Efficient Workflow Analysis to Address Paper Persistence in Tuberculin Testing.

Despite widespread adoption and maturity, paper persistence endures in many Electronic Health Record (EHR) systems, particularly for complex workflows involving multiple steps from different stakeholders separated in time. In our health system, Latent Tuberculosis Infection (LTBI) testing was one such workflow where a Tuberculin Skin Test (TST) must be administered and then correctly read 48-72 hours later and documented. This paper discusses a low-resource workflow analysis and clinical decision support approach to replace a paper workflow and garner the benefits of the EHR for clearer documentation and retrieval of LTBI results. Our approach resulted in a significant increase in completed TST documentation, 57% (24/42) to 95% (18/19), P < 0.003. Human-centered design practices such as work system analysis and formative usability testing are feasible with limited resources and improve the likelihood of success of electronic workflows by designing solutions that fit existing clinical workflows and automating processes wherever possible.

The potential of virtual fencing technology to facilitate sustainable livestock grazing management.

Virtual fencing (VF) technology is gaining interest due to its potential to facilitate sustainable grazing management. It allows farmers to contain grazing livestock without physical fences, thereby reducing the time and labour associated with the implementation of conventional fences. From a conservation perspective, some sensitive areas within uplands should not be grazed during certain periods of the year, and VF provides an invisible and moveable fence line that can exclude livestock from these areas. However, there are also concerns associated with its use, including animal welfare impacts, cost-effectiveness, and public perception. The extent to which VF can contribute to make livestock systems more sustainable remains to be investigated. To address this gap, this study investigates the potential of VF to promote sustainable grazing management using the Efficiency, Substitution, and Redesign framework, which has been used for the first time in this context. The framework is particularly relevant in taking an active and normative approach to identify key aspects to focus on to help achieve sustainability. We consulted stakeholders including farmers, wildlife inspectors, veterinarians, policy officers, researchers, NGOs, farm advisors or certification managers, through focus groups (N = 4) and in-depth, semi-structured interviews (N = 5). Stakeholders have highlighted the potential of VF to provide new opportunities to increase the efficiency and sustainability of livestock grazing systems, enabling their redesign, and contributing to improved environmental and animal welfare outcomes, as well as higher financial and social performance. However, there are important aspects that remain to be addressed to achieve such redesign, including issues of reliability due to poor network signal, animals' ability to learn, biosecurity and safety issues related to the absence of physical fences, farm suitability and farmers' ability to use the systems effectively. This study highlights the need to ensure that the development and uptake of VF are mutually beneficial to farmers, animals, and the wider farming industry. This includes a highlight on the importance of participative approaches to involve key stakeholders to address concerns and maximise the potential of the technology.

Improving primary care access for rural women Veterans: the Boost Team.

Objectives: To improve healthcare access for rural cisgender women and gender diverse Veterans, we created the "Boost Team," a clinician-driven telehealth outreach service to connect this population to Veterans Health Administration (VHA) services. Methods: Between 9/2021 and 2/2022, we conducted a needs assessment in the Veterans Integrated Service Network (VISN) 21 and used those data to develop an outreach intervention. We piloted a clinician-led outreach intervention in 3/2022, and formally deployed an outreach team in 9/2022. Results: The needs assessment uncovered opportunities to educate Veterans, staff, and clinicians about available VHA women's health services, and a need for easily-accessible gender-sensitive services. During the pilot, 58% (7/12) rural cisgender women Veterans were successfully contacted, all reported positive experiences with the intervention. The formal outreach team launched in 9/2022 and consists of a nurse practitioner (NP), scheduler, Peer Support Specialist, and medical director. From 9/2022 to 12/2022 the Boost NP called 110 rural cisgender women and gender diverse Veterans and spoke to 65 (59%) of them. Common care needs identified and addressed included care coordination, new referrals, medication management, and diagnostics. Discussion: Data from Boost show that clinician-led outreach can engage rural cisgender women and gender diverse Veterans in VHA services, there is a desire for more gender-sensitive services, and there is a need for systems-level improvements to allow for improved care coordination and decreased leakage outside of VHA. Using robust strategies grounded in implementation sciences, we will continue conducting a program evaluation to study the impact of Boost and scale and expand the program.

