Horizon Health Network

Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.

The sixth update of the Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Reintegration following Stroke. Part one: Rehabilitation and Recovery Following Stroke is a comprehensive set of evidence-based guidelines addressing issues surrounding impairments, activity limitations, and participation restrictions following stroke. Rehabilitation is a critical component of recovery, essential for helping patients to regain lost skills, relearn tasks, and regain independence. Following a stroke, many people typically require rehabilitation for persisting deficits related to hemiparesis, upper-limb dysfunction, pain, impaired balance, swallowing, and vision, neglect, and limitations with mobility, activities of daily living, and communication. This module addresses interventions related to these issues as well as the structure in which they are provided, since rehabilitation can be provided on an inpatient, outpatient, or community basis. These guidelines also recognize that rehabilitation needs of people with stroke may change over time and therefore intermittent reassessment is important. Recommendations are appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. Unlike the previous set of recommendations, in which pediatric stroke was included, this set of recommendations includes primarily adult rehabilitation, recognizing many of these therapies may be applicable in children. Recommendations related to community reintegration, which were previously included within this rehabilitation module, can now be found in the companion module, Rehabilitation, Recovery, and Community Participation following Stroke. Part Two: Transitions and Community Participation Following Stroke.

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Gelsolin, a Ca(2+) -regulated actin filament severing, capping, and nucleating protein, is an ubiquitous, multifunctional regulator of cell structure and metabolism. More recent data show that gelsolin can act as a transcriptional cofactor in signal transduction and its own expression and function can be influenced by epigenetic changes. Here, we review the functions of the plasma and cytoplasmic forms of gelsolin, and their manifold impacts on cancer, apoptosis, infection and inflammation, cardiac injury, pulmonary diseases, and aging. An improved understanding of the functions and regulatory mechanisms of gelsolin may lead to new considerations of this protein as a potential biomarker and/or therapeutic target.

Whole genome sequencing (WGS) of Salmonella supports both molecular typing and detection of antimicrobial resistance (AMR). Here, we evaluated the correlation between phenotypic antimicrobial susceptibility testing (AST) and in silico prediction of AMR from WGS in Salmonella enterica (n = 1321) isolated from human infections in Canada. Phenotypic AMR results from broth microdilution testing were used as the gold standard. To facilitate high-throughput prediction of AMR from genome assemblies, we created a tool called Staramr, which incorporates the ResFinder and PointFinder databases and a custom gene-drug key for antibiogram prediction. Overall, there was 99% concordance between phenotypic and genotypic detection of categorical resistance for 14 antimicrobials in 1321 isolates (18,305 of 18,494 results in agreement). We observed an average sensitivity of 91.2% (range 80.5–100%), a specificity of 99.7% (98.6–100%), a positive predictive value of 95.4% (68.2–100%), and a negative predictive value of 99.1% (95.6–100%). The positive predictive value of gentamicin was 68%, due to seven isolates that carried aac(3)-IVa, which conferred MICs just below the breakpoint of resistance. Genetic mechanisms of resistance in these 1321 isolates included 64 unique acquired alleles and mutations in three chromosomal genes. In general, in silico prediction of AMR in Salmonella was reliable compared to the gold standard of broth microdilution. WGS can provide higher-resolution data on the epidemiology of resistance mechanisms and the emergence of new resistance alleles.

To determine the influence of time from injury to surgery on neurological recovery and length of stay (LOS) in an observational cohort of individuals with traumatic spinal cord injury (tSCI), we analyzed the baseline and follow-up motor scores of participants in the Rick Hansen Spinal Cord Injury Registry to specifically assess the effect of an early (less than 24 h from injury) surgical procedure on motor recovery and on LOS. One thousand four hundred and ten patients who sustained acute tSCIs with baseline American Spinal Injury Association Impairment Scale (AIS) grades A, B, C, or D and were treated surgically were analyzed to determine the effect of the timing of surgery (24, 48, or 72 h from injury) on motor recovery and LOS. Depending on the distribution of data, we used different types of generalized linear models, including multiple linear regression, gamma regression, and negative binomial regression. Persons with incomplete AIS B, C, and D injuries from C2 to L2 demonstrated motor recovery improvement of an additional 6.3 motor points (SE=2.8 p<0.03) when they underwent surgical treatment within 24 h from the time of injury, compared with those who had surgery later than 24 h post-injury. This beneficial effect of early surgery on motor recovery was not seen in the patients with AIS A complete SCI. AIS A and B patients who received early surgery experienced shorter hospital LOS. While the issues of when to perform surgery and what specific operation to perform remain controversial, this work provides evidence that for an incomplete acute tSCI in the cervical, thoracic, or thoracolumbar spine, surgery performed within 24 h from injury improves motor neurological recovery. Early surgery also reduces LOS.

