Achieving rapid and significant results in healthcare services by using the theory of constraints.

Lack of timeliness and capacity are seen as fundamental problems that jeopardise healthcare delivery systems everywhere. Many believe the shortage of medical providers is causing this timeliness problem. This action research presents how one doctor implemented the theory of constraints (TOC) to improve the throughput (quantity of patients treated) of his ophthalmology imaging practice by 64% in a few weeks with little to no expense. The five focusing steps (5FS) guided the TOC implementation - which included the drum-buffer-rope scheduling and buffer management - and occurred in a matter of days. The implementation provided significant bottom-line results almost immediately. This article explains each step of the 5FS in general terms followed by specific applications to healthcare services, as well as the detailed use in this action research. Although TOC successfully addressed the practice problems, this implementation was not sustained after the TOC champion left the organisation. However, this drawback provided valuable knowledge. The article provides insightful knowledge to help readers implement TOC in their environments to provide immediate and significant results at little to no expense.

The ubiquitin conjugase Rad6 mediates ribosome pausing during oxidative stress.

Oxidative stress causes K63-linked ubiquitination of ribosomes by the E2 ubiquitin conjugase Rad6. How Rad6-mediated ubiquitination of ribosomes affects translation, however, is unclear. We therefore perform Ribo-seq and Disome-seq in Saccharomyces cerevisiae and show that oxidative stress causes ribosome pausing at specific amino acid motifs, which also leads to ribosome collisions. However, these redox-pausing signatures are lost in the absence of Rad6 and do not depend on the ribosome-associated quality control (RQC) pathway. We also show that Rad6 is needed to inhibit overall translation in response to oxidative stress and that its deletion leads to increased expression of antioxidant genes. Finally, we observe that the lack of Rad6 leads to changes during translation that affect activation of the integrated stress response (ISR) pathway. Our results provide a high-resolution picture of the gene expression changes during oxidative stress and unravel an additional stress response pathway affecting translation elongation.

Juneteenth in STEMM and the barriers to equitable science.

We are 52 Black scientists. Here, we establish the context of Juneteenth in STEMM and discuss the barriers Black scientists face, the struggles they endure, and the lack of recognition they receive. We review racism's history in science and provide institutional-level solutions to reduce the burdens on Black scientists.

The central role of translation elongation in response to stress.

Protein synthesis is essential to support homeostasis, and thus, must be highly regulated during cellular response to harmful environments. All stages of translation are susceptible to regulation under stress, however, the mechanisms involved in translation regulation beyond initiation have only begun to be elucidated. Methodological advances enabled critical discoveries on the control of translation elongation, highlighting its important role in translation repression and the synthesis of stress-response proteins. In this article, we discuss recent findings on mechanisms of elongation control mediated by ribosome pausing and collisions and the availability of tRNAs and elongation factors. We also discuss how elongation intersects with distinct modes of translation control, further supporting cellular viability and gene expression reprogramming. Finally, we highlight how several of these pathways are reversibly regulated, emphasizing the dynamics of translation control during stress-response progression. A comprehensive understanding of translation regulation under stress will produce fundamental knowledge of protein dynamics while opening new avenues and strategies to overcome dysregulated protein production and cellular sensitivity to stress.

Redox-sensitive E2 Rad6 controls cellular response to oxidative stress via K63-linked ubiquitination of ribosomes.

Protein ubiquitination is an essential process that rapidly regulates protein synthesis, function, and fate in dynamic environments. Within its non-proteolytic functions, we showed that K63-linked polyubiquitinated conjugates heavily accumulate in yeast cells exposed to oxidative stress, stalling ribosomes at elongation. K63-ubiquitinated conjugates accumulate mostly because of redox inhibition of the deubiquitinating enzyme Ubp2; however, the role and regulation of ubiquitin-conjugating enzymes (E2) in this pathway remained unclear. Here, we show that the E2 Rad6 associates and modifies ribosomes during stress. We further demonstrate that Rad6 and its human homolog UBE2A are redox regulated by forming a reversible disulfide with the E1 ubiquitin-activating enzyme (Uba1). This redox regulation is part of a negative feedback regulation, which controls the levels of K63 ubiquitination under stress. Finally, we show that Rad6 activity is necessary to regulate translation, antioxidant defense, and adaptation to stress, thus providing an additional physiological role for this multifunctional enzyme.

