Hospital Workforce Engagement and Inpatient Mortality Rate: Findings from the English National Health Service Staff Surveys.

BACKGROUND: Healthcare workforce engagement may represent a proactive approach against provider burnout, a widely prevalent condition that is associated with poor patient outcomes. OBJECTIVE: We examine whether workforce engagement is associated with better hospital performance, measured as lower inpatient mortality, in English National Health Services (NHS) acute Trusts. DESIGN: Panel study using cross-lagged regression, applying an optimally time-lagged value of the dependent variable as covariate to account for unmeasured Trust characteristics. PARTICIPANTS: NHS acute Trusts and respondents to the NHS Staff Surveys, 2012-2018. MAIN MEASURES: We measured engagement using three survey questions corresponding to validated engagement factors, and hospital performance using the Summary Hospital-level Mortality Indicator (SHMI). In the first analyses, associations of SHMI (dependent variable) with workforce engagement in the current, prior, and subsequent years were studied to find the optimum lag period for lagged regression analysis. In the subsequent cross-lagged regression analysis, bi-directional associations between SHMI and engagement were studied. Heterogeneity in engagement components across Trusts was studied in detail for the year 2017. KEY RESULTS: In the first analyses, current SHMI was negatively associated with engagement in the current year (ß = - 0.044; p = 0.035) more than with the prior year (ß = - 0.037; p = 0.049). In the second analysis, (a) engagement predicted same-year SHMI after controlling for prior-year SHMI (ß = - 0.044; p = 0.035). A 1-unit higher engagement score was associated with 4.4% lower SHMI. (b) SHMI predicted engagement in the same year (ß = - 0.066; p = 0.001) after controlling for prior-year engagement. More in-depth analysis showed high inter-trust heterogeneity on all three engagement factors (I2 > 85%). CONCLUSION: Higher workforce engagement predicts lower mortality which in turn predicts engagement. Heterogeneity in workforce well-being suggests an opportunity to foster mutual learning across Trusts.

Risk of adverse perinatal outcomes with antithyroid treatment during pregnancy: a nationwide population-based study.

OBJECTIVE: To compare, using two large nationwide population-based data sets, the risk of adverse pregnancy outcomes (low birthweight [LBW], preterm birth, small for gestational age [SGA] and congenital anomalies) among pregnant women with hyperthyroidism classified into three groups: receiving propylthiouracil (PTU) treatment during pregnancy, receiving methimazole/carbimazole (MMI) treatment, and no antithyroid treatment during pregnancy. DESIGN: A matched case-control study. SETTING: Taiwan. SAMPLE: A total of 2830 mothers with hyperthyroidism and 14,150 age-matched randomly selected mothers without hyperthyroidism were included. METHODS: Conditional logistic regression analyses were performed to examine the risk of adverse pregnancy outcomes (LBW, preterm birth, SGA and major congenital anomalies) among these three groups. MAIN OUTCOME MEASURES: LBW, preterm birth, SGA and major congenital anomalies. RESULTS: Women receiving PTU treatment during pregnancy had a higher risk of giving birth to LBW infants than those not receiving antithyroid treatment (odds ratio = 1.40; 95% CI 1.00-1.96), after adjusting for maternal education, anaemia, hyperlipidaemia, pregestational diabetes, pregestational hypertension, hyperemesis gravidarum and infant's gender and birth order. However, children of women receiving MMI treatment did not have increased risks of any adverse fetal outcome relative to mothers not receiving antithyroid treatment. CONCLUSIONS: Our study finds an increased risk of LBW among babies of mothers with hyperthyroidism receiving PTU treatment during pregnancy relative to untreated mothers with hyperthyroidism.

Procedure volume of gastric cancer resections versus 5-year survival.

AIM: We used nationwide, population-based data to examine associations between hospital and surgeon volumes of gastric cancer resections and their patients' short-term and long-term survival likelihood. METHODS: The study uses 1997-1999 inpatient claims data from Taiwan's National Health Insurance linked to "cause of death" data for 1997-2004. The total cohort of 6909 gastric cancer resection patients were categorized by their surgeon's/hospital's procedure volume, and examined for differences in 6-month mortality and 5-year mortality (post 6 months), by procedure volume, using Cox proportional hazard regressions, adjusting for surgeon, hospital and patient characteristics. We hypothesized that surgeons' case volume and age but not hospital volume will predict short-term and long-term survival. RESULTS: Adjusted estimates show that increasing surgeon volume predicts better 6-month survival (adjusted mortality hazard ratio = 1.3 for low-volume surgeons relative to very high-volume surgeons; p < 0.01) and 5-year survival (adjusted mortality hazard ratios = 1.3; p < 0.001 for low-volume; 1.2 with p < 0.01 for medium volume) and increasing surgeon's age (adjusted hazards ratio = 1.4 for age < 41 years relative to 41-50 years; p < or = 0.001; 0.8 for > or = 51 years relative to 41-50 years; p < 0.05). In hospital volume regressions, surgeon's age is a consistent and significant predictor, not hospital volume. Findings suggest a key role of experience in surgical skill and sensitivity for early stage diagnosis in gastric cancer survival. CONCLUSIONS: Although a key study limitation is the lack of cancer stage data, the pattern of findings suggests that experienced surgeons have relatively better survival outcomes among gastric cancer patients.

