Minimal breast milk transfer of rituximab, a monoclonal antibody used in neurological conditions.

ObjectiveTo determine the transfer of rituximab, an anti-CD20 monoclonal antibody widely used for neurologic conditions, into mature breast milk.MethodsBreast milk samples were collected from 9 women with MS who received rituximab 500 or 1,000 mg intravenous once or twice while breastfeeding from November 2017 to April 2019. Serial breast milk samples were collected before infusion and at 8 hours, 24 hours, 7 days, and 18-21 days after rituximab infusion in 4 patients. Five additional patients provided 1-2 samples at various times after rituximab infusion.ResultsThe median average rituximab concentration in mature breast milk was low at 0.063 μg/mL (range 0.046-0.097) in the 4 patients with serial breast milk collection, with an estimated median absolute infant dose of 0.0094 mg/kg/d and a relative infant dose (RID) of 0.08% (range 0.06%-0.10%). Most patients had a maximum concentration at 1-7 days after infusion. The maximum concentration occurred in a woman with a single breast milk sample and was 0.29 μg/mL at 11 days postinfusion, which corresponds with an estimated RID of 0.33%. Rituximab concentration in milk was virtually undetectable by 90 days postinfusion.ConclusionsWe determined minimal transfer of rituximab into mature breast milk. The RID for rituximab was less than 0.4% and well below theoretically acceptable levels of less than 10%. Low oral bioavailability would probably also limit the absorption of rituximab by the newborn. In women with serious autoimmune neurologic conditions, monoclonal antibody therapy may afford an acceptable benefit to risk ratio, supporting both maternal treatment and breastfeeding

How can we improve stroke thrombolysis rates? : a review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care

Background: Thrombolysis using intravenous (IV) tissue plasminogen activator (tPA) is one of few evidence-based acute stroke treatments, yet achieving high rates of IV tPA delivery has been problematic. The 4.5-h treatment window, the complexity of determining eligibility criteria and the availability of expertise and required resources may impact on treatment rates, with barriers encountered at the levels of the individual clinician, the social context and the health system itself. The review aimed to describe health system factors associated with higher rates of IV tPA administration for ischemic stroke and to identify whether system-focussed interventions increased tPA rates for ischemic stroke. Methods: Published original English-language research from four electronic databases spanning 1997-2014 was examined. Observational studies of the association between health system factors and tPA rates were described separately from studies of system-focussed intervention strategies aiming to increase tPA rates. Where study outcomes were sufficiently similar, a pooled meta-analysis of outcomes was conducted. Results: Forty-one articles met the inclusion criteria: 7 were methodologically rigorous interventions that met the Cochrane Collaboration Evidence for Practice and Organization of Care (EPOC) study design guidelines and 34 described observed associations between health system factors and rates of IV tPA. System-related factors generally associated with higher IV tPA rates were as follows: urban location, centralised or hub and spoke models, treatment by a neurologist/stroke nurse, in a neurology department/stroke unit or teaching hospital, being admitted by ambulance or mobile team and stroke-specific protocols. Results of the intervention studies suggest that telemedicine approaches did not consistently increase IV tPA rates. Quality improvement strategies appear able to provide modest increases in stroke thrombolysis (pooled odds ratio=2.1, p=0.05). Conclusions: In order to improve IV tPA rates in acute stroke care, specific health system factors need to be targeted. Multi-component quality improvement approaches can improve IV tPA rates for stroke, although more thoughtfully designed and well-reported trials are required to safely increase rates of IV tPA to eligible stroke patients

Psychometric properties of leadership scales for health professionals : a systematic review

