High Impact Changes Research Articles

Microbial dynamics in rapidly transforming Arctic proglacial landscapes

Arctic glacial environments are rapidly changing, as the Arctic warms at a rate three to four times faster than the global average (the phenomenon known as Arctic amplification). Microorganisms are uniquely adapted to extreme glacial environments and studying how ecological and climatic feedback loops affect the diversity of these communities is crucial to the characterisation of vulnerable Arctic habitats. Glacial landscapes span a wide range of habitats, from glacier ice to marine waters, and encompass terrestrial, aquatic, and interzonal systems. While glacier shrinkage has been the focus of scientific attention, auxiliary habitats are also impacted by rapid glacier retreat. Auxiliary habitats include terrestrial systems, such as outwash plains, vegetated periglacial environments, and aquatic systems, such as glacier-fed streams, lakes, and glacier-adjacent marine environments. Glacier recession drives high-impact changes in glacier-associated habitats: rising temperatures, increased light penetration of glacial streams, changes in nitrogen-to-phosphate ratios, and increases in availability of glacier-derived organic compounds. In turn, microbial systems in these habitats may experience changes in nutrient dynamics and shifts in community structures. The exposure of new lands by retreating glaciers may also result in increased dust and microbial dispersal into the atmosphere. Here, we discuss the effects of climate change on glacial microbiomes and the feedback loops between microbial community dynamics and the large-scale climatic processes in the Arctic. We characterise aspects of vulnerable microbial ecosystems and highlight the importance of preserving unseen microbial biodiversity. We then outline current capacities for microbial conservation, focusing on cryopreservation and biobanking. Lastly, we suggest future research directions and steps that academic and governmental institutions may take to foster research and collaboration with Indigenous communities.

A short guide to addressing accessibility at scientific conferences.

Although encouraging progress to address issues of accessibility at scientific conferences has been made in recent years, further efforts are required to enact the comprehensive solutions necessary to accommodate the diverse needs of disabled scientists. This Opinion provides an easy-to-follow guide to ensuring that scientific conferences are accessible to disabled scientists and is aimed at conference organizers and funders in the field of cell biology. In this piece, I, a person who identifies as a disabled scientist, advocate for collective action within the cell biology community to promote the routine inclusion of accessibility officers on conference organizing panels and the use of accessibility checklists as part of applications for conference funding in order to build inclusive practices into conference planning and organization. I propose a move away from requiring personal disclosures of disability needs on a person-to-person basis towards community-agreed guidelines that ensure accessibility for scientists with a wide variety of needs. To that end, I detail a list of practical, cost-effective adjustments to standard conference activities that can enhance accessibility. Moreover, I suggest several long-term, high-impact changes - including guaranteeing the availability of wheelchair-accessible facilities and making hybrid meeting formats standard - aimed at enabling conference participation for all scientists.

Implementing a new living concept for persons with dementia in long-term care: evaluation of a quality improvement process

BackgroundImproving quality of nursing home care for residents is a constant focus of stakeholders involved within quality improvement projects. Though, achieving change in long-term care is challenging. Process evaluations provide insight into the nature, exposure and experiences of stakeholders and influencing mechanisms for implementation. The aim of this study is to gain insight into the process and facilitating and hindering mechanisms of implementing a quality improvement project that seeks to create a dementia-friendly community with a nursing home at its core.MethodsFor the process evaluation we planned a case study design with an ethnographic approach. Various research methods were used: qualitative observations, focus groups, interviews and questionnaires for various stakeholders and document review. Data collection and analyses in this study is based on the Consolidated Framework for Implementation Research.ResultsFour main lessons were learned. Firstly, nursing staff are crucial to achieve more freedom for residents. Secondly, high-impact changes in daily care need strong and sustainable focus from the care organisation. Thirdly, dementia-friendly societies should be deployed from multiple actors, which entails long-term collaborations with external stakeholders. Fourthly, the transition to a dementia-friendly society requires meeting spaces for and a focus on both residents and people from the community. Consequently, local residents are shifting from external to internal stakeholders, extending beyond the regular involvement of informal carers and volunteers within the nursing home.ConclusionsNursing homes are part of the local community and provide opportunities to collaborate on a dementia-friendly society. However, the change that is required (promoting freedom, residents’ autonomy and the redesign of care processes) is complex and influenced by various mechanisms. Understanding these mechanisms can benefit other care organisations that strive to implement a similar initiative.

