Closing the delivery gap.

Purpose The purpose of this paper is to describe the authors' experience operationalizing the care delivery value chain (CDVC) as a management and continuous quality improvement (QI) approach to strengthen HIV/AIDS services provided in Northern Togo through addressing gaps across a care continuum. Design/methodology/approach The authors led a series of discussions to develop a CDVC specific to existing HIV/AIDS services in Northern Togo. Using the CDVC framework, 28 specific gaps in service delivery were identified and integrated into a strategic QI plan. Findings At 12 months, 92 percent of delivery gaps had demonstrated improvement. The CDVC framework proved to be valuable in the following ways. First, it facilitated the first comprehensive mapping of HIV/AIDS services in the Kara region of Togo. Second, it enabled the identification of gaps or insufficiencies in the currently available services across the full continuum of care. Third, it catalyzed the creation of a strategic QI plan based on identified gaps. Research limitations/implications This case description is the authors' experience in one setting and should not be considered comparative in nature. Furthermore, the approach described may not be applicable to all initiatives and/or organizations. As described, the lack of sophisticated and comprehensive data collection systems limited the authors' ability to collect reliable data on some of the QI initiatives planned. Practical implications The operationalization of the CDVC framework is an effective approach to drive continuous QI. Originality/value Through the operationalization of the CDVC, the authors developed a new approach for assessing existing services, identifying gaps in service delivery and directing continuous QI initiatives in a strategic manner.

Closing the delivery gaps in pediatric HIV care in Togo, West Africa: using the care delivery value chain framework to direct quality improvement.

Providing quality care for all children living with HIV/AIDS remains a global challenge and requires the development of new healthcare delivery strategies. The care delivery value chain (CDVC) is a framework that maps activities required to provide effective and responsive care for a patient with a particular disease across the continuum of care. By mapping activities along a value chain, the CDVC enables managers to better allocate resources, improve communication, and coordinate activities. We report on the successful application of the CDVC as a strategy to optimize care delivery and inform quality improvement (QI) efforts with the overall aim of improving care for Pediatric HIV patients in Togo, West Africa. Over the course of 12 months, 13 distinct QI activities in Pediatric HIV/AIDS care delivery were monitored, and 11 of those activities met or exceeded established targets. Examples included: increase in infants receiving routine polymerase chain reaction testing at 2 months (39-95%), increase in HIV exposed children receiving confirmatory HIV testing at 18 months (67-100%), and increase in patients receiving initial CD4 testing within 3 months of HIV diagnosis (67-100%). The CDVC was an effective approach for evaluating existing systems and prioritizing gaps in delivery for QI over the full cycle of Pediatric HIV/AIDS care in three specific ways: (1) facilitating the first comprehensive mapping of Pediatric HIV/AIDS services, (2) identifying gaps in available services, and (3) catalyzing the creation of a responsive QI plan. The CDVC provided a framework to drive meaningful, strategic action to improve Pediatric HIV care in Togo.

Direct four-dimensional structural and functional imaging of cardiovascular dynamics in mouse embryos with 1.5 MHz optical coherence tomography.

High-resolution three-dimensional (3D) imaging of cardiovascular dynamics in mouse embryos is greatly desired to study mammalian congenital cardiac defects. Here, we demonstrate direct four-dimensional (4D) imaging of the cardiovascular structure and function in live mouse embryos at a ∼43 Hz volume rate using an optical coherence tomography (OCT) system with a ∼1.5 MHz Fourier domain mode-locking swept laser source. Combining ultrafast OCT imaging with live mouse embryo culture protocols, 3D volumes of the embryo are directly and continuously acquired over time for a cardiodynamics analysis without the application of any synchronization algorithms. We present the time-resolved measurements of the heart wall motion based on the 4D structural data, report 4D speckle variance and Doppler imaging of the vascular system, and quantify spatially resolved blood flow velocity over time. These results indicate that the ultra-high-speed 4D imaging approach could be a useful tool for efficient cardiovascular phenotyping of mouse embryos.

Genome sequence of bacteriophage Djungelskog isolated from an Arthrobacter globiformis culture.