Exploring cost changes with time-driven activity-based costing after service delivery redesign in Dutch maternity care.

The implementation of Value-Based Healthcare (VBHC) has spread across international healthcare systems, aiming to improve decision-making by combining information about patient outcomes and costs of care. Time-Driven Activity-Based Costing (TDABC) is introduced as a pragmatic yet accurate method to calculate costs of care pathways. It is often applied to demonstrate value-improving opportunities, such as interventions aimed at service delivery redesign. It is imperative for healthcare managers to know whether these interventions yield the expected outcome of improving patient value, for which TDABC is also suitable. However, its application becomes more complex and labour intensive if the intervention extends beyond activity-level changes in existing care pathways, to the implementation of entirely new care pathways. The complexity arises from the potential influence of such interventions on the costs of related care pathways. To fully comprehend the impact of such interventions on organizational costs, it is important to include these factors in the cost calculation. Given the substantial effort required for this analysis, this may explain the limited number of prior TDABC studies with similar objectives. This methodological development paper addresses this gap by offering a pragmatic enrichment of the TDABC methodology. This enrichment is twofold. First, it provides guidance on calculating a change in costs without the need for a total cost calculation. Second, to secure granularity, a more detailed level of cost-allocation is proposed. The aim is to encourage further application of TDABC to conduct financial evaluations of promising interventions in the domain of VBHC and service delivery redesign.

AlphaFold-guided redesign of a plant pectin methylesterase inhibitor for broad-spectrum disease resistance.

Plant cell walls are a critical site where plants and pathogens continuously struggle for physiological dominance. Here we show that dynamic remodeling of pectin methylesterification of plant cell walls is a component of the physiological and co-evolutionary struggles between hosts and pathogens. A Phytophthora sojae secreted pectin methylesterase (PsPME1) decreases the degree of pectin methylesterification, thus synergizing with an endo-polygalacturonase (PsPG1) to weaken plant cell walls. To counter PsPME1-mediated susceptibility, a plant-derived pectin methylesterase inhibitor protein, GmPMI1, protects pectin to maintain a high methylesterification status. GmPMI1 protects plant cell walls from enzymatic degradation by inhibiting both soybean and P. sojae pectin methylesterases during infection. However, constitutive expression of GmPMI1 disrupted the tradeoff between host growth and defense responses. So, we used AlphaFold structure tools to design a modified form of GmPMI1 (GmPMI1R) which specifically targets and inhibits pectin methylesterases secreted from pathogens but not from the plants. Transient expression of GmPMI1R enhanced plant resistance to oomycetes and fungal pathogens. In summary, our work highlights biochemical modification of the cell wall as an important focal point in the physiological and co-evolutionary conflict between the hosts and microbes and serves as an important proof-of-concept for how rapid advancements in AI-driven structure-based tools can accelerate the prediction of new strategies for plant protection.

Rational Redesign of an Introductory Pharmacy Practice Experience Curriculum.

