What are the differences among occupational groups related to their palliative care-specific educational needs and intensity of interprofessional collaboration in long-term care homes?

Background

The purpose of this study was to compare the differences across occupational groups related to their end-of-life care-specific educational needs and reported intensity of interprofessional collaboration in long-term care (LTC) homes.

Methods

A cross-sectional survey, based on two questionnaires, was administered at four LTC homes in Ontario, Canada using a modified Dilman’s approach. The first questionnaire, End of Life Professional Caregiver Survey, included three domains: patients and family-centered communication, cultural and ethical values, effective care delivery. The Intensity of Interprofessional Collaboration Scale included two subscales: care sharing activities, and interprofessional coordination. In total, 697 LTC staff were given surveys, including personal support workers, support staff (housekeeping, kitchen, recreation, laundry, dietician aids, office staff), and registered staff (licensed nurses, physiotherapists, social workers, pharmacists, physicians).

Results

A total of 317 participants completed the survey (126 personal support workers, 109 support staff, 82 registered staff) for a response rate of 45%. Significant differences emerged among occupational groups across all scales and subscales. Specifically, support staff rated their comfort of working with dying patients significantly lower than both nurses and PSWs. Support staff also reported significantly lower ratings of care sharing activities and interprofessional coordination compared to both registered staff and personal support workers.

Conclusions

These study findings suggest there are differing educational needs and sense of interprofessional collaboration among LTC staff, specific to discipline group. Both the personal support workers and support staff groups appeared to have higher needs for education; support staff also reported higher needs related to integration on the interdisciplinary team. Efforts to build capacity within support staff related to working with dying residents and their families are needed. Optimal palliative care may require resources to increase the availability of support for all staff involved in the care of patients.

Assessing connectivity related injury burden in diffuse traumatic brain injury

Many of the clinical and behavioral manifestations of traumatic brain injury (TBI) are thought to arise from disruption to the structural network of the brain due to diffuse axonal injury (DAI). However, a principled way of summarizing diffuse connectivity alterations to quantify injury burden is lacking. In this study, we developed a connectome injury score, Disruption Index of the Structural Connectome (DISC), which summarizes the cumulative effects of TBI-induced connectivity abnormalities across the entire brain. Forty patients with moderate-to-severe TBI examined at 3 months postinjury and 35 uninjured healthy controls underwent magnetic resonance imaging with diffusion tensor imaging, and completed behavioral assessment including global clinical outcome measures and neuropsychological tests. TBI patients were selected to maximize the likelihood of DAI in the absence of large focal brain lesions. We found that hub-like regions, with high betweenness centrality, were most likely to be impaired as a result of diffuse TBI. Clustering of participants revealed a subgroup of TBI patients with similar connectivity abnormality profiles who exhibited relatively poor cognitive performance. Among TBI patients, DISC was significantly correlated with post-traumatic amnesia, verbal learning, executive function, and processing speed. Our experiments jointly demonstrated that assessing structural connectivity alterations may be useful in development of patient-oriented diagnostic and prognostic tools. Hum Brain Mapp 38:2913-2922, 2017. © 2017 Wiley Periodicals, Inc.

Altered brain network integrity after childhood maltreatment: A structural connectomic DTI-study

Childhood maltreatment is associated with alterations in neural architecture that potentially put these children at increased risk for psychopathology. Alterations in white matter (WM) tracts have been reported, however no study to date has investigated WM connectivity in brain networks in maltreated children to quantify global and local abnormalities through graph theoretical analyses of DTI data. We aimed for a multilevel investigation examining the DTI-based structural connectome and its associations with basal cortisol levels of 25 children with documented maltreatment experiences before age 3, and 24 matched controls (age: 10.6 ± 1.75 years). On the global and lobar level, maltreated children showed significant reductions in global connectivity strength, local connectivity and increased path length, suggesting deviations from the small-world network architecture previously associated with psychopathology. Reductions in global connectivity were associated with placement instability, attenuated cortisol secretion and higher levels of internalizing and externalizing behaviours. Regional measures revealed lower connectivity strength especially in regions within the ventromedial prefrontal cortex (vMPFC) in maltreated children. These findings show that childhood maltreatment is associated with systemic global neurodevelopmental alterations in WM networks next to regional alterations in areas involved in the regulation of affect. These alterations in WM organization could underlie global functional deficits and multi-symptom patterns frequently observed in children with maltreatment experiences. Hum Brain Mapp 38:855-868, 2017. © 2016 Wiley Periodicals, Inc.

