This article presents an experience of deploying an integrated performance management system as a catalyst for the integration of a service trajectory for children in vulnerable situations. Called ‘‘Jimmy’’, the project identifies how the integrated performance management system makes it possible to improve accessibility, continuity of services and well-being at work among stakeholders.An action research was conducted in a large healthcare organization in Canada, between August 2016 and October 2018. Data was systematically collected throughout the various cycles of research using field notes, more than 350 hours of observations, 15 interviews and 3 focus groups.This research supports using an integrated performance management system as a model for collaborative management that supports both horizontal and vertical integration in the service trajectory. The use of visual boards and status sheet meetings were determining factors for service integration and the functioning of integrated teams. This also led to improvements in accessibility and continuity of services, as well as in employee well-being.Supported by the various tools of the integrated performance management system, Project ‘‘Jimmy’’ reinforces the implementation of linkage and coordination models, which in turn helps create strong connections among teams. The status sheet meetings and visual boards are tools that vertically integrate different hierarchical levels and horizontally integrate various front-line stakeholders through the user-oriented trajectory. In recent decades, many industrialised countries have made significant reforms to their health care systems, which has led to the implementation of integration mechanisms . For exaIn the wave of this change, the Quebec ministry of health and social services showed a strong desire to improve performance through the implementation of management tools. One target in its strategic planning  was the “By March 31, 2018, all institutions will have deployed their strategic control room and on March 31, 2020, organisations must have deployed 80% of their tactical and operational control rooms.”2. This territory has experienced significant population decline and low population density, which are sources of concern when it comes to service continuity for children, youth and families. Like many regions in Quebec, the territory served by the IHSSC studied here is experiencing a demographic decline and has a low population density. These appear to be contributing factors in the review of how services are organized in their current form. This territory also has challenges when it comes to updating programs or services for youth. The insufficient pool of target clients combined with the risks of social stigma associated with marginalized groups may constitute barriers to implementing programs for family clients.This article aims to ascertain how service integration processes are improved through the adoption of an integrated performance management system. This action research was carried out in IHSSC and specifically in the centre’s programmes for children, youth and families. In the 2015 reform, this IHSSC was created through the merger of 7 institutions that included 49 facilities spread out over more than 20,000 kmThis action research, which took place over more than two years, contributes to the literature by demonstrating the operational strength of the tools of the integrated performance management system (IPMS) to answer the following question: “Which integrated performance system tools support the integration of social services for children and their families?” The literature is scant on which integrated performance management system tools foster the integration of services for a target clientele. This article aims to fill this gap.Services can be integrated either vertically or horizontally 3438. Hor3455610Leutz  places tAlthough the tools of the integrated performance management system (particularly the control rooms) have been deployed in Quebec, few studies significantly demonstrate how these rooms add value to integrating care and services for a target clientele. This paper addresses this shortcoming by exploring the integrated performance management system tools that support better vertical and horizontal integration, particularly in programs for children, youth and families.The integrated performance management system currently deployed in Quebec’s health and social services network may be considered a key to the integration of services. This system is supported by a management philosophy based on continuous improvement and consists of a coherent set of standardised and coordinated principles, practices and tools that, through shared leadership, help an institution achieve clearly stated organisational objectives that aim to create value for all stakeholders.Organizational performance requires a performance management model that establishes a basis for organizational governance and a framework for how managers should make decisions when it comes to creating and distributing value in the organization . A leadiTo that end, performance assessment needs to consider multiple criteria necessary for the organization to find balance. Central to this notion is the quadruple aim  to assesThe tools and practices used for this action research were kaikaku, A3 reports, kaizen, control rooms, status sheets and kata.Kaikaku is a Japanese word that translates as “radical change” and is seen as a process that can generate significant results when existing practices are replaced with new ones . KaikakuThe A3 report is a summary document that conveys information about projects on a single A3-sized sheet (11 × 17 inches format in North America) on which a problem-solving approach is expressed in a structured way . There iKaizen means a “change for the better” and thus translates continuous improvement into a problem-solving process . This apControl rooms, or obeya in Japanese, are places where team members can meet to assess current performance in a dynamic way and engage in discussion to support future performance 3044. Con3039The status sheet represents a standardised dialogue between an employee and his or her immediate superior. The sheet helps the employee learn about and better understand the organisation’s operations and prevent potential problems within a trajectory. A status sheet meeting is facilitated by a senior administrator from the management committee based on status sheets from the field.Kata are small, structured practice routines. Learning and then combining these individual practice routines is a way of developing competency in the overall way or pattern of doing something . It is iFigure 1 synthesizes these various tools and how they are linked within the organization.All of these tools use the Plan, Do, Check, Adjust (PDCA) problem-solving cycle popularised by Deming . Figure This study uses action research, which consists of generating scientific knowledge to better understand and change the social reality of individuals . This ty17This action research was carried out between June 2016 and October 2018. More than 350 hours of data collection was performed to create field notes taken from semi-structured interviews, focus groups and participant observation. Semi-structured interviews were conducted at the participants’ workplace with four psychosocial workers, six senior administrators, and five middle managers. Each interview lasted between 60 and 90 minutes and was conducted using a semi-structured interview guide. The questions aimed to ascertain what happened and why it happened (diagnosis) and what could have been done differently (reflection). Saturation was reached once the themes and categories became repetitive or no longer provided new or different information .The data analysis strategies led to a detailed description of the various sources, including a full transcript of the content of all individual interviews from the audio recordings. These strategies related to grounded theory include three main coding steps: open coding, axial coding and selective coding .Three 90-minutes focus groups were also conducted in October 2018 based on the organisation’s hierarchical logic, i.e., strategic, tactical and operational. The focus groups were largely based on the learning history approach . A documAdditionally, over 350 hours of data was recorded in field notes from non-participant observations during different interdisciplinary meetings and during strategic, tactical and operational steering-room activities. The field notes were helpful for recording relevant information throughout the data collection period and were also useful for interpreting observations .The adopted methodology minimized the risks of bias thanks to in-depth knowledge of the study setting and great attention paid to the methodology employed . To asseThe research project was approved by the Research and Ethics Committee of the Université du Québec à Trois-Rivières (No. CER-18-244-07.01).Table 1 presents a summary of the results. Each phase of the PDCA cycle touches upon the types of intervention used for the tools of the integrated performance management system and the results obtained for the service integration project. However, some phases may have overlapped due to the cyclical process of the research.The results are presented based on the cyclical logic structured by the PDCA and action research methodology. In June 2016, senior managers invited 4 middle managers from the integrated youth teams and 4 senior managers to a kaikaku event and to an initial activity whose goal was to improve coordination between the youth programmes directorate and youth protection directorate. The meeting took place over two days.At the start of the kaikaku, senior managers conveyed a very clear vision as part of a true client-centred strategy :A child will never suffer alone.A child will always be supported in his or her pathway.Do the impossible to avoid putting the development or safety of a child in danger. (Children must receive the full range of services to ensure their development and safety.)Internal partners  and external partners were asked to contribute at a later date. As one staff member explained:“Jimmy” is not just young; he has other needs too. He may have impairments and be autistic as well […].”Prior to the kaikaku, the continuous improvement specialist documented the actual service pathway of a child and the child’s family. The initial service request was for a language impairment detected by a perinatal nurse when the child was 20 months old. The last intervention noted in the child’s record was a report that was under assessment, even though the child was almost 10 years old. First, the continuous improvement specialist documented response times, number of staff members, number of interventions, etc. The Chief Executive Officer (CEO) believes that it would have been useful to invite a child or their parents to participate in the service integration project. Nevertheless, two obstacles quickly became apparent. The first stemmed from the merger of 7 institutions and a new culture of collaboration that had to be created among different partners. The second related to the confidentiality of reported situations and the need to manage the risks of social stigmatization given the territory’s minimal client base .A major concern for the kaikaku participants was simplifying the child’s pathway through services. As youths in difficulty are truly at the heart of the integration project, the managers decided to give the project the name of a child— “Jimmy”—so that everyone saw this child as a real partner. The CEO stated that the kaikaku gave the project momentum:“After doing the kaikaku, we made a radical change and stayed focused on our goal.”The use of the A3 reports on the second day to deploy the integration project helped clarify the performance indicators that could improve service accessibility and continuity for the target clientele and each manager at the session signed it as a formal commitment to carry out and help implement the process. A member of the management team said:“The A3 reports allowed people who were supposed to contribute to the project to reflect on the project [….] when the managers signed the collaboration contract at the beginning of the project  that’s when people really became engaged.”Four kaizen workshops required more tactical and operational approaches and the idea was not to establish complete integration for each youth but rather to reflect on a trajectory that could be adjusted based on the profiles of each little “Jimmy” in the territory. The performance indicators were tracked in the tactical control room and in the multiple operational control rooms of the integrated teams.Despite the A3 tracking in the strategic control room, the integration project encountered issues that seriously impeded the integration project. Difficulties arising from the leadership of the senior managers of the different youth directorates hindered cooperation between the two sectors involved in the integration project. According to Kodner and