A Quality Improvement Program in a Safety Net Clinic Serving Vulnerable Populations

The Patient Protection and Affordable Care Act of 2010 resulted in major changes to healthcare infrastructure in the United States, with two main areas of concentration: healthcare financing and population health management. Quality improvement programs focus on improving healthcare quality for populations with conscious efforts to decrease healthcareassociated expenditures. Quality improvement interventions can include patient-reported outcomes, clinical decision support systems, and clinical dashboards. The purpose of the Doctor of Nursing Practice project was to formally implement a quality improvement program for chronic disease management in a safety net clinic serving vulnerable populations. The Donabedian model served as the conceptual model to frame the formal quality improvement program. The Plan-Do-Study-Act model guided the implementation of the formal quality improvement program. Despite the lack of statistically significant differences between pre- and post-implementation outcome measures, the Doctor of Nursing Practice project established a standard documentation process for several chronic diseases supported by a procedure manual, volunteer education modules, and clinical dashboards. Limitations of the project included the brief evaluation period, the low daily volume of patients with the selected chronic diseases, and the inadequate volunteer survey response rate. Recommendations for sustainability and future iterations involve an investigation into the documentation process of underperforming outcome measures, the identification of an effective process to solicit volunteer feedback on training modules, and the continuation of the clinical dashboard process to generate monthly compliance data to monitor documentation variation over time. The formalization of the quality improvement program in the safety net clinic during this Plan-Do-Study-Act cycle provided a strong foundation from which to launch the next Plan-Do-Study-Act cycle focusing on improved volunteer involvement

Perspectives on long-term bee vitality monitoring

Bienen sind essentielle Bestäuber und daher ist ihr Schutz von zentraler Bedeutung für die Sicherung der biologischen Vielfalt und der landwirtschaftlichen Produktion. Innerhalb des Projekts MonViA werden viele Partner zusammen­arbeiten, um wirksame Strategien zur Förderung der biologischen Vielfalt zu entwickeln. Wir präsentieren eine Langzeit-Fallstudie wie sich Klima auf die Leistungsfähigkeit von Honigbienenvölkern auswirkt. Veränderungen des mitteleuropäischen Honigertrags haben wir in Bezug auf die Änderung von Temperatur und Niederschlag modelliert. Eine + 1°C Temperaturänderung steigert den jährlichen Honigertrag um + 0,9 kg pro Volk, während + 100 mm Niederschlag den Ertrag um – 0,4 kg verringert. Basierend auf Klimawandelprognosen im Zeitraum 2020–2050, schätzen wir eine potenzielle Ertragssteigerung von + 0,4 bis + 0,8 kg Honig pro Volk. Wir schließen daraus, dass die Honigbienenpopulation in Deutschland von steigenden Temperaturen profitieren könnte. Weiterhin diskutieren wir, wie die Bienenleistung mit dem Wetter zusammenhängt und wie unsere Analysen durch die Einbeziehung weiterer Daten, mit einer höhe­ren zeitlichen und räumlichen Auflösung, gestärkt werden könnten. Die Einflüsse extremer Wetterbedingungen, imkerlicher Praxis, Krankheitsbelastung, Verfügbarkeit von Nahrungsressourcen, Landnutzung und auch Landschaftsstrukturen sollten im Rahmen des Monitorings der Bienenvitalität miterfasst werden.Bees are essential pollinators and their protection is relevant to secure biodiversity and agricultural production. MonViA-project members and partners collaborate in monitoring projects to develop effective policies to support biodiversity in Germany. In the current case-study, the impact of climate on honey bee population performance was assessed. We modeled year-to-year Central-European honey yield changes and found + 1°C temperature change to stimulate annual honey yield by + 0.9 kg per colony, and + 100 mm precipitation to reduce honey yields – 0.4 kg. In regard to different climate change scenarios for Germany, our modelling suggests a potential + 0.4 to + 0.8 kg honey yield gain per colony in 2050, as compared to 2020. We conclude that the German honey bee population may benefit by rising temperatures. We discuss how bee performance is linked to weather and how our analysis would be strengthened by including more data, with a higher temporal and spatial resolution, i.e., intra-annually and -nationally. Pollinator trend monitoring should be extended with analyses that include e.g., extreme weather conditions, disease loads, availability of floral resource, beekeeping practice, land use and landscape structure