Acute spontaneous intracerebral haemorrhage: does a care bundle approach work?

A care bundle is a small but crucial set of treatments that, when implemented together, can improve outcomes. 1 NHS Modernisation Agency10 high impact changes for service improvement and delivery: a guide for NHS leaders. http://www.nursingleadership.org.uk/publications/HIC.pdfDate: 2004 Date accessed: April 24, 2023 Google Scholar Acute spontaneous intracerebral haemorrhage has few effective treatments and intracerebral haemorrhage-specific recommendations for care bundles. 2 Parry-Jones AR Sammut-Powell C Paroutoglou K et al. Intracerebral hemorrhage care bundle is associated with lower case fatality. Ann Neurol. 2019; 86: 495-503 Crossref PubMed Scopus (40) Google Scholar , 3 Middleton S McElduff P Ward J et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet. 2011; 378: 1699-1706 Summary Full Text Full Text PDF PubMed Scopus (266) Google Scholar In clinical practice, intracerebral haemorrhage is often approached with negativity. 4 Willie JT Gross RE Beyond therapeutic nihilism? The neurosurgical treatment of intracerebral hemorrhage. World Neurosurg. 2013; 80: e135-e137 Crossref PubMed Scopus (1) Google Scholar Moreover, the synergistic benefits of specialised nursing care, neurointensive and neurosurgical care, blood pressure control, reversal of coagulopathy, and other interventions have not been ascertained. 5 Greenberg SM Ziai WC Cordonnier C et al. 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022; 53: e282-e361 Crossref PubMed Scopus (107) Google Scholar The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trialImplementation of a care bundle protocol for intensive blood pressure lowering and other management algorithms for physiological control within several hours of the onset of symptoms resulted in improved functional outcome for patients with acute intracerebral haemorrhage. Hospitals should incorporate this approach into clinical practice as part of active management for this serious condition. Full-Text PDF Open Access

Explaining and Predicting Earth System Change: A World Climate Research Programme Call to Action

Abstract The World Climate Research Programme (WCRP) envisions a world “that uses sound, relevant, and timely climate science to ensure a more resilient present and sustainable future for humankind.” This bold vision requires the climate science community to provide actionable scientific information that meets the evolving needs of societies all over the world. To realize its vision, WCRP has created five Lighthouse Activities to generate international commitment and support to tackle some of the most pressing challenges in climate science today. The overarching goal of the Lighthouse Activity on Explaining and Predicting Earth System Change is to develop an integrated capability to understand, attribute, and predict annual to decadal changes in the Earth system, including capabilities for early warning of potential high impact changes and events. This article provides an overview of both the scientific challenges that must be addressed, and the research and other activities required to achieve this goal. The work is organized in three thematic areas: (i) monitoring and modeling Earth system change; (ii) integrated attribution, prediction, and projection; and (iii) assessment of current and future hazards. Also discussed are the benefits that the new capability will deliver. These include improved capabilities for early warning of impactful changes in the Earth system, more reliable assessments of meteorological hazard risks, and quantitative attribution statements to support the Global Annual to Decadal Climate Update and State of the Climate reports issued by the World Meteorological Organization.

Whole-exome sequencing of oral epithelial dysplasia samples reveals an association with new genes.

