Monitoring groundwater quality with real-time data, stable water isotopes, and microbial community analysis: A comparison with conventional methods.

Groundwater provides much of the world's potable water. Nevertheless, groundwater quality monitoring programmes often rely on a sporadic, slow, and narrowly focused combination of periodic manual sampling and laboratory analyses, such that some water quality deficiencies go undetected, or are detected too late to prevent adverse consequences. In an effort to address this shortcoming, we conducted enhanced monitoring of untreated groundwater quality over 12 months (February 2019-February 2020) in four shallow wells supplying potable water in Finland. We supplemented periodic manual sampling and laboratory analyses with (i) real-time online monitoring of physicochemical and hydrological parameters, (ii) analysis of stable water isotopes from groundwater and nearby surface waters, and (iii) microbial community analysis of groundwater via amplicon sequencing of the 16S rRNA gene and 16S rRNA. We also developed an early warning system (EWS) for detecting water quality anomalies by automating real-time online monitoring data collection, transfer, and analysis - using electrical conductivity (EC) and turbidity as indirect water quality indicators. Real-time online monitoring measurements were largely in fair agreement with periodic manual measurements, demonstrating their usefulness for monitoring water quality; and the findings of conventional monitoring, stable water isotopes, and microbial community analysis revealed indications of surface water intrusion and faecal contamination at some of the studied sites. With further advances in technology and affordability expected into the future, the supplementary methods used here could be more widely implemented to enhance groundwater quality monitoring - by contributing new insights and/or corroborating the findings of conventional analyses.

Surface Water Intrusion, Land Use Impacts, and Bacterial Community Composition in Shallow Groundwater Wells Supplying Potable Water in Sparsely Populated Areas of a Boreal Region.

Rural communities often rely on groundwater for potable water supply. In this study, untreated groundwater samples from 28 shallow groundwater wells in Finland (<10 m deep and mostly supplying untreated groundwater to <200 users in rural areas) were assessed for physicochemical water quality, stable water isotopes, microbial water quality indicators, host-specific microbial source tracking (MST) markers, and bacterial community composition, activity, and diversity (using amplicon sequencing of the 16S rRNA gene and 16S rRNA). Indications of surface water intrusion were identified in five wells, and these indications were found to be negatively correlated, overall, with bacterial alpha diversity (based on amplicon sequencing of the 16S rRNA gene). High levels of turbidity, heterotrophs, and iron compromised water quality in two wells, with values up to 2.98 nephelometric turbidity units (NTU), 16,000 CFU/ml, and 2,300 µg/liter, respectively. Coliform bacteria and general fecal indicator Bacteroidales bacteria (GenBac3) were detected in 14 and 10 wells, respectively (albeit mostly at low levels), and correlations were identified between microbial, physicochemical, and environmental parameters, which may indicate impacts from nearby land use (e.g., agriculture, surface water, road salt used for deicing). Our results show that although water quality was generally adequate in most of the studied wells, the continued safe use of these wells should not be taken for granted. IMPORTANCE Standard physicochemical water quality analyses and microbial indicator analyses leave much of the (largely uncultured) complexity of groundwater microbial communities unexplored. This study combined these standard methods with additional analyses of stable water isotopes, bacterial community data, and environmental data about the surrounding areas to investigate the associations between physicochemical and microbial properties of 28 shallow groundwater wells in Finland. We detected impaired groundwater quality in some wells, identified potential land use impacts, and revealed indications of surface water intrusion which were negatively correlated with bacterial alpha diversity. The potential influence of surface water intrusion on groundwater wells and their bacterial communities is of particular interest and warrants further investigation because surface water intrusion has previously been linked to groundwater contamination, which is the primary cause of waterborne outbreaks in the Nordic region and one of the major causes in the United States and Canada.

The Escherichia coli MarA protein regulates the ycgZ-ymgABC operon to inhibit biofilm formation.

The Escherichia coli marRAB operon is a paradigm for chromosomally encoded antibiotic resistance. The operon exerts its effect via an encoded transcription factor called MarA that modulates efflux pump and porin expression. In this work, we show that MarA is also a regulator of biofilm formation. Control is mediated by binding of MarA to the intergenic region upstream of the ycgZ-ymgABC operon. The operon, known to influence the formation of curli fibres and colanic acid, is usually expressed during periods of starvation. Hence, the ycgZ-ymgABC promoter is recognised by σ38 (RpoS)-associated RNA polymerase (RNAP). Surprisingly, MarA does not influence σ38 -dependent transcription. Instead, MarA drives transcription by the housekeeping σ70 -associated RNAP. The effects of MarA on ycgZ-ymgABC expression are coupled with biofilm formation by the rcsCDB phosphorelay system, with YcgZ, YmgA and YmgB forming a complex that directly interacts with the histidine kinase domain of RcsC.

