The Stickland Reaction Precursor trans-4-Hydroxy-l-Proline Differentially Impacts the Metabolism of Clostridioides difficile and Commensal Clostridia.

An intact gut microbiota confers colonization resistance against Clostridioides difficile through a variety of mechanisms, likely including competition for nutrients. Recently, proline was identified as an important environmental amino acid that C. difficile uses to support growth and cause significant disease. A posttranslationally modified form, trans-4-hydroxyproline, is highly abundant in collagen, which is degraded by host proteases in response to C. difficile toxin activity. The ability to dehydrate trans-4-hydroxyproline via the HypD glycyl radical enzyme is widespread among gut microbiota, including C. difficile and members of the commensal Clostridia, suggesting that this amino acid is an important nutrient in the host environment. Therefore, we constructed a C. difficile ΔhypD mutant and found that it was modestly impaired in fitness in a mouse model of infection, and was associated with an altered microbiota when compared to mice challenged with the wild-type strain. Changes in the microbiota between the two groups were largely driven by members of the Lachnospiraceae family and the Clostridium genus. We found that C. difficile and type strains of three commensal Clostridia had significant alterations to their metabolic gene expression in the presence of trans-4-hydroxyproline in vitro. The proline reductase (prd) genes were elevated in C. difficile, consistent with the hypothesis that trans-4-hydroxyproline is used by C. difficile to supply proline for energy metabolism. Similar transcripts were also elevated in some commensal Clostridia tested, although each strain responded differently. This suggests that the uptake and utilization of other nutrients by the commensal Clostridia may be affected by trans-4-hydroxyproline metabolism, highlighting how a common nutrient may be a signal to each organism to adapt to a unique niche. Further elucidation of the differences between them in the presence of hydroxyproline and other key nutrients will be important in determining their role in nutrient competition against C. difficile. IMPORTANCE Proline is an essential environmental amino acid that C. difficile uses to support growth and cause significant disease. A posttranslationally modified form, hydroxyproline, is highly abundant in collagen, which is degraded by host proteases in response to C. difficile toxin activity. The ability to dehydrate hydroxyproline via the HypD glycyl radical enzyme is widespread among gut microbiota, including C. difficile and members of the commensal Clostridia, suggesting that this amino acid is an important nutrient in the host environment. We found that C. difficile and three commensal Clostridia strains had significant, but different, alterations to their metabolic gene expression in the presence of hydroxyproline in vitro. This suggests that the uptake and utilization of other nutrients by the commensal Clostridia may be affected by hydroxyproline metabolism, highlighting how a common nutrient may be a signal to each organism to adapt to a unique niche. Further elucidation of the differences between them in the presence of hydroxyproline and other key nutrients will be important to determining their role in nutrient competition against C. difficile.

Effect of organizational change on the individual employee.

Increasing market pressures force companies to implement drastic organizational changes in order to remain competitive. Budget decreases, reduction efforts, and similar changes create significant morale and job-satisfaction concerns. This study assesses the effects of budget reductions and other organizational changes on the morale of hospital employees. A survey dealing with employee perceptions of stress, workload, and performance was given to hospital employees. Not surprisingly, the survey found that morale problems resulted from the organizational changes. Employees' gender and job classification showed little significant effect on the survey results, while respondents' length of employment with the organization influenced the results slightly. The findings provide information useful for dealing with challenges of employee satisfaction, morale, and trust during times of budget limitations.

Room at the top?

Nurse executives have joined hospital administrative teams, but are they accepted as fully integrated team executives? Learn how nurse executives and their influential colleagues view integration and its influences.

Enrollee satisfaction with HMOs and its relationship with disenrollment.

Relying on 1997 data from a universe of 740 HMOs, this study uniquely documented, from the perspective of health plan administrators, rates of enrollee satisfaction and disenrollments. On the basis of various reporting totals per variable or indicator, the average level of satisfaction was 83.9%; the average number of disenrollments was 20,996 per plan. Among different datasets, an average of 18.9% members disenrolled per plan; an average of 10.2% were voluntary disenrollments; and an average of 18.3% were involuntary disenrollments. Plans with higher satisfaction enrollees had predominantly lower disenrollment rates, more enrollees likely to recommend plans to family or friends, fewer older enrollees, fewer male enrollees, and higher overall plan performance. To enhance the gaining and retaining of enrollees, plan administrators should closely monitor the various dimensions of satisfaction, such as services complement, quality of care, administrative efficiency, care management, enrollees' complaints, plan performance, appointment convenience, and waiting times.

Effectiveness of nurse executives: measurement of role factors and attitudes.

This article describes the outcome of a survey of 40 nurse executives and 56 influential colleagues. Both groups agreed that leadership was the most important quality for the executive role. The nurses' primary focus was resolution of patient care problems. Influential colleagues stated resource allocation and initiation of change were two qualities needing improvement. The nurses rated themselves high in confidence about their job responsibilities, scored relationships as the most satisfying attribute, and cited provision of quality health care as the greatest advantage of their position. The greatest disadvantage was lack of administrative support. The results suggest the educational preparation needed for nurse executives.

Health care policy reform: a microanalytic model for comparing hospitals in the United States and Germany.

Microcomparison, or single-component analysis, of health care systems offers a potentially better basis for reform than traditional macrocomparison analysis of aggregate elements. Using macroanalysis, available evidence shows that Germany provides cheaper but more effective hospital care than the United States. To find the causes for this outcome, we developed a microanalytic model of hospital administrators' perceptions, financial ratios, medical outcomes, and pharmaceutical costs. However, only data on pharmaceutical costs were available, and these were similar in both countries. Our significant outcome was development of a microcomparative model that gives world medical care providers new criteria for analyzing and improving cost to care ratios.

