Background:
Multidisciplinary care of patients with chronic kidney disease (CKD) as it previously existed was predicated on an evidence and experience base of improved patient outcomes within an ...established and well-described service delivery model. The onset of the COVID-19 pandemic brought with it a departure from this established care delivery model toward integration of virtual care and in-person care.
Objective:
To develop an evaluation framework to determine whether this shift in service delivery models has affected quality of multidisciplinary kidney care and/or patient-clinician interactions and relationships.
Design:
A sequential multiphase, mixed-methods evaluation.
Setting:
All 15 British Columbia (BC) multidisciplinary kidney care clinics (KCCs).
Participants:
All patients and all clinicians in all KCCs across BC will be invited to participate in the planned evaluation.
Measurements:
Qualitative and quantitative feedback from patients and families living with CKD and KCC clinicians.
Methods:
The planned multiphase evaluation of virtual care integration in KCCs will be conducted across all 15 KCCs in the province of BC, Canada. The following phases are proposed: (1) review of current virtual care integration and practices, (2) assessment of patient and clinician experiences and perspectives via semi-structured interviews, (3) validation of those patient and clinician perspectives via survey of a larger sample, (4) compilation and analysis of all phases to provide informed recommendations for patient and visit format selection in a mixed in-person and virtual multidisciplinary clinic setting.
Limitations:
This work will not capture any information about the relationship between differences in virtual usage parameters and clinical outcomes or financial implications.
Conclusions:
There is no existing framework for either evaluation of multidisciplinary CKD care quality in a virtual setting or evaluation of care quality following a substantial change in service delivery models. The proposed evaluation protocol will enable better understanding of the nuances in kidney care delivery in this new format and inform how best to optimize the integration of virtual and pre-existing formats into kidney clinic care delivery beyond the pandemic. Beyond the current evaluation, this protocol may be of use for other jurisdictions to evaluate their own local instances of virtual care implementation and integration. The model may be adapted to evaluate quality of multidisciplinary kidney care delivery following other changes to clinic service delivery models.
Background:
Following onset of the COVID-19 pandemic, chronic kidney disease (CKD) clinics in BC shifted from established methods of mostly in-person care delivery to virtual care (VC) and thereafter ...a hybrid of the two.
Objectives:
To determine strengths, weaknesses, quality-of-care delivery, and key considerations associated with VC usage to inform optimal way(s) of integrating virtual and traditional methods of care delivery in multidisciplinary kidney clinics.
Design:
Qualitative evaluation.
Setting:
British Columbia, Canada.
Participants:
Patients and health care providers associated with multidisciplinary kidney care clinics.
Methods:
Development and delivery of semi-structured interviews of patients and health care providers.
Results:
11 patients and/or caregivers and 12 health care providers participated in the interviews. Participants reported mixed experiences with VC usage. All participants foresaw a future where both VC and in-person care was offered. A reported benefit of VC was convenience for patients. Challenges identified with VC included difficulty establishing new therapeutic relationships, and variable of abilities of both patients and health care providers to engage and communicate in a virtual format. Participants noted a preference for in-person care for more complex situations. Four themes were identified as considerations when selecting between in-person and VC: person’s nonmedical context, support available, clinical parameters and tasks to be completed, and clinic operations. Participants indicated that visit modality selection is an individualized and ongoing process involving the patient and their preferences which may change over time. Health care provider participants noted that new workflow challenges were created when using both VC and in-person care in the same clinic session.
Limitations:
Limited sample size in the setting of one-on-one interviews and use of convenience sampling which may result in missing perspectives, including those already facing challenges accessing care who could potentially be most disadvantaged by implementation of VC.
Conclusions:
A list of key considerations, aligned with quality care delivery was identified for health care providers and programs to consider as they continue to utilize VC and refine how best to use different visit modalities in different patient and clinical situations. Further work will be needed to validate these findings and evaluate clinical outcomes with the combination of virtual and traditional modes of care delivery.
Trial registration:
Not registered.
Mutant endo-mannanases, in which the catalytic nucleophile has been replaced, function as glycosynthases in the synthesis of manno-oligosaccharides of defined lengths.