The 2015 update of the Canadian Stroke Best Practice Recommendations Hyperacute Stroke Care guideline highlights key elements involved in the initial assessment, stabilization, and treatment of patients with transient ischemic attack (TIA), ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and acute venous sinus thrombosis. The most notable change in this 5th edition is the addition of new recommendations for the use of endovascular therapy for patients with acute ischemic stroke and proximal intracranial arterial occlusion. This includes an overview of the infrastructure and resources required for stroke centers that will provide endovascular therapy as well as regional structures needed to ensure that all patients with acute ischemic stroke that are eligible for endovascular therapy will be able to access this newly approved therapy; recommendations for hyperacute brain and enhanced vascular imaging using computed tomography angiography and computed tomography perfusion; patient selection criteria based on the five trials of endovascular therapy published in early 2015, and performance metric targets for important time-points involved in endovascular therapy, including computed tomography-to-groin puncture and computed tomography-to-reperfusion times. Other updates in this guideline include recommendations for improved time efficiencies for all aspects of hyperacute stroke care with a movement toward a new median target door-to-needle time of 30 min, with the 90th percentile being 60 min. A stronger emphasis is placed on increasing public awareness of stroke with the recent launch of the Heart and Stroke Foundation of Canada FAST signs of stroke campaign; reinforcing the public need to seek immediate medical attention by calling 911; further engagement of paramedics in the prehospital phase with prehospital notification to the receiving emergency department, as well as the stroke team, including neuroradiology; updates to the triage and same-day assessment of patients with transient ischemic attack; updates to blood pressure recommendations for the hyperacute phase of care for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The goal of these recommendations and supporting materials is to improve efficiencies and minimize the absolute time lapse between stroke symptom onset and reperfusion therapy, which in turn leads to better outcomes and potentially shorter recovery times.

Prostate cancer is the most frequent cancer in men and a leading cause of cancer death. Determining a patient's optimal therapy is a challenge, where oncologists must select a therapy with the highest likelihood of success and the lowest likelihood of toxicity. International standards for prognostication rely on non-specific and semi-quantitative tools, commonly leading to over- and under-treatment. Tissue-based molecular biomarkers have attempted to address this, but most have limited validation in prospective randomized trials and expensive processing costs, posing substantial barriers to widespread adoption. There remains a significant need for accurate and scalable tools to support therapy personalization. Here we demonstrate prostate cancer therapy personalization by predicting long-term, clinically relevant outcomes using a multimodal deep learning architecture and train models using clinical data and digital histopathology from prostate biopsies. We train and validate models using five phase III randomized trials conducted across hundreds of clinical centers. Histopathological data was available for 5654 of 7764 randomized patients (71%) with a median follow-up of 11.4 years. Compared to the most common risk-stratification tool-risk groups developed by the National Cancer Center Network (NCCN)-our models have superior discriminatory performance across all endpoints, ranging from 9.2% to 14.6% relative improvement in a held-out validation set. This artificial intelligence-based tool improves prognostication over standard tools and allows oncologists to computationally predict the likeliest outcomes of specific patients to determine optimal treatment. Outfitted with digital scanners and internet access, any clinic could offer such capabilities, enabling global access to therapy personalization.

