The feasibility of introducing a whole blood component for traumatic haemorrhage in the UK.

BACKGROUND: The interest in re-introducing whole blood (WB) transfusion for the management of traumatic major haemorrhage is increasing. However, due to the current leucodepletion filters used in the UK a WB component was not readily available. Instead, an alternative but similar component, leucocyte depleted red cell and plasma (LD-RCP), which provided a unique experience in assessing the feasibility of a WB component was used whilst a WB component was being manufactured. STUDY DESIGN AND METHODS: Between November 2018 and October 2020, LD-RCP replaced RBC as standard of care for all trauma patients with major haemorrhage in London. The aims of the study were to assess (a) deliverability, (b) component wastage and (c) safety. RESULTS: Over the study period a total of 1208 LD-RCP units were delivered, of which 96.5% were delivered 'On Time In Full' (OTIF). Of the 1208 units, 733 (60.68%) were transfused and 475 (39.3%) units were wasted. Component wastage reduced significantly throughout the study (p = 0.001). A total of 177 patients had a blood group recorded, 86 were group O and 91 were non-group O. There was no statistically significantly difference between haemoglobin (p = 0.422), or bilirubin levels (p = 0.084) between group O and non-group O patients. DISCUSSION: It was feasible for NHS Blood and Transplant to deliver LD-RCP on time in full, however component wastage was high due to short shelf life and limited use of the component. Low titre group O LD-RCP units were not associated with clinical evidence of haemolysis.

Improving perioperative management of surgical sets for trauma surgeries: the 4S approach.

BACKGROUND: The perioperative management of the surgical instruments and implants that comprise sets for trauma surgeries has been identified as a complex and resource-intensive activity due to non-standardized inventories, redundant surgical instruments and unnecessary sterilization cycles. The 4S Intelligent Trauma Care program aims to improve perioperative management and thereby reduce environmental impact by utilizing standardized inventories, a sterile implant portfolio, a barcode that enables a digital safety certification, and a digitized restocking service. OBJECTIVE: The objective of this study was to investigate the impact of the introduction of the 4S program for the management of surgical sets in open reduction internal fixation (ORIF) trauma surgeries. METHODS: This was a single-center, quality improvement study of ORIF trauma surgeries, comparing the current practice (30 procedures) to the procedure following the introduction of the 4S program (30 procedures). The primary outcome was the proportion of procedures requiring only one sterilization cycle. Secondary outcomes were the number of sterilization cycles per procedure, set processing time across departments, total set processing costs, number of missing or damaged implants, number of cleaning cycles per procedure, time taken to assemble containers for sterilization, number of containers entering the autoclave per procedure, environmental impact, number of baskets entering the cleaning machine per procedure, and staff satisfaction. RESULTS: Introduction of the 4S program resulted in a reduction in the mean number of sterilization cycles required from 2.1 to 1.0 (p < 0.001). In the current practice, only 30.0% of procedure sets were sterilized within one cycle, compared to 100.0% following introduction of the 4S program (p < 0.001). A reduction in the mean set processing time of 24.1% in the OR and 35.3% in the sterilization department was observed. Mean set processing costs for the current practice were €81.23, compared to €50.30 following introduction of the 4S program. Furthermore, following the introduction of the 4S program, procedures were associated with significant reductions in water and electricity usage, and increased staff satisfaction. CONCLUSIONS: This quality improvement study demonstrates the substantial time and cost savings, positive environmental impact and staff satisfaction that could be achieved by streamlining surgical set management through the 4S program. To our knowledge, this is the first study of this type and our findings may be instructive to other hospitals and surgical specialties.

Assessment of local supply chains and stock management practices for trauma care resources in Ghana: a comparative small sample cross-sectional study.

