Conservation of the insert-2 motif confers Rev1 from different species with an ability to disrupt G-quadruplexes and stimulate translesion DNA synthesis.

In some organisms, the replication of G-quadruplex (G4) structures is supported by the Rev1 DNA polymerase. We previously showed that residues in the insert-2 motif of human Rev1 (hRev1) increased the affinity of the enzyme for G4 DNA and mediated suppression of mutagenic replication near G4 motifs. We have now investigated the conservation of G4-selective properties in Rev1 from other species. We compared Rev1 from Danio rerio (zRev1), Saccharomyces cerevisiae (yRev1), and Leishmania donovani (lRev1) with hRev1, including an insert-2 mutant form of hRev1 (E466A/Y470A or EY). We found that zRev1 retained all of the G4-selective prowess of the human enzyme, but there was a marked attenuation of G4 binding affinity for the EY hRev1 mutant and the two Rev1 proteins lacking insert-2 (yRev1 and lRev1). Perhaps most strikingly, we found that insert-2 was important for disruption of the G4 structure and optimal stimulation of processive DNA synthesis across the guanine-rich motif by DNA polymerase kappa (pol κ). Our findings have implications for how Rev1 might contribute to G4 replication in different species spanning the evolutionary tree - signaling the importance of selection for enzymes with robust G4-selective properties in organisms where these non-B DNA structures may fulfill taxa-specific physiological functions.

Characteristics and Outcomes of Sepsis Presenting in Inpatient Pediatric Settings.

OBJECTIVE: The pediatric sepsis literature lacks studies examining the inpatient setting, yet sepsis remains a leading cause of death in children's hospitals. More information is needed about sepsis arising in patients already hospitalized to improve morbidity and mortality outcomes. This study describes the clinical characteristics, process measures, and outcomes of inpatient sepsis cases compared with emergency department (ED) sepsis cases within the Improving Pediatric Sepsis Outcomes data registry from 46 hospitals that care for children. METHODS: This retrospective cohort study included Improving Pediatric Sepsis Outcomes sepsis cases from January 2017 to December 2019 with onset in inpatient or ED. We used descriptive statistics to compare inpatient and ED sepsis metrics and describe inpatient sepsis outcomes. RESULTS: The cohort included 26 855 cases; 8.4% were inpatient and 91.6% were ED. Inpatient cases had higher sepsis-attributable mortality (2.0% vs 1.4%, P = .025), longer length of stay after sepsis recognition (9 vs 5 days, P <.001), more intensive care admissions (57.6% vs 54.1%, P = .002), and greater average vasopressor use (18.0% vs 13.6%, P <.001) compared with ED. In the inpatient cohort, >40% of cases had a time from arrival to recognition within 12 hours. In 21% of cases, this time was >96 hours. Improved adherence to sepsis treatment bundles over time was associated with improved 30-day sepsis-attributable mortality for inpatients with sepsis. CONCLUSIONS: Inpatient sepsis cases had longer lengths of stay, more need for intensive care, and higher vasopressor use. Sepsis-attributable mortality was significantly higher in inpatient cases compared with ED cases and improved with improved sepsis bundle adherence.

Human Rev1 relies on insert-2 to promote selective binding and accurate replication of stabilized G-quadruplex motifs.

We previously reported that human Rev1 (hRev1) bound to a parallel-stranded G-quadruplex (G4) from the c-MYC promoter with high affinity. We have extended those results to include other G4 motifs, finding that hRev1 exhibited stronger affinity for parallel-stranded G4 than either anti-parallel or hybrid folds. Amino acids in the αE helix of insert-2 were identified as being important for G4 binding. Mutating E466 and Y470 to alanine selectively perturbed G4 binding affinity. The E466K mutant restored wild-type G4 binding properties. Using a forward mutagenesis assay, we discovered that loss of hRev1 increased G4 mutation frequency >200-fold compared to the control sequence. Base substitutions and deletions occurred around and within the G4 motif. Pyridostatin (PDS) exacerbated this effect, as the mutation frequency increased >700-fold over control and deletions upstream of the G4 site more than doubled. Mutagenic replication of G4 DNA (±PDS) was partially rescued by wild-type and E466K hRev1. The E466A or Y470A mutants failed to suppress the PDS-induced increase in G4 mutation frequency. These findings have implications for the role of insert-2, a motif conserved in vertebrates but not yeast or plants, in Rev1-mediated suppression of mutagenesis during G4 replication.