Kyriacou , weak in“In some situations, we are still working in silos. We can’t work on Jimmy’s case on our own; these are young people with service episodes who may be transiently intellectually disabled or experiencing dependency  but all we have to help Jimmy together. The project helps us do that.”The arrival, in 2018, of two new senior managers with backgrounds in collaborative practices allowed for a single tactical control room to be set up for these two directorates. This was a major innovation. A middle manager had this to say about this innovation:“Implementing the tactical room jointly between the youth program and the youth protection directorate has advantages, such as continuity. The tactical control room mobilized everyone in a new integration context.”The tactical control room is where the continuum of services required by “Jimmy” and any areas of discontinuity identified by the operational control rooms are monitored. The comments of a middle manager support the importance of the tactical control room:“We have concrete results  we’re taking action and things are happening  there’s follow-up in the other control rooms.”Improvement Kata are an important practice methodology used during activities at operational or visual stations that identify improvement opportunities and next steps based on a PDCA cycle.An example of cooperation and a staff member’s concern for service integration was made through an Improvement Kata in the operational control room. Lack of contact over a long period led to dissatisfaction among foster families who need ongoing support to help a foster child who is coping with personal and family issues. With this approach, the institution can now confirm that all children placed with foster families are met with monthly. “Jimmy” no longer suffers alone and is always supported. The target was then set by the integrated youth team.Given the slow progress in the integration project and the lack of results to help Jimmy due to a lack of leadership, in June 2017 the CEO proposed creating a status sheet to better understand and document the trajectory through dialogue between an employee and his or her immediate superior. This new step created an anchor point for a new PDCA cycle. This individual status sheet was added as a complement to the activities in the operational control rooms and aimed to resolve the problems of accessibility, continuity and workplace well-being. Managers received training on the status sheets. Discussions were held to link the status sheets with the goals set out within the strategic A3 reports and the A3 projects. To reinforce this new practice, the CEO relied on the relationship skills of the continuous improvement specialist. The coaching of managers and teams was one reason for Project Jimmy’s success.Within six months, the status sheet helped minimise problems tracking significant indicators meant to improve the targets set at the start of the integration project. This tool opened the door to service integration by getting the other youth directorates involved to alleviate problems related to fragmentation that, in the words of a middle manager, “could let a Jimmy fall through the cracks.” One manager was impressed by the speed of this tool and said:“For me, the status sheet was a revelation out of the whole process.”Once a week, all managers are invited to a conference call with the associate chief executive officer to report on each team’s progress. Called “status sheet meetings,” these weekly calls held every Friday between 8:00 a.m. and 9:00 a.m. let staff assess performance in terms of service accessibility and continuity in the trajectory and report on progress made and obstacles encountered since the previous meeting. For example, one question asked at the meeting relates to the number of users who do not show up for their appointments. For each no-show, the staff member is asked to explain why. Another issue relates more to staff well-being: the manager asks the staff member about their perception of their workload, and if the staff member feels overwhelmed, action is taken immediately. Comments from senior manager highlight the potential of this tool of the integrated performance management system:“Without the status sheet, we would have no links between our control rooms; there would be a piece missing. The status sheet meetings allow staff to see how proactively removing obstacles to operational performance puts “Jimmy” at the heart of this approach.”Six months after the status sheet was implemented in complementarity with the control rooms, improvements had been made in relation to targets to enhance service accessibility and continuity. At the start of the integration project, the average time between the assessment and a first intervention was 16.96 days, whereas the ministerial target was 12 days. In November 2017, the average time had decreased to 8.35 days. This significant time reduction helps staff respond more quickly to protect the needs of vulnerable children and prevent their situations from deteriorating. The service intensity, which had been 0.96 interventions per day per worker, improved significantly and rose to 3.6 interventions per day per worker. A 275% improvement over two years indicates improved access to services. Improving service intensity in turn optimizes staff case load and reduces the wait times for families experiencing problems. Clear improvements were also noted in the implementation of intervention plans, for which the ministerial target was 85%, as the results showed an increase in intervention plans from 70% to 85% in a statutory context and from 10% to 43% in a voluntary context. The fact that families can have an intervention plan makes it easier to determine the problem and the best tools to resolve it, which in turn creates better linkage, better coordination, and fuller integration. Finally, the disability insurance rate dropped from 14.30% to 8.70%, which generated substantial savings. When staff return to work, this provides better service continuity for families by ensuring that their services do not become fragmented. In addition to indicator performance, team actions helped fulfill the vision set out during the kaikaku, i.e., that Jimmy will never be alone again.Communication is a major challenge in an organisational integration project . The dep“There are advantages […] in our day-to-day reality  as problems crop up […] and then solutions do too.”The advantage of using the weekly status sheet to improve “Jimmy’s” service trajectory is that it generates quick wins in terms of improved coordination and improved communication at all organisational levels.The goal of this exploratory qualitative study is to explain whether integration is supported by an integrated performance management system, particularly through the deployment of control rooms and the status sheet. At IHSSC, the issue of integration is being addressed through the implementation of a service trajectory that ensures service accessibility and continuity for children, youth and family clients and that improves the well-being of staff to reduce the risk of early attrition.This research supports the idea that the integrated performance management system is a collaborative model for trajectory management and that it can therefore support vertical and horizontal integration 1124. Sig11To improve the use of the strategic control room, it would have been interesting to have visual boards of “Jimmy’s” trajectory, with the idea that visual management provides a better understanding of processes, highlights opportunities for improvement, and reduces waste . Visual 7The central component of this integration project has been the implementation of an integrated youth team through strategic, tactical and operational control rooms to offer coordinated services. This action research shows how interdependence was created between the two directorates in particular through the tactical and operational control room thanks to trajectory review meetings that fostered discussions between each directorate’s respective stakeholders and forced them to broaden their knowledge, perspectives and interests. The control rooms and the status sheet became true catalysts for integration. These complementary tools fostered the linkage, coordination and full integration of services for the benefit of children, youth and families. The innovation of deploying a single tactical control room integrating the youth protection directorate and the youth programmes directorate supports better communication and, accordingly, confirms that communication among all stakeholders is a key issue in integration processes .The control rooms and the status sheet reinforced the project proposed by the CEO in 2016 to integrate services for the well-being of the territory’s children, youth and families, which in turn reinforces the idea of complementarity between vertical and horizontal integration 6. For theThe integrated performance management system deployed for the Jimmy project upholds the idea that performance is multidimensional and is contingent on the balanced approach of the quadruple aim model. The various tools resulting from the management model has generated not only financial gains but also gains in the areas of accessibility, continuity and staff engagement. Although lacking at the start of the project, performance measurement saw great progress, as the status sheet consolidated the processes defining the trajectory’s measurable objectives and therefore collected performance data generated by the integration project.Importance of defining the concept of integration during the kaikaku to give the project meaning. The stakeholders of the trajectory must have a better knowledge of an integration continuum.Personalizing the project by naming it “Jimmy.” He became the catalyst for the integration project. He participates in the creation of meaning. Each worker who took part in the project had a very clear reference to a “Jimmy” in a vulnerable situation in his entourage. The speakers were keen to contribute to Jimmy’s well-being in a more fluid and improved trajectory. There was no fear or resistance to integrating the services.The use of the tools of the integrated performance management system supports the stakeholders on a daily basis. Staff members no longer face the challenges of working with vulnerable clients alone, as they are met with on a weekly basis both through the status sheet and the control room. These tools of the integrated performance management system support active listening and create the conditions for requests to be grouped so that staff can adequately respond to children’s needs through a standardisation of formal communications.The integrated performance management system is first and foremost a collaborative management model supporting the integration and improvement of care and services. The control rooms and the status report demonstrate the proactive action of operational teams in identifying obstacles and solutions to an optimal path to meet customer needs.The creation of a single tactical control room between two complementary departments that supports processes to better coordinate services. Observations from this research suggest that the tactical control room makes any obstacles in the trajectory flow instantly visible to managers. Having staff members participate in the operational control room helps them work together to ensure service access and continuity while drawing from expertise from different areas.Like many institutions in Quebec’s health and social services network, the IHSSC had to improve its performance while tackling the integration challenges posed by the 2015 reform. To face this challenge, the institution decided to deploy an integrated performance management system. Supported by the different tools of the integrated performance management system, the “Jimmy” integration project reinforces the implementation of linkage, coordination and full integration models that become strong connections between teams. The status sheet and control room are tools that vertically integrate different hierarchical levels and horizontally integrate various front-line stakeholders through the user-oriented trajectory.Based on this study’s observations, future research avenues could address how an integration project supported by different tools of the integrated performance management system improves employee workplace well-being to ensure accessible and continuous services. Future research could also determine how target indicators change over a longer period and explore the optimal conditions to ensure the organisational sustainability of this type of integration project for different clienteles. Overall, it would be useful to look at the principles of the “learning organization” as part of an organizational transformation that fosters service integration processes. Useful outcomes could also come about through a convergence of the integrated performance management system with organizational capacity to improve results in a context in which practice innovation is encouraged.