BACKGROUND: Injuries are a major public health problem globally. With sound planning and organization, essential trauma care can be reliably provided with relatively low-cost equipment and supplies. However, availability of these resources requires an effective and efficient supply chain and good stock management practices. Therefore, this study aimed to assess trauma care resource-related supply management structures and processes at health facilities in Ghana. By doing so, the findings may allow us to identify specific structures and processes that could be improved to facilitate higher quality and more timely care. METHODS: Ten hospitals were purposively selected using results from a previously performed national trauma care capacity assessment of hospitals of all levels in Ghana. Five hospitals with low resource availability and 5 hospitals with high resource availability were assessed using the United States Agency for International Development (USAID) Logistics Indicators Assessment Tool and stock ledger review. Data were described and stock management practices were correlated with resource availability. RESULTS: There were differences in stock management practices between low and high resource availability hospitals, including frequency of reporting and audit, number of stock-outs on day of assessment (median 9 vs 2 stock-outs, range 3-57 vs 0-9 stock-outs, respectively; p = 0.05), duration of stock-outs (median 171 vs 8 days, range 51-1268 vs 0-182 days, respectively; p = 0.02), and fewer of up-to-date stock cards (24 vs 31 up-to-date stock cards, respectively; p = 0.07). Stock-outs were common even among low-cost, essential resources (e.g., nasal cannulas and oxygen masks, endotracheal tubes, syringes, sutures, sterile gloves). Increased adherence to stock management guidelines and higher percentage of up-to-date stock cards were correlated with higher trauma resource availability scores. However, the variance in trauma resource availability scores was poorly explained by these individual factors or when analyzed in a multivariate regression model (r2 = 0.72; p value for each covariate between 0.17-0.34). CONCLUSIONS: Good supply chain and stock management practices are correlated with high trauma care resource availability. The findings from this study demonstrate several opportunities to improve stock management practices, particularly at low resource availability hospitals.

First genomic study on Lake Tanganyika sprat Stolothrissa tanganicae: a lack of population structure calls for integrated management of this important fisheries target species.

BACKGROUND: Clupeid fisheries in Lake Tanganyika (East Africa) provide food for millions of people in one of the world's poorest regions. Due to climate change and overfishing, the clupeid stocks of Lake Tanganyika are declining. We investigate the population structure of the Lake Tanganyika sprat Stolothrissa tanganicae, using for the first time a genomic approach on this species. This is an important step towards knowing if the species should be managed separately or as a single stock. Population structure is important for fisheries management, yet understudied for many African freshwater species. We hypothesize that distinct stocks of S. tanganicae could be present due to the large size of the lake (isolation by distance), limnological variation (adaptive evolution), or past separation of the lake (historical subdivision). On the other hand, high mobility of the species and lack of obvious migration barriers might have resulted in a homogenous population. RESULTS: We performed a population genetic study on wild-caught S. tanganicae through a combination of mitochondrial genotyping (96 individuals) and RAD sequencing (83 individuals). Samples were collected at five locations along a north-south axis of Lake Tanganyika. The mtDNA data had low global FST and, visualised in a haplotype network, did not show phylogeographic structure. RAD sequencing yielded a panel of 3504 SNPs, with low genetic differentiation (FST = 0.0054; 95% CI: 0.0046-0.0066). PCoA, fineRADstructure and global FST suggest a near-panmictic population. Two distinct groups are apparent in these analyses (FST = 0.1338 95% CI: 0.1239,0.1445), which do not correspond to sampling locations. Autocorrelation analysis showed a slight increase in genetic difference with increasing distance. No outlier loci were detected in the RADseq data. CONCLUSION: Our results show at most very weak geographical structuring of the stock and do not provide evidence for genetic adaptation to historical or environmental differences over a north-south axis. Based on these results, we advise to manage the stock as one population, integrating one management strategy over the four riparian countries. These results are a first comprehensive study on the population structure of these important fisheries target species, and can guide fisheries management.

Availability of essential medicines and pharmaceutical inventory management practice at health centers of Adama town, Ethiopia.

BACKGROUND: Good inventory management practices in the health facilities are one of the critical aspects that influence the availability of essential medicines (EMs). This study aimed to assess EMs availability and inventory management practices at health centers (HCs) of Adama town, Ethiopia. METHOD: Institution based cross sectional survey was conducted among six HCs in Adama Town from March 19 to April 12, 2017. Self-administered questionnaire and observational checklists were used to collect quantitative information. Eleven tracer drugs (TDs) that were selected by the Federal ministry of health and included in the TD list of the HCs were used to assess the availability of EMs at the time of the survey; and during the past 12 months. The data were entered and analyzed using SPSS version 21. The accuracy of record keeping was assessed using inventory management assessment tool (IMAT) indicators. RESULT: Five HCs had Essential drug list and the procurement was made as per the list. Out of six HCs, four of them procured EMs from both pharmaceutical fund and supply agency (PFSA) of Ethiopia and private suppliers. Stock status of PFSA and transportation were the major challenges during the procurement process. The overall average availability of TDs on the day of the survey was 76.3%. Average length of stock out days for TDs during the past 12 months from each HC was 40.6 days. Among the TDs assessed at HCs, oral rehydrating salt was stock outed for 144 days while paracetamol was stock outed only for 1.4 days. The discrepancy of TDs between physical count and on bincard for which physical inventory less than the balance on bincard ranges from 0 to 33.3%. CONCLUSION: The availability of EMs was low and there was also poor inventory management practice in some of the HCs during the study period.

