AChR+ MG referred to an MG clinic from January 1, 2007, to December 31, 2015. The patients were treated with rituximab and followed up for 18 to 84 months after treatment. MAIN OUTCOMES AND MEASURES: Assessment of long-term clinical response, durability of response and/or relapse rate, AChR autoantibody levels, adverse effects, and inflammatory markers. RESULTS: In the 16 patients (6 men and 10 women; median age, 42 [range, 18-69] years), clinical improvement was observed in parallel with complete withdrawal or reduction of other immunotherapies, with all patients achieving complete stable remission, pharmacologic remission, or minimal manifestations based on the Myasthenia Gravis Foundation of America postintervention status criteria. Nine patients (56%) had a relapse during a mean follow-up of 36 (range, 24-47) months. Seven patients (44%) remained relapse free with a mean follow-up of 47 (range, 18-81) months since the last rituximab treatment. All values were normalized to a pretreatment anti-AChR antibody level of 100% and the mean levels after each rituximab cycle were calculated. A 33% decrease was seen after cycle 1 of rituximab treatment (100% vs 67%; P = .004); 20% after cycle 2 (compared with cycle 1) (67% vs 47%; P = .008); and 17% after cycle 3 (compared with cycle 2) (47% vs 30%; P = .02). However, the serum cytokine levels measured were found to be unchanged. CONCLUSIONS AND RELEVANCE: Rituximab therapy appears to be an effective option in patients with refractory AChR+ MG, who were observed to have a durable response after treatment. Identification of markers of disease relapse and sustained remission are critical next steps in the development of pathophysiology-relevant, evidence-based practice parameters for rituximab in the treatment of MG

Training Intervention and Program of Support for Fostering the Adoption of Family-Centered Telehealth in Pediatric Rehabilitation: Protocol for a Multimethod, Prospective, Hybrid Type 3 Implementation-Effectiveness Study

BackgroundChildren with disability face long wait times for rehabilitation services. Before the COVID-19 pandemic, telehealth adoption was low across pediatric rehabilitation. Owing to the COVID-19 pandemic restrictions, pediatric therapists were asked to rapidly shift to telehealth, often with minimal training. To facilitate the behavior changes necessary for telehealth adoption, provision of appropriate evidence-based training and support is required. However, evidence to support the effective implementation of such training is lacking. The successful real-world implementation of a training intervention and program of support (TIPS) targeting pediatric therapists to enhance the adoption of family-centered telerehabilitation (FCT) requires the evaluation of both implementation and effectiveness. ObjectiveThis study aimed to evaluate TIPS implementation in different pediatric rehabilitation settings and assess TIPS effectiveness, as it relates to therapists’ adoption, service wait times, families’ perception of service quality, and costs. MethodsThis 4-year, pan-Canadian study involves managers, pediatric occupational therapists, physiotherapists, speech-language pathologists, and families from 20 sites in 8 provincial jurisdictions. It will use a multimethod, prospective, hybrid type 3 implementation-effectiveness design. An interrupted time series will assess TIPS implementation. TIPS will comprise a 1-month training intervention with self-paced learning modules and a webinar, followed by an 11-month support program, including monthly site meetings and access to a virtual community of practice. Longitudinal mixed modeling will be used to analyze indicators of therapists’ adoption of and fidelity to FCT collected at 10 time points. To identify barriers and facilitators to adoption and fidelity, qualitative data will be collected during implementation and analyzed using a deductive-inductive thematic approach. To evaluate effectiveness, a quasi-experimental pretest-posttest design will use questionnaires to evaluate TIPS effectiveness at service, therapist, and family levels. Generalized linear mixed effects models will be used in data analysis. Manager, therapist, and family interviews will be conducted after implementation and analyzed using reflective thematic analysis. Finally, cost data will be gathered to calculate public system and societal costs. ResultsEthics approval has been obtained from 2 jurisdictions (February 2022 and July 2022); approval is pending in the others. In total, 20 sites have been recruited, and data collection is anticipated to start in September 2022 and is projected to be completed by September 2024. Data analysis will occur concurrently with data collection, with results disseminated throughout the study period. ConclusionsThis study will generate knowledge about the effectiveness of TIPS targeting pediatric therapists to enhance FCT adoption in pediatric rehabilitation settings, identify facilitators for and barriers to adoption, and document the impact of telehealth adoption on therapists, services, and families. The study knowledge gained will refine the training intervention, enhance intervention uptake, and support the integration of telehealth as a consistent pediatric rehabilitation service option for families of children with disabilities. Trial RegistrationClinicalTrials.gov NCT05312827; https://clinicaltrials.gov/ct2/show/NCT05312827 International Registered Report Identifier (IRRID)PRR1-10.2196/4021

Long-term efficacy and safety of eculizumab in Japanese patients with generalized myasthenia gravis: A subgroup analysis of the REGAIN open-label extension study

The terminal complement inhibitor eculizumab was shown to improve myasthenia gravis-related symptoms in the 26-week, phase 3, randomized, double-blind, placebo-controlled REGAIN study (NCT01997229). In this 52-week sub-analysis of the open-label extension of REGAIN (NCT02301624), eculizumab's efficacy and safety were assessed in 11 Japanese and 88 Caucasian patients with anti-acetylcholine receptor antibody-positive refractory generalized myasthenia gravis. For patients who had received placebo during REGAIN, treatment with open-label eculizumab resulted in generally similar outcomes in the Japanese and Caucasian populations. Rapid improvements were maintained for 52 weeks, assessed by change in score from open-label extension baseline to week 52 (mean [standard error]) using the following scales (in Japanese and Caucasian patients, respectively): Myasthenia Gravis Activities of Daily Living (−2.4 [1.34] and − 3.3 [0.65]); Quantitative Myasthenia Gravis (−2.9 [1.98] and − 4.3 [0.79]); Myasthenia Gravis Composite (−4.5 [2.63] and − 4.9 [1.19]); and Myasthenia Gravis Quality of Life 15-item questionnaire (−8.6 [5.68] and − 6.5 [1.93]). Overall, the safety of eculizumab was consistent with its known safety profile. In this interim sub-analysis, the efficacy and safety of eculizumab in Japanese and Caucasian patients were generally similar, and consistent with the overall REGAIN population