Performance management systems have been introduced in health and social services institutions to improve organizational performance, supporting the emergence of new management behaviors that are more rooted in collaborative management practices. This study aims to understand how different leadership styles emerge through the implementation of a performance management system and its related tools, and how these can foster distributed leadership.Over two years, the implementation of an integrated performance management system supporting the integration of social services for children, youth, and families was studied at a recently merged Canadian healthcare organization. Qualitative analysis of data collected from 15 interviews, 3 focus groups, and over 350 h of non-participant observation was conducted.The results show that leadership evolved to adapt to the context of organizational integration and was no longer confined to a single manager. Transformational leadership was needed to encourage the emergence of a new integrated performance management system and new behaviors among middle managers and team members. Transactional leadership was legitimized through the use of a status sheet when the integration project did not deliver the expected results. Both transformational and transactional leadership paved the way to distributed leadership, which in turn promoted collaborative practices associated with activities in control rooms and dialogue stemming from the status sheets. Distributed leadership among team members made a difference in the outcome of the integration project, which became a driver of collaboration.The integrated performance management system and the use of its tools can help renew leadership in health and social service organizations. The results lend credence to the importance of distributed leadership in promoting collaborative practices to improve services for children, youth, and families. The results also highlight how various leadership styles can contribute to the emergence of distributed leadership over time. In recent decades, health and social service organizations have attempted to implement various initiatives to improve performance , particuA condition for successful service integration is collaboration, which is often presented as a tool to find new solutions to the complex problems of the fragmentation of care and services  and to rOn April 1, 2015, the province of Quebec, Canada, restructured its health and social services network by reducing its number of institutions from 182 to 34. These new institutions now group the facilities and services for the population of its region. The initial goal of the reform was to reduce bureaucracy by flattening organizational structures from three to two levels and centralizing powers with the Minister of health and social services. This flattening of the management hierarchy resulted in the elimination of 1300 managerial positions.The transformation of the health and social services network is supported by the deployment of a new performance management system that encourages stakeholders to reflect on the evolving role of managers. An IPMS encourages traditional models, in which leadership resides in a single individual, to evolve into leadership development efforts that extend to all levels of the organization. Transformational leadership and transactional leadership are powerful concepts for improving organizational performance , 18. HowThis paper studies how different leadership styles evolve during the deployment of an IPMS. Through a longitudinal case study, it aims to demonstrate how the adaptation of different leadership styles in conjunction with IPMS tools can support the integration of social services for children, youth, and families. The following section draws from a literature review to summarize the main leadership typologies and presents the integrated performance management system and the various tools used by the organization. This is followed by a presentation of the organizational context and the research methodology. The results reveal a multi-dimensional experience of how leadership styles evolved over more than two years. The paper concludes with a discussion of the results, the implications, and future avenues of research.Over the last forty years, the literature on leadership has evolved from the “Great Person Theory” into how leaders behave and develop relationships with followers . AccordiLaissez-faire leadership is a passive form of leadership, where leaders provide little to no feedback which can often leave employees in the dark. This is usually detrimental to employee engagement. This type of leader is nowhere to be seen when problems arise and is not very engaged with his or her employees. These leaders seek a hands-off approach to management .Transactional leaders focus on the resources they manage. They also employ management by exception either in an active way (trying to prevent problems) or a passive way (only intervening when a problem occurs) . Transac and care  about each employee, who can articulate a vision that inspires employees, and foster the acceptance of group goals  when the managers signed the collaboration contract at the beginning of the project  that’s when people really became engaged.”To reinforce collaboration between directors and middle managers, a strategic A3From the strategic A3 report, four other A3 projects were developed using rapid improvement events and were named Charlotte, Henriette, Rosalie, and Juliette. These activities required more tactical and operational approaches, and the goal was to develop an action plan to help integrate services in the desired trajectory. To monitor these A3s, operational control rooms were quickly deployed in the integrated youth teams, where employees, directors, and middle managers were brought together every week to set targets for the service integration project.“During the summer  I had a team member take over to get us to the point that the room was part of our team […] and all employees had taken ownership of it.”This reality was further unpacked by the following statement from a staff member:“Since we became an integrated team, it has been much easier for us to work together and in proximity to each other. It’s been really positive.”The operational control rooms of the new integrated youth teams provided part of the foundation for the emergence of distributed leadership, by democratizing management activities, i.e. team members take turns leading the activity, and this task is no longer under the purview of the manager. As one middle manager explained about the team’s ownership and accountability:“We dramatically reduced the wait time between assessment and the start of case management.”From the start of activities in the operational control rooms, the participants submitted many improvement initiatives , which dInitial staff engagement in the integration project appeared good, especially following efforts made to urgently remove daily irritants that had persisted for many years. However, once these irritants had been dealt with, improvement initiatives became increasingly rare or addressed routine issues, such as poorly soundproofed consultation rooms. One middle manager said, “These are minor annoyances.” After one year, no improvements had been made on the key performance indicators, which indicated that problem-solving to find solutions to trajectory-related challenges was unfortunately not taking place.“I think there are challenges in making the numbers reflect the living reality of the service offer.”The project encountered major difficulties during the first year not so much due to the project managers’ commitment and belief in the project’s rationale but because of how performance indicators were monitored. According to one middle manager, performance measurement was one of the main reasons for low levels of engagement from staff, who felt that quantitative evaluation did not properly represent the fundamentally human dimension of their jobs:“Take away the statistics, performance, and everything. They are completely useless. It just puts pressure on staff.”Observations from the research showed a laissez-faire leadership style on the part of some directors who experienced difficulties engaging their teams in measuring indicators. Comments from one staff member speak to this problem:The action plans for the A3 projects, therefore, remained conceptual and were not conducive to quick action. An informal status quo bogged down the project in a kind of non-performance, and the service trajectory was not monitored at all. At this point, it was observed that some leaders with formal power over the team were negatively influencing the project.“The meeting was key for the project. It gave a glimmer of hope [for us to] work more as a team. We had to look at what wasn’t working.”After observing the directors’ laissez-faire style, the CEO and her associate (COO) organized a project review day in June of the following year. They started the meeting by sharing their disappointments and communicating their reservations about any real progress having been made with the service integration project with the various middle managers involved since the project started in June 2017. The integration project was not bearing the expected fruits. The directors and middle managers found it difficult to be confronted and questioned about why collaborative spaces were being hindered. However, as one middle manager expressed:Aware that the philosophy of the IPMS reinforces a bottom-up approach to problem-solving to help staff identify problems and find the right solutions, the CEO set up a status sheet so that everyone could become better aware of the trajectory and could more effectively document it. Every week, using the status sheet, a performance review was conducted by monitoring the effectiveness of the interfaces of the trajectory through accessibility and continuity indicators. This action by the CEO embodied a more directive transactional leadership approach aimed at getting the project back on track. At first, middle managers were reluctant to adopt this practice with their teams because they felt obligated to apply top-down decisions. However, it proved to be a turning point toward the success of the integration project. As one middle manager explained:“I feel like the status sheet is what changed things.”The inevitable centralization of leadership toward the executives led to a genuine renewal in the deployment of the IPMS so that the trajectory targets could be achieved. Furthermore, the difficulties encountered during the first year of the integration project and the subsequent changes implemented by the CEO contributed to the departure of two key opinion leaders (directors) who did not agree with the organizational priorities expressed by the executives.Status sheet sessions were held weekly during a Friday morning conference call attended by all middle managers. The observations suggest that transactional leadership was an excellent vehicle for leading the status sheet, as this tool is task and results-oriented. The sessions began with a review of indicators related to accessibility, continuity, and quality so that everyone could quickly detect any deviations from the standard. Leaders could focus on generating possible solutions from an employee in order to have corrective action taken. However, the leader (director) could also help collaboration emerge during the second part of the status sheet, which focused on qualitative aspects, particularly the perceptions of the team climate, risk management, and comments received by users.