Individualized Map of White Matter Pathways: Connectivity-Based Paradigm for Neurosurgical Planning

BACKGROUND

Advances in white matter tractography enhance neurosurgical planning and glioma resection, but white matter tractography is limited by biological variables such as edema, mass effect, and tract infiltration or selection biases related to regions of interest or fractional anisotropy values.

OBJECTIVE

To provide an automated tract identification paradigm that corrects for artifacts created by tumor edema and infiltration and provides a consistent, accurate method of fiber bundle identification.

METHODS

An automated tract identification paradigm was developed and evaluated for glioma surgery. A fiber bundle atlas was generated from 6 healthy participants. Fibers of a test set (including 3 healthy participants and 10 patients with brain tumors) were clustered adaptively with this atlas. Reliability of the identified tracts in both groups was assessed by comparison with 2 experts with the Cohen κ used to quantify concurrence. We evaluated 6 major fiber bundles: cingulum bundle, fornix, uncinate fasciculus, arcuate fasciculus, inferior fronto-occipital fasciculus, and inferior longitudinal fasciculus, the last 3 tracts mediating language function.

RESULTS

The automated paradigm demonstrated a reliable and practical method to identify white mater tracts, despite mass effect, edema, and tract infiltration. When the tumor demonstrated significant mass effect or shift, the automated approach was useful for providing an initialization to guide the expert with identification of the specific tract of interest.

CONCLUSION

We report a reliable paradigm for the automated identification of white matter pathways in patients with gliomas. This approach should enhance the neurosurgical objective of maximal safe resections.

ABBREVIATIONS

AF, arcuate fasciculusDTI, diffusion tensor imagingIFOF, inferior fronto-occipital fasciculusILF, inferior longitudinal fasciculusROI, region of interestWM, white matter.

Label-Informed Non-negative Matrix Factorization with Manifold Regularization for Discriminative Subnetwork Detection

In this paper, we present a novel method for obtaining a low dimensional representation of a complex brain network that: (1) can be interpreted in a neurobiologically meaningful way, (2) emphasizes group differences by accounting for label information, and (3) captures the variation in disease subtypes/severity by respecting the intrinsic manifold structure underlying the data. Our method is a supervised variant of non-negative matrix factorization (NMF), and achieves dimensionality reduction by extracting an orthogonal set of subnetworks that are interpretable, reconstructive of the original data, and also discriminative at the group level. In addition, the method includes a manifold regularizer that encourages the low dimensional representations to be smooth with respect to the intrinsic geometry of the data, allowing subjects with similar disease-severity to share similar network representations. While the method is generalizable to other types of non-negative network data, in this work we have used structural connectomes (SCs) derived from diffusion data to identify the cortical/subcortical connections that have been disrupted in abnormal neurological state. Experiments on a traumatic brain injury (TBI) dataset demonstrate that our method can identify subnetworks that can reliably classify TBI from controls and also reveal insightful connectivity patterns that may be indicative of a biomarker.

Pharmacogenetics of antiepileptic drugs: A brief review

The goal of pharmacogenetic research is to assist clinicians in predicting patient response to medications when genetic variations are identified. The pharmacogenetic variation of antiepileptic drug response and side effects has yielded findings that have been included in drug labeling and guidelines. The goal of this review is to provide a brief overview of the pharmacogenetic research on antiepileptic drugs. It will focus on findings that have been included in drug labeling, guidelines, and candidate pharmacogenetic variation. Overall, several genes have been included in guidelines by national and international organizations; however, much work is needed to implement and evaluate their use in clinical settings.

