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The purpose of this scoping review is to map the existing evidence that describes strategies to improve handover from the acute care to rehabilitation settings. Poor handover processes have been associated with preventable errors, delays in care, and adverse patient outcomes. Effective physician-to-physician handover during transitions of care is critical to ensuring patient safety and optimizing clinical outcomes. Physician handover between acute and rehabilitation care settings is particularly complicated, as it requires transferring detailed and timely information for continuity of care for medically and/or surgically complex patients between components of healthcare systems with different cultures and goals of care. Despite numerous studies being published on handover, there has yet to be a synthesis of the existing literature that seeks to explore handovers across acute to rehabilitation settings as well as how care transitions can be improved. This scoping review aims to map the existing evidence on physician-to-physician handover from acute care to rehabilitation. This review will be conducted following the Joanna Briggs Institute (JBI) framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. A comprehensive search will be performed across the following electronic databases: MEDLINE(R) ALL (Ovid), Embase Classic + Embase (Ovid), APA PsycINFO (Ovid), Cochrane Central Register of Controlled Trials (Ovid), Emcare (Ovid), CINAHL Ultimate (EBSCO) and Web of Science (Clarivate). All rounds of screening, data extraction, and data synthesis will be conducted independently with each stage performed in duplicate. The extracted data will be summarized both quantitively with descriptive statistics and qualitatively using content analysis. Qualitative and quantitative studies published in English that discuss physician-physician handover from acute care to rehabilitation settings will be included. All geographical areas will be considered. Case reports, case series, commentaries, protocols, opinion pieces (editorials), or abstracts from conferences will be excluded.

Here, we examine the effect of long-term pH differences and short-term pH change on N₂O emissions from soil, and the microbial source (ammonia oxidation versus denitrification) of ¹⁵N-N₂O emissions. ¹⁵N-fertiliser (20 g N m⁻²; 10 atom% excess ¹⁵N) was applied to (1) a silt loam soil of pH 7 held at 50% and 65% water-filled pore space (WFPS) (experiment 1) and (2) a loamy sand soil maintained at pH 4.5 and pH 7 for over 40 years (experiment 2). Soils were limed with CaCO₃ or acidified with H₂SO₄, and comparisons were made with unadjusted soils. Ammonia oxidation was the main microbial source of ¹⁵N-N₂O in soils limed to pH 7.0-8.1, unadjusted pH 7.1 (Experiment 1) and long-term pH 7 (experiment 2) soils. Eighty percent of ¹⁵N-N₂O from the long-term pH 4.5 soil (experiment 2) was derived from denitrification suggesting a possible inhibition of N₂O reduction. Short-term acidification to pH 5.6 or 4.3 lowered N₂O emissions. Liming of the pH 4.5 soil resulted in over four times greater N₂O emission (11 mg ¹⁴⁺¹⁵N-N₂O m⁻² over 41 days) than from the long-term pH 7.0 soil (experiment 2), with an associated increase in ammonia oxidiser-N₂O and decrease in denitrifier-N₂O production. This is the first report of a pH-induced change in microbial source of N₂O. Our results highlight the importance of distinguishing between short- and long-term effects of pH management when predicting N₂O emissions from soil, as they exhibit predominance of different microbial groups in N₂O production, with likely adaptation of the microbial community.

PurposeThe aim of this study was to update the clinical practice guidelines for the use of agents for the prevention and/or treatment of gastrointestinal mucositis (GIM).MethodsA systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society for Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. Based on the evidence level, one of the following three guideline determinations was possible: Recommendation, Suggestion, and No Guideline Possible.ResultsA total of 78 papers across 13 interventions were examined of which 25 were included in the final review. No new guidelines were possible for any agent due to inadequate and/or conflicting evidence. Existing guidelines for probiotics and hyperbaric oxygen were unchanged.ConclusionsOf the agents studied for the prevention and treatment of GIM, the evidence continues to support use of probiotics containing Lactobacillus spp. for prevention of chemoradiotherapy and radiotherapy-induced diarrhea in patients with pelvic malignancy, and hyperbaric oxygen therapy to treat radiation-induced proctitis. Additional well-designed research is encouraged to enable a decision regarding palifermin, glutamine, sodium butyrate, and dietary interventions, for the prevention or treatment of GIM.

