In patients with haemophilia, evidence suggests that the physical examination alone is not sensitive enough to detect small amounts of blood within a joint. Attention has shifted to methods of improving the sensitivity of the physical examination through adding diagnostic modalities such as point-of-care ultrasonography (POC-US). Proficiency with the physical examination and understanding of the role of POC-US are important competencies for physiotherapists. Despite training, implementation of POC-US by physiotherapists in haemophilia treatment centres in Canada has been mixed.
Using a theory-based approach, the aim of the current study is to achieve expert consensus regarding the barriers to physiotherapy performed POC-US in haemophilia treatment centres in Canada using a modified Delphi approach.
Materials and Methods
Using the Knowledge-to-Action Framework and the Consolidated Framework for Implementation Research (CFIR), a modified Delphi approach was completed using the Modified BARRIERS Scale (MBS). Participants were blinded and consensus was reached over three rounds at the Canadian Hemophilia Society’s annual three-day conference.
Twenty-two physiotherapists participated; 20 participants completed Round 1, and 21 completed Rounds 2 and 3. Four items of the MBS reached consensus: 1) The physiotherapist does not have time to read research related to POC-US; 2) The physiotherapist is isolated from knowledgeable colleagues with whom to discuss POC-US; 3) Administration will not allow POC-US implementation; 4) There is insufficient time on the job to implement new ideas. All four consensus items can be mapped to one domain of the CFIR: the inner setting.
The haemophilia treatment centre within a healthcare organisation appears to be an important target for addressing barriers to the implementation of physiotherapy performed POC-US.
Feeder-free monolayer culture and the suspension culture of embryoid bodies (EB) followed by
adherent culture, rosette selection, and expansion are 2 methods for deriving neural progenitor cells (NPCs). Direct comparison of these 2 methods has not yet been reported.
To compare the influence of NPC derivation methods on the properties of NPCs derived from rhesus monkey (Macaca mulatta) embryonic stem cells (rhESCs).
rhESCs were used to derive NPC lines using 2 different methods. EB were produced from a suspension culture of rhESC clumps and rhESCs were cultured in feeder-free monolayers on poly-L-ornithine/laminin coated plates. NPCs were derived by exposure to induction factors. Cell morphology, neural and nonneural lineage markers were evaluated. We measured the expression of nuclear receptor tailless (TLX), which acts as repressor of glial fibrillary acidic protein (GFAP) expression.
NPCs were successful derived using either method, with homogenous populations based on the
expression of nestin (>97%) and Pax6 (>99%) as shown by flow cytometry. No significant difference in NPC specific markers or ability to differentiate into neurons in vitro was found between the methods. However, the expression of GFAP was >400-fold higher in cells produced by the feeder-free method. This distinction was consistent with the lower expression of TLX.
NPCs derived by feeder-free and EB methods share similar morphology and properties. The elevated expression of GFAP and reduced expression of TLX in NPCs derived using the feeder-free method may explain their greater heterogeneity and tendency to differentiate toward cells of an astrocyte lineage.
Adherence to treatment recommendations in patients with chronic disease is complex and is influenced by numerous factors. Haemophilia is a chronic disease with reported levels of adherence ranging from 17–82%.
Based on the theoretical foundation of the World Health Organization Multidimensional Adherence Model, the objective of this study was to identify the best combination of the variables infusion frequency, annualised bleed rate, age, distance to haemophilia treatment centre (HTC) and Haemophilia Joint Health Score (HJHS), to predict adherence to treatment recommendations in patients with haemophilia A and B on home infusion prophylaxis in Canada.
A one-year retrospective cohort study investigated adherence to treatment recommendations using two measures: 1) subjective report via home infusion diaries, and 2) objective report of inventory ordered from Canadian Blood Services. Stepwise regression was performed for both measures.
Eighty-seven patients with haemophilia A and B, median age 21 years, were included. Adherence for both measures was 81% and 93% respectively. The sample consisted largely of patients performing an infusion frequency of every other day (34%). Median scores on the HJHS was 10.5; annualised bleed rate was two. Distance to the HTC was 51km. Analysis of the objective measure weakly supported greater infusion frequency as a treatment-related factor for the prediction of lower adherence, however the strength of this relationship was not clinically relevant (R2=0.048). For the subjective measure, none of the explanatory variables were significant.
Adherence is a multifaceted construct. Despite the use of theory, most of the variance in adherence to treatment recommendations in this sample of patients with haemophilia remains unknown. Further research on other potential predictors of adherence, and possible variables and relationships within factors of the MAM is required.