Models for Quality Improvement in CAHs: The Role of State Flex Programs (Briefing Paper #25)

A central goal of the Flex Program, as defined in the original and reauthorizing legislation, is to help Critical Access Hospitals (CAHs) develop and sustain effective quality improvement (QI) programs. This study examined the range of multi-CAH QI and performance measurement reporting initiatives supported by the Flex Program in nine states, assessed the role of State Flex Programs in developing and supporting these initiatives, and explored their impact on the QI programs of CAHs. Key Findings: State Flex Program funding was frequently the primary, if not sole, source of funding to support these efforts. Collaboration and shared learning are common Flex Program strategies underlying state QI initiatives. Quality measurement and reporting is a challenge due to a lack of agreement on common measures across state QI and benchmarking systems and a common belief that Hospital Compare measures are not “rurally relevant” (i.e., specific to the needs of CAHs). Administrative, clinical, and board leadership and buy-in were consistently identified as crucial to the success and sustainability of CAH-level QI initiatives. States reported that the scope of their QI has to be scaled to the available resources and capacity of CAHs to avoid QI fatigue among CAH staff. There is limited hard evidence on the impact of the QI initiatives adopted by State Flex Programs; much of the “evidence” supporting these initiatives is anecdotal or based on postconference or webinar evaluations

Benzamil inhibits neuronal and heterologously expressed small conductance Ca2²⁺-activated K⁺ channels

Small conductance Ca^{2+}-activated K^{+} (SK) channels are expressed throughout the soma and dendrites of pyramidal neurons in the neocortex and hippocampal formation, where they participate in the local regulation of membrane excitability and synaptic signals. Through their inter-play with Ca^{2+} channels, SK channels regulate Ca^{2+} influx triggered by back-propagating action potentials in dendrites. Inhibition of SK channels affects both the amplitude and duration of Ca^{2+} transients, but the role of Ca^{2+} clearance mechanisms and their link to SK channel activity has not been established. Here we report the effect of the Na^{+}/Ca^{2+} exchanger (NCX) inhibitor benzamil on Ca^{2+} extrusion and SK channels in the regulation of dendritic Ca^{2+} signals. Benzamil increased the duration and amplitude of dendritic Ca^{2+} transients elicited by back-propagating action potentials in hippocampal pyramidal neurons. This data is consistent with previous studies with SK channel blockers and suggests that benzamil inhibits SK channels in addition to the Na^{+}/Ca^{2+} exchanger. Here we show that indeed both the neuronal SK-mediated IAHP current and the currents mediated by heterologously expressed SK channels were inhibited by benzamil. The inhibition of recombinant SK channels was seen with different K+ concentration gradients, and was stronger at negative voltages. The suppression of SK channels by benzamil is consistent with previous findings on the modulation of Ca^{2+} signals by SK channels in neurons. We additionally show that benzamil inhibits neuronal voltage-gated calcium currents. The results prompt a careful reassessment of the effects of benzamil on Ca^{2+} transients in native systems, given the spectrum of ion channels and exchangers this compound targets within a similar range of concentrations

The Role of State Flex Programs in Supporting Quality Improvement in CAHs (Policy Brief #16)

This study examined QI activities supported by the Flex Program in nine states, assessed the role of the State Flex Programs in developing and supporting QI activities, and explored the effect of these initiatives on CAH QI efforts. Key Findings: The Flex Program has been instrumental in funding and providing leadership for the development of CAH quality improvement initiatives. Collaborative shared learning strategies have been central to the success of Flex Program QI programs. Scaling QI program activities to the capacity and resources of CAHs is critical to success. Administrative, clinical, and board leadership and buy-in are also critical to the success of CAH QI initiatives. Despite widespread support for these QI initiatives, there is limited hard evidence on their impact. Overlap between the quality measures in Hospital Compare and those used by state and multi-state QI reporting and benchmarking programs offers the opportunity for developing a common set of “rural relevant” hospital quality measures

The relevance of outsourcing and leagile strategies in performance optimization of an integrated process planning and scheduling

Over the past few years growing global competition has forced the manufacturing industries to upgrade their old production strategies with the modern day approaches. As a result, recent interest has been developed towards finding an appropriate policy that could enable them to compete with others, and facilitate them to emerge as a market winner. Keeping in mind the abovementioned facts, in this paper the authors have proposed an integrated process planning and scheduling model inheriting the salient features of outsourcing, and leagile principles to compete in the existing market scenario. The paper also proposes a model based on leagile principles, where the integrated planning management has been practiced. In the present work a scheduling problem has been considered and overall minimization of makespan has been aimed. The paper shows the relevance of both the strategies in performance enhancement of the industries, in terms of their reduced makespan. The authors have also proposed a new hybrid Enhanced Swift Converging Simulated Annealing (ESCSA) algorithm, to solve the complex real-time scheduling problems. The proposed algorithm inherits the prominent features of the Genetic Algorithm (GA), Simulated Annealing (SA), and the Fuzzy Logic Controller (FLC). The ESCSA algorithm reduces the makespan significantly in less computational time and number of iterations. The efficacy of the proposed algorithm has been shown by comparing the results with GA, SA, Tabu, and hybrid Tabu-SA optimization methods

A Cross-Sectional Survey of Anesthetic Airway Equipment and Airway Management Practices in Uganda.