Cytotoxicity (i.e. cell death) is the core mechanism by which chemotherapy induces its anti-cancer effects. Unfortunately, this same mechanism underpins the collateral damage it causes to healthy tissues. The gastrointestinal tract is highly susceptible to chemotherapy’s cytotoxicity, resulting in ulcerative lesions (termed gastrointestinal mucositis, GI-M) that impair the functional capacity of the gut leading to diarrhea, anorexia, malnutrition and weight loss, which negatively impact physical/psychological wellbeing and treatment adherence. Preventing these side effects has proven challenging given the overlapping mechanisms that dictate chemotherapy efficacy and toxicity. Here, we report on a novel dietary intervention that, due to its localized gastrointestinal effects, is able to protect the intestinal mucosal from unwanted toxicity without impairing the anti-tumor effects of chemotherapy. The test diet (containing extensively hydrolyzed whey protein and medium chain triglycerides (MCTs)), was investigated in both tumor-naïve and tumor-bearing models to evaluate its effect on GI-M and chemo-efficacy, respectively. In both models, methotrexate was used as the representative chemotherapeutic agent and the diet was provided ad libitum for 14 days prior to treatment. GI-M was measured using the validated biomarker plasma citrulline, and chemo-efficacy defined by tumor burden (cm 3 /g body weight). The test diet significantly attenuated GI-M ( P  = 0.03), with associated reductions in diarrhea ( P  < 0.0001), weight loss ( P  < 0.05), daily activity ( P  < 0.02) and maintenance of body composition ( P  < 0.02). Moreover, the test diet showed significant impact on gut microbiota by increasing diversity and resilience, whilst also altering microbial composition and function (indicated by cecal short and brained chain fatty acids). The test diet did not impair the efficacy of methotrexate against mammary adenocarcinoma (tumor) cells. In line with the first model, the test diet minimized intestinal injury ( P  = 0.001) and diarrhea ( P  < 0.0001). These data support translational initiatives to determine the clinical feasibility, utility and efficacy of this diet to improve chemotherapy treatment outcomes.

This Review article approaches the area of targeted therapies from two angles: efficacy and side effects. The authors outline the successes that have been achieved in treating cancer with targeted therapies and also discuss the pitfalls and quality of life issues that still need to be addressed. The advent of targeted anticancer therapies over the past few decades has reinvigorated the field of cancer therapeutics, with the promise of increased cancer cure rates accompanied by decreased toxicity. But, has that promise been fulfilled? The short answer is definitely 'no', both because of disappointing tumor responses and unexpectedly high toxicity, as well as the extremely high financial cost of these agents. However, failing to completely fulfill initial promise does not mean that targeted therapies should be abandoned. Increased progression-free survival might ultimately lead to increased overall survival, and targeted therapies have changed the course of cancers such as breast, lung and renal. Therefore, we would argue that despite some disappointments, targeted therapies have a vital role in future cancer treatment. This Review will discuss the positives and negatives of targeted agents, and propose a way to optimize their use and development to ensure proper personalized cancer medicine that tailors not only the anticancer treatment, but also the antitoxicity strategies, to achieve the best outcome for the patient in terms of both quality and quantity of life. Key Points Incremental benefits of cancer treatments over the past few decades have substantially improved survival and mortality rates for many cancer types; however, treatment-related toxicity remains a large problem Targeted therapies have contributed considerably to anticancer benefits; however, co-expression of many targets on normal cells means that toxicity is still a problem Despite toxicities and costs, targeted therapies have such a positive impact on progression-free survival and overall cancer survival, as well as quality of life, that their continued use is justified To further support use of targeted therapies, more research needs to be done on toxicity profiling, toxicity mechanisms and long-term follow-up analyses More research into targeted agents and their toxicities will further contribute to the repertoire of anticancer treatments, building on past success Successful cancer treatment in the future will be multidisciplinary, allowing for maximization of tumor control with concomitant minimization of adverse effects and cost of treatment