Establishing a link between sex-related differences in the structural connectome and behaviour

Recent years have witnessed an increased attention to studies of sex differences, partly because such differences offer important considerations for personalized medicine. While the presence of sex differences in human behaviour is well documented, our knowledge of their anatomical foundations in the brain is still relatively limited. As a natural gateway to fathom the human mind and behaviour, studies concentrating on the human brain network constitute an important segment of the research effort to investigate sex differences. Using a large sample of healthy young individuals, each assessed with diffusion MRI and a computerized neurocognitive battery, we conducted a comprehensive set of experiments examining sex-related differences in the meso-scale structures of the human connectome and elucidated how these differences may relate to sex differences at the level of behaviour. Our results suggest that behavioural sex differences, which indicate complementarity of males and females, are accompanied by related differences in brain structure across development. When using subnetworks that are defined over functional and behavioural domains, we observed increased structural connectivity related to the motor, sensory and executive function subnetworks in males. In females, subnetworks associated with social motivation, attention and memory tasks had higher connectivity. Males showed higher modularity compared to females, with females having higher inter-modular connectivity. Applying multivariate analysis, we showed an increasing separation between males and females in the course of development, not only in behavioural patterns but also in brain structure. We also showed that these behavioural and structural patterns correlate with each other, establishing a reliable link between brain and behaviour.

A device for characterising the mechanical properties of the plantar soft tissue of the foot

The plantar soft tissue is a highly functional viscoelastic structure involved in transferring load to the human body during walking. A Soft Tissue Response Imaging Device was developed to apply a vertical compression to the plantar soft tissue whilst measuring the mechanical response via a combined load cell and ultrasound imaging arrangement. Accuracy of motion compared to input profiles; validation of the response measured for standard materials in compression; variability of force and displacement measures for consecutive compressive cycles; and implementation in vivo with five healthy participants. Static displacement displayed average error of 0.04 mm (range of 15 mm), and static load displayed average error of 0.15 N (range of 250 N). Validation tests showed acceptable agreement compared to a Houndsfield tensometer for both displacement (CMC > 0.99 RMSE > 0.18 mm) and load (CMC > 0.95 RMSE < 4.86 N). Device motion was highly repeatable for bench-top tests (ICC = 0.99) and participant trials (CMC = 1.00). Soft tissue response was found repeatable for intra (CMC > 0.98) and inter trials (CMC > 0.70). The device has been shown to be capable of implementing complex loading patterns similar to gait, and of capturing the compressive response of the plantar soft tissue for a range of loading conditions in vivo.

Connectome and Maturation Profiles of the Developing Mouse Brain Using Diffusion Tensor Imaging

This paper presents a comprehensive effort to establish a structural mouse connectome using diffusion tensor magnetic resonance imaging coupled with connectivity analysis tools. This work lays the foundation for imaging-based structural connectomics of the mouse brain, potentially facilitating a whole-brain network analysis to quantify brain changes in connectivity during development, as well as deviations from it related to genetic effects. A connectomic trajectory of maturation during postnatal ages 2-80 days is presented in the C57BL/6J mouse strain, using a whole-brain connectivity analysis, followed by investigations based on local and global network features. The global network measures of density, global efficiency, and modularity demonstrated a nonlinear relationship with age. The regional network metrics, namely degree and local efficiency, displayed a differential change in the major subcortical structures such as the thalamus and hippocampus, and cortical regions such as visual and motor cortex. Finally, the connectomes were used to derive an index of "brain connectivity index," which demonstrated a high correlation (r = 0.95) with the chronological age, indicating that brain connectivity is a good marker of normal age progression, hence valuable in detecting subtle deviations from normality caused by genetic, environmental, or pharmacological manipulations.

