Examining the impacts of salt specificity on freshwater microbial community and functional potential following salinization.

The degradation of freshwater systems by salt pollution is a threat to global freshwater resources. Salinization is commonly identified by increased specific conductance (conductivity), a proxy for salt concentrations. However, conductivity fails to account for the diversity of salts entering freshwaters and the potential implications this has on microbial communities and functions. We tested 4 types of salt pollution-MgCl2, MgSO4, NaCl, and Na2SO4-on bacterial taxonomic and functional α-, ß-diversity of communities originating from streams in two distinct localities (Nebraska [NE] and Ohio [OH], USA). Community responses depended on the site of origin, with NE and OH exhibiting more pronounced decreases in community diversity in response to Na2SO4 and MgCl2 than other salt amendments. A closer examination of taxonomic and functional diversity metrics suggests that core features of communities are more resistant to induced salt stress and that marginal features at both a population and functional level are more likely to exhibit significant structural shifts based on salt specificity. The lack of uniformity in community response highlights the need to consider the compositional complexities of salinization to accurately identify the ecological consequences of instances of salt pollution.

Integral equation models for solvent in macromolecular crystals.

The solvent can occupy up to ∼70% of macromolecular crystals, and hence, having models that predict solvent distributions in periodic systems could improve the interpretation of crystallographic data. Yet, there are few implicit solvent models applicable to periodic solutes, and crystallographic structures are commonly solved assuming a flat solvent model. Here, we present a newly developed periodic version of the 3D-reference interaction site model (RISM) integral equation method that is able to solve efficiently and describe accurately water and ion distributions in periodic systems; the code can compute accurate gradients that can be used in minimizations or molecular dynamics simulations. The new method includes an extension of the Ornstein-Zernike equation needed to yield charge neutrality for charged solutes, which requires an additional contribution to the excess chemical potential that has not been previously identified; this is an important consideration for nucleic acids or any other charged system where most or all the counter- and co-ions are part of the "disordered" solvent. We present several calculations of proteins, RNAs, and small molecule crystals to show that x-ray scattering intensities and the solvent structure predicted by the periodic 3D-RISM solvent model are in closer agreement with the experiment than are intensities computed using the default flat solvent model in the refmac5 or phenix refinement programs, with the greatest improvement in the 2 to 4 Šrange. Prospects for incorporating integral equation models into crystallographic refinement are discussed.

Refinement of RNA Structures Using Amber Force Fields.

Atomic models for nucleic acids derived from X-ray diffraction data at low resolution provide much useful information, but the observed scattering intensities can be fit with models that can differ in structural detail. Tradtional geometric restraints favor models that have bond length and angle terms derived from small molecule crystal structures. Here we explore replacing these restraints with energy gradients derived from force fields, including recently developed integral equation models to account for the effects of water molecules and ions that are not part of the explicit model. We compare conventional and force-field based refinements for 22 RNA crystals, ranging in resolution from 1.1 to 3.6 Å. As expected, it can be important to account for solvent screening of charge-charge interactions, especially in the crowded environment of a nucleic acid crystal. The newly refined models can show improvements in torsion angles and hydrogen-bonding interactions, and can significantly reduce unfavorable atomic clashes, while maintaining or improving agreement with observed scattering intensities.

What can we learn about systems leadership from the building of a Welsh surge hospital and how might this be applied beyond the current COVID-19 response?

Methods: It draws on a series of 20 interviews with key protagonists and employs a Bakhtinian approach to narrative analysis, which explores the interplay between individual accounts and larger sociocultural themes. Conclusions: It concludes that the success in managing the complexity of this project can largely be attributed to a systems leader approach that draws on the power of an agile network to be replenished and redeployed against rapidly evolving strategic objectives. This effectively constitutes a parallel operating structure, which is devoted to the design and implementation of strategy based on a continual assessment of the organisation and serves to strengthen rather than supersede established hierarchical structures of authority.

Distribution and co-occurrence of antibiotic and metal resistance genes in biofilms of an anthropogenically impacted stream.

