Knowledge management infrastructure to support quality improvement: A qualitative study of maternity services in four European hospitals

The influence of multilevel healthcare system interactions on clinical quality improvement (QI) is still largely unexplored. Through the lens of knowledge management (KM) theory, this study explores how hospital managers can enhance the conditions for clinical QI given the specific multilevel and professional interactions in various healthcare systems. The research used an in-depth multilevel analysis in maternity departments in four purposively sampled European hospitals (Portugal, England, Norway and Sweden). The study combines analysis of macro-level policy documents and regulations with semi-structured interviews (96) and non-participant observations (193 hours) of hospital and clinical managers and clinical staff in maternity departments. There are four main conclusions: First, the unique multilevel configuration of national healthcare policy, hospital management and clinical professionals influence the development of clinical QI efforts. Second, these different configurations provide various and often insufficient support and guidance which affect professionals’ action strategies in QI efforts. Third, hospital managers’ opportunities and capabilities for developing a consistent KM infrastructure with reinforcing enabling conditions which merge national policies and guidelines with clinical reality is crucial for clinical QI. Fourth, understanding these interrelationships provides an opportunity for improvement of the KM infrastructure for hospital managers through tailored interventions

Feasibility and acceptability of implementing early infant diagnosis of HIV in Papua New Guinea at the point of care: a qualitative exploration of health worker and key informant perspectives

Introduction: Early infant diagnosis (EID) of HIV and timely initiation of antiretroviral therapy can significantly reduce morbidity and mortality among HIV-positive infants. Access to EID is limited in many low-income and middle-income settings, particularly those in which standard care involves dried blood spots (DBS) sent to centralised laboratories, such as in Papua New Guinea (PNG). We conducted a qualitative exploration of the feasibility and acceptability of implementing a point-of-care (POC) EID test (Xpert HIV-1 Qualitative assay) among health workers and key stakeholders working within the prevention of mother-to-child transmission of HIV (PMTCT) programme in PNG. Methods: This qualitative substudy was conducted as part of a pragmatic trial to investigate the effectiveness of the Xpert HIV-1 Qualitative test for EID in PNG and Myanmar. Semistructured interviews were undertaken with 5 health workers and 13 key informants to explore current services, experiences of EID testing, perspectives on the Xpert test and the feasibility of integrating and scaling up POC EID in PNG. Coding was undertaken using inductive and deductive approaches, drawing on existing acceptability and feasibility frameworks. Results: Health workers and key informants (N=18) felt EID at POC was feasible to implement and beneficial to HIV-exposed infants and their families, staff and the PMTCT programme more broadly. All study participants highlighted starting HIV-positive infants on treatment immediately as the main advantage of POC EID compared with standard care DBS testing. Health workers identified insufficient resources to follow up infants and caregivers and space constraints in hospitals as barriers to implementation. Participants emphasised the importance of adequate human resources, ongoing training and support, appropriate coordination and a sustainable supply of consumables to ensure effective scale-up of the test throughout PNG. Conclusions: Implementation of POC EID in a low HIV prevalence setting such as PNG is likely to be both feasible and beneficial with careful planning and adequate resources

Understanding barriers and outcomes of unspecified (non-directed altruistic) kidney donation from both professional's and patient's perspectives: research protocol for a national multicentre mixed-methods prospective cohort study.

INTRODUCTION: Living donation accounts for over one-third of all kidney transplants taking place in the UK. 1 The concept of anonymously donating a kidney to a stranger (non-directed altruistic or unspecified kidney donation (UKD)) remains uncomfortable for some clinicians, principally due to concerns about the motivations and long-term physical and psychological outcomes in this donor group. AIMS: The research programme aims to provide a comprehensive assessment of the unspecified donor programme in the UK. It aims to identify reasons for variations in practice across centres, explore outcomes for donors and ascertain barriers and facilitators to UKD, as well as assess the economic implications of unspecified donation. METHODS: The research programme will adopt a mixed-methods approach to assessing UKD nationally using focus groups, interviews and questionnaires. Two study populations will be investigated. The first will include transplant professionals involved in unspecified kidney donation. The second will include a 5-year prospective cohort of individuals who present to any of the 23 UK transplant centres as a potential unspecified living kidney donor. Physical and psychological outcomes will be followed up to 1 year following donation or withdrawal from the donation process. A matched sample of specified donors (those donating to someone they know) will be recruited as a control group. Further qualitative work consisting of interviews will be performed on a purposive sample of unspecified donors from both groups (those who do and do not donate). DISSEMINATION: The findings will be reported to NHS Blood and Transplant and the British Transplant Society with a view to developing national guidelines and a protocol for the management of those presenting for unspecified donation. TRIAL REGISTRATION NUMBER: ISRCTN23895878, Pre-results