OBJECTIVE: To utilize a process to identify strengths and weaknesses of an introductory pharmacy practice experience (IPPE) curriculum from stakeholder perspectives and undergo IPPE curricular revision. METHODS: An IPPE curriculum redesign taskforce was created, and a 5-step systematic quality improvement process was developed and applied to redesign an IPPE curriculum. The steps were to identify existing curriculum challenges and strengths, determine potential solutions to challenges, redesign IPPE curricular structure, obtain stakeholder input and support, and redesign IPPE content. Throughout these steps, surveys were administered, and feedback was solicited from stakeholder groups through focus groups and meetings. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed using inductive content analysis and peer debriefing to identify themes. RESULTS: Student survey and focus group results identified desires to limit student-preceptor negotiations when scheduling hours, decrease conflict between IPPE hours and scheduled classes, and increase direct patient care opportunities. Structural revisions included transition of IPPE hours from the first and second year of the program into the third year, revising course schedule grids to allow third-year students 1 day per week to complete hours, and aligning rotation dates during class-free times. Curricular content was strengthened through curricular mapping, threading, and course coordinator collaborations. CONCLUSION: A 5-step IPPE redesign systematic quality improvement process utilizing solicitation, analysis, and incorporation of stakeholder feedback was used to revise an IPPE curriculum to maintain framework and content strengths and address weaknesses. Other pharmacy programs could utilize this process to redesign their IPPE curriculum.

Research protocol and recruitment redesign of a study of pregnant women and their infants during the COVID-19 pandemic: Childhood Allergy and the NeOnatal Environment (CANOE).

Background: Recruitment for research studies is a challenging endeavor that was further complicated by the coronavirus disease 2019 pandemic. We launched a new multicenter birth cohort, Childhood Allergy and the NeOnatal Environment (CANOE), supported by the National Institutes of Health in January 2020 across 4 sites. Although the pandemic temporarily halted clinical research, we restructured the study and instituted novel recruitment methods that we hypothesized would enable brisk enrollment when research activities resumed. Objective: We sought to develop protocol modifications and recruitment methods that promote successful recruitment of diverse populations in clinical research despite a global pandemic. Methods: Even though study activities were suspended, we modified recruitment strategies to limit in-person contact, shifting toward alternative HIPAA-compliant methods such as clinician referrals, institutional social media, and telemedicine screening and consent procedures. Protocol changes included reducing the frequency of in-person visits, leveraging clinical care visits to collect biospecimens, expanded self-collection of samples at home, and making study materials available online. Results: Remote methods, including targeted social media posts, mailed letters, and email, combined with in-clinic recruitment with modifications for social distancing led to successful recruitment at all sites. Rates of consent have been similar across recruitment sites, with the highest rates of enrollment of mother-infant dyads realized by sites that implemented multiple recruitment strategies. Conclusions: Study procedures that prioritize health and safety measures such as social distancing, study participant convenience, and use diverse recruitment strategies enable successful enrollment of pregnant women and their newborns into clinical research while adhering to public health restrictions during a global pandemic.

The Impact of Pandemic-Driven Care Redesign on Hospital Efficiency.

Purpose: This study aims to identify medical care transformations during the COVID-19 pandemic and to assess the economic efficiency of these care transformations. Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviewing and Meta-Analysis (PRISMA) guidelines. The databases used in the search protocol included PubMed, RSCI, and Google Scholar. Results: Ten eligible studies in English and one publication in Russian were identified. In general, the following changes in organization of health care processes since 2020 are observed: hospital at home, telemedicine (physician-to-patient), and the adoption of new information communication technologies within physician-to-physician and physician-to-nurse communication. Earlier trends, such as (a) wider use of electronic devices, (b) adoption of Lean techniques, (c) the incorporation of patient and other customer experience feedback, and (d) the implementation of clinical decision support systems and automation of workflow, tend to be preserved. Conclusion: The most common changes in hospital care organization and the respective impacts of workflow changes (ie, workflow interventions, redesign, and transformations) on the efficiency of hospital care were summarized and avenues for future research and policy implications were discussed. The pandemic demonstrated a need for building more resilient and adaptive healthcare systems, enhancing crisis preparedness along with rapid and effective responses.

Influences of crop diversification on yield, resource use efficiency, and environmental footprint in farmland landscapes in intensive farming.