Interprofessional Attitudes and Interdisciplinary Practices for Older Adults With Back Pain Among Doctors of Chiropractic: A Descriptive Survey.

OBJECTIVE: The purpose of this study is to report on attitudes of doctors of chiropractic (DCs) toward integrative medicine and their self-reported interdisciplinary practices for older adults with back pain. METHODS: This descriptive survey was conducted with licensed DCs in a Midwestern community in the United States. Respondents completed a 53-item postal survey of demographics, practice characteristics, referral and co-management patterns, attitudes toward interdisciplinary practice, and the Integrative Medicine-30 Questionnaire (IM-30). Descriptive statistical analysis was performed. RESULTS: Fifty-seven DCs completed the survey (29% response). Geriatric-focused chiropractic practices were uncommon (<15%), although 56% reported that 25% to 49% of the patients treated each week were older adults. Respondents had a moderate orientation toward collaboration with other health care providers (IM-30 mean [standard deviation] 61.3 [11.5]). The IM-30 subscales placed DCs high on measures of integrative medicine safety; moderate on patient-centeredness, openness to working with other providers, and referral readiness; and low on learning from alternative paradigms. Doctors of chiropractic most referred older patients to neurologists, family physicians, massage therapists, orthopedists, and other chiropractors. Doctors of chiropractic reported the highest levels of co-management with family physicians, physical therapists, and massage therapists. Most DCs (92%) were confident in their own ability to manage back pain in older adults, with modest confidence expressed for treatments from professionals using manual therapies. Most (77%) responded that older patients would experience the most improvement if DCs collaborated with another chiropractor, rather than with medical professionals. CONCLUSION: Doctors of chiropractic in one geographic community are moderately oriented toward interprofessional practice with other health care providers for older adults with back pain. Follow-up studies in representative national and international samples are recommended.

Interdisciplinary Practice Models for Older Adults With Back Pain: A Qualitative Evaluation.

Purpose: Older adults seek health care for low back pain from multiple providers who may not coordinate their treatments. This study evaluated the perceived feasibility of a patient-centered practice model for back pain, including facilitators for interprofessional collaboration between family medicine physicians and doctors of chiropractic. Design and Methods: This qualitative evaluation was a component of a randomized controlled trial of 3 interdisciplinary models for back pain management: usual medical care; concurrent medical and chiropractic care; and collaborative medical and chiropractic care with interprofessional education, clinical record exchange, and team-based case management. Data collection included clinician interviews, chart abstractions, and fieldnotes analyzed with qualitative content analysis. An organizational-level framework for dissemination of health care interventions identified norms/attitudes, organizational structures and processes, resources, networks-linkages, and change agents that supported model implementation. Results: Clinicians interviewed included 13 family medicine residents and 6 chiropractors. Clinicians were receptive to interprofessional education, noting the experience introduced them to new colleagues and the treatment approaches of the cooperating profession. Clinicians exchanged high volumes of clinical records, but found the logistics cumbersome. Team-based case management enhanced information flow, social support, and interaction between individual patients and the collaborating providers. Older patients were viewed positively as change agents for interprofessional collaboration between these provider groups. Implications: Family medicine residents and doctors of chiropractic viewed collaborative care as a useful practice model for older adults with back pain. Health care organizations adopting medical and chiropractic collaboration can tailor this general model to their specific setting to support implementation.

Patient-centered professional practice models for managing low back pain in older adults: a pilot randomized controlled trial.

