Making molehills out of a mountain: experience with a new scheduling strategy to diminish workload variations in response to increased treatment demands.

PURPOSE: A new scheduling strategy was implemented. Before implementation, treatments and planning computed tomography (ct) imaging were both scheduled at the same time. Maximal wait times for treatment are defined by the Quebec Ministry of Health's plan of action according to treatment aim and site. After implementation, patients requiring rapid treatment (priorities 0-3) continued to have their treatments scheduled at the same time as their planning ct; treatments for priority 4 (P4) patients were scheduled only after the treatment plan was approved. That approach aims to compensate for unexpected increases in planning workload by relocating less delay-sensitive cases to other time slots. We evaluated the impact on the patient experience, workload in various sectors, the care team's perception of care delivery, access to care, and the department's efficiency in terms of hours worked per treatment delivered. METHODS: Three periods were defined for analysis: the pre-transitional phase, for baseline evaluation; the transitional phase, during which there was an overlap in the way patients were being scheduled; and the post-transitional phase. Wait times were calculated from the date that patients were ready to treat to the date of their first treatment. Surveys were distributed to pre- and post-transitional phase patients. Care team members were asked to complete a survey evaluating their perception of how the change affected workload and patient care. Operational data were analyzed. RESULTS: We observed a 24% increase in the number of treatments delivered in the post-transitional phase. Before implementation, priority 0-3 patients waited a mean of 7.9 days to begin treatments (n = 241); afterward, they waited 6.3 days (n = 340, p = 0.006). Before implementation, P4 patients waited a mean 15.1 days (n = 233); after implementation, they waited 16.1 days (n = 368, p = 0.22). Surveys showed that patients felt that the time it took to inform them of treatment appointments was acceptable in both phases. No significant change in overtime hours occurred in dosimetry (p = 0.7476) or globally (p = 0.4285) despite the increased number of treatments. However, departmental efficiency improved by 16% (p = 0.0001). CONCLUSIONS: This new scheduling strategy for P4 cases resulted in improved access to care for priority 0-3 patients. Departmental efficiency was improved, and overtime hours did not increase. Patient satisfaction remained high.

Relation of Sociodemographics and Personal Hygiene on Different Childhood Dermatoses.

BACKGROUND: Skin diseases in children contribute to significant morbidity and psychological distress. Infective dermatoses are one of the major dermatoses in children. Low socioeconomic status, overcrowding and poor personal hygiene has been linked to skin diseases. OBJECTIVE: To find out the prevalence of infectious skin disease in children, rate of transmissible skin disease and association of sociodemographic factors and personal hygiene on infective childhood dermatoses. METHOD: This was a cross-sectional study conducted in the Pediatric and Dermatology Department, Manipal Teaching Hospital, Pokhara, Nepal. A total of 226 patients were examined over a period of one year. Relation of sociodemographics, crowding and personal hygiene on skin disease were assessed. RESULT: The most common category was Infections and Infestations (51.3%) followed by Dermatitis (27.9%). Transmissible skin disease was seen in 49.6%. Low socioeconomic status and overcrowding were associated with increased risk for infective dermatoses. CONCLUSION: Skin disease in children constitutes a public health problem. Improving the socioeconomic status and personal hygiene can help to reduce the incidence of skin disease in children.

Implementing a regional oncology information system: approach and lessons learned.

RATIONALE: Paper-based medical record systems are known to have major problems of inaccuracy, incomplete data, poor accessibility, and challenges to patient confidentiality. They are also an inefficient mechanism of record-sharing for interdisciplinary patient assessment and management, and represent a major problem for keeping current and monitoring quality control to facilitate improvement. To address those concerns, national, regional, and local health care authorities have increased the pressure on oncology practices to upgrade from paper-based systems to electronic health records. OBJECTIVES: Here, we describe and discuss the challenges to implementing a region-wide oncology information system across four independent health care organizations, and we describe the lessons learned from the initial phases that are now being applied in subsequent activities of this complex project. RESULTS: The need for change must be shared across centres to increase buy-in, adoption, and implementation. It is essential to establish physician leadership, commitment, and engagement in the process. Work processes had to be revised to optimize use of the new system. Culture change must be included in the change management strategy. Furthermore, training and resource requirements must be thoroughly planned, implemented, monitored, and modified as required for effective adoption of new work processes and technology. Interfaces must be established with multiple existing electronic systems across the region to ensure appropriate patient flow. Periodic assessment of the existing project structure is necessary, and adjustments are often required to ensure that the project meets its objectives. CONCLUSIONS: The implementation of region-wide oncology information systems across different health practice locations has many challenges. Leadership is essential. A strong, collaborative information-sharing strategy across the region and with the supplier is essential to identify, discuss, and resolve implementation problems. A structure that supports project management and accountability contributes to success.

Benefits, issues, and recommendations for personalized medicine in oncology in Canada.