Benefits of nurse-led continence prescription services for effective stock management and streamlined prescribing.

The UK has an ageing population, and with continence-related issues expected to rise, there will be increasing demands for specialist input within nurse-led continence prescription services. Continence nurse specialists can apply expert product knowledge to ensure patients are prescribed bladder and bowel appliances that are of high quality, the most appropriate product for the patient and also cost effective. The management of catheter drainage and fixation supplies can be challenging, particularly for services managing caseloads of multiple patients living with catheters. Ugo 4 Weeks has been created to help streamline the process of ordering continence products and reducing appliance wastage for catheterised patients living in the community setting. Each box provides a 4-week supply of catheter drainage and fixation supplies and can be prescribed on a single prescription. It enables better control over stock levels, reducing the risk of accidental over-ordering and stockpiling, thereby generating significant cost savings.

Clupeiformes' Egg Envelope Proteins characterization: The case of Engraulis encrasicolus as a proxy for stock assessment through a novel molecular tool.

Zona radiata proteins are essential for ensuring bactericidal resistance, oocyte nutrients uptake and functional buoyancy, sperm binding and guidance to the micropyle, and protection to the growing oocyte or embryo from the physical environment. Such glycoproteins have been characterized in terms of molecular structure, protein composition and phylogenetics in several chordate models. Nevertheless, research on teleost has not been extensive. In Clupeiformes, one of the most biologically relevant and commercially important order which accounts for over 400 species and totally contributes to more than a quarter of the world fish catch, Egg Envelope Protein (EEP) information exist only for the Clupea pallasii and Engraulis japonicus species. The European anchovy, Engraulis encrasicolus, the target of a well-consolidated fishery in the Mediterranean Sea, has been ignored until now and the interest on the Otocephala superorder has been fragmentally limited to some Cypriniformes and Gonorynchiformes, as well. The aim of the present study was to fill the ZP protein-wise gap of knowledge afflicting the understanding of the European anchovy's reproductive process and to expand the background on Clupeiformes. We cloned the five Engraulis encrasicolus' zp genes and deduced their products, determined their tissue distribution, quantified their mRNA expression throughout the reproductive cycle and provided an insight into their evolution through phylogenetic tools. Furthermore, we proposed a multivariate statistics-based method to objectively infer and/or confirm the classification of Engraulis encrasicolus' sexual maturity stages by analyzing data of zp mRNAs' relative abundance.

How Fish Population Genomics Can Promote Sustainable Fisheries: A Road Map.

Maintenance of genetic diversity in marine fishes targeted by commercial fishing is a grand challenge for the future. Most of these species are abundant and therefore important for marine ecosystems and food security. Here, we present a road map of how population genomics can promote sustainable fisheries. In these species, the development of reference genomes and whole genome sequencing is key, because genetic differentiation at neutral loci is usually low due to large population sizes and gene flow. First, baseline allele frequencies representing genetically differentiated populations within species must be established. These can then be used to accurately determine the composition of mixed samples, forming the basis for population demographic analysis to inform sustainably set fish quotas. SNP-chip analysis is a cost-effective method for determining baseline allele frequencies and for population identification in mixed samples. Finally, we describe how genetic marker analysis can transform stock identification and management.

Comparative Population Dynamics of Schizothorax wangchiachii (Cyprinidae: Schizothoracinae) in the Middle Reaches of the Yalong River and the Upper Reaches of the Jinsha River, China.

To explore the differences in the growth characteristics and population dynamics of Schizothorax wangchiachii populations in the Jinsha River (JSR) and the Yalong River (YLR), samples were collected in the upper reaches of the JSR (n = 230) from 2019 to 2020 and the middle reaches of the YLR (n = 187) from 2017 to 2018. In the JSR and YLR populations, the age range was 11 and 12 years old, respectively, and the best growth equation was the Von Bertalanffy equation. The comparative analysis of the two populations showed that the growth coefficient, initial sexual maturity age and age at first capture of the YLR population were greater than those of the JSR population. Comparing the mortality rates of the two groups, we found that the YLR population had the higher female mortality rate (0.658 years-1) and the lower male mortality rate (0.453 years-1). Our assessment of the three natural mortality rates showed that the Fcur of both male and female populations was greater than F25%, indicating that both populations were in an overexploited state. Therefore, we suggest considering the two groups as separate protection units and implementing management measures such as ecological regulation, restoration of tributary habitat and strengthening of fishing ban monitoring to protect their resources.