Tacrolimus to Belatacept Conversion Following Hand Transplantation: A Case Report

Vascularized composite allotransplantation (VCA) has emerged as a viable limb replacement strategy for selected patients with upper limb amputation. However, allograft rejection has been seen in essentially all reported VCA recipients indicating a requirement for substantial immunosuppressive therapy. Calcineurin inhibitors have served as the centerpiece agent in all reported cases, and CNI-associated complications associated with the broad therapeutic effects and side effects of calcineurin inhibitors have been similarly common. Recently, belatacept has been approved as a calcineurin inhibitor replacement in kidney transplantation, but to date, its use in VCA has not been reported. Herein, we report on the case of a hand transplant recipient who developed recurrent acute rejection with alloantibody formation and concomitant calcineurin inhibitor nephrotoxicity, all of which resolved upon conversion from a maintenance regimen of tacrolimus, mycophenolate mofetil and steroids to belatacept and sirolimus. This case indicates that belatacept may be a reasonable maintenance immunosuppressive alternative for use in VCA, providing sufficient prophylaxis from rejection with a reduced side effect profile, the latter being particularly relevant for nonlife threatening conditions typically treated by VCA.

A case of granulomatous slack skin cutaneous T-cell lymphoma: PET/CT imaging findings

A 24-year-old female presented with granulomatous slack skin (GSS) cutaneous T-cell lymphoma. The patient underwent systemic chemotherapy. Owing to the development of several chemotherapy-related complications, therapy was discontinued. Subsequently, disease progression was noted clinically. Our patient’s disease progression was clearly demonstrated by 18F-fludeoxyglucose positron emission tomography (PET)/CT findings. PET/CT imaging findings of GSS have not yet previously been reported. In this report, we present PET/CT characteristics of a patient with GSS.

An extremely high-altitude plume seen at Mars' morning terminator

The Martian limb (that is, the observed 'edge' of the planet) represents a unique window into the complex atmospheric phenomena occurring there. Clouds of ice crystals (CO2 ice or H2O ice) have been observed numerous times by spacecraft and ground-based telescopes, showing that clouds are typically layered and always confined below an altitude of 100 kilometres; suspended dust has also been detected at altitudes up to 60 kilometres during major dust storms. Highly concentrated and localized patches of auroral emission controlled by magnetic field anomalies in the crust have been observed at an altitude of 130 kilometres. Here we report the occurrence in March and April 2012 of two bright, extremely high-altitude plumes at the Martian terminator (the day-night boundary) at 200 to 250 kilometres or more above the surface, and thus well into the ionosphere and the exosphere. They were spotted at a longitude of about 195° west, a latitude of about -45° (at Terra Cimmeria), extended about 500 to 1,000 kilometres in both the north-south and east-west directions, and lasted for about 10 days. The features exhibited day-to-day variability, and were seen at the morning terminator but not at the evening limb, which indicates rapid evolution in less than 10 hours and a cyclic behaviour. We used photometric measurements to explore two possible scenarios and investigate their nature. For particles reflecting solar radiation, clouds of CO2-ice or H2O-ice particles with an effective radius of 0.1 micrometres are favoured over dust. Alternatively, the plume could arise from auroral emission, of a brightness more than 1,000 times that of the Earth's aurora, over a region with a strong magnetic anomaly where aurorae have previously been detected. Importantly, both explanations defy our current understanding of Mars' upper atmosphere.

Towards a Quantified Network Portrait of a Population

Computational network analysis has enabled researchers to investigate patterns of interactions between anatomical regions of the brain. Identification of subnetworks of the human connectome can reveal how the network manages an interplay of the seemingly competing principles of functional segregation and integration. Despite the study of subnetworks of the human structural connectome by various groups, the level of expression of these subnetworks in each subject remains for the most part largely unexplored. Thus, there is a need for methods that can extract common subnetworks that together render a network portrait of a sample and facilitate analysis of the same, such as group comparisons based on the expression of the subnetworks in each subject. In this paper, we propose a framework for quantifying the subject-specific expression of subnetworks. Our framework consists of two parts, namely subnetwork detection and reconstructive projection onto subnetworks. The first part identifies subnetworks of the connectome using multi-view spectral clustering. The second part quantifies subject specific manifestations of these subnetworks by nonnegative matrix decomposition. Positivity constraint is imposed to treat each subnetwork as a structure depicting the connectivity between specific anatomical regions. We have assessed the applicability of the framework by delineating a network portrait of a clinical sample consisting of children affected by autism spectrum disorder (ASD), and a matched group of typically developing controls (TDCs). Subsequent statistical analysis on the intra- and inter-subnetwork connections, revealed decreased connectivity in ASD group between regions of social cognition, executive functions, and emotion processing.