Urban stream biofilms are potential hotspots for resistomes and antibiotic resistance genes (ARGs). Biofilm communities that harbor resistance genes may be influenced by contaminant input (e.g., metals and antibiotics) from urban drainage (i.e., Wastewater Treatment Plant effluent and stormwater runoff); understanding the ecology of these communities and their resistome is needed. Given the potential importance of the co-occurrence of ARGs and metal resistance genes (MRGs), we investigated the spatial and temporal distribution of three ARGs (tetracycline [tetW] and sulfonamides [sulI and sulII]), four MRGs (lead [pbrT], copper [copA], and cadmium/cobalt/zinc [czcA and czcC]) via quantitative PCR and biofilm bacterial community composition via MiSeq 16S sequencing at four time points along an urbanization gradient (i.e., developed, agriculture, and forested sites) in a stream's watershed. Our results revealed that ARG and MRG abundances were significantly affected by land use-time interaction, with greater resistance abundances occurring in more urban locations during particular times of the year. It was also observed that changes in ARG and MRG profiles were influenced by differences in community composition among land use types, and that these differences were in response to changes in stream physicochemical parameters (pH, redox, temperature, nutrient availability, and metal concentration) that were driven by sub-watershed land use. Moreover, the dynamics between ARGs and MRGs within these communities correlated strongly and positively with one another. Taken altogether, our results demonstrate that changes in environmental properties due to human activity may drive the ARG-MRG profiles of biofilm communities by modulating community structure over time and space.

Saving 20 000 Days and Beyond: a realist evaluation of two quality improvement campaigns to manage hospital demand in a New Zealand District Health Board.

Background: The current paper reports on a realist evaluation of two consecutive quality improvement campaigns based on the Institute for Healthcare Improvement's Breakthrough Series. The campaigns were implemented by a District Health Board to manage hospital demand in South Auckland, New Zealand. A realist evaluation design was adopted to investigate what worked in the two campaigns and under what conditions. Methods: A mixed-methods approach was used, involving three phases of data collection. During the first phase, a review of campaign materials and relevant literature, as well as key informant interviews were undertaken to generate an initial logic model of how the campaign was expected to achieve its objective. In phase II, the model was tested against the experiences of participants in the first campaign via a questionnaire to all campaign participants, interviews with campaign sponsors and collaborative team leaders and a review of collaborative team dashboards. In phase III, the refined model was tested further against the experiences of participants in the second campaign through interviews with collaborative team leaders, case studies of four collaborative teams and a review of the overall system-level dashboard. Results: The evaluation identified four key mechanisms through which the campaigns' outcomes were achieved. These were characterised as 'an organisational preparedness to change', 'enlisting the early adopters', 'strong collaborative teams' and 'learning from measurement'. Contextual factors that both enabled and constrained the operation of these mechanisms were also identified. Conclusions: By focusing on the explication of a theory of how the campaigns achieved their outcomes and under what circumstances, the realist evaluation reported in this paper provides some instructive lessons for future evaluations of quality improvement initiatives.

What initiatives do healthcare leaders agree are needed for healthcare system improvement? Results of a modified-Delphi study.

PURPOSE: The purpose of this paper is to identify five quality improvement initiatives for healthcare system leaders, produced by such leaders themselves, and to provide some guidance on how these could be implemented. DESIGN/METHODOLOGY/APPROACH: A multi-stage modified-Delphi process was used, blending the Delphi approach of iterative information collection, analysis and feedback, with the option for participants to revise their judgments. FINDINGS: The process reached consensus on five initiatives: change information privacy laws; overhaul professional training and work in the workplace; use co-design methods; contract for value and outcomes across health and social care; and use data from across the public and private sectors to improve equity for vulnerable populations and the sickest people. RESEARCH LIMITATIONS/IMPLICATIONS: Information could not be gathered from all participants at each stage of the modified-Delphi process, and the participants did not include patients and families, potentially limiting the scope and nature of input. PRACTICAL IMPLICATIONS: The practical implications are a set of findings based on what leaders would bring to a decision-making table in an ideal world if given broad scope and capacity to make policy and organisational changes to improve healthcare systems. ORIGINALITY/VALUE: This study adds to the literature a suite of recommendations for healthcare quality improvement, produced by a group of experienced healthcare system leaders from a range of contexts.

Sediment bacteria in an urban stream: Spatiotemporal patterns in community composition.