BACKGROUND: Anesthesia-related causes contribute to a significant proportion of perioperative deaths, especially in low and middle-income countries (LMICs). There is evidence that complications related to failed airway management are a significant contributor to perioperative morbidity and mortality. While existing data have highlighted the magnitude of airway management complications in LMICs, there are inadequate data to understand their root causes. This study aimed to pilot an airway management capacity tool that evaluates airway management resources, provider practices, and experiences with difficult airways in an attempt to better understand potential contributing factors to airway management challenges. METHODS: We developed a novel airway management capacity assessment tool through a nonsystematic review of existing literature on anesthesia and airway management in LMICs, internationally recognized difficult airway algorithms, minimum standards for equipment, the safe practice of anesthesia, and the essential medicines and health supplies list of Uganda. We distributed the survey tool during conferences and workshops, to anesthesia care providers from across the spectrum of surgical care facilities in Uganda. The data were analyzed using descriptive methods. RESULTS: Between May 2017 and May 2018, 89 of 93 surveys were returned (17% of anesthesia providers in the country) from all levels of health facilities that provide surgical services in Uganda. Equipment for routine airway management was available to all anesthesia providers surveyed, but with a limited range of sizes. Pediatric airway equipment was always available 54% of the time. There was limited availability of capnography (15%), video laryngoscopes (4%), cricothyroidotomy kits (6%), and fiber-optic bronchoscopes (7%). Twenty-one percent (18/87) of respondents reported experiencing a "can't intubate, can't ventilate" (CICV) scenario in the 12 months preceding the survey, while 63% (54/86) reported experiencing at least 1 CICV during their career. Eighty-five percent (74/87) of respondents reported witnessing a severe airway management complication during their career, with 21% (19/89) witnessing a death as a result of a CICV scenario. CONCLUSIONS: We have developed and implemented an airway management capacity tool that describes airway management practices in Uganda. Using this tool, we have identified significant gaps in access to airway management resources. Gaps identified by the survey, along with advocacy by the Association of Anesthesiologists of Uganda, in partnership with the Ugandan Ministry of Health, have led to some progress in closing these gaps. Expanding the availability of airway management resources further, providing more airway management training, and identifying opportunities to support skilled workforce expansion have the potential to improve perioperative safety in Uganda

State-of-the-Art Duolingo Features and Applications

Duolingo is a rapidly growing on-line platform for language learning. In this paper learning theories that are embodied in its design are analyzed and certain shortcomings are identified. In the past two years, Duolingo has expanded its platform with the addition of new applications and features. State-of-the-art updates are reviewed in order to uncover whether they address limitations of Duolingo’s original design or provide enhancements to the learning platform

Revealing a signaling role of phytosphingosine-1-phosphate in yeast

Perturbing metabolic systems of bioactive sphingolipids with genetic approachMultiple types of “omics” data collected from the systemSystems approach for integrating multiple “omics” informationPredicting signal transduction information flow: lipid; TF activation; gene expressio

A broad distribution of the alternative oxidase in microsporidian parasites

Microsporidia are a group of obligate intracellular parasitic eukaryotes that were considered to be amitochondriate until the recent discovery of highly reduced mitochondrial organelles called mitosomes. Analysis of the complete genome of Encephalitozoon cuniculi revealed a highly reduced set of proteins in the organelle, mostly related to the assembly of ironsulphur clusters. Oxidative phosphorylation and the Krebs cycle proteins were absent, in keeping with the notion that the microsporidia and their mitosomes are anaerobic, as is the case for other mitosome bearing eukaryotes, such as Giardia. Here we provide evidence opening the possibility that mitosomes in a number of microsporidian lineages are not completely anaerobic. Specifically, we have identified and characterized a gene encoding the alternative oxidase (AOX), a typically mitochondrial terminal oxidase in eukaryotes, in the genomes of several distantly related microsporidian species, even though this gene is absent from the complete genome of E. cuniculi. In order to confirm that these genes encode functional proteins, AOX genes from both A. locustae and T. hominis were over-expressed in E. coli and AOX activity measured spectrophotometrically using ubiquinol-1 (UQ-1) as substrate. Both A. locustae and T. hominis AOX proteins reduced UQ-1 in a cyanide and antimycin-resistant manner that was sensitive to ascofuranone, a potent inhibitor of the trypanosomal AOX. The physiological role of AOX microsporidia may be to reoxidise reducing equivalents produced by glycolysis, in a manner comparable to that observed in trypanosome

Evidence for the Emergence of New Rice Types of Interspecific Hybrid Origin in West African Farmers' Fields

In West Africa two rice species (Oryza glaberrima Steud. and Oryza sativa L.) co-exist. Although originally it was thought that interspecific hybridization is impossible without biotechnological methods, progenies of hybridization appear to occur in farmer fields