Background: The important role of leaders in the translation of health research is acknowledged in the implementation science literature. However, the accurate measurement of leadership traits and behaviours in health professionals has not been directly addressed. This review aimed to identify whether scales which measure leadership traits and behaviours have been found to be reliable and valid for use with health professionals. Methods: A systematic review was conducted. MEDLINE, EMBASE, PsycINFO, Cochrane, CINAHL, Scopus, ABI/ INFORMIT and Business Source Ultimate were searched to identify publications which reported original research testing the reliability, validity or acceptability of a leadership-related scale with health professionals. Results: Of 2814 records, a total of 39 studies met the inclusion criteria, from which 33 scales were identified as having undergone some form of psychometric testing with health professionals. The most commonly used was the Implementation Leadership Scale (n = 5) and the Multifactor Leadership Questionnaire (n = 3). Of the 33 scales, the majority of scales were validated in English speaking countries including the USA (n = 15) and Canada (n = 4), but also with some translations and use in Europe and Asia, predominantly with samples of nurses (n = 27) or allied health professionals (n = 10). Only two validation studies included physicians. Content validity and internal consistency were evident for most scales (n = 30 and 29, respectively). Only 20 of the 33 scales were found to satisfy the acceptable thresholds for good construct validity. Very limited testing occurred in relation to test-re-test reliability, responsiveness, acceptability, cross-cultural revalidation, convergent validity, discriminant validity and criterion validity. Conclusions: Seven scales may be sufficiently sound to be used with professionals, primarily with nurses. There is an absence of validation of leadership scales with regard to physicians. Given that physicians, along with nurses and allied health professionals have a leadership role in driving the implementation of evidence-based healthcare, this constitutes a clear gap in the psychometric testing of leadership scales for use in healthcare implementation research and practice

Staff perspectives from Australian hospitals seeking to improve implementation of thrombolysis care for acute stroke

Background: Intravenous thrombolysis is one of few evidence-based treatments for acute stroke. Treatment uptake is low outside major stroke care centres. There is a need for greater understanding of barriers encountered by clinicians when seeking to increase thrombolysis rates.This work is related to a National Health and Medical Research Council (NHMRC) partnership grant (ID569328) and is part-funded by a Translating Research Into Practice fellowship, with collaborative funding from Boehringer Ingelheim and in-kind support from the Agency for Clinical Innovation Stroke Care Network/Stroke Services NSW, Victorian Stroke Clinical Network, National Stroke Foundation and NSW Cardiovascular Research Network–National Heart Foundation, Hunter Medical Research Institute and the University of Newcastle. Christine Paul is supported by an NHMRC Career Development Fellowship (APP1061335)

Phospho‐RNA‐seq: a modified small RNA‐seq method that reveals circulating mRNA and lncRNA fragments as potential biomarkers in human plasma

Extracellular RNAs (exRNAs) in biofluids have attracted great interest as potential biomarkers. Although extracellular microRNAs in blood plasma are extensively characterized, extracellular messenger RNA (mRNA) and long non‐coding RNA (lncRNA) studies are limited. We report that plasma contains fragmented mRNAs and lncRNAs that are missed by standard small RNA‐seq protocols due to lack of 5′ phosphate or presence of 3′ phosphate. These fragments were revealed using a modified protocol (“phospho‐RNA‐seq”) incorporating RNA treatment with T4‐polynucleotide kinase, which we compared with standard small RNA‐seq for sequencing synthetic RNAs with varied 5′ and 3′ ends, as well as human plasma exRNA. Analyzing phospho‐RNA‐seq data using a custom, high‐stringency bioinformatic pipeline, we identified mRNA/lncRNA transcriptome fingerprints in plasma, including tissue‐specific gene sets. In a longitudinal study of hematopoietic stem cell transplant patients, bone marrow‐ and liver‐enriched exRNA genes were tracked with bone marrow recovery and liver injury, respectively, providing proof‐of‐concept validation as a biomarker approach. By enabling access to an unexplored realm of mRNA and lncRNA fragments, phospho‐RNA‐seq opens up new possibilities for plasma transcriptomic biomarker development.SynopsisA modified RNA‐seq method (Phospho‐RNA‐seq) revealed a new population of mRNA/lncRNA fragments in plasma, including ones that track with disease. This opens up new possibilities for disease detection via RNA profiling of plasma and other biofluids.Phospho‐RNA‐seq reveals a large population of mRNA and long non‐coding RNA fragments in human plasma, which are missed by standard small RNA‐seq protocols that depend on target RNAs having a 5′ P and 3′ OH.Accurate detection of plasma mRNA and lncRNA fragments requires a stringent bioinformatic analysis pipeline to avoid false positive alignments to mRNA and lncRNA genes.Phospho‐RNA‐seq identified ensembles of tissue‐specific transcripts in plasma of hematopoietic stem cell transplant patients, which show co‐expression patterns that vary dynamically and track with pathophysiological processes.By enabling access to an unexplored space of extracellular mRNA and lncRNA fragments, phospho‐RNA‐seq opens up new possibilities for monitoring health and disease via transcriptome fragment profiling of plasma and potentially other biofluids.A modified RNA‐seq method reveals a large population of mRNA/lncRNA fragments in plasma that are missed by standard small RNA‐seq protocols including ones that are associated with disease.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149518/1/embj2019101695_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149518/2/embj2019101695-sup-0002-EVFigs.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149518/3/embj2019101695.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149518/4/embj2019101695-sup-0001-Appendix.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149518/5/embj2019101695.reviewer_comments.pd