The endo-β-1,4-mannanase from the soil bacterium Cellulomonas fimi is a modular plant cell wall degrading enzyme involved in the hydrolysis of the backbone of mannan, one of the most abundant ...polysaccharides of the hemicellulosic network in the plant cell wall. The crystal structure of a recombinant truncated endo-β-1,4-mannanase from C. fimi (CfMan26A-50K) was determined by X-ray crystallography to 2.25 Å resolution using the molecular replacement technique. The overall structure of the enzyme consists of a core (β/α)8-barrel catalytic module characteristic of clan GH-A, connected via a linker to an immunoglobulin-like module of unknown function. A complex with the oligosaccharide mannotriose to 2.9 Å resolution has also been obtained. Both the native structure and the complex show a cacodylate ion bound at the −1 subsite, while subsites −2, −3, and −4 are occupied by mannotriose in the complex. Enzyme kinetic analysis and the analysis of hydrolysis products from manno-oligosaccharides and mannopentitol suggest five important active-site cleft subsites. CfMan26A-50K has a high affinity −3 subsite with Phe325 as an aromatic platform, which explains the mannose releasing property of the enzyme. Structural differences with the homologous Cellvibrio japonicus β-1,4-mannanase (CjMan26A) at the −2 and −3 subsites may explain the poor performance of CfMan26A mutants as “glycosynthases”.
The Gram‐positive soil bacterium Cellulomonas fimi is shown to produce at least two intracellular β‐N‐acetylglucosaminidases, a family 20 β‐N‐acetylhexosaminidase (Hex20), and a novel family ...3‐β‐N‐acetylglucosaminidase/β‐glucosidase (Nag3), through screening of a genomic expression library, cloning of genes and analysis of their sequences. Nag3 exhibits broad substrate specificity for substituents at the C2 position of the glycone: kcat/Km values at 25 °C were 0.066 s−1·mm−1 and 0.076 s−1·mm−1 for 4′‐nitrophenyl β‐N‐acetyl‐d‐glucosaminide and 4′‐nitrophenyl β‐d‐glucoside, respectively. The first glycosidase with this broad specificity to be described, Nag3, suggests an interesting evolutionary link between β‐N‐acetylglucosaminidases and β‐glucosidases of family 3. Reaction by a double‐displacement mechanism was confirmed for Nag3 through the identification of a glycosyl–enzyme species trapped with the slow substrate 2′,4′‐dinitrophenyl 2‐deoxy‐2‐fluoro‐β‐d‐glucopyranoside. Hex20 requires the acetamido group at C2 of the substrate, being unable to cleave β‐glucosides, since its mechanism involves an oxazolinium ion intermediate. However, it is broad in its specificity for the d‐glucosyl/d‐galactosyl configuration of the glycone: Km and kcat values were 53 µm and 482.3 s−1 for 4′‐nitrophenyl β‐N‐acetyl‐d‐glucosaminide and 66 µm and 129.1 s−1 for 4′‐nitrophenyl β‐N‐acetyl‐d‐galactosaminide.
The conformational reaction pathway for β‐mannosidases proposed here is distinct from that of glucosidases and cellulases. The proposal is based on substrate distortions along the reaction pathway of ...a β‐mannosidase (see picture) that were revealed by X‐ray crystallography and are close in conformational space to known β‐mannosidase inhibitors.
Cellulomonas fimi genomic DNA was digested with HpaI, MunI, HindIII, and NsiI, producing fragments ranging in size from 20 to 1400 kbp that were resolved by pulsed field gel electrophoresis. Genetic ...and physical linkages were determined by Southern blotting and were used to construct a genome map. Cellulomonas fimi has a single circular chromosome of approx. 4000 kbp. Except for two closely linked genes, cbh6A and cel5A, the genes known to encode glycoside hydrolases are scattered widely on the chromosome.Key words: Cellulomonas fimi, genome map, pulsed field gel electrophoresis, glycoside hydrolases.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Engineering enzymes: The glutamic acid nucleophile of a retaining β‐mannosidase has been replaced with a serine residue to form a β‐mannosynthase. When the new enzyme is provided with an α‐mannosyl ...fluoride donor and an appropriate acceptor, β‐mannoside linkages are synthesized (see scheme). Remarkably, α‐mannosyl fluoride can be generated in situ by providing the mannosynthase with excess fluoride ion.
Cellulomonas fimi genomic DNA was digested with HpaI, MunI, HindIII, and NsiI, producing fragments ranging in size from 20 to 1400 kbp that were resolved by pulsed field gel electrophoresis. Genetic ...and physical linkages were determined by Southern blotting and were used to construct a genome map. Cellulomonas fimi has a single circular chromosome of approx. 4000 kbp. Except for two closely linked genes, cbh6A and cel5A, the genes known to encode glycoside hydrolases are scattered widely on the chromosome.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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