Body Composition Findings by Computed Tomography in SARS-CoV-2 Patients: Increased Risk of Muscle Wasting in Obesity

Obesity is a characteristic of COVID-19 patients and the risk of malnutrition can be underestimated due to excess of fat: a paradoxical danger. Long ICU hospitalization exposes patients to a high risk of wasting and loss of lean body mass. The complex management precludes the detection of anthropometric parameters for the definition and monitoring of the nutritional status. The use of imaging diagnostics for body composition could help to recognize and treat patients at increased risk of wasting with targeted pathways. COVID-19 patients admitted to the ICU underwent computed tomography within 24 h and about 20 days later, to evaluate the parameters of the body and liver composition. The main results were the loss of the lean mass index and a greater increase in liver attenuation in obese subjects. These could be co-caused by COVID-19, prolonged bed rest, the complex medical nutritional therapy, and the starting condition of low-grade inflammation of the obese. The assessment of nutritional status, with body composition applied to imaging diagnostics and metabolic profiles in COVID-19, will assist in prescribing appropriate medical nutritional therapy. This will reduce recovery times and complications caused by frailty.

Differential DNA methylation analysis across the promoter regions using methylated DNA immunoprecipitation sequencing profiling of porcine loin muscle

Background and Aim:

Pork leanness and marbling are among the essential traits of consumer preference. To acquire knowledge about universal epigenetic regulations for improving breed selection, a meta-analysis of methylated DNA immunoprecipitation sequencing (MeDIP-seq) profiling data of mixed loin muscle types was performed in this study.

Materials and Methods:

MeDIP-seq profiling datasets of longissimus dorsi muscle and psoas major muscles from male and female pigs of Landrace and Tibetan breeds were preprocessed and aligned to the porcine genome. Analysis of differential methylated DNA regions (DMRs) between the breeds was performed by focusing on transcription start sites (TSSs) of known genes (−20,000-3000 bases from TSS). All associated genes were further reviewed for their functions and predicted for transcription factors (TF) possibly associated with their TSSs.

Results:

When the methylation levels of DMRs in TSS regions of Landrace breed were compared to those of Tibetan breed, 10 DMRs were hypomethylated (Landrace < Tibetan), and 19 DMRs were hypermethylated (Landrace > Tibetan), accordingly (p≤0.001). According to the reviews about gene functions, all associated genes were pieces of evidence for their roles in a variety of muscle and lipid metabolisms. Prediction of the binding TFs revealed the six most abundant binding TFs to such DMRs-associated TSS (p≤0.0001) as follows: ZNF384, Foxd3, IRF1, KLF9, EWSR1-FLI1, HES5, and TFAP2A.

Conclusion:

Common DMRs-associated TSS between the lean-type and the marbled-type loin muscles were identified in this study. Interestingly, the genes associated with such regions were strongly evidenced for their possible roles on the muscle trait characteristics by which further novel research topics could be focused on them in the future.

Process Approach for Managing Health Information System-Induced Medication Errors

Health information systems (HIS) and clinical workflows generate medication errors that affect the quality of patient care. The rigorous evaluation of the medication process's error risk, control, and impact on clinical practice enable the understanding of latent and active factors that contribute to HIS-induced errors. This paper reports the preliminary findings of an evaluation case study of a 1000-bed Japanese secondary care teaching hospital using observation, interview, and document analysis methods. Findings were analysed from a process perspective by adopting a recently introduced framework known as Human, Organisation, Process, and Technology-fit. Process factors influencing risk in medication errors include template- and calendar-based systems, intuitive design, barcode check, ease of use, alert, policy, systematic task organisation, and safety culture Approaches for managing medication errors also exert an important role on error reduction and clinical workflow.

[Lean, work and psychological well-being.]

Many studies have confirmed the existence of a close relationship between job satisfaction and health. The Siena University Hospital introduced the Lean approach to support personnel development/empowerment and promote a constant improvement in work organization, with the aim of creating value for patients, professionals and the whole organization. The purpose of this study was to examine whether the introduction and the development of this improvement approach in healthcare could contribute to the enhancement of psychological wellbeing and employee satisfaction, with a positive value in preventing related stress work. The Lyne and Barrett Employee Wellbeing Questionnaire (EWQ) was administered to employees involved in selected Lean projects carried out at the Siena University Hospital. The EWQ is composed of 59 items and it is structured in three areas: organizational wellbeing, working satisfaction and workload. The analysis of the results showed significant evidence of the impact of improvement activities on the working satisfaction and the workload.