Management of T1-T2 glottic carcinoma: with a specific focus on T2 glottic carcinoma

During recent decades, many studies have been performed in patients with early glottic cancer, which provide new insight into the two main treatment modalities, TOLMS and radiotherapy, and their outcomes. The aim of this thesis was: (i) What is the role of TOLMS in T2 glottic carcinoma in the Netherlands? (ii) Should more patients with T2 glottic carcinoma be treated with TOLMS? Within this thesis, we found that (i) the laryngeal preservation rate for T2 glottic carcinoma is higher after primary treatment with TOLMS than after primary treatment with radiotherapy; (ii) that the binary use (yes/no) for the involvement of the anterior commissure (AC) as a prognostic factor leads to inconsistent results, whereas studies with a more detailed classification of the AC show that there is a significant impact on oncological outcomes; (iii) that vertical involvement of the AC on imaging has a significant impact on local control not only in patients treated with TOLMS but also in patients receiving primary radiotherapy; and (iv) that patient with T2 glottic carcinoma treated with radiotherapy reported good long-term functional outcomes, although patients with tumors infiltrating the vocal fold muscle show a trend toward a higher degree of voice handicap than patients with tumor with only superficial spread.Department of Otorhinolaryngology and Head & Neck Surgery LUMC, Daleco Pharma, Meditop Medical Products, Pentax, Stopler, ViatrisLUMC / Geneeskund

Individual and Colony Level Foraging Decisions of Bumble Bees and Honey Bees in Relation to Balancing of Nutrient Needs

Foraging decisions of social animals occur in the context of social groups, and thus may be subject to considerations of not only an individual's nutritional state and nutrient input, but those of the social group in which they live. In eusocial insects, which live in colonies containing workers that forage for food that is mostly consumed by others, foraging decisions that reflect colony needs may also be considered at both the colony and individual level. If colony energy balance is perturbed, is the counteracting response occurring on the group level (a change in division of labor) or on the individual level (a change in individual foraging choices)? To address this, colony and individual level foraging behaviors were observed in two species of eusocial bees: the highly social honey bee Apis mellifera and the primitively eusocial bumble bee Bombus terrestris. After manipulations of protein (P) and carbohydrate (C) stores in colonies of both species, there were changes in multiple different behavioral responses including colony level (number of foragers, allocation to nectar and pollen foraging, nutrient mass foraged) and individual level (P and C concentration preference and loading during foraging). These results suggest both honey bee and bumble bee colonies balance nutrient needs through a combination of both colony level shifts in foraging allocation, as well as slight modulation of individual nutrient preferences. This study also uncovered colony level differences between the two bee species; honey bees balanced P intake while bumble bees balanced C intake. These patterns may reflect differences in life history traits such as perenniality and hoarding, traits that are developed in more highly social species. Overall, this study highlights the importance of considering both group and individual level behavioral responses in foraging decisions in social animals

Quality of life and voice outcome of patients treated with transoral CO2 laser microsurgery for early glottic carcinoma (T1-T2): a 2-year follow-up study

Purpose Longitudinal studies in laryngeal cancer can provide clinicians information about short-term and long-term functional outcomes, like quality of life (QoL) and voice outco