Anal Cancer debuting as Cancer of Unknown Primary

Anal cancer usually presents with a visible or palpable tumour. In this case we describe a 54-year old man diagnosed with Cancer of Unknown Primary (CUP) with a single inguinal node as the only finding. Thorough examination failed to identify any primary tumour. The patient was treated with lymph node dissection and not until nearly two years after initial diagnosis, was the primary tumour found, and the patient was diagnosed with anal cancer. The patient was treated with chemoradiotherapy and 45 months after initial diagnosis there is still no sign of relapse. This case illustrates, that anal cancer can metastasise before the primary tumour is detectable. Furthermore, it demonstrates the necessity of thorough clinical follow-up after treatment of CUP since the primary tumour was found later. Finally this is a case of a long-term survivor following treatment for metastatic inguinal lymph nodes from an initially unknown primary cancer

Green Infrastructure and Placemaking Strategies for the Rush Line Bus Rapid Transit Project

Report completed by students enrolled in SUST 4004: Sustainable Community Capstone, taught by Amir Nadav in Spring 2019.This project was completed as part of the 2018-2019 Resilient Communities Project (rcp.umn.edu) partnership with Ramsey County. The Rush Line is a future bus rapid transit line that will provide all-day, high-frequency transit service in Ramsey County between Saint Paul and White Bear Lake by way of Maplewood, Vadnais Heights, Gem Lake, and White Bear Township. The new infrastructure that will be constructed as part of the project will have storm water impacts that will need to be mitigated. Ramsey County project lead Frank Alarcon worked with students in Amir Nadav’s SUST 4004: Sustainable Communities Capstone to explore context-appropriate storm water management techniques that could enhance the aesthetics and recreational value of the areas surrounding the Rush Line’s stations and guideway. The students' final report is available.This project was supported by the Resilient Communities Project (RCP), a program at the University of Minnesota whose mission is to connect communities in Minnesota with U of MN faculty and students to advance community resilience through collaborative, course-based projects. RCP is a program of the Center for Urban and Regional Affairs (CURA). More information at http://www.rcp.umn.edu

Moving towards multi-layered, mixed-species forests in riparian buffers will enhance their long-term function in boreal landscapes

Riparian buffers are the primary tool in forest management for protecting the habitat structure and function of streams. They help protect against biogeochemical perturbation, filter sediments and nutrients, prevent erosion, contribute food to aquatic organisms, regulate light and hence water temperature, contribute deadwood, and preserve biodiversity. However, in production forests of Sweden and Finland, many headwater streams have been straightened, ditched, and/or channelized, resulting in altered hydrology and reduced natural disturbance by floods, which in turn affects important riparian functions. Furthermore, in even-aged management systems as practiced in much of Fennoscandia, understory trees have usually been cleared right up to the stream's edge during thinning operations, especially around small, headwater streams. Fire suppression has further favored succession towards shade tolerant species. In the regions within Fennoscandia that have experienced this combination of intensive management and lack of natural disturbance, riparian zones are now dominated by single-storied, native Norway spruce. When the adjacent forest is cut, thin (5 - 15m) conifer-dominated riparian buffers are typically left. These buffers do not provide the protection and subsidies, in terms of leaf litter quality, needed to maintain water quality or support riparian or aquatic biodiversity. Based on a literature review, we found compelling evidence that the ecological benefits of multi-layered, mixed-species riparian forest with a large component of broadleaved species are higher than what is now commonly found in the managed stands of Fennoscandia. To improve the functionality of riparian zones, and hence the protection of streams in managed forest landscapes, we present some basic principles that could be used to enhance the ecological function of these interfaces. These management actions should be prioritized on streams and streamside stands that have been affected by simplification either through forest management or hydrological modification. Key to these principles is the planning and managing of buffer zones as early as possible in the rotation to ensure improved function throughout the rotation cycle and not only at final felling. This is well in line with EU and national legislation which can be interpreted as requiring landscape planning at all forest ages to meet biodiversity and other environmental goals. However, it is still rare that planning for conservation is done other than at the final felling stage. Implementing this new strategy is likely to have long-term positive effects and improve the protection of surface waters from negative forestry effects and a history of fire suppression. By following these suggested management principles, there will be a longer time period with high function and greater future management flexibility in addition to the benefits provided by leaving riparian buffers at the final felling stage

