Quality in the balance? Competing in the age of black swans and grey rhinos

Paper accepted for 26th APQO INTERNATIONAL CONFERENCE 2021The 21st century has produced both opportunity and crisis. The era of ‘industry 4.0’ has brought global connectivity, cyber-physical systems, Artificial Intelligence and other innovations to production and service delivery systems. We operate now in a context of globalised markets, supply networks, logistics and data where increasingly sophisticated customers demand ever more competitive quality, delivery and price. Consumer wants and needs can be determined at an almost individualised level. Over the same period, events and megatrends including: shifts in corporate and geopolitical power balance; financial system volatility; supply chain fraud and adulteration; cyber-crime, terrorism and piracy; natural disasters; and the devastation brought to many businesses by the COVID pandemic have sharply highlighted the vulnerabilities, threats and risks to those same supply networks. Additionally, narrowing margins, shrinking market share, and cash-strapped governments have created renewed cost pressures. It is not surprising, then, that quality professionals and academics are busily seeking to understand the role that quality management should play in this brave new world where the rules of engagement seem to change every year. In this talk I aim to provide one viewpoint on the answer to this question through firstly deconstructing quality management to its core elements, and then exploring how those elements relate to the current context. I will discuss the relevance and roles of various quality tools and methodologies within this turbulent environment.fals

Comparing the effectiveness of small-particle versus large-particle inhaled corticosteroid in COPD

Dirkje S Postma,1 Nicolas Roche,2 Gene Colice,3 Elliot Israel,4 Richard J Martin,5 Willem MC van Aalderen,6 Jonathan Grigg,7 Anne Burden,8 Elizabeth V Hillyer,8 Julie von Ziegenweidt,8 Gokul Gopalan,9 David Price8,10 1University of Groningen, Department of Pulmonary Medicine and Tuberculosis, University Medical Center Groningen, Groningen, the Netherlands; 2Respiratory and Intensive Care Medicine, Cochin Hospital Group, APHP, Paris-Descartes University (EA2511), Paris, France; 3Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center and George Washington University School of Medicine, Washington DC, USA; 4Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; 5Department of Medicine, National Jewish Health, Denver, CO, USA; 6Dept of Pediatric Respiratory Medicine and Allergy, Emma Children's Hospital AMC, Amsterdam, the Netherlands; 7Blizard Institute, Queen Mary University London, London, UK; 8Research in Real Life, Ltd, Cambridge, UK; 9Respiratory, Global Scientific Affairs, Teva Pharmaceuticals, Frazer, PA, USA; 10Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK Purpose: Small airway changes and dysfunction contribute importantly to airway obstruction in chronic obstructive pulmonary disease (COPD), which is currently treated with inhaled corticosteroids (ICS) and long-acting bronchodilators at Global initiative for Obstructive Lung Disease (GOLD) grades 2–4. This retrospective matched cohort analysis compared effectiveness of a representative small-particle ICS (extrafine beclomethasone) and larger-particle ICS (fluticasone) in primary care patients with COPD. Patients and methods: Smokers and ex-smokers with COPD ≥40 years old initiating or stepping-up their dose of extrafine beclomethasone or fluticasone were matched 1:1 for demographic characteristics, index prescription year, concomitant therapies, and disease severity during 1 baseline year. During 2 subsequent years, we evaluated treatment change and COPD exacerbations, defined as emergency care/hospitalization for COPD, acute oral corticosteroids, or antibiotics for lower respiratory tract infection. Results: Mean patient age was 67 years, 57%–60% being male. For both initiation (n=334:334) and step-up (n=189:189) patients, exacerbation rates were comparable between extrafine beclomethasone and fluticasone cohorts during the 2 year outcome period. Odds of treatment stability (no exacerbation or treatment change) were significantly greater for patients initiating extrafine beclomethasone compared with fluticasone (adjusted odds ratio 2.50; 95% confidence interval, 1.32–4.73). Median ICS dose exposure during 2 outcome years was significantly lower (P<0.001) for extrafine beclomethasone than fluticasone cohorts (315 µg/day versus 436 µg/day for initiation, 438 µg/day versus 534 µg/day for step-up patients). Conclusion: We observed that small-particle ICS at significantly lower doses had comparable effects on exacerbation rates as larger-particle ICS at higher doses, whereas initiation of small-particle ICS was associated with better odds of treatment stability during 2-years' follow-up. Keywords: COPD exacerbation, extrafine particle, matched cohort analysis, real life, small airway