INTRODUCTION: Ineffective coping may lead to impaired job performance and burnout, with adverse consequences to staff well-being and patient outcomes. We examined the relationship between coping styles and burnout in emergency physicians, nurses and support staff at seven small, medium and large emergency departments (ED) in a Canadian health region (population 500,000). METHODS: Linear regression with the Coping Inventory for Stressful Situations (CISS) and Maslach Burnout Inventory (MBI) was used to evaluate the effect of coping style on levels of burnout in a cross-sectional survey of 616 ED staff members. CISS measures coping style in three categories: task-oriented, emotion-oriented and avoidance-oriented coping; MBI, in use for 30 years, assesses the level of burnout in healthcare workers. RESULTS: Task-oriented coping was associated with decreased risk of burnout, while emotion-oriented coping was associated with increased risk of burnout. DISCUSSION: Specific coping styles are associated with varied risk of burnout in ED staff across several different types of hospitals in a regional network. Coping style intervention may reduce burnout, while leading to improvement in staff well-being and patient outcomes. Further studies should focus on building and sustaining task-oriented coping, along with alternatives to emotion-oriented coping.

Background: Influenza is an important cause of morbidity and mortality among older adults. Even so, effectiveness of influenza vaccine for older adults has been reported to be lower than for younger adults, and the impact of frailty on vaccine effectiveness (VE) and outcomes is uncertain. We aimed to study VE against influenza hospitalization in older adults, focusing on the impact of frailty. Methods: We report VE of trivalent influenza vaccine (TIV) in people ≥65 years of age hospitalized during the 2011-2012 influenza season using a multicenter, prospective, test-negative case-control design. A validated frailty index (FI) was used to measure frailty. Results: Three hundred twenty cases and 564 controls (mean age, 80.6 and 78.7 years, respectively) were enrolled. Cases had higher baseline frailty than controls (P = .006). In the fully adjusted model, VE against influenza hospitalization was 58.0% (95% confidence interval [CI], 34.2%-73.2%). The contribution of frailty was important; adjusting for frailty alone yielded a VE estimate of 58.7% (95% CI, 36.2%-73.2%). VE was 77.6% among nonfrail older adults and declined as frailty increased. Conclusions: Despite commonly held views that VE is poor in older adults, we found that TIV provided good protection against influenza hospitalization in older adults who were not frail, though VE diminished as frailty increased. Clinical Trials Registration: NCT01517191.

NUT midline carcinoma is an aggressive tumor that occurs mainly in the head and neck and, less frequently, the mediastinum and lung. Following identification of an index case of a NUTM1 fusion positive undifferentiated soft tissue tumor, we interrogated additional cases of primary undifferentiated soft tissue and visceral tumors for NUTM1 abnormalities. Targeted next-generation sequencing was performed on RNA extracted from formalin-fixed paraffin-embedded tissue, and results validated by fluorescence in situ hybridization using custom bacterial artificial chromosome probes. Six patients were identified: mean age of 42 years (range, 3 to 71 y); equal sex distribution; and, tumors involved the extremity soft tissues (N=2), kidney (N=2), stomach, and brain. On systemic work-up at presentation all patients lacked a distant primary tumor. Morphologically, the tumors were heterogenous, with undifferentiated round-epithelioid-rhabdoid cells arranged in solid sheets, nests, and cords. Mitotic activity was generally brisk. Four cases expressed pancytokeratin, but in only 2 cases was this diffuse. Next-generation sequencing demonstrated the following fusions: BRD4-NUTM1 (3 cases), BRD3-NUTM1, MXD1-NUTM1, and BCORL1-NUTM1. Independent testing by fluorescence in situ hybridization confirmed the presence of NUTM1 and partner gene rearrangement. This study establishes that NUT-associated tumors transgress the midline and account for a subset of primitive neoplasms occurring in soft tissue and viscera. Tumors harboring NUTM1 gene fusions are presumably underrecognized, and the extent to which they account for undifferentiated mesenchymal, neuroendocrine, and/or epithelial neoplasms is unclear. Moreover, the relationship, if any, between NUT-associated tumors in soft tissue and/or viscera, and conventional NUT carcinoma, remains to be elucidated.