“The other thing I really like is how good performance is recognized. This is very positive because we never used to take the time to do this every week. It happened maybe once or twice a year. We definitely point it out and we have peers recognize each other. Peer recognition increases team spirit.”Without calling it a recognition program as such, team members’ positive performance was highlighted by their peers every week both during the control room activities and during the status sheet sessions. The purpose of this recognition was to improve the working climate so that each team member felt valued, which was appreciated by both middle managers and employees:After six months of using the status sheet in conjunction with the control rooms, significant improvements to accessibility and continuity had been achieved. Initially, the average wait time in child protection was 16.96 days, compared to the government target of 12 days. The achieved result was 8.35 days. Service intensity at the start of the project was 0.96 interventions per day per worker and improved to 3.6 interventions per day per worker. Significant gains were also achieved regarding the implementation of intervention plans, which rose from 70% to the government target of 85% and from 10 to 43% in statutory and voluntary contexts respectively. Furthermore, the disability insurance rate decreased to 8.70% from its initial level of 14.30%. The target was 6.03% at the time.“We’ve got a director of youth protection and a director of youth programs working side by side, and that’s a big win.”As mentioned previously, two directors left and were replaced during the first year of the integration project. This change in top management for the youth programs led to a new dynamic that supported greater interprofessional collaboration, particularly in the control room. After this change, leadership started to be distributed based on trust and based on the managers’ mutual knowledge of each other. As one middle manager pointed out:“You have to be completely in sync. Since the fall, we haven’t felt that the two departments were working as well together, [nor did we have anything] facilitating a strong feeling of cohesion in our control room.”When the new directors arrived, they began sharing leadership and moved toward better collaboration that left no room for interdepartmental competition, which confirms that service integration is more dependent on human factors and added value for the client experience rather than on organizational and structural issues . The twoThe two new directors supported the clear and integrated vision of Jimmy’s trajectory articulated by the CEO and upheld the need for measurement to achieve the performance targets. Meetings in the tactical control room provided opportunities for both departments together to evaluate team performance by sharing essential information to raise important issues about Jimmy’s trajectory and devise collective solutions through consensus, thus supporting Barnas’ view  that the“Implementing the tactical room jointly between the youth program and the youth protection directorate has advantages, such as continuity  there are projects that, even though they are more the responsibility of the other department, considering that I am involved, I take responsibility for them.”Given that no formal activities were held in the tactical control room during the first year of the project’s deployment, the new directors had to take ownership of how the tactical control room functioned. The decision that the two departments with the same clientele should share the same control room led to a change in leadership and gave the teams the legitimacy to commit to the service integration project. The goals that the directors shared with the teams to help everyone understand the reasoning behind the changes created a climate of mutual trust, which was a key factor that allowed distributed leadership to emerge after two years of experimentation. Democratizing control room activities also fostered the emergence of distributed leadership. Both directors made this a collective responsibility. Other departments were also involved in Project Jimmy. Managers or staff were invited to attend control room activities to find collective solutions to the problems of accessibility, continuity, and quality throughout Jimmy’s trajectory. Distributed leadership made it possible to develop a culture of integration between the first and second service lines. For example, as a director pointed out:Distributed leadership is considered an effective way to foster team performance in complex situations, such as those found in programs for children and youth in difficulty. This paper tracks the evolution of the different leadership styles adopted during the implementation of a new management model Fig. . The resAt the onset of the integration project, the CEO exhibited transformational leadership by articulating a clear vision, by challenging directors and managers to actively participate in the integration project, and by fostering their participation by signing the Jimmy A3. Transformational leadership exhibited by top administrators is frequently cited as behavior that allows institutions to evolve through continuous improvement . The traThe matrix organizational structure implemented because of the new reform seemed to have negatively impacted the development of collaboration, as the leader with formal power had a purview that was too broad. This partially explains why distributed leadership at the strategic level still had not fully emerged by the end of our study.This case study demonstrates that transformational leadership from executives did not initially influence the type of leadership adopted at the tactical level, as highlighted by the dotted arrows in Fig. Laissez-faire leadership led to the emergence of transactional leadership from the CEO, through the implementation of the status sheet, as a response to address the absence of progress made in the project. This course of action is typically more conducive in crises . TransacThe executives used the reform as an opportunity to create territorial teams dedicated to children, youth, and families. The pooling of professional and multidisciplinary expertise and the initial familiarity of members contributed to the emergence of distributed leadership. From the start of the project and the set-up of the control rooms, each member’s contribution to providing accessible services was an important mechanism for achieving the required interdependence to develop distributed leadership . Our obsDespite good proximity, a certain degree of familiarity, and high task complexity, our findings show that the teams still seemed to wait for a leader to provide solutions to their problems. The control room lets staff identify problems and propose appropriate solutions. The control rooms, particularly the operational control rooms, therefore became more like information rooms. According to Pearce and Sims , the basThe implementation of an IPMS can support a new way of managing organizations where leadership and decision-making are shared in teams at all levels of the organization. Notwithstanding this willingness to share and adopt distributed leadership through collaborative practices, a more traditional top-down management style is a fundamental source of decision-making for organizations to run smoothly.In the end, some leadership responsibilities have been retained by the department head while other responsibilities are now distributed among the integrated team through the control rooms and status sheet. Distributed leadership is more in keeping with collaborative profiles or competencies that are strongly ingrained in individuals. The complementarity between transformational leadership and distributed leadership at all hierarchical levels is a promising avenue to reinforce the organization’s capacity to change. The more that this leadership combination evolves, the more the organizational capacity to change will improve as new top and middle managers with a collaborative style arrive and real improvements are made in terms of care and service accessibility, and continuity.recognizing individuals). Through transformational leadership, she asked top and middle managers to contribute to this project, based on their knowledge and expertise in the field of services for children. This would ultimately legitimize the emergence of distributed leadership further down the line, even though the short-term effects were not conclusive.Overall, this case study shows that a service integration project does not need to be guided by a single leadership style but rather by distributed leadership that emerges over time. This study also highlights the interdependence of leadership styles, where one is usually the result of another. While distributed leadership did not emerge quickly, its foundations were laid at the onset of the integration project. The CEO recognized the complexity of the project to integrate psychosocial services and that she needed to work with people who had skills and expertise that were complementary to her own  in the deployment of an IPMS. This study was carried out in the child, youth, and family social services sector, where different hierarchical levels, i.e. both managers and staff, were required to adopt new behaviors so that distributed leadership could emerge. This qualitative study makes a useful contribution regarding the complementarity of the foundations of distributed leadership, the tools of the IPMS, and integration processes applied over time.This case study raises questions about its transferability, along with certain limitations. The scope of this study was limited to the youth sector. A comparison with other sectors could be useful. Future research could be done in similar contexts  to explore the conditions and barriers for success, and for organizations to learn collective lessons to improve the performance of health and social services networks. Our results also show that recognition of team performance may have helped trigger the emergence of shared leadership. Hence, future research could explore this phenomenon through a positive psychological lens , to stud