Towards the integration of lean principles and optimization for agricultural production systems: a conceptual review proposition

Operative planning in agricultural production has historically had the objective of improving yields and quality. Sowing, cropping, and harvesting are usually treated independently, and waste and the sustainability of operations are generally not integrated into operational planning methodologies for agricultural production. This study shows the need to have a clear and precise methodology to minimize waste in agricultural production systems to ensure sustainability. This need is addressed with a novel methodological guide to minimizing waste in agricultural operations, crop maintenance, and harvesting. The proposed methodology is founded on the use of lean manufacturing as a waste-management tool. Lean manufacturing principles allow agricultural operations and the variables that represent wastes to be identified, mathematical models to be built, constraints to be defined, and the cost of waste to be illustrated, as well as its minimization through an objective function. To guide implementation, we propose a conceptual model to explain the construction of a mathematical model that represents the development of decision variables on agricultural operations with the elements to consider and the constraints and theoretical proposal of the necessary objective function. The proposed conceptual model and the constructed methodology constitute a novel development within agricultural production systems that could be used by decision makers and farmers. © 2019 Society of Chemical Industry.

Reducing opioid use for chronic pain in older adults

PURPOSE

Implementation of the SAFE PAIN algorithm for reducing opioid use for chronic pain in older adults is described.

SUMMARY

A multidisciplinary team at Sheppard Pratt Health System, the largest private provider of psychiatric care in Maryland, used lean methodology to identify the root causes for noncompliance to evidence-based practices for patients in the geropsychiatry unit treated for osteoarthritis or chronic back pain. The team collaborated to develop a facility-specific treatment algorithm, called SAFE PAIN (Sheppard Pratt Health System Algorithm For Elderly Patient Centered Analgesia Interdisciplinary Nagara), was based on the Center for Disease Control and Prevention's evidence-based recommendations that included nonpharmacologic interventions as a first-line therapy for patients with osteoarthritis or chronic back pain. Rates of prescribing new opioids and prescribing evidence-based alternative medications via the SAFE PAIN algorithm were evaluated from March 1 to September 30, 2017 and compared with baseline (2012-2016). The lean methodology interventions led to zero new opioid orders during the study period, a significant decrease compared with previous years (p < 0.01). The rates of prescribing evidence-based alternative medications increased significantly from the baseline period to postimplementation (p < 0.01). Lean methodology interventions also decreased waste in several processes.

CONCLUSION

The prescribing rate of new opioids for osteoarthritis and chronic back pain decreased and the prescribing rate for evidence-based medications increased after implementation of the SAFE PAIN algorithm in a geropsychiatry unit.

Indiscriminate Pathologic Examination of Pediatric Supraglottoplasty Specimens: An Evidence-Based Approach toward Exempt Status

OBJECTIVE

The primary aim of this study was to demonstrate that indiscriminate pathologic evaluation of supraglottoplasty specimens is unnecessary and does not influence postoperative management. The secondary objective was to determine the costs associated with pathologic evaluation of supraglottoplasty specimens.

METHODS

A planned chart review was conducted to evaluate data from consecutive patients undergoing supraglottoplasty. Demographic data were extracted and pathology reports were reviewed. Projected cost savings were estimated based on 2018 Centers for Medicare & Medicaid Services reimbursement rates for Current Procedural Terminology code 88304 (surgical pathology, gross and microscopic examination).

RESULTS

A total of 1417 consecutive patients were identified. All specimens underwent gross and microscopic examination. Pathologic outcomes were categorized into 3 major categories: no diagnostic abnormality (n = 1069), chronic inflammation (n = 346), and other (n = 2). Pathologic evaluation did not alter postoperative management in any patient. Projected yearly and 5-year cost- savings totaled $11,818.08 and $59,173.92, respectively.

DISCUSSION

These findings demonstrate that pathologic examination of supraglottoplasty specimens adds no value to patient management. A more selective approach to pathologic examination of certain surgical specimens is an improvement opportunity to enhance the value of patient care by eliminating direct financial costs and "hidden costs" associated with unnecessarily increased workload.

IMPLICATIONS FOR PRACTICE

Addressing inappropriate, indiscriminate pathologic examination of certain surgical specimens is a potential quality improvement opportunity that has a meaningful impact on the value of patient care and reduces strains on the workload of surgical and pathology department personnel.

Insulin Resistance and β-Cell Function of Lean versus Overweight or Obese Filipino Patients with Newly Diagnosed Type 2 Diabetes Mellitus

Objectives

To compare the level of insulin resistance and β-cell function between lean and overweight/obese Filipino patients with newly diagnosed type 2 diabetes mellitus (T2DM).

