Critical success factors in inter-institutional project collaborations

Since its establishment in 2007, Ako Aotearoa: National Centre for Tertiary Teaching Excellence has funded over 150 projects focused on changing practice and improving learner outcomes through the three Regional Hub Project Funds (RHPF): Northern Region, Central Region and Southern. Project teams are encouraged to consult and collaborate with others leveraging what Huxham (1996) calls the ‘collaborative advantage’, achieved when something new is produced - perhaps an objective is met - that no single organisation could have produced. By mid-2014, the total number of completed projects supported by the Regional Hub Project Fund and published on Ako Aotearoa’s website which had involved inter-institutional project teams had reached 44. This report outlines an evaluation of the collaboration experience within these multi-organisation projects with the purpose of determining the factors which contribute to a successful project team and sustainable community of practice. The two overarching objectives were first, to address gaps in both organisational knowledge and the literature about inter-institutional collaborations and what makes them reach, exceed, or fail their potential to deliver long term value and benefits to participants; and second, to summarise the learnings from project teams’ experience of collaborative work to produce a resource for future teams. This investigation, from its inception, was intended to be both applied and practicable in its outcomes, with a high relevance to the wider tertiary education community; this ethos has guided all aspects of the project design and reporting. A four-phase enquiry was conducted, comprising 1) a document analysis of all completed RHPF projects to determine those which had involved inter-institutional project teams (n=44); 2) a literature review; 3) an online survey (n=41, representing a 34% response rate), and 4) interviews with invited participants (n=18). In addition, the report also recounts the research team’s own experience of establishing a good interinstitutional collaborative process, placing the researchers within the project as participants themselves: a deliberate and conscious approach to generate insights into useful tools, techniques and timing. The survey was adapted from an existing instrument for measuring collaboration effectiveness, the Wilder Collaboration Factors Inventory (n.d.) which generated a series of ranked responses per factor for each project (see Appendix A). By assigning a numerical value to these responses, high, medium and low-scoring projects were identified, enabling the team to ensure a cross-section of experiences were selected for follow-up interviews. Although this comparison was undertaken as part of the team’s decision-making, rather than for any external reporting, one important outcome can be shared: all 22 projects represented in the sample scored positively (between 1 and 79) within a range of -100 to +100. The final stage of survey data analysis was to aggregate individual factor scores across projects to identify the overall weighting for each of the 24 factors. Next, the 18 candidates for the semi-structured interviews identified from the survey responses were invited to share their experiences of inter-institutional collaborative project work. Ten question prompts (Appendix B) covered four stages in the collaboration: the precondition, or relationship-building period; the beginning, when the work is planned; the process-interaction stage; and the outcomes period of reflection, evaluation and change (Gray, 1989). These interviews were transcribed and coded for emerging themes. Survey results are presented as a brief discussion of the highest and lowest scoring factors, while interview results are collated under ten topic areas, with interview participants’ voice included throughout to allow readers a sense of the variety of experiences encompassed, and the impact these have had on those involved. A key finding was that 10 of the 18 interviewees were still collaborating with some or all members of the original team in activities such as research, resource development, co-authoring, co-teaching and copresenting, meaning that just over half the collaborative networks developed through RHPF projects were sustainable and had led to long-term significant and tangible benefits for team members. Other findings discussed in this report relate to the ‘trickle-down effect’ where informants described the way practitioner involvement in collaborative change projects led to learner benefits, and to specific approaches, issues and circumstances which either enabled or restricted the success of the collaboration. Results from all phases of the project were mined to identify the most important elements that make a collaboration work, again using the adapted Wilder Collaboration Factors Inventory (n.d.), and Gray’s (1989) collaboration stages as a framework. These elements then inform the main (and separate) output from this project: “Getting on: A Guide to Good Practice in Inter-Institutional Collaborative Projects”. This guide is available at https://akoaotearoa.ac.nz/research-register/list/critical-success-factors-inter-institutionalproject-collaborations and is intended to assist teams who are embarking on a new collaborative project

Perioperative research into memory (PRiMe), part 2:Adult burns intensive care patients show altered structure and function of the default mode network