Osmoregulation of the Australian freshwater crocodile, Crocodylus johnstoni, in fresh and saline waters

An unusual saltwater population of the "freshwater" crocodilian, Crocodylus johnstoni, was studied in the estuary of the Limmen Bight River in Australia's Northern Territory and compared with populations in permanently freshwater habitats. Crocodiles in the river were found across a large salinity gradient, from fresh water to a salinity of 24 mg.ml-1, more than twice the body fluid concentration. Plasma osmolarity, concentrations of plasma Na+, Cl-, and K+, and exchangeable Na+ pools were all remarkably constant across the salinity spectrum and were not substantially higher or more variable than those in crocodiles from permanently freshwater habitats. Body fluid volumes did not vary; condition factor and hydration status of crocodiles were not correlated with salinity and were not different from those of crocodiles from permanently fresh water. C. johnstoni clearly has considerable powers of osmoregulation in waters of low to medium salinity. Whether this osmoregulatory competence, extends to continuously hyperosmotic environments is not known, but distributional data suggest that C. johnstoni in hyperosmotic conditions may require periodic access to hypoosmotic water. The study demonstrates a physiological capacity for colonisation of at least some estuarine waters by this normally stenohaline freshwater crocodilian

Irrigated lands assessment for water management: Technique test

A procedure for estimating irrigated land using full frame LANDSAT imagery was demonstrated. Relatively inexpensive interpretation of multidate LANDSAT photographic enlargements was used to produce a map of irrigated land in California. The LANDSAT and ground maps were then linked by regression equations to enable precise estimation of irrigated land area by county, basin, and statewide. Land irrigated at least once in California in 1979 was estimated to be 9.86 million acres, with an expected error of less than 1.75% at the 99% level of confidence. To achieve the same level of error with a ground-only sample would have required 3 to 5 times as many ground sample units statewide. A procedure for relatively inexpensive computer classification of LANDSAT digital data to irrigated land categories was also developed. This procedure is based on ratios of MSS band 7 and 5, and gave good results for several counties in the Central Valley

Relations among math self-efficacy, interest, intentions, and achievement: a social cognitive perspective

Drawing on social cognitive perspectives, the present study examined an integrative model of the interplay among math self-efficacy, interests, aspirations, and achievement among early and middle adolescents. Based on short-term longitudinal data from approximately 400 students, analyses using fully latent structural equation analyses, establishing requisite levels of longitudinal invariance, revealed that (a) math self-efficacy positively predicted math achievement using both class grades and standardized test score operationalizations; (b) prior math achievement positively predicted basal levels of math self-efficacy but not changes in self-efficacy; (c) math interest and intentions were reciprocally linked over time; and (d) prior math interest positively predicted subsequent math self-efficacy whereas the opposite was not true. Notably, all effects were observed while accounting for prior variance in outcomes as well as the effects of known covariates. The current findings contribute to understandings of the motivational processes involved in math achievement and choosing educational pathways, and suggest that multidimensional interventions may be most profitable if both achievement and selection outcomes are at stake

Day-ahead allocation of operation reserve in composite power systems with large-scale centralized wind farms

This paper focuses on the day-ahead allocation of operation reserve considering wind power prediction error and network transmission constraints in a composite power system. A two-level model that solves the allocation problem is presented. The upper model allocates operation reserve among subsystems from the economic point of view. In the upper model, transmission constraints of tielines are formulated to represent limited reserve support from the neighboring system due to wind power fluctuation. The lower model evaluates the system on the reserve schedule from the reliability point of view. In the lower model, the reliability evaluation of composite power system is performed by using Monte Carlo simulation in a multi-area system. Wind power prediction errors and tieline constraints are incorporated. The reserve requirements in the upper model are iteratively adjusted by the resulting reliability indices from the lower model. Thus, the reserve allocation is gradually optimized until the system achieves the balance between reliability and economy. A modified two-area reliability test system (RTS) is analyzed to demonstrate the validity of the method.This work was supported by National Natural Science Foundation of China (No. 51277141) and National High Technology Research and Development Program of China (863 Program) (No. 2011AA05A103)

Carbonaceous particulate matter on the lung surface from adults living in São Paulo, Brazil.