Individually rare, large copy number variants (CNVs) contribute to genetic vulnerability for schizophrenia. Unresolved questions remain, however, regarding the anticipated yield of clinical microarray testing in schizophrenia. Using high-resolution genome-wide microarrays and rigorous methods, we investigated rare CNVs in a prospectively recruited community-based cohort of 459 unrelated adults with schizophrenia and estimated the minimum prevalence of clinically significant CNVs that would be detectable on a clinical microarray. A blinded review by two independent clinical cytogenetic laboratory directors of all large (>500 kb) rare CNVs in cases and well-matched controls showed that those deemed to be clinically significant were highly enriched in schizophrenia (16.4-fold increase, P < 0.0001). In a single community catchment area, the prevalence of individuals with these CNVs was 8.1%. Rare 1.7 Mb CNVs at 2q13 were found to be significantly associated with schizophrenia for the first time, compared with the prevalence in 23 838 population-based controls (42.9-fold increase, P = 0.0002). Additional novel findings that will facilitate the future clinical interpretation of smaller CNVs in schizophrenia include: (i) a greater proportion of individuals with two or more rare exonic CNVs >10 kb in size (1.5-fold increase, P = 0.0109) in schizophrenia; (ii) the systematic discovery of new candidate genes for schizophrenia; and, (iii) functional gene enrichment mapping highlighting a differential impact in schizophrenia of rare exonic deletions involving diverse functions, including neurodevelopmental and synaptic processes (4.7-fold increase, P = 0.0060). These findings suggest consideration of a potential role for clinical microarray testing in schizophrenia, as is now the suggested standard of care for related developmental disorders like autism.

Immune checkpoint inhibitors (icis) such as inhibitors of ctla-4, PD-1, and PD-L1, given as monotherapy or combination therapy have emerged as effective treatment options for immune-sensitive solid tumours and hematologic malignancies. The benefits of icis can be offset by immune-related adverse events (iraes) that leave all organ systems vulnerable and subsequently increase the risk for morbidity and mortality. Because of fluctuating onset and prolonged duration, the toxicities associated with iraes represent a shift from the understanding of conventional anticancer toxicities. The ctla-4 and PD-1/PD-L1 inhibitors modulate T-cell response differently, resulting in distinct toxicity patterns, toxicity kinetics, and dose-toxicity relationships. Using individualized patient education, screening, and assessment for the early identification of iraes is key to proactive management and is therefore key to improving outcomes and prolonging therapy. Management of iraes is guided by appropriate grading, which sets the stage for the treatment setting (outpatient vs. inpatient), ici treatment course (delay vs. discontinuation), supportive care, corticosteroid use, organ specialist consultation, and additional immunosuppression. Health care professionals in oncology must work collaboratively with emergency and community colleagues to facilitate an understanding of iraes in an effort to optimize seamless care.

INTRODUCTION: Pregnancy is a critical period of body weight regulation. Maternal obesity and excessive gestational weight gain have become increasingly common and contribute to poor obstetrical outcomes for mother and baby. Regular participation in physical activity may improve risk profiles in pregnant women. PURPOSE AND METHODS: Our objectives were to provide an overview of maternal-fetal exercise physiology, summarize current evidence on the effects of physical activity during pregnancy on maternal-fetal outcomes, and review the most recent clinical practice guidelines. In addition, we summarize the findings in the context of the current obesity epidemic and discuss implications for clinical practice. A literature review was completed in which we queried OVID (Medline), EMBASE, and PSYCHINFO databases with title words "exercise or physical activity" and "pregnancy or gestation" from 1950 to March 1, 2010. A total of 212 articles were selected for review. RECOMMENDATIONS: Care providers should recommend physical activity to most pregnant women (i.e., those without contraindications) and view participation as a safe and beneficial component of a healthy pregnancy. TARGET AUDIENCE: Obstetricians & Gynecologists and Family Physicians. LEARNING OBJECTIVES: After participating in this CME activity, physicians should be better able to classify the potential impact of physical activity on maternal glycemic control and fetal growth outcomes. Assess maternal lifestyle and provide recommendations on appropriate gestational weight gain, evaluate pregnant women for contraindications to physical activity participation, make individualized recommendations for exercise participation, and educate patients on the merits of physical activity for health benefit.