Enhancing crop diversification in intensive fields has the potential to increase crop yield and reduce environmental footprint. However, these relationships at the landscape scale remained unclear in intensive farming. Addressing this gap, this paper aims to elucidate how crop yield, resources use efficiency (RUE), and environmental footprint (EF) vary with crop diversification levels in the North China Plain. Management practices, including crop pattern, field size, and agronomic inputs, were collected for 421 landscapes of 1 × 1 km subplots using Sentinel-2 and Landsat-8 images and survey. The results showed that, at the landscape scale, energy and fertilizer contributed over 53 %, and 37 % of the carbon footprint, respectively. N fertilizer constituted >98 % of the nitrogen footprint. P fertilizer accounted for over 80 %, while electricity comprised >13 % of the phosphorus footprint. Compared with simplified landscapes, diversified landscapes exhibited several significant features: 1) 56 % reduction of the area ratio of winter wheat-summer maize double crop pattern (WM), 2) a significant decrease in field size, 3) the decreased use of total NPK fertilizers at 32 %, 30 %, and 30 %, respectively, 4) the increased inputs of irrigation water, diesel, electricity, pesticide and labour at 21 %, 19 %, 21 %, 77 %, and 92 %, respectively. Although yield could be reduced at 33 % when transforming simplified landscapes into moderately diversified ones, they increased with the further promotion of crop diversification. Thus, the diversified landscapes could achieve a balance in yield, RUE, and EF to enhance sustainability, whereas simplified landscapes can similarly achieve a balance to benefit productivity. We emphasize the viable potential of diversified landscapes to enhance sustainable agricultural development by optimizing crop composition. This analysis offers pioneering evidence of landscape-scale agronomic and environmental performances of crop diversification.

Translating 'proportionate universal healthcare' into meaningful system design to optimize equity in child and family services.

AIM: To conduct a child and family health nursing service redesign to improve pathways of access, response and outcomes for all families with children aged 0-5 years. DESIGN: The study was conducted as an iterative, mixed-method study of the process and impact of the service redesign, informed by a participatory action research paradigm and the NSW Agency for Clinical Innovation process for developing a model of care. METHODS: Diagnostic, solution design, implementation and sustainability phases were undertaken. Quantitative analyses were undertaken of administrative data, and child and family health nurse and client surveys. Qualitative analyses were undertaken of design workshops. RESULTS: The administrative data demonstrated that prior to the redesign service provision was the same for all clients regardless of levels of risk. The design solution, developed through a series of diagnostic and visioning workshops, included multiple new client response pathways. Implementation included development of tools and training. Sustainability of the redistribution of resources to the new pathways was assessed though an evaluation demonstrating a positive impact for families with adversity, with no deleterious effects for families receiving a universal response, and improvements in the emotional labour undertaken by nurses. Despite this, nurse burnout increased post-redesign. CONCLUSION: The shift from equal services (everyone receives the same) to equitable proportionate universal provision in response to need can be achieved and has positive impacts for nurses and families. IMPACT: This study shows the value of undertaking a systematic and participatory approach to service redesign. A proportionate universalism approach can ensure that early childhood nursing services are available to all in relation to needs. REPORTING METHOD: The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) check-list was used to guide reporting. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Audit of a Revised Pathway Aimed at Expediting Diagnosis and Treatment for Suspected Achilles Tendon Rupture.

Treatment outcomes for Achilles tendon ruptures depend upon prompt diagnosis and management. A local study in 2018 highlighted inefficiencies in patient management, and a revised protocol was introduced allowing investigation and referral to be initiated by other healthcare professionals. This retrospective audit evaluates the impact of this on the timescale from presentation to treatment. It analyzes all suspected Achilles tendon ruptures within one District General Hospital from April 2021 to March 2022. Data regarding patient timelines was compared to the 2018 study. Over 12 months, 99 patients were referred to Virtual Fracture Clinic, 87.8% (n = 87) of which had a complete or partial tear on ultrasound scan (USS). In comparison to 2018, the average time from presentation to USS request reduced from 2.9 to 1.1 days (p < .01). 95% were scanned within one week of USS request and 31.3% within 48 hours (81% and 18%, previously). The average time from USS request to scan went from 6.8 to 3.2 days (p < .01). The time from presentation to treatment decision reduced from 10.9 to 6.2 days (p < .01) and the percentage of patients with a definitive treatment plan within one week increased from 34.5% to 74.2% (p < .01). Patients required 0.8 fewer appointments (p < .01) giving an estimated total saving of $10,110 ($128 per patient) during the analyzed period. The Achilles Tendon Rupture Pathway has significantly improved the proportion of patients undergoing USS within 48 hours and receiving a treatment decision within one week. This study demonstrates an efficient, cost-saving and replicable pathway for Achilles tendon ruptures.