Outcomes of managing healthcare services using the Theory of Constraints: A systematic review.

Despite ever-increasing resources devoted to healthcare, lack of capacity and timeliness are still chronic problems worldwide. This systematic review aims to present an overview of the Theory of Constraints (TOC) implementations in healthcare services and their outcomes. We analysed 42 TOC implementations (15 full-text articles, 12 video proceedings, and 2 theses/disserations) from major scientific electronic databases and TOC International Certification Organization Conferences. All implementations reported positive outcomes, both tangible and intangible. The two main improvements reported by authors were in productivity (98%; n = 41) - more patients treated - and in the timeliness of care (83%; n = 35). Furthermore, the selected studies reported dramatic improvements: 50% mean reductions in patient waiting time; 38% reduction in patient length of stay; 43% mean increase in operating room productivity and 34% mean increase in throughput. TOC implementations attained positive results in all levels of the health and social care chain. Most TOC recommendations and changes showed almost immediate results and required little or no additional cost to implement. Evidence supports TOC as a promising solution for the chronic healthcare problem, improving quality and timeliness, both necessary conditions for providing effective healthcare.

Identifying and Addressing the Underlying Core Problems in Healthcare Environments: An Illustration Using an Emergency Department Game.

The emergency department (ED) crowding is a critical healthcare issue worldwide that leads to long waits and poorer healthcare outcomes. Goldratt's theory of constraints (TOC) has been used effectively to improve such problematic environments for more than three decades. While most TOC solutions are simple, with many viewing them as purely common sense, they represent paradigm shifts in how to manage complex, uncertain, and silo environments. Goldratt used a simple dice game with a straight flow (I-shape) to illustrate the impact of dependent resources and statistical fluctuations in managing resources. Additionally, games help to overcome resistance to change and gain ownership by having participants develop their solutions. This new cooperative game illustrates an ED environment where patients may follow different care pathways according to their clinical needs, timeliness of care is measured in minutes, the demand is highly uncertain, and treatment must frequently start almost immediately. A Monte Carlo simulation validated the TOC solution to this ED game, achieving results similar to the real TOC's implementations. Moreover, this article provides a thorough process to Socratically introduce TOC to healthcare professionals and others to recognize that the EDs' (like other healthcare systems') core problem is the traditional approach to managing them.

Associations between Movement Behaviours and Obesity Markers among Preschoolers Compliant and Non-Compliant with Sleep Duration: A Latent Profile Analysis.

This study identifies physical activity (PA) and sedentary behaviour (SB) clusters in preschoolers compliant (C) or non-compliant (NC) with sleep recommendations; and associates these clusters with obesity markers. PA and SB were objectively assessed (Actigraph WGT3-X) in 272 preschoolers (4.4 ± 0.7 years old). Sleep duration was parent-reported, and preschoolers were classified as C (3-4 years old: 600-780 min/day; 5 years old: 540-660 min/day) or NC with sleep recommendations. Body mass index (BMI) and waist circumference (WC) were assessed according to international protocols. Moderate to vigorous physical activity (MVPA) and light physical activity (LPA) were categorized as low/high (<60 min/>60 min/day or <180 min/180 min/day, respectively). SB was defined according to mean values between clusters. Latent profile analysis was performed. Associations between the observed clusters and obesity markers were determined using linear regression (RStudio; 1.3.1073). Four cluster solutions for C and NC preschoolers were identified. A negative association between C/Low MVPA cluster and BMI, and a positive association between NC/Low MVPA and BMI (ß = -0.8, 95%CI = -1.6;-0.1, and ß = 0.9, 95%CI = 0.1;1.7, respectively) were observed. No association was seen for SB clusters. Adequate sleep duration may have a protective role for preschoolers' BMI, even if the children do not comply with MVPA recommendations.

Deubiquitinating enzymes (DUBs): Regulation, homeostasis, and oxidative stress response.