Methodology

This was a cross-sectional analytical study including newly diagnosed T2DM Filipino patients from St. Luke’s Medical Center - Quezon City. The patients were classified as either lean or overweight/obese. Age, sex, smoking history, anthropometric measures and blood pressure were obtained. Insulin resistance and β-cell function were determined using the homeostasis model assessment (HOMA). The original model (HOMA1) and the updated model (HOMA2) were used.

Results

A total of 80 subjects were included. There were 40 subjects in each group. The overweight/obese subjects had significantly higher mean insulin resistance (HOMA1-IR 9.8±11.7, HOMA2-IR 3.0±2.0) compared to the lean group (HOMA1-IR 2.9±1.5, HOMA2-IR 1.3±0.5). This was consistent in both HOMA1 and HOMA2 (p-values=0.001 and <0.001, respectively). The mean β-cell function of the overweight/obese patients was significantly higher than the lean subjects when using HOMA1 (lean=57.8±35.5, overweight/obese=93.6±66.4, p-value=0.003), but not in HOMA2 (lean=57.6±30.5, overweight/obese=74.8±45.7, p-value=0.051). Overweight/obesity increased HOMA1-IR by 4.0 and HOMA1-B by 46.1 (p-values= 0.002 and <0.001, respectively). Through the use of HOMA2, overweight/obesity increased HOMA2-IR by 1.4 and HOMA2-B by 29.1 (p-values<0.001). Being overweight/obese was also associated with significantly higher odds for developing greater insulin resistance (HOMA1-IR adjOR = 5.6, 95%CI= 1.7-19.2, p-value=0.005; HOMA2-IR adjOR=10.9, 95%CI=3.4-34.9, p-value<0.001) and lower odds for a decreased β-cell function (HOMA1-B adjOR = 0.2, 95%CI = 0.05-0.9, p-value=0.033; HOMA2-B adjOR=0.2, 95%CI=0.04-0.9, p-value=0.043) compared to being lean.

Conclusion

Newly diagnosed overweight/obese T2DM had higher mean insulin resistance and β-cell function compared to lean T2DM. Overweight/obesity was also associated with higher odds of developing insulin resistance and lower odds for a decreased β-cell function compared to being lean. The overweight/obese T2DM group also had worse metabolic profile manifested by higher FPG, HbA1c, SGPT and blood pressures compared to the lean T2DM group.

Integrating Lean Thinking and Implementation Science Determinants Checklists for Quality Improvement: A Scoping Review

It is not known how often lean tools and implementation determinants frameworks or checklists are used concurrently in health care quality improvement activities. The authors systematically reviewed the literature for studies that used a lean tool along with an implementation science determinants framework (January 1999 through August 2018). Seven studies (8 publications) were identified, inclusive of 2 protocols and 6 research articles across multiple continents. All included studies used the consolidated framework for implementation research as their implementation science determinants framework. Lean tools included in more than 1 publication were process mapping (4 publications), process redesign (3 publications), and 5S standardization (2 publications). Only 1 study proposed using a lean tool concurrently with an implementation science determinants framework in the design and execution of the QI project. Few published studies utilize both an implementation science determinants framework or checklist and 1 or more lean tool in their study design.

Increased effectiveness of urinalysis testing via the integration of automated instrumentation, the lean management approach, and autoverification

Background

In 2014, the Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand developed and implemented a new process that uses fully automated instrumentation, the lean management approach, and autoverification to improve the productivity and efficiency of the urinalysis workflow process. The aim of this study was to evaluate analytical turnaround time compared with our old urinalysis workflow process and our new urinalysis workflow process that was launched in 2014.

Methods

This study was performed at the Central Laboratory of our center during June 2017 using data collected from the July 2012 (old process) and July 2014 (new process) study periods. We used our laboratory information system to compute and analyze turnaround time of urinalysis tests, and those results were compared between processes.

Results

The 90th percentile turnaround time in overall data was dramatically decreased from approximately 60 minutes in 2012 to <50 minutes in 2014. The mean during both 6:00 am to 9:00 am and 9:00 am to 12:00 pm was approximately 42 minutes in 2012; however, that duration was reduced to approximately 30 minutes for both of those time periods in 2014. Specimens within 60 minutes in both intervals increase from approximately 80% to more than 90%.

Conclusion

The results of this study revealed our new urinalysis workflow process that incorporates fully automated instrumentation, the lean management approach, and autoverification to be effective for significantly increasing productivity as measured by analytical turnaround time and removing 1 staff to another section.