Application of Respondent Driven Sampling to Collect Baseline Data on FSWs and MSM for HIV Risk Reduction Interventions in Two Urban Centres in Papua New Guinea

The need to obtain unbiased information among hard–to-reach and hidden populations for behavioural and biological surveillance, epidemiological studies, and intervention program evaluations has led researchers to search for a suitable sampling method. One method that has been tested among IDU and MSM recently is respondent-driven sampling (RDS). We used RDS to conduct a behavioural survey among FSWs and MSM in two urban centres in Papua New Guinea (PNG). In this paper we present the lessons learned implementing RDS in a developing country setting. We also present comparisons of RDSAT-adjusted versus unadjusted crude estimates of some key socio-demographic indicators as well as comparisons between the estimates from RDS and a hypothetical time–location sample (TLS). Overall, the use of RDS among the MSM and FSWs in PNG had numerous advantages in terms of collecting a required sample size in a short time period, minimizing costs and maximising security for staff and respondents. Although there were a few problems these were easily remedied and we would recommend RDS for other similar studies in PNG and other developing countries

Analytic philosophy for biomedical research: the imperative of applying yesterday's timeless messages to today's impasses

The mantra that "the best way to predict the future is to invent it" (attributed to the computer scientist Alan Kay) exemplifies some of the expectations from the technical and innovative sides of biomedical research at present. However, for technical advancements to make real impacts both on patient health and genuine scientific understanding, quite a number of lingering challenges facing the entire spectrum from protein biology all the way to randomized controlled trials should start to be overcome. The proposal in this chapter is that philosophy is essential in this process. By reviewing select examples from the history of science and philosophy, disciplines which were indistinguishable until the mid-nineteenth century, I argue that progress toward the many impasses in biomedicine can be achieved by emphasizing theoretical work (in the true sense of the word 'theory') as a vital foundation for experimental biology. Furthermore, a philosophical biology program that could provide a framework for theoretical investigations is outlined

PAK3 Exacerbates Cardiac Lipotoxicity via SREBP1c in Obesity Cardiomyopathy

Obesity-induced lipid overload in cardiomyocytes contributes to profound oxidative stress and cardiomyopathy, culminating in heart failure. In this study, we investigate a novel mechanism whereby lipids accumulate in cardiomyocytes and seek the relevant treatment strategies. P21-activated kinase 3 (PAK3) was elevated in obese human myocardium, and the murine hearts and cardiomyocytes upon diet- or fatty acid-induced stress, respectively. Mice with cardiac-specific overexpression of PAK3 were more susceptible to the development of cardiac dysfunction upon diet stress, at least partially, due to increased deposition of toxic lipids within the myocardium. Mechanistically, PAK3 promoted the nuclear expression of sterol regulatory element binding protein 1c (SREBP1c) through activation of mammalian target of rapamycin (mTOR) and ribosomal protein S6 kinase beta-1 (S6K1) pathway in cardiomyocytes, resulting in abnormal lipid genes profile, accumulation of excessive lipids, and oxidative stress. More importantly, PAK3 knockdown attenuated fatty acid-induced lipotoxicity and cell death in rat and human cardiomyocytes. More importantly, the S6K1 or SREBP1c inhibitor alleviated PAK3-triggered intracellular lipid overload and cardiac dysfunction under obese stress. Collectively, we have demonstrated that PAK3 impairs myocardial lipid homeostasis, while inhibition of cardiac lipotoxicity mitigates cardiac dysfunction. Our study provides a promising therapeutic strategy for ameliorating obesity cardiomyopathy.<br/