Purpose The aim of this study was to review the available literature and define clinical practice guidelines for the use of agents for the prevention and treatment of gastrointestinal mucositis. Methods A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, and no guideline possible. Results A total of 251 clinical studies across 29 interventions were examined. Panel members were able to make one new evidence-based negative recommendation; two new evidence-based suggestions, and one evidence-based change from previous guidelines. Firstly, the panel recommends against the use of misoprostol suppositories for the prevention of acute radiation-induced proctitis. Secondly, the panel suggests probiotic treatment containing Lactobacillus spp., may be beneficial for prevention of chemotherapy and radiotherapy-induced diarrhea in patients with malignancies of the pelvic region. Thirdly, the panel suggests the use of hyperbaric oxygen as an effective means in treating radiation-induced proctitis. Finally, new evidence has emerged which is in conflict with our previous guideline surrounding the use of systemic glutamine, meaning that the panel is unable to form a guideline. No guideline was possible for any other agent, due to inadequate and/or conflicting evidence. Conclusions This updated review of the literature has allowed new recommendations and suggestions for clinical practice to be reached. This highlights the importance of regular updates.

Background/objectives Dietary carbohydrate quality and quantity fluctuate but it is unknown which attribute takes precedence in vascular health preservation. We investigated all four permutations of glycemic index (GI) and glycemic load (GL) on acute vascular and glycemic responses. Subjects/methods Twenty-one healthy adults were screened for this crossover trial. Seventeen (8 M:9 F; 26.7 ± 12.3 y; BMI 22.2 ± 2.8 kg/m 2 ) entered randomization and completed the study, receiving four isocaloric meals, varying in GI and GL, in random order at least 3 days apart. The four meals included either chickpeas (GI = 28, GL = 14, 50 g available carbohydrates (CHO)), a small potato portion (GI = 85, GL = 14, CHO = 17 g), pasta (GI = 45, GL = 42, CHO = 94 g) or a large potato portion (GI = 85, GL = 42, CHO = 50 g) as the source of carbohydrate. Augmentation index (AIx) and central and peripheral blood pressure were measured fasting, 1, 2, 3, and 4 h post-consumption. Capillary blood glucose was analyzed fasting, 15, 30, 45, 60, 90, 120, 180, and 240 min. Results A reduction in AIx from baseline was observed 4 h following the chickpeas (low GI–low GL) ( p  = 0.046). The incremental area under blood glucose curves were significantly higher 2 h post-consumption following high compared with low GL meals ( p  < 0.001). Despite doubling carbohydrates, there was no difference in glycemic response between the large potato (high GI–high GL) and the pasta (low GI–high GL) meals. No significant differences in AIx or blood pressure were seen between meals. Conclusions Low GI, low-carbohydrate meals may support a healthy vascular tone. Varying meal GI and GL results in different glycemic profiles, which are not necessarily predicted by carbohydrate content. Further investigations on cardiometabolic profiles to meals varying in GI and GL are warranted.

Background: Despite preventability, 20–50% of patients with acute spinal cord injury/disease (SCI/D) develop hospital-acquired pressure injuries (PIs). The Spinal Cord Injury Implementation and Evaluation Quality Care Consortium (SCI IEQCC) aimed to mitigate PI risk through patient-reported daily skin checks alongside usual care. Methods: This quality improvement initiative utilized an interrupted time series design, encompassing adults ≥ 18 years admitted for inpatient rehabilitation across five Ontario sites from 2020 to 2023. Patient demographics, etiology, and impairment data were obtained from a national registry, while participating sites gathered data on PI onset, location, and severity. Run charts depicted temporal trends, and statistical analyses, including chi-square and logistic regression, compared patients with and without PIs. Results: Data from 1767 discharged SCI/D patients revealed that 26% had ≥1 PI, with 59% being prevalent and 41% incident. Most severe PIs (stages III and IV and unstageable) were acquired prior to admission. Process indicator fidelity was reasonable at 68%. Patients with PIs experienced longer hospital stays, lower Functional Independence Measure (FIM) changes, and FIM efficiency during rehabilitation. Conclusions: PI prevalence is increasing, particularly sacral injuries at admission, while incident cases have decreased since 2021 due to regular skin checks. This trend calls for proactive health system interventions to reduce costs and improve patient outcomes.

