Tackling the hard problems: implementation experience and lessons learned in newborn health from the African Health Initiative

Background The Doris Duke Charitable Foundation’s African Health Initiative supported the implementation of Population Health Implementation and Training (PHIT) Partnership health system strengthening interventions in designated areas of five countries: Ghana, Mozambique, Rwanda, Tanzania, and Zambia. All PHIT programs included health system strengthening interventions with child health outcomes from the outset, but all increasingly recognized the need to increase focus to improve health and outcomes in the first month of life. This paper uses a case study approach to describe interventions implemented in newborn health, compare approaches, and identify lessons learned across the programs’ collective implementation experience. Methods Case studies were built using quantitative and qualitative methods, applying the World Health Organization Health Systems Strengthening Framework, and maternal, newborn and child health continuum of care framework. We identified the following five primary themes in health systems strengthening intervention strategies used to target improvement in newborn health, which were incorporated by all PHIT projects with varying results: health service delivery at the community level (Tanzania), combining community and health facility level interventions (Zambia), participatory information feedback and clinical training (Ghana), performance review and enhancement (Mozambique), and integrated clinical and system-level improvement (Rwanda), and used individual case studies to illustrate each of these themes. Results Tanzania and Zambia included significant community-based components, including mobilization and sensitization for increased uptake of essential services, while Ghana, Mozambique, and Rwanda focused more efforts on improving the quality of services delivered once a patient enters a health facility. All countries included aspects that improved communication across levels of the health system, whether through district-wide data sharing and peer learning networks in Mozambique and Rwanda, or improved referral processes and systems in Tanzania, Zambia, and Ghana. Conclusion Key lessons learned include the importance of focusing intervention components on addressing drivers of neonatal mortality across the maternal and newborn care continuum at all levels of the health system, matching efforts to improve service utilization with provision of high quality facility-based services, and the critical role of leadership to catalyze improvements in newborn health

“Quality teaches you how to use water. It doesn’t provide a water pump”: a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program

Background Quality improvement collaboratives are a common approach to bridging the quality-of-care gap, but little is known about implementation in low-income settings. Implementers rarely consider mechanisms of change or the role of context, which may explain collaboratives’ varied impacts. Methods To understand mechanisms and contextual influences we conducted 55 in-depth interviews with staff from four health centres and two hospitals involved in quality improvement collaboratives in Ethiopia. We also generated control charts for selected indicators to explore any impacts of the collaboratives. Results The cross facility learning sessions increased the prominence and focus on quality, allowed learning from experts and peers and were motivational through public recognition of success or a desire to emulate peers. Within facilities, new structures and processes were created. These were fragile and sometimes alienating to those outside the improvement team. The trusted and respected mentors were important for support, motivation and accountability. Where mentor visits were infrequent or mentors less skilled, team function was impacted. These mechanisms were more prominent, and quality improvement more functional, in facilities with strong leadership and pre-existing good teamwork; as staff had shared goals, an active approach to problems and were more willing and able to be flexible to implement change ideas. Quality improvement structures and processes were more likely to be internally driven and knowledge transferred to other staff in these facilities, which reduced the impact of staff turnover and increased buy-in. In facilities which lacked essential inputs, staff struggled to see how the collaborative could meaningfully improve quality and were less likely to have functioning quality improvement. The unexpected civil unrest in one region strongly disrupted the health system and the collaborative. These contextual issues were fluid, with multiple interactions and linkages. Conclusions The study confirms the need to carefully consider context in the implementation of quality improvement collaboratives. Facilities that implement quality improvement successfully may be those that already have characteristics that foster quality. Quality improvement may be alienating to those outside of the improvement team and implementers should not assume the organic spread or transfer of quality improvement knowledge

The effect of airfoil scaling on the predicted unsteady loading onthe blade of a 1 and 1/2 stage transonic turbine and a comparison with experimental results

ABSTRACT In this study, two time-accurate Navier-Stokes analyses were obtained to predict the first-vane/first-blade interaction in a 1 and 1/2-stage turbine rig for comparison with measurements. In the first computation, airfoil scaling was applied to the turbine blade to achieve periodicity in the circumferential direction while modeling 1/18 of the annulus. In the second, 1/4 of the wheel was modeled without the use of airfoil scaling. For both simulations the predicted unsteady pressures on the blade were similar in terms of time-averaged pressure distributions and peak-peak unsteady pressure envelopes. However, closer inspection of the predictions in the frequency domain revealed significant differences in the magnitudes of unsteadiness at twice vane-passing frequency (and the vane-passing frequency itself, to a lesser extent). The results of both computations were compared to measurements of the vane-blade interaction in a full-scale turbine rig representative of an early design iteration of the PW6000 engine. These measurements were made in the short-duration turbine-test facility at The Ohio State University Gas Turbine Laboratory. The experimentally determined, time-resolved pressures were in good agreement with those predicted with the 1/4-wheel simulation

