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Background Careful development of interventions using principles of co-production is now recognized as an important step for clinical trial development, but practical guidance on how to do this in practice is lacking. This paper aims (1) provide practical guidance for researchers to co-produce interventions ready for clinical trial by describing the 4-stage process we followed, the challenges experienced and practical tips for researchers wanting to co-produce an intervention for a clinical trial; (2) describe, as an exemplar, the development of our intervention package. Method We used an Integrated Knowledge Translation (IKT) approach to co-produce a telehealth-delivered exercise program for people with stroke. The 4-stage process comprised of (1) a start-up planning phase with the co-production team. (2) Content development with knowledge user informants. (3) Design of an intervention protocol. (4) Protocol refinement. Results and reflections The four stages of intervention development involved an 11-member co-production team and 32 knowledge user informants. Challenges faced included balancing conflicting demands of different knowledge user informant groups, achieving shared power and collaborative decision making, and optimising knowledge user input. Components incorporated into the telehealth-delivered exercise program through working with knowledge user informants included: increased training for intervention therapists; increased options to tailor the intervention to participant’s needs and preferences; and re-naming of the program. Key practical tips include ways to minimise the power differential between researchers and consumers, and ensure adequate preparation of the co-production team. Conclusion Careful planning and a structured process can facilitate co-production of complex interventions ready for clinical trial. Graphical Abstract

Objectives: This is a protocol for a Cochrane Review (overview). The objectives are as follows:. To summarise and appraise the evidence from Cochrane Reviews assessing the effects of interventions for the recovery and/or the improvement of walking in people after stroke. We will conduct an overview of Cochrane Reviews involving stakeholders to:. provide accessible high-quality evidence on the effects of interventions aiming to recover and/or improve walking in people after stroke; summarise the evidence of the effects of included interventions; clearly present to readers relevant, high-quality evidence of effective interventions; and direct them to original reviews. A secondary objective will be to explore the outcomes reported in Cochrane Reviews assessing the effects of interventions to improve walking; how different measures are combined in reviews; and how this varies between reviews.

End-stage kidney disease (ESKD) is common in the U.S. There is no cure, and survival requires either dialysis or kidney transplant. Medicare provides coverage for most ESKD patients in the U.S., though non-citizens are excluded from most current policies providing standard ESKD care, especially regarding kidney transplants. Despite being eligible to be organ donors, non-citizens often have few avenues to be organ recipients—a major equity problem. Overall, transplants are cost-saving compared to dialysis, and non-citizens have comparable outcomes to the general population. We reviewed the literature regarding the vastly different policies across the U.S., with a focus on current Illinois policy, including updates regarding Illinois legislation which passed in 2014 providing non-citizens to receive coverage for transplants. Unfortunately, despite legislation providing avenues for transplants, funds were not allocated, and the bill has not had the impact that was expected when initially passed. We outline opportunities for improving current policies.

Older Black adults face a disproportionate burden of HIV prevalence, but less is known about racial disparities in age-related outcomes in HIV. We assessed the effect of HIV status and race on motor and pulmonary function, as well as how they contribute to mobility disability. Community-based study; Chicago, IL Participants were 363 community-dwelling adults age ≥ 50 years, 48% living with HIV, and 68% Black. Participants with HIV were recruited from a specialty HIV clinic, and participants without HIV (comparable on key demographic, lifestyle, and behavioral characteristics) were recruited from the community. Measures included motor function summarized by 10 motor performance measures, pulmonary function summarized by 3 measures assessed using handheld spirometry, and self-reported mobility disability. In fully adjusted linear models, HIV was associated with better motor (β = 9.35, p

Objectives: To examine individual, medication, system, and healthcare related predictors of hospitalization and emergency department (ED) presentation within 90 days of entering the aged care sector, and to create risk-profiles associated with these outcomes. Design and setting: Retrospective population-based cohort study using data from the Registry of Senior Australians. Participants: Older people (aged 65 and older) with an aged care eligibility assessment in South Australia between January 1, 2013 and May 31, 2016 (N = 22,130). Measurements: Primary outcomes were unplanned hospitalization and ED presentation within 90 days of assessment. Individual, medication, system, and healthcare related predictors of the outcomes at the time of assessment, within 90 days or 1-year prior. Fine–Gray models were used to calculate subdistribution hazard ratios (sHR) and 95% confidence intervals (CI). Harrell's C-index assessed predictive ability. Results: Four thousand nine-hundred and six (22.2%) individuals were hospitalized and 5028 (22.7%) had an ED presentation within 90 days. Predictors of hospitalization included: being a man (hospitalization sHR = 1.33, 95% CI 1.26–1.42), ≥3 urgent after-hours attendances (hospitalization sHR = 1.21, 95% CI 1.06–1.39), increasing frailty index score (hospitalization sHR = 1.19, 95% CI 1.11–1.28), individuals using glucocorticoids (hospitalization sHR = 1.11, 95% CI 1.02–1.20), sulfonamides (hospitalization sHR = 1.18, 95% CI 1.10–1.27), trimethoprim antibiotics (hospitalization sHR = 1.15, 95% CI 1.03–1.29), unplanned hospitalizations 30 days prior (hospitalization sHR = 1.13, 95% CI 1.04–1.23), and ED presentations 1 year prior (hospitalization sHR = 1.07, 95% CI 1.04–1.10). Similar predictors and hazard estimates were also observed for ED presentations. The hospitalization models out-of-sample predictive ability (C-index = 0.653, 95% CI 0.635–0.670) and ED presentations (C-index = 0.647, 95% CI 0.630–0.663) were moderate. Conclusions: One in five individuals with aged care eligibility assessments had unplanned hospitalizations and/or ED presentation within 90 days with several predictors identified at the time of aged care eligibility assessment. This is an actionable period for targeting at-risk individuals to reduce hospitalizations. Refereed/Peer-reviewed