Suicide trends following the Taiwan earthquake of 1999: empirical evidence and policy implications.

OBJECTIVE: Mental health impact of severe earthquakes on survivors has attracted considerable attention. Suicide represents a terminal outcome of the spectrum of potential major mental health issues spawned by severe earthquakes. This study used time-series analysis to examine the time trends of increased suicide rates after the Chi-Chi earthquake of 1999 in Taiwan in the affected counties. METHOD: Adult cause of death data were used to study monthly suicide rates per 100,000 adult population in the study and control counties, during January 1995 to December 2001. Box and Tiao's event intervention analysis was used to examine changes in monthly suicide rates before and after the Chi-Chi earthquake. RESULTS: During the post-quake period, October 1999 to December 2001, the mean monthly suicide rate in the affected counties was 1.567 per 100,000, compared with the control counties' rate of 1.297 per 100,000. Mean monthly suicide rate among the high-exposure group was 42% higher during the 26 months following the earthquake than the average for the entire observation period. Examined by time trends, the increased suicide rate registered in the first month following the quake began a monthly gradual decline by 0.7/100,000 thereafter, accounting for a total reduction of 98% in quake-related suicides by the end of 10 months. Suicide rates fell to the baseline level after 10 months. CONCLUSION: We found that the mean monthly suicide rate for earthquake victims was higher while the low-exposure group remained stable and consistent throughout the observation period, indicating that the impact on the high-exposure group was attributable to the earthquake. This indicates the need for providing strengthened psychiatric services during the first year following major disasters.

Vav1 regulates phospholipase cgamma activation and calcium responses in mast cells.

The hematopoietic cell-specific protein Vav1 is a substrate of tyrosine kinases activated following engagement of many receptors, including FcepsilonRI. Vav1-deficient mice contain normal numbers of mast cells but respond more weakly than their normal counterparts to a passive systemic anaphylaxis challenge. Vav1-deficient bone marrow-derived mast cells also exhibited reduced degranulation and cytokine production, although tyrosine phosphorylation of FcepsilonRI, Syk, and LAT (linker for activation of T cells) was normal. In contrast, tyrosine phosphorylation of phospholipase Cgamma1 (PLCgamma1) and PLCgamma2 and calcium mobilization were markedly inhibited. Reconstitution of deficient mast cells with Vav1 restored normal tyrosine phosphorylation of PLCgamma1 and PLCgamma2 and calcium responses. Thus, Vav1 is essential to FcepsilonRI-mediated activation of PLCgamma and calcium mobilization in mast cells. In addition to its known role as an activator of Rac1 GTPases, these findings demonstrate a novel function for Vav1 as a regulator of PLCgamma-activated calcium signals.

A perspective: regulation of IgE receptor-mediated mast cell responses by a LAT-organized plasma membrane-localized signaling complex.

BACKGROUND: To understand how the high-affinity IgE receptor (FcepsilonRI) communicates with downstream effectors, we focused on exploring the functional importance of the FcepsilonRI-mediated formation and localization of a signaling complex that contains the hematopoietic cell-specific scaffolding protein linker for activation of T cells (LAT) and the guanine nucleotide exchange factor Vav1. METHODS: Using the mast cell line RBL-2H3, we explored the localization of these proteins by confocal microscopy and cell fractionation. Additionally, the mechanism of function and the importance of LAT and Vav1 to mast cells was studied in genetically disrupted mice and in mast cells derived from their bone marrow. RESULTS: We found that LAT, Vav1 and the adapter molecule SLP-76 associated in detergent-resistant microdomains (lipid rafts) found in the plasma membrane upon FcepsilonRI stimulation. In the absence of LAT, mast cells showed a remarkable loss of the secretory response and reduced cytokine responses. Vav1 deficiency also affected secretion, although not to the extent of LAT deficiency, and inhibited IL-2 and IFN-gamma production. LAT- and Vav1-deficient mice showed reduced blood histamine levels after a systemic anaphylaxis challenge as compared to their normal counterparts. CONCLUSIONS: The results demonstrate that LAT is a central mediator in IgE receptor signaling by regulating multiple signaling pathways that affect mast cell degranulation and cytokine production. Vav1, a component of this LAT-containing signaling complex, regulates a specific subset of these responses.