Actinobacteriophage Djungelskog was isolated from a sample of degraded organic material in Poughkeepsie, NY, using Arthrobacter globiformis B-2979. Its genome is 54,512 bp and encodes 86 putative protein-coding genes. Djungelskog has a siphovirus morphology and is assigned to cluster AW based on gene content similarity to actinobacteriophages.

Viral Modulation of the DNA Damage Response and Innate Immunity: Two Sides of the Same Coin.

The DDR consists of multiple pathways that sense, signal, and respond to anomalous DNA. To promote efficient replication, viruses have evolved to engage and even modulate the DDR. In this review, we will discuss a select set of diverse viruses and the range of mechanisms they evolved to interact with the DDR and some of the subsequent cellular consequences. There is a dichotomy in that the DDR can be both beneficial for viruses yet antiviral. We will also review the connection between the DDR and innate immunity. Previously believed to be disparate cellular functions, more recent research is emerging that links these processes. Furthermore, we will discuss some discrepancies in the literature that we propose can be remedied by utilizing more consistent DDR-focused assays. By doing so, we hope to obtain a much clearer understanding of how broadly these mechanisms and phenotypes are conserved among all viruses. This is crucial for human health since understanding how viruses manipulate the DDR presents an important and tractable target for antiviral therapies.

Increased posterior tibial slope is an independent risk factor of anterior cruciate ligament reconstruction graft rupture irrespective of graft choice.

INTRODUCTION: Anterior cruciate ligament (ACL) reconstruction failure remains a commonly seen complication despite advances in technique and graft options. Recently, several studies have shown that the inclination of the tibial plateau in the sagittal plane affects the stability of the knee joint. The purpose of this study was to determine if an increased posterior slope of the tibia is associated with failure of ACL reconstruction irrespective of the graft used. METHODS: From June 2002 to August 2003, a total of 100 patients with a symptomatic ACL-deficient knee were randomised to receive either a hamstring autograft or posterior tibialis allograft. All allografts were from a single tissue bank, aseptically processed, and fresh-frozen without terminal irradiation. ACL graft failures requiring reoperation with a minimum of 10-year follow-up were identified via telephone survey. Lateral radiographs of the knee of all patients were reviewed, and the slope of the tibia was measured using a standardised technique. Two fellowship-trained orthopaedic sports medicine specialists, one board-certified general orthopaedic surgeon, and two fellowship-trained musculoskeletal radiologists measured the tibial slope in all patients. RESULTS: At a minimum of 10-year follow-up, there were four (8.3%) autograft and 13 (26.5%) allograft failures that required revision reconstruction. The overall average tibial slope of the nonfailure cohort was 9.4°. The overall average tibial slope of the failure cohort was 11.9° (P â€‹= â€‹0.0002). The average slope of the allograft failures was 11.5°compared with an average slope of 9.6° in the nonfailures (P â€‹= â€‹0.01). The average slope of the autograft failures was 13.1° compared with 9.3° in the nonfailures (P â€‹= â€‹0.011). The mean difference in tibial slope measurements was 0.665 (95% confidence interval: 0.569-0.750). The interrater reliability, as measured by the intraclass correlation coefficient, for tibial slope was 0.898 (95% confidence interval: 0.859-0.928). The Cronbach α was 0.904. CONCLUSION: In a prospective, randomised trial of ACL reconstructions using either autograft or allograft, failures were associated with a significantly increased slope of the tibia compared with the nonfailures at 10-year follow-up.

Dynamic Imaging of Mouse Embryos and Cardiac Development in Static Culture.

Dynamic imaging is a powerful approach to assess the function of a developing organ system. The heart is a dynamic organ that undergoes quick morphological and mechanical changes through early embryonic development. Defining the embyonic mouse heart's normal function is important for our own understanding of human heart development and will inform us on treatments and prevention of congenital heart defects (CHD). Traditional methods such as ultrasound or fluorescence-based microscopy are suitable for live dynamic imaging, are excellent to visualize structure and connect gene expression to phenotypes, but can be of low quality in resolving fine features and lack imaging depth and scale to fully appreciate organ morphogenesis. Additionally, previous methods can be limited in accommodating a live imaging apparatus capable of sustaining whole embryo development for extended periods time. Optical coherence tomography (OCT) is unique in this circumstance because acquisition of three-dimensional images without contrast reagents, at single cell resolution make it a suitable modality to visualize fine structures in the developing embryo. OCT setups are highly customizable for live imaging because of the tethered imaging arm, due to its setup as a fiber-based interferometer. OCT allows for 4D (3D + time) functional imaging of living mouse embryos and can provide functional and mechanical information to ascertain how the heart's pump function changes through development. In this chapter, we will focus on how we use OCT to visualize live heart dynamics at different stages of development and provide mechanical information to reveal functional properties of the developing heart.