Breast cancer treatment pathway improvement using time-driven activity-based costing

Time-driven activity-based costing (TDABC) is increasingly used to establish more accurate and time-dependent costs for complex health care pathways. We propose to extend this approach to detect the specific improvements (eg, lean methods) that can be introduced into a care process. We analyzed a care trajectory in radiation oncology for breast cancer patients at major Canadian urban hospital. This approach allowed us to identify the activities and resource groups related to the execution of each activity, and to estimate the execution time for each. Based on the model, we were able to extract financial data with which we could evaluate process costs. The total cost of the care trajectory was $2383.82 for 2015 to 2016. Out of a total of 1389 trajectories, only 268 were completed. The implementation of TDABC gives users a clearer idea of costs and encourages managers to understand how they break down over the course of a care trajectory. Once these costs are understood, decisions can be made regarding resource allocation and waste elimination, enabling lean methods to be implemented. The result is better reorganization of work by allocating resources differently, optimizing the care trajectory, and thereby reducing its costs.

Comparison of clinical characteristics between lean and obese nonalcoholic fatty liver disease in the northeast Chinese population

Introduction

Nonalcoholic fatty liver disease (NAFLD) is seen commonly in patients with obesity, but there are many non-obese people who also have NAFLD, which we call lean NAFLD. The objective of this study is to compare the characters of lean and obese NAFLD individuals aimed to better understand the pathogenesis of NAFLD.

Material and methods

A total of 496 NAFLD cases (history of alcohol consumption, medication used within the last 3 months, hepatitis virus infection, autoimmune or hereditary liver disease were excluded), divided into an obese (body mass index (BMI) ≥ 25 kg/m²) NAFLD group (n = 395) and lean (BMI < 25 kg/m²) NAFLD group (n = 101), were investigated. Gender, age, alanine aminotransferase, triglycerides, cholesterol, and the blood glucose were compared between the two groups.

Results

A male-dominated discrepancy of gender distribution was more evident in obese NAFLD group. Elevated alanine amonotransferase was more common in the obese NAFLD group. 50–59 years was the peak age of both lean and obese NAFLD groups. Normal triglycerides (TG) patients were more common in the lean NAFLD group, while the proportion of elevated TG patients was higher in the obese NAFLD group. No statistically significant difference in the proportion of elevated cholesterol patients was found between the two groups. In the lean NAFLD group, the proportion of females was higher in the normal fasting glucose group.

Conclusions

Sexual dimorphism exists in lean NAFLD patients, but this trend was most pronounced during the age range 40–49 years and disappeared after entering the 50–59-year-old age range. In lean NAFLD patients, normal levels of TG and blood glucose were more common, and occurrence of non-alcoholic steatohepatitis was less common than among obese NAFLD.

Utilizing Quality Improvement Methods to Examine the Radiation Therapy Pathway for Patients Requiring Palliative Radiation Therapy at a Community Cancer Center

BACKGROUND

At a community cancer center, during weekly quality improvement huddles, the radiation therapy team expressed stress and frustration with the pretreatment pathway for patients requiring palliative radiotherapy. As the department was meeting provincial targets with respect to wait times, it was unknown why the consensus around the department reflected discomfort and stress.

METHODS

Four radiation therapists formed a quality improvement project team, intent on utilizing a data-driven improvement cycle to investigate and address opportunities to improve the discomfort around this pretreatment pathway. After defining the process and identifying the customers (the health care providers operating in this pathway), the team conducted interviews with each person, transcribing answers verbatim, and grouping results by discipline. Utilizing the interview themes, each discipline identified one or two priorities to measure, as well as metrics to capture the magnitude and prevalence of these priorities.

RESULTS

Each discipline's priorities were measured and analyzed. The identified issues brought forward at the weekly quality improvement huddles were not as prevalent as expected. Minor changes were implemented for priority issues.

CONCLUSION

The team focused on the four principles of quality improvement: the patient, team, process, and data to address the expressed discomfort around this specific radiation therapy pathway. The results dispelled some of the myths among teams and provided solutions to areas where minor improvements were required. Utilizing the data, an evidence-informed timeline was validated, encouraging task deadlines to be more evenly distributed across the pathway. Plans to monitor this pathway are being established. The team was successful in contributing to a growing culture of continuous improvement at this community cancer center.