Records of century-scale climate variability in the Upper Midwest generally agree that moisture availability increased between 4000 and 3000 cal. yr BP (calendar years before present = 1950 CE), and that there were large, frequent droughts 1000–700 cal. yr BP followed by wetter/cooler conditions. Variability among regional sites, however, remains problematic. In this study we reconstruct climate on the Northwest Wisconsin Sand Plain (NWSP), USA, to identify potential climatic drivers of previously documented changes in vegetation and fire regimes. Oak pollen was replaced by pollen from xeric pine taxa at several sites on the NWSP ~1425 cal. yr BP, accompanied by a change to larger, less frequent charcoal peaks. Another major vegetation change occurred ~700 cal. yr BP, when pollen of the more mesic P. strobus L. (white pine) increased and charcoal influx decreased. We used a vegetation-independent lake-level record to determine whether long-term changes in moisture availability were associated with these ecosystem changes. Decreases in percent organic matter in shallow-water sediment cores from Cheney Lake indicate that the lake level decreased sharply ~1500 cal. yr BP, consistent with the interpretation that the changes in vegetation and fire regime were driven by a severe and previously undocumented drought. The lake level rose again, reaching approximately modern levels by 800–700 cal. yr BP, consistent with the hypothesis of cooler/wetter conditions in the Upper Midwest in the past ~700 years and with the expansion of mesic taxa on the NWSP 700 cal. yr BP.

Traumatic stress and posttraumatic stress disorder (PTSD) are overrepresented in urban African American communities, and associated with health risk behaviors such as tobacco use. Support and resources provided by churches may reduce trauma-related health risks. In the current study, we assessed weekly church attendance as a moderator of relations between (a) traumatic event exposure and probable PTSD, and (b) probable PTSD and tobacco use. Data were drawn from a health surveillance study conducted in seven churches located in Chicago's West Side. Participants (N = 1015) were adults from churches as well as the surrounding community. Trauma exposure was reported by 62% of participants, with 25% of those who experienced trauma reporting probable PTSD. Overall, more than one-third of participants (37.2%) reported current tobacco use. As compared with non-weekly church attendance, weekly church attendance was associated with a lower likelihood of PTSD (odds ratio [OR] = 0.41; 95% confidence interval [CI] = 0.26-0.62; p < .0001) and lower tobacco use overall (OR = 0.22; 95% CI = 0.16-0.30; p < .0001), but did not moderate the effect of trauma exposure on risk of PTSD, or the effect of PTSD on tobacco use. Findings support church attendance as a potential buffer of trauma-related stress.

We explored the perspectives of professionals working in health and aged care services in South Australia about factors that influenced successful transitions from hospital to home or residential aged care home for older people. We examined successful and recommended strategies that could support safe transitions following hospital discharge and reduce avoidable hospital admissions in South Australia.Nineteen professionals from acute, post-acute, primary, community and aged care settings in South Australia participated in semi-structured interviews. Qualitative content analysis was conducted.Participants reported that navigating service provision could be difficult, compounded by different funding arrangements for hospitals, community, primary care and aged care services. Some participants felt that there was an over-reliance on the hospital sector, leaving primary care and community-based services under-utilised to support hospital transitions. The importance of good communication between services and sectors was highlighted. Participants described different categories of services that supported safe transitions by supporting older people immediately post-discharge; services that provided support to stay at home in the weeks and months following discharge; and services that helped the person receive health care at locations other than hospitals or emergency departments when they were unwell. Participants noted that successful programs were not always maintained.Division of responsibility of aged and health-care services between state and national governance contributes to fragmentation of care in South Australia. Careful planning of transitions and coordination of services across sectors is required to ensure older people are supported in the months following discharge from hospital to reduce avoidable rehospitalisations.