Automated unit dose dispensing systems producing individually packaged and labelled drugs for inpatients: a systematic review.

OBJECTIVES: Pharmacy automation is increasing in hospitals. The aim of this systematic review was to identify and evaluate the literature on automated unit dose dispensing systems (UDDS) producing individually packaged and labelled drugs for inpatients. METHODS: The search was conducted on eight electronic databases, including Scopus, Medline Ovid, and Cinahl, and limited to peer reviewed articles with English abstracts published 2000-2020. Studies were included in the review if drug dispensing was performed by an automated UDDS where individually packaged and labelled unit doses were subsequently assembled patient specifically for inpatients. All outcomes related to UDDS functionality were included with specific interest in medication safety, cost-efficiency and stock management. Outcomes were categorised and results synthesised qualitatively. RESULTS: 664 publications were screened, one article identified manually, resulting in eight included articles. Outcomes of the studies were categorised as medication administration errors (MAEs), dispensing errors, costs and cost-effectiveness. Studies showed that automated UDDS reduced significantly MAEs of inpatients compared with traditional ward stock system (WSS), especially when UDs were dispensed patient specifically by unit dose dispensing robot. Patient specific drug dispensing with automated UDDS was very accurate. Of three different automated medication systems (AMSs), patient specific AMS (psAMS) was the most cost-effective and complex AMS (cAMS) the most expensive system across all error types due to the higher additional investments and operation costs of automated dispensing cabinets (ADCs). None of the studies investigated the impact on the medication management process such as efficiency, costs and stock management as primary outcome. CONCLUSIONS: UDDS improved patient safety. However, automation is a costly investment and the implementation process is complex and time consuming. Further controlled studies are needed on the clinical and economical outcomes of automated UDDS to produce reliable knowledge for hospital decision makers on the cost-benefit of the investment and to support decision making.

The procurement and supply chain strengthening project: improving public health supply chains for better access to HIV medicines, Uganda 2011-2016.

BACKGROUND: With countries moving towards reaching the UNAIDS 90-90-90 goal to achieve HIV epidemic control, there are going to be an unprecedented number of persons who will need to be tested, treated, and regularly monitored for viral suppression. However, most of the countries with the greatest burden of HIV/AIDS experience regular stock outages which could be detrimental to reaching these targets. ART and other commodities such as HIV test kits and laboratory supplies need to be readily and consistently available to achieve these targets. The main objective was to improve access to HIV/AIDS related commodities and strengthening institutional capacity for the management of HIV/AIDS logistics services through the MAUL procurement and supply chain strengthening project (PSSP) that rolled out four interventions on mentorship and support supervision, stock level monitoring, spatial visualization of stock indicators using GIS, and using WhatsApp to submit order reports as photo images. METHODS: Medical Access Uganda Limited, a private-not-for-profit supply chain management company in Uganda, implemented these interventions as part of a procurement and supply chain strengthening project (PSSP). These interventions were evaluated using performance monitoring indicators from 2011-2016. We tested for the significance in the change in scores of performance monitoring indicators using the test for difference in proportions. Health facilities were scored on 6 categories and accredited as bronze, silver or gold based on their total scores. Kaplan-Meier estimates were computed for time to silver, and gold ranking and univariate and multivariate Cox proportional hazards models were computed for time to gold ranking. RESULTS: We observed a significant reduction in reported stock-outs from 46 to 4% (p < 0.001) in the analysis period. Accurate stock card inventory rose from 79 to 91% (p < 0.001); adequate stock levels rose from 54 to 71% (p = 0.002) and stock reporting rates from 91 to 100% (p < 0.001). The stock order fill rate improved from a high of 93% to 97% (p = 0.375). Patient load (medium vs low adjusted hazard ratio (aHR): 2.19, p = 0.026; high vs low aHR: 2.97, p = 0.034) and number of support supervision visits (6-10 aHR: 3.33, p = 0.024; > 10 aHR: 5.78, p = 0.003) were associated with better stock management ranking scores. CONCLUSIONS: Improvements in supply chain management in countries committed to achieving the 90-90-90 goals are crucial to achieving HIV epidemic control. Health system strengthening and mentorship investments in Uganda were feasible and are essential for sustainable disease control efforts.

