International quality improvement initiatives.

AbstractAcross the globe, the implementation of quality improvement science and collaborative learning has positively affected the care and outcomes for children born with CHD. These efforts have advanced the collective expertise and performance of inter-professional healthcare teams. In this review, we highlight selected quality improvement initiatives and strategies impacting the field of cardiovascular care and describe implications for future practice and research. The continued leveraging of technology, commitment to data transparency, focus on team-based practice, and recognition of cultural norms and preferences ensure the success of sustainable models of global collaboration

Linking world bank development indicators and outcomes of congenital heart surgery in low-income and middle-income countries: Retrospective analysis of quality improvement data

Objective Many low-income and middle-income countries (LMICs) struggle to provide the health services investment required for life-saving congenital heart disease (CHD) surgery. We explored associations between risk-adjusted CHD surgical mortality from 17 LMICs and global development indices to identify patterns that might inform investment strategies. Design Retrospective analysis: country-specific standardised mortality ratios were graphed against global development indices reflective of wealth and healthcare investment. Spearman correlation coefficients were calculated. Setting and participants The International Quality Improvement Collaborative (IQIC) keeps a volunteer registry of outcomes of CHD surgery programmes in low-resource settings. Inclusion in the IQIC is voluntary enrolment by hospital sites. Patients in the registry underwent congenital heart surgery. Sites that actively participated in IQIC in 2013, 2014 or 2015 and passed a 10% data audit were asked for permission to share data for this study. 31 sites in 17 countries are included. Outcome measures In-hospital mortality: standardised mortality ratios were calculated. Risk adjustment for in-hospital mortality uses the Risk Adjustment for Congenital Heart Surgery method, a model including surgical risk category, age group, prematurity, presence of a major non-cardiac structural anomaly and multiple congenital heart procedures during admission. Results The IQIC registry includes 24 917 congenital heart surgeries performed in children less than 18 years of age. The overall in-hospital mortality rate was 5.0%. Country-level congenital heart surgery standardised mortality ratios were negatively correlated with gross domestic product (GDP) per capita (r=-0.34, p=0.18), and health expenditure per capita (r=-0.23, p=0.37) and positively correlated with under-five mortality (r=0.60, p=0.01) and undernourishment (r=0.39, p=0.17). Countries with lower development had wider variation in mortality. GDP per capita is a driver of the association between some other measures and mortality. Conclusions Results display a moderate relationship among wealth, healthcare investment and malnutrition, with significant variation, including superior results in many countries with low GDP per capita. These findings provide context and optimism for investment in CHD procedures in low-resource settings. © 2019 BMJ Publishing Group Limited

Consistent patterns of common species across tropical tree communities

Trees structure the Earth’s most biodiverse ecosystem, tropical forests. The vast number of tree species presents a formidable challenge to understanding these forests, including their response to environmental change, as very little is known about most tropical tree species. A focus on the common species may circumvent this challenge. Here we investigate abundance patterns of common tree species using inventory data on 1,003,805 trees with trunk diameters of at least 10 cm across 1,568 locations1,2,3,4,5,6 in closed-canopy, structurally intact old-growth tropical forests in Africa, Amazonia and Southeast Asia. We estimate that 2.2%, 2.2% and 2.3% of species comprise 50% of the tropical trees in these regions, respectively. Extrapolating across all closed-canopy tropical forests, we estimate that just 1,053 species comprise half of Earth’s 800 billion tropical trees with trunk diameters of at least 10 cm. Despite differing biogeographic, climatic and anthropogenic histories7, we find notably consistent patterns of common species and species abundance distributions across the continents. This suggests that fundamental mechanisms of tree community assembly may apply to all tropical forests. Resampling analyses show that the most common species are likely to belong to a manageable list of known species, enabling targeted efforts to understand their ecology. Although they do not detract from the importance of rare species, our results open new opportunities to understand the world’s most diverse forests, including modelling their response to environmental change, by focusing on the common species that constitute the majority of their trees.Publisher PDFPeer reviewe

Atrial approaches in mitral valve surgery: a propensity analysis of differences in the incidence of clinically relevant adverse effects

Abstract Background The lack of evidence on complications using mitral valve approaches leaves the choice of risk exposure to the surgeon’s preference, based on individual experience, speed, ease, and quality of exposure. Methods The present study analysed patients undergoing mitral valve surgery using a superior transseptal approach or a left-atrial approach between 2006 and 2018. We included first-time elective mitral valve procedures, isolated, or combined, without a history of rhythm disturbances. We used propensity score matching based on 26 perioperative variables. The primary endpoint was the association between the superior transeptal approach and clinically significant adverse outcomes, including arrhythmias, need for a permanent pacemaker, cerebrovascular events, and mortality. Results A total of 652 patients met the inclusion criteria; 391 received the left atrial approach, and 261 received the superior transseptal approach. After matching, 96 patients were compared with 69 patients, respectively. The distribution of the preoperative and perioperative variables was similar. There was no difference in the incidence of supraventricular tachyarrhythmias or the need for treatment. The incidence of nodal rhythm (p = 0.008) and length of stay in intensive care (p = 0.04) were higher in the superior transseptal group, but the need for permanent pacemaker implantation was the same. Likewise, there was no difference in the need for anticoagulation due to arrhythmia, the incidence of cerebrovascular events or mortality in the postoperative period or in the long-term follow-up. Conclusion We did not find an association with permanent heart rhythm disorders or any other significant adverse clinical outcome. Therefore, the superior transeptal approach is useful and safe for mitral valve exposure