Ubiquitin signaling is a conserved, widespread, and dynamic process in which protein substrates are rapidly modified by ubiquitin to impact protein activity, localization, or stability. To regulate this process, deubiquitinating enzymes (DUBs) counter the signal induced by ubiquitin conjugases and ligases by removing ubiquitin from these substrates. Many DUBs selectively regulate physiological pathways employing conserved mechanisms of ubiquitin bond cleavage. DUB activity is highly regulated in dynamic environments through protein-protein interaction, posttranslational modification, and relocalization. The largest family of DUBs, cysteine proteases, are also sensitive to regulation by oxidative stress, as reactive oxygen species (ROS) directly modify the catalytic cysteine required for their enzymatic activity. Current research has implicated DUB activity in human diseases, including various cancers and neurodegenerative disorders. Due to their selectivity and functional roles, DUBs have become important targets for therapeutic development to treat these conditions. This review will discuss the main classes of DUBs and their regulatory mechanisms with a particular focus on DUB redox regulation and its physiological impact during oxidative stress.

Structural impact of K63 ubiquitin on yeast translocating ribosomes under oxidative stress.

Subpopulations of ribosomes are responsible for fine tuning the control of protein synthesis in dynamic environments. K63 ubiquitination of ribosomes has emerged as a new posttranslational modification that regulates protein synthesis during cellular response to oxidative stress. K63 ubiquitin, a type of ubiquitin chain that functions independently of the proteasome, modifies several sites at the surface of the ribosome, however, we lack a molecular understanding on how this modification affects ribosome structure and function. Using cryoelectron microscopy (cryo-EM), we resolved the first three-dimensional (3D) structures of K63 ubiquitinated ribosomes from oxidatively stressed yeast cells at 3.5-3.2 Å resolution. We found that K63 ubiquitinated ribosomes are also present in a polysome arrangement, similar to that observed in yeast polysomes, which we determined using cryoelectron tomography (cryo-ET). We further showed that K63 ubiquitinated ribosomes are captured uniquely at the rotated pretranslocation stage of translation elongation. In contrast, cryo-EM structures of ribosomes from mutant cells lacking K63 ubiquitin resolved at 4.4-2.7 Å showed 80S ribosomes represented in multiple states of translation, suggesting that K63 ubiquitin regulates protein synthesis at a selective stage of elongation. Among the observed structural changes, ubiquitin mediates the destabilization of proteins in the 60S P-stalk and in the 40S beak, two binding regions of the eukaryotic elongation factor eEF2. These changes would impact eEF2 function, thus, inhibiting translocation. Our findings help uncover the molecular effects of K63 ubiquitination on ribosomes, providing a model of translation control during oxidative stress, which supports elongation halt at pretranslocation.

Isoleucine 44 Hydrophobic Patch Controls Toxicity of Unanchored, Linear Ubiquitin Chains through NF-κB Signaling.

Ubiquitination is a post-translational modification that regulates cellular processes by altering the interactions of proteins to which ubiquitin, a small protein adduct, is conjugated. Ubiquitination yields various products, including mono- and poly-ubiquitinated substrates, as well as unanchored poly-ubiquitin chains whose accumulation is considered toxic. We previously showed that transgenic, unanchored poly-ubiquitin is not problematic in Drosophila melanogaster. In the fruit fly, free chains exist in various lengths and topologies and are degraded by the proteasome; they are also conjugated onto other proteins as one unit, eliminating them from the free ubiquitin chain pool. Here, to further explore the notion of unanchored chain toxicity, we examined when free poly-ubiquitin might become problematic. We found that unanchored chains can be highly toxic if they resemble linear poly-ubiquitin that cannot be modified into other topologies. These species upregulate NF-κB signaling, and modulation of the levels of NF-κB components reduces toxicity. In additional studies, we show that toxicity from untethered, linear chains is regulated by isoleucine 44, which anchors a key interaction site for ubiquitin. We conclude that free ubiquitin chains can be toxic, but only in uncommon circumstances, such as when the ability of cells to modify and regulate them is markedly restricted.