Effects of a chelated copper as growth promoter on performance and carcass traits in pigs

Three studies were conducted to investigate whether a chelated Cu can replace CuSO₄ as a growth promoter in pigs. In Exp. 1, a total of 240 piglets (Large White×Landrace, 7.36±0.10 kg) were randomly allocated to 1 of 3 treatments with 8 replicates and 10 piglets per pen. Treatments included a NRC control (CuSO₄, 6 mg/kg), two Cu supplementations from either CuSO₄ or Cu(HMTBa)₂ at 170 mg/kg. Pigs fed Cu(HMTBa)₂ were 6.0% heavier than pigs fed either the NRC control or 170 mg/kg CuSO₄ (p = 0.03) at the end of the experiment. During the 42 days of experimental period, pigs fed Cu(HMTBa)₂ gained 9.0% more (p = 0.01), tended to eat more feed (p = 0.09), and had better feed efficiency (p = 0.06) than those fed CuSO₄. Compared with the 6 mg/kg CuSO₄ NRC control, liver Cu was increased 2.7 times with 170 mg/kg CuSO₄ supplementation, and was further increased with Cu(HMTBa)₂ (4.5 times, p<0.05). In Exp. 2, a total of 616 crossbred piglets (PIC, 5.01±0.25 kg) were randomly allocated to 1 of 4 treatments with 7 replicates and 22 piglets per pen. Treatments included a NRC control (from CuSO₄), and three pharmaceutical levels of Cu (150 mg/kg) supplemented either from CuSO₄, tri-basic copper chloride (Cu₂[OH]₃Cl), or Cu(HMTBa)₂. Pigs fed CuSO₄ or Cu(HMTBa)₂ had better feed efficiency (p = 0.01) and tended to gain more (p = 0.08) compared with those fed the NRC control. Pigs fed Cu₂(OH)₃Cl were intermediate. Pigs fed Cu(HMTBa)₂ had the highest liver Cu, which was significantly higher than those fed (Cu₂[OH]₃Cl) or the negative control (p = 0.01). In Exp. 3, a total of 1,048 pigs (PIC, 32.36±0.29 kg) were allotted to 6 treatments with 8 replicates per treatment and 20 to 22 pigs per pen. The treatments included a NRC control with 4 mg/kg Cu from CuSO₄, a positive control with 160 mg/kg Cu from CuSO₄, and incremental levels of Cu(HMTBa)₂ at 20, 40, 80, and 160 mg/kg. During the overall experimental period of 100 days, no benefit from 160 mg/kg CuSO₄ was observed. Pigs fed Cu(HMTBa)₂ had increased ADG (linear and quadratic, p≤0.05) and feed efficiency (linear and quadratic, p≤0.05) up to 80 mg/kg and no further improvement was observed at 160 mg/kg for the whole experimental period. Pigs fed 80 mg/kg Cu(HMTBa)₂ weighed 1.8 kg more (p = 0.07) and were 2.3 kg heavier in carcass (p<0.01) compared with pigs fed 160 mg/kg CuSO₄. In addition, loin depth was increased with increased Cu(HMTBa)₂ supplementation with pigs fed 80 mg/kg Cu(HMTBa)₂ had the greatest loin depth (p<0.05). In summary, Cu(HMTBa)₂ can be used to replace high CuSO₄ as a growth promoter in nursery and grower-finisher pigs.