OBJECTIVES: We therefore sought to identify the exposures associated with lung surface in long-term residents of São Paulo, Brazil. METHODS: Lung surface carbon were analyzed in 72 autopsy specimens by image analysis. Smoking history, measured PM10 nearest to the home, distance to main road, and distance-weighted traffic density were used as exposure variables. Data are summarized as median (IQR), and compared by Mann Whitney Test, with correlations done by Spearman's correlation. RESULTS: There was no association between lung surface and age or gender. There was no statistically significant association in lung surface between smokers and non-smokers 6.74 cm2 (3.47 to 10.02) versus 5.20cm2 (2.29 to 7.54), and there was no significant association between lung surface carbon and exposure to environmental PM and markers of traffic exposure. CONCLUSION: We did not find a statistically significant association between lung surface and smokers and non-smokers, and no statistically significant association between lung surface carbon and environmental exposure variables. These results suggest that lung surface carbon in long-term residents of São Paulo may predominately be from environmental PM, but the most appropriate environmental exposure marker remains unclear.This study was supported by CAPES (Coordination for the Improvement of Higher Level -or Education- Personnel), Brazil, grant number: 99999.010610/2014-06, http://www.capes.gov.br/, to MP

Add-on LABA in a separate inhaler as asthma step-up therapy versus increased dose of ICS or ICS/LABA combination inhaler.

Asthma management guidelines recommend adding a long-acting β2-agonist (LABA) or increasing the dose of inhaled corticosteroid (ICS) as step-up therapy for patients with uncontrolled asthma on ICS monotherapy. However, it is uncertain which option works best, which ICS particle size is most effective, and whether LABA should be administered by separate or combination inhalers. This historical, matched cohort study compared asthma-related outcomes for patients (aged 12-80 years) prescribed step-up therapy as a ≥50% extrafine ICS dose increase or add-on LABA, via either a separate inhaler or a fine-particle ICS/LABA fixed-dose combination (FDC) inhaler. Risk-domain asthma control was the primary end-point in comparisons of cohorts matched for asthma severity and control during the baseline year. After 1:2 cohort matching, the increased extrafine ICS versus separate ICS+LABA cohorts included 3232 and 6464 patients, respectively, and the fine-particle ICS/LABA FDC versus separate ICS+LABA cohorts included 7529 and 15 058 patients, respectively (overall mean age 42 years; 61-62% females). Over one outcome year, adjusted OR (95% CI) for achieving asthma control were 1.25 (1.13-1.38) for increased ICS versus separate ICS+LABA and 1.06 (1.05-1.09) for ICS/LABA FDC versus separate ICS+LABA. For patients with asthma, increased dose of extrafine-particle ICS, or add-on LABA via ICS/LABA combination inhaler, is associated with significantly better outcomes than ICS+LABA via separate inhalers.Research in Real-Life ltd. Teva Pharmaceutical Industries

Exposure to diesel exhaust particles increases susceptibility to invasive pneumococcal disease.

BACKGROUND: The World Health Organization estimates that air pollution is responsible for 7 million deaths per annum, with 7% of these attributable to pneumonia. Many of these fatalities have been linked to exposure to high levels of airborne particulates, such as diesel exhaust particles (DEPs). OBJECTIVES: We sought to determine whether exposure to DEPs could promote the progression of asymptomatic nasopharyngeal carriage of Streptococcus pneumoniae to invasive pneumococcal disease. METHODS: We used mouse models and in vitro assays to provide a mechanistic understanding of the link between DEP exposure and pneumococcal disease risk, and we confirmed our findings by using induced sputum macrophages isolated from healthy human volunteers. RESULTS: We demonstrate that inhaled exposure to DEPs disrupts asymptomatic nasopharyngeal carriage of S pneumoniae in mice, leading to dissemination to lungs and blood. Pneumococci are transported from the nasopharynx to the lungs following exposure to DEPs, leading to increased proinflammatory cytokine production, reduced phagocytic function of alveolar macrophages, and consequently, increased pneumococcal loads within the lungs and translocation into blood. These findings were confirmed by using DEP-exposed induced sputum macrophages isolated from healthy volunteers, demonstrating that impaired innate immune mechanisms following DEP exposure are also at play in humans. CONCLUSION: Lung inhaled DEPs increase susceptibility to pneumococcal disease by leading to loss of immunological control of pneumococcal colonisation, increased inflammation, tissue damage, and systemic bacterial dissemination