Mitochondrial marker implies fishery separate management units for spotted sardinella, Amblygaster sirm (Walbaum, 1792) populations in the South China Sea and the Andaman Sea.

The spotted sardinella, Amblygaster sirm (Walbaum, 1792), is a commercial sardine commonly caught in Malaysia. Lack of management of these marine species in Malaysian waters could lead to overfishing and potentially declining fish stock populations. Therefore, sustainable management of this species is of paramount importance to ensure its longevity. As such, molecular information is vital in determining the A. sirm population structure and management strategy. In the present study, mitochondrial DNA Cytochrome b was sequenced from 10 A. sirm populations: the Andaman Sea (AS) (two), South China Sea (SCS) (six), Sulu Sea (SS) (one), and Celebes Sea (CS) (one). Accordingly, the intra-population haplotype diversity (Hd) was high (0.91-1.00), and nucleotide diversity (π) was low (0.002-0.009), which suggests a population bottleneck followed by rapid population growth. Based on the phylogenetic trees, minimum spanning network (MSN), population pairwise comparison, and F ST,and supported by analysis of molecular variance (AMOVA) and spatial analysis of molecular variance (SAMOVA) tests, distinct genetic structures were observed (7.2% to 7.6% genetic divergence) between populations in the SCS and its neighboring waters, versus those in the AS. Furthermore, the results defined A. sirm stock boundaries and evolutionary between the west and east coast (which shares the same waters as western Borneo) of Peninsular Malaysia. In addition, genetic homogeneity was revealed throughout the SCS, SS, and CS based on the non-significant F STpairwise comparisons. Based on the molecular evidence, separate management strategies may be required for A. sirm of the AS and the SCS, including its neighboring waters.

[Analyses of the relationship between the concentrations of essential trace elements in total mixed ration and faeces samples from Holstein Friesian dairy cows and the estimation of faeces reference values]. / Untersuchungen zum Zusammenhang der Konzentrationen an essenziellen Spurenelementen in totalen Misch­rationen- und Kotproben bei Holstein Friesian Milchkühen und Ableitung von Kotreferenzwerten.

INTRODUCTION: Undersupply and oversupply of dairy cows with essential trace elements should be avoided from the point of view of animal health and environmental pollution. The aim of the study was to proof the results faecal analyzes on the nutritional supply situation with essential trace elements in comparison to measurements from total mixed ration (TMR) analyses. Concentrations of iron (Fe), copper (Cu), zinc (Zn), Mangan (Mn), selenium (Se), cobalt (Co), molybdenum (Mo) were measured as representative multicentric random sample in 574 TMR, 600 pooled faecal and blood samples from dairy cows. Trace elements, Fe in 0 %, Se 18 %, Zn 43 %, Cu 52 %, Co 53 % and Mn 59 %, were within the target range. Undersupply was found in 0 to 8 % and an oversupply in 39 to 100 % of the TMR samples. The tolerance limit for Fe was exceeded in 11 % and for Mo in 13 %. The results indicate the need for optimized ration design. The trace element concentrations in the faecal samples varied over a wide range. Results of pooled faecal samples (n=10 per pool) corresponded closely with the mean values calculated from the individual samples (r2 > 0,9). Correlation between element concentrations in the TMR and faecal samples for Fe (r=0,687), Cu (r=0,675), Zn (r=0,635), Mn (r=0,656), Se (r=0,573), Co (r=0,795), and Mo (r=0,708) were highly significant. No correlations were detected between the element concentrations in the TMR and in the blood samples. The regression analyzes showed a highly significant linear adjustment of the measured value distribution around the regression lines over the entire value range including the zero point. Reference values were calculated for the faecal concentrations of Cu, Zn, Mn, Se and Co. Tolerance reference limits in the TMR were calculated for the faecal concentrations of Fe and Mo. The trace element concentrations in the TMR samples reflect the nutritional supply situation. Knowledge of the nutritional supply situation of the herd is of great importance for the stock management of dairy cow. Fecal sample analyzes can be used as an alternative to TMR examinations to assess the nutritional supply situation.