BACKGROUND: Low back pain is a debilitating condition for older adults, who may seek healthcare from multiple providers. Few studies have evaluated impacts of different healthcare delivery models on back pain outcomes in this population. The purpose of this study was to compare clinical outcomes of older adults receiving back pain treatment under 3 professional practice models that included primary medical care with or without chiropractic care. METHODS: We conducted a pilot randomized controlled trial with 131 community-dwelling, ambulatory older adults with subacute or chronic low back pain. Participants were randomly allocated to 12 weeks of individualized primary medical care (Medical Care), concurrent medical and chiropractic care (Dual Care), or medical and chiropractic care with enhanced interprofessional collaboration (Shared Care). Primary outcomes were low back pain intensity rated on the numerical rating scale and back-related disability measured with the Roland-Morris Disability Questionnaire. Secondary outcomes included clinical measures, adverse events, and patient satisfaction. Statistical analyses included mixed-effects regression models and general estimating equations. RESULTS: At 12 weeks, participants in all three treatment groups reported improvements in mean average low back pain intensity [Shared Care: 1.8; 95% confidence interval (CI) 1.0 to 2.6; Dual Care: 3.0; 95% CI 2.3 to 3.8; Medical Care: 2.3; 95% CI 1.5 to 3.2)] and back-related disability (Shared Care: 2.8; 95% CI 1.6 to 4.0; Dual Care: 2.5; 95% CI 1.3 to 3.7; Medical Care: 1.5; 95% CI 0.2 to 2.8). No statistically significant differences were noted between the three groups on the primary measures. Participants in both models that included chiropractic reported significantly better perceived low back pain improvement, overall health and quality of life, and greater satisfaction with healthcare services than patients who received medical care alone. CONCLUSIONS: Professional practice models that included primary care and chiropractic care led to modest improvements in low back pain intensity and disability for older adults, with chiropractic-inclusive models resulting in better perceived improvement and patient satisfaction over the primary care model alone. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01312233 , 4 March 2011.

Jefferson Teamwork Observation Guide (JTOG): An Instrument to Observe Teamwork Behaviors.

Interprofessional education (IPE) is becoming an integral part of the education of health professions students. However, teaching students to become successful members of interprofessional teams is complex, and it is important for students to learn the combinations of skills necessary for teams to function effectively. There are many instruments available to measure many features related to IPE. However, these instruments are often too cumbersome to use in an observational situation since they tend to be lengthy and contain many abstract characteristics that are difficult to identify. The Jefferson Teamwork Observation Guide (JTOG) is a short tool that was created for students early in their educational program to observe teams in action with a set of guidelines to help them focus their observation on behaviors indicative of good teamwork. The JTOG was developed over a 2-year period based on student and clinician feedback and the input of experts in IPE. While initially developed as a purely educational tool for prelicensure students, it is becoming clear that it is an easy-to-use instrument that assesses the behavior of clinicians in practice.

Jefferson interprofessional clinical rounding project: an innovative approach to patient care.

BACKGROUND: Bedside rounding is an historical clinical model that brings together care providers and the patient to discuss the plan of care. Interprofessional clinical rounding is an approach that uses this historical model to involve multiple health professions. This study was conducted to determine if a model of interprofessional clinical rounding could be implemented successfully in an acute care setting. METHODS: Teams consisting of medical, nursing, and pharmacy students were assigned to work with the attending physician (AP) in the colorectal surgery service. Prior to the rounding experience, students met to review and discuss patients' data from their discipline-specific perspective and then made a presentation of the case to the AP, who used these presentations as an educational opportunity, asking probing questions. A structured observation form was used to assess the team members' interaction during this process, and a debriefing was held at the conclusion of each experience. FINDINGS: Results of the observations suggested that most students were very engaged in the process, while summaries of the debriefing revealed a high level of satisfaction among participants. All groups suggested that they had a better understanding of the roles of other professions as a result of the increased communication and claimed that the process resulted in a more patient-centered approach. They also claimed that the additional information provided through the team approach resulted in a more integrated plan of care because input is provided from these different perspectives. CONCLUSION: Interprofessional bedside rounding can be implemented successfully, resulting in a more effective experience for health professions students.

Perspectives of older adults on co-management of low back pain by doctors of chiropractic and family medicine physicians: a focus group study.

BACKGROUND: While older adults may seek care for low back pain (LBP) from both medical doctors (MDs) and doctors of chiropractic (DCs), co-management between these providers is uncommon. The purposes of this study were to describe the preferences of older adults for LBP co-management by MDs and DCs and to identify their concerns for receiving care under such a treatment model. METHODS: We conducted 10 focus groups with 48 older adults who received LBP care in the past year. Interviews explored participants' care seeking experiences, co-management preferences, and perceived challenges to successful implementation of a MD-DC co-management model. We analyzed the qualitative data using thematic content analysis. RESULTS: Older adults considered LBP co-management by MDs and DCs a positive approach as the professions have complementary strengths. Participants wanted providers who worked in a co-management model to talk openly and honestly about LBP, offer clear and consistent recommendations about treatment, and provide individualized care. Facilitators of MD-DC co-management included collegial relationships between providers, arrangements between doctors to support interdisciplinary referral, computer systems that allowed exchange of health information between clinics, and practice settings where providers worked in one location. Perceived barriers to the co-management of LBP included the financial costs associated with receiving care from multiple providers concurrently, duplication of tests or imaging, scheduling and transportation problems, and potential side effects of medication and chiropractic care. A few participants expressed concern that some providers would not support a patient-preferred co-managed care model. CONCLUSIONS: Older adults are interested in receiving LBP treatment co-managed by MDs and DCs. Older adults considered patient-centered communication, collegial interdisciplinary interactions between these providers, and administrative supports such as scheduling systems and health record sharing as key components for successful LBP co-management.