Ultrasound-guided sternoclavicular joint injection: technique and case series.

Sternoclavicular joint pathology can be an uncommon cause of pain and discomfort around the neck and shoulder region. Typically, patients localize their pain deep to the joint and experience referred pain to the ipsilateral neck and shoulder; however, it often presents as a diffuse nonspecific pain. Given the paucity of this pathology and atypical presentation, the use of injections can be helpful to confirm the diagnosis of sternoclavicular arthropathy. Currently, most injections are done via computed tomography. Although this method is accurate, it exposes patients to radiation and burdens the patient with the requirement of multiple appointments. This case series outlines the use of ultrasound-guided sternoclavicular joint injections conducted in the clinic. The patients in this series underwent an ultrasound-guided injection in the affected sternoclavicular joint, which confirmed the diagnosis, and they were subsequently treated with resection arthroplasty. The use of ultrasound-guided injections of the sternoclavicular joint is a safe and accurate alternative diagnostic method, which saves the patient from harmful radiation and additional appointments. Limitations and efficacy may vary depending on skill and comfort level of the operator.

Correlation of stress radiographs to injuries associated with lateral ankle instability.

BACKGROUND: Stress radiographs have demonstrated superior efficacy in the evaluation of ankle instability. AIM: To determine if there is a degree of instability evidenced by stress radiographs that is associated with pathology concomitant with ankle ligamentous instability. METHODS: A retrospective review of 87 consecutive patients aged 18-74 who had stress radiographs performed at a single institution between 2014 and 2020 was performed. These manual radiographic stress views were then correlated with magnetic resonance imaging and operative findings. RESULTS: A statistically significant association was determined for the mean and median stress radiographic values and the presence of peroneal pathology (P = 0.008 for tendonitis and P = 0.020 for peroneal tendon tears). A significant inverse relationship was found between the presence of an osteochondral defect and increasing degrees of instability (P = 0.043). CONCLUSION: Although valuable in the clinical evaluation of ankle instability, stress radiographs are not an independent predictor of conditions associated with ankle instability.

APEX2 Proximity Proteomics Resolves Flagellum Subdomains and Identifies Flagellum Tip-Specific Proteins in Trypanosoma brucei.

Trypanosoma brucei is the protozoan parasite responsible for sleeping sickness, a lethal vector-borne disease. T. brucei has a single flagellum (cilium) that plays critical roles in transmission and pathogenesis. An emerging concept is that the flagellum is organized into subdomains, each having specialized composition and function. The overall flagellum proteome has been well studied, but a critical knowledge gap is the protein composition of individual subdomains. We have tested whether APEX-based proximity proteomics could be used to examine the protein composition of T. brucei flagellum subdomains. As APEX-based labeling has not previously been described in T. brucei, we first fused APEX2 to the DRC1 subunit of the nexin-dynein regulatory complex, a well-characterized axonemal complex. We found that DRC1-APEX2 directs flagellum-specific biotinylation, and purification of biotinylated proteins yields a DRC1 "proximity proteome" having good overlap with published proteomes obtained from purified axonemes. Having validated the use of APEX2 in T. brucei, we next attempted to distinguish flagellar subdomains by fusing APEX2 to a flagellar membrane protein that is restricted to the flagellum tip, AC1, and another one that is excluded from the tip, FS179. Fluorescence microscopy demonstrated subdomain-specific biotinylation, and principal-component analysis showed distinct profiles between AC1-APEX2 and FS179-APEX2. Comparing these two profiles allowed us to identify an AC1 proximity proteome that is enriched for tip proteins, including proteins involved in signaling. Our results demonstrate that APEX2-based proximity proteomics is effective in T. brucei and can be used to resolve the proteome composition of flagellum subdomains that cannot themselves be readily purified.IMPORTANCE Sleeping sickness is a neglected tropical disease caused by the protozoan parasite Trypanosoma brucei The disease disrupts the sleep-wake cycle, leading to coma and death if left untreated. T. brucei motility, transmission, and virulence depend on its flagellum (cilium), which consists of several different specialized subdomains. Given the essential and multifunctional role of the T. brucei flagellum, there is need for approaches that enable proteomic analysis of individual subdomains. Our work establishes that APEX2 proximity labeling can, indeed, be implemented in the biochemical environment of T. brucei and has allowed identification of proximity proteomes for different flagellar subdomains that cannot be purified. This capacity opens the possibility to study the composition and function of other compartments. We expect this approach may be extended to other eukaryotic pathogens and will enhance the utility of T. brucei as a model organism to study ciliopathies, heritable human diseases in which cilium function is impaired.