The genetic basis of oral epithelial (OED) is unknown, and there is no reliable method for evaluating the risk of malignant transformation. Somatic mutations are responsible for the transformation of dysplastic mucosa to invasive cancer. In addition, these genomic variations could represent objective markers of the potential for malignant transformation. We performed whole-exome sequencing of 10 OED samples from Brazilian and Chilean patients. Using public genetic repositories, we identified 41 deleterious variants that could produce high-impact changes in the amino acid structures of 38 genes. In addition, the variants were filtered according to normal skin and Native American genome profiles. Finally, 13 genes harboring 15 variants were found to be exclusively related to OED. High-grade epithelial dysplasia samples showed a tendency to accumulate highly deleterious variants. We observed that 62% of 13 OED genes identified in our study were also found in head and neck squamous cell carcinoma. Among the shared genes, eight were not identified in oral squamous cell carcinoma. To our knowledge, we have described for the first time 13 genes that are found in OED in a Latin American population, of which five genes have already been observed in oral squamous cell carcinoma. Through this study, we identified genes that may be related to basal biological functions in OED.

Reanalysis of eMERGE phase III sequence variants in 10,500 participants and infrastructure to support the automated return of knowledge updates

PurposeThe clinical genomics knowledgebase is dynamic with variant classifications changing as newly identified cases, additional population data, and other evidence become available. This is a challenge for the clinical laboratory because of limited resource availability for variant reassessment. MethodsThroughout the Electronic Medical Records and Genomics phase III program, clinical sites associated with the Mass General Brigham/Broad sequencing center received automated, real-time notifications when reported variants were reclassified. In this study, we summarized the nature of these reclassifications and described the proactive reassessment framework we used for the Electronic Medical Records and Genomics program data set to identify variants most likely to undergo reclassification. ResultsReanalysis of 1855 variants led to the reclassification of 2% (n = 45) of variants, affecting 0.6% (n = 67) of participants. Of these reclassifications, 78% (n = 35) were high-impact changes affecting reportability, with 8 variants downgraded from likely pathogenic/pathogenic to variants of uncertain significance (VUS) and 27 variants upgraded from VUS to likely pathogenic/pathogenic. Most upgraded variants (67%) were initially classified as VUS–Favor Pathogenic, highlighting the benefit of VUS subcategorization. The most common reason for reclassification was new published case data and/or functional evidence. ConclusionOur results highlight the importance of periodic sequence variant reevaluation and the need for automated approaches to advance routine implementation of variant reevaluations in clinical practice.

Abstract 10565: A Systematic and Reliable Process for Performing Cost Containment Analysis within the Operating Room

Purpose: Healthcare spending within the United States increased 4.6% in 2019 and represented over $3.8 trillion, or 17.7% of our GDP. The operating margin for most hospitals is 1-3%. As costs continue to rise, insurers will continue to shift these financial risks and responsibilities onto hospitals and hospitals eventually onto surgeons. Methods: Using a recently introduced surgical receipt function within Epic, we set out to develop cost containment strategies within congenital cardiac surgery at Duke University Hospital. Surgical receipt data was obtained between January 1, 2020 and January 1, 2021. Variability in case costs and product utilization were identified. Findings were discussed with surgeons to identify high impact changes with low barriers to implementation. Results: Between January 1, 2020 and January 1, 2021, there were 340 index cases and 449 unique surgical receipts. Four procedures representing 54 patients accounted for more than 50% of the total annual direct operating room supply costs (LVAD, 5 patients, 22.7% of annual costs; Norwood, 20 patients, 12.7%; RV-PA shunt, 16 patients, 9.9%; PVR, 13 patients, 9.4%). Exploration chest for postoperative hemorrhage was associated with the highest variability in case cost. In addition to mechanical devices and valves, cost drivers included the use of disposable vascular clips, suture brand preference between surgeons, and surgical patch material utilization which accounted for 3.7%, 6.6%, and 26.5% of overall annual direct operating room supply costs. Conclusions: We project 6-6.5% in annual savings due to changes in suture and surgical clip utilization. Changes to surgical patch utilization should carry an additional 4-4.5% in savings. The surgical receipt represents a reliable and uniform way of reporting surgical costs with broader implications for all surgical subspecialties.