Financial scarcity, psychological well-being and perceptions: an evaluation of the Nigerian currency redesign policy outcomes.

BACKGROUND: The relationship between insufficient financial resources and psychological health has been extensively studied and established in various contexts. However, there remains uncertainty regarding the potential impact of the Nigerian naira currency redesign policy on the psychological well-being of Nigerians. This policy, which aimed to demonetize the economy and promote economic stability, involved changes to the physical appearance of some naira denominations (200, 500 and 1000). Understanding the effects of this policy on psychological health is essential for evaluating its overall societal impact and identifying potential areas for improvement in future currency redesign initiatives. METHODS: The study is a cross-sectional mixed-methods study involving 2237 respondents across the six geopolitical zones of Nigeria. Utilizing the simple random, snowball and convenience sampling technique, social media platforms (Facebook and WhatsApp) were used to recruit respondents. Variables were analyzed at descriptive and inferential levels. The qualitative component comprised seven (7) in-depth interviews with participants across the geo-political zones. RESULTS: The perceptions of respondents towards the policy were diverse across different demographic groups. It was widely perceived that the timing of the policy was inappropriate, considering the challenges faced in utilizing online payment platforms and the significant inaccessibility of cash. Furthermore, the analysis revealed that demographic variables played a role in explaining systematic variations in the experience of financial scarcity and its effect on psychological health during the cash crunch that ensued as a result of the Nigerian naira currency redesign policy. CONCLUSIONS: This study identified a significant association between the psychological inventory of financial scarcity and psychological well-being among residents in Nigeria during the cash crunch resulting from the Naira redesign policy. The findings suggest that the financial scarcity experienced by Nigerians due to the policy had a substantial impact on individuals' psychological well-being. We recommend that a holistic approach be undertaken by policymakers to ensure that policy actions not only address economic objectives but also safeguard the mental health and overall well-being of the population.

Persistence of changed attitudes among students in an integrated anatomy curriculum.

Many medical schools in the United States have integrated anatomy into an organ-based preclinical curriculum with some schools using anatomy as the cornerstone of their reorganization efforts. Curricular change could affect one or more of the three domains of learning, with the cognitive domain often scrutinized exclusively. A previous study reported the impact of anatomy integration on the affective domain, specifically, student attitudes toward learning anatomy. This mixed methods follow-up study asked if the observed attitudinal changes and lack of effect on student knowledge and confidence persisted using knowledge and confidence surveys, focus groups, internal and national surveys, and United States Medical Licensing Examination® performance metrics. Results evidenced the persistence of specific attitudinal differences between cohorts with blocked versus integrated anatomy with no apparent short- or long-term differences in anatomy learning or confidence in this learning. Altered attitudes included lower value placed on working in teams and reflective practices, and less recognition of anatomy's contribution (or less contribution of anatomy learning) to professional identity formation. These attitudinal changes could result in a weaker foundation for building collaborative skills throughout the medical curriculum. A decreased sense of student engagement also followed curricular change, as assessed by data from the American Association of Medical Colleges Year 2 Questionnaire. Overall, results emphasized the necessity of anticipating, monitoring, and if necessary, addressing changes in the affective domain when undertaking curricular change.

