Building a regional pediatric asthma learning health system in support of optimal, equitable outcomes.

Introduction: Asthma is characterized by preventable morbidity, cost, and inequity. We sought to build an Asthma Learning Health System (ALHS) to coordinate regional pediatric asthma improvement activities. Methods: We generated quantitative and qualitative insights pertinent to a better, more equitable care delivery system. We used electronic health record data to calculate asthma hospitalization rates for youth in our region. We completed an "environmental scan" to catalog the breadth of asthma-related efforts occurring in our children's hospital and across the region. We supplemented the scan with group-level assessments and focus groups with parents, clinicians, and community partners. We used insights from this descriptive epidemiology to inform the definition of shared aims, drivers, measures, and prototype interventions. Results: Greater Cincinnati's youth are hospitalized for asthma at a rate three times greater than the U.S. average. Black youth are hospitalized at a rate five times greater than non-Black youth. Certain neighborhoods bear the disproportionate burden of asthma morbidity. Across Cincinnati, there are many asthma-relevant activities that seek to confront this morbidity; however, efforts are largely disconnected. Qualitative insights highlighted the importance of cross-sector coordination, evidence-based acute and preventive care, healthy homes and neighborhoods, and accountability. These insights also led to a shared, regional aim: to equitably reduce asthma-related hospitalizations. Early interventions have included population-level pattern recognition, multidisciplinary asthma action huddles, and enhanced social needs screening and response. Conclusion: Learning health system methods are uniquely suited to asthma's complexity. Our nascent ALHS provides a scaffold atop which we can pursue better, more equitable regional asthma outcomes.

Reducing Caregiver Hunger During Pediatric Hospitalization.

BACKGROUND AND OBJECTIVES: Pediatric hospitalizations are costly, stressful events for families. Many caregivers, especially those with lower incomes, struggle to afford food while their child is hospitalized. We sought to decrease the mean percentage of caregivers of Medicaid-insured and uninsured children who reported being hungry during their child's hospitalization from 86% to <24%. METHODS: Our quality improvement efforts took place on a 41-bed inpatient unit at our large, urban academic hospital. Our multidisciplinary team included physicians, nurses, social workers, and food services leadership. Our primary outcome measure was caregiver-reported hunger; we asked caregivers near to the time of discharge if they experienced hunger during their child's hospitalization. Plan-do-study-act cycles addressed key drivers: awareness of how to obtain food, safe environment for families to seek help, and access to affordable food. An annotated statistical process control chart tracked our outcome over time. Data collection was interrupted because of the COVID-19 pandemic; we used that time to advocate for hospital-funded support for optimal and sustainable changes to caregiver meal access. RESULTS: We decreased caregiver hunger from 86% to 15.5%. A temporary test of change, 2 meal vouchers per caregiver per day, resulted in a special cause decrease in the percentage of caregivers reporting hunger. Permanent hospital funding was secured to provide cards to purchase 2 meals per caregiver per hospital day, resulting in a sustained decrease in rates of caregiver hunger. CONCLUSIONS: We decreased caregivers' hunger during their child's hospitalization. Through a data-driven quality improvement effort, we implemented a sustainable change allowing families to access enough food.

Toward an ontology of collaborative learning healthcare systems.

Objective: To establish a basis for a domain ontology - a formal, explicit specification of a shared conceptualization - of collaborative learning healthcare systems (CLHSs) in order to facilitate measurement, explanation, and improvement. Methods: We adapted the "Methontology" approach to begin building an ontology of CLHSs. We specified the purpose of an ontology, acquired domain knowledge via literature review, conceptualized a common framework of CLHSs using a grounded approach, refined these concepts based on expert panel input, and illustrated concept application via four cases. Results: The set of concepts identified as important to include in an ontology includes goals, values, structure, actors, environment, and products. To establish this set of concepts, we gathered input from content experts in two ways. First, expert panel methods were used to elicit feedback on these concepts and to test the elicitation of terms for the vocabulary of the Values concept. Second, from these discussions we developed a mapping exercise to test the intuitiveness of the concepts, requesting that network leaders from four CLHSs complete a mapping exercise to associate characteristics of their networks with the high-level concepts, building the vocabulary for each concept in a grounded fashion. We also solicited feedback from these participants on the experience of completing the mapping exercise, finding that the exercise is acceptable and could aid in CLHS development and collaboration. Respondents identified opportunities to improve the operational definitions of each concept to ensure that corresponding vocabularies are distinct and non-overlapping. Discussion: Our results provide a foundation for developing a formal, explicit shared conceptualization of CLHSs. Once developed, such a tool can be useful for measurement, explanation, and improvement. Further work, including alignment to a top-level ontology, expanding the vocabulary, and defining relations between vocabulary is required to formally build out an ontology for these uses.

Evaluation of the benefits of a kripalu yoga program for police academy trainees: a pilot study.

BACKGROUND: Law enforcement ranks as one of the most stressful occupations in the world. Yoga is a mind-body practice composed of postures, breathing, and meditation techniques, and is known for its beneficial effects on stress and mood disturbance. OBJECTIVES: This pilot study evaluated the effects of Kripalu yoga on perceived stress, mood, and mindfulness during police academy training. METHOD: Forty-two recruits participated in a 6-class yoga intervention. Participants completed the Profile of Mood States-Short Form, Perceived Stress Scale, and the Five Facet Mindfulness Questionnaire prior to and immediately following completion of the yoga program, as well as an exit survey. RESULTS: Paired samples t-tests revealed significant postintervention changes in perceived stress and mood, reductions in tension and fatigue, and a trend toward reduced anger. Changes in mindfulness were not detected. The exit survey indicated perceived benefits of yoga for some participants. CONCLUSIONS: This preliminary study suggests that yoga may be beneficial for reducing stress, tension, and fatigue among police academy trainees. Future longitudinal randomized controlled trials are needed to evaluate its full potential as a permanent component of police academy training.

