Impact of PEWS on Perceived Quality of Care During Deterioration in Children With Cancer Hospitalized in Different Resource-Settings

BackgroundChildren with cancer are at high risk for clinical deterioration and subsequent mortality. Pediatric Early Warning Systems (PEWS) have proven to reduce the frequency of clinical deterioration in hospitalized patients. This qualitative study evaluates provider perspectives on the impact of PEWS on quality of care during deterioration events in a high-resource and a resource-limited setting.MethodsWe conducted semi-structured interviews with 83 healthcare staff (nurses, pediatricians, oncology fellows, and intensivists) involved in recent deterioration events at two pediatric oncology hospitals of different resource levels: St. Jude Children’s Research Hospital (SJCRH; n = 42) and Unidad Nacional de Oncología Pediátrica (UNOP; n = 41). Interviews were conducted in the participant’s native language (English or Spanish), translated into English, and transcribed. Transcripts were coded and analyzed inductively.ResultsProviders discussed both positive and negative perspectives of clinical deterioration events. Content analysis revealed “teamwork,” “experience with deterioration,” “early awareness,” and “effective communication” as themes associated with positive perception of events, which contributed to patient safety. Negative themes included “lack of communication,” “inexperience with deterioration,” “challenges with technology”, “limited material resources,” “false positive score,” and “objective tool.” Participants representing all disciplines across both institutions shared similar positive opinions. Negative opinions, however, differed between the two institutions, with providers at UNOP highlighting limited resources while those at SJCRH expressing concerns about technology misuse.ConclusionProviders that care for children with cancer find PEWS valuable to improve the quality of hospital care, regardless of hospital resource-level. Identified challenges, including inadequate critical care resources and challenges with technology, differ by hospital resource-level. These findings build on growing data demonstrating the positive impact of PEWS on quality of care and encourage wide dissemination of PEWS in clinical practice.

Evolutionary coexistence in a fluctuating environment by specialization on resource level

Microbial communities in fluctuating environments can contain many species and diversity within species, both in natural environments such as the human gut, and in laboratory settings when communities are propagated for a long time. Whether this diversity is at the species level, within the species level, or a combination of both, the question remains: what processes lead to the origination and maintenance of this diversity? When nutrient levels fluctuate over time, one possibly relevant process is that different types specialize on low and high nutrient levels. The relevance of this process is supported by observations of types co-existing through this mechanism when put together in the laboratory, and simple models, which show that negative frequency dependence of two types, specialized on low and high resource level, can stabilize coexistence. However, when microbial populations are in an environment for a long time, they will evolve. In this article we determine what happens when species can evolve; whether branching can occur to create diversity and whether evolution will destabilize coexistence. We find that for the trade-off data between growth at low and high substrate concentrations, available for the bacterium Escherichia coli and the yeast Saccharomyces cerevisiae on glucose, there is only a small portion of the trait-space that allows for coexistence. Moreover, this coexistence is destabilized by evolution, and the only evolutionary stable outcome is a single strategy. When we combine two species that are well-adapted on their own, we do find that they can form an evolutionary singular coalition. We conclude that although specialization on resource level can support diversity within a species, it is likely not a cause by itself. In contrast, for species consortia this specialization can lead to evolutionary stable coexistence.

Penyuluhan Makanan Bergizi Seimbang Melalui Pendekatan Metode Ular Tangga

The health issue is still a primary obstacle in Indonesia. All sectors need to pay attention to it; otherwise, the human resource level will be low. In line with this socialization is needed to encourage children especially, to start aware of consuming a healthy diet. In addition, this can broaden children’s horizons about what they better eat. The method in this activity is by using snake ladder game which is more attractive and fun for children. This method, in fact, can enhance children's knowledge. During the pre-test, the correct answers were 11,9 on average; while after the socialization the right answers were 14,5 on average. It shows that the sharing knowledge by snake ladder game is effectively helpful for children to increase their knowledge.

HOW DO PARTIALLY HIDING BEHAVIOR AND COMPLETELY HIDING BEHAVIOR IMPACT INTERACTING POPULATIONS?

As the two main behaviors of prey populations in ecological systems, the partially hiding behavior (PHB) and the completely hiding behavior (CHB) play a significant role in determining the dynamics of predator–prey models. This work examines to the dynamical consequences of predator–prey systems with the PHB and the CHB. Previous research has independently studied the two behaviors, and the general conclusions are that the two behaviors can have positive and/or negative impacts on the considered population models. However, to our knowledge, no study has combined and compared the two behaviors in studying the dynamical consequences of predation interactions. Motivated by this, we investigated the dynamical consequences induced by the PHB and the CHB. From a mathematical point of view, the dynamical behaviors are studied and the corresponding sufficient conditions are given. Our findings are general and some published models are special cases of ours. From an ecological point of view, we find that the size of the ecological regions is mainly determined by the two behaviors, and which one is ecologically beneficial for the health coexistence of the interacting populations are primarily determined by the functional response and the attack coefficient of predators. Moreover, we conclude that the evolutionary and optimal choices of prey behavior (PHB or CHB) depend on the predators attack coefficient (large or small attack coefficient) and the resource level (abundant or pool resource level).

Resource-Stratified Diagnostics in India: Current Practices and Aspirations for a National Standard

Purpose As international health systems set goals to improve and expand access to cancer care services, the global health community has applied evidence-based principles to develop resource-stratified pathways for cancer detection, diagnosis, and treatment. The Breast Health Global Initiative (BHGI) defines four detailed sets of infrastructure at the levels of basic, limited, enhanced, and maximal. Operationalizing these pathways to improve and expand breast cancer care requires an assessment of current resource availability and use, as well as an understanding of how clinical stakeholders value and prioritize various modalities. This study adapted the BHGI framework for breast cancer diagnostics to characterize the natural state of health system capabilities in India. This work aims to contribute to the validation of the resource stratification schema while collecting implicit practitioner impressions of an aspirational resource level, as would be codified by a national standard. Methods We interviewed oncologists at public and private hospitals in six urban areas throughout India with a multisection survey tool about the effects of cancer care infrastructure on patient care. In this section, respondents filled out a grid representation of 30 BHGI 2.5 diagnostic modalities divided into clinical tools, imaging and laboratory tests, and pathology. Respondents indicated whether they currently used each modality, and whether they would recommend that this should be included in a national standard of breast cancer care for India. Results At least three fourths of respondents indicated that they personally use 21 of the diagnostic modalities (n = 52), but only recommended 15 modalities for the national standard (n = 50). The top 11 modalities currently used included six basic, three limited, and two enhanced, whereas the top 11 modalities recommended for the national standard included four basic, one limited, three enhanced, and three maximal. Conclusion Diagnostic modalities consistently used by urban oncologists are not fully congruent with the group’s collective vision for a national standard of care, nor do the oncologists recommend a consistently more basic or limited national approach compared with urban practice. These heterogeneous results indicate that expanding breast cancer care in India will likely require dynamic recalibration of goal resource level definitions across the nodes of each regional referral network. AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . No COIs for the author.