Using Changes in Leaf Transmission to Investigate Chloroplast Movement in Arabidopsis thaliana.

Chloroplast movement in leaves has been shown to help minimize photoinhibition and increase growth under certain conditions. Much can be learned about chloroplast movement by studying the chloroplast positioning in leaves using e.g., confocal fluorescence microscopy, but access to this type of microscopy is limited. This protocol describes a method that uses the changes in leaf transmission as a proxy for chloroplast movement. If chloroplasts are spread out in order to maximize light interception, the transmission will be low. If chloroplasts move towards the anticlinal cell walls to avoid light, the transmission will be higher. This protocol describes how to use a straightforward, home-built instrument to expose leaves to different blue light intensities and quantify the dynamic changes in leaf transmission. This approach allows researchers to quantitatively describe chloroplast movement in different species and mutants, study the effects of chemicals and environmental factors on it, or screen for novel mutants e.g., to identify missing components in the process that leads from light perception to the movement of chloroplasts.

Quality improvement training: experiences of frontline staff.

PURPOSE: Healthcare organizations have employed numerous strategies to promote quality improvement (QI) initiatives, yet little is known about their effectiveness. In 2008, staff in one organization developed an in-house QI training program designed for frontline managers and staff and this article aims to report employee perspectives. DESIGN/METHODOLOGY/APPROACH: Qualitative interviews were conducted with 22 course participants to examine satisfaction, self-assessed change in proficiency and ability to successfully engage with QI initiatives. Sampling bias may have occurred as the participants volunteered for the study and they may not represent all course participants. Recall bias is also possible since most interviews took place one year after the course was completed to assess long-term impact. Respondents were asked to self-rate their pre- and post-course knowledge and skill, which may not represent what was actually learned. FINDINGS: Informants reported that the course expanded their QI knowledge and skills, and that supervisor support for the course was essential for success. Additionally, the course QI project provided participants with an opportunity to translate theory into practice, which has the potential to influence patient outcomes. PRACTICAL IMPLICATIONS: Several lessons for future QI training can be gleaned from this evaluation, including respondent opinions that it is challenging to offer one program when participants have different QI knowledge levels before the course begins, that "booster sessions" or refresher classes after the course ends would be helpful and that supervisor support was critical to successful QI-initiative implementation. ORIGINALITY/VALUE: This study conducts in-depth interviews with QI course participants to elicit staff feedback on program structure and effectiveness. These findings can be used by QI educators to disseminate more effective training programs.

Designing insurance to promote use of childhood obesity prevention services.

Childhood obesity is a recognized public health crisis. This paper reviews the lessons learned from a voluntary initiative to expand insurance coverage for childhood obesity prevention and treatment services in the United States. In-depth telephone interviews were conducted with key informants from 16 participating health plans and employers in 2010-11. Key informants reported difficulty ensuring that both providers and families were aware of the available services. Participating health plans and employers are beginning new tactics including removing enrollment requirements, piloting enhanced outreach to selected physician practices, and educating providers on effective care coordination and use of obesity-specific billing codes through professional organizations. The voluntary initiative successfully increased private health insurance coverage for obesity services, but the interviews described variability in implementation with both best practices and barriers identified. Increasing utilization of obesity-related health services in the long term will require both family- and provider-focused interventions in partnership with improved health insurance coverage.

A two-pronged quality improvement training program for leaders and frontline staff.

BACKGROUND: A unique two-pronged QI training program was developed at Emory Healthcare (Atlanta), which encompasses five hospitals and a multispecialty physician practice. One two-day program, Leadership for Healthcare Improvement, is offered to leadership, and a four-month program, Practical Methods for Healthcare Improvement, is offered to frontline staff and middle managers. KNOWLEDGE ASSESSMENT: Participants in the leadership program completed self-assessments of QI competencies and pre- and postcourse QI knowledge tests. Semistructured interviews with selected participants in the practical methods program were performed to assess QI project sustainability and short-term outcomes. RESULTS: More than 600 employees completed one of the training programs in 2008 and 2009. Leadership course participants significantly improved knowledge in all content areas, and self-assessments revealed high comfort levels with QI principles following the training. All practical methods participants were able to initiate and implement QI projects. Participants described significant challenges with team functionality, but a majority of the QI projects made progress toward achieving their aim statement goals. A review of completed projects shows that a significant number were sustained up to one year after program completion. Quality leaders continue to modify the program based on learner feedback and institutional goals. CONCLUSIONS: This initiative shows the feasibility of implementing a broad-based in-house QI training program for multidisciplinary staff across an integrated health system. Initial assessment shows knowledge improvements and successful QI project implementations, with many projects active up to one year following the courses.