BACKGROUND: Long-term cognitive impairment (LTCI) is experienced by up to two thirds of patients discharged from burns intensive care units (BICUs), however little is known about its neurobiological basis. This study investigated if patients previously admitted to BICU showed structural and functional MRI changes of the Default Mode Network (DMN).METHODS: Fifteen patients previously admitted to BICU with a significant burns injury, and 15 matched volunteers, underwent structural and functional MRI scans. Functional connectivity, fractional anisotropy and cortical thickness of the main DMN subdivisions (anterior DMN (aDMN), posterior DMN (pDMN) and right (rTPJ) and left (lTPJ) temporo-parietal junctions) were compared between patients and volunteers, with differences correlated against cognitive performance.RESULTS: Functional connectivity between rTPJ and pDMN (t = 2.91, p = 0.011) and between rTPJ and lTPJ (t = 3.18, p = 0.008) was lower in patients compared to volunteers. Functional connectivity between rTPJ and pDMN correlated with cognitive performance (r 2 =0.33, p &lt; 0.001). Mean fractional anisotropy of rTPJ (t = 2.70, p = 0.008) and lTPJ (T = 2.39, p = 0.015) was lower in patients but there was no difference in cortical thickness. CONCLUSIONS: Patients previously admitted to BICU show structural and functional disruption of the DMN. Since functional changes correlate with cognitive performance, this should direct further research into intensive-care-related cognitive impairment.</p

Perioperative research into memory (PRiMe), part 2: Adult burns intensive care patients show altered structure and function of the default mode network

Background: Long-term cognitive impairment (LTCI) is experienced by up to two thirds of patients discharged from Burns Intensive Care Units (BICU), however little is known about its neurobiological basis. This study investigated if patients previously admitted to BICU showed structural and functional MRI changes of the Default Mode Network (DMN). Methods: Fifteen patients previously admitted to BICU with a significant burns injury, and 15 matched volunteers, underwent structural and functional MRI scans. Functional connectivity, fractional anisotropy and cortical thickness of the main DMN subdivisions (anterior DMN (aDMN), posterior DMN (pDMN) and right (rTPJ) and left (lTPJ) temporo-parietal junctions) were compared between patients and volunteers, with differences correlated against cognitive performance. Results: Functional connectivity between rTPJ and pDMN (t = 2.91, p = 0.011) and between rTPJ and lTPJ (t = 3.18, p = 0.008) was lower in patients compared to volunteers. Functional connectivity between rTPJ and pDMN correlated with cognitive performance (r2 =0.33, p < 0.001). Mean fractional anisotropy of rTPJ (t = 2.70, p = 0.008) and lTPJ (T = 2.39, p = 0.015) was lower in patients but there was no difference in cortical thickness. Conclusions: Patients previously admitted to BICU show structural and functional disruption of the DMN. Since functional changes correlate with cognitive performance, this should direct further research into intensive care related cognitive impairment

Analysis of ageing-associated grey matter volume in patients with multiple sclerosis shows excess atrophy in subcortical regions

Age of onset in multiple sclerosis (MS) exerts an influence on the course of disease. This study examined whether global and regional brain volumes differed between “younger” and “older” onset MS subjects who were matched for short disease duration, mean 1.9 years and burden as measured by the MS Severity Score and relapses. 21 younger-onset MS subjects (age 30.4 ± 3.2 years) were compared with 17 older-onset (age 48.7 ± 3.3 years) as well as age-matched controls (n = 31, 31.9 ± 3.5 years and n = 21, 47.3 ± 4.0 years). All subjects underwent 3D volumetric T1 and T2-FLAIR imaging. White matter (WM) and grey matter (GM) lesions were outlined manually. Lesions were filled prior to tissue and structural segmentation to reduce classification errors. Volume loss versus control was predominantly in the subcortical GM, at > 13% loss. Younger and older-onset MS subjects had similar, strong excess loss in the putamen, thalamus, and nucleus accumbens. No excess loss was detected in the amygdala or pallidum. The hippocampus and caudate showed significant excess loss in the younger group (p < 0.001) and a strong trend in the older-onset group. These results provide a potential imaging correlate of published neuropsychological studies that reported the association of younger age at disease onset with impaired cognitive performance, including decreased working memory

