How does one voluntary organisation engage with multiple stakeholder views of effectiveness?

The literature on effectiveness and multiple constituency theory is explored as background to a consideration of the many interpretations of effectiveness existing amongst stakeholders of one organisation. A case study is used to examine how stakeholders judge effectiveness and the process by which their different perspectives are incorporated in the shaping and constant updating of a core view of effectiveness. The management strategies adopted in handling this process are explored, and some elements identified which may provide initial steps towards a management theory

Current state of antimicrobial stewardship in children’s hospital emergency departments

BACKGROUND Antimicrobial stewardship programs (ASPs) effectively optimize antibiotic use for inpatients; however, the extent of emergency department (ED) involvement in ASPs has not been described. OBJECTIVE To determine current ED involvement in children's hospital ASPs and to assess beliefs and preferred methods of implementation for ED-based ASPs. METHODS A cross-sectional survey of 37 children's hospitals participating in the Sharing Antimicrobial Resistance Practices collaboration was conducted. Surveys were distributed to ASP leaders and ED medical directors at each institution. Items assessed included beliefs regarding ED antibiotic prescribing, ED prescribing resources, ASP methods used in the ED such as clinical decision support and clinical care guidelines, ED participation in ASP activities, and preferred methods for ED-based ASP implementation. RESULTS A total of 36 ASP leaders (97.3%) and 32 ED directors (86.5%) responded; the overall response rate was 91.9%. Most ASP leaders (97.8%) and ED directors (93.7%) agreed that creation of ED-based ASPs was necessary. ED resources for antibiotic prescribing were obtained via the Internet or electronic health records (EHRs) for 29 hospitals (81.3%). The main ASP activities for the ED included production of antibiograms (77.8%) and creation of clinical care guidelines for pneumonia (83.3%). The ED was represented on 3 hospital ASP committees (8.3%). No hospital ASPs actively monitored outpatient ED prescribing. Most ASP leaders (77.8%) and ED directors (81.3%) preferred implementation of ED-based ASPs using clinical decision support integrated into the EHR. CONCLUSIONS Although ED involvement in ASPs is limited, both ASP and ED leaders believe that ED-based ASPs are necessary. Many children's hospitals have the capability to implement ED-based ASPs via the preferred method: EHR clinical decision support. Infect Control Hosp Epidemiol 2017;38:469-475

Loss of Function in Escherichia coli exposed to Environmentally Relevant Concentrations of Benzalkonium Chloride

Assessing the risk of resistance associated with biocide exposure commonly involves exposing microorganisms to biocides at concentrations close to the MIC. With the aim of representing exposure to environmental biocide residues, MG1655 was grown for 20 passages in the presence or absence of benzalkonium chloride (BAC) at 100 ng/L and 1000 ng/L (0.0002% and 0.002% of the MIC respectively). BAC susceptibility, planktonic growth rates, motility and biofilm-formation were assessed, and differentially expressed genes determined via RNA-sequencing. Planktonic growth rate and biofilm-formation were significantly reduced (p<0.001) following BAC adaptation, whilst BAC minimum bactericidal concentration increased two-fold. Transcriptomic analysis identified 289 upregulated and 391 downregulated genes after long-term BAC adaptation when compared to the respective control organism passaged in BAC-free-media. When the BAC-adapted bacterium was grown in biocide-free medium, 1052 genes were upregulated and 753 were down regulated. Repeated passage solely in biocide-free medium resulted in 460 upregulated and 476 downregulated genes compared to unexposed bacteria. Long-term exposure to environmentally relevant BAC concentrations increased the expression of genes associated with efflux and reduced gene expression associated with outer-membrane porins, motility and chemotaxis. This was manifested phenotypically through loss-of-function (motility). Repeated passage in a BAC-free-environment resulted in the up-regulation of multiple respiration-associated genes, which was reflected by increased growth rate. In summary, repeated exposure of to BAC residues resulted in significant alterations in global gene expression that were associated with minor decreases in biocide susceptibility, reductions in growth-rate and biofilm-formation, and loss of motility. Exposure to very low concentrations of biocide in the environment is a poorly understood risk factor for antimicrobial resistance. Repeated exposure to trace levels of the biocide BAC resulted in loss of function (motility) and a general reduction in bacterial fitness, but relatively minor decreases in susceptibility. These changes were accompanied by widespread changes in the transcriptome. This demonstrates the importance of including phenotypic characterisation in studies designed to assess the risks of biocide exposure. [Abstract copyright: Copyright © 2018 American Society for Microbiology.