Lean Path for High-Quality Development of Chinese Logistics Enterprises Based on Entropy and Gray Models

According to literature review and the data of China’s logistics listed companies, this paper firstly designs the high-quality development evaluation system of logistics enterprises and establishes the panel data model group. Secondly, the method of entropy weight-Technique for Order Preference by Similarity to an Ideal Solution (TOPSIS method) is used to synthesize and regress the indexes, and obtains that the fitting degree of the model is low, which is caused by the lack of data of some indicators in the logistics enterprises. Due to the gray nature of data information, the improved gray relational model and the three-dimensional gray relational model are constructed to study, in-depth, the strategic focus and breakthrough of high-quality development of Chinese logistics enterprises. The research finds that the innovation and the operation ability of Chinese logistics enterprises are weak, which shows specifically in the following aspects: (1) The irrational structure of the employees, the proportion of employees with a bachelor degree or above is small, and the high-education personnel fail to significantly promote the corporate performance; (2) R&D expenditure has little effect on the high-quality development of enterprises. The proportion of R&D expenses is small and cannot be translated into actual benefits, and the ability of enterprise management innovation is insufficient. According to these findings, this paper gives three lean paths for the high-quality development of China’s logistics enterprises.

Wanted in health care: Lean experts with a broad perspective

AIM

To reflect on Lean experts' perspective on components of Lean management in health care and its implications for practice.

BACKGROUND

The involvement of Lean experts is one of the key succes factors of a sustainable Lean transformation in health care.

METHODS

Thirteen Lean experts participated in two focus groups. They all had experience in the implementation of Lean in healthcare organizations.

RESULTS

Lean experts all seem to have a unique perspective on Lean management in health care. Experts without a healthcare degree appear to focus more on the entire management system, where experts with a nursing degree seem to concentrate more on the soft Lean principles.

CONCLUSION

It seems plausible their professional background appears to have an influence.

IMPLICATIONS FOR NURSING MANAGEMENT

In selecting a Lean expert, nurse managers may want to gauge what elements the Lean expert tends to emphasize. It seems plausible to opt for a Lean expert without a healthcare degree to accomplish the Lean transformation as they have a broader view on Lean. It may also be useful for managers to involve several Lean experts, all with complementary perspectives and backgrounds.

Metabolic disturbances in non-obese women with polycystic ovary syndrome: a systematic review and meta-analysis

OBJECTIVE

To explore metabolic disturbances in nonobese women with polycystic ovary syndrome (PCOS) compared with nonobese healthy controls.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Nonobese women with PCOS and nonobese healthy controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Prevalence of metabolic disturbances including hyperinsulinemia, insulin resistance (IR), impaired fasting glucose (IFG), impaired glucose intolerance (IGT), prediabetes, dyslipidemia, hypercholesterolemia, hypertriglyceridemia, and low high-density lipoprotein (low-HDL), as well as other metabolic outcomes such as type 2 diabetes mellitus (T2DM), hypertension, metabolic syndrome (Mets), myocardial infarction, stroke, cerebrovascular accident, arterial occlusive disease, and coronary heart disease.

RESULT(S)

Compared to nonobese controls, nonobese women with PCOS showed a higher prevalence of hyperinsulinemia (odds ratio [OR], 36.27; 95% confidence interval [CI] 1.76-747.12), IR (OR, 5.70; 95% CI 1.46-22.32), IGT (OR, 3.42; 95% CI 1.56-7.52), T2DM (OR, 1.47; 95% CI 1.11-1.93), hypertriglyceridemia (OR, 10.46; 95% CI 1.39-78.56), low-HDL (OR, 4.03; 95% CI 1.26-12.95), and Mets (OR, 2.57; 95% CI 1.30-5.07). No significant difference was observed for IFG, pre-DM, dyslipidemia, hypercholesterolemia, and hypertension. In subgroup analysis, Whites exhibited increased risks of IR, IGT, IFG, T2DM, hypertension, and Mets, whereas no significant metabolic change was found in Asians. No study reported specifically an incidence of myocardial infarction, stroke, cerebrovascular accident, arterial occlusive disease, and coronary heart disease in nonobese women with PCOS.

CONCLUSION(S)

Nonobese women with PCOS also suffer from metabolic disturbances and the risk of long-term metabolic complications. Further efforts should be made to elucidate underlying mechanisms and possible interventions in the early phase.