Nurses' perceptions and experiences with the implementation of a medication administration system.

The purpose of this article was to describe facilitators and barriers to the implementation of a commercially available electronic medication administration record system at two pediatric hospitals. Qualitative interviews were conducted at 6 and 18 months after implementation with a convenience sample of nurses working on either the medical-surgical or ICUs. The 18-month interview reassessed barriers identified to the adoption of the electronic medication administration record system at the 6-month interview. The vast majority of respondents (85%) indicated that the implementation plan met their expectations. The most significant barrier to adoption (identified by 72% of respondents) was excessive time for logging into the system. After 18 months, respondent satisfaction increased considerably as modifications to the electronic medication administration record system were made, and adjustments to workflow resulted in streamlined nurse work processes coupled with increased productivity and enhanced patient safety. While this study confirms that nursing staff acceptance of health information technology is aided by the system's ability to improve patient safety and accessibility of patient information, we also found that factors unrelated to the actual software or the system could be important determinants of users' satisfaction.

Metabolic imaging in the anesthetized rat brain using hyperpolarized [1-13C] pyruvate and [1-13C] ethyl pyruvate.

Formulation, polarization, and dissolution conditions were developed to obtain a stable hyperpolarized solution of [1-(13)C]-ethyl pyruvate. A maximum tolerated concentration and injection rate were determined, and (13)C spectroscopic imaging was used to compare the uptake of hyperpolarized [1-(13)C]-ethyl pyruvate relative to hyperpolarized [1-(13)C]-pyruvate into anesthetized rat brain. Hyperpolarized [1-(13)C]-ethyl pyruvate and [1-(13)C]-pyruvate metabolic imaging in normal brain is demonstrated and quantified in this feasibility and range-finding study.

Patient activation is associated with healthy behaviors and ease in managing diabetes in an indigent population.

PURPOSE: The purpose of this study is to assess the validity of the patient activation construct as measured by the Patient Activation Measure (PAM) survey by correlating PAM scores with diabetes self-management behaviors, attitudes, and knowledge in a predominantly minority and uninsured population. METHODS: A convenience sample of patients presenting to an urban public hospital diabetes clinic was surveyed and contacted by phone 6 months later. The survey included questions about activation, health behaviors, and health care utilization. RESULTS: A total of 287 patients agreed to participate. Most were African American, female, and uninsured. Most respondents (62.2%) scored in the highest category of activation according to the PAM. Activated patients were more likely to perform feet checks, receive eye examinations, and exercise regularly. Activation was consistently associated with less reported difficulty in managing diabetes care but not with A1C knowledge. PAM scores at the initial interview were highly correlated with scores at 6-month follow-up. Activation level did not predict differences in health care utilization during the 6 months following the survey. CONCLUSIONS: Higher scores on the PAM were associated with higher rates of self-care behaviors and ease in managing diabetes; however, the indigent urban population reported higher activation scores than found in previous studies. The relationship between activation and outcomes needs to be explored further prior to expanding use of this measure in this patient population.

Implementing a pharmacy system: facilitators and barriers.

To describe facilitators and barriers to the implementation of an inpatient pharmacy system at two pediatric hospitals. Interviews, pre- and post-implementation, were conducted with pharmacy and clinical managers. Key findings from the pre-implementation survey were included in the post-implementation survey to further assess facilitators and barriers to the adoption of a pharmacy system. The majority of pharmacy participants and all clinical leaders believed that project goals were being met. Pharmacist's described staff readiness-to-change as the most significant facilitator to adoption and concerns with the usability of information in the pediatric drug file as the most significant barrier. Clinical managers described system training and education as the most significant facilitator to adoption and adjustment to new work processes as the most significant barrier. We described major facilitators and barriers to the adoption of an inpatient pharmacy system at two pediatric hospitals. Strategies identified by our informants to overcome barriers may promote successful pharmacy implementations at other pediatric facilities.

Hyperpolarized 13C lactate, pyruvate, and alanine: noninvasive biomarkers for prostate cancer detection and grading.