BACKGROUND: The Scandinavian Total Ankle Replacement (STAR) prosthesis has been in clinical use since 1981, with investigational use in the U.S. since 1998. Few studies of the North American version of the STAR are available. This prospective cohort study analyzed intermediate to long-term outcomes of total ankle arthroplasty with use of the STAR prosthesis at two Canadian centers. METHODS: Consecutive patients who received the STAR prosthesis between 2001 and 2005 were enrolled at two large, urban teaching hospitals. Patients were annually evaluated clinically, and the Ankle Osteoarthritis Scale (AOS) and the Short Form (SF)-36 were administered. RESULTS: One hundred and eleven ankles underwent arthroplasty with the STAR prosthesis. One-half of the patients were male; the mean age was 61.9 ± 11.7 years. Sixty-eight of the ankles underwent a total of 121 additional procedures during ankle arthroplasty, including gastrocnemius release, subtalar arthrodesis, triple arthrodesis, tendoachilles lengthening, and removal of hardware. The mean duration of follow-up for all living patients without revision (seventy-three ankles) was 9.0 ± 1.0 years. Thirteen (12%) of the ankles required metal component revision at a mean of 4.3 ± 3.0 years (range, 0.6 to 10.2 years). Twenty (18%) of the prostheses underwent polyethylene bearing exchange, mostly due to fracture, at a mean of 5.2 ± 2.1 years (range, 1.5 to 9.3 years). Most (97%) of the revisions and exchanges occurred in patients with a diagnosis of primary, secondary, or posttraumatic osteoarthritis (p = 0.0003). The mean change from baseline to final follow-up was -36.5 ± 23.3 points for AOS pain, -38.6 ± 26.8 points for AOS disability, and 9.6 ± 10.3 points for the SF-36 physical component summary score. The SF-36 mental component summary score was unchanged. CONCLUSIONS: Intermediate patient-reported outcomes were good after ankle arthroplasty with the STAR prosthesis performed by experienced surgeons, and long-term outcomes demonstrated a 12% rate of metal component revision and 18% rate of polyethylene bearing failure. The revision rate was substantially higher among the first twenty ankles than among subsequent ankles, but the early ankles had nearly two years' longer follow-up than subsequent ankles. Additional study to elucidate possible reasons for polyethylene bearing failure is warranted. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: Key performance indicators (KPIs) are quantifiable measures of quality. There are no published, systematically derived clinical pharmacy KPIs (cpKPIs). OBJECTIVE: A group of hospital pharmacists aimed to develop national cpKPIs to advance clinical pharmacy practice and improve patient care. METHODS: A cpKPI working group established a cpKPI definition, 8 evidence-derived cpKPI critical activity areas, 26 candidate cpKPIs, and 11 cpKPI ideal attributes in addition to 1 overall consensus criterion. Twenty-six clinical pharmacists and hospital pharmacy leaders participated in an internet-based 3-round modified Delphi survey. Panelists rated 26 candidate cpKPIs using 11 cpKPI ideal attributes and 1 overall consensus criterion on a 9-point Likert scale. A meeting was facilitated between rounds 2 and 3 to debate the merits and wording of candidate cpKPIs. Consensus was reached if 75% or more of panelists assigned a score of 7 to 9 on the consensus criterion during the third Delphi round. RESULTS: All panelists completed the 3 Delphi rounds, and 25/26 (96%) attended the meeting. Eight candidate cpKPIs met the consensus definition: (1) performing admission medication reconciliation (including best-possible medication history), (2) participating in interprofessional patient care rounds, (3) completing pharmaceutical care plans, (4) resolving drug therapy problems, (5) providing in-person disease and medication education to patients, (6) providing discharge patient medication education, (7) performing discharge medication reconciliation, and (8) providing bundled, proactive direct patient care activities. CONCLUSIONS: A Delphi panel of hospital pharmacists was successful in determining 8 consensus cpKPIs. Measurement and assessment of these cpKPIs will serve to advance clinical pharmacy practice and improve patient care.