Expedited re-design of multi-band passive microwave circuits using orthogonal scaling directions and gradient-based tuning.

Geometry scaling of microwave circuits is an essential but challenging task. In particular, the employment of a given passive structure in a different application area often requires re-adjustment of the operating frequencies/bands while maintaining top performance. Achieving this necessitates the utilization of numerical optimization methods. Nonetheless, if the intended frequencies are distant from the ones at the starting point, local search procedures tend to fail, whereas global search algorithms are computationally expensive. As recently demonstrated, a combination of large-scale concurrent geometry parameter scaling with intermittent local tuning allows for dependable re-design of high-frequency circuits at low CPU costs. Unfortunately, the procedure is only applicable to single-band structures due to synchronized modifications of all operating bands under scaling. This article discusses a novel procedure that leverages a similar overall concept, but allows for independent control of all center frequencies. To achieve this goal, an automated decision-making procedure is developed in which a set of orthogonal scaling directions are determined based on their effect on individual circuit bands, and using auxiliary optimization sub-problems. The scaling range is then automatically computed by solving an appropriately-defined least-square design relocation problem. The methodology introduced in the work is illustrated using two planar passive devices. In both cases, wide-range operating frequency re-design has been demonstrated and favorably compared to conventional gradient-based tuning. Furthermore, the presented procedure has been shown to be computationally efficient. It is also easy to implement and integrate with a variety of gradient-based optimization procedures of a descent type.

Performance and robustness analysis of V-Tiger PID controller for automatic voltage regulator.

This paper presents a comprehensive study on the implementation and analysis of PID controllers in an automated voltage regulator (AVR) system. A novel tuning technique, Virtual Time response-based iterative gain evaluation and re-design (V-Tiger), is introduced to iteratively adjust PID gains for optimal control performance. The study begins with the development of a mathematical model for the AVR system and initialization of PID gains using the Pessen Integral Rule. Virtual time-response analysis is then conducted to evaluate system performance, followed by iterative gain adjustments using Particle Swarm Optimization (PSO) within the V-Tiger framework. MATLAB simulations are employed to implement various controllers, including the V-Tiger PID controller, and their performance is compared in terms of transient response, stability, and control signal generation. Robustness analysis is conducted to assess the system's stability under uncertainties, and worst-case gain analysis is performed to quantify robustness. The transient response of the AVR with the proposed PID controller is compared with other heuristic controllers such as the Flower Pollination Algorithm, Teaching-Learning-based Optimization, Pessen Integral Rule, and Zeigler-Nichols methods. By measuring the peak closed-loop gain of the AVR with the controller and adding uncertainty to the AVR's field exciter and amplifier, the robustness of proposed controller is determined. Plotting the performance degradation curves yields robust stability margins and the accompanying maximum uncertainty that the AVR can withstand without compromising its stability or performance. Based on the degradation curves, robust stability margin of the V-Tiger PID controller is estimated at 3.5. The worst-case peak gains are also estimated using the performance degradation curves. Future research directions include exploring novel optimization techniques for further enhancing control performance in various industrial applications.

Fit-for-purpose-The bottom-up redesign of the nursing home system: The Australian Aged Care System.

Nursing homes struggle to meet the needs of their residents as they become older and frailer, live with more complex co-morbidity, and are impacted by memory impairment and dementia. Moreover, the nursing home system is overwhelmed with significantly constraining organisational and regulatory demands that stand in the way of achieving resident-focused outcomes. These issues are compounded by the perceptions of poor working environments, poor remuneration, and poor satisfaction amongst staff. The system is beyond the state of 'reform' and requires a fundamental redesign based on first organisational systems understandings: a clearly defined purpose and goal, shared values, and system-wide agreed "simple (or operating) rules". A 'fit-for-purpose' future requires a complex adaptive nursing home system characterised by seamless 'bottom-up and top-down' information flows to ensure that the necessary 'work that needs to be done' is done, and a governance structure that focuses on quality improvement and holds the system accountable for the quality of care that is provided.