In this work, we did our best to develop a novel and interesting analytical method based on coupling of spectrofluorimetry with first-order multivariate calibration techniques for simultaneous determination of lead (Pd), zinc (Zn) and cadmium (Cd) in HeLa cells. To achieve this goal, quenching of the emission of graphene (GR) was individually investigated in the presence of Pb, Zn and Cd and then, according to the linear ranges obtained from individual calibration graphs, a multivariate calibration model was developed based on modeling of the quenching of the emission of GR in the presence of the mixtures of Pb, Zn and Cd. First-order multivariate calibration models were constructed by partial least squares (PLS), principal component regression (PCR), orthogonal signal correction-PLS (OSC-PLS), continuum power regression (CPR), robust continuum regression (RCR) and partial robust M-regression (PRM) and their performances were evaluated and statistically compared. Finally, the OSC-PLS was chosen as the best model with the best practical performance for analytical purposes.  •The GR was uptaken by the HeLa cells and then, the cells uptook Pb, Cd and Zn.•Individual and multivariate calibration models were developed by the use of several first-order algorithms.•Comparing the performance of the models was performed and the OSC-PLS showed the best performance.•Performance of the OSC-PLS was compared with a reference method.•Our records showed that the OSC-PLS had a comparable performance with the reference method. Sometimes, the heavy metals are considered as contaminants which can be hazardous for human health therefore, monitoring of them is important. Lead (Pb) and cadmium (Cd) are heavy metals which are widely and naturally distributed toxic metals. There are some reports on determination of these metals with zinc (Zn) HeLa is an immortal cell line which is the most commonly used human cell line in scientific research. The HeLa cell line is durable and prolific which make it to be extremely suitable for scientific research. Therefore in this study, we have used the HeLa cells as a very interesting case for developing a novel analytical method for simultaneous determination of the Pb, Cd and Zn.Chemometrics combines chemical data with mathematical and statistical methods to extract useful information which can help the chemists to better justify their observations. Chemometricians have performed different projects by the use of instrumental data 22.13)2 were purchased from Sigma. Commercial Pb, Cd and Zn standards (1 g l−1) were prepared from Merck. Graphene quantum dots (blue luminescent) were purchased from Sigma-Aldrich. The other chemicals which were needed for doing this project were available in archive of our laboratory which had been purchased from Sigma or Merck. Doubly distilled water was used wherever water was needed. A phosphate buffer solution  was prepared from Na2HPO4 and its pH was adjusted at 7.4 by the use of H3PO4 and NaOH.Trypsin-EDTA, Dulbecco’s modified Eagle’s medium (DMEM/F-12 (1:1)), fetal bovine serum , penicillin-streptomycin (PEN-STREP), zinc nitrate hexahydrate, cadmium nitrate tetrahydrate and Pb(NO2.2Spectrofluorimetric data were recorded by a Cary Varian spectrofluorimeter equipped with a quartz cell (1 cm length path). First-order multivariate calibration algorithms including PLS, PCR, OSC-PLS, CPR, RCR, PRM, smoothing of the data and elliptical joint confidence region (EJCR) were run in MATLAB (Version 7.5) by the use of a series of m-files. The first-order multivariate calibration algorithms have been run in MATLAB with the help of PLS-toolbox or TOMCAT. The HeLa cells were prepared from the cell bonk of Kermanshah University of Medical Sciences. Then, the flask was transferred into a culture room where a deep-freezer (−80 °C), a memmert incubator, a JTLV CZS hood and a Motic microscope were existed for cell culturing. pH adjustments were performed by a Jenway pH meter 3510. Performance of the developed methodology was compared with the results of an Agilent atomic absorption spectrometer as reference method (AAS). Operating conditions for the AAS were: PMT voltage (450 V), slit width (0.40 nm), lamp current (9.0 mA), sample volume (20 µl), purging gas (argon), sample injection replicates (2) and measurement (peak height). All the calculations which were needed for data processing were performed on a Dell XPS laptop.2.32 +95% air) at 37 °C during a day (24 h). For uptaking the GR, 100 ng mL−1 GR was added to different culture dishes and incubated at different times and then, the cells were washed with PBS  and left to be in the PBS.Dispersion of the HeLa cells were performed in DMEM + FBS (10%) + PEN-STREP (1%) and seeded on five confocal dishes and then, they were incubated at an humidified atmosphere  were added to the dishes. The cells were further incubated for 2 h and washed with the PBS for three times and kept in the PBS. Spectrofluorimetric monitoring of the Pb, Cd and Zn was performed by excitation at 405 nm. For performing background correction on the data, the control cells which had not been incubated with GR (didn’t have any GR) was prepared. The procedures described above were continued by digestion of the treated and control cells with trypsin and then, the cells were kept in the PBS. Afterwards, the cells were counted, broken by ultrasonic and centrifuged. Finally, the supernatant of cells were measured spectrofluorimetrically.For simultaneous determination of Pb, Cd and Zn in HeLa cells, the seeded cells were allowed to grow during a day (24 h) and 1 mL DMEM having 1300 ng mL2.4In this work, we are going to develop a novel spectrofluorimetric method assisted by chemometric methods which will enable us to simultaneous determine Pb, Cd and Zn in living cells. Data treatment and development of multivariate calibration models must be very carefully performed to achieve the final goal. Prior to data modeling, all the spectrofluorimetric data were treated according to the following equation RMSEP: root mean square error of prediction and REP: relative error of prediction):yact and ypred are nominal and predicted concentrations, respectively, and ymean is the mean of the nominal concentrations. n are the number of samples in the validation set. Precision and accuracy of the developed calibration models will be compared according to the ellipses of the EJCR as well. Univariate calibrations and multivariate calibration and validation sets were performed in internal medium of the cells and by digestion of the cells with trypsin, the medium was extracted. This is a very important advantage which causes having a same medium for calibration and validation of the method which can help us for exploiting first-order advantage.All the data used in this work after passing this correction step was used for the next steps. Emission of the control cells was subtracted from the emission of the all of the cells and the corrected emissions were used for developing multivariate calibration models. Background correction was performed on the whole of data by subtracting emission of the control cells from emission of the whole of sets. Performance of the calibration models will be compared by the use of the following equations  and PRM: number of LVs = 3 and PDC = 0.12. After application of the algorithms and optimization of their parameters and constructing multivariate calibration models, their performance was verified by their application to a validation set having cells with different concentrations of Pb, Cd and Zn whose composition is shown by In order to multivariate calibrate the emission of the GR with concentration of Pb, Cd and Zn, a central composite design was developed based on linear ranges obtained from individual calibration graphs. Composition of the calibration set is shown in In order to further verification of the performance of the spectrofluorimetric method assisted by OSC-PLS, the AAS was applied to the prediction of the concentrations of the validation set as reference method and the results are shown in RSD) for the analysis of 800 ng mL−1 Pb, Zn and Cd in six replicates which gave us RSDs of 2.08%, 2.15% and 2.11% for Pb, Zn and Cd, respectively. Inter-day precision was determined by the analysis of six replicates 800 ng mL−1 Pb, Zn and Cd on three consecutive days which gave us RSDs of 2.34%, 2.28% and 2.21% for Pb, Zn and Cd, respectively. The results obtained for examination of intra-day and inter-day precision confirmed acceptable precisions for the developed methodology.The intra-day precision of the assay was estimated by calculating the relative standard deviation (4In this work, a novel and interesting analytical methodology based on coupling of spectrofluorimetry and chemometrics was developed for simultaneous determination of Pb, Cd and Zn in Hela cells. Among the tested chemometric algorithms, the OSC-PLS showed the best performance for simultaneous monitoring of Pb, Cd and Zn whose performance was comparable with AAS as reference method. The results of this work showed that chemometrics has a great potential for assisting instrumental techniques to develop accurate novel methods which have very better performance than those instrumental alone. As a new research field for our research group, we are going to continue coupling of chemometric method with instrumental techniques for bioanalytical purposes and definitely, this work will be a bridge to connect the world of chemometricians with the world of bioanalysts.The main idea of this project belongs to Dr. Ali R. Jalalvand and the other authors contributed equally in this project.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


We thank Dr. Landry and colleagues  for theiAdherence to dietary prescriptions is of pivotal importance in studies comparing different nutritional interventions. In our randomized clinical trial, self-reported dietary compliance was assessed by trained dietitians at 2 and 4 weeks of diet using semiquantitative food frequency questionnaires, according to previously described methods ,4. NutriAs already pointed out and discussed , a low-cLastly, participants’ satisfaction with their assigned diet was not formally assessed and quantified in our study. However, none withdrew the diet or complained about its composition during the 4-week intervention, suggesting the feasibility of these dietary prescriptions, at least in the short term. In conclusion, our study emphasizes important differences in the effectiveness of two calorie-restricted eating patterns on weight loss and glucose homeostatic mechanisms in morbidly obese individuals. A great effort has been made to maximize participants’ engagement to nutritional interventions and reduce heterogeneity, with the final aim to minimize the influence of dietary adherence on study findings.


The authors are listed out of order. The last author should be Paula Garcia Chiarello. Please view the correct author order, affiliations, and citation here:1, Gabriel Ruiz Sizoto2, Lorena Vega-Piris3, Guillermina Barril Cuadrado4, Paula Garcia Chiarello5Natália Tomborelli Bellafronte1 Post-graduate Program in Health Sciences, Ribeirão Preto Faculty of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil, 2 Nutrition and Metabolism Undergraduate Course, Ribeirão Preto Faculty of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil, 3 Methodology Unit, Instituto de Investigación Sanitaria del Hospital Universitario de la Princesa, Madrid, Spain, 4 Nephrology Department, Hospital Universitario La Princesa, Madrid, Spain, 5 Department of Health Sciences, Ribeirão Preto Faculty of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazilhttps://doi.org/10.1371/journal.pone.0242671Bellafronte NT, Sizoto GR, Vega-Piris L, Cuadrado GB, Chiarello PG (2020) Bed-side measures for diagnosis of low muscle mass, sarcopenia, obesity, and sarcopenic obesity in patients with chronic kidney disease under non-dialysis-dependent, dialysis dependent and kidney transplant therapy. PLoS ONE 15(11): e0242671.