Embryonic Mouse Cardiodynamic OCT Imaging.

The embryonic heart is an active and developing organ. Genetic studies in mouse models have generated great insight into normal heart development and congenital heart defects, and suggest mechanical forces such as heart contraction and blood flow to be implicated in cardiogenesis and disease. To explore this relationship and investigate the interplay between biomechanical forces and cardiac development, live dynamic cardiac imaging is essential. Cardiodynamic imaging with optical coherence tomography (OCT) is proving to be a unique approach to functional analysis of the embryonic mouse heart. Its compatibility with live culture systems, reagent-free contrast, cellular level resolution, and millimeter scale imaging depth make it capable of imaging the heart volumetrically and providing spatially resolved information on heart wall dynamics and blood flow. Here, we review the progress made in mouse embryonic cardiodynamic imaging with OCT, highlighting leaps in technology to overcome limitations in resolution and acquisition speed. We describe state-of-the-art functional OCT methods such as Doppler OCT and OCT angiography for blood flow imaging and quantification in the beating heart. As OCT is a continuously developing technology, we provide insight into the future developments of this area, toward the investigation of normal cardiogenesis and congenital heart defects.

Optogenetic cardiac pacing in cultured mouse embryos under imaging guidance.

The mouse embryo is an established model for investigation of regulatory mechanisms controlling cardiac development and congenital heart defects in humans. Since cultured mouse embryos are very sensitive to any manipulations and environmental fluctuations, controlled alterations in mouse embryonic cardiac function are extremely challenging, which is a major hurdle in mammalian cardiac biomechanics research. This manuscript presents first optogenetic manipulation of cardiodynamics and hemodynamics in cultured mouse embryos. Optogenetic pacing was combined with 4D (3D + time) optical coherence tomography structural and Doppler imaging, demonstrating that embryonic hearts under optogenetic pacing can function efficiently and produce strong blood flows. This study demonstrates that the presented method is a powerful tool giving quick, consistent, reversible control over heart dynamics and blood flow under real time visualization, enabling various live cardiac biomechanics studies toward better understanding of normal cardiogenesis and congenital heart defects in humans.

HIV Vpr Modulates the Host DNA Damage Response at Two Independent Steps to Damage DNA and Repress Double-Strand DNA Break Repair.

The DNA damage response (DDR) is a signaling cascade that is vital to ensuring the fidelity of the host genome in the presence of genotoxic stress. Growing evidence has emphasized the importance of both activation and repression of the host DDR by diverse DNA and RNA viruses. Previous work has shown that HIV-1 is also capable of engaging the host DDR, primarily through the conserved accessory protein Vpr. However, the extent of this engagement has remained unclear. Here, we show that HIV-1 and HIV-2 Vpr directly induce DNA damage and stall DNA replication, leading to the activation of several markers of double- and single-strand DNA breaks. Despite causing damage and activating the DDR, we found that Vpr represses the repair of double-strand breaks (DSB) by inhibiting homologous recombination (HR) and nonhomologous end joining (NHEJ). Mutational analyses of Vpr revealed that DNA damage and DDR activation are independent from repression of HR and Vpr-mediated cell cycle arrest. Moreover, we show that repression of HR does not require cell cycle arrest but instead may precede this long-standing enigmatic Vpr phenotype. Together, our data uncover that Vpr globally modulates the host DDR at at least two independent steps, offering novel insight into the primary functions of lentiviral Vpr and the roles of the DNA damage response in lentiviral replication.IMPORTANCE The DNA damage response (DDR) is a signaling cascade that safeguards the genome from genotoxic agents, including human pathogens. However, the DDR has also been utilized by many pathogens, such as human immunodeficiency virus (HIV), to enhance infection. To properly treat HIV-positive individuals, we must understand how the virus usurps our own cellular processes. Here, we have found that an important yet poorly understood gene in HIV, Vpr, targets the DDR at two unique steps: it causes damage and activates DDR signaling, and it represses the ability of cells to repair this damage, which we hypothesize is central to the primary function of Vpr. In clarifying these important functions of Vpr, our work highlights the multiple ways human pathogens engage the DDR and further suggests that modulation of the DDR is a novel way to help in the fight against HIV.