An extraordinary new technique using hyperpolarized (13)C-labeled pyruvate and taking advantage of increased glycolysis in cancer has the potential to improve the way magnetic resonance imaging is used for detection and characterization of prostate cancer. The aim of this study was to quantify, for the first time, differences in hyperpolarized [1-(13)C] pyruvate and its metabolic products between the various histologic grades of prostate cancer using the transgenic adenocarcinoma of mouse prostate (TRAMP) model. Fast spectroscopic imaging techniques were used to image lactate, alanine, and total hyperpolarized carbon (THC = lactate + pyruvate + alanine) from the entire abdomen of normal mice and TRAMP mice with low- and high-grade prostate tumors in 14 s. Within 1 week, the mice were dissected and the tumors were histologically analyzed. Hyperpolarized lactate SNR levels significantly increased (P < 0.05) with cancer development and progression (41 +/- 11, 74 +/- 17, and 154 +/- 24 in normal prostates, low-grade primary tumors, and high-grade primary tumors, respectively) and had a correlation coefficient of 0.95 with the histologic grade. In addition, there was minimal overlap in the lactate levels between the three groups with only one of the seven normal prostates overlapping with the low-grade primary tumors. The amount of THC, a possible measure of substrate uptake, and hyperpolarized alanine also increased with tumor grade but showed more overlap between the groups. In summary, elevated hyperpolarized lactate and potentially THC and alanine are noninvasive biomarkers of prostate cancer presence and histologic grade that could be used in future three-dimensional (13)C spectroscopic imaging studies of prostate cancer patients.

Hyperpolarized C-13 spectroscopic imaging of the TRAMP mouse at 3T-initial experience.

The transgenic adenocarcinoma of mouse prostate (TRAMP) mouse is a well-studied murine model of prostate cancer with histopathology and disease progression that mimic the human disease. To investigate differences in cellular bioenergetics between normal prostate epithelial cells and prostate tumor cells, in vivo MR spectroscopic (MRS) studies with non-proton nuclei, such as (13)C, in the TRAMP model would be extremely useful. The recent development of a method for retaining dynamic nuclear polarization (DNP) in solution permits high signal-to-noise ratio (SNR) (13)C MRI or MRSI data to be obtained following injection of a hyperpolarized (13)C agent. In this transgenic mouse study, this method was applied using a double spin-echo (DSE) pulse sequence with a small-tip-angle excitation RF pulse, hyperbolic-secant refocusing pulses, and a flyback echo-planar readout trajectory for fast (10-14 s) MRSI of (13)C pyruvate (pyr) and its metabolic products at 0.135 cm(3) nominal spatial resolution. Elevated (13)C lactate (lac) was observed in both primary and metastatic tumors, demonstrating the feasibility of studying cellular bioenergetics in vivo with DNP hyperpolarized (13)C MRSI.

Adopting National Quality Forum medication safe practices: Progress and barriers to hospital implementation.

BACKGROUND: To reduce medical errors, the National Quality Forum (NQF) developed consensus-based guidelines of 30 safe practices recommended for all hospitals OBJECTIVE: To determine the hospital characteristics and barriers that influence the rates of adoption of these practices. DESIGN: Retrospective review of annual self-assessment surveys from 2003 to 2004. Medication and culture of safety questions from the survey were mapped to the relevant NQF safe practices. SETTING: One hundred and forty-eight acute care hospitals. MEASUREMENTS: Bivariate analysis was used to examine variation in adoption rates by hospital demographic characteristics. RESULTS: Most hospitals had adopted 7 of the 9 medication-related practices. Lower adoption rates were seen for resource-intensive safe practices such as consultant pharmacists (52.0%) or CPOE (2.7%). The safety culture questions showed broad diffusion of nonpunitive error reporting (83.7%) but more limited adoption of proactive processes to detect and prevent errors (44.9%). There were no differences by urban versus rural setting and few differences by hospital size. Safe practices that affected hospital-based physicians such as ensuring that new prescribers had access to all currently prescribed medications and minimizing distractions during order writing were difficult for many hospitals. Lower adoption rates were also seen for processes requiring direct physician participation such as eliminating verbal orders and using standardized abbreviations. CONCLUSIONS: Adoption of NQF-recommended safe practices appeared related to resource constraints and hospital culture. Promoting physician involvement as clinical leaders and team builders, moving from reactive reporting systems to proactive processes that prevent errors, and developing more robust monitoring systems will facilitate further adoption of safe practices.

Accurate flip-angle calibration for 13C MRI.

(13)C imaging and spectroscopy in the presence of injected labeled compounds can vastly extend the capability of MRI to perform metabolic imaging. The details of imaging in the presence of injected compounds, however, pose new technological challenges. Pulse sequences, in general, rely on precise flip-angle (FA) calibration to create high signal-to-noise ratio (SNR), artifact-free images. Signal quantification also requires precise knowledge of the excitation FA. In MRI scans that rely on signal acquisitions from injected compounds, however, such FA calibration is challenged by low natural-abundance (13)C signal levels before injection, and by time-varying signal following injection. A method to precisely set the FA at the (13)C frequency based on FA calibration at the (23)Na frequency is presented here. A practical implementation of a coil (a dual-tuned, (23)Na/(13)C low-pass birdcage coil) suitable for this calibration in vivo is also documented. Accurate FA calibration is demonstrated at the (13)C frequency for in vivo rat experiments using this approach.