Implementation of Lean and Six Sigma principles in ophthalmology for improving quality of care and patient flow

Lean management is a set of principles aimed at improving processes by identifying and eliminating steps that do not add value to the consumer. Such steps lead to wasted time, resources, and expenses and result in customer and employee dissatisfaction. Although initially invented and perfected for factory assembly lines in the automobile industry, it has since disseminated extensively and has repeatedly proven a powerful "engine" for improving quality and quantity in the health-care setting. Lean implementation benefits include improved safety, reduced waiting times, increased patient satisfaction, and cost reduction. Nevertheless, it appears to be less familiar and appreciated in ophthalmology and more specifically as a tool for managing an efficient eye care clinic. In this review, we explain what "Lean" and Six Sigma are and highlight their implementation in settings such as cataract surgery, laser capsulotomy, an ophthalmic emergency room and its role as a powerful tool for improving clinic patient flow. We discuss basic principles of Lean management, review examples of implementing these principles in an ophthalmology practice, and finally, offer physicians practical tools for identifying "wasteful" processes and ways to eliminate them.

The impact of lipid accumulation product (LAP) and visceral adiposity index (VAI) on clinical, hormonal and metabolic parameters in lean women with polycystic ovary syndrome

This study was performed to assess the impact of lipid accumulation product (LAP) and visceral adiposity index (VAI) on clinical, hormonal, and metabolic parameters in lean women with PCOS. Retrospective analysis of 120 consecutive lean PCOS subjects was performed. Subjects were divided into two groups according to HOMA-IR, as IR + and IR-. A HOMA-IR value above 2.5 was used to indicate IR. Clinical, hormonal and metabolic parameters were compared between the two groups. Correlations between LAP and VAI and clinical, hormonal, metabolic features in women PCOS were analyzed. One hundred twenty lean PCOS subjects were enrolled, of which 39 were insulin resistant. Comparison of group means showed significantly higher values for TG levels, FAI, FGS, TG/HDL-c, TyG, LAP, and VAI indexes and lower values for glucose/insulin ratio and QUICKI in the IR + group. LAP and VAI were both found to be positively correlated with each other and with WC, FAI, FGS, TG, TC levels, lipid ratios, TyG index, and HOMA-IR and negatively correlated with Glucose/Insulin ratio, QUICKI, and HDL-c in lean women with PCOS. LAP and VAI may be promising in early identification of IR and cardiometabolic risk and may be useful for the assessment of hyperandrogenism in lean women with PCOS.

What Does It Really Look Like to Properly Address a "Human Error Problem" in Biopharma? The Human Performance Blue-Sky Description That Will Help Improve Industry Performance

A clear picture of what Human Performance success looks like is now available from BioPhorum, where members of the Human Performance workstream have defined a blue-sky for the industry. This blue-sky document is both a guide and an assessment tool, which includes warning flags that help to identify significant obstacles in the way of effective human performance integration with operations that must be addressed. The effort to improve reliable operations within biopharma using elements of human performance borrowed from other industries have experienced uneven results and slow progress across the last seven years and has been bogged down for multiple significant reasons. These include a mental model that persists within the industry where workers are assumed to be the problem that needs fixing, the mistaken belief that Lean/Operational Excellence is a cure-all and nearly equivalent to human performance, neglecting the need to fundamentally rethink why and how investigations are performed, and truly underestimating the time, effort, strength of sponsor support, and strategy needed to change how work is designed, executed, and then later learned from.LAY ABSTRACT: Human Performance is an integrated risk management approach to improving systems, that includes human factors and systems safety, that leads to higher reliability and enhanced operational resilience. A clear picture of what Human Performance looks like in biopharma is available from the BioPhorum, where members of the Human Performance workstream have defined a blue-sky for the industry. This blue-sky document is both a guide and an assessment tool that will help to identify the steps to effective human performance integration with operations. The effort to improve reliable operations within biopharma using elements of human performance borrowed from other industries has experienced uneven results and slow progress across the last seven years and has been bogged down for multiple significant reasons. These include a mental model that persists within the industry where workers are assumed to be the problem that needs fixing, the mistaken belief that Lean practices (intended to improve productivity & efficiency) is a cure-all and nearly equivalent to human performance, neglecting the need to fundamentally rethink why and how investigations are performed, and truly underestimating the time, effort, strength of sponsor support needed to change how work is designed, executed, and then later learned from.

Predictors of nonalcoholic steatohepatitis and significant fibrosis in non-obese nonalcoholic fatty liver disease

AIMS

We compared (a) demographic and clinical characteristics and (b) determinants of nonalcoholic steatohepatitis and significant fibrosis in non-obese and obese nonalcoholic fatty liver disease.

METHODS

A cross-sectional study of 664 Asian subjects (mean age 53.1 years; men 50.3%) with biopsy-proven nonalcoholic fatty liver disease and controls was conducted. Subjects were divided by their body mass index into obese (body mass index ≥25 kg/m² ) and non-obese (body mass index <25 kg/m² ).