Does Structured Exercise Improve Cognitive Impairment in People with Mild to Moderate Dementia? A Cost-Effectiveness Analysis from a Confirmatory Randomised Controlled Trial:The Dementia and Physical Activity (DAPA) Trial

Background Previous studies suggest that physical exercise could slow dementia progression. However, evidence for the cost effectiveness of structured exercise is conflicting and based on small trials. Objectives The objective of this study was to compare the cost effectiveness of a tailored, structured, moderate- to high-intensity exercise programme versus usual care in people with mild to moderate dementia. Methods An economic evaluation was conducted from the UK National Health Service and personal social services perspective, based on data from a large randomised controlled trial. The primary clinical outcome was the participant reported ADAS-Cog (Alzheimer’s Disease Assessment Scale–Cognitive Subscale) at 12 months. Costs (£; 2014–2015 prices) were collected prospectively over a 12-month follow-up period. A bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted with the view to estimating the incremental cost per QALY gained and the incremental net monetary benefit (INMB) associated with the exercise programme plus usual care versus usual care. Sensitivity analyses were undertaken to assess the impact of uncertainty surrounding aspects of the economic evaluation, and pre-specified subgroup analyses explored heterogeneity in the cost-effectiveness results. Results Participants (n = 494) were randomised to exercise plus usual care or usual care only. By 12 months the mean ADAS-Cog score had worsened slightly to 25.2 (standard deviation [SD] 12.3) in the exercise arm and 23.8 (SD 10.4) in the usual care: difference − 1.4, 95% confidence interval (CI) − 2.6 to − 0.2 (p = 0.03). The mean (standard error [SE]) costs over 12 months for experimental versus control was £5945 (USD7856) versus £4597 (USD6574), respectively; (difference: £1347 [$1926]; p = 0.0426). Mean (SE) QALY estimates were 0.787 (0.012) versus 0.826 (0.019), respectively (p = 0.090). The probability that the exercise programme is cost effective was  Conclusions Building on the clinical results of the trial, which showed that the structured exercise programme evaluated does not slow cognitive impairment in people with mild to moderate dementia, this economic evaluation shows that the programme is not cost effective.</p

Formulation of Biocides Increases Antimicrobial Potency and Mitigates the Enrichment of Non-Susceptible Bacteria in Multi-Species Biofilms

The current investigation aimed to generate data to inform the development of risk-assessments of biocide usage. Stabilised domestic drain biofilm microcosms were exposed daily over six months to increasing concentrations (0.01 to 1 %) of the biocide benzalkonium chloride in simple aqueous solution (BAC-s) or in a complex formulation (BAC-f) representative of a domestic cleaning agent. Biofilms were analysed by culture, differentiating by bacterial functional group and by BAC or antibiotic susceptibility. Bacterial isolates were identified by 16S rRNA sequencing and changes in biofilm composition were assessed by high throughput sequencing. Exposure to BAC-f resulted in significantly larger reductions in viable bacteria than BAC-s, whilst bacterial diversity greatly decreased during exposure to both BAC-s and BAC-f, as evidenced by sequencing and viable counts. Increases in the abundance of bacteria exhibiting reduced antibiotic or BAC susceptibility following exposure to BAC at 0.1 % were significantly greater for BAC-s than BAC-f. Bacteria with reduced BAC and antibiotic susceptibility were generally suppressed by higher BAC concentrations and formulation significantly enhanced this effect. Significant decreases in the antimicrobial susceptibility of bacteria isolated from the systems before and after long-term BAC exposure were not detected. In summary, dose-dependent suppression of bacterial viability by BAC was enhanced by formulation. Biocide exposure decreased bacterial diversity and transiently enriched organisms with lower antimicrobial susceptibility that were subsequently supressed by exposure to 1% BAC-f, the concentration most closely reflecting deployment in formulated products

Developing ‘deep mathematical thinking’ in geometry with 3- and 4-year-olds: A collaborative study between early years teachers and University-based mathematicians

Mathematics in early years settings is often restricted to learning to count and identifying simple shapes. This is partly due to the narrow scope of many early years curricula and insufficient teacher training for exploring deeper mathematical concepts. We note that geometry is an area particularly neglected. In an innovative year-long project, a group of university-based mathematicians and early years teachers collaborated on a child-led exploration of ‘patterns in nature.’ The early years teachers ran the project within the setting, meeting regularly with the mathematicians to discuss potential areas of interest, and to highlight the children’s mathematical thinking. We found that, with the appropriate environment and guidance, the children naturally displayed deep levels of geometrical thinking and found enjoyment and satisfaction in the exploration of mathematical ideas. We define what we mean by the term ‘deep geometrical thinking’ and demonstrate this by looking at three excerpts through the lens of the van Hiele levels of geometric thought, finding that the children are capable of exhibiting thought at level 3 (abstraction), more advanced than previously thought of children of this age. Using a second taxonomy we also assess the range of skills across which they are demonstrating such geometric thought