Abstract 10556: A Systematic and Reliable Process for Performing Cost Containment Analysis Within the Operating Room

Purpose: Healthcare spending within the United States increased 4.6% in 2019 and represented over $3.8 trillion, or 17.7% of our GDP. The operating margin for most hospitals is 1-3%. As costs continue to rise, insurers will continue to shift these financial risks and responsibilities onto hospitals and hospitals eventually onto surgeons. Methods: Using a recently introduced surgical receipt function within Epic, we set out to develop cost containment strategies within congenital cardiac surgery at Duke University Hospital. Surgical receipt data was obtained between January 1, 2020 and January 1, 2021. Variability in case costs and product utilization were identified. Findings were discussed with surgeons to identify high impact changes with low barriers to implementation. Results: Between January 1, 2020 and January 1, 2021, there were 340 index cases and 449 unique surgical receipts. Four procedures representing 54 patients accounted for more than 50% of the total annual direct operating room supply costs (LVAD, 5 patients, 22.7% of annual costs; Norwood, 20 patients, 12.7%; RV-PA shunt, 16 patients, 9.9%; PVR, 13 patients, 9.4%). Exploration chest for postoperative hemorrhage was associated with the highest variability in case cost. In addition to mechanical devices and valves, cost drivers included the use of disposable vascular clips, suture brand preference between surgeons, and surgical patch material utilization which accounted for 3.7%, 6.6%, and 26.5% of overall annual direct operating room supply costs. Conclusions: We project 6-6.5% in annual savings due to changes in suture and surgical clip utilization. Changes to surgical patch utilization should carry an additional 4-4.5% in savings. The surgical receipt represents a reliable and uniform way of reporting surgical costs with broader implications for all surgical subspecialties.

Integrating eHealth within a Transforming Mental Healthcare Setting: A Qualitative Study into Values, Challenges, and Prerequisites.

Mental health care is shifting towards more person-centered and community-based health care. Although integrating eHealth within a transforming healthcare setting may help accomplishing the shift, research studying this is lacking. This study aims to improve our understanding of the value of eHealth within a transforming mental healthcare setting and to define the challenges and prerequisites for implementing eHealth in particular within this transforming context. In this article, we present the results of 29 interviews with clients, social network members, and professionals of an ambulatory team in transition within a Dutch mental health care institute. The main finding is that eHealth can support a transforming practice shifting towards more recovery-oriented, person-centered, and community-based service in which shared-decision making is self-evident. The main challenge revealed is how to deal with clients’ voices, when professionals see the value of eHealth but clients do not want to start using eHealth. The shift towards client-centered and network-oriented care models and towards blended care models are both high-impact changes in themselves. Acknowledging the complexity of combining these high-impact changes might be the first step towards creating blended client-centered and network-oriented care. Future research should examine whether and how these substantial shifts could be mutually supportive.

Improving care transfers for homeless patients after hospital discharge: a realist evaluation