Facilitators and barriers to 10 National Quality Forum safe practices.

The objective of this study was to identify facilitators and barriers to the implementation of 10 National Quality Forum (NQF) medication processes and the culture of safety practices in Georgia hospitals. In-depth interviews with hospital administrators were conducted to identify facilitators and barriers to the implementation of programs that support the NQF safe practices. Hospitals identified significant as well as other key factors that resulted in the adoption and/or nonadoption of medication and culture of safety practices. Informants also identified strategies used to overcome barriers that were experienced. Facilitators to both practices include administrative leadership support and education and training. The resistance to change was the most significant barrier identified in both the safe medication process interviews and the culture of safety interviews. Implementing safety practices can be a difficult process, replete with organizational, financial, and professional barriers. Strategies identified by our informants to overcome these barriers may assist other hospitals currently facing this challenge.

A simple low-cost microcontroller-based photometric instrument for monitoring chloroplast movement.

A new microcontroller-based photometric instrument for monitoring blue light dependent changes in leaf transmission (chloroplast movement) was developed based on a modification of the double-beam technique developed by Walzcak and Gabrys [(1980) Photosynthetica 14: 65-72]. A blue and red bicolor light emitting diode (LED) provided both a variable intensity blue actinic light and a low intensity red measuring beam. A phototransistor detected the intensity of the transmitted measuring light. An inexpensive microcontroller independently and precisely controlled the light emission of the bicolor LED. A typical measurement event involved turning off the blue actinic light for 100 mus to create a narrow temporal window for turning on and measuring the transmittance of the red light. The microcontroller was programmed using LogoChip Logo (http://www.wellesley.edu/Physics/Rberg/logochip/) to record fluence rate response curves. Laser scanning confocal microscopy was utilized to correlate the changes in leaf transmission with intercellular chloroplast position. In the dark, the chloroplasts in the spongy mesophyll exhibited no evident asymmetries in their distribution, however, in the palisade layer the cell surface in contact with the overlying epidermis was devoid of chloroplasts. The low light dependent decrease in leaf transmittance in dark acclimated leaves was correlated with the movement of chloroplasts within the palisade layer into the regions previously devoid of chloroplasts. Changes in leaf transmittance were evident within one minute following the onset of illumination. Minimal leaf transmittance was correlated with chloroplasts having retreated from cell surfaces perpendicular to the incident light (avoidance reaction) in both spongy and palisade layers.

Magnetic resonance imaging at 9.4 T as a tool for studying neural anatomy in non-vertebrates.

This report describes magnetic resonance imaging (MRI) methods we have developed at 9.4 T for observing internal organs and the nervous system of an invertebrate organism, the crayfish, Cherax destructor. We have compared results acquired using two different pulse sequences, and have tested manganese (Mn(2+)) as an agent to enhance contrast of neural tissues in this organism. These techniques serve as a foundation for further development of functional MRI and neural tract-tracing methods in non-vertebrate systems.

Preliminary validation of a UK-modified version of the BASIS-32.

INTRODUCTION: The authors examined the reliability and validity of a UK-modified version of the Behavioral and Symptom Identification Scale (BASIS-32). METHOD: Data from two samples of patients from acute psychiatric inpatient settings were used in the analyses ( n =303, n =92). The factor structure of the scale differed from that of the original BASIS-32. RESULTS: Five factors emerged: (i) depression and anxiety, (ii) lability, (iii) psychosis, (iv) substance misuse and (v) functioning. The full scale of the modified BASIS demonstrated high internal consistency (Cronbach's alpha=0.93). Internal consistency for the subscales ranged from 0.86 to 0.45. The depression and anxiety subscale discriminated patients with a diagnosis of unipolar depression from those with other diagnoses (median score=3.11 (Inter quartile range (IQR)=2.67,3.33) versus median score=2.44 (1.67,3.11), P < 0.001). The substance misuse subscale discriminated patients with a diagnosis of alcohol or opiate dependence from those with other diagnoses (median score=2.33 (2, 3) versus median score=1.33 (0.67, 2), P < 0.001). However, the psychosis subscale did not differentiate patients with a psychotic illness from those with a nonpsychotic diagnosis (median score=1.4 (0.6,2.4) versus median score=1.2, (0.6,2), P = 0.16). CONCLUSION: The total scale appeared to be at least as good as the Brief Symptom Inventory (BSI) in its responsiveness to change. The effect size for the BASIS=1.17 versus 0.91 for the BSI. Convergent validity was partially demonstrated between the modified BASIS and the BSI. ( Int J Psych Clin Pract 2001; 5:41-48).