Does the h-index and self-citation affect external funding of orthopedic surgery research? An analysis of fellowship directors and their subspecialties.

PURPOSE: Determine the impact of self-citation on external funding for orthopedic fellowship directors. METHODS: The San Francisco Match's website identified directors encompassing 8 subspecialties. The Scopus database identified the number of publications, citations, and h-index for each director. H-index was assessed with/without self-citation. RESULTS: Mean publications, citations, self-citation rate, and h-index for the 446 directors were 71.2, 1816, 3.86%, and 18.3, respectively. Excluding self-citations reduces mean h-index to 18.0; and h-index changed by ≤ 1 integer in 95% of directors. CONCLUSIONS: Self-citation has minimal impact among fellowship directors and should not be adjusted for when considering external funding.

Second harmonic generation microscopy of early embryonic mouse hearts.

The understanding of biomechanical regulation of early heart development in genetic mouse models can contribute to improved management of congenital cardiovascular defects and embryonic cardiac failures in humans. The extracellular matrix (ECM), and particularly fibrillar collagen, are central to heart biomechanics, regulating tissue strength, elasticity and contractility. Here, we explore second harmonic generation (SHG) microscopy for visualization of establishing cardiac fibers such as collagen in mouse embryos through the earliest stages of development. We detected significant increase in SHG positive fibrillar content and organization over the first 24 hours after initiation of contractions. SHG microscopy revealed regions of higher fibrillar organization in regions of higher contractility and reduced fibrillar content and organization in mouse Mlc2a model with cardiac contractility defect, suggesting regulatory role of mechanical load in production and organization of structural fibers from the earliest stages. Simultaneous volumetric SHG and two-photon excitation microscopy of vital fluorescent reporter EGFP in the heart was demonstrated. In summary, these data set SHG microscopy as a valuable non-bias imaging tool to investigate mouse embryonic cardiogenesis and biomechanics.

Dynamic Imaging of Mouse Embryos and Cardiodynamics in Static Culture.

The heart is a dynamic organ that quickly undergoes morphological and mechanical changes through early embryonic development. Characterizing these early moments is important for our understanding of proper embryonic development and the treatment of heart disease. Traditionally, tomographic imaging modalities and fluorescence-based microscopy are excellent approaches to visualize structural features and gene expression patterns, respectively, and connect aberrant gene programs to pathological phenotypes. However, these approaches usually require static samples or fluorescent markers, which can limit how much information we can derive from the dynamic and mechanical changes that regulate heart development. Optical coherence tomography (OCT) is unique in this circumstance because it allows for the acquisition of three-dimensional structural and four-dimensional (3D + time) functional images of living mouse embryos without fixation or contrast reagents. In this chapter, we focus on how OCT can visualize heart morphology at different stages of development and provide cardiodynamic information to reveal mechanical properties of the developing heart.

Dynamic imaging and quantitative analysis of cranial neural tube closure in the mouse embryo using optical coherence tomography.

Neural tube closure is a critical feature of central nervous system morphogenesis during embryonic development. Failure of this process leads to neural tube defects, one of the most common forms of human congenital defects. Although molecular and genetic studies in model organisms have provided insights into the genes and proteins that are required for normal neural tube development, complications associated with live imaging of neural tube closure in mammals limit efficient morphological analyses. Here, we report the use of optical coherence tomography (OCT) for dynamic imaging and quantitative assessment of cranial neural tube closure in live mouse embryos in culture. Through time-lapse imaging, we captured two neural tube closure mechanisms in different cranial regions, zipper-like closure of the hindbrain region and button-like closure of the midbrain region. We also used OCT imaging for phenotypic characterization of a neural tube defect in a mouse mutant. These results suggest that the described approach is a useful tool for live dynamic analysis of normal neural tube closure and neural tube defects in the mouse model.