Effect of the health mentors program on student attitudes toward team care.

Based on a growing body of literature documenting improved cost and quality outcomes related to good team care, interprofessional education (IPE) has been widely endorsed as critical to preparing the future healthcare workforce. This study evaluated the effect of a longitudinal team-based 2-year IPE curriculum on attitudes toward health care teams. Analyses included comparison of baseline measures to the end of the 2-year curriculum of each of the six participating disciplines (medicine, nursing, occupational therapy, pharmacy, physical therapy, and couple and family therapy). Differences between the disciplines were also analyzed. A significant improvement on a 14-item quality of care and teamwork of health professionals subscale of the Attitudes Toward Health Care Teams scale was found. Students surveyed in each of the six disciplines demonstrated significant improvements in attitudes toward quality of care and teamwork from the baseline measure at the beginning of the IPE program to the end of the 2-year program. There were no significant differences noted between disciplines. Assessment of attitudes toward health care teams assisted in evaluation and ongoing quality improvement of the IPE program and could potentially be used in other interprofessional programs that focus on health care teamwork. Next steps include longitudinal assessment of students throughout their programs and into practice to explore the sustainability of attitudes and behaviors, as well as impact on patient outcomes.

Collaborative Care for Older Adults with low back pain by family medicine physicians and doctors of chiropractic (COCOA): study protocol for a randomized controlled trial.

BACKGROUND: Low back pain is a prevalent and debilitating condition that affects the health and quality of life of older adults. Older people often consult primary care physicians about back pain, with many also receiving concurrent care from complementary and alternative medicine providers, most commonly doctors of chiropractic. However, a collaborative model of treatment coordination between these two provider groups has yet to be tested. The primary aim of the Collaborative Care for Older Adults Clinical Trial is to develop and evaluate the clinical effectiveness and feasibility of a patient-centered, collaborative care model with family medicine physicians and doctors of chiropractic for the treatment of low back pain in older adults. METHODS/DESIGN: This pragmatic, pilot randomized controlled trial will enroll 120 participants, age 65 years or older with subacute or chronic low back pain lasting at least one month, from a community-based sample in the Quad-Cities, Iowa/Illinois, USA. Eligible participants are allocated in a 1:1:1 ratio to receive 12 weeks of medical care, concurrent medical and chiropractic care, or collaborative medical and chiropractic care. Primary outcomes are self-rated back pain and disability. Secondary outcomes include general and functional health status, symptom bothersomeness, expectations for treatment effectiveness and improvement, fear avoidance behaviors, depression, anxiety, satisfaction, medication use and health care utilization. Treatment safety and adverse events also are monitored. Participant-rated outcome measures are collected via self-reported questionnaires and computer-assisted telephone interviews at baseline, and at 4, 8, 12, 24, 36 and 52 weeks post-randomization. Provider-rated expectations for treatment effectiveness and participant improvement also are evaluated. Process outcomes are assessed through qualitative interviews with study participants and research clinicians, chart audits of progress notes and content analysis of clinical trial notes. DISCUSSION: This pragmatic, pilot randomized controlled trial uses a mixed method approach to evaluate the clinical effectiveness, feasibility, and participant and provider perceptions of collaborative care between medical doctors and doctors of chiropractic in the treatment of older adults with low back pain.

Attitudes of faculty and students in medicine and the health professions toward interprofessional education.

BACKGROUND: This study evaluated the important relationship between faculty and student attitudes toward interprofessional education using the Interdisciplinary Education Perception Scale (IEPS). METHODS: Medicine, nursing, occupational therapy, pharmacy, and physical therapy faculty (n = 177) completed the IEPS. Students from these disciplines participate in a 2-year, interdisciplinary curriculum in which they were assigned to a team to work with a patient volunteer. Students (n = 496) completed the IEPS at the end of program year one. The IEPS measures four factors: professional competence/autonomy; perceived need for professional cooperation; perception of actual cooperation/resource sharing within and across professions; and understanding the value of other professions. FINDINGS: Overall attitude scores for faculty and students were high, ranging from 3.93 to 4.40 on a 5-point scale. Attitudes on each factor were also high, with the exception of factor 4, "understanding the value of other professions," having the lowest scores, 3.26 to 3.92. CONCLUSION: The positive attitudes among faculty and students and across professions suggest an acceptance of the principles of interprofessional education and a readiness to engage in interprofessional practice. The lower scores on factor 4 indicate the need for additional educational programs focusing on understanding the roles of each profession.