An MRS- and PET-guided biopsy tool for intraoperative neuronavigational systems

OBJECTIVEGlioma heterogeneity and the limitations of conventional structural MRI for identifying aggressive tumor components can limit the reliability of stereotactic biopsy and, hence, tumor characterization, which is a hurdle for developing and selecting effective treatment strategies. In vivo MR spectroscopy (MRS) and PET enable noninvasive imaging of cellular metabolism relevant to proliferation and can detect regions of more highly active tumor. Here, the authors integrated presurgical PET and MRS with intraoperative neuronavigation to guide surgical biopsy and tumor sampling of brain gliomas with the aim of improving intraoperative tumor-tissue characterization and imaging biomarker validation.METHODSA novel intraoperative neuronavigation tool was developed as part of a study that aimed to sample high-choline tumor components identified by multivoxel MRS and 18F-methylcholine PET-CT. Spatially coregistered PET and MRS data were integrated into structural data sets and loaded onto an intraoperative neuronavigation system. High and low choline uptake/metabolite regions were represented as color-coded hollow spheres for targeted stereotactic biopsy and tumor sampling.RESULTSThe neurosurgeons found the 3D spherical targets readily identifiable on the interactive neuronavigation system. In one case, areas of high mitotic activity were identified on the basis of high 18F-methylcholine uptake and elevated choline ratios found with MRS in an otherwise low-grade tumor, which revealed the possible use of this technique for tumor characterization.CONCLUSIONSThese PET and MRI data can be combined and represented usefully for the surgeon in neuronavigation systems. This method enables neurosurgeons to sample tumor regions based on physiological and molecular imaging markers. The technique was applied for characterizing choline metabolism using MRS and 18F PET; however, this approach provides proof of principle for using different radionuclide tracers and other MRI methods, such as MR perfusion and diffusion.</jats:sec

Imaging and Tissue Biomarkers of Choline Metabolism in Diffuse Adult Glioma: 18F-Fluoromethylcholine PET/CT, Magnetic Resonance Spectroscopy, and Choline Kinase α

The cellular and molecular basis of choline uptake on PET imaging and MRS-visible choline containing compounds is not well understood. Choline kinase alpha (ChoKa) is an enzyme that phosphorylates choline, an essential step in membrane synthesis. We investigate choline metabolism through 18F-fluoromethylcholine (18F-FMC) PET, MRS and tissue ChoKa in human glioma. 14 patients with suspected diffuse glioma underwent multimodal 3T MRI and dynamic 18F FMC PET/CT prior to surgery. Co-registered PET and MRI data were used to target biopsies to regions of high and low choline signal, and immunohistochemistry for ChoKa expression was performed. 18F-FMC/PET differentiated WHO grade IV from grade II and III tumours, whereas MRS differentiated grade III/IV from grade II tumours. Tumoural 18F-FMC/PET uptake was higher than in normal-appearing white matter across all grades and markedly elevated within regions of contrast enhancement. 18F-FMC/PET correlated weakly with MRS Cho ratios. ChoKa expression on IHC was negative or weak in all but one GBM sample, and did not correlate with tumour grade or imaging choline markers. MRS and 18F-FMC/PET provide complimentary information on glioma choline metabolism. Tracer uptake is, however, potentially confounded by blood-brain barrier permeability. ChoKa overexpression does not appear to be a common feature in diffuse glioma

Reliability of dynamic contrast-enhanced magnetic resonance imaging data in primary brain tumours: a comparison of Tofts and shutter speed models

Purpose To investigate the robustness of pharmacokinetic modelling of DCE-MRI brain tumour data and to ascertain reliable perfusion parameters through a model selection process and a stability test. Methods DCE-MRI data of 14 patients with primary brain tumours were analysed using the Tofts model (TM), the extended Tofts model (ETM), the shutter speed model (SSM) and the extended shutter speed model (ESSM). A no-effect model (NEM) was implemented to assess overfitting of data by the other models. For each lesion, the Akaike Information Criteria (AIC) was used to build a 3D model selection map. The variability of each pharmacokinetic parameter extracted from this map was assessed with a noise propagation procedure, resulting in voxel-wise distributions of the coefficient of variation (CV). Results The model selection map over all patients showed NEM had the best fit in 35.5% of voxels, followed by ETM (32%), TM (28.2%), SSM (4.3%) and ESSM (<0.1%). In analysing the reliability of Ktrans, when considering regions with a CV<20%, ≈25% of voxels were found to be stable across all patients. The remaining 75% of voxels were considered unreliable. Conclusions The majority of studies quantifying DCE-MRI data in brain tumours only consider a single model and whole-tumour statistics for the output parameters. Appropriate model selection, considering tissue biology and its effects on blood brain barrier permeability and exchange conditions, together with an analysis on the reliability and stability of the calculated parameters, is critical in processing robust brain tumour DCE-MRI data

Disconnection between the default mode network and medial temporal lobes in post-traumatic amnesia