Risk factors associated with mammary tumors in female dogs / Fatores de risco para tumores mamários em cadelas de Uberlândia e Patos de Minas, Minas Gerais

Mammary tumors in female dogs are the most frequent and corresponds to half of the canine tumors. The objectives of this study were to determine the risk factors associated with the occurrence of mammary tumors in female dogs and to evaluate the macroscopic characteristics of these neoformations, using 386 dogs from the "Outubro Rosa Pets" events done within the cities of Uberlândia and Patos de Minas, Minas Gerais State, Brazil, in 2015 (n=194), 2016 (n=105) and 2017 (n=87). For the determination of risk factors, the binary logistic regression test (P<0.05) was performed. The occurrence of mammary tumors was 23.6% (91/386). The significant risk factors identified were increased age (P<0.001), overweight (P=0.048) and non-castration (P<0.001) with a chance of, respectively, 1.6, 2.3 and 9.3 times for the development of mammary tumors. In dogs with mammary tumors (n=91), 153 lesions were present, of which 39 female dogs had two or more lesions (42.8%). Most of the lesions were at the caudal abdominal (M4) and inguinal (M5) mammary glands (60.13%, 92/153). Relative to the size of the lesions, it was observed that in 78% of the female dogs the lesions were determined asT1 (<3cm), 16.5% were T2 (3-5cm) and 5.5% T3 (>5cm). At least 15.4% (14/91) of the dogs had one of the regional lymph nodes increased. In conclusion, the occurrence of mammary tumors in the evaluated population was 23.6% and that age, overweight and non-realization of ovariohysterectomy are risk factors associated with the development of mammary tumors.(AU)

Em cadelas os tumores mamários são os mais frequentes e correspondem a aproximadamente metade dos tumores em cães. Este estudo teve os objetivos de determinar os fatores de risco envolvidos na ocorrência de tumores mamários em cadelas e avaliar as características macroscópicas destas neoformações, utilizando 386 cadelas do evento "Outubro Rosa Pets" nos municípios de Uberlândia e Patos de Minas, Minas Gerais, Brasil, em 2015 (n=194), 2016 (n=105) e 2017 (n=87). Para a determinação dos fatores de risco utilizou-se o teste de Regressão logística binária (P<0,05). A ocorrência de tumores mamários foi de 23,6% (91/386). Os fatores de risco significativos identificados foram aumento da idade (P<0,001), sobrepeso (P=0,048) e não-castração (P<0,001) com a chance de, respectivamente, 1,6, 2,3 e 9,3 vezes de desenvolvimento de tumores mamários. Nas cadelas com tumores mamários (n=91), constatou-se a presença de 153 lesões, sendo que 39 cadelas apresentaram duas ou mais lesões (42,8%). A maioria das lesões localizaram-se nas mamas abdominais caudais (M4) e inguinais (M5) (60,13%; 92/153). Em relação ao tamanho das lesões, observou-se que 78% das cadelas eram T1 (<3cm), 16,5% T2 (3-5cm) e 5,5% T3 (>5cm). Pelo menos 15,4% (14/91) das cadelas apresentaram um dos linfonodos regionais aumentados. Conclui-se que a ocorrência dos tumores mamários na população avaliada foi de 23,6% e que a idade, sobrepeso e não ovariohisterectomia são fatores de risco para o desenvolvimento de tumores mamários.(AU)

Expanding Role of Ubiquitin in Translational Control.

The eukaryotic proteome has to be precisely regulated at multiple levels of gene expression, from transcription, translation, and degradation of RNA and protein to adjust to several cellular conditions. Particularly at the translational level, regulation is controlled by a variety of RNA binding proteins, translation and associated factors, numerous enzymes, and by post-translational modifications (PTM). Ubiquitination, a prominent PTM discovered as the signal for protein degradation, has newly emerged as a modulator of protein synthesis by controlling several processes in translation. Advances in proteomics and cryo-electron microscopy have identified ubiquitin modifications of several ribosomal proteins and provided numerous insights on how this modification affects ribosome structure and function. The variety of pathways and functions of translation controlled by ubiquitin are determined by the various enzymes involved in ubiquitin conjugation and removal, by the ubiquitin chain type used, by the target sites of ubiquitination, and by the physiologic signals triggering its accumulation. Current research is now elucidating multiple ubiquitin-mediated mechanisms of translational control, including ribosome biogenesis, ribosome degradation, ribosome-associated protein quality control (RQC), and redox control of translation by ubiquitin (RTU). This review discusses the central role of ubiquitin in modulating the dynamism of the cellular proteome and explores the molecular aspects responsible for the expanding puzzle of ubiquitin signals and functions in translation.