The burden of cancer for Canadian citizens and society is large. New technologies have the potential to increase the use of genetic information in clinical decision-making, furthering prevention, surveillance, and safer, more effective drug therapies for cancer patients. Personalized medicine can have different meanings to different people. The context for personalized medicine in the present paper is genetic testing, which offers the promise of refining treatment decisions for those diagnosed with chronic and life-threatening illnesses. Personalized medicine and genetic characterization of tumours can also give direction to the development of novel drugs. Genetic testing will increasingly become an essential part of clinical decision-making. In Canada, provinces are responsible for health care, and most have unique policies and programs in place to address cancer control. The result is inconsistency in access to and delivery of therapies and other interventions, beyond the differences expected because of demographic factors and clinical education. Inconsistencies arising from differences in resources, policy, and application of evidence-informed personalized cancer medicine exacerbate patient access to appropriate testing and quality care. Geographic variations in cancer incidence and mortality rates in Canada-with the Atlantic provinces and Quebec having higher rates, and British Columbia having the lowest rates-are well documented. Our purpose here is to provide an understanding of current and future applications of personalized medicine in oncology, to highlight the benefits of personalized medicine for patients, and to describe issues and opportunities for improvement in the coordination of personalized medicine in Canada. Efficient and more rapid adoption of personalized medicine in oncology in Canada could help overcome those issues and improve cancer prevention and care. That task might benefit from the creation of a National Genetics Advisory Panel that would review research and provide recommendations on tests for funding or reimbursement, guidelines, service delivery models, laboratory quality assurance, education, and communication. More has to be known about the current state of personalized cancer medicine in Canada, and strategies have to be developed to inform and improve understanding and appropriate coordination and delivery. Our hope is that the perspectives emphasized in this paper will stimulate discussion and further research to create a more informed response.

Addition and correction: the NF-kappa B-like DNA binding activity observed in Dictyostelium nuclear extracts is due to the GBF transcription factor.

We have previously reported that a NF-kappa B transduction pathway was likely to be present in the cellular slime mold Dictyostelium discoideum. This conclusion was based on several observations, including the detection of developmentally regulated DNA binding proteins in Dictyostelium nuclear extracts that bound to bona fide kappa B sequences. We have now performed additional experiments which demonstrate that the protein responsible for this NF-kappa B-like DNA binding activity is the Dictyostelium GBF (G box regulatory element binding factor) transcription factor. This result, along with the fact that no sequence with significant similarity to components of the mammalian NF-kappa B pathway can be found in Dictyostelium genome, now almost entirely sequenced, led us to reconsider our previous conclusion on the occurrence of a NF-kappa B signal transduction pathway in Dictyostelium.

Microarray-based analysis of early development in Xenopus laevis.

In order to examine transcriptional regulation globally, during early vertebrate embryonic development, we have prepared Xenopus laevis cDNA microarrays. These prototype embryonic arrays contain 864 sequenced gastrula cDNA. In order to analyze and store array data, a microarray analysis pipeline was developed and integrated with sequence analysis and annotation tools. In three independent experimental settings, we demonstrate the power of these global approaches and provide optimized protocols for their application to molecular embryology. In the first set, by comparing maternal versus zygotic transcription, we document groups of genes that are temporally regulated. This analytical approach resulted in the discovery of novel temporally regulated genes. In the second, we examine changes in gene expression spatially during development by comparing dorsal and ventral mesoderm dissected from early gastrula embryos. We have discovered novel genes with spatial enrichment from these experiments. Finally, we use the prototype microarray to examine transcriptional responses from embryonic explants treated with activin. We selected genes (two of which are novel) regulated by activin for further characterization. All results obtained by the arrays were independently tested by RT-PCR or by in situ hybridization to provide a direct assessment of the accuracy and reproducibility of these approaches in the context of molecular embryology.

CBP1 associates with the Dictyostelium cytoskeleton and is important for normal cell aggregation under certain developmental conditions.

In cells of the eukaryotic microorganism Dictyostelium discoideum, at least eight small, four-EF-hand Ca(2+)-binding proteins of unknown function are expressed at specific times during development. One of these proteins, calcium-binding protein 1 (CBP1), first appears just prior to cell aggregation and then is present at relatively constant levels throughout development. To determine a role for CBP1 during development, the protein was used as bait in a yeast two-hybrid screen to reveal putative CBP1-interacting proteins. Two proteins identified in this screen were the actin-binding proteins, protovillin and EF-1alpha. Using an in vitro binding assay, both of these proteins were found to interact with CBP1 in the absence of Ca(2+), but the interaction of CBP1 with EF-1alpha was increased substantially by Ca(2+). CBP1 was also shown by fluorescence microscopy and by binding assays to associate with the actin cytoskeleton of Dictyostelium cells during development, and these interactions were partially Ca(2+)-dependent. cbpA-null cells grew normally, but under certain developmental conditions, cell aggregation was prolonged and irregular. This defect in aggregation appeared to be related to a general reduction in cell motility rather than to a decrease in the ability of the cells to respond to the chemoattractant cAMP. Together, these results suggest that CBP1 might function to help regulate the reorganization of the Dictyostelium actin cytoskeleton during cell aggregation.

Evidence for the presence of an NF-kappaB signal transduction system in Dictyostelium discoideum.

The Rel/NF-kappaB family of transcription factors and regulators has so far only been described in vertebrates and arthropods, where they mediate responses to many extracellular signals. No counterparts of genes coding for such proteins have been identified in the Caenorhabditis elegans genome and no NF-kappaB activity was found in Saccharomyces cerevisiae. We describe here the presence of an NF-kappaB transduction pathway in the lower eukaryote Dictyostelium discoideum. Using antibodies raised against components of the mammalian NF-kappaB pathway, we demonstrate in Dictyostelium cells extracts the presence of proteins homologous to Rel/NF-kappaB, IkappaB and IKK components. Using gel-shift experiments in nuclear extracts of developing Dictyostelium cells, we demonstrate the presence of proteins binding to kappaB consensus oligonucleotides and to a GC-rich kappaB-like sequence, lying in the promoter of cbpA, a developmentally regulated Dictyostelium gene encoding the Ca(2+)-binding protein CBP1. Using immunofluorescence, we show specific nuclear translocation of the p65 and p50 homologues of the NF-kappaB transcription factors as vegetatively growing cells develop to the slug stage. Taken together, our results strongly indicate the presence of a complete NF-kappaB signal transduction system in Dictyostelium discoideum that could be involved in the developmental process.