Post-traumatic amnesia is very common immediately after traumatic brain injury. It is characterised by a confused, agitated state and a pronounced inability to encode new memories and sustain attention. Clinically, post-traumatic amnesia is an important predictor of functional outcome. However, despite its prevalence and functional importance, the pathophysiology of post-traumatic amnesia is not understood. Memory processing relies on limbic structures such as the hippocampus, parahippocampus and parts of the cingulate cortex. These structures are connected within an intrinsic connectivity network, the Default Mode Network. Interactions within the Default Mode Network can be assessed using resting state functional magnetic resonance imaging, which can be acquired in confused patients unable to perform tasks in the scanner. Here we used this approach to test the hypothesis that the mnemonic symptoms of post-traumatic amnesia are caused by functional disconnection within the Default Mode Network. We assessed whether the hippocampus and parahippocampus showed evidence of transient disconnection from cortical brain regions involved in memory processing. 19 traumatic brain injury patients were classified into post-traumatic amnesia and traumatic brain injury control groups, based on their performance on a paired associates learning task. Cognitive function was also assessed with a detailed neuropsychological test battery. Functional interactions between brain regions were investigated using resting-state functional magnetic resonance imaging. Together with impairments in associative memory patients in post-traumatic amnesia demonstrated impairments in information processing speed and spatial working memory. Patients in post-traumatic amnesia showed abnormal functional connectivity between the parahippocampal gyrus and posterior cingulate cortex. The strength of this functional connection correlated with both associative memory and information processing speed and normalised when these functions improved. We have previously shown abnormally high posterior cingulate cortex connectivity in the chronic phase after traumatic brain injury, and this abnormality was also observed in patients with post-traumatic amnesia. Patients in post-traumatic amnesia showed evidence of widespread traumatic axonal injury measured using diffusion magnetic resonance imaging. This change was more marked within the cingulum bundle, the tract connecting the parahippocampal gyrus to the posterior cingulate cortex. These findings provide novel insights into the pathophysiology of post-traumatic amnesia and evidence that memory impairment acutely after traumatic brain injury results from altered parahippocampal functional connectivity, perhaps secondary to the effects of axonal injury on white matter tracts connecting limbic structures involved in memory processing

Patient preferences for whole-body MRI or conventional staging pathways in lung and colorectal cancer:a discrete choice experiment

OBJECTIVES: To determine the importance placed by patients on attributes associated with whole-body MRI (WB-MRI) and standard cancer staging pathways and ascertain drivers of preference.METHODS: Patients recruited to two multi-centre diagnostic accuracy trials comparing WB-MRI with standard staging pathways in lung and colorectal cancer were invited to complete a discrete choice experiment (DCE), choosing between a series of alternate pathways in which 6 attributes (accuracy, time to diagnosis, scan duration, whole-body enclosure, radiation exposure, total scan number) were varied systematically. Data were analysed using a conditional logit regression model and marginal rates of substitution computed. The relative importance of each attribute and probabilities of choosing WB-MRI-based pathways were estimated.RESULTS: A total of 138 patients (mean age 65, 61% male, lung n = 72, colorectal n = 66) participated (May 2015 to September 2016). Lung cancer patients valued time to diagnosis most highly, followed by accuracy, radiation exposure, number of scans, and time in the scanner. Colorectal cancer patients valued accuracy most highly, followed by time to diagnosis, radiation exposure, and number of scans. Patients were willing to wait 0.29 (lung) and 0.45 (colorectal) weeks for a 1% increase in pathway accuracy. Patients preferred WB-MRI-based pathways (probability 0.64 [lung], 0.66 [colorectal]) if they were equivalent in accuracy, total scan number, and time to diagnosis compared with a standard staging pathway.CONCLUSIONS: Staging pathways based on first-line WB-MRI are preferred by the majority of patients if they at least match standard pathways for diagnostic accuracy, time to diagnosis, and total scan number.KEY POINTS: • WB-MRI staging pathways are preferred to standard pathways by the majority of patients provided they at least match standard staging pathways for accuracy, total scan number, and time to diagnosis. • For patients with lung cancer, time to diagnosis was the attribute valued most highly, followed by accuracy, radiation dose, number of additional scans, and time in a scanner. Preference for patients with colorectal cancer was similar. • Most (63%) patients were willing to trade attributes, such as faster diagnosis, for improvements in pathway accuracy and reduced radiation exposure.</p