Does pre-ordering tests enhance the value of the periodic examination? Study Design - Process implementation with retrospective chart review

<p>Abstract</p> <p>Background</p> <p>To evaluate the value of a pre-ordering process for the pro-active scheduling and completion of appropriate preventive and chronic disease monitoring tests prior to a periodic health examination (PHE).</p> <p>Methods</p> <p>A standardized template was developed and used by our nursing staff to identify and schedule appropriate tests prior to the patients PHE. Chart reviews were completed on all 602 PHE visits for a 3-month interval in a primary care setting. A patient satisfaction survey was administered to a convenience sample of the PHE patients.</p> <p>Results</p> <p>Of all the patients with tests pre-ordered, 87.8% completed the tests. All providers in the division used the process, but some evolved from one template to another over time. Most patients (61%) preferred to get their tests done prior to their PHE appointment. Many of our patients had abnormal test results. With this process, patients were able to benefit from face-to-face discussion of these results directly with their provider.</p> <p>Conclusions</p> <p>A pre-order process was successfully implemented to improve the value of the PHE visit in an internal medicine primary care practice using a standardized approach that allowed for provider autonomy. The process was accepted by patients and providers and resulted in improved office efficiency through reduced message handling. Completion of routine tests before the PHE office visit can help facilitate face-to-face discussions about abnormal results and subsequent management that otherwise may only occur by telephone.</p

A non-randomised controlled pilot study of clinical pharmacist collaborative intervention for community dwelling patients with COPD

UK, home-based patients with COPD receive specialist care from respiratory physicians, nurses, and general practitioners (GPs), but increasing complexity of therapeutic options and a GP/Nurse workforce crisis suggests merit in testing the role of home visits by a clinical pharmacist. We conducted a non-randomised intervention study with a contemporaneous comparator group, in Glasgow (Scotland). A clinical pharmacist (working closely with a consultant respiratory physician) visited patients with COPD living at home, assessing respiratory and other co-morbid conditions, and medicines then, with patient approval, agreed treatment modifications with a consultant physician. Comparator group-patients were drawn from another hospital out-patient clinic. Main outcomes were exacerbations during 4-months of follow-up and respiratory hospitalisations (number and duration) after 1 year. In the intervention group, 86 patients received a median of three home visits; 87 received usual care (UC). At baseline, patients in the intervention group were similar to those in UC in terms of respiratory hospitalisations although slightly younger, more likely to receive specific maintenance antibiotics/Prednisolone and to have had exacerbations. Sixty-two (72.1%) of the intervention group received dose changes; 45 (52.3%) had medicines stopped/started and 21 (24.4%) received an expedited review at the specialist respiratory consultant clinic; 46 (53.5%) were referred to other healthcare services. Over one-third were referred for bone scans and 11% received additional investigations. At follow-up, 54 (63.5%) of intervention group participants had an exacerbation compared with 75 (86.2%) in the UC group (p = 0.001); fewer had respiratory hospitalisations (39 (45.3%) vs. 66 (76.7%); p &lt; 0.001). Hospitalisations were shorter in the intervention group. Pharmacist-consultant care for community dwelling patients with COPD, changed clinical management and improved outcomes. A randomised controlled trial would establish causality

What place for ethics? An overview of ethics teaching in occupational therapy and physiotherapy programs in Canada

Purpose: The recent introduction of master’s level curricula for Occupational Therapy and Physiotherapy training programs in Canada raises both challenges and opportunities to address ethical issues during professional training. This study evaluated the inclusion of ethics content in course descriptions and course calendars in order to develop a preliminary understanding of how rehabilitation ethics is taught in Canadian universities. Method: We reviewed the ethics content in the online curricula of 27 Canadian rehabilitation programs (OT & PT). Courses addressing ethical issues were identified through keyword searches, and were then subjected to both quantitative and textual descriptive analyses. Results: The mean proportion of credits allotted to courses that included ethics terminology was 5.9% (SD=1.4) for OT and 6.5% (SD=4.8) for PT (p=0.69). The most common terms in the course descriptions were ‘ethics/ethical’ followed by ‘legal’, ‘professionalism’, ‘deontology’ and ‘regulatory’. Textual analysis revealed eight course topics, the most frequent being: standards of practice, ethical decision-making, clinical courses and mediation/communication. Conclusion: With the growing recognition and status of occupational therapy and physiotherapy in the healthcare system, and corresponding shifts in how professionals are being trained, it is crucial to assess and reflect upon the place accorded to and manner of teaching ethics