Since reproductive interference in plants may occur through interspecific pollination, the effective range of reproductive interference may reflects the spatial range of interspecific pollination. Therefore, we hypothesized that the coexistence of congeners on a small spatial scale would be less likely to occur by chance but that such coexistence would be likely to occur on a scale larger than interspecific pollination frequently occur. In the present study, we tested this hypothesis using spatially explicit woody plant survey data. Contrary to our prediction, congeneric tree species often coexisted at the finest spatial scale and significant exclusive distribution was not detected. Our results suggest that cooccurrence of congeneric tree species is not structured by reproductive interference, and they indicate the need for further research to explore the factors that mitigate the effects of reproductive interference.In plants, negative reproductive interaction among closely related species ( However, the CRH has also been widely discussed  limits the coexistence of closely related species  are less likely to coexist by chance on a local scale  congeneric species do not coexist on a fine spatial scale where reproductive interference frequently occurs but coexist on a large spatial scale; and (2) on large scales where reproductive interference does not occur, congeneric species coexist while avoiding each other, resulting in an exclusive or checkerboard distribution .2) was located in the Kasugayama primary forest, Nara prefecture, western Japan (34′41′N135′51′E) (Sapium sebiferum and Nagia nagi (The study area (∼1 km35′51′E) . Because35′51′E) . In the 35′51′E) ; howevergia nagi . The fieField studies were conducted from June to September 2015. In the study area, 30 transect plots (∼0.1 ha in size) at 200 m intervals were established . Tree spIn this study, we defined congeners as closely related species based on the definition by a priori-defined spatial scales . In this study we established 30 plots at 200 m intervals. A priori-defined spatial scales corresponded to the area of each plot extended horizontally.We employed the species-to-genus ratio (S/G ratio) as an indicator of intragenic interactions for the categorized tree, shrub, and liana species. The S/G ratio has long been used to describe community patterns and to infer levels of competitive interactions among species within genera . Note that there are differing opinions among researchers on whether the genus Prunus should be considered as a single genus or not .where N species, there are P = N(N − 1)/2 species pairs; thus, the C-score is calculated as follows: For The C-score becomes larger as the two species occur more commonly across different plots. We simulated null models to compare the observed C-score with stochastic distributions. The null models, which were run 999 times for each species pair, randomly shuffles the number of species (α-diversity) among sampling locations while preserving the species occurrence totals (the plant density). All statistical analyses were performed using R software version 3.6.1 . EcoSimRAt the study site, we recorded 42 tree species  from 31 genera, 20 shrub species  from 19 genera, and seven liana species from six genera . The resultant S/G ratios for trees, shrubs, and lianas were 1.350, 1.021, and 1.200, respectively. Only the S/G ratio for tree species significantly deviated from the 1:1 ratio, whereas those for shrub and liana species did not .The average S/G for trees increased as spatial scale increased. Even at the smallest spatial scale, however, the average S/G ratio for trees exceeded the 1:1 ratio , indicatQuercus, Carpinus, and Prunus. It indicates that statistically significant exclusive distribution of species from the same genus did not occur . Since a low S/G ratio is generally a product of strong intrageneric competition  is within a few tens of meters (Quercus, shows considerable variation in annual seed production (In plants, the spatial extent of reproductive interference corresponds to pollen transfer distance ; consequf meters . This suf meters . One of oduction , which moduction . Eaton ePrevious studies reveal that specialist natural enemies, such as herbivores and pathogens, maintain tree species diversity by the reducing survival rates of conspecific seeds and seedlings located close to reproductive adults or in high conspecific density areas (Janzen–Connell effect; In future research, investigation on a larger spatial scale with a more complex analysis will be required to determine the relationship between plant life history and the spatial scale of exclusive distribution. Previous studies on herbaceous plants suggest that reproductive interference plays an important role in community assembly ; however10.7717/peerj.12150/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.12150/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.12150/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.12150/supp-4Supplemental Information 4Click here for additional data file.


Hartmann’s procedure involves resecting the rectosigmoid colon, closure of the distal rectal stump, and forming an end colostomy for complicated left colon diverticulitis or malignancy. Recovery from the initial operation can, in a second stage, be followed by a reversal stage with the restoration of bowel continuity. This study aimed to assess the reversal rate and its correlation with demographic data, ASA grade, and length of hospital stay. All patients who underwent Hartmann’s emergency procedure from 2014 to 2018 at Lewisham and Greenwich hospital were enrolled in this retrospective study. Data was collected from the inpatient electronic files and NELA . 118 patients were included in the study, with 57.6% females and a median age of patients of 69 years (range 35–91). Findings of the study indicate that the most common indications for Hartmann’s procedure were diverticular complications 60% (n=71) and benign perforated sigmoid or rectosigmoid cancer 16% (n=19). The average length of hospital stay was 24 days (range n=2 – 212 days). The reversal rate was 34.9% (41/118 cases). No significant difference was observed between gender and length of hospital stay in relation to the reversal rate while there was a significant correlation between age and ASA grade in relation to reversal rate; the calculated P values were recorded as (<0.000) and (<0.009) respectively. Our results show that the highest reversal rate was observed in younger and fitter (I–II) ASA grade patients. The most common medical complication from reversal of Hartmann’s procedure was an anastomotic leak . Reversal rate of Hartmann’s procedure was 34.9%. The average timeframe for reversal was within 18–20 months. There was a significant correlation between age and ASA grade in relation to reversal rate. In the early twenties of the past century, the French surgeon Henri Albert Hartmann introduced and described a surgical procedure for obstructive rectosigmoid cancer in 1921, with postoperative sequel superordinate for other surgical techniques. Hartmann’s procedure is defined as a surgical procedure that mainly includes rectosigmoid resection and closure of rectal stump plus establishment of an end colostomy . MoreoveAmerican Society of Anesthesiologists Physical Status (ASA PS) classification was first implemented in clinical practice more than seventy years ago to classify patients according to tolerance and fitness for specific surgical procedures. The ASA class is a subjective evaluation of a patient’s overall health, and it only measures the amount of physiological allowance that a patient has at the time they are evaluated for a surgical procedure. Also, it should not be used as the only indicator of an operative risk to the patient . ASA scoOur study aims to identify the factors that affect the reversal rate, mainly the age, gender and ASA grade, and length of hospital stay . In addiThis is a retrospective observational study. All patients who underwent emergency Hartmann’s procedure between 2014 and 2018 at Lewisham and Greenwich hospitals were identified and included. We excluded patients who have their Hartmann’s procedure on an elective basis. The cases were retrieved from a computerized medical records database and NELA  bowel database. Analysis was completed by examining the inpatient files in selected patients where appropriate. Collected data included the following parameters: demographics, indications for Hartmann’s procedure, duration of the surgery, hospital stay, ASA grade, and reversal rate. In addition, the type of surgery (open or laparoscopic) covering ileostomy and postoperative complications was collected for patients who underwent a reversal. All the reversal procedures were performed by qualified colorectal surgeons, while the original Hartmann’s procedure was performed by a mixture of emergency surgeons, general surgeons, and colorectal surgeons. Data analysis was performed using the SPSS software. A chi-squared test was used to assess categorical variables. A p-value of less than <0.05 was considered to be statistically significant.A total of 118 patients were identified during the study period from 2014 to 2018 at Lewisham and Greenwich hospital. 68 (57.6%) of the 118 patients were female. The median age was 69 years (range from 35 to 91). A substantial proportion of patients were ASA grade III–V , as summarized in Sigmoidoscopy to assess the rectal stump length and colonoscopy through the stoma to rule out residual proximal pathology were routinely performed prior to reversal. The reversal rate of Hartmann’s procedure was 34.7% (41/118 cases). Seventy-seven patients (65%) did not proceed to reversal . The reaForty-one patients underwent successful reversal (34.9%). Defunctioning ileostomy was used in 10 patients (24%), an anastomotic leak occurred in 6 patients (14.6%). The operative time mean was 3 hrs.15 min, and the average length of hospital stay following reversal was 11 days (range 2–159 days). The Chi-square test was used to determine the significance of differences between the reversal rate of Hartmann’s procedure and the demographic data of the patients, ASA grade, and length of hospital stay . No signet al. [et al. [et al. [This study involved the selection of 118 consecutive patients who underwent Hartmann’s procedure to measure the reversal rate and mortality rate and assess the correlation between demographic data, ASA grade, length of hospital stay, and the reversal rate of Hartmann’s procedure. The most common indication for Hartmann’s procedure in our study was diverticular complications (60%), similar to the studies conducted by Hallam et al.  and Chri [et al. , while t [et al.  was coloet al. [et al. [In this study, the reversal rate of Hartmann’s procedure was assessed. 34.9% of the patients underwent a successful reversal, which is higher to previously reported data by Christou et al. , where o [et al. , who repet al. (16.1%) [et al. observed a low rate of laparoscopic surgery for a colostomy reversal. However, good results have been published with its use, and a laparoscopic reversal is comparable or superior to open reversal [et al. [Thirty-day mortality following Hartmann’s procedure was 16.9%; it was higher in those aged above 80 years. This was in accordance with previously reported results by Zarnescu  (16.1%) . It woulreversal . Post re [et al.  was diaret al. [Our results revealed that there was no significant difference between gender and reversal rate (p<0.737), while a significant relation was observed between age (p<0.001) and ASA grade (p<0.009) in relation to reversal rate, the highest reversal rate was observed in younger and (I–II) ASA grade patients. In addition, there was a higher rate of reversal in benign conditions than malignant conditions. These results were in accordance with previous results reported by Hallam et al. , where tThere are several other surgical trends to approach the management of diverticular complications or obstructed rectosigmoid tumors, such as colonic stent insertion and primary anastomosis with or without a stoma. The colonic stent can convert the emergency surgery to a semi-elective surgery which allows more time for patient optimization and a procedure performed by a colorectal surgeon. Primary anastomosis with or without diverting ileostomy is another option that can save the patient from undergoing another major and morbid surgery. This latter approach was not adopted in our current study as most of Hartmann’s procedures were performed by emergency consultants who are not specialized in colorectal surgery and only occasionally perform colon resections. On the other hand, colorectal surgeons performed all reversal operations, who conducted primary anastomosis and diverting ileostomy in one-quarter of the reversed patients. Moving towards centralizing services with 24 hours access to colorectal surgeons may reduce the number of Hartmann’s procedures performed overall. In addition, providing up-to-date information on the management of those common problems in the surgical department is crucial.One limitation of our study is the retrospective data collection from a dual centers group, involving many surgeons not necessarily specialized in colorectal surgery. Second, our patient group was rather heterogeneous. However, this variety in the patient mix was a caveat to assess possible risk factors for non-reversal. The value of our study is that it demonstrates that Hartmann’s procedure is still a very prevalent surgery that carries high mortality and morbidity, but it can still save lives in high-risk comorbid patients, and by implementing new evolving surgical options, we can improve the quality of patient care.In conclusion, Hartmann’s procedure is still a commonly performed emergency colorectal operation. Reversal rate of Hartmann’s procedure was 34.9%. The predicted mortality on NELA v/s actual mortality is an important figure to compare to identify areas needing a particular focus. The number of patients turned down for reversal may well reflect the poor general health of the cohort and may have a relation to the low socioeconomic status of the population in this area. As expected, there is a significant correlation between age and ASA grade in relation to reversal rate. Our high comorbidity rate and high ASA grade may have contributed to the high leakage rate.The authors declare that there is no conflict of interest.The study was approved by the Audit Committee of the Lewisham and Greenwich Trust .Written informed consent was obtained from the participants in the study.MF contributed to data collection and writing the article. PS, RK, and OO designed the methodology and PN reviewed the article.