Can a multicomponent multidisciplinary implementation package change physicians' and nurses' perceptions and practices regarding thrombolysis for acute ischemic stroke? : an exploratory analysis of a cluster-randomized trial

Background: The Thrombolysis ImPlementation in Stroke (TIPS) trial tested the effect of a multicomponent, multidisciplinary, collaborative intervention designed to increase the rates of intravenous thrombolysis via a cluster randomized controlled trial at 20 Australian hospitals (ten intervention, ten control). This sub-study investigated changes in self-reported perceptions and practices of physicians and nurses working in acute stroke care at the participating hospitals. Methods: A survey with 74 statements was administered during the pre-and post-intervention periods to staff at 19 of the 20 hospitals. An exploratory factor analysis identified the structure of the survey items and linear mixed modeling was applied to the final survey domain scores to explore the differences between groups over time. Result: The response rate was 45% for both the pre-(503 out of 1127 eligible staff from 19 hospitals) and post-intervention (414 out of 919 eligible staff from 18 hospitals) period. Four survey domains were identified: (1) hospital performance indicators, feedback, and training; (2) personal perceptions about thrombolysis evidence and implementation; (3) personal stroke skills and hospital stroke care policies; and (4) emergency and ambulance procedures. There was a significant pre-to post-intervention mean increase (0.21 95% CI 0.09; 0.34; p < 0.01) in scores relating to hospital performance indicators, feedback, and training; for the intervention hospitals compared to control hospitals. There was a corresponding increase in mean scores regarding perceptions about the thrombolysis evidence and implementation (0.21, 95% CI 0.06; 0.36; p < 0.05). Sub-group analysis indicated that the improvements were restricted to nurses' responses. Conclusion: TIPS resulted in changes in some aspects of nurses' perceptions relating to the evidence for intravenous thrombolysis and its implementation and hospital performance indicators, feedback, and training. However, there is a need to explore further strategies for influencing the views of physicians given limited statistical power in the physician sample

Thrombolysis implementation intervention and clinical outcome : a secondary analysis of a cluster randomized trial

Background: Multiple studies have attempted to increase the rate of intravenous thrombolysis for ischemic stroke using interventions to promote adherence to guidelines. Still, many of them did not measure individual-level impact. This study aimed to make a posthoc comparison of the clinical outcomes of patients in the "Thrombolysis ImPlementation in Stroke (TIPS)"study, which aimed to improve rates of intravenous thrombolysis in Australia. Methods: A posthoc analysis was conducted using individual-level patient data. Excellent (Three-month post treatment modified Rankin Score 0-2) and poor clinical outcome (Three-month post treatment modified Rankin Score 5-6) and post treatment parenchymal haematoma were the three main outcomes, and a mixed logistic regression model was used to assess the difference between the intervention and control groups. Results: There was a non-significant higher odds of having an excellent clinical outcome of 57% (odds ratio: 1.57; 95% CI: 0.73-3.39) and 33% (odds ratio: 1.33; 95% CI: 0.73-2.44) during the active-And post-intervention period respectively, for the intervention compared to the control group. A non-significant lower odds of having a poor clinical outcome was also found in the intervention, relative to control group of 4% (odds ratio: 0.96; 95% CI: 0.56-2.07) and higher odds of having poor outcome of 44% (odds ratio: 1.44 95% CI: 0.61-3.41) during both active and post-intervention period respectively. Similarly, a non-significant lower odds of parenchymal haematoma was also found for the intervention group during the both active-(odds ratio: 0.53; 95% CI: 0.21-1.32) and post-intervention period (odds ratio: 0.96; 95% CI: 0.36-2.52). Conclusion: The TIPS multi-component implementation approach was not effective in reducing the odds of post-Treatment severe disability at 90 days, or post-thrombolysis hemorrhage