Background In 2013, 70% of people who were homeless on admission to hospital were discharged back to the street without having their care and support needs addressed. In response, the UK government provided funding for 52 new specialist homeless hospital discharge schemes. This study employed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines between September 2015 and 2019 to undertake a realist evaluation to establish what worked, for whom, under what circumstances and why. It was hypothesised that delivering outcomes linked to consistently safe, timely care transfers for homeless patients would depend on hospital discharge schemes implementing a series of high-impact changes (resource mechanisms). These changes encompassed multidisciplinary discharge co-ordination (delivered through clinically led homeless teams) and ‘step-down’ intermediate care. These facilitated time-limited care and support and alternative pathways out of hospital for people who could not go straight home. Methods The realist hypothesis was tested empirically and refined through three work packages. Work package 1 generated seven qualitative case studies, comparing sites with different types of specialist homeless hospital discharge schemes (n = 5) and those with no specialist discharge scheme (standard care) (n = 2). Methods of data collection included interviews with 77 practitioners and stakeholders and 70 people who were homeless on admission to hospital. A ‘data linkage’ process (work package 2) and an economic evaluation (work package 3) were also undertaken. The data linkage process resulted in data being collected on > 3882 patients from 17 discharge schemes across England. The study involved people with lived experience of homelessness in all stages. Results There was strong evidence to support our realist hypothesis. Specialist homeless hospital discharge schemes employing multidisciplinary discharge co-ordination and ‘step-down’ intermediate care were more effective and cost-effective than standard care. Specialist care was shown to reduce delayed transfers of care. Accident and emergency visits were also 18% lower among homeless patients discharged at a site with a step-down service than at those without. However, there was an impact on the effectiveness of the schemes when they were underfunded or when there was a shortage of permanent supportive housing and longer-term care and support. In these contexts, it remained (tacitly) accepted practice (across both standard and specialist care sites) to discharge homeless patients to the streets, rather than delay their transfer. We found little evidence that discharge schemes fired a change in reasoning with regard to the cultural distance that positions ‘homeless patients’ as somehow less vulnerable than other groups of patients. We refined our hypothesis to reflect that high-impact changes need to be underpinned by robust adult safeguarding. Strengths and limitations To our knowledge, this is the largest study of the outcomes of homeless patients discharged from hospital in the UK. Owing to issues with the comparator group, the effectiveness analysis undertaken for the data linkage was limited to comparisons of different types of specialist discharge scheme (rather than specialist vs. standard care). Future work There is a need to consider approaches that align with those for value or alliance-based commissioning where the evaluative gaze is shifted from discrete interventions to understanding how the system is working as a whole to deliver outcomes for a defined patient population. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 17. See the NIHR Journals Library website for further project information.

Changes in North Atlantic Atmospheric Circulation in a Warmer Climate Favor Winter Flooding and Summer Drought over Europe

AbstractChanges in atmospheric circulation under increasing greenhouse gas concentrations are important because of their implications for weather extremes and associated societal risks. However, uncertainties in models and future projections are still large and drivers behind circulation changes are not well understood. Particularly for Europe, a potential weakening of the Atlantic meridional overturning circulation (AMOC) is considered important as it affects SST patterns and ocean–atmosphere heat fluxes and, subsequently, European climate. Here we detect and characterize changes in atmospheric circulation patterns over the North Atlantic under increasing CO2 concentrations in simulations of a very high-resolution, fully coupled climate model (CM2.6) with a realistic representation of the AMOC. We use an objective clustering technique (self-organizing maps) and validate the model’s clusters against reanalysis data. We compare the frequency of those patterns in a CO2 doubling experiment, characterized by an AMOC decline, with those in a preindustrial run, and find statistically significant changes. The most robust findings are 1) a ~30% increase in zonal flow regimes in February, relevant for flood risk in northwestern Europe, and 2) a ~60% increase in anticyclonic (high pressure) circulation directly west of the United Kingdom in August, relevant for western and central European drought. A robust decrease in the frequency of Scandinavian blocking is also seen across most months and seasons. Despite the uncertainties regarding atmospheric circulation response to climate change, our findings contribute to the increasing evidence for the emergence of robust high-impact changes over Europe.

Genome-wide discovery of DNA variants in cucumber somaclonal lines

The emergence of somaclonal variability in in vitro cultures is undesirable during micropropagation, but this phenomenon may be a source of genetic variability sought by breeders. The main factors that affect the appearance of variability are known, but the exact mechanism has not yet been determined. In this paper, we used next-generation sequencing and comparative genomics to study changes in the genomes of cucumber lines resulting from in vitro regeneration and somaclonal mutation in comparison to a reference, the highly inbred B10 line. The total number of obtained polymorphisms differed between the three somaclonal lines S1, S2 and S3, with 8369, 7591 and 44510, respectively. Polymorphisms occurred most frequently in non-coding regions and were mainly SNPs. High-impact changes accounted for 1%–3% of all polymorphisms and most often caused an open reading frame shift. Functional analysis of genes affected by high impact variants showed that they were related to transport, biosynthetic processes, nucleotide-containing compounds and cellular protein modification processes. The obtained results indicated significant factors affecting somaclonal variability and the appearance of changes in the genome, and demonstrated a lack of dependence between phenotype and the number of genomic polymorphisms.