Food is an integral part of human culture. Aside from its nutritional role, it connects us on a daily basis through the act of sitting and eating together, it contributes to feelings of shared identity in populations, it is an essential component of many formative events in our lives, and is a gateway to experiencing new cultures.While the influence of food in defining human culture is well-understood, there is a growing appreciation of the role of microbial cultures in defining the properties of food. Archaeological evidence points to the use of fermentation over many thousands of years for the production of a range of foods and beverages. Fermentation serves to make foods more digestible, longer-lasting, safer, and more palatable. For our species, the role of fermentation in food production has arguably been as influential as the role of fire for cooking food.For much of our history, these fermentation processes have been carried out by complex assemblages of organisms, with the use of single strains for fermentation of bread, beer, wine, etc. being a relatively recent development. We have however been seeing a growing interest in the use of microbial communities in food production. In the western world, this revival has been driven in part by the popularity of craft beer, natural wine, fermented non-alcoholic beverages , and sourdough bread. In other parts of the world, complex cultures in fermentation represent continuation of tradition rather than revival.This Research Topic from Frontiers in Microbiology aims to highlight the beneficial role of microbial complexity in driving fermentation processes and influencing food quality. The issue features ten articles describing investigations into complex microbial fermentation for the production of food, feed, and beverages. Contributions were received from Africa, Asia, Australia, Europe, and South America—highlighting the global importance of fermentation. Demonstrated benefits of particular communities during fermentation include improved flavor and color, greater safety, increased nutritional value, faster fermentation rates, reduced alcohol content, and better industrial applicability.Elhalis et al., who show improved sensory properties of coffee after fermentation with the yeast Pichia Kudriavzevii. Likewise, Köhler et al. note how specific yeast and bacteria combinations can improve the flavor of water kefir. Liu et al. describe the relationship between bacterial composition and flavor profile of Xifeng liquor (a spirit prepared from fermented sorghum).One of the most direct impacts of fermentation is the creation of specific flavor profiles. We see this in the work of Su et al. for example, note how fermentation of corn by-products with Saccharomyces yeast and lactic acid bacteria can improve their suitability for use as feed. Dahunsi et al. provide a comprehensive account of how the presence of lactic acid bacteria within fermentative microbial consortia have a critical role in ensuring the safety and shelf-life of many fermented African foods. Likewise, Huang et al. describe the metabolites produced by the yeast Debaryomyces hansenii can prevent the growth of contaminant molds during Danish cheese production.Palatability of foods is not the only factor influenced by fermentation. Benefits extend also to improved digestibility and safety. Martinez et al. who describe how coffee fermentation is influenced by altitude, and how this is associated with changes in the natural microbiota. Substrate also influences the development of populations, as illustrated by Liu et al. who show how different microbial communities develop depending on the type of sorghum used in Xifeng liquour production. Su et al. likewise show how communities develop differently in different by-products of the corn starch industry. These, and other studies described in this Research Topic, demonstrate the power of high-throughput sequencing in studying microbial communities. This is particularly important for dynamic, complex or under-researched communities. This is exemplified in the studies on dark tea fermentation by Yan et al. or the work of Atter et al. on Ghanian cereal fermentation.The composition of species in a fermenting culture is strongly impacted by the environment, a fact that must be considered when trying to control or direct fermentation processes. The effect of environment is clearly seen in the study of Huang et al. coffee fermentation by Elhalis et al. and water kefir production by Köhler et al.Despite the advantages of complex fermentations with respect to product quality, it should be noted that industrial application of such cultures is not without complications. More complexity may lead to less consistency in fermentation processes. The controlled use of cultures, e.g., supplementing natural microbial consortia with specific species, or rationalizing consortia so that they contain only the keystone species, represents a compromise in this respect. Examples are seen here in the work on cheese production by Complex fermentations demonstrate great potential for improving food process efficiency, enhancing food quality, and increasing diversity of available foods and beverages. It is clear however that our ability to fully exploit such fermentations is limited by insufficient knowledge of how individuals in mixed populations interact to influence each other and their environment. It is our hope that this Research Topic represents a step forward in our understanding of these complex systems, and will to some extent facilitate the efficient production of a range of high quality food products in the future.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


A comprehensive review of relevant clinical literature on evidence-based recommendations and existing prediction models specific to lung cancer surgery was undertaken. Preoperative risk assessment parameters such as pulmonary function tests (PFT), cardiopulmonary exercise testing (CPET), Brunelli models, Thoracoscore and frailty were analyzed for predicting postoperative risk of complications. (DLCO ) showed conflicting evidence in determining a positive correlation with postoperative mortality. CPET variables predicted higher complication risk when VO2peak < 10ml/kg/min, AT < 11ml/kg/min and ventilation/carbon dioxide production (VE/VCO2) was in range of 34-40. While a cardiac risk index like the Thoracic Revised Cardiac Risk Index (ThRCRI) predicted major cardiovascular compromise, a thoracic risk index like Thoracoscore proved imprecise. Lastly, frailty is used to risk stratify patients in clinical practice but a recognized validated model specific to thoracic surgery is non-existent.When assessing fitness for surgery, the primarily used PFT parameters such as predictive postoperative forced expiratory volume in one second (FEV1) and diffusion capacity for carbon monoxideWhen considering patients for lung cancer surgery, some dilemma exists regarding the accuracy of clinical prediction models and their external validation. There is a pressing need for the development of a consolidated clinically robust risk stratification model to predict complications after thoracic resections. Lung cancer is the leading cause of oncological deaths worldwide . It is aTreatment of early-stage lung cancer primarily involves surgical resection as it delivers a strong probability of cure . DespiteThis highlights the need to risk stratify to predict mortality, morbidity and long-term shortness of breath in lung cancer patients. In the last decade, an increasing amount of literature has addressed the role of various parameters used in preoperative risk assessment. This often involves cardiorespiratory evaluation in conjunction with assessment of operative mortality, lung function and exercise testing. More recently, there has been an emphasis on frailty as a significant surgical risk factor and practical screening tool. Individual preoperative investigations such as pulmonary function tests (PFT), cardiopulmonary exercise testing (CPET), Brunelli models, Thoracoscore and frailty can be useful in clinical practice and the accuracy of these in predicting postoperative risk has been analyzed in this article. Pulmonary function testsppoFEV1Assessment of pulmonary function parameters such as forced expiratory volume in one second (FEV1) and predicted postoperative FEV1 (ppoFEV1) is important in-patient selection for lung cancer surgery. This is to evaluate the possibility of postoperative pulmonary complications (PPC) and operative mortality, defined as death within 30 days of surgery. Patients with an estimated ppoFEV1>40% are considered as having an average risk, and high risk is determined by an estimated ppoFEV1 <40% [Various small studies have been carried out at local or regional units to establish the risk indicators for developing PPC. A four-year prospective observational study of 285 patients undergoing video-assisted thoracoscopic surgery (VATS) for non-small cell lung cancer (NSCLC) was carried out. Data on gender, age, predicted %FEV1, ASA score, perioperative activity level, BMI, smoking status, and NSCLC staging were recorded. Of the 21 participants who went on to develop postoperative pulmonary complications, the percentage of predicted FEV1 was 88.8% compared with 87.5% in patients who did not develop complications. Predicted %FEV1 was not found to be a significant independent risk factor in determining