Development and Optimization of a Machine-Learning Prediction Model for Acute Desquamation After Breast Radiation Therapy in the Multicenter REQUITE Cohort

Breast Radiation Therapy; Machine-Learning Prediction; Acute DesquamationRaditeràpia de mama; Predicció d'aprenentatge automàtic; Descamació agudaRadioterapia de mama; Predicción de aprendizaje automático; Descamación agudaPurpose Some patients with breast cancer treated by surgery and radiation therapy experience clinically significant toxicity, which may adversely affect cosmesis and quality of life. There is a paucity of validated clinical prediction models for radiation toxicity. We used machine learning (ML) algorithms to develop and optimise a clinical prediction model for acute breast desquamation after whole breast external beam radiation therapy in the prospective multicenter REQUITE cohort study. Methods and Materials Using demographic and treatment-related features (m = 122) from patients (n = 2058) at 26 centers, we trained 8 ML algorithms with 10-fold cross-validation in a 50:50 random-split data set with class stratification to predict acute breast desquamation. Based on performance in the validation data set, the logistic model tree, random forest, and naïve Bayes models were taken forward to cost-sensitive learning optimisation. Results One hundred and ninety-two patients experienced acute desquamation. Resampling and cost-sensitive learning optimisation facilitated an improvement in classification performance. Based on maximising sensitivity (true positives), the “hero” model was the cost-sensitive random forest algorithm with a false-negative: false-positive misclassification penalty of 90:1 containing m = 114 predictive features. Model sensitivity and specificity were 0.77 and 0.66, respectively, with an area under the curve of 0.77 in the validation cohort. Conclusions ML algorithms with resampling and cost-sensitive learning generated clinically valid prediction models for acute desquamation using patient demographic and treatment features. Further external validation and inclusion of genomic markers in ML prediction models are worthwhile, to identify patients at increased risk of toxicity who may benefit from supportive intervention or even a change in treatment plan

Dementia and physical activity (DAPA) trial of moderate to high intensity exercise training for people with dementia : randomised controlled trial

Objective: To estimate the effect of a moderate to high intensity aerobic and strength exercise training programme on cognitive impairment and other outcomes in people with mild to moderate dementia. Design: Multicentre, pragmatic, investigator masked, randomised controlled trial. Setting: National Health Service primary care, community and memory services, dementia research registers, and voluntary sector providers in 15 English regions. Participants: 494 people with dementia: 329 were assigned to an aerobic and strength exercise programme and 165 were assigned to usual care. Random allocation was 2:1 in favour of the exercise arm. Interventions: Usual care plus four months of supervised exercise and support for ongoing physical activity, or usual care only. Interventions were delivered in community gym facilities and NHS premises. Main outcome measures: The primary outcome was score on the Alzheimer’s disease assessment scale-cognitive subscale (ADAS-cog) at 12 months. Secondary outcomes included activities of daily living, neuropsychiatric symptoms, health related quality of life, and carer quality of life and burden. Physical fitness (including the six minute walk test) was measured in the exercise arm during the intervention. Results: The average age of participants was 77 (SD 7.9) years and 301/494 (61%) were men. By 12 months the mean ADAS-cog score had increased to 25.2 (SD 12.3) in the exercise arm and 23.8 (SD 10.4) in the usual care arm (adjusted between group difference −1.4, 95% confidence interval −2.6 to −0.2, P=0.03). This indicates greater cognitive impairment in the exercise group, although the average difference is small and clinical relevance uncertain. No differences were found in secondary outcomes or preplanned subgroup analyses by dementia type (Alzheimer’s disease or other), severity of cognitive impairment, sex, and mobility. Compliance with exercise was good. Over 65% of participants (214/329) attended more than three quarters of scheduled sessions. Six minute walking distance improved over six weeks (mean change 18.1 m, 95% confidence interval 11.6 m to 24.6 m). Conclusion: A moderate to high intensity aerobic and strength exercise training programme does not slow cognitive impairment in people with mild to moderate dementia. The exercise training programme improved physical fitness, but there were no noticeable improvements in other clinical outcomes