Multidisciplinary centres for safety and quality improvement: learning from climate change science

Effective improvement and research rely on sustained multidisciplinary collaboration, but few examples are available of centres with the broad range of disciplines and practical experience that are needed to sustain long-term improvement in healthcare quality and safety. In a number of respects, the parlous state of the quality and safety of medical care resembles the problem of climate change. Both constitute a profoundly serious man-made threat to the public good which have until recently been both ignored and denied but are increasingly being recognised, taken seriously and acted on. Among the most interesting and important responses to the challenge of climate change has been the creation of Centres of Climate Change in which experts from multiple diverse disciplines are brought together to tackle the problem. Such centres, while science-based, express their vision in solid pragmatic terms and embrace policy, public engagement and education as essential components of that vision. Cross-discipline collaboration has unfortunately not achieved the same effectiveness or visibility in healthcare quality and safety as it has in the area of climate change. The authors argue that there is a need to create multidisciplinary centres in healthcare to accelerate the improvement of safety and quality, and provide the necessary theoretical and empirical foundations. Such centres would draw on disciplines such as epidemiology, statistics and relevant clinical disciplines but equally from psychology, engineering, ergonomics, sociology, economics, organisational development in addition to engaging with patients and citizens and leaders with practical experience of improvement in the field. In this paper, we address some of the pragmatic challenges of creating such centres and consider how the right groups and networks of researchers and practitioners might be assembled

Effects of lithium on electrical activity and potassium ion distribution in the vertebrate central nervous system

Three different regions of the vertebrate central nervous system maintained in vitro (frog spinal cord, guinea pig olfactory cortex and hippocampus) have been used to investigate how Li+ influences membrane potential, membrane resistance, action potentials, synaptic potentials and the transmembrane K+-distribution of neurons and glial cells. In view of the therapeutic action of Li+ in manicdepressive disease, a special effort was made to determine the threshold concentration for the actions of Li+ on the parameters described above. It was observed that Li+ induced a membrane depolarization of both neurons and glial cells, a decrease of action potential amplitudes, a facilitation of monosynaptic excitatory postsynaptic potentials and a depression of polysynaptic reflexes. The membrane resistance of neurons was not altered. Li+ also induced an elevation of the free extracellular potassium concentration and a decrease of the free intracellular potassium concentration. Furthermore, in the presence of Li+ a slowing of the recovery of the membrane potential of neurons and glial cells, and of the extracellular potassium concentration after repetitive synaptic stimulation was observed. The threshold concentrations for the effects of Li+ were below 5 mmol/l in the frog spinal cord and below 2 mmol/l in the guinea pig olfactory cortex and hippocampus. The basic mechanism underlying the action of Li+ may be an interaction with the transport-function of the Na+/K+ pump

Identifying quality improvement intervention publications - A comparison of electronic search strategies

Abstract Background The evidence base for quality improvement (QI) interventions is expanding rapidly. The diversity of the initiatives and the inconsistency in labeling these as QI interventions makes it challenging for researchers, policymakers, and QI practitioners to access the literature systematically and to identify relevant publications. Methods We evaluated search strategies developed for MEDLINE (Ovid) and PubMed based on free text words, Medical subject headings (MeSH), QI intervention components, continuous quality improvement (CQI) methods, and combinations of the strategies. Three sets of pertinent QI intervention publications were used for validation. Two independent expert reviewers screened publications for relevance. We compared the yield, recall rate, and precision of the search strategies for the identification of QI publications and for a subset of empirical studies on effects of QI interventions. Results The search yields ranged from 2,221 to 216,167 publications. Mean recall rates for reference publications ranged from 5% to 53% for strategies with yields of 50,000 publications or fewer. The 'best case' strategy, a simple text word search with high face validity ('quality' AND 'improv*' AND 'intervention*') identified 44%, 24%, and 62% of influential intervention articles selected by Agency for Healthcare Research and Quality (AHRQ) experts, a set of exemplar articles provided by members of the Standards for Quality Improvement Reporting Excellence (SQUIRE) group, and a sample from the Cochrane Effective Practice and Organization of Care Group (EPOC) register of studies, respectively. We applied the search strategy to a PubMed search for articles published in 10 pertinent journals in a three-year period which retrieved 183 publications. Among these, 67% were deemed relevant to QI by at least one of two independent raters. Forty percent were classified as empirical studies reporting on a QI intervention. Conclusions The presented search terms and operating characteristics can be used to guide the identification of QI intervention publications. Even with extensive iterative development, we achieved only moderate recall rates of reference publications. Consensus development on QI reporting and initiatives to develop QI-relevant MeSH terms are urgently needed

Technology mediator: a new role for the reference librarian?