PPC such as pneumonia, atelectasis, longer hospital stays in high-dependency units or admission to intensive care following VATS   and %FEV1 was collected. A cut-off value of 70% for FEV1 was defined as obstructive ventilatory impairment. In Japan, FEV1 of less than 70% is defined as obstructive ventilatory impairment which is in contrast to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification. Postoperative complications were present in 35% of patients with a %FEV1 <70% compared to 23% of patients with an FEV1 ≥70%. Univariate analysis showed that FEV1 <70% was associated with a greater risk of postoperative atelectasis, pneumonia, and air leakage. These findings oppose the aforementioned studies likely due to the larger population size and demonstrate %FEV1 as an important predictor and significant risk factor of postoperative complications [Moreover, a study using whole lung CT to determine preoperative pulmonary function was carried out in 390 patients who underwent resection for lung cancer. The development cohort had 290 patients and 100 patients formed the validation cohort. Whole lung CT along with patient demographics was used to develop a regression equation for FEV1 to determine preoperative pulmonary function and ppoFEV1. The ppoFEV1 was also calculated based on the anatomic equation: measured %FEV1 x (42 - number of subsegments resected)/42. Both regression analysis and actual measured FEV1/FVC, %FEV1 and %ppoFEV1 were shown to be significant variables associated with predicting postoperative cardiopulmonary complications in both cohorts. Both calculated ppoFEV1 and actual ppoFEV1 were positively correlated with the occurrence of PPC . The useTaking these studies into account, pulmonary function parameters continue to provide conflicting evidence for their ability to predict postoperative complications. The smaller population size of these studies is a limiting factor and we need stronger studies collaborated at national or international units to improve reliabilityDiffusion capacity for carbon monoxide (DLCO)In addition to spirometric parameters, the diffusion capacity for carbon monoxide (DLCO), also known as the transfer factor for carbon monoxide (TLCO), is considered in most preoperative assessments in addition to ppoFEV1. DLCO is based on the ability of carbon monoxide to bind to haemoglobin, therefore DLCO represents the efficiency of gas transfer from inspired air into red blood cells. A low DLCO predicts (a) a higher likelihood of pulmonary complications requiring either supplemental oxygen or hospitalization and (b) a worse dyspnea score. DLCO is also strongly associated with the risk of higher operative mortality . DLCO isA prospective study involving 351 patients with NSCLC was conducted to determine the risk factors associated with PPC after lung cancer surgery. The preoperative evaluation demonstrated a lower predicted DLCO in the COPD group compared to non-COPD counterparts. Univariate analysis found that patients with COPD who went on to develop a PPC had a lower percentage of predicted DLCO of 86% compared to 93.1% in patients who did not develop PPC. Moreover, in the non-COPD group, predicted DLCO was 87.7% in patients who developed a PPC compared with 96.7% in patients who did not develop a PPC. This study signifies low DLCO as a vital risk factor for postoperative complications in both COPD and non-COPD groups thus highlighting the importance of measuring DLCO in patients with normal spirometry prior to resection for NSCLC [DLCO was also found to be a significant prognostic factor following surgical resection for stage I NSCLC. In a study, 426 patients who underwent resection for stage I NSCLC were recruited to investigate the short and long-term outcomes in those with a 'marginal-risk' versus 'normal-risk'. Marginal-risk was defined as a ppoFEV1 of 30-60% and/or ppoDLCO of 30-60%; while, normal-risk was defined as ppoFEV1 ≥ 60% and ppoDLCO ≥ 60%. After applying exclusion criteria, 391 patients were included with 73 classified as marginal-risk and 318 as normal-risk. Overall, marginal-risk patients compared to normal-risk had higher postoperative morbidity (48% vs 21% respectively), pulmonary complications (34% vs 11%) and prolonged hospital stay (23% vs 6%). Among six patients with a ppoFEV1 and/or ppoDLCO of <40%, postoperative morbidity was found to be 83%. Furthermore, in the 27 patients with a ppoFEV1 and/or ppoDLCO of <50%, postoperative morbidity occurred in 44%, PPC occurred in 33% and 22% had longer hospital stays . Cardiopulmonary exercise testing (CPET) Cardiopulmonary exercise testing (CPET) is a complex, non-invasive approach to cardiorespiratory evaluation during exercise and at rest under controlled physiological conditions . Of lateVO2 peak is the maximum value of oxygen uptake measured during CPET at the end of the exercise phase . It is tAnaerobic/ lactate threshold (AT) is a measure of submaximal exercise capacity, i.e. oxygen consumption achieved almost exclusively under aerobic conditions . Since iVE/VCO2 is not only a ratio of the minute ventilation to CO2 output but also an expression of gas exchange efficiency . ElevateCardiac and thoracic risk indicesAs cardiovascular complications are potential risks following lung cancer resection, a cardiovascular risk assessment must be performed preoperatively . The NatThoracic Revised Cardiac Risk IndexThe Revised Cardiac Risk Index (RCRI) was proposed in 1999 by Lee et al. for evaluation of stable non-urgent major non-cardiac surgery patients . This waThe sum of these scores then divides patients into different risk classes that estimate their risk of cardiac complications, thus determining those who require further cardiac assessments: (1) Class A - 0 points (1.5%), (2) Class B - 1-1.5 points (5.8%), (3) Class C - 2-2.5 points (19%) (4) Class D - >2.5 points (23%).The validity of the ThRCRI in predicting cardiovascular risk after major lung resection has been supported in multiple studies -20 , which specifically looks at in-hospital mortality following general thoracic surgery. The nine variables it uses include age , sex, American Society of Anesthesiologists (ASA) score , Zubrod score , dyspnea score , the priority of surgery  and procedure class  . NICE reThoracoscore and the modified Thoracoscore (dyspnea score excluded) have previously been externally validated, including a retrospective study in which 1675 patients who underwent thoracic surgery (n=626 for lung resections) were analyzed from 2002 to 2006. The modified Thoracoscore proved to be an effective predictor of in-hospital mortality and midterm mortality (mean follow-up of 25 months), with in-hospital mortality risk increasing by 20% for every 1% increase of the modified Thoracoscore, and midterm mortality increasing by 12% for every 1% increase  Table 33.However, studies in recent years have shown the inaccuracy of Thoracoscore, particularly when compared to other models. One such study aimed to externally validate Thoracoscore, as well as other multivariable prediction models , looking at their effectiveness in estimating perioperative mortality. The survival time (number of days from surgery to date of death) was measured in 6600 patients who underwent lung resection between 2012 and 2018. Each model was produced to predict either in-hospital or perioperative mortality; 5/6 of the models had an inaccurate estimation of the type of mortality they were made for, with the modified Eurolung model producing the only acceptable prediction (observed:expected ratio of 0.92). However, this model has limited variables and does not factor in patient comorbidities, thereby bringing its clinical validity into question .A brief summary of some of the available risk models in thoracic surgery along with their disadvantages is mentioned in the table below -28 Tabl. Their uFrailty Frailty assessment is defined as an age-related decline in multiple physiological systems and can be used to flag vulnerable patients who may benefit from pre-operative rehab or non-surgical therapies . The curmFI was formed by matching the Canadian Study of Health and Aging Frailty index (CSHA-FI) to the 11 variables, for example, MI history and diabetes, compiled by the American College of Surgeons NSQIP . RCRI usA study on frailty assessment was conducted at a single-site thoracic surgical clinic - out of the 180 eligible patients, 125 completed screening. Results showed that 71 (57%) were prefrail and 15 (12%) were frail . This isPreoperative risk assessments for lung cancer resection play a vital role in determining whether it is appropriate to operate, deciding if further assessments or treatments are required, and predicting a patient’s prognosis. Some of these assessments, such as a frailty assessment, CPET and ThRCRI, have been externally validated by studies, proving their accuracy in predicting complications. Their use in combination, depending on the patient, would provide a detailed picture of what a patient’s outcome following surgery would be. However, other assessments, such as pulmonary function tests and Thoracoscore, still have conflicting evidence regarding their efficacy. This is possibly skewed by small underpowered studies, hence need for larger studies using acceptable cut off values. These assessments require further external validation, and should not, at this time, replace the use of the assessments that have proven to be effective.