Polyubiquitin Chains Linked by Lysine Residue 48 (K48) Selectively Target Oxidized Proteins In Vivo.

Aims: Ubiquitin is a highly conserved protein modifier that heavily accumulates during the oxidative stress response. Here, we investigated the role of the ubiquitination system, particularly at the linkage level, in the degradation of oxidized proteins. The function of ubiquitin in the removal of oxidized proteins remains elusive because of the wide range of potential targets and different roles that polyubiquitin chains play. Therefore, we describe in detail the dynamics of the K48 ubiquitin response as the canonical signal for protein degradation. We identified ubiquitin targets and defined the relationship between protein ubiquitination and oxidation during the stress response. Results: Combining oxidized protein isolation, linkage-specific ubiquitination screens, and quantitative proteomics, we found that K48 ubiquitin accumulated at both the early and late phases of the stress response. We further showed that a fraction of oxidized proteins are conjugated with K48 ubiquitin. We identified ∼750 ubiquitinated proteins and ∼400 oxidized proteins that were modified during oxidative stress, and around half of which contain both modifications. These proteins were highly abundant and function in translation and energy metabolism. Innovation and Conclusion: Our work showed for the first time that K48 ubiquitin modifies a large fraction of oxidized proteins, demonstrating that oxidized proteins can be targeted by the ubiquitin/proteasome system. We suggest that oxidized proteins that rapidly accumulate during stress are subsequently ubiquitinated and degraded during the late phase of the response. This delay between oxidation and ubiquitination may be necessary for reprogramming protein dynamics, restoring proteostasis, and resuming cell growth.

Can openEHR Represent the Clinical Concepts of an Obstetric-Specific EHR - ObsCare Software?

ObsCare is an obstetric-specific Electronic Health Record in use in nine Portuguese obstetric departments. Like other EHRs, it faces major challenges related to semantic interoperability and data quality. openEHR is proposed to address those needs. This study aimed to describe a summary representation of Obscare workflow and to validate whether archetypes in the openEHR Clinical Knowledge Manager repository can represent ObsCare clinical concepts. The study included the phases: a) ObsCare form selection; b) Description of the workflow care process; c) Detailed data extraction; and d) CKM models analysis. 379 variables were analyzed: 219 were fully represented in CKM repository; 99 were partially represented and needed archetype modification; and 61 were not represented and need new archetypes. To conclude, our study showed that the openEHR CKM repository requires further enhancements to be able to fully answer to the needs of an obstetric-specific EHR, the ObsCare software.

OpenEHR and General Data Protection Regulation: Evaluation of Principles and Requirements.

BACKGROUND: Concerns about privacy and personal data protection resulted in reforms of the existing legislation in the European Union (EU). The General Data Protection Regulation (GDPR) aims to reform the existing directive on the topic of personal data protection of EU citizens with a strong emphasis on more control of the citizens over their data and in the establishment of rules for the processing of personal data. OpenEHR is a standard that embodies many principles of interoperable and secure software for electronic health records (EHRs) and has been advocated as the best approach for the development of hospital information systems. OBJECTIVE: This study aimed to understand to what extent the openEHR standard can help in the compliance of EHR systems to the GDPR requirements. METHODS: A list of requirements for an EHR to support GDPR compliance and also a list of the openEHR design principles were made. The requirements were categorized and compared with the principles by experts on openEHR and GDPR. RESULTS: A total of 50 GDPR requirements and 8 openEHR design principles were identified. The openEHR principles conformed to 30% (15/50) of GDPR requirements. All the openEHR principles were aligned with GDPR requirements. CONCLUSIONS: This study showed that the openEHR principles conform well to GDPR, underlining the common wisdom that truly realizing security and privacy requires it to be built in from the start. By using an openEHR-based EHR, the institutions are closer to becoming compliant with GDPR while safeguarding the medical data.

Economic selection index in small rural dairy farms.