Women's autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study.

BACKGROUND: Maternal and neonatal outcomes in, Kakamega County is characterized by a maternal mortality rate of 316 per 100,000 live births and a neonatal mortality rate of 19 per 1,000 live births. In 2018, approximately 70,000 births occurred in the county, with 35% at home, 28% in primary care facilities, and 37% in hospitals. A maternal and child health service delivery redesign (SDR) that aims to reorganize maternal and newborn health services is being implemented in Kakamega County in Kenya to improve the progress of these indicators. Research has shown that women's ability to make decisions (voice, agency, and autonomy) is critical for gender equality, empowerment and an important determinant of access and utilization. As part of the Kakamega SDR process evaluation, this study sought to understand women's processes of decision-making in seeking maternal health care and how these affect women's ability to access and use antenatal, delivery, and post-natal services. METHODS: We adapted the International Centre for Research on Women (ICRW) conceptual framework for reproductive empowerment to focus on the interrelated concepts of "female autonomy", and "women's agency" with the latter incorporating 'voice', 'choice' and 'power'. Our adaptation did not consider the influence of sexual relationships and leadership on SRH decision-making. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. A thematic analysis approach was used to analyze the data in NVivo 12. RESULTS: The results revealed notable findings across three dimensions of agency. Women with previous birthing experiences, high self-esteem, and support from their social networks exhibited greater agency. Additionally, positive previous birthing experiences were associated with increased confidence in making reproductive health choices. Women who had control over financial resources and experienced respectful communication with their partners exhibited higher levels of agency within their households. Distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women's agency and autonomy. Finally, women who faced barriers such as long waiting times or limited staff availability experienced reduced agency in seeking healthcare. CONCLUSIONS: Individual agency, immediate relational agency, and distance relational agency all play crucial roles in shaping women's decision-making power and control over their utilization of maternal health services. This study offers valuable insights that can guide the ongoing implementation of an innovative service delivery redesign model, emphasizing the critical need for developing context-specific strategies to promote women's voices for sustained use.

Improving emergency department care for adults presenting with mental illness: a systematic review of strategies and their impact on outcomes, experience, and performance.

Background: Care delivery for the increasing number of people presenting at hospital emergency departments (EDs) with mental illness is a challenging issue. This review aimed to synthesise the research evidence associated with strategies used to improve ED care delivery outcomes, experience, and performance for adults presenting with mental illness. Method: We systematically reviewed the evidence regarding the effects of ED-based interventions for mental illness on patient outcomes, patient experience, and system performance, using a comprehensive search strategy designed to identify published empirical studies. Systematic searches in Scopus, Ovid Embase, CINAHL, and Medline were conducted in September 2023 (from inception; review protocol was prospectively registered in Prospero CRD42023466062). Eligibility criteria were as follows: (1) primary research study, published in English; and (2) (a) reported an implemented model of care or system change within the hospital ED context, (b) focused on adult mental illness presentations, and (c) evaluated system performance, patient outcomes, patient experience, or staff experience. Pairs of reviewers independently assessed study titles, abstracts, and full texts according to pre-established inclusion criteria with discrepancies resolved by a third reviewer. Independent reviewers extracted data from the included papers using Covidence (2023), and the quality of included studies was assessed using the Joanna Briggs Institute suite of critical appraisal tools. Results: A narrative synthesis was performed on the included 46 studies, comprising pre-post (n = 23), quasi-experimental (n = 6), descriptive (n = 6), randomised controlled trial (RCT; n = 3), cohort (n = 2), cross-sectional (n = 2), qualitative (n = 2), realist evaluation (n = 1), and time series analysis studies (n = 1). Eleven articles focused on presentations related to substance use disorder presentation, 9 focused on suicide and deliberate self-harm presentations, and 26 reported mental illness presentations in general. Strategies reported include models of care (e.g., ED-initiated Medications for Opioid Use Disorder, ED-initiated social support, and deliberate self-harm), decision support tools, discharge and transfer refinements, case management, adjustments to liaison psychiatry services, telepsychiatry, changes to roles and rostering, environmental changes (e.g., specialised units within the ED), education, creation of multidisciplinary teams, and care standardisations. System performance measures were reported in 33 studies (72%), with fewer studies reporting measures of patient outcomes (n = 19, 41%), patient experience (n = 10, 22%), or staff experience (n = 14, 30%). Few interventions reported outcomes across all four domains. Heterogeneity in study samples, strategies, and evaluated outcomes makes adopting existing strategies challenging. Conclusion: Care for mental illness is complex, particularly in the emergency setting. Strategies to provide care must align ED system goals with patient goals and staff experience.