Floral abundance and resource quality influence pollinator choice

1. Pollinator declines caused by forage habitat loss threaten insect pollination services. Pollinating insects depend on adequate floral resources, and their ability to track these resources. Variability of these resources and the effect on insect foraging choice is poorly understood. 2. We record patterns of visitation to six wildflower species and test the hypotheses that: pollinators preferentially visit the most rewarding flowers; nectar diurnal variations affect foraging preferences; pollinators respond most strongly to nectar rewards. 3. Nectar volume and sugar concentration were negatively correlated within plant species over time of day where greater concentration and lower volume was evident in the afternoon, but this did not correspond to pollinator visitation. Both floral abundance and nectar quality (total sugar per inflorescence) positively affect insect visitation. For some foragers, the positive effects of high quality rewards were only evident when floral abundance was high (>50 inflorescences per patch), perhaps reflecting the low probability of pollinators detecting scarce rewards. Pollen quality (total protein per inflorescence) was negatively related to visitation of Apis mellifera and Bombus pascuorum. 4. Fewer pollinators visiting flowers of higher pollen quality could reflect plant allocation trade-offs or the presence of secondary metabolites in pollen, meaning pollen foraging is likely affected by factors other than protein concentration. Nectar rather than pollen appeared to be the main driver of floral choice by insects in this system. 5. Conservation schemes for bees in farmland or gardens might benefit from ensuring that rewarding plant species are present at high density and/or are aggregated in space

Voice outcome after unilateral ELS type III or bilateral type II resections for T1-T2 glottic carcinoma: Results after 1 year

Abstract Background: Voice outcome was assessed in patients with extended T1 and limited T2 glottic carcinoma, treated with a unilateral type III or a bilateral type II resection according to the European Laryngological Society (ELS) classification. Methods: Objective evaluation (acoustic and aerodynamic parameters), perceptual evaluation (GRBAS), and patients' self-assessment (voice handicap index [VHI]) were performed before and 1 year after treatment. Results were evaluated according to ELS resection type and the involvement of the anterior commissure. Results: The majority of voice parameters in all resection subgroups showed an improvement of the mean score 1 year postoperatively. Grade of dysphonia varied between 1.15 and 1.66 postoperatively and VHI score varied from 23.3 to 24.5. Conclusion: Voice outcome after ELS unilateral type III or a bilateral type II resection for extended T1 and limited T2 glottic carcinoma is good with mild to very moderate perceptive dysphonia and low self-reported voice impairment

Nutrient balancing of the adult worker bumblebee ( Bombus terrestris

Animals carefully regulate the amount of protein that they consume. The quantity of individual essential amino acids (EAAs) obtained from dietary protein depends on the protein source, but how the proportion of EAAs in the diet affects nutrient balancing has rarely been studied. Recent research using the Geometric Framework for Nutrition has revealed that forager honeybees who receive much of their dietary EAAs from floral nectar and not from solid protein have relatively low requirements for dietary EAAs. Here, we examined the nutritional requirements for protein and carbohydrates of foragers of the bufftailed bumblebee Bombus terrestris. By using protein (sodium caseinate) or an equimolar mixture of the 10 EAAs, we found that the intake target (nutritional optimum) of adult workers depended on the source and proportion of dietary EAAs. When bees consumed caseinate-containing diets in a range of ratios between 1:250 and 1:25 (protein to carbohydrate), they achieved an intake target (IT) of 1:149 (w/w). In contrast to those fed protein, bees fed the EAA diets had an IT more biased towards carbohydrates (1:560 w/w) but also had a greater risk of death than those fed caseinate. We also tested how the dietary source of EAAs affected free AAs in bee haemolymph. Bees fed diets near their IT had similar haemolymph AA profiles, whereas bees fed diets high in caseinate had elevated levels of leucine, threonine, valine and alanine in the haemolymph. We found that like honeybees, bumblebee workers prioritize carbohydrate intake and have a relatively low requirement for protein. The dietary source of EAAs influenced both the ratio of protein/EAA to carbohydrate and the overall amount of carbohydrate eaten. Our data support the idea that EAAs and carbohydrates in haemolymph are important determinants of nutritional state in insects.Biotechnology and Biological Sciences Research Council, Natural Environment Research Council, the Wellcome Trust, Department for the Environment, Food, and Rural Affairs, and the Scottish Government under the Insect Pollinators Initiative [BB/I000968/1].http://jeb.biologists.orghb201