The dual vitamin D pathways: considerations for adequate supplementation.

Vitamin D insufficiency and deficiency have been identified as having a correlation with poor clinical outcomes in patients with chronic kidney disease (CKD). The availability of vitamin D for metabolism into 25(OH)D and the ability to further metabolize to 1,25(OH)D are known to have a significant impact on the endocrine system and the modulation of iPTH, calcium, and phosphorus imbalances in patients with CKD. Until recently, the focus of care for these patients has been to support the endocrine need for 1,25(OH)D because the loss of kidney function eliminates the ability to synthesize calcitriol effectively. However, recent findings have identified an autocrine role for vitamin D and its metabolism at local sites as having a potentially profound impact on gene transcription and clinical outcomes in multiple body systems. The National Kidney Foundation Kidney Disease Outcomes Quality Improvement guidelines recommend the use of ergocalciferol in the treatment of vitamin D insufficiency in CKD Stages 3 and 4, and the use of active vitamin D hormone in the treatment of vitamin D deficiency in patients with CKD Stage 5 who also have secondary hyperparathyroidism. Data clearly identify that the insufficiency of 25(OH)D persists as patients progress through Stage 3 and Stage 4 CKD into Stage 5 CKD. This article discusses the treatment of both the deficiency and insufficiency by supplementing both the endocrine and autocrine pathways with appropriate vitamin D therapies.

Mutations define cross-talk between the N-terminal nucleotide-binding domain and transmembrane helix-2 of the yeast multidrug transporter Pdr5: possible conservation of a signaling interface for coupling ATP hydrolysis to drug transport.

The yeast Pdr5 multidrug transporter is an important member of the ATP-binding cassette superfamily of proteins. We describe a novel mutation (S558Y) in transmembrane helix 2 of Pdr5 identified in a screen for suppressors that eliminated Pdr5-mediated cycloheximide hyper-resistance. Nucleotides as well as transport substrates bind to the mutant Pdr5 with an affinity comparable with that for wild-type Pdr5. Wild-type and mutant Pdr5s show ATPase activity with comparable K(m)((ATP)) values. Nonetheless, drug sensitivity is equivalent in the mutant pdr5 and the pdr5 deletion. Finally, the transport substrate clotrimazole, which is a noncompetitive inhibitor of Pdr5 ATPase activity, has a minimal effect on ATP hydrolysis by the S558Y mutant. These results suggest that the drug sensitivity of the mutant Pdr5 is attributable to the uncoupling of NTPase activity and transport. We screened for amino acid alterations in the nucleotide-binding domains that would reverse the phenotypic effect of the S558Y mutation. A second-site mutation, N242K, located between the Walker A and signature motifs of the N-terminal nucleotide-binding domain, restores significant function. This region of the nucleotide-binding domain interacts with the transmembrane domains via the intracellular loop-1 (which connects transmembrane helices 2 and 3) in the crystal structure of Sav1866, a bacterial ATP-binding cassette drug transporter. These structural studies are supported by biochemical and genetic evidence presented here that interactions between transmembrane helix 2 and the nucleotide-binding domain, via the intracellular loop-1, may define at least part of the translocation pathway for coupling ATP hydrolysis to drug transport.

Subcellular trafficking of the yeast plasma membrane ABC transporter, Pdr5, is impaired by a mutation in the N-terminal nucleotide-binding fold.

The plasma membrane ATP-binding cassette (ABC) transporter, Pdr5p, mediates resistance to many different xenobiotic compounds in yeast. We have isolated several mutated forms that fail to confer resistance to cycloheximide and itraconazole. Here, we examined two variants, the expression of which was abnormally low when cells reach the stationary phase of growth. The Pdr5(1157) variant lacked the C-terminal transmembrane domain due to the presence of a nonsense mutation at codon 1158. The second variant, Pdr5(L183P), contained a Leu183Pro substitution close to the Walker A motif in the N-terminal nucleotide-binding domain. This substitution impaired UTPase activity as well as protein stability. The Pdr5(L183P) variant induced the unfolded protein response and was targeted to the proteasome for degradation. Fluorescence microscopy showed that the highly unstable Pdr5(L183P) was mislocalized to endoplasmic reticulum (ER)-associated compartments, whereas the truncated Pdr5(1157) protein was retained in the ER. When threonine 363 (located in the first nucleotide-binding domain, close to the Walker B motif) in Pdr5(L183P) was replaced with isoleucine, this double mutant conferred partial drug resistance. These results suggest that Pdr5p requires a properly folded nucleotide-binding domain for trafficking to the plasma membrane.

Characteristics of assaultive psychiatric patients: fifteen-year analysis of the Assaulted Staff Action Program (ASAP).

This study reports on a fifteen-year longitudinal analysis of the characteristics of assaultive patients in one public-sector mental health care system. The data were gathered within the context of the Assaulted Staff Action Program (ASAP), a crisis intervention service for staff victims. The fifteen-year findings were consistent with previous worldwide research on assaultive patients and included both older male patients with schizophrenia and younger personality-disordered patients as high-risk assailants. Both groups had appreciable histories of violence toward others, personal victimization, and substance use disorders. The role of these three clinical variables in association with subsequent assaults, the role of trauma in female assailants, and the consistency of the fundamental characteristics of assaultive patients during several service system initiatives were examined. Implications for research and intervention are discussed.