The glass ceiling in academe: health administration is no exception.

This paper reviews gender issues in academe and presents findings of a limited survey of ACEHSA-accredited health administration graduate programs. The survey shows gender ratios adverse to women at the full, associate, and assistant professor levels. Men to women ratio among faculty was 1.98, among full-time faculty it was 2.24, and among tenured/tenure-track faculty it was 2.69, despite an excess of female students over male students in graduate programs, and despite equal proportions of women and men faculty holding doctoral degrees. Distribution by rank showed 48.5 percent full professors, 27.8 percent associate professors, and, 20.1 percent assistant professors among men, vs. 27.4 percent, 41.1 percent, and 31.5 percent respectively among women. In other academic fields similar gender ratios prevail, and many researchers have documented evidence of continuing gender inequities in tenure, promotion and salary, given comparable performance, despite the enactment of Title IX in 1972. Gender disparities are rooted in a complex web of gender-specific constraints interwoven with secular human capital and structural variables, and confounded by sexist discriminatory factors. In light of these issues, recommendations are made toward creating an equitable academic climate without compromising the ideal of meritocracy, through gender-sensitive initiatives and vigilance mechanisms to bring policies to fruition.

RNA structure inhibits the TRAP (trp RNA-binding attenuation protein)-RNA interaction.

TRAP (trp RNA-binding attenuation protein) regulates expression of the tryptophan biosynthetic genes in response to tryptophan in Bacillus subtilis by binding to two sites containing a series of 9 or 11 (G/U)AG triplet repeats that are generally separated by two or three spacer nucleotides. Previous mutagenesis experiments have identified three TRAP residues, Lys-37, Lys-56, and Arg-58 that are essential for RNA binding. The location of these residues on the TRAP oligomer supports the proposal that RNA binds TRAP by encircling the TRAP oligomer. In this work, we show that RNAs containing 11 GAG or UAG repeats separated by CC dinucleotide spacers (((G/U)AGCC)11) form stable structures that inhibit binding to TRAP. This conclusion is based on the effects of temperature and Mg2+ on the affinity of TRAP for RNAs with CC spacers combined with UV hyperchromicity and circular dichroism. Furthermore, introducing the base analogue 7-deazaguanosine in the ((G/U)AGCC)11 RNAs stabilized the TRAP-RNA interaction. This effect was associated with decreased stability of the RNA structure as measured by circular dichroism spectroscopy. The precise nature of the structure of the ((G/U)AGCC)11 RNAs is not known but evidence is presented that it involves noncanonical interactions. We also observed that substitution of Arg-58 with Lys further reduced the ability of TRAP to interact with structured RNAs. Since in vivo function of TRAP may involve binding to structured RNAs, we suggest a potential function for this residue, which is conserved in TRAP from three different bacilli.

The trp RNA-binding attenuation protein (TRAP) from Bacillus subtilis binds to unstacked trp leader RNA.

TRAP (trp RNA-binding attenuation protein) is a tryptophan-activated RNA-binding protein that regulates expression of the trp biosynthetic genes by binding to a series of GAG and UAG trinucleotide repeats generally separated by two or three spacer nucleotides. Previously, we showed that TRAP contains 11 identical subunits arranged in a symmetrical ring. Based on this structure, we proposed a model for the TRAP.RNA interaction where the RNA wraps around the protein with each repeat of the RNA contacting one or a combination of two adjacent subunits of the TRAP oligomer. Here, we have shown that RNAs selected in vitro based on their ability to bind tryptophan-activated TRAP contain multiple G/UAG repeats and show a strong bias for pyrimidines as the spacer nucleotides between these repeats. The affinity of the TRAP.RNA interaction displays a nonlinear temperature dependence, increasing between 5 degrees C and 47 degrees C and then decreasing from 47 degrees C to 67 degrees C. Differential scanning calorimetry and circular dichroism spectroscopy demonstrate that TRAP is highly thermostable with few detectable changes in the structure between 25 degrees C and 70 degrees C, suggesting that the temperature dependence of this interaction reflects changes in the RNA. Results from circular dichroism and UV absorbance spectroscopy support this hypothesis, demonstrating that trp leader RNA becomes unstacked upon binding TRAP. We propose that the bias toward pyrimidines in the spacer nucleotides of the in vitro selected RNAs represents the inability of Us and Cs to form stable base stacking interactions, which allows the flexibility needed for the RNA to wrap around the TRAP oligomer.