Exploring types of focused factories in hospital care: a multiple case study

Background: Focusing on specific treatments or diseases is proposed as a way to increase the efficiency of hospital care. The definition of "focus" or "focused factory", however, lacks clarity. Examples in health care literature relate to very different organizations.\ud Our aim was to explore the application of the focused factory concept in hospital care, including an indication of its performance, resulting in a conceptual framework that can be helpful in further identifying different types of focused factories. Thus contributing to the understanding of the diversity of examples found in the literature. - \ud \ud Methods: We conducted a cross-case comparison of four multiple-case studies into hospital care. To cover a broad array of focus, different specialty fields were selected. Each study investigated the organizational context, the degree of focus, and the operational performance. Focus was measured using an instrument translated from industry. Data were collected using both qualitative and quantitative methods and included site visits. A descriptive analysis was performed at the case study and cross-case studies level. - \ud \ud Results: The operational performance per specialty field varied considerably, even when cases showed comparable degrees of focus. Cross-case comparison showed three focus domains. The product domain considered specialty based focused factories that treated patients for a single-specialty, but did not pursue a specific strategy nor adapted work-designs or layouts. The process domain considered delivery based focused factories that treated multiple groups of patients and often pursued strategies to improve efficiency and timeliness and adapted work-designs and physical layouts to minimize delays. The product-process domain considered procedure based focused factories that treated a single well-defined group of patients offering one type of treatment. The strategic focusing decisions and the design of the care delivery system appeared especially important for delivery and procedure based focused factories. - \ud \ud Conclusions: Focus in hospital care relates to limitations on the patient group treated and the range of services offered. Based on these two dimensions, we identified three types of focused factories: specialty based, delivery based, and procedure based. Focus could lead to better operational performance, but only when clear strategic focusing decisions are made

Lessons Learned from a Decade of Sudden Oak Death in California: Evaluating Local Management

Sudden Oak Death has been impacting California’s coastal forests for more than a decade. In that time, and in the absence of a centrally organized and coordinated set of mandatory management actions for this disease in California’s wildlands and open spaces, many local communities have initiated their own management programs. We present five case studies to explore how local-level management has attempted to control this disease. From these case studies, we glean three lessons: connections count, scale matters, and building capacity is crucial. These lessons may help management, research, and education planning for future pest and disease outbreaks

Not all shellfish "allergy" is allergy!

The popularity of shellfish has been increasing worldwide, with a consequent increase in adverse reactions that can be allergic or toxic. The approximate prevalence of shellfish allergy is estimated at 0.5-2.5% of the general population, depending on degree of consumption by age and geographic regions. The manifestations of shellfish allergy vary widely, but it tends to be more severe than most other food allergens

Pan-cancer analysis of whole genomes

Cancer is driven by genetic change, and the advent of massively parallel sequencing has enabled systematic documentation of this variation at the whole-genome scale(1-3). Here we report the integrative analysis of 2,658 whole-cancer genomes and their matching normal tissues across 38 tumour types from the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium of the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA). We describe the generation of the PCAWG resource, facilitated by international data sharing using compute clouds. On average, cancer genomes contained 4-5 driver mutations when combining coding and non-coding genomic elements; however, in around 5% of cases no drivers were identified, suggesting that cancer driver discovery is not yet complete. Chromothripsis, in which many clustered structural variants arise in a single catastrophic event, is frequently an early event in tumour evolution; in acral melanoma, for example, these events precede most somatic point mutations and affect several cancer-associated genes simultaneously. Cancers with abnormal telomere maintenance often originate from tissues with low replicative activity and show several mechanisms of preventing telomere attrition to critical levels. Common and rare germline variants affect patterns of somatic mutation, including point mutations, structural variants and somatic retrotransposition. A collection of papers from the PCAWG Consortium describes non-coding mutations that drive cancer beyond those in the TERT promoter(4); identifies new signatures of mutational processes that cause base substitutions, small insertions and deletions and structural variation(5,6); analyses timings and patterns of tumour evolution(7); describes the diverse transcriptional consequences of somatic mutation on splicing, expression levels, fusion genes and promoter activity(8,9); and evaluates a range of more-specialized features of cancer genomes(8,10-18).Peer reviewe

Spatial and temporal patterns of root distribution in developing stands of four woody crop species grown with drip irrigation and fertilization.