RESULTS

Observations in subjects with non-obese nonalcoholic fatty liver disease were in between non-obese controls and subjects with obese nonalcoholic fatty liver disease for body mass index, sagittal abdominal diameter, aminotransferase levels, insulin resistance and abdominal visceral adipose tissue area. There was no significant difference in histology between non-obese and obese subjects with nonalcoholic fatty liver disease except for lower grade of hepatic steatosis in nonobese nonalcoholic fatty liver disease and higher severity of hepatic fibrosis in nonobese nonalcoholic steatohepatitis. Predictors of nonalcoholic steatohepatitis in nonobese subjects included females (odds ratio 2.49), higher alanine aminotransferase (odds ratio 1.03), lower high-density lipoprotein cholesterol (odds ratio 0.96), higher prevalence of diabetes (odds ratio 3.65) and higher visceral adipose tissue area (odds ratio 1.63 per standard deviation increase of visceral adipose tissue area) while age (odds ratio 1.04), higher aspartate aminotransferase (odds ratio 1.02), diabetes (odds ratio 2.76) and higher visceral adipose tissue area (odds ratio 1.57 per standard deviation increase) were associated with significant fibrosis in the non-obese. Sagittal abdominal diameter was independently associated with nonalcoholic steatohepatitis or significant fibrosis among subjects with non-obese nonalcoholic fatty liver disease.

CONCLUSION

While there were a few phenotypic differences from obese subjects, non-obese subjects with nonalcoholic fatty liver disease displayed a similar severity of histological liver damage. Potential factor(s) beyond obesity may play a role as non-obese nonalcoholic fatty liver disease advances to more severe disease.

Automation and productivity in the clinical laboratory: experience of a tertiary healthcare facility

Clinical laboratories for in vitro diagnostics are facing pressure to preserve cost control while providing better services through new initiatives. Laboratory automation is a partial answer to this problem, having come a long way from the early days of clinical laboratory testing. The journey and implementation of automation in the Singapore General Hospital's Clinical Biochemistry Laboratory has allowed for sustained performance in the light of increasing workload and service commitments amid an evolving healthcare environment. Key to realising predicted outcomes is the optimisation of workflow processes, reduction of errors, and spatial placement of specimen reception and analytical areas. This paper gives an overview of our experience with automation in the clinical laboratory and its subsequent impact on service standards.

A Quality Improvement Initiative: Using Lean Methodology to Improve Efficiency of the Morning Cycle Monitoring at an Ambulatory Academic Fertility Clinic

OBJECTIVE

Patients receiving fertility treatments require near-daily blood work and ultrasound for cycle monitoring. Patient volumes at an academic hospital-based ambulatory clinic were expected to increase with expanded provincial funding. The aim of this quality improvement project was for 85% of cycle monitoring patients to have a turnaround time (TAT) of 20 minutes or less from arrival until checkout.

METHODS

This is a time series study analyzed with statistical process control methodology. A baseline survey was conducted to understand patient priorities. Multiple site-specific change ideas were developed by front-line staff using lean methodology including standard processes, standard work, supportive tools, visual management, and staffing and scheduling to meet Takt time. Patient and staff satisfaction surveys were conducted after implementation (Canadian Task Force Classification II-2).

RESULTS

With the start of funding in December 2015 the clinic accommodated a 17% increase in daily patient volumes and increased the proportion of patients receiving education at each visit from 50% to 100%. Despite increased patient volumes and added education time, the control chart showed special cause variation with decreased TATs from 38.2 to 34.7 minutes. Patient surveys showed that their priorities were being met or exceeded, and all staff reported increased satisfaction with the new process.

CONCLUSION

By using lean methodology in an ambulatory fertility setting, the clinic was able to improve efficiency in the morning monitoring process to decrease patient TATs while accommodating increased patient volumes and improving the quality of patient care.

Reducing errors in the administration of medication with infusion pumps in the intensive care department: A lean approach

Background:

Medication errors occur frequently and may potentially harm patients. Administering medication with infusion pumps carries specific risks, which lead to incidents that affect patient safety.

Objective:

Since previous attempts to reduce medication errors with infusion pumps failed in our intensive care unit, we chose the Lean approach to accomplish a 50% reduction of administration errors in 6 months. Besides improving quality of care and patient safety, we wanted to determine the effectiveness of Lean in healthcare.

Methods:

We conducted a before-and-after observational study. After baseline measurement, a value stream map (a detailed process description, used in Lean) was made to identify important underlying causes of medication errors. These causes were discussed with intensive care unit staff during frequent stand-up sessions, resulting in small improvement cycles and bottom-up defined improvement measures. Pre-intervention and post-intervention measurements were performed to determine the impact of the improvement measures. Infusion pump syringes and related administration errors were measured during unannounced sequential audits.