Identifying inequities in maternal and child health through risk stratification to inform health systems strengthening in Northern Togo.

OBJECTIVE: In Togo, substantial progress in maternal and child health is needed to reach global development goals. To better inform clinic and community-based health services, this study identifies factors associated with maternal and child health care utilization in the Kara region of Northern Togo. METHODS: We conducted a population-representative household survey of four health clinic catchment areas of 1,075 women of reproductive age in 2015. Multivariable logistic regression was used to model individual and structural factors associated with utilization of four maternal and child health services. Key outcomes were: facility-based delivery, maternal postnatal health check by a health professional within the first six weeks of birth, childhood vaccination, and receipt of malaria medication for febrile children under age five within 72 hours of symptom onset. RESULTS: 83 percent of women who gave birth in the last 2 years delivered at a health facility. In adjusted models, the strongest predictor of facility delivery in the rural catchment areas was proximity to a health center, with women living under three kilometers having 3.7 (95% CI 1.7, 7.9) times the odds of a facility birth. Only 11 percent of women received a health check by a health provider at any time in the postnatal period. Postnatal health checks were less likely for women in the poorest households and for women who resided in rural areas. Children of polygamous mothers had half the odds of receiving malaria medication for fever within 72 hours of symptom onset, while children with increased household wealth status had increased odds of childhood vaccination and receiving treatment for malaria. CONCLUSION: Our analysis highlights the importance of risk stratification analysis to inform the delivery and scope of maternal and child health programs needed to reach those with the least access to care.

Four-dimensional live imaging of hemodynamics in mammalian embryonic heart with Doppler optical coherence tomography.

Hemodynamic analysis of the mouse embryonic heart is essential for understanding the functional aspects of early cardiogenesis and advancing the research in congenital heart defects. However, high-resolution imaging of cardiac hemodynamics in mammalian models remains challenging, primarily due to the dynamic nature and deep location of the embryonic heart. Here we report four-dimensional micro-scale imaging of blood flow in the early mouse embryonic heart, enabling time-resolved measurement and analysis of flow velocity throughout the heart tube. Our method uses Doppler optical coherence tomography in live mouse embryo culture, and employs a post-processing synchronization approach to reconstruct three-dimensional data over time at a 100 Hz volume rate. Experiments were performed on live mouse embryos at embryonic day 9.0. Our results show blood flow dynamics inside the beating heart, with the capability for quantitative flow velocity assessment in the primitive atrium, atrioventricular and bulboventricular regions, and bulbus cordis. Combined cardiodynamic and hemodynamic analysis indicates this functional imaging method can be utilized to further investigate the mechanical relationship between blood flow dynamics and cardiac wall movement, bringing new possibilities to study biomechanics in early mammalian cardiogenesis. Four-dimensional live hemodynamic imaging of the mouse embryonic heart at embryonic day 9.0 using Doppler optical coherence tomography, showing directional blood flows in the sinus venosus, primitive atrium, atrioventricular region and vitelline vein.

Imaging of cardiovascular development in mammalian embryos using optical coherence tomography.

The cardiovascular system is the first functional organ system to develop within the mammalian embryo. During the early stages of cardiovascular development, the heart and blood vessels undergo rapid growth and remodeling required for embryo viability, proper morphogenesis, and the function of all organ systems. Live imaging of these dynamic events in early mouse embryos is critical to understanding when and how these morphological changes occur during normal development and how mutations and pharmacological agents affect cardiovascular structure and function in vivo. The use of optical coherence tomography (OCT) allows for rapid, three-dimensional structural and functional imaging of mouse embryos at cellular resolution without the aid of contrast agents. In this chapter, we will describe how OCT can be used to assess the morphology of vessels and the heart, dynamic analysis of cardiac function, and hemodynamics within extraembryonic and embryonic blood vessels.