Human GST P1-1 Redesigned for Enhanced Catalytic Activity with the Anticancer Prodrug Telcyta and Improved Thermostability.

Protein engineering can be used to tailor enzymes for medical purposes, including antibody-directed enzyme prodrug therapy (ADEPT), which can act as a tumor-targeted alternative to conventional chemotherapy for cancer. In ADEPT, the antibody serves as a vector, delivering a drug-activating enzyme selectively to the tumor site. Glutathione transferases (GSTs) are a family of naturally occurring detoxication enzymes, and the finding that some of them are overexpressed in tumors has been exploited to develop GST-activated prodrugs. The prodrug Telcyta is activated by GST P1-1, which is the GST most commonly elevated in cancer cells, implying that tumors overexpressing GST P1-1 should be particularly vulnerable to Telcyta. Promising antitumor activity has been noted in clinical trials, but the wildtype enzyme has modest activity with Telcyta, and further functional improvement would enhance its usefulness for ADEPT. We utilized protein engineering to construct human GST P1-1 gene variants in the search for enzymes with enhanced activity with Telcyta. The variant Y109H displayed a 2.9-fold higher enzyme activity compared to the wild-type GST P1-1. However, increased catalytic potency was accompanied by decreased thermal stability of the Y109H enzyme, losing 99% of its activity in 8 min at 50 °C. Thermal stability was restored by four additional mutations simultaneously introduced without loss of the enhanced activity with Telcyta. The mutation Q85R was identified as an important contributor to the regained thermostability. These results represent a first step towards a functional ADEPT application for Telcyta.

Where are we now? Evaluating the one year impact of an anti-racism curriculum review.

PURPOSE: Undergraduate medical education has had a call to action to acknowledge racist practices that are impacting learners throughout their training. In 2020, our school performed a detailed curricular review and provided recommendations to address racism in the curriculum. Many schools have now undergone a similar curricular review process, but little is known about whether suggested antiracist curricular changes impact faculty teaching behavior or the overall curriculum. MATERIAL AND METHODS: In 2021, as part of the medical school's annual educational quality improvement process, course directors were required to answer a question about the changes they made to address racism in their courses based on recommendations provided the year prior from an antiracism curricular review. The documented changes were analyzed for themes and then organized by course and curricular year. These changes were compared with the suggested recommendations to analyze the number and types of changes implemented after one year. To evaluate student perceptions of change the general comments from academic years 2019-2021 were reviewed. RESULTS: After 1 year, approximately, 74% of our school's 328 anti-racism curricular review recommendations were implemented in courses. Over 80% were implemented in curricular year 1. The greatest number of recommendations implemented were related to the theme of critiquing the strength of evidence in race-based medical practices. The least amount change was made around the theme of challenging the biologic notion of race. CONCLUSIONS: An antiracism curricular review followed by an embedded continuous quality improvement process can be an effective approach to address racism in medical school curricula. Addressing racism in medical education requires medical schools to regularly identify curricular gaps, faculty needs and monitor their progress.