Sediment bacterial communities play a critical role in biogeochemical cycling in lotic ecosystems. Despite their ecological significance, the effects of urban discharge on spatiotemporal distribution of bacterial communities are understudied. In this study, we examined the effect of urban discharge on the spatiotemporal distribution of stream sediment bacteria in a northeast Ohio stream. Water and sediment samples were collected after large storm events (discharge > 100 m) from sites along a highly impacted stream (Tinkers Creek, Cuyahoga River watershed, Ohio, USA) and two reference streams. Although alpha (α) diversity was relatively constant spatially, multivariate analysis of bacterial community 16S rDNA profiles revealed significant spatial and temporal effects on beta (ß) diversity and community composition and identified a number of significant correlative abiotic parameters. Clustering of upstream and reference sites from downstream sites of Tinkers Creek combined with the dominant families observed in specific locales suggests that environmentally-induced species sorting had a strong impact on the composition of sediment bacterial communities. Distinct groupings of bacterial families that are often associated with nutrient pollution (i.e., Comamonadaceae, Rhodobacteraceae, and Pirellulaceae) and other contaminants (i.e., Sphingomonadaceae and Phyllobacteriaceae) were more prominent at sites experiencing higher degrees of discharge associated with urbanization. Additionally, there were marked seasonal changes in community composition, with individual taxa exhibiting different seasonal abundance patterns. However, spatiotemporal variation in stream conditions did not affect bacterial community functional profiles. Together, these results suggest that local environmental drivers and niche filtering from discharge events associated with urbanization shape the bacterial community structure. However, dispersal limitations and interactions among other species likely play a role as well.

Are quality improvement collaboratives effective? A systematic review.

BACKGROUND: Quality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness. METHOD: We searched Medline, Embase, CINAHL, PsycINFO and the Cochrane Library databases from January 1995 to December 2014. Studies were included if they met the criteria for a QIC intervention and the Cochrane Effective Practice and Organisation of Care (EPOC) minimum study design characteristics for inclusion in a review. We assessed study bias using the EPOC checklist and the quality of the reported intervention using a subset of SQUIRE 1.0 standards. RESULTS: Of the 220 studies meeting QIC criteria, 64 met EPOC study design standards for inclusion. There were 10 cluster randomised controlled trials, 24 controlled before-after studies and 30 interrupted time series studies. QICs encompassed a broad range of clinical settings, topics and populations ranging from neonates to the elderly. Few reports fully described QIC implementation and methods, intensity of activities, degree of site engagement and important contextual factors. By care setting, an improvement was reported for one or more of the study's primary effect measures in 83% of the studies (32/39 (82%) hospital based, 17/20 (85%) ambulatory care, 3/4 nursing home and a sole ambulance QIC). Eight studies described persistence of the intervention effect 6 months to 2 years after the end of the collaborative. Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline. CONCLUSIONS: QICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.

Healthcare leaders' views on successful quality improvement initiatives and context.

Purpose The purpose of this paper is to investigate the contextual factors contributing to the sustainability of healthcare quality improvement (QI) initiatives. Design/methodology/approach Themes from semi-structured interviews with international healthcare leaders are compared with Kaplan and Provost et al.'s (2012) model for understanding success in quality (MUSIQ). Critical success factors within these themes are shown in detail. Findings The interviews provide a rich source of information on critical success factors. The themes largely correspond with MUSIQ, reinforcing its robustness. An important factor emerging from the interviews was the importance of engagement with patients and families in QI, and this needs consideration in seeking to understand context in QI. Research limitations/implications Interview participants represent a limited set of western countries and health systems. Their experiences may not hold true in other settings. Practical implications The detail on critical success factors provides QI practitioners with guidance on designing and implementing sustainable initiatives. Originality/value Including consideration of contextual factors for engagement with patients and families in frameworks for context in QI appears to be an original idea that will add value to such frameworks. Researchers in patient engagement are starting to address contextual factors and connections should be made with this work.

Enhanced Recovery After Surgery in elective hip and knee arthroplasty reduces length of hospital stay.

BACKGROUND: Standardized perioperative care within an Enhanced Recovery After Surgery (ERAS) programme aims to reduce postoperative morbidity and length of hospital stay (LOS). This study evaluated the effect of ERAS in patients undergoing elective, primary total hip and knee arthroplasty (THA and TKA) in a New Zealand public hospital. METHODS: Data collected prospectively on patients who had undergone THA and TKA in an ERAS programme (ERAS: August-December 2013) were compared to a retrospective cohort of patients managed in a traditional perioperative care environment (control: June-August 2012). The Breakthrough Series Model for Improvement provided a framework to implement components of the ERAS protocol. The primary outcome was median LOS. Secondary outcomes included 30-day readmission rates, complications and cost. RESULTS: There were 206 patients who met the eligibility criteria (106 ERAS, 100 control). There were no significant differences in baseline characteristics. After the implementation of ERAS, median LOS was reduced by 1 day (5 control versus 4 ERAS; P < 0.001). Short-term complications were similar (P = 0.372) as were readmission rates (P = 0.258). Cost analysis identified ERAS patients to have reduced cost overall. CONCLUSIONS: ERAS in THA and TKA has been shown to be safe and effective in improving recovery through shorter hospital stay.