Optimizing the HOMME dynamical core for multicore platforms

The approach of the next-generation computing platforms offers a tremendous opportunity to advance the state-of-the-art in global atmospheric dynamical models. We detail our incremental approach to utilize this emerging technology by enhancing concurrency within the High-Order Method Modeling Environment (HOMME) atmospheric dynamical model developed at the National Center for Atmospheric Research (NCAR). The study focused on improvements to the performance of HOMME which is a Fortran 90 code with a hybrid (MPIOpenMP) programming model. The article describes the changes made to the use of message passing interface (MPI) and OpenMP as well as single-core optimizations to achieve significant improvements in concurrency and overall code performance. For our optimization studies, we utilize the “Cori” system with an Intel Xeon Phi Knights Landing processor deployed at the National Energy Research Supercomputing Center and the “`Cheyenne” system with an Intel Xeon Broadwell processor installed at the NCAR. The results from the studies, using “workhorse” configurations performed at NCAR, show that these changes have a transformative impact on the computational performance of HOMME. Our improvements have shown that we can effectively increase potential concurrency by efficiently threading the vertical dimension. Further, we have seen a factor of two overall improvement in the computational performance of the code resulting from the single-core optimizations. Most notably from the work is that our incremental approach allows for high-impact changes without disrupting existing scientific productivity in the HOMME community.

Modelling and discrete differential evolution algorithm for order rescheduling problem in steel industry

Order management is a critical and complicated issue in the production process of iron and steel industry, since orders are the bridge between customers and semi-finished/final products in different units. Usually, the scheduling of orders is arranged by skilled planners. However, the initial scheduling may be infeasible during the production process due to the dynamic and frequent variation of production environment. This paper investigates a practical order rescheduling problem to adapt various changes that affect the normal production. The problem is formulated as a mixed integer programming mathematical model considering the original objective, the deviation from the initial scheduling and the equilibrium of production capacity. A discrete differential evolution algorithm with new mutation and crossover operators is proposed to find near-optimal solutions of this problem. Computational experiments are presented on both randomly generated instances and the instances from the practical production. Experimental results illustrate that the proposed algorithm could obtain better solutions compared with four standard differential evolution algorithms and the manual method. Furthermore, a production data based practical decision support system embedding the model and algorithm is developed to monitor the production process, diagnose whether there are high-impact changes of the orders and units, and make rescheduling decisions if necessary.

A randomized trial comparing fluorocholine-PET/CT with conventional imaging in prostate cancer.