PurposeRadiotherapy-induced gut toxicity (RIGT) is associated with significant diarrhoea, pain and rectal bleeding. Matrix metalloproteinases (MMPs) have been reported to be involved in chemotherapy-induced gut toxicity and RIGT following single-dose irradiation in vivo. We therefore proposed MMPs would be involved in the pathobiology of RIGT following fractionated irradiation.MethodsDark Agouti rats were treated with fractionated radiation (3 × 2.5 Gy/week for 6 weeks). Rats were killed at 3, 6 and 15 weeks to represent acute and chronic toxicities. Sections of jejunum and colon were immunostained for MMP-1, MMP-2, MMP-9 and MMP-14. Relative mRNA expression in jejunum and colon was quantified by RT-PCR for MMP-1, MMP-2, MMP-9 and MMP-14. Western blotting was also conducted on jejunum and colon tissue collected at week 6 to determine protein levels of pro- and active MMP-2.ResultsMMP-2 total protein levels, determined by western blotting, significantly increased in both the jejunum (p = 0.0359) and the colon (p = 0.0134) 6 weeks into the fractionated radiation schedule. MMP-1, MMP-2, and MMP-14 mRNA expression significantly increased in the jejunum. MMP-2 mRNA expression was also significantly increased in the colon. Immunostaining of MMP-2 was observed to be increased in both crypt enterocytes and the lamina propria.ConclusionsMMP-2 plays a role in the pathobiology of gastrointestinal toxicities following fractionated irradiation. Whilst MMP-1 and MMP-14 mRNA expression was increased, this occurred only in the jejunum, suggesting MMPs are differentially involved in RIGT depending on the intestinal region. Further studies are needed to elucidate the role these mediators play in the development and potentiation of RIGT.

BackgroundLaboratory overutilisation increases healthcare costs, and can lead to overdiagnosis, overtreatment and negative health outcomes. Discipline-specific guidelines do not support routine testing for Vitamin D and thyroid-stimulating hormone (TSH) in the inpatient rehabilitation setting, yet 94% of patients had Vitamin D and TSH tests on admission to inpatient rehabilitation at our institution. Our objective was to reduce Vitamin D and TSH testing by 25% on admission to inpatient Stroke, Spinal Cord Injury, Acquired Brain Injury and Amputee Rehabilitation units.MethodsA fishbone framework for root cause analysis revealed potential causes underlying overutilisation of Vitamin D and TSH testing. A series of Plan-Do-Study-Act (PDSA) cycles were introduced to target remediable factors, starting with an academic detailing intervention with key stakeholders that reviewed applicable clinical guidelines for each patient care discipline and the rationale for reducing admission testing. Simultaneously, computerised clinical decision support (CCDS) limited Vitamin D testing to specific criteria. Audit and feedback were used in a subsequent PDSA cycle. Frequency of Vitamin D and TSH testing on admission was the primary outcome measure. The number of electronic admission order caresets containing automatic Vitamin D and/or TSH orders before and after the interventions was the process measure. Rate of Vitamin D supplementation and changes in thyroid-related medication were the balancing measures.ResultsAfter implementation, 2.9% of patients had admission Vitamin D testing (97% relative reduction) and 53% of patients had admission TSH testing (43% relative reduction). Admission order caresets with prepopulated Vitamin D and TSH orders decreased from 100% (n=6) to 0%. The interventions were successful; similar to previous literature, CCDS was more effective than education and audit and feedback interventions alone. The interventions represent >$9000 annualised savings.