A hospital-randomized controlled trial of a formal quality improvement educational program in rural and small community Texas hospitals: one year results.

OBJECTIVE: To investigate the effectiveness of a quality improvement educational program in rural hospitals. DESIGN: Hospital-randomized controlled trial. PARTICIPANTS: A total of 47 rural and small community hospitals in Texas that had previously received a web-based benchmarking and case-review tool. INTERVENTION: The 47 hospitals were randomized either to receive formal quality improvement educational program or to a control group. The educational program consisted of two 2-day didactic sessions on continuous quality improvement techniques, followed by the design, implementation and reporting of a local quality improvement project, with monthly coaching conference calls and annual follow-up conclaves. MAIN OUTCOME MEASURES: Performance on core measures for community-acquired pneumonia and congestive heart failure were compared between study groups to evaluate the impact of the educational program. RESULTS: No significant differences were observed between the study groups on any measures. Of the 23 hospitals in the intervention group, only 16 completed the didactic program and 6 the full training program. Similar results were obtained when these groups were compared with the control group. CONCLUSIONS: While the observed results suggest no incremental benefit of the quality improvement educational program following implementation of a web-based benchmarking and case-review tool in rural hospitals, given the small number of hospitals that completed the program, it is not conclusive that such programs are ineffective. Further research incorporating supporting infrastructure, such as physician champions, financial incentives and greater involvement of senior leadership, is needed to assess the value of quality improvement educational programs in rural hospitals.

Challenges in conducting a hospital-randomized trial of an educational quality improvement intervention in rural and small community hospitals.

The study design for this hospital-randomized controlled trial of an educational quality improvement intervention in rural and small community hospitals, following the implementation of a Web-based quality benchmarking and case review tool, specified a control group and a rapid-cycle quality improvement education group of >or= 30 hospitals each. Of the 64 hospitals initially interested in participating, 7 could not produce the required quality data and 10 refused consent to randomization. Of the 23 hospitals randomized to the educational intervention, 16 completed the educational program, 1 attended the didactic sessions but did not complete the required quality improvement project, 3 enrolled in "make-up" sessions, and 3 were unable to attend. Of the 42 individuals who attended educational sessions, 5 (12%) have left their positions. Quality improvement interventions require several different approaches to engage participating organizations and should include plans to train new staff given the high turnover of health care quality improvement personnel.

Accelerating Best Care in Pennsylvania: adapting a large academic system's quality improvement process to rural community hospitals.

Industrial quality improvement (QI) methods such as continuous quality improvement (CQI) may help bridge the gap between evidence-based "best care" and the quality of care provided. In 2006, Baylor Health Care System collaborated with Jefferson Medical College of Thomas Jefferson University to conduct a QI demonstration project in select Pennsylvania hospitals using CQI techniques developed by Baylor. The training was provided over a 6-month period and focused on methods for rapid-cycle improvement; data system design; data management; tools to improve patient outcomes, processes of care, and cost-effectiveness; use of clinical guidelines and protocols; leadership skills; and customer service skills. Participants successfully implemented a variety of QI projects. QI education programs developed and pioneered within large health care systems can be adapted and applied successfully to other settings, providing needed tools to smaller rural and community hospitals that lack the necessary resources to establish such programs independently.

A hospital-randomized controlled trial of an educational quality improvement intervention in rural and small community hospitals in Texas following implementation of information technology.

Rural and small community hospitals typically have few resources and little experience with quality improvement (QI) and, on average, demonstrate poorer quality of care than larger facilities. Formalized QI education shows promise in improving quality, but little is known about its effect in rural and small community hospitals. The authors describe a randomized controlled trial assigning 47 rural and small community Texas hospitals to such a program (n = 23) or to the control group (n = 24), following provision of a Web-based quality benchmarking and case review tool. Centers for Medicare and Medicaid Services Core Measures composite scores for congestive heart failure (CHF) and community-acquired pneumonia (CAP), using Texas Medical Foundation data collected via the QualityNet Exchange system, are compared for the groups, for 2 years postintervention. Given the estimated baseline rates for the CHF (68%) and CAP (66%) composites, the cohort enables the detection of 14% and 11% differences (alpha = .05; power = 0.8), respectively.