Results:

Including the baseline measurement, 1748 syringes were examined. The percentage of errors concerning the administration of medication by infusion pumps decreased from 17.7% (95% confidence interval, 13.7–22.4; 55 errors in 310 syringes) to 2.3% (95% confidence interval, 1–4.6; 7 errors in 307 syringes) in 18 months (p < 0.0001).

Conclusion and Relevance:

The Lean approach proved to be helpful in reducing errors in the administration of medication with infusion pumps in a high complex intensive care environment.

Lean non-alcoholic fatty liver disease patients had comparable total caloric, carbohydrate, protein, fat, iron, sleep duration and overtime work as obese non-alcoholic fatty liver disease patients

BACKGROUND AND AIM

Non-alcoholic fatty liver disease (NAFLD) is a multifactorial disease that involves a complex interaction between genetics, diet, and lifestyle. Although closely related with obese subjects, it is also common in lean humans. This study aimed to characterize the diet and lifestyle of lean and obese NAFLD patients in China.

METHODS

To characterize the diet and lifestyle of lean and obese NAFLD patients, we conducted a matched case-control study that included 351 Chinese adults. General characteristics, dietary intake, and lifestyle were gathered by using a valid and reliable dietary questionnaire. We compared the dietary intake and lifestyle between lean and obese NAFLD patients.

RESULTS

All NAFLD patients had more total caloric, calorigenic nutrients (carbohydrate, fat, and protein), grain, potato, fruit, and iron with higher levels of waist circumference and overtime work but shorter sleep duration than their corresponding controls. Particularly, lean NAFLD patients consumed comparable total caloric, calorigenic nutrients, iron, sleep duration, and overtime work as obese NAFLD patients, though they consumed lower levels of grain, potato, and fruit (lean NAFLD patients vs. obese NAFLD patients: mean ± SD, g/day grain: 291.8 ± 83.8, 365.2 ± 89.0; potato: 63.5 ± 33.1, 80.4 ± 37.6; fruit: 324.3 ± 148.4, 414.0 ± 220.4; P < 0.0001).

CONCLUSION

Non-alcoholic fatty liver disease patients had higher total caloric, calorigenic nutrients, grain, potato, fruit, iron, and overtime work but shorter sleep duration. Lean NAFLD patients had comparable total caloric, calorigenic nutrients, iron, sleep duration, and overtime work as obese NAFLD patients. These features could be used to the nutritional education and therapeutic guidance for lean NAFLD patients in the future.

Toll like receptors (TLRs) in response to human gut microbiota of Indian obese and lean individuals

Background:

The rising incidence of obesity is one of the most serious public health issues in the developed as well as in developing countries like India. Obesity and overweight are most important risk factors for many chronic diseases, including cardiovascular diseases, diabetes and cancer. In this study the body mass index (BMI) cut off was taken as 18.5-22.9 kg/m² for normal, 23.0-24.9 kg/m² for Overweight and >25 kg/m² for obese as per WHO recommendation for Asian Indians, which is different for developed and developing countries. Role of gut microbiota mediated immune response in the development of obesity has been studied but the literature on Indian population are lacking. Therefore, a study was conducted to determine Toll like receptors (TLRs) in response to human gut microbiota of Indian obese and lean individuals using viable colonocytes in a Non invasive technique and Flowcytometry.

Methods:

A total of 20 healthy volunteer (10 obese and 10 lean) were enrolled in the study as per inclusion and exclusion criteria. Viable colonocytes were isolated from fecal samples using a Non invasive technique (SCSR Method). Toll like receptors (TLRs) and immunoglobulin (IgA &IgG) receptor concentration were measured by standard Flowcytometry methods using specific fluorochrome conjugated antibodies.

Results:

Average TLR2 receptor concentration was significantly higher in obese (6.35 %) as compared to lean (2.9 %) (P = 0.01). TLR4 receptor concentration was 1.4 % in obese and 1.65 % in lean although the difference was not statistically significant (P = 0.59). IgA & IgG receptor concentration was 49.6 % & 11.2 % in the obese and 67.15 % & 8.05 % in the lean respectively but the differences among both the group were not statistically significant.

Conclusion:

The results of the present study will be helpful for physicians and researchers to find some biomarkers which can determine predisposition of the obesity in Indian population and helps to use alternative therapeutics such as probiotics to maintain gut homeostasis and immune modulation to prevent obesity.