This study aimed to calculate economic values (EVs) and economic selection indices for milk production systems in small rural properties. The traits 305-d milk yield in kg (MY), fat (FP) and protein (PP) percentage, daily fat (FY) and protein (PY) yield, cow live weight in kg (LW), calving interval (CI), and logarithm of daily somatic cell count (SCC) in milk were considered the goals and selection criteria. The production systems were identified from 29 commercial properties based on the inventory of revenues and costs and of zootechnical field data. Later, bioeconomic models were developed to calculate the productive performance, revenues, and costs concerning milk production to estimate EVs, which were calculated as the difference in annual profit with dairy production resulting from a change in one unit of the trait while keeping the others constant and dividing the value by the number of cows. After the EVs were known, ten economic selection indices were estimated for each system so they could be compared by modifying the selection criteria and calculating the relative importance of each selection criteria, the accuracy of the economic selection index, and response expected to the selection in USD, among other parameters. One of the systems detected was called less intensive (LS) and was characterized by having ten cows in lactation that produced 13·5 l/d and consumed 1·8 kg of concentrate/d. The second system detected was called more intensive (IS) and had 22 cows in lactation that produced 17·5 l/d and consumed 3·4 kg of concentrate/d. Monthly profits per cows in lactation of USD 2·60 and USD 68·77 were recorded for LS and IS, respectively. The EVs of the traits MY, FP, and PP were all positive, while for the other traits they were all negative in all situations. The best economic selection indices were those featuring selection criteria MY, LW, and CI, while the trait LW had the greatest importance in both systems. These results indicate that animal frame must be controlled in order to maximize the system's profit.

Site-Specific K63 Ubiquitinomics Provides Insights into Translation Regulation under Stress.

During oxidative stress, K63-linked polyubiquitin chains modify a variety of proteins including ribosomes. Knowledge of the precise sites of K63 ubiquitin is key to understand its function during the response to stress. To identify the sites of K63 ubiquitin, we developed a new mass spectrometry based method that quantified >1100 K63 ubiquitination sites in yeast that responded to oxidative stress induced by H2O2. We determined that under stress, K63 ubiquitin-modified proteins were involved in several cellular functions including ion transport, protein trafficking, and translation. The most abundant ubiquitin sites localized to the head of the 40S subunit of the ribosome, modified assembled polysomes, and affected the binding of translation factors. The results suggested a new pathway of post-initiation control of translation during oxidative stress and illustrated the importance of high-resolution mapping of noncanonical ubiquitination events.

Disturbed blood flow induces endothelial apoptosis without mobilizing repair mechanisms in hypertension.

AIMS: The influence of blood flow disturbances on vascular function, endothelial activation and repair capacity has not been fully elucidated either in physiological conditions or in cardiovascular disease. We aimed to determine the impact of increases in retrograde blood flow (RBF) on vascular function, endothelial biomarkers and repair capacity in healthy subjects and patients with hypertension. MAIN METHODS: In seven healthy (CT; 32 ±â€¯15 yr) and eight hypertensive (HT; 34 ±â€¯23 yr) men, flow mediated-dilation (FMD) was assessed before and 10 min after a 30-min maneuver to increase brachial artery RBF in which a pneumatic cuff was inflated to 75 mm Hg on forearm. Blood samples were obtained at rest and during the last minute of the maneuver. KEY FINDINGS: Endothelial activation, apoptosis and endothelial progenitor cells (EPC) were measured by flow cytometry; nitrite was measured by ozone-chemiluminescence. No significant disparities were observed in FMD, endothelial activation and circulating EPC between groups at baseline (p > 0.05). However, HT presented higher resting endothelial apoptosis (p = 0.01 vs CT). Exacerbated RBF induced reductions in FMD (p = 0.02 vs baseline) and increases in endothelial activation in both groups (p = 0.049 vs baseline). Endothelial apoptosis increased only in HT (p = 0.02 vs baseline; p = 0.004 vs CT), whereas EPC (p = 0.02 vs baseline; p = 0.03 vs HT) and nitrite (p = 0.04 vs baseline; p = 0.004 vs HT) increased only in CT during the maneuver. SIGNIFICANCE: While findings indicate that increased RBF impairs endothelial function and triggers the EPC mobilization in healthy subjects, patients with hypertension presented greater apoptosis and impaired repair capacity in response to RBF.