The dynamic action of SecA during the initiation of protein translocation

Biotechnology and Biological Sciences Research Council (BBSRC) [a doctoral training grant Ph.D. studentship to S.W. and project grant number BB/I008675/1] and the Wellcome Trust [project grant number 084452]

Mobility of the SecA 2-helix-finger is not essential for polypeptide translocation via the SecYEG complex

The bacterial ATPase SecA and protein channel complex SecYEG form the core of an essential protein translocation machinery. The nature of the conformational changes induced by each stage of the hydrolytic cycle of ATP and how they are coupled to protein translocation are not well understood. The structure of the SecA–SecYEG complex revealed a 2-helix-finger (2HF) of SecA in an ideal position to contact the substrate protein and push it through the membrane. Surprisingly, immobilization of this finger at the edge of the protein channel had no effect on translocation, whereas its imposition inside the channel blocked transport. This analysis resolves the stoichiometry of the active complex, demonstrating that after the initiation process translocation requires only one copy each of SecA and SecYEG. The results also have important implications on the mechanism of energy transduction and the power stroke driving transport. Evidently, the 2HF is not a highly mobile transducing element of polypeptide translocation

Clinical informatics to improve quality of care: a population-based system for patients with diabetes mellitus

Background The prevalence of diabetes mellitus is increasing in the USA. However, control of intermediate outcome measures remains substandard. Recently, significant emphasis has been placed on the value of electronic medical records and informatics systems to improve the delivery of health care. Objective To determine whether a clinical informatics system improves care of patients with diabetes mellitus. Methods In this quality improvement pilot initiative, we identified 48 patients with diabetes mellitus who were due for their annual haemoglobin A1c (HbA1c), low-density lipoprotein (LDL) and microalbumin tests. Through our newly developed clinical informatics initiative, patients were reminded to schedule tests and a physician appointment. Seventy-five patients without reminders served as controls. Results A significant improvement in LDL control was achieved in the intervention group (35.4% vs 13.3%; P=0.004). The intervention group had a greater percentage of patients who underwent the three tests, and members of this group also showed greater control of haemoglobin A1c, but these differences were not statistically significant. Conclusions A clinical informatics system, used to deliver proactive, co-ordinated care to a population of patients with diabetes mellitus, can improve process and also quality outcome measures. Larger studies are needed to confirm these early findings

De novo design of protein logic gates

The design of modular protein logic for regulating protein function at the posttranscriptional level is a challenge for synthetic biology. Here, we describe the design of two-input AND, OR, NAND, NOR, XNOR, and NOT gates built from de novo–designed proteins. These gates regulate the association of arbitrary protein units ranging from split enzymes to transcriptional machinery in vitro, in yeast and in primary human T cells, where they control the expression of the TIM3 gene related to T cell exhaustion. Designed binding interaction cooperativity, confirmed by native mass spectrometry, makes the gates largely insensitive to stoichiometric imbalances in the inputs, and the modularity of the approach enables ready extension to three-input OR, AND, and disjunctive normal form gates. The modularity and cooperativity of the control elements, coupled with the ability to de novo design an essentially unlimited number of protein components, should enable the design of sophisticated posttranslational control logic over a wide range of biological functions

Assessment of a Program for SARS-CoV-2 Screening and Environmental Monitoring in an Urban Public School District