INTRODUCTION: Les sous-approvisionnements et les surapprovisionnements des vaches laitières en oligo-éléments essentiels doivent être évités du point de vue de la santé animale et de la pollution de l'environnement. L'objectif de cette étude était de vérifier la pertinence des analyses de fèces pour évaluer l'apport nutritionnel en oligo-éléments essentiels en les comparant aux valeurs mesurées dans les analyses de RTM (ration totale mélangée). Dans un échantillon aléatoire multicentrique représentatif, les concentrations de fer (Fe), de cuivre (Cu), de zinc (Zn), de manganèse (Mn), de sélénium (Se), de cobalt (Co) et de molybdène (Mo) ont été mesurées dans 574 échantillons de RTM et 600 échantillons de fèces regroupés de vaches laitières et des échantillons de sang ont été analysés. La plage cible pour la teneur en oligo-éléments dans la RTM a été respectée pour Fe à 0 %, Se à 18 %, Zn à 43 %, Cu à 52 %, Co à 53 % et Mn à 59 %. La plage de sous-alimentation a été constatée dans 0 à 8 % des échantillons de RTM, la plage de suralimentation dans 39 à 100 %. La limite de tolérance pour le Fe a été dépassée dans 11 %, pour le Mo dans 13 %. Ces résultats indiquent la nécessité d'optimiser les rations. Dans les échantillons de fèces, les concentrations en oligo-éléments variaient sur une large plage. Les résultats d'analyse des échantillons de fèces regroupés (n=10 par pool) correspondaient étroitement, avec une valeur r2 supérieure à 0,9, aux valeurs moyennes calculées à partir des échantillons individuels. Il y avait des corrélations très significatives entre les concentrations d'éléments dans les échantillons de RTM et de fèces pour Fe (r=0,687), Cu (r=0,675), Zn (r=0,635), Mn (r=0,656), Se (r=0,573), Co (r=0,795), et Mo (r=0,708). Aucune corrélation n'a pu être établie entre les concentrations d'éléments dans le RTM et dans les échantillons de sang. Les analyses de régression ont montré un ajustement linéaire hautement significatif de la distribution des valeurs mesurées autour de la droite de régression sur l'ensemble de la plage de valeurs, y compris le point zéro. Des valeurs de référence ont été calculées pour les concentrations de Cu, Zn, Mn, Se et Co dans les fèces. Pour les concentrations de Fe et Mo dans les fèces, des limites de référence ont été calculées pour les limites de tolérance dans la RTM. Les concentrations en oligo-éléments dans les échantillons de RTM reflètent la situation nutritionnelle. Pour le suivi des troupeaux de vaches laitières, il est très important de connaître l'état nutritionnel du troupeau. Les analyses d'échantillons de fèces peuvent être utilisées comme alternative aux analyses de RTM pour évaluer la situation nutritionnelle.

Using Lean Six Sigma to Redesign the Supply Chain to the Operating Room Department of a Private Hospital to Reduce Associated Costs and Release Nursing Time to Care.

Continuity of the supply chain is an integral element in the safe and timely delivery of health services. Lean Six Sigma (LSS), a continuous improvement approach, aims to drive efficiencies and standardisation in processes, and while well established in the manufacturing and supply chain industries, also has relevance in healthcare supply chain management. This study outlines the application of LSS tools and techniques within the supply chain of an Operating Room (OR) setting in a private hospital in Dublin, Ireland. A pre-/post-intervention design was employed following the Define, Measure, Analyse, Improve, Control (DMAIC) framework and applying LSS methodology to redesign the current process for stock management both within the OR storage area and within a pilot OR suite, through collaborative, inclusive, and participatory engagement with staff. A set of improvements were implemented to standardise and streamline the stock management in both areas. The main outcomes from the improvements implemented were an overall reduction in the value of stock held within the operating theatre by 17.7%, a reduction in the value of stock going out of date by 91.7%, and a reduction in the time spent by clinical staff preparing stock required for procedures by 45%, all demonstrating the effectiveness of LSS in healthcare supply chain management.

Article 4: Impact assessment of supervision performance assessment and recognition strategy (SPARS) to improve supply chain management in health facilities in Uganda: a national pre and post study.