Background: Obtaining an accurate and complete medication list (i.e., the best possible medication history [BPMH]) is the first step in completing medication reconciliation. The ability of pharmacy technicians to obtain medication histories, relative to that of pharmacists, has not been formally assessed.Objectives: To determine whether pharmacy technicians at the authors' institution could obtain a BPMH as accurately and completely as pharmacists and if both groups met national norms for unintentional discrepancies and the success index for medication reconciliation.Methods: Pharmacy technicians were trained in obtaining a BPMH at the beginning of the study, before any patients were enrolled. Patients presenting to the emergency department were prospectively enrolled to be interviewed separately by both a pharmacist and a technician, with information recorded on standard medication reconciliation forms. The completed forms for each patient were compared following each set of interviews, and discrepancies were clarified with the patient.Results: Fifty-nine patients were included in the study, and 3 pharmacists and 2 technicians obtained the histories. There was no significant difference between pharmacists and technicians in terms of discrepancies involving prescription drugs (&chi;2 = 0.52, df = 1, n = 118, p = 0.47, Cramer's V for effect size = 0.07) or over-the-counter medications (&chi;2 = 0.09, df = 1, n = 118, p = 0.77, Cramer's V = 0.03). The mean number of discrepancies per patient did not differ significantly between the pharmacists and technicians (t = 0.15, df = 58, p = 0.88 for prescription drugs; t = -0.22, df = 58, p = 0.83 for over-the-counter products). For both groups, the number of unintentional discrepancies per patient was significantly lower and the success index for medication reconciliation significantly higher than the national average.Conclusions: Trained pharmacy technicians at the authors' institution were able to obtain a BPMH with as much accuracy and completeness as pharmacists. Both groups were significantly superior to the national average in terms of unintentional discrepancies and success index for medication reconciliation.R&Eacute;SUM&Eacute;Contexte : L'obtention d'une liste pr&eacute;cise et compl&egrave;te des medicaments (c.-&agrave;-d. le meilleur sch&eacute;ma th&eacute;rapeutique possible [MSTP]) est la premi&egrave;re &eacute;tape du bilan comparatif des m&eacute;dicaments. La capacit&eacute; des techniciens en pharmacie, comparativement &agrave; celle des pharmaciens, d'obtenir les histoires m&eacute;dicamenteuses n'a pas &eacute;t&eacute; &eacute;valu&eacute;e officiellement.Objectifs : D&eacute;terminer si les techniciens en pharmacie dans l'&eacute;tablissement des auteurs pouvaient obtenir un MSTP aussi pr&eacute;cis et complet que les pharmaciens et si les deux groupes satisfaisaient aux normes nationals pour ce qui est des divergences non intentionnelles et de l'indice de r&eacute;ussite pour ce qui est du bilan comparatif des m&eacute;dicaments.M&eacute;thodes : Les techniciens en pharmacie ont &eacute;t&eacute; form&eacute;s sur la technique d'obtention du MSTP au d&eacute;but de l'&eacute;tude, avant l'inscription des patients. Les patients qui consultaient au service des urgences ont &eacute;t&eacute; inscrits de fa&ccedil;on prospective pour &ecirc;tre interview&eacute;s s&eacute;par&eacute;ment par un pharmacien et par un technicien, et l'information &eacute;tait consignee sur des formulaires standard de bilan comparatif des m&eacute;dicaments. Les formulaires remplis pour chaque patient ont &eacute;t&eacute; compar&eacute;s &agrave; la suite de chaque s&eacute;rie d'entrevues, et les divergences ont &eacute;t&eacute; clarifi&eacute;es avec les patients.R&eacute;sultats : Un total de 59 patients ont &eacute;t&eacute; inscrits &agrave; l'&eacute;tude. Trois pharmaciens et deux techniciens ont obtenu les histoires m&eacute;dicamenteuses. Aucune diff&eacute;rence significative n'a &eacute;t&eacute; observ&eacute;e entre les pharmaciens et les techniciens pour ce qui est des divergences au chapitre des medicaments d'ordonnance &chi;2 = 0,52, df = 1, n = 118, p = 0,47, V de Cramer pour l'ampleur de l'effet = 0,07) ou des m&eacute;dicaments en vente libre (&chi;2 = 0,09, df = 1, n = 118, p = 0,77, V de Cramer = 0,03). Aucune difference significative n'a &eacute;t&eacute; observ&eacute;e quant au nombre moyen de divergences par patient entre les pharmaciens et les techniciens (t = 0,15, df = 58, p = 0,88 pour les m&eacute;dicaments d'ordonnance; t = - 0,22, df = 58, p = 0,83 pour les produits en vente libre). Le nombre de divergences non intentionnelles par patient pour les deux groupes &eacute;tait significativement plus bas et l'indice de r&eacute;ussite pour ce qui est du bilan comparatif des medicaments &eacute;tait significativement plus &eacute;lev&eacute; que les moyennes nationales.Conclusions : Les techniciens en pharmacie qualifi&eacute;s dans l'&eacute;tablissement des auteurs ont pu obtenir un MSTP aussi pr&eacute;cis et complet que celui des pharmaciens. Les deux groupes ont eu des r&eacute;sultats significativement sup&eacute;rieurs &agrave; ceux de la moyenne nationale quant aux divergences non intentionnelles et &agrave; l'indice de r&eacute;ussite pour ce qui est du bilan comparative des m&eacute;dicaments.