Factores que afectan la producción de cacao (Theobroma cacao L.) en el tejido Francisco I. Madero del plan chontalpa, Tabasco, México

This study was carried out in Francisco I. Madero, Plan Chontalpa, in Tabasco. The purpose was to find out the factors involved in production, commercialization and income obtained by producers in relation to the Unit of Familiar Production. The diagnosis method applied was the participative rural soundings, the economic analysis and the historical series on surface and production of cacao in the Plan Chontalpa region from 1968 through 1980. As a result, low productivity was related to factors such as the age of the plantation, inefficient pests and disease control, the inadequate drainage system needed for rainy seasons, low application of fertilizers, inappropriate handling of shades in the cocoa plantation, lack of technical support and training to producers, and insufficient support by the state for the production. In this study, the results show that the cocoa production in the study area provides between 42% and 86% of net income to farmer families. The total income that producers obtained were affected by low prices and low yields per hectare. In addition, the government programs such as Alianza para el Campo were not enough to be applied by producers. It is necessary to design a local and national strategic program in order to rescue this diversified production system, which has shown its ecological and economic sustainability in this region, for more than 500 years.Este estudio fue realizado en el ejido Francisco I. Madero del Plan Chontalpa, Tabasco. El objetivo fue conocer los problemas que afectan la producción, la comercialización y el ingreso que aporta a los productores con relación a la Unidad de Producción Familiar. El método de diagnóstico aplicado fue el sondeo rural participativo, el análisis económico y de series históricas de superficie y producción del cacao en el Plan Chontalpa del periodo de 1968 a 1998. Se encontró que la baja productividad estaba relacionada con: la edad avanzada de las plantaciones; el deficiente control de plagas y enfermedades; el inadecuado drenaje del suelo en épocas de lluvias; la baja aplicación de fertilizantes; el manejo inadecuado de las sombras en el cacaotal y la nula asistencia técnica y capacitación a productores, así como los insuficientes apoyos del estado a la producción. En este estudio de campo, los resultados muestran que la producción de cacao en el ejido de estudio aporta a las familias campesinas entre 42% y 86% de ingresos netos. Se encontró que los ingresos de los productores se vieron afectados por los bajos precios y por los bajos rendimientos por hectárea. Además los programas gubernamentales existentes a través de Alianza para el Campo fueron insuficientes para el productor. Es urgente un programa estratégico estatal y nacional, que tenga como misión el rescate de este sistema de producción campesina diversificada, la cual por más de 500 años ha demostrado su sostenibilidad ecológica y económica en la región

Blood-Vessel-Inspired Hierarchical Trilayer Scaffolds: PCL/Gelatin-Driven Protein Adsorption and Cellular Interaction

Fabrication of scaffolds with hierarchical structures exhibiting the blood vessel topological and biochemical features of the native extracellular matrix that maintain long-term patency remains a major challenge. Within this context, scaffold assembly using biodegradable synthetic polymers (BSPs) via electrospinning had led to soft-tissue-resembling microstructures that allow cell infiltration. However, BSPs fail to exhibit the sufficient surface reactivity, limiting protein adsorption and/or cell adhesion and jeopardizing the overall graft performance. Here, we present a methodology for the fabrication of three-layered polycaprolactone (PCL)-based tubular structures with biochemical cues to improve protein adsorption and cell adhesion. For this purpose, PCL was backbone-oxidized (O-PCL) and cast over a photolithography-manufactured microgrooved mold to obtain a bioactive surface as demonstrated using a protein adsorption assay (BSA), Fourier transform infrared spectroscopy (FTIR) and calorimetric analyses. Then, two layers of PCL:gelatin (75:25 and 95:5 w/w), obtained using a novel single-desolvation method, were electrospun over the casted O-PCL to mimic a vascular wall with a physicochemical gradient to guide cell adhesion. Furthermore, tensile properties were shown to withstand the physiological mechanical stresses and strains. In vitro characterization, using L929 mouse fibroblasts, demonstrated that the multilayered scaffold is a suitable platform for cell infiltration and proliferation from the innermost to the outermost layer as is needed for vascular wall regeneration. Our work holds promise as a strategy for the low-cost manufacture of next-generation polymer-based hierarchical scaffolds with high bioactivity and resemblance of ECM’s microstructure to accurately guide cell attachment and proliferation