Objectives Short sleep duration and poor sleep quality are more prevalent among African Americans (AAs) and may be a modifiable risk factor for cardiometabolic disorders. However, research is limited about sleep-related attitudes, beliefs, and practices among AAs. Our objective was to evaluate these practices and beliefs surrounding sleep among urban-dwelling AAs. Design Qualitative study comprised of five 90-minute focus groups using a semistructured interview guide. Setting Five churches located on the west side of Chicago. Participants Adults (N = 43) ages 25-75 years. Measurements Transcripts were voice recorded, transcribed, and then coded for content analysis using NVivo 12 Pro to capture themes in the discussions. Results Most participants (86%) reported sleeping less than the recommended 7 or more hours. The discrepancy between actual and desired sleep duration was nearly 3 hours per night. Participants reported that sleep is essential for mental and physical health. Napping and consuming caffeine were frequently reported techniques for coping with lack of sleep. Noise, physical discomfort, and stress were reported as barriers to sleep, and participants reported using TV and other electronics to cope with racing thoughts or worry. Many participants were diagnosed with or knew someone with obstructive sleep apnea, but few participants had been diagnosed with insomnia or were aware of nonpharmacologic insomnia treatments. Conclusion A cycle of stress/disruptive environment, stress, rumination at night, and coping by use of electronics and daytime napping may perpetuate sleep disparities in this community. Results suggest that sleep-related interventions should include stress reduction and environmental improvements in addition to the typical sleep hygiene–related behavioral recommendations.

PURPOSE:\ud Despite growth in rehabilitation research, implementing research findings into rehabilitation practice has been slow. This creates inequities for patients and is an ethical issue. However, methods to investigate and facilitate evidence implementation are being developed. This paper aims to make these methods relevant and accessible for rehabilitation researchers and practitioners.\ud \ud METHODS:\ud Rehabilitation practice is varied and complex and occurs within multilevel healthcare systems. Using a "road map" analogy, we describe how implementation concepts and theories can inform implementation strategies in rehabilitation. The roadmap involves a staged journey that considers: the nature of evidence; context for implementation; navigation tools for implementation; strategies to facilitate implementation; evaluation of implementation outcomes; and sustainability of implementation. We have developed a model to illustrate the journey, and four case studies exemplify implementation stages in rehabilitation settings.\ud \ud RESULTS AND CONCLUSIONS:\ud Effective implementation strategies for the complex world of rehabilitation are urgently required. The journey we describe unpacks that complexity to provide a template for effective implementation, to facilitate translation of the growing evidence base in rehabilitation into improved patient outcomes. It emphasizes the importance of understanding context and application of relevant theory, and highlights areas which should be targeted in new implementation research in rehabilitation. Implications for rehabilitation Effective implementation of research evidence into rehabilitation practice has many interconnected steps and a roadmap analogy is helpful in defining them. Understanding context for implementation is critically important and using theory can facilitate development of understanding. Research methods for implementation in rehabilitation should be carefully selected and outcomes should evaluate implementation success as well as clinical change. Sustainability requires regular revisiting of the interconnected steps.

Background The Needs in Recovery Assessment (NiRA) is a newly developed needs assessment tool, designed to identify the needs of people recovering from mental illness. This tool has been evaluated outside of the clinical context for validity and reliability. The aim of this study is to introduce the NiRA into clinical practice and to evaluate the value of the NiRA as an adjunct to service delivery from the perspectives of stakeholders and to evaluate the barriers and facilitators of embedding the NiRA in a mental health service. Methods The establishment of the NiRA in a tertiary mental health unit over a 6-month period will be evaluated using a multi-methods approach. Quantitative data will be collected using the NiRA itself and the Recovery Self-Assessment (RSA). Face-to-face interviews with service users and clinicians will be conducted following the initial completion of the NiRA, with a follow-up interview for service users on discharge from the service. Regular informal follow-up with clinicians throughout the study will support the introduction of the NiRA. Descriptive statistics will be used to analyse quantitative data, and descriptive qualitative methods will be used to analyse data from interviews. Discussion Aligning mental health services with recovery-oriented frameworks of care is imperative. The NiRA is a tool that has been designed in accordance with recovery principles and may assist services to be more recovery-oriented. If the NiRA is able to achieve the aims and objectives of this project, a larger implementation study will be conducted. Trial registration Australian and New Zealand Clinical Trial Registry (ANZCTR), ACTRN12621000316808

Older Black adults face a disproportionate burden of HIV prevalence, but less is known about racial disparities in age-related outcomes in HIV. We assessed the effect of HIV status and race on motor and pulmonary function, as well as how they contribute to mobility disability.Community-based study; Chicago, IL METHODS: Participants were 363 community-dwelling adults age ≥ 50 years, 48% living with HIV, and 68% Black. Participants with HIV were recruited from a specialty HIV clinic, and participants without HIV (comparable on key demographic, lifestyle, and behavioral characteristics) were recruited from the community. Measures included motor function summarized by 10 motor performance measures, pulmonary function summarized by 3 measures assessed using handheld spirometry, and self-reported mobility disability.In fully adjusted linear models, HIV was associated with better motor (β = 9.35, p lt; 0.001) and pulmonary function (β = 16.34, p lt; 0.001). For pulmonary function, the effect of HIV status was moderated by race (interaction between Black race and HIV status: β = - 11.66, p = 0.02), indicating that better pulmonary function among participants with HIV was less evident among Black participants. In fully adjusted models, odds of mobility disability did not differ by race, HIV status, or pulmonary function; better motor function was associated with lower odds of mobility disability (OR = 0.91 per 1-point higher, 95% CI 0.88-0.93).Better motor and pulmonary function exhibited by participants with HIV could reflect access to medical care. Racial differences in lung function among participants with HIV indicate potential disparities in prevention or treatment of pulmonary disease or underlying risk factors.