The issue of male farmers' mental health raises many concerns including high rates of psychological distress and suicide amid the poor uptake of health services among this subgroup. Gender is an important social determinant of health, and this paper provides an overview of connections between farming and masculinities in the context of men's mental health disorders. This scoping review summarises findings drawn from 46 studies to discuss male farmers' mental health disorders, psychosocial interventions and barriers to help-seeking. In providing the review, recommendations are made including the need for an array of study and intervention approaches to advance the mental health and well-being of male farmers and their families.

Clinical trials of therapies for acute traumatic spinal cord injury (tSCI) have failed to convincingly demonstrate efficacy in improving neurologic function. Failing to acknowledge the heterogeneity of these injuries and under-appreciating the impact of the most important baseline prognostic variables likely contributes to this translational failure. Our hypothesis was that neurological level and severity of initial injury (measured by the American Spinal Injury Association Impairment Scale [AIS]) act jointly and are the major determinants of motor recovery. Our objective was to quantify the influence of these variables when considered together on early motor score recovery following acute tSCI. Eight hundred thirty-six participants from the Rick Hansen Spinal Cord Injury Registry were analyzed for motor score improvement from baseline to follow-up. In AIS A, B, and C patients, cervical and thoracic injuries displayed significantly different motor score recovery. AIS A patients with thoracic (T2-T10) and thoracolumbar (T11-L2) injuries had significantly different motor improvement. High (C1-C4) and low (C5-T1) cervical injuries demonstrated differences in upper extremity motor recovery in AIS B, C, and D. A hypothetical clinical trial example demonstrated the benefits of stratifying on neurological level and severity of injury. Clinically meaningful motor score recovery is predictably related to the neurological level of injury and the severity of the baseline neurological impairment. Stratifying clinical trial cohorts using a joint distribution of these two variables will enhance a study's chance of identifying a true treatment effect and minimize the risk of misattributed treatment effects. Clinical studies should stratify participants based on these factors and record the number of participants and their mean baseline motor scores for each category of this joint distribution as part of the reporting of participant characteristics. Improved clinical trial design is a high priority as new therapies and interventions for tSCI emerge.

Globally, the advent and rapid spread of the COVID-19 virus has created significant disruption to health professions education and practice, and consequently interprofessional education, leading to a model of learning and practicing where much is unknown. Key questions for this ongoing evolution emerge for the global context leading to reflections on future directions for the interprofessional education field and its role in shaping future practice models. Health professions programs around the world have made a dramatic shift to virtual learning platforms in response to closures of academic institutions and restrictions imposed on learners accessing practice settings. Telemedicine, slow to become established in many countries to date, has also revolutionized practice in the current environment. Within the state of disruption and rapid change is the awareness of a silver lining that provides an opportunity for future growth. Key topics explored in this commentary include reflection on the application of existing competency frameworks, consideration of typology of team structures, reconsideration of theoretical underpinnings, revisiting of core dimensions of education, adaptation of interprofessional education activities, and the role in the future pandemic planning. As an international community of educators and researchers, the authors consider current observations relevant to interprofessional education and practice contexts and suggest a response from scholarship voices across the globe. The current pandemic offers a unique opportunity for educators, practitioners, and researchers to retain what has served interprofessional education and practice well in the past, break from what has not worked as well, and begin to imagine the new.