Rural referrals represent significant revenue for managed care organizations.

A study was conducted to evaluate the potential economic effect of referrals on managed care organizations by rural physicians to providers outside a rural county. Patient referral records and associated financial data were gathered for a three-month period. Referrals by this group of rural primary care physicians to specialists outside their rural county resulted in an average of approximately $1,100 of collected revenues per episode of care and in an average of more than $2,600 of expected payments per hospital inpatient stay. The results from this study can serve as a preliminary guide for managed care providers as they structure their services for rural settings.

Nurse executives' leadership roles. Perceptions of incumbents and influential colleagues.

The authors present a leadership profile of employed nurse executives (NEs). Interviews and survey data show that the typical NE is a married, middle-aged woman who has a masters degree in clinical nursing and extensive clinical experience. When comparing NEs' and influential colleagues' perceptions of the effectiveness of NEs leadership skills, the former rate themselves higher than the latter, and both groups perceive that NEs' leadership styles are more "task motivated" than "relationship motivated." The authors apply these findings to the career planning of NEs, chief executive officers, and educators in healthcare fields.

Academic preparation for healthcare executive-track personnel.

This study focuses on career aspirations of executive-track health care administrative personnel and their perceptions of the competencies required to become hospital chief executive officers (CEOs). This article examines these topics using the results of a 1994 survey of 162 junior- and mid-level healthcare managers who work in hospitals in a western state. Respondents included 34 CEO aspirants and 128 CEO nonaspirants. The majority of both groups reported high satisfaction with several work-related activities. Significantly more CEO nonaspirants than CEO aspirants perceived a need for additional self-development in several work areas. CEO aspirants reported that CEOs five years from now would need improved strategy formulation and negotiation skills. CEO aspirants also perceived that in the future, successful CEOs will have to be more proficient in several areas, such as interpersonal skills and medical staff relations. Three lists of academic subject matter considered important to career preparation were generated from (1) the Association of University Programs in Health Administration (AUPHA) undergraduate standards, combined with curriculum graduate standards of the Accrediting Commission on Education for Health Services Administration (ACEHSA); (2) study participants' responses; and (3) professional literature. When compared for relatedness, the contents of the three lists were not significantly different statistically. The implications of these findings for health administration education are discussed.

Hospital administrators' career paths: which way to the top?

This article examines career paths of aspirants to hospital administrator positions. It focuses on successful career objectives, barriers, and paths. The 1994 survey data from 162 hospital-employed executive track personnel in a western state facilitate comparisons with nonaspirants. Only 34 (21 percent) self-reported a goal to become an administrator. Aspirants require institutional and mentor support, and need to follow more proactive and diverse career paths than they have done previously.

UCHP: a case study of access for the medically uninsured.

Utah Community Health Plan (UCHP) is one of fifteen Robert Wood Johnson Foundation Programs for the uninsured. The experience of UCHP is similar to the other nine demonstration programs for the uninsured who have actually enrolled individuals: offering premium subsidies to uninsured small employers is an ineffective way to expand coverage among the working uninsured.

Revenue enhancement through total quality management/continuous quality improvement (TQM/CQI) in outpatient coding and billing.

To survive and thrive, rural hospitals are seeking enhanced revenues. This study focuses on outpatient laboratory and radiology coding and billing accuracy in a nonrandom sample of seven rural hospitals in a Western state. Information was gathered on (1) procedures incorrectly coded, (2) potential revenue increases from correct coding and billing, (3) barriers to implementing changes, and (4) perceived audit value. The identified major source of potential revenue enhancement was increased fees from private payers. Correct coding and billing to Medicare and Medicaid offered the potential of additional revenue. Participating administrators appreciated the validation of coding and billing practices and identification of potential enhanced revenues. Five of seven hospitals (71.4%) selectively implemented recommended changes. Complete compliance with recommended changes was limited by barriers of tradition, competition, and reimbursement, which must be overcome to realize successful implementation. Joint Commission on Accreditation of Healthcare Organization's (JCAHO) new Total Quality Management/Continuous Quality Improvement (TQM/CQI) emphasis provides an opportunity for revenue enhancement through coding/billing assessments and interdepartmental focus and coordination.

The new nurse executive. An emerging role.

In recent years, the nurse executive (NE) has become an integral part of the hospital administrative team. The position has taken on a higher profile, and many questions are surfacing about every facet of NE administration. Since 1991, the literature is replete with articles discussing the new NE role. This article is a review summary and consolidation of 19 recently published articles, selected from a much broader list of periodical articles. It also reflects the results of six focus groups with hospital administrators and NEs in both urban and rural healthcare delivery settings. The summary pinpoints attributes identified as essential to an NE and those areas in which more research is needed. It also discloses that to function effectively, the new NE must have flexible and action-oriented personality qualities, possess executive level business management skills, have completed some graduate level degree work, and be an expert on clinical affairs. Future research should concentrate on the diverse educational needs of NEs and how to best meet those needs.

Calculating the economic impact of healthcare facilities on communities.

A methodology has been developed to calculate the direct, indirect, and induced spending effects of a healthcare facility on the community it serves. This methodology may be used by financial managers to produce data that demonstrate the effect of facilities on local economies. The data may be used by administrators to increase awareness of the pivotal economic role healthcare facilities play in communities among business and government leaders, economic development organizations, medical staff members, facility employees, trustees, and patients.