Background Repeated admission to hospital can be stressful for older people and their families and puts additional pressure on the health care system. While there is some evidence about strategies to better integrate care, improve older patients’ experiences at transitions of care, and reduce preventable hospital readmissions, implementing these strategies at scale is challenging. This program of research comprises multiple, complementary research activities with an overall goal of improving the care for older people after discharge from hospital. The program leverages existing large datasets and an established collaborative network of clinicians, consumers, academics, and aged care providers. Methods The program of research will take place in South Australia focusing on people aged 65 and over. Three inter-linked research activities will be the following: (1) analyse existing registry data to profile individuals at high risk of emergency department encounters and hospital admissions; (2) evaluate the cost-effectiveness of existing ‘out-of-hospital’ programs provided within the state; and (3) implement a state-wide quality improvement collaborative to tackle key interventions likely to improve older people’s care at points of transitions. The research is underpinned by an integrated approach to knowledge translation, actively engaging a broad range of stakeholders to optimise the relevance and sustainability of the changes that are introduced. Discussion This project highlights the uniqueness and potential value of bringing together key stakeholders and using a multi-faceted approach (risk profiling; evaluation framework; implementation and evaluation) for improving health services. The program aims to develop a practical and scalable solution to a challenging health service problem for frail older people and service providers.

To identify health professionals awareness of stroke rehabilitation guidelines, and factors perceived to influence guideline use internationally.Online survey study. Open-ended responses were thematically analysed, guided by the Consolidated Framework for Implementation Research.Data from 833 respondents from 30 countries were included. Locally developed guidelines were available in 22 countries represented in the sample. Respondents from high-income countries were more aware of local guidelines compared with respondents from low- and middle-income countries.Local contextual factors such as management support and a culture of valuing evidence-based practice were reported to positively influence guideline use, whereas inadequate time and shortages of skilled staff inhibited the delivery of guideline-recommended care. Processes reported to improve guideline use included education, training, formation of workgroups, and audit-feedback cycles. Broader contextual factors included accountability (or lack thereof) of health professionals to deliver rehabilitation consistent with guideline recommendations.While many health professionals were aware of clinical guidelines, they identified multiple barriers to their implementation. Efforts should be made to raise awareness of local guidelines in low- and middle-income countries. More attention should be paid to addressing local contextual factors to improve guideline use internationally, going beyond traditional strategies focused on individual health professionals.IMPLICATIONS FOR REHABILITATIONSystems are required so people and organisations are held accountable to deliver evidence-based care in stroke rehabilitation.Locally developed stroke rehabilitation guidelines should be promoted to boost awareness of these guidelines in low- and middle-income countries.In all regions, strategies to influence or adapt to the local setting, are required to optimise guideline use.

Background: Increasing physical activity (PA) and improving diet quality are opportunities to improve secondary stroke prevention, but access to appropriate services is limited. Interventions co-designed with stroke survivors and delivered by telehealth are a potential solution. Aim: The aim of this study is to test the feasibility, safety, and potential efficacy of a 6-month, telehealth-delivered PA and/or dietary (DIET) intervention. Methods: Pilot randomized trial. 80 adults with previous stroke who are living at home with Internet access and able to exercise will be randomized in a 2 × 2 factorial (4-arm) pilot randomized, open-label, blinded outcome assessment trial to receive PA, DIET, PA + DIET, or control interventions via telehealth. The PA intervention aims to support participants to meet the minimum recommended levels of PA (150 min/week moderate exercise), and the DIET intervention aims to support participants to follow the AusMed (Mediterranean-style) diet. The control group receives usual care plus education about PA and healthy eating. The co-primary outcomes are feasibility (proportion and characteristics of eligible participants enrolled and proportion of scheduled intervention sessions attended) and safety (adverse events) at 6 months. The secondary outcomes include recurrent stroke risk factors (blood pressure, physical activity levels, and diet quality), fatigue, mood, and quality of life. Outcomes are measured at 3, 6, and 12 months. Conclusion: This trial will produce evidence for the feasibility, safety, and potential effect of telehealth-delivered PA and DIET interventions for people with stroke. Results will inform development of an appropriately powered trial to test effectiveness to reduce major risk factors for recurrent stroke. Trial registration: ACTRN12620000189921.