BACKGROUND: To strengthen medicines management capacity, including supply chain management, at public sector health facilities in Uganda, the Ministry of Health introduced a multipronged supervision, performance assessment, and recognition strategy (SPARS). The aim of this study was to assess the impact of SPARS on improving supply chain management. A series of four papers on SPARS described the SPARS concept, its impact on overall and domain practices and appropriate medicines use, and now in the fourth paper describing the effect on supply chain management. METHODS: District-based health workers trained as supervisors build facility-level capacity in medicines management using an indicator-based performance assessment followed by targeted supervisory visits. From 2010 to 2013, 1222 SPARS visits were implemented, and the SPARS performance indicator scores determined. This article assesses impact on 13 indicators in three of the five SPARS domains-stock management, storage management, and ordering and reporting quality-using a pre-post design. We also explored factors that may have influenced these outcomes. RESULTS: Between the first and last visit within one year of SPARS implementation, we found an average improvement of 16 percentage points (p < 0.001) in supply chain management measures across all levels of care. The improvement in scores for stock management, storage management, and ordering and reporting was 22 (ns), 16 (p < 0.001), and 11 (p = 0.032) percentage points, respectively. The study identified the key predictors of positive change as a low initial indicator score, frequent supervisory visits, and engagement of the district health officer. CONCLUSIONS: The multipronged SPARS approach was effective in building supply chain management capacity in lower-level health care facilities with statistically significant improvements in supply chain management overall and in almost all stock and storage- management and ordering and reporting measures after one year of implementation. We recommend broad dissemination of the SPARS approach as an effective strategy to strengthen supply chain management in low-income countries. TRIAL REGISTRATION: The study did not involve or use human participants or identifiable personal data, human tissue, or animals and thus did not require ethical approval or a waiver. It is a study implemented in collaboration with the Ministry of Health and does not require trial registration.

Using environmental DNA analyses to assess the occurrence and abundance of the endangered amphidromous fish Plecoglossus altivelis ryukyuensis.

The Ryukyu ayu Plecoglossus altivelis ryukyuensis is an endangered amphidromous fish that inhabits rivers in the Ryukyu Archipelago (Japan). Populations of the species have declined dramatically. Consequently, the Ryukyu ayu has been registered as a natural monument in Japan and monitoring surveys with direct catching are restricted legally. This restriction, unfortunately, makes monitoring of population abundances difficult and creates a barrier to both advancing understanding of the species' status and the development of appropriate conservation plans. We developed a non-invasive monitoring methodology using eDNA analyses. We designed a specific quantitative PCR assay for the Ryukyu ayu using the mitochondrial ND4 region. Using this primer/probe set, we conducted eDNA analyses in three rivers on Amami-Ohshima Island. The DNA fragments were amplified from the eDNA extracted from natural water in each river. The numbers of DNA fragments detected were positively correlated with individual counts of fish obtained by visual snorkelling surveys. Our method does not contravene restrictions and facilitates abundance monitoring of this endangered fish species.

Weak genetic structure despite strong genomic signal in lesser sandeel in the North Sea.

Sandeels are an ecologically important group of fishes; they are a key part of the food chain serving as food for marine mammals, seabirds and fish. Sandeels are further targeted by a large industrial fishery, which has led to concern about ecosystem effects. In the North Sea, the lesser sandeel Ammodytes marinus is by far the most prevalent species of sandeel in the fishery. Management of sandeel in the North Sea plus the Kattegat is currently divided into seven geographical areas, based on subtle differences in demography, population dynamics and results from simulations of larval dispersal. However, little is known about the underlying genetic population structure. In this study, we used 2,522 SNPs derived from restriction site-associated DNA sequencing (RADseq) typed in 429 fish representing four main sandeel management areas. Our main results showed (a) a lack of a clear spatially defined genetic structure across the majority of genetic markers and (b) the existence of a group of at least 13 SNPs under strong linkage disequilibrium which together separate North Sea sandeel into three haplotype clusters, suggestive of one or more structural variants in the genome. Analyses of the spatial distribution of these putative structural variants suggest at least partial reproductive isolation of sandeel in the western management area along the Scottish coast, supporting a separate management. Our results highlight the importance of the application of a large number of markers to be able to detect weak patterns of differentiation. This study contributes to increasing the genetic knowledge of this important exploited species, and results can be used to improve our understanding of population dynamics and stock structure.

Vaccine stock management in primary health care facilities in OR Tambo District, Eastern Cape, South Africa.