Importance: Scalable programs for school-based SARS-CoV-2 testing and surveillance are needed to guide in-person learning practices and inform risk assessments in kindergarten through 12th grade settings. Objectives: To characterize SARS-CoV-2 infections in staff and students in an urban public school setting and evaluate test-based strategies to support ongoing risk assessment and mitigation for kindergarten through 12th grade in-person learning. Design, Setting, and Participants: This pilot quality improvement program engaged 3 schools in Omaha, Nebraska, for weekly saliva polymerase chain reaction testing of staff and students participating in in-person learning over a 5-week period from November 9 to December 11, 2020. Wastewater, air, and surface samples were collected weekly and tested for SARS-CoV-2 RNA to evaluate surrogacy for case detection and interrogate transmission risk of in-building activities. Main Outcomes and Measures: SARS-CoV-2 detection in saliva and environmental samples and risk factors for SARS-CoV-2 infection. Results: A total of 2885 supervised, self-collected saliva samples were tested from 458 asymptomatic staff members (mean [SD] age, 42.9 [12.4] years; 303 women [66.2%]; 25 Black or African American [5.5%], 83 Hispanic [18.1%], 312 White [68.1%], and 35 other or not provided [7.6%]) and 315 students (mean age, 14.2 [0.7] years; 151 female students [48%]; 20 Black or African American [6.3%], 201 Hispanic [63.8%], 75 White [23.8%], and 19 other race or not provided [6.0%]). A total of 46 cases of SARS-CoV-2 (22 students and 24 staff members) were detected, representing an increase in cumulative case detection rates from 1.2% (12 of 1000) to 7.0% (70 of 1000) among students and from 2.1% (21 of 1000) to 5.3% (53 of 1000) among staff compared with conventional reporting mechanisms during the pilot period. SARS-CoV-2 RNA was detected in wastewater samples from all pilot schools as well as in air samples collected from 2 choir rooms. Sequencing of 21 viral genomes in saliva specimens demonstrated minimal clustering associated with 1 school. Geographical analysis of SARS-CoV-2 cases reported district-wide demonstrated higher community risk in zip codes proximal to the pilot schools. Conclusions and Relevance: In this study of staff and students in 3 urban public schools in Omaha, Nebraska, weekly screening of asymptomatic staff and students by saliva polymerase chain reaction testing was associated with increased SARS-CoV-2 case detection, exceeding infection rates reported at the county level. Experiences differed among schools, and virus sequencing and geographical analyses suggested a dynamic interplay of school-based and community-derived transmission risk. Collectively, these findings provide insight into the performance and community value of test-based SARS-CoV-2 screening and surveillance strategies in the kindergarten through 12th grade educational setting

(En)gendering the political: Citizenship from marginal spaces

This introduction sets out the central concerns of this special issue, the relationship between marginality and the political. In doing so it makes the argument that the process of marginalisation, the sites and experiences of ‘marginality’ provide a different lens through which to understand citizenship. Viewing the political as the struggle over belonging it considers how recent studies of citizenship have understood political agency. It argues that marginality can help us understand multiple scales, struggles and solidarities both within and beyond citizenship. Whilst there is a radical potential in much of the existing literature in citizenship studies it is also important to consider political subjectivities and acts which are not subsumed by right claims. Exploring marginality in this way means understanding how subjects are disenfranchised by regimes of citizenship and at the same how time this also (en)genders new political possibilities which are not always orientated towards 'inclusion'. The introduction then sets out how each article contributes to this project

Similarity of multicomponent nanomaterials in a safer-by-design context : the case of core–shell quantum dots

Concepts of similarity, such as grouping, categorization, and read-across, enable a fast comparative screening of hazard, reducing animal testing. These concepts are established primarily for molecular substances. We demonstrate the development of multi-dimensional similarity assessment methods that can be applied to multicomponent nanomaterials (MCNMs) for the case of core–shell quantum dots (QDs). The term ‘multicomponent’ refers to their structural composition, which consists of up to four different heavy metals (cadmium, zinc, copper, indium) in different mass percentages, with different morphologies and surface chemistries. The development of concepts of similarity is also motivated by the increased need for comparison of innovative against conventional materials in the safe and sustainable by design (SSbD) context. This case study thus considers the industrial need for an informed balance of functionality and safety: we propose two different approaches to compare and rank the case study materials amongst themselves and against well-known benchmark materials, here ZnO NM110, BaSO4 NM220, TiO2 NM105, and CuO. Relative differences in the sample set are calibrated against the biologically relevant range. The choice of properties that are subjected to similarity assessment is guided by the integrated approaches to testing and assessment (IATA) for the inhalation hazard of simple nanomaterials, which recommends characterizing QDs by (i) dynamic dissolution in lung simulant fluids and (ii) the surface reactivity in the abiotic ferric reducing ability of serum (FRAS) assay. In addition, the similarity of fluorescence spectra was assessed as a measure of the QD performance for the intended functionality as a color converter. We applied two approaches to evaluate the data matrix: in the first approach, specific descriptors for each assay (i.e., leachable mass (%) and mass based biological oxidative damage (mBOD)) were selected based on expert knowledge and used as input data for generation of similarity matrices. The second approach introduces the possibility of evaluating multidimensional raw data by a meaningful similarity analysis, without the need for predefined descriptors. We discuss the strengths and weaknesses of each of the two approaches. We anticipate that the similarity assessment approach is transferable to the assessment of further advanced materials (AdMa) that are composed of multiple components