Abstract In forest trees, roots mediate such significant carbon fluxes as primary production and soil C02 efflux. Despite the central role of roots in these critical processes, information on root distribution during stand establishment is limited, yet must be described to accurately predict how various forest types, which are growing with a range of resource limitations, might respond to environmental change. This study reports root length density and biomass development in young stands of eastern cottonwood (Populus deltoidies Bartr.) and American sycamore (Platanus occidentalis L.) that have narrow, high resource site requirements, and compares them with sweetgum (Liquidambar styraczj7ua L.) and loblolly pine (Pinus taeda L.), which have more robust site requirements. Fine roots (5 mm) were sampled to determine spatial distribu-tion in response to fertilizer and irrigation treatments delivered through drip irrigation tubes. Root length density and biomass were predominately controlled by stand development, depth and proximity to drip tubes. After accounting for this spatial and temporal variation, there was a significant increase in RLD with fertilization and irrigation for all genotypes. The response to fertilization was greater than that of irrigation. Both fine and coarse roots responded positively to resources delivered through the drip tube, indicating a wholeroot- system response to resource enrichment and not just a feeder root response. The plastic response to drip tube water and nutrient enrichment demonstmte the capability of root systems to respond to supply heterogeneity by increasing acquisition surface. Fineroot biomass, root density and specific root length were greater for broadleaved species than pine. Roots of all genotypes explored the rooting volume within 2 years, but this occurred faster and to higher root length densities in broadleaved species, indicating they had greater initial opportunity for resource acquisition than pine. Sweetgum's root characteristics and its response to resource availability were similar to the other broadleaved species, despite its hnctional resemblance to pine regarding robust site requirements. It was concluded that genotypes, irrigation arid fertilization significantly influenced tree root system development, which varied spatially in response to resource-supply heterogeneity created by dnp tubes. Knowledge of spatial and temporal patterns of root distribution in these stands will be used to interpret nutrient acquisition and soil respiration measurements

4-aminobutyrate aminotrasferase (ABAT): genetic and pharmacological evidence for an involvement in gastro esophageal reflux disease

Extent: 9p.Gastro-esophageal reflux disease (GERD) is partly caused by genetic factors. The underlying susceptibility genes are currently unknown, with the exception of COL3A1. We used three independent GERD patient cohorts to identify GERD susceptibility genes. Thirty-six families, demonstrating dominant transmission of GERD were subjected to whole genome microsatellite genotyping and linkage analysis. Five linked regions were identified. Two families shared a linked region (LOD 3.9 and 2.0) on chromosome 16. We used two additional independent GERD patient cohorts, one consisting of 219 trios (affected child with parents) and the other an adult GERD case control cohort consisting of 256 cases and 485 controls, to validate individual genes in the linked region through association analysis. Sixty six single nucleotide polymorphism (SNP) markers distributed over the nine genes present in the linked region were genotyped in the independent GERD trio cohort. Transmission disequilibrium test analysis followed by multiple testing adjustments revealed a significant genetic association for one SNP located in an intron of the gene 4-aminobutyrate aminotransferase (ABAT) (Padj = 0.027). This association did not replicate in the adult case-control cohort, possibly due to the differences in ethnicity between the cohorts. Finally, using the selective ABAT inhibitor vigabatrin (c-vinyl GABA) in a dog study, we were able to show a reduction of transient lower esophageal sphincter relaxations (TLESRs) by 57.3611.4 % (p = 0.007) and the reflux events from 3.160.4 to 0.860.4 (p = 0.007). Our results demonstrate the direct involvement of ABAT in pathways affecting lower esophageal sphincter (LES) control and identifies ABAT as a genetic risk factor for GERD.Johan Jirholt, Bengt Åsling, Paul Hammond, Geoffrey Davidson, Mikael Knutsson, Anna Walentinsson, Jörgen M. Jensen, Anders Lehmann, Lars Agreus and Maria Lagerström-Ferme