BackgroundRepeated admission to hospital can be a stressful and negative experience for older people and their families and puts additional pressure on the health care system. While there is evidence about strategies to better integrate care and improve older patients' experiences at transitions of care, thus helping to reduce hospital readmissions, implementing these strategies at scale is challenging. The objective of this project is to improve the pathways of care for older people after discharge from hospital by leveraging existing large datasets and an established collaborative network of clinicians, consumers, academics, and aged care providers. MethodsThe project will be undertaken in the state of South Australia and focuses on people aged 65 and over. A mixed methods approach will be adopted, with three inter-linked work packages that aim to: analyse existing registry data to profile individuals at high risk of emergency department encounters and hospital admissions; evaluate the effectiveness and cost-effectiveness of existing ‘out-of-hospital’ programs provided within the state; implement and evaluate a statewide quality improvement collaborative to tackle key interventions likely to improve older people’s care at points of transitions. The study is underpinned by an integrated approach to knowledge translation, with active engagement of a broad range of stakeholders throughout, to optimize the relevance and sustainability of the changes that are introduced. DiscussionThis project highlights the uniqueness and potential value of a multi-faceted approach (risk profiling; evaluation framework; implementation and evaluation) to improving health services. The project aims to develop a practical and scalable solution to a challenging health service problem for frail older people and service providers.Trial registrationNot applicable.

Objective The COVID-19 pandemic has seen a rapid shift to telehealth-delivered physical therapy services. Common impairments after stroke create unique challenges when providing rehabilitation via telehealth, particularly when it involves activities undertaken in weight-bearing or standing positions, including walking training. Our scoping review maps the evidence regarding safety, efficacy, and feasibility of remotely supervised telehealth interventions involving activities undertaken in weight-bearing or standing positions for people after stroke. Methods Searches of relevant databases for primary research studies were conducted using keywords relating to exercise and telehealth. Studies of stroke survivors undertaking interventions involving activities in weight-bearing or standing positions, supervised in real-time via telehealth were included. Two reviewers independently appraised all studies. Data were charted by one reviewer, checked by another, and results synthesized narratively. Results Seven studies (2 randomized trials, 1 mixed-methods, and 4 pre-post studies) were included, involving 179 participants. Some studies included stroke survivors with cognitive impairment, and 2 (29%) studies included only participants who walked independently. Adherence (reported in 3 studies) and satisfaction (reported in 4 studies) were good, and no serious adverse events (data from 4 studies) related to interventions were reported. Strategies to overcome technological barriers were used to optimize intervention safety and feasibility, along with physiological monitoring, caregiver assistance, and in-person exercise prescription. However, there is limited high-quality evidence of efficacy. Conclusions We identified strategies used in research to date that can support current practice. However, urgent research is needed to ensure that stroke survivors are receiving evidence-based, effective services. Impact The COVID-19 pandemic has necessitated a rapid shift to telerehabilitation services for people with stroke, but there is little evidence to guide best practice. Our review provides practical guidance and strategies to overcome barriers and optimize safety and adherence for telehealth interventions involving activities in weight-bearing or standing positions.

Hypertension is a chronic condition that disproportionately affects African Americans. Managing high blood pressure (HBP) requires adherence to daily medication. However, many patients with hypertension take their HBP medication inconsistently, putting them at heightened risk of heart disease. Researchers have shown that these health risks are greater for African Americans than for Caucasians. In this article, we examine barriers and facilitators of medication adherence among urban African Americans with hypertension. We interviewed 24 African Americans with hypertension (58.5% women, average age 59.5 years) and conducted a comprehensive thematic analysis. Twenty-two barriers and 32 facilitators to medication adherence emerged. Barriers included side effects and forgetting while facilitators included reminders, routines, and social support. Using this data, we developed a diagram of theme connectedness of factors that affect medication adherence. This diagram can guide multi-level HBP intervention research that targets African Americans to promote medication adherence, prevent heart disease, and reduce ethnic and racial health disparities.

Objective To test whether a previously tested, small-changes weight loss program could be translated for use in African American churches. Methods The program consisted of 12 group sessions held weekly at a partner church. Key intervention messages were disseminated via Facebook. A single-arm pretest-posttest evaluation included assessments at baseline, program completion (3-month), and after three months with no contact (6-month). Results Participants (N = 17; 16 women, age 57.5±12.1 years, body mass index 36.5 kg/m2±5.4, hemoglobin A1c 6.3±0.5, blood pressure 132±14/82±7) attended an average of 77% (mdn=9) of treatment sessions and 94% and 100% completed the 3- and 6-month assessment visits. All participants reported they were "somewhat" or "very satisfied" with the program. There was minimal interaction with Facebook with an average of 0.5 comments and 3.9 reactions per post. Three- and six-month reductions (all p's≤.01) were observed for weight (mdn=-2.7 kg; mdn=-2.6 kg), waist circumference (mdn=-3.8cm; mdn=-5.1cm), and hemoglobin A1c (mdn=-0.5; mdn=-0.3). At 3-months, there were significant reductions in systolic (mdn=-10.7 mmHg) and diastolic blood pressure (mdn=-8.0) but not at 6 months. Conclusions This study suggests that a faith-based, faith-placed intervention utilizing a small-changes approach in African American churches may achieve sustained weight loss in parishioners with obesity.