A longitudinal, multi-level comparative study of quality and safety in European hospitals: the QUASER study protocol

although there is a wealth of information available about quality improvement tools and techniques in healthcare there is little understanding about overcoming the challenges of day-to-day implementation in complex organisations like hospitals. The 'Quality and Safety in Europe by Research' (QUASER) study will investigate how hospitals implement, spread and sustain quality improvement, including the difficulties they face and how they overcome them. The overall aim of the study is to explore relationships between the organisational and cultural characteristics of hospitals and how these impact on the quality of health care; the findings will be designed to help policy makers, payers and hospital managers understand the factors and processes that enable hospitals in Europe to achieve-and sustain-high quality services for their patients

Gaia Data Release 2: Calibration and mitigation of electronic offset effects in the data

The European Space Agency Gaia satellite was launched into orbit around L2 in December 2013. This ambitious mission has strict requirements on residual systematic errors resulting from instrumental corrections in order to meet a design goal of sub-10 microarcsecond astrometry. During the design and build phase of the science instruments, various critical calibrations were studied in detail to ensure that this goal could be met in orbit. In particular, it was determined that the video-chain offsets on the analogue side of the analogue-to-digital conversion electronics exhibited instabilities that could not be mitigated fully by modifications to the flight hardware. We provide a detailed description of the behaviour of the electronic offset levels on microsecond timescales, identifying various systematic effects that are known collectively as offset non-uniformities. The effects manifest themselves as transient perturbations on the gross zero-point electronic offset level that is routinely monitored as part of the overall calibration process. Using in-orbit special calibration sequences along with simple parametric models, we show how the effects can be calibrated, and how these calibrations are applied to the science data. While the calibration part of the process is relatively straightforward, the application of the calibrations during science data processing requires a detailed on-ground reconstruction of the readout timing of each charge-coupled device (CCD) sample on each device in order to predict correctly the highly time-dependent nature of the corrections. We demonstrate the effectiveness of our offset non-uniformity models in mitigating the effects in Gaia data. We demonstrate for all CCDs and operating instrument and modes on board Gaia that the video-chain noise-limited performance is recovered in the vast majority of science samples

Noncompliance in people living with HIV: accuracy of defining characteristics of the nursing diagnosis

ABSTRACT Objective: to evaluate the accuracy of the defining characteristics of the NANDA International nursing diagnosis, noncompliance, in people with HIV. Method: study of diagnostic accuracy, performed in two stages. In the first stage, 113 people with HIV from a hospital of infectious diseases in the Northeast of Brazil were assessed for identification of clinical indicators of noncompliance. In the second, the defining characteristics were evaluated by six specialist nurses, analyzing the presence or absence of the diagnosis. For accuracy of the clinical indicators, the specificity, sensitivity, predictive values and likelihood ratios were measured. Results: the presence of the noncompliance diagnosis was shown in 69% (n=78) of people with HIV. The most sensitive indicator was, missing of appointments (OR: 28.93, 95% CI: 1.112-2.126, p = 0.002). On the other hand, nonadherence behavior (OR: 15.00, 95% CI: 1.829-3.981, p = 0.001) and failure to meet outcomes (OR: 13.41; 95% CI: 1.272-2.508; P = 0.003) achieved higher specificity. Conclusion: the most accurate defining characteristics were nonadherence behavior, missing of appointments, and failure to meet outcomes. Thus, in the presence of these, the nurse can identify, with greater security, the diagnosis studied

Investigation into the cause of spontaneous emulsification of a free steel droplet : validation of the chemical exchange pathway

Small Fe-based droplets have been heated to a molten phase suspended within a slag medium to replicate a partial environment within the basic oxygen furnace (BOF). The confocal scanning laser microscope (CSLM) has been used as a heating platform to interrogate the effect of impurities and their transfer across the metal/slag interface, on the emulsification of the droplet into the slag medium. The samples were then examined through X-ray computer tomography (XCT) giving the mapping of emulsion dispersion in 3D space, calculating the changing of interfacial area between the two materials, and changes of material volume due to material transfer between metal and slag. Null experiments to rule out thermal gradients being the cause of emulsification have been conducted as well as replication of the previously reported study by Assis et al.[1] which has given insights into the mechanism of emulsification. Finally chemical analysis was conducted to discover the transfer of oxygen to be the cause of emulsification, leading to a new study of a system with undergoing oxygen equilibration