Target CLAB Zero: A national improvement collaborative to reduce central line-associated bacteraemia in New Zealand intensive care units.

AIM: Central line-associated bacteraemia (CLAB) is a preventable cause of patient morbidity and mortality in intensive care units. Target CLAB Zero was a national campaign that ran from October 2011 to March 2013 across all New Zealand ICUs (intensive care units). The campaign aimed to reduce the national CLAB rate to less than one incident per 1,000 line days and to establish a national measurement system for CLAB. METHOD: We used Institute for Healthcare Improvement (IHI) Breakthrough Series methodology to structure the campaign. IHI bundles of care for catheter insertion and maintenance were implemented across 25 New Zealand ICUs. We collected monthly data on line days, CLAB infections and compliance with the bundles. Data were analysed using run charts. RESULTS: The rate of CLAB per 1,000 line days fell from 3.32 at baseline to an average of 0.28 between April 2012 and March 2013. In the final 3-month period, January to March 2013, average insertion bundle compliance was 80% and average maintenance bundle compliance was 75%. All ICUs participated in the collaborative. Over 90% of those invited attended all three national learning sessions and bi-monthly regional learning sessions. CONCLUSION: National collaboratives can effect improvement and shared learning in New Zealand. International evidence combined with New Zealand experience, a supportive methodology, partnership, clinical respect and an effective communication plan were keys to successful engagement.

An innovative community organizing campaign to improve mental health and wellbeing among Pacific Island youth in South Auckland, New Zealand.

OBJECTIVE: To examine whether being an organizer in a community organizing program improves personal agency and self-reported mental health outcomes among low-income Pacific Island youth in Auckland, New Zealand. METHOD: Counties Manukau Health initiated a community organizing campaign led and run by Pacific Island youth. We used interviews, focus groups and pre- and post-campaign surveys to examine changes among 30 youths as a result of the campaign. RESULTS: Ten youths completed both pre- and post-campaign surveys. Eleven youths participated in focus groups, and four in interviews. Overall, youths reported an increased sense of agency and improvements to their mental health. CONCLUSIONS: Community organizing has potential as a preventive approach to improving mental health and developing agency over health among disempowered populations.

Exploring the role of communications in quality improvement: A case study of the 1000 Lives Campaign in NHS Wales.

INTRODUCTION: Effective communication is critical to successful large-scale change. Yet, in our experience, communications strategies are not formally incorporated into quality improvement (QI) frameworks. The 1000 Lives Campaign ('Campaign') was a large-scale national QI collaborative that aimed to save an additional 1000 lives and prevent 50 000 episodes of harm in Welsh health care over a 2-year period. We use the Campaign as a case study to describe the development, application, and impact of a communications strategy embedded in a large-scale QI initiative. METHODS: A comprehensive communications strategy guided communications work during the Campaign. The main aims of the communications strategy were to engage the hearts and minds of frontline National Health Service (NHS) staff in the Campaign and promote their awareness and understanding of specific QI interventions and the wider patient safety agenda. We used qualitative and quantitative measures to monitor communications outputs and assess how the communications strategy influenced awareness and knowledge of frontline NHS staff. RESULTS: The communications strategy facilitated clear and consistent framing of Campaign messages and allowed dissemination of information related to the range of QI interventions. It reaffirmed the aim and value of the Campaign to frontline staff, thereby promoting sustained engagement with Campaign activities. The communications strategy also built the profile of the Campaign both internally with NHS organizations across Wales and externally with the media, and played a pivotal role in improving awareness and understanding of the patient safety agenda. Ultimately, outcomes from the communications strategy could not be separated from overall Campaign outcomes. CONCLUSION AND RECOMMENDATIONS: Systematic and structured communications can support and enhance QI initiatives. From our experience, we developed a 'communications bundle' consisting of six core components. We recommend that communications bundles be incorporated into existing QI methodology, though details should be tailored to the specific context and available resource.