The Arizona Health Sciences Library has collaborated with clinical faculty to develop a federated search engine that is useful for meeting real-time clinical information needs. This article proposes a technology mediation role for the reference librarian that was inspired by the project, and describes the collaborative model used for developing technology-mediated services for targeted users

Potential climatic transitions with profound impact on Europe

We discuss potential transitions of six climatic subsystems with large-scale impact on Europe, sometimes denoted as tipping elements. These are the ice sheets on Greenland and West Antarctica, the Atlantic thermohaline circulation, Arctic sea ice, Alpine glaciers and northern hemisphere stratospheric ozone. Each system is represented by co-authors actively publishing in the corresponding field. For each subsystem we summarize the mechanism of a potential transition in a warmer climate along with its impact on Europe and assess the likelihood for such a transition based on published scientific literature. As a summary, the ‘tipping’ potential for each system is provided as a function of global mean temperature increase which required some subjective interpretation of scientific facts by the authors and should be considered as a snapshot of our current understanding. <br/

Horizontal DNA transfer mechanisms of bacteria as weapons of intragenomic conflict

Horizontal DNA transfer (HDT) is a pervasive mechanism of diversification in many microbial species, but its primary evolutionary role remains controversial. Much recent research has emphasised the adaptive benefit of acquiring novel DNA, but here we argue instead that intragenomic conflict provides a coherent framework for understanding the evolutionary origins of HDT. To test this hypothesis, we developed a mathematical model of a clonally descended bacterial population undergoing HDT through transmission of mobile genetic elements (MGEs) and genetic transformation. Including the known bias of transformation toward the acquisition of shorter alleles into the model suggested it could be an effective means of counteracting the spread of MGEs. Both constitutive and transient competence for transformation were found to provide an effective defence against parasitic MGEs; transient competence could also be effective at permitting the selective spread of MGEs conferring a benefit on their host bacterium. The coordination of transient competence with cell-cell killing, observed in multiple species, was found to result in synergistic blocking of MGE transmission through releasing genomic DNA for homologous recombination while simultaneously reducing horizontal MGE spread by lowering the local cell density. To evaluate the feasibility of the functions suggested by the modelling analysis, we analysed genomic data from longitudinal sampling of individuals carrying Streptococcus pneumoniae. This revealed the frequent within-host coexistence of clonally descended cells that differed in their MGE infection status, a necessary condition for the proposed mechanism to operate. Additionally, we found multiple examples of MGEs inhibiting transformation through integrative disruption of genes encoding the competence machinery across many species, providing evidence of an ongoing "arms race." Reduced rates of transformation have also been observed in cells infected by MGEs that reduce the concentration of extracellular DNA through secretion of DNases. Simulations predicted that either mechanism of limiting transformation would benefit individual MGEs, but also that this tactic's effectiveness was limited by competition with other MGEs coinfecting the same cell. A further observed behaviour we hypothesised to reduce elimination by transformation was MGE activation when cells become competent. Our model predicted that this response was effective at counteracting transformation independently of competing MGEs. Therefore, this framework is able to explain both common properties of MGEs, and the seemingly paradoxical bacterial behaviours of transformation and cell-cell killing within clonally related populations, as the consequences of intragenomic conflict between self-replicating chromosomes and parasitic MGEs. The antagonistic nature of the different mechanisms of HDT over short timescales means their contribution to bacterial evolution is likely to be substantially greater than previously appreciated

The effects of siblings on the migration of women in two rural areas of Belgium and the Netherlands, 1829-1940

This study explores the extent to which the presence and activities of siblings shaped the chances of women migrating to rural and urban areas in two rural areas of Belgium and the Netherlands during the second half of the nineteenth and first decades of the twentieth century. Shared-frailty Cox proportional hazard analyses of longitudinal data from historical population registers show that siblings exerted an additive impact on women's migration, independently of temporal and household characteristics. Just how siblings influenced women's migration depended on regional modes of production and on employment opportunities. In the Zeeland region, sisters channelled each other into service positions. In the Pays de Herve, where men and women found industrial work in the Walloon cities, women were as much influenced by their brothers' activities. Evidence is found for two mechanisms explaining the effects of siblings: micro-economic notions of joint-household decision-making and social capital theory

Evangelical Christianity and Women’s Changing Lives

Women have outnumbered men as followers of Christianity at least since the transition to industrial capitalist modernity in the West. Yet developments in women's lives in relation to employment, family and feminist values are challenging their Christian religiosity. Building on a new strand of gender analysis in the sociology of religion, this article argues that gender is central to patterns of religiosity and secularization in the West. It then offers a case study of evangelical Christianity in England to illustrate how changes in women's lives are affecting their religiosity. Specifically, it argues that evangelical Christianity continues to be important among women occupying more traditional social positions (as wives and mothers), but adherence is declining among the growing number whose lives do not fit this older model