Objective: To identify factors associated with receiving acute goal-directed treatment, being assessed for ongoing rehabilitation,and receiving post-acute rehabilitation after having a stroke. Design: Retrospective analysis of National Stroke Audit data for patients with acute stroke treated at Australian hospitals during 1 September 2014 – 28 February 2015. Setting, participants: 112 Australian hospitals that admit adults with acute stroke. Main outcomes: Associations between patient-related and organisational factors and the provision of rehabilitation interventions. Results: Data for 3462 patients were eligible for analysis; their median age was 74 years, 1962 (57%) were men, and 2470 (71%) had received care in a stroke unit. 2505 patients (72%) received goal-directed treatment during their acute admission; it was not provided to 364 patients (10.5%) who were responsive, had not fully recovered, and did not refuse treatment. Factors associated with higher odds of receiving goal-directed treatment included goal-setting with the patient and their family (odds ratio [OR], 6.75;95% CI, 5.07–8.90) and receiving care in a stroke unit (OR, 2.08;95% CI, 1.61–2.70). 1358 patients (39%) underwent further rehabilitation after discharge from acute care; factors associated with receiving post-acute rehabilitation included care in a stroke unit(OR, 1.73; 95% CI, 1.34–2.22) and having an arm or speech deficit.Dementia was associated with lower odds of receiving acute goal-directed treatment (OR, 0.49; 95%, 0.33–0.73) and post-acute rehabilitation (OR, 0.43; 95%, 0.30–0.61). Conclusions: Access to stroke units and to early and ongoing rehabilitation for patients after stroke can be improved in Australia,both to optimise outcomes and to reduce the burden of care on underresourced community and primary care providers. Refereed/Peer-reviewed

The developmental fate of hematopoietic stem and progenitor cells is influenced by their physiological context. Although most hematopoietic stem and progenitor cells are found in the bone marrow of the adult, some are found in other tissues, including the spleen. The extent to which the fate of stem cells is determined by the tissue in which they reside is not clear. In this study, we identify a new progenitor population, which is enriched in the mouse spleen, defined by cKit+CD71lowCD24high expression. This previously uncharacterized population generates exclusively myeloid lineage cells, including erythrocytes, platelets, monocytes, and neutrophils. These multipotent progenitors of the spleen (MPPS) develop from MPP2, a myeloid-biased subset of hematopoietic progenitors. We find that NR4A1, a transcription factor expressed by myeloid-biased long term-hematopoietic stem cells, guides the lineage specification of MPPS. In vitro, NR4A1 expression regulates the potential of MPPS to differentiate into erythroid cells. MPPS that express NR4A1 differentiate into a variety of myeloid lineages, whereas those that do not express NR4A1 primarily develop into erythroid cells. Similarly, in vivo, after adoptive transfer, Nr4a1-deficient MPPS contribute more to erythrocyte and platelet populations than do wild-type MPPS. Finally, unmanipulated Nr4a1−/− mice harbor significantly higher numbers of erythroid progenitors in the spleen compared with wild-type mice. Together, our data show that NR4A1 expression by MPPS limits erythropoiesis and megakaryopoeisis, permitting development to other myeloid lineages. This effect is specific to the spleen, revealing a unique molecular pathway that regulates myeloid bias in an extramedullary niche.

Supplemental Digital Content is available in the text., IMPORTANCE: Studying interhospital transfer of critically ill patients with coronavirus disease 2019 pneumonia in the spring 2020 surge may help inform future pandemic management. OBJECTIVES: To compare outcomes for mechanically ventilated patients with coronavirus disease 2019 transferred to a tertiary referral center with increased surge capacity with patients admitted from the emergency department. DESIGN, SETTING, PARTICIPANTS: Observational cohort study of single center urban academic medical center ICUs. All patients admitted and discharged with coronavirus disease 2019 pneumonia who received invasive ventilation between March 17, 2020, and October 14, 2020. MAIN OUTCOME AND MEASURES: Demographic and clinical variables were obtained from the electronic medical record. Patients were classified as emergency department admits or interhospital transfers. Regression models tested the association between transfer status and survival, adjusting for demographics and presentation severity. RESULTS: In total, 298 patients with coronavirus disease 2019 pneumonia were admitted to the ICU and received mechanical ventilation. Of these, 117 were transferred from another facility and 181 were admitted through the emergency department. Patients were primarily male (64%) and Black (38%) or Hispanic (45%). Transfer patients differed from emergency department admits in having English as a preferred language (71% vs 56%; p = 0.008) and younger age (median 57 vs 61 yr; p < 0.001). There were no differences in race/ethnicity or primary payor. Transfers were more likely to receive extracorporeal membrane oxygenation (12% vs 3%; p = 0.004). Overall, 50 (43%) transferred patients and 78 (43%) emergency department admits died prior to discharge. There was no significant difference in hospital mortality or days from intubation to discharge between the two groups. CONCLUSIONS AND RELEVANCE: In a single-center retrospective cohort, no significant differences in hospital mortality or length of stay between interhospital transfers and emergency department admits were found. While more study is needed, this suggests that interhospital transfer of critically ill patients with coronavirus disease 2019 can be done safely and effectively.