2 Background: We conducted a randomised trial comparing 18Flourocholine-PET/CT (FCH) to Computed Tomography (abdomen and pelvis) plus 99mTc-Whole Body Bone Scan (Conventional Imaging [CIm]) to determine imaging performance in prostate cancer (PC). Methods: This prospective two-arm 1:1 randomised trial enrolled men with newly diagnosed or biochemically recurrent PC to first-line imaging (FLI) with either CIm or FCH. Participants without evidence of metastases proceeded to second-line imaging (SLI) using the alternative imaging strategy. The primary aim was to determine whether FCH was more effective as a FLI approach in changing management. Secondary endpoints included incremental utility of SLI and negative predictive value (NPV) based on progression-free survival (PFS). Australian New Zealand Clinical Trials Registry ACTRN12608000641392. Results: 108 men were enrolled; 44% were for staging of newly-diagnosed PC and median follow-up 43 months. Imaging impacted clinical management in 32.4% of men (95% CI=23.7-42.1%), mostly with FLI (n=30). High-impact management changes occurred in 27.8% (95% CI=16.5-41.6%) of FCH cases compared with 11.1% (95% CI=4.2-22.6%) in the CIm arm (p=0.032). The final management plan was derived using FCH in 98.1% (95% CI = 90.1-100%) of cases and 92.6% (95%CI = 82.1-97.9%) of CIm cases (p=0.242). FLI with FCH showed unequivocally N1 or M1 disease in 22.2% (95% CI = 12-35.6%), and 16.7% (95% CI = 7.9-29.3%; p= 0.531) of CIm cases. The overall NPV for stage TxN0M0 (from all imaging) was 26.3% (95% CI: 13.9 - 41.2%), with no significant difference between arms (p=0.9). For N1M0 cases, the NPV was 14.3% (95% CI: 7.1 - 35.7%). The identification of N1M0 by FCH resulted in a longer time to identification of progressive disease, with a median PFS of 32 months (95% CI=2-68months) compared with 3 months (95% CI=1-16 months) in the CIm N1M0 cohort (p=0.05). Conclusions: FCH-PET/CT identifies more high-clinical-impact lesions than CIm as first-line imaging. All imaging modalities were poor at predicting subsequent progressive disease. Isolated node-positive disease seen with FCH is associated with a longer time to - but similarly high rates of - recurrence, suggesting a lead-time bias. Clinical trial information: ACTRN12608000641392.

VALUE PROPOSITIONS FOR INFORMATION TECHNOLOGY TO IMPROVE HOSPITAL READMISSIONS IN NURSING HOMES

This report details a qualitative study using an iterative group process bringing together 49 interdisciplinary healthcare stakeholders who are part of the Missouri Quality Improvement Initiative (MOQI). Stakeholders were part of a healthcare network (post-acute/acute), using health information technology (HIT) to reduce avoidable hospitalizations in nursing homes (NH). Group process methods included (1) forming 6 groups with 6–8 stakeholders per group, 2) each group identified changes that HIT contributes toward reducing avoidable hospitalizations, 3) changes identified were then separated by change experienced by stakeholder type, finally, 4) through an iterative consensus building process each group ranked changes identified for each stakeholder type by high, medium, low impact. Stakeholders identified eight common areas of change from HIT use to reduce avoidable hospitalizations in MOQI: Access, Safety, Workflow, Partnerships, Quality of Information, Patient/Family Satisfaction, Legal, and Improved Health. Thirteen stakeholder types were identified that benefit from HIT in MOQI. Within these 13 stakeholder types high impact areas of change were experienced by Directors of Nursing: Administrators, IT/Vendors, Charge Nurses, Admissions Coordinators, Physicians, Social Services, Advanced Practice Nurses, and Care Consultants. Stakeholders experienced high impact change in their ability to perform work using IT to reduce avoidable hospitalizations including: “deep dive into admissions,”; “get a true picture of admission”; “Faster feedback, clarification, authorization”; “Reviewing orders for correctness”; “Provide immediate care”. High impact changes contributed to the effectiveness of the MOQI multidimensional intervention including HIT, Advanced Directives, and APRNs working in NH to improve care and help staff better manage resident change in condition.

Changes in climate extremes over West and Central Africa at 1.5 °C and 2 °C global warming

In this study, we investigate changes in temperature and precipitation extremes over West and Central Africa (hereafter, WAF domain) as a function of global mean temperature with a focus on the implications of global warming of 1.5 °C and 2 °C according the Paris Agreement. We applied a scaling approach to capture changes in climate extremes with increase in global mean temperature in several subregions within the WAF domain: Western Sahel, Central Sahel, Eastern Sahel, Guinea Coast and Central Africa including Congo Basin.While there are several uncertainties and large ensemble spread in the projections of temperature and precipitation indices, most models show high-impact changes in climate extremes at subregional scale. At these smaller scales, temperature increases within the WAF domain are projected to be higher than the global mean temperature increase (at 1.5 °C and at 2 °C) and heat waves are expected to be more frequent and of longer duration. The most intense warming is observed over the drier regions of the Sahel, in the central Sahel and particularly in the eastern Sahel, where the precipitation and the soil moisture anomalies have the highest probability of projected increase at a global warming of 1.5 °C. Over the wetter regions of the Guinea Coast and Central Africa, models project a weak change in total precipitation and a decrease of the length of wet spells, while these two regions have the highest increase of heavy rainfall in the WAF domain at a global warming of 1.5 °C. Western Sahel is projected by 80% of the models to experience the strongest drying with a significant increase in the length of dry spells and a decrease in the standardized precipitation evapotranspiration index. This study suggests that the ‘dry gets drier, wet gets wetter’ paradigm is not valid within the WAF domain.