Novel De Novo Mutation in Sulfonylurea Receptor 1 Presenting as Hyperinsulinism in Infancy Followed by Overt Diabetes in Early Adolescence

OBJECTIVE—Congenital hyperinsulinism, usually associated with severe neonatal hypoglycemia, may progress to diabetes, typically during the 4th decade of life in nonpancreatectomized patients. We aimed to genotype the ATP-sensitive K+ channel in a 10.5-year-old girl presenting with overt diabetes following hyperinsulinism in infancy

Intracellular Vesicles as Reproduction Elements in Cell Wall-Deficient L-Form Bacteria

Cell wall-deficient bacteria, or L-forms, represent an extreme example of bacterial plasticity. Stable L-forms can multiply and propagate indefinitely in the absence of a cell wall. Data presented here are consistent with the model that intracellular vesicles in Listeria monocytogenes L-form cells represent the actual viable reproductive elements. First, small intracellular vesicles are formed along the mother cell cytoplasmic membrane, originating from local phospholipid accumulation. During growth, daughter vesicles incorporate a small volume of the cellular cytoplasm, and accumulate within volume-expanding mother cells. Confocal Raman microspectroscopy demonstrated the presence of nucleic acids and proteins in all intracellular vesicles, but only a fraction of which reveals metabolic activity. Following collapse of the mother cell and release of the daughter vesicles, they can establish their own membrane potential required for respiratory and metabolic processes. Premature depolarization of the surrounding membrane promotes activation of daughter cell metabolism prior to release. Based on genome resequencing of L-forms and comparison to the parental strain, we found no evidence for predisposing mutations that might be required for L-form transition. Further investigations revealed that propagation by intracellular budding not only occurs in Listeria species, but also in L-form cells generated from different Enterococcus species. From a more general viewpoint, this type of multiplication mechanism seems reminiscent of the physicochemical self-reproducing properties of abiotic lipid vesicles used to study the primordial reproduction pathways of putative prokaryotic precursor cells

Constructing Fluorogenic Bacillus Spores (F-Spores) via Hydrophobic Decoration of Coat Proteins

Background: Bacterial spores are protected by a coat consisting of about 60 different proteins assembled as a biochemically complex structure with intriguing morphological and mechanical properties. Historically, the coat has been considered a static structure providing rigidity and mainly acting as a sieve to exclude exogenous large toxic molecules, such as lytic enzymes. Over recent years, however, new information about the coat’s architecture and function have emerged from experiments using innovative tools such as automated scanning microscopy, and high resolution atomic force microscopy. Principal Findings: Using thin-section electron microscopy, we found that the coat of Bacillus spores has topologically specific proteins forming a layer that is identifiable because it spontaneously becomes decorated with hydrophobic fluorogenic probes from the milieu. Moreover, spores with decorated coat proteins (termed F-spores) have the unexpected attribute of responding to external germination signals by generating intense fluorescence. Fluorescence data from diverse experimental designs, including F-spores constructed from five different Bacilli species, indicated that the fluorogenic ability of F-spores is under control of a putative germination-dependent mechanism. Conclusions: This work uncovers a novel attribute of spore-coat proteins that we exploited to decorate a specific layer imparting germination-dependent fluorogenicity to F-spores. We expect that F-spores will provide a model system to gai

Single-cell analysis reveals individual spore responses to simulated space vacuum

Outer space is a challenging environment for all forms of life, and dormant spores of bacteria have been frequently used to study the survival of terrestrial life in a space journey. Previous work showed that outer space vacuum alone can kill bacterial spores. However, the responses and mechanisms of resistance of individual spores to space vacuum are unclear. Here, we examined spores’ molecular changes under simulated space vacuum (~10−5 Pa) using micro-Raman spectroscopy and found that this vacuum did not cause significant denaturation of spore protein. Then, live-cell microscopy was developed to investigate the temporal events during germination, outgrowth, and growth of individual Bacillus spores. The results showed that after exposure to simulated space vacuum for 10 days, viability of spores of two Bacillus species was reduced up to 35%, but all spores retained their large Ca2 +-dipicolinic acid depot. Some of the killed spores did not germinate, and the remaining germinated but did not proceed to vegetative growth. The vacuum treatment slowed spore germination, and changed average times of all major germination events. In addition, viable vacuum-treated spores exhibited much greater sensitivity than untreated spores to dry heat and hyperosmotic stress. Among spores’ resistance mechanisms to high vacuum, DNA-protective α/β−type small acid-soluble proteins, and non- homologous end joining and base excision repair of DNA played the most important roles, especially against multiple cycles of vacuum treatment. Overall, these results give new insight into individual spore’s responses to space vacuum and provide new techniques for microorganism analysis at the single-cell level