Special issue on interprofessional education and care.

It's been 12 years since the Journal published its last special themed issue (see Winter 1998, volume 27, no. 1), focused on the World Congress held in Telford, UK, in July 1997. Since that time, there have been a number of subjects that probably warranted special attention, but were not addressed. For that, you can blame one of the Editors of this special issue, who served as Journal Editor during that 10-year period. The topic of interprofessional education (IPE) and care (IPC) is one such theme that warrants our attention at this time. Interprofessional approaches by now have received not only increased attention in the United States, but attention from across the globe. This makes the task of putting together this issue both easy but, at the same time, a bit daunting. Easy in the sense that there is no lack of reports, programs, and efforts at implementing both IPE and IPC from which to choose. Daunting for the same reason: Which are the ones that deserve special attention? What major initiative have we missed?

Attitudes of students in medicine, nursing, occupational therapy, and physical therapy toward interprofessional education.

With the growing interest in interprofessional education and practice, methods to evaluate the effectiveness of related curricular activities are essential. The purpose of this study was twofold: (1) to assess the attitudes of students in medicine, nursing, occupational therapy, and physical therapy toward interprofessional education using the Interdisciplinary Education Perception Scale and Readiness for Interprofessional Learning Scale and (2) to compare data with normative data previously reported. The two instruments were administered to 474 first-year students in medicine, nursing, occupational therapy, and physical therapy who completed the forms in the context of a workshop at the conclusion of the first year of an interprofessional health mentor program. Differences among professions were reported. Students in medicine and physical therapy rated members of their own professions significantly higher in the areas of competence/autonomy and need for cooperation as compared with those in nursing and occupational therapy. Along with reporting similarities and differences, the results provide additional normative data on these tools that can be used when choosing tools to evaluate interprofessional education attitudes.

The effect of an interdisciplinary community health project on student attitudes toward community health, people who are indigent and homeless, and team leadership skill development.

This study examined whether students' attitudes about community health practice, attitudes toward people who are indigent and homeless, and perceived leadership skills changed after participation in a planned interdisciplinary community health experience with an urban homeless or formerly homeless population. Data were collected from medicine, nursing, occupational therapy, physical therapy, and social work students who participated in the community health experiences and from students in these disciplines who did not participate in this curriculum. The interdisciplinary community health curriculum and practicum experiences, based on the Community Health Empowerment Model (CHEM), were designed and implemented by a coalition of community and academic partners. Students in the CHEM project self-selected into the curriculum and initially showed more positive attitudes about community health and indigent and homeless people than their peers not participating. Despite the CHEM students' positive initial attitudes, data from pretests and posttests revealed a significant positive change in their attitudes toward community health practice at the completion of the curriculum.

A study of job satisfaction of nursing and allied health graduates from a Mid-Atlantic university.

There have been numerous changes in the health care system, including cost-containment efforts, the increased growth of managed care, and shortages of many health professionals. It is important to assess the impact these changes are having on the quality of health care delivery and the way various health professionals view their jobs. To accomplish this assessment, a sample of experienced nursing and allied health professionals were asked to provide their assessment of positive and negative changes in the health system over a 5-year period. They also were asked to indicate their level of satisfaction with their profession, their current job, and various aspects of that job. A Health Care Environment Survey was mailed to six groups of graduates of a mid-Atlantic college of health professions. Three of the groups had been in practice for 5 years, and three of the groups had been in practice for 10 years. The survey asked respondents to assess the magnitude of certain changes in the health system over the previous 5 years and to provide an assessment of their satisfaction with their current job. A total of 1,610 surveys were mailed, and 787 were returned for a rate of 49%. Nursing and allied health professionals who responded to the survey reported that there have been many more negative than positive changes in the health care system, including less job security, efficiency, and time available to spend with individual patients and increases in workload, paperwork, and control of health care by insurance companies. Even with these negative changes, nurses and allied health professionals report a high level of satisfaction with their jobs. In investigating the aspects of their jobs that were most related to satisfaction, having a feeling of worthwhile accomplishment from their job, opportunities for personal and professional growth, recognition and satisfaction with their workload were found to be the best predictors of job satisfaction.