Bedrock ground stone features, found throughout the world, are particularly concentrated in the canyons of the Southern Plains of North America. Morphological analysis offers powerful tools for developing descriptions of bedrock ground stone (BGS) which can be used to discuss how prehistoric landscapes were inhabited. Metric representations of morphological variation can be used to test hypotheses about the nature of BGS features, which are often difficult to investigate and analyze. This paper presents a morphological approach to describe and analyze BGS surfaces in a side canyon of southeastern Colorado which can be applied by researchers to datasets in other regions. Results indicate that while variation exists, the BGS design (as determined by shape and size) are similar across the side canyon supporting the hypothesis that the canyon was occupied by a group of closely related people through time; although not all sites were used in the same manner.

Bedrock ground stone features are ubiquitous along the canyons of the Chaquaqua Plateau in southeastern Colorado, U.S.A, however, we know very little about their distribution, function or relationship to the regional archaeology. While some argue that prehistoric inhabitants of southeastern Colorado constructed permanent milling spaces to process local food resources, others think they may have processed corn. Most assume they were used by groups of women to process food resources together. Recent research suggests that the bedrock ground stone features differ depending on where they occur on the landscape, but may also vary because of socio-cultural ideals, as yet unknown. Sub-features are used as heuristic categories to discuss ways in which bedrock ground stone features are indicative of social processes such as group work or social reproduction of knowledge through collective labor. In this paper, we use close-range photogrammetry to examine the use of the sub-feature category as a means to refine the archaeology of bedrock ground stone surfaces in the region. Results illustrate that CRP offers an objective means to critically analyze the relationship of ground stone surfaces on bedrock features.

The aim of this study was to describe differences in long-term outcomes for patients discharged to inpatient rehabilitation facilities (IRFs) following stroke compared to patients discharged directly home or to residential aged care facilities (RACFs). Cohort study. Data from the Australian Stroke Clinical Registry were linked to hospital admissions records and the national death index. Main outcomes: death and hospital readmissions up to 12 months post-admission, Health-related Quality of Life (HRQoL) 90-180 days post-admission. Of 8,555 included patients (median age 75, 55% male, 83% ischemic stroke), 4,405 (51.5%) were discharged home, 3,442 (40.2%) to IRFs, and 708 (8.3%) to RACFs. No between-group differences were observed in hazard of death between patients discharged to IRFs versus home. Fewer patients discharged to IRFs were readmitted to hospital within 90, 180 or 365-days compared to patients discharged home (adjusted subhazard ratio [aSHR]:90-days 0.54, 95%CI 0.49, 0.61; aSHR:180-days 0.74, 95%CI 0.67, 0.82; aSHR:365-days 0.85, 95%CI 0.78, 0.93). Fewer patients discharged to IRFs reported problems with mobility compared to those discharged home (adjusted OR 0.54, 95%CI 0.47, 0.63), or to RACFs (aOR 0.35, 95%CI 0.25, 0.48). Overall HRQoL between 90-180 days was worse for people discharged to IRFs versus those discharged home and better than those discharged to RACFs. Several long-term outcomes differed significantly for patients discharged to different settings after stroke. Patients discharged to IRFs reported some better outcomes than people discharge directly home despite having markers of more severe stroke.Implications for rehabilitationPeople with mild strokes are usually discharged directly home, people with moderate severity strokes to inpatient rehabilitation, and people with very severe strokes are usually discharged to residential aged care facilities.People discharged to inpatient rehabilitation reported fewer problems with mobility and had a reduced risk of hospital readmission in the first year post-stroke compared to people discharged directly home after stroke.The median self-reported health-related quality of life for people discharged to residential aged care equated to ‘worst health state imaginable’. People with mild strokes are usually discharged directly home, people with moderate severity strokes to inpatient rehabilitation, and people with very severe strokes are usually discharged to residential aged care facilities. People discharged to inpatient rehabilitation reported fewer problems with mobility and had a reduced risk of hospital readmission in the first year post-stroke compared to people discharged directly home after stroke. The median self-reported health-related quality of life for people discharged to residential aged care equated to ‘worst health state imaginable’.