Perchlorate levels in soil and waters from the Atacama Desert

Perchlorate is an anion that originates as a contaminant in ground and surface waters. The presence of perchlorate in soil and water samples from northern Chile (Atacama Desert) was investigated by ion chromatography-electrospray mass spectrometry. Results indicated that perchlorate was found in five of seven soils (cultivated and uncultivated) ranging from 290 ± 1 to 2,565 ± 2 μg/kg. The greatest concentration of perchlorate was detected in Humberstone soil (2,565 ± 2 μg/kg) associated with nitrate deposits. Perchlorate levels in Chilean soils are greater than those reported for uncultivated soils in the United States. Perchlorate was also found in superficial running water ranging from 744 ± 0.01 to 1,480 ± 0.02 μg/L. Perchlorate water concentration is 30-60 times greater than levels established by the United States Environmental Protection Agency (24.5 μg/L) for drinking.

Uptake and accumulation of four PPCP/EDCs in two leafy vegetables

Many pharmaceutical and personal care products (PPCPs) and endocrine-disrupting chemicals (EDCs) are present in reclaimed water, leading to concerns of human health risks from the consumption of food crops irrigated with reclaimed water. This study evaluated the potential for plant uptake and accumulation of four commonly occurring PPCP/EDCs, i.e., bisphenol A (BPA), diclofenac sodium (DCL), naproxen (NPX), and 4-nonylphenol (NP), by lettuce (Lactuca sativa) and collards (Brassica oleracea) in hydroponic culture, using (14)C-labeled compounds. In both plant species, plant accumulation followed the order of BPA > NP > DCL > NPX and accumulation in roots was much greater than in leaves and stems. Concentrations of (14)C-PPCP/EDCs in plant tissues ranged from 0.22 ± 0.03 to 927 ± 213 ng/g, but nearly all (14)C-residue was non-extractable. PPCP/EDCs, particularly BPA and NP, were also extensively transformed in the nutrient solution. Dietary uptake of these PPCP/EDCs by humans was predicted to be negligible.

Design and characterization of a laterally mounted phased-array transducer breast-specific MRgHIFU device with integrated 11-channel receiver array

PURPOSE

This work presents the design and preliminary evaluation of a new laterally mounted phased-array MRI-guided high-intensity focused ultrasound (MRgHIFU) system with an integrated 11-channel phased-array radio frequency (RF) coil intended for breast cancer treatment. The design goals for the system included the ability to treat the majority of tumor locations, to increase the MR image's signal-to-noise ratio (SNR) throughout the treatment volume and to provide adequate comfort for the patient.

METHODS

In order to treat the majority of the breast volume, the device was designed such that the treated breast is suspended in a 17-cm diameter treatment cylinder. A laterally shooting 1-MHz, 256-element phased-array ultrasound transducer with flexible positioning is mounted outside the treatment cylinder. This configuration achieves a reduced water volume to minimize RF coil loading effects, to position the coils closer to the breast for increased signal sensitivity, and to reduce the MR image noise associated with using water as the coupling fluid. This design uses an 11-channel phased-array RF coil that is placed on the outer surface of the cylinder surrounding the breast. Mechanical positioning of the transducer and electronic steering of the focal spot enable placement of the ultrasound focus at arbitrary locations throughout the suspended breast. The treatment platform allows the patient to lie prone in a face-down position. The system was tested for comfort with 18 normal volunteers and SNR capabilities in one normal volunteer and for heating accuracy and stability in homogeneous phantom and inhomogeneous ex vivo porcine tissue.

RESULTS

There was a 61% increase in mean relative SNR achieved in a homogeneous phantom using the 11-channel RF coil when compared to using only a single-loop coil around the chest wall. The repeatability of the system's energy delivery in a single location was excellent, with less than 3% variability between repeated temperature measurements at the same location. The execution of a continuously sonicated, predefined 48-point, 8-min trajectory path resulted in an ablation volume of 8.17 cm(3), with one standard deviation of 0.35 cm(3) between inhomogeneous ex vivo tissue samples. Comfort testing resulted in negligible side effects for all volunteers.

CONCLUSIONS

The initial results suggest that this new device will potentially be suitable for MRgHIFU treatment in a wide range of breast sizes and tumor locations.