BACKGROUND: Poor stock management has been identified as one of the causes of vaccine stock-outs in health facilities. This study assessed the occurrence of vaccine stock-outs and vaccine stock management practices in primary health care facilities in OR Tambo district of the Eastern Cape province, South Africa. METHODS: Descriptive cross-sectional study design was used in this study to assess both the stock management practices and the availability of vaccines in the facilities. The study was conducted in 64 primary health care facilities across all sub-districts in OR Tambo. Data were collected using a questionnaire administered by the researcher, record checks and through observation. The occurrence of stock-outs of six tracer vaccines on the day of the visit and in the preceding 24 months were assessed. The data were captured into REDCap tool and analysed using STATA version 14. RESULTS: Most standard stock management procedures were not adhered to, as these procedures were mostly handled by health care workers who either required formal training or refresher training on vaccine management. Cold chain capacity was not adequate and some vaccines were exposed to freezing. Both stock cards and the stock visibility solution (SVS) device were used in all the facilities for vaccine stock management. Less than half of the facilities visited 27 (44%) filled their stock cards regularly. Delays in receiving supplies from the pharmaceutical depot were commonly reported by facilities, which contributed to stock-outs. A total of 49 (77%) health facilities had at least one stockout for at least one vaccine on the day of the visit. Furthermore, BCG and OPV were the most affected vaccines in 37 (58%) and 28 (44%) of facilities, respectively. CONCLUSION: Interventions for improving vaccine availability should be considered, especially those targeting human resources and the entire stock management system.

Mobile reporting of vaccine stock-levels in primary health care facilities in the Eastern Cape Province of South Africa: perceptions and experiences of health care workers.

The use of mobile and wireless digital technologies - mobile health (mhealth)- is increasingly been adopted in low- and middle-income countries (LMICs) to improve data visibility, improve decision-making, and consequently help ensure availability of health commodities in health facilities. In a bid to improve availability of medicines in primary health care facilities, the South African department of Health launched the Stock Visibility Solution (SVS), a mobile application developed for the purpose of capturing and monitoring stock levels of medicines including vaccines using mobile phones. The stock levels of medicines in facilities are usually uploaded to the central stock management system so that managers can act promptly to address stock-out situations. Pilot studies show that the SVS has the potential to reduce stock-outs from occurring. This study aimed to explore the perceptions and experiences of the SVS system amongst healthcare workers (HCWs) who are involved with managing stock levels of medicines in primary health care facilities in the Eastern Cape Province. This will help identify potential barriers and facilitators to implementation of the system and contribute to the development of strategies to improve its efficiency and effectiveness. A qualitative research design was employed, including semi-structured interviews with 64 HCWs working in primary health care facilities in the OR Tambo district, Eastern Cape Province in South Africa. Data was transcribed verbatim and analyzed using thematic analysis. Most HCWs understood the SVS as a system for reporting stock levels to managers and conveyed commitment to ensuring the system works. However, they highlighted a number of factors that demotivated efficient usage of the system: inadequate training, staff shortages and high staff turnover, lack of responses from the managers, the extra workload that comes with the system, amongst others. HCWs made various suggestions for how the system might be improved, most pertinently the need for more pharmacists and pharmacy assistants and for these cadres to be primarily in-charge of stock management and the use of the SVS. While HCWs are committed to addressing vaccine stock-outs, they face various barriers to an effective and efficient implementation of the SVS system. We make various recommendations for how these barriers might be addressed.

Protocol for a systematic review of the effects of interventions for vaccine stock management.

BACKGROUND: Inadequate vaccine stock management in health facilities leads to vaccine stock-outs. The latter threatens the success of immunisation programmes. Countries have used various approaches to reduce stock-outs and improve vaccine availability, but we are not aware of a systematic review of these interventions. This protocol describes the methods we will use to assess the effects of existing approaches for improving vaccine stock management. METHODS: We include randomised and non-randomised studies identified through a compehensive search of peer-reviewed and grey literature databases. We will search PubMed, Cochrane Central Register of Controlled Trials, Embase, Web of Science, PDQ-Evidence and Scopus. We will also search websites of the World Health Organisation (WHO), Global Alliance for Vaccine and Immunisation, PATH Vaccine Resources Library and United Nations Children's Fund. In addition, we will search the WHO International Clinical Trials Registry Platform and reference lists of included studies and relevant reviews. Finally, we plan to do a citation search for included studies. We will use Cochrane recommended methods to screen search outputs, assess study eligibility and risk of bias, extract and analyse study results. We will use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool to assess the certainty of the evidence on the effects of the interventions. DISCUSSION: We believe that the findings of this review will serve as valuable information for policy makers on ways to improve vaccine stock management and vaccine availability. When vaccine availability is improved, those who need them, especially children, will be adequately protected from vaccine-preventable diseases. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018092215.