Variant discovery in the sheep milk transcriptome using RNA sequencing

BackgroundThe identification of genetic variation underlying desired phenotypes is one of the main challenges of current livestock genetic research. High-throughput transcriptome sequencing (RNA-Seq) offers new opportunities for the detection of transcriptome variants (SNPs and short indels) in different tissues and species. In this study, we used RNA-Seq on Milk Sheep Somatic Cells (MSCs) with the goal of characterizing the genetic variation within the coding regions of the milk transcriptome in Churra and Assaf sheep, two common dairy sheep breeds farmed in Spain.ResultsA total of 216,637 variants were detected in the MSCs transcriptome of the eight ewes analyzed. Among them, a total of 57,795 variants were detected in the regions harboring Quantitative Trait Loci (QTL) for milk yield, protein percentage and fat percentage, of which 21.44% were novel variants. Among the total variants detected, 561 (2.52%) and 1,649 (7.42%) were predicted to produce high or moderate impact changes in the corresponding transcriptional unit, respectively. In the functional enrichment analysis of the genes positioned within selected QTL regions harboring novel relevant functional variants (high and moderate impact), the KEGG pathway with the highest enrichment was “protein processing in endoplasmic reticulum”. Additionally, a total of 504 and 1,063 variants were identified in the genes encoding principal milk proteins and molecules involved in the lipid metabolism, respectively. Of these variants, 20 mutations were found to have putative relevant effects on the encoded proteins.ConclusionsWe present herein the first transcriptomic approach aimed at identifying genetic variants of the genes expressed in the lactating mammary gland of sheep. Through the transcriptome analysis of variability within regions harboring QTL for milk yield, protein percentage and fat percentage, we have found several pathways and genes that harbor mutations that could affect dairy production traits. Moreover, remarkable variants were also found in candidate genes coding for major milk proteins and proteins related to milk fat metabolism. Several of the SNPs found in this study could be included as suitable markers in genotyping platforms or custom SNP arrays to perform association analyses in commercial populations and apply genomic selection protocols in the dairy production industry.

P139 To attend or not to attend – “why” is the question?

<h3>Background/introduction</h3> Documents such as “10 high impact changes for genitourinary medicine 48 h access” produced by the Department of Health (DH) in 2006 have helped reduce waiting times and increase capacity. Our service experienced a significant increase in the rate of non-attendance of appointments following a change in service base in February 2014. In response we decided to ascertain whether adopting some or all of the DH’s high impact changes would improve the poor attendance. <h3>Aim(s)/objectives</h3> On review we were already employing most of the recommended changes. One omission was high impact change 5: “Review current access system and make it easier for patients to access the service”, therefore we asked patients their preferred means of attendance (appointment or drop in) and times of attendance. <h3>Methods</h3> 105 services users were questioned over a 4 week period from the 1st until the 31st August 2014. <h3>Results</h3> 44% preferred the option of both appointments and drop in, whilst 28% each favoured either all appointments or drop in access only. There was no preferred time of attendance. <h3>Discussion/conclusion</h3> As the service already provides both appointments and drop in access the audit provided little to no evidence that a change to service delivery would reduce levels of non-attendance. There remains minimal data about how best to fulfil public and individual sexual health obligations, especially to an extensive rural community such as ours. A further audit on actual non-attenders could identify patterns in patient expectation.