Periodontal-endodontic lesion of a three-rooted maxillary premolar: report of a case.

BACKGROUND: A 43-year-old African American male initially presented for a dental evaluation of a recurrent swelling on the buccal aspect of tooth #12. His medical history was unremarkable except for a 20-pack year history of smoking. He was eventually diagnosed as having a necrotic pulp #12, and received root canal treatment. The patient's problem was unresolved, and he was subsequently referred for a periodontal evaluation with a presumptive diagnosis of a periodontal abscess. METHODS: A flap was reflected from teeth #11 through #15. A buccal furcation invasion was discovered on #12. Shortly thereafter, three distinct roots with three grade III furcation invasions were located. The tooth was deemed untreatable, and was extracted. The thin buccal plate of the extraction socket was preserved using freeze-dried bone allograft to facilitate future prosthodontic replacement. RESULTS: Healing was uneventful. Periodontal open flap debridement surgery was provided for the remainder of the mouth, and the patient was placed on a 3-month recall program. CONCLUSIONS: Periodontitis associated with endodontic lesions are among the most daunting diagnostic and therapeutic challenges faced by periodontists. This is particularly true for maxillary premolars with multiple roots. The tooth in this case, once periodontally involved, had a very poor prognosis. The prognosis was further compromised by the pulpal involvement. Therapy consisted of extraction of the tooth to relieve the patient's discomfort and treating the adjacent teeth with periodontal open flap debridement surgery. A review of the literature pertinent to the diagnosis and management of periodontal-endodontic lesions is also presented.

Identification and prioritization of quality indicators in clinical genetics: an international survey.

The range and demand for clinical genetic services will continue to grow, and now is an ideal time to assess current service quality. Based on the previous work of quality professional organizations such as the Institute of Medicine (IOM) and The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) which is now known as The Joint Commission (TJC), an independent group of genetic and healthcare quality professionals (InheritQual) drafted and defined a list of potential quality indicators for clinical genetics. Perspectives on the appropriateness and the practicality of each indicator were surveyed and analyzed. The Quality Special Interest Group of the American College of Medical Genetics (ACMG) chartered the survey results. After measuring the degree of consensus, an expert panel was selected to review the quality indicators based on practicality and applicability. This expert panel comprised of members of the ACMG Quality Sig workgroup met for final consensus and developed a methodology to pilot these indicators.

Improving service delivery by evaluation of the referral pattern and capacity in a clinical genetics setting.

Quality improvement in specialist services such as clinical genetics is challenging largely due to the complexity of the service and the difficulty in obtaining accurate, reproducible, and measurable data. The objectives were to evaluate the pattern of referrals to the All Wales Medical Genetics Service (AWMGS) North Wales Genetics team based in three separate hospitals, define the capacity of the team and implement change to improve equity, timeliness and efficiency of care delivery to patients. The methodology required collating the monthly referral rates retrospectively for each center over a 2.5-year period and plotting on statistical process control charts. Process mapping of the referral process in each center was undertaken, differences documented and a common pathway implemented. "Did not attend" and "time to first appointment" rates were also measured in one center. PDSA methodology was used to implement "patient focused booking." The results show that the range for referral rates in any given month for each center was 3-33 referrals. The range for referral rate for the whole team was 18-64 per month. Since January 2004 the average number of monthly referrals to the North Wales service has increased by 50%. The potential range in monthly referrals varies between centers and the range of the variability has also increased also in two out of the three centers. Introduction of Patient Focused Booking reduced the "Failed to Attend" rate and 100% of patients were offered a choice of appointments. In addition 100% had a first face-to-face contact within 6 weeks if they chose. The measurement of improvement involved firstly introducing a series of continuous measures to provide a baseline for the process prior to the implementation of any changes and secondly to indicate the impact of the changes following implementation. The measures implemented included process (referrals numbers, percentage of patients offered a choice of appointments), outcome (percentage of patients seen within 6 weeks and the percentage failing to attend), and balancing measures (percentage declining the service or failing to respond). It was concluded that general tools of quality improvement can be used to good effect within specialist services. Good processes and accurate, reproducible and measurable data are essential. Small changes can have a major impact both on the quality of the service offered and the ability to deliver the service.