West Side Alive (WSA) is a partnership among pastors, church members and health researchers with the goal of improving health in the churches and surrounding community in the West Side of Chicago, a highly segregated African American area of Chicago with high rates of premature mortality and social disadvantage. To inform health intervention development, WSA conducted a series of health screenings that took place in seven partner churches. Key measures included social determinants of health and healthcare access, depression and PTSD screeners, and measurement of cardiometabolic risk factors, including blood pressure, weight, cholesterol and hemoglobin A1C (A1C). A total of 1106 adults were screened, consisting of WSA church members (n = 687), members of the local community served by the church (n = 339) and 80 individuals with unknown church status. Mean age was 52.8 years, 57% were female, and 67% reported at least one social risk factor (e.g. food insecurity). Almost all participants had at least one cardiovascular risk factor (92%), including 50% with obesity, 79% with elevated blood pressure and 65% with elevated A1C. A third of participants experienced ≥ 4 potentially traumatic events and 26% screened positive for depression and/or post-traumatic stress disorder. Participants were given personalized health reports and referred to services as needed. Information from the screenings will be used to inform the design of interventions targeting the West Side community and delivered in partnership with the churches. Sharing these results helped mobilize community members to improve their own health and the health of their community.

Purpose: To identify perceived enablers and barriers that may influence the implementation of water protocols (WPs) as an intervention for dysphagia in acute stroke settings. Method: Semi-structured interviews were conducted with nine nurses, eight speech-language pathologists (SLPs), five doctors and four dietitians working in acute stroke units in a major city in Australia. Data were thematically analysed and themes were mapped to the Theoretical Domains Framework. Result: Ten barriers and nine enablers were identified. Key barriers were: nurses lack oral care skills and agency nurses lack stroke-specific skills; only SLPs are perceived to be involved with WPs; WP rules will not get followed and may lead to adverse patient outcomes; WPs increase nursing workload; transient workforce impacts efficiency of implementation; and established culture of using thickened fluids. Key enablers were: patients would benefit from WPs; communication and education systems are already in place; acute hospital brings unique benefits; and peer support and modelling support implementation. Conclusion: The perceptions of barriers and enablers to implementation of WPs can be used to inform future studies designed to evaluate the safety and efficacy of WPs and subsequently facilitate their uptake in acute stroke as an alternate dysphagia management strategy.

Literature is lacking on the impact of diet quality on glycemic control in those with type 2 diabetes (T2DM), especially African Americans with T2DM. 211 African American adults with T2DM and A1c ≥ 7.0% were randomized into intervention (26 sessions) and control (2 sessions) for an 18-month randomized community-based control trial, Lifestyle Improvement Through Food and Exercise (LIFE), assessing the impact of culturally-relevant lifestyle education on glycemic control. Participants lived in low-income Chicago-area neighborhoods and had regular medical care. Diet quality was assessed via 24-hour recall and translated into the Alternative Healthy Eating Index 2010 (AHEI-2010). AHEI-2010 total scores (0-110: higher score=healthier pattern) for intervention (n=95) and control (n=92) respectively were baseline: 47.4 ± 1.1 vs. 51.2 ± 1.1, 12 months: 51.4 ± 1.0 vs. 50.5 ± 1.1, 18 months: 50.3 ± 1.2 vs. 51.6 ± 1.2. Using repeated measures ANOVA, the AHEI-2010 18 month increase from baseline was significantly higher in the intervention group, df (2, 370), F (3.18), p=0.043. A1c% decline over 18 months (intervention: 9.1 ± 0.2 to 8.5 ± 0.2; control: 8.9 ± 0.2 to 8.6 ± 0.2, p Disclosure B. Tahsin: None. K.S. Keim: None. L. Fogelfeld: None. L. Fogg: None. E. Lynch: None. Funding National Institutes of Health

BACKGROUND: African Americans suffer more than non-Hispanic whites from type 2 diabetes, but diabetes self-management education (DSME) has been less effective at improving glycemic control for African Americans. Our objective was to determine whether a novel, culturally tailored DSME intervention would result in sustained improvements in glycemic control in low-income African-American patients of public hospital clinics. RESEARCH DESIGN AND METHODS: This randomized controlled trial (n = 211) compared changes in hemoglobin A1c (A1c) at 6, 12, and 18 months between two arms: (1) Lifestyle Improvement through Food and Exercise (LIFE), a culturally tailored, 28-session community-based intervention, focused on diet and physical activity, and (2) a standard of care comparison group receiving two group DSME classes. Cluster-adjusted ANCOVA modeling was used to assess A1c changes from baseline to 6, 12, and 18 months, respectively, between arms. RESULTS: At 6 months, A1c decreased significantly more in the intervention group than the control group (− 0.76 vs − 0.21%, p = 0.03). However, by 12 and 18 months, the difference was no longer significant (12 months − 0.63 intervention vs − 0.45 control, p = 0.52). There was a decrease in A1c over 18 months in both the intervention (β = − 0.026, p = 0.003) and the comparison arm (β = − 0.018, p = 0.048) but no difference in trend (p = 0.472) between arms. The intervention group had greater improvements in nutrition knowledge (11.1 vs 6.0 point change, p = 0.002) and diet quality (4.0 vs − 0.5 point change, p = 0.018) while the comparison group had more participants with improved medication adherence (24% vs 10%, p