Background

A significant minority of patients do not receive all the evidence-based care recommended for their conditions. Health care quality may be improved by reducing this observed variation. Composite measures offer a different patient-centred perspective on quality and are utilized in acute hospitals via the ‘care bundle’ concept as indicators of the reliability of specific (evidence-based) care delivery tasks and improved outcomes. A care bundle consists of a number of time-specific interventions that should be delivered to every patient every time. We aimed to apply the care bundle concept to selected QOF data to measure the quality of evidence-based care provision.

Methods

Care bundles and components were selected from QOF indicators according to defined criteria. Five clinical conditions were suitable for care bundles: Secondary Prevention of Coronary Heart Disease (CHD), Stroke & Transient Ischaemic Attack (TIA), Chronic Kidney Disease (CKD), Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus (DM). Each bundle has 3-8 components. A retrospective audit was undertaken in a convenience sample of nine general medical practices in the West of Scotland. Collected data included delivery (or not) of individual bundle components to all patients included on specific disease registers. Practice level and overall compliance with bundles and components were calculated in SPSS and expressed as a percentage.

Results

Nine practices (64.3%) with a combined patient population of 56,948 were able to provide data in the format requested. Overall compliance with developed QOF-based care bundles (composite measures) was as follows: CHD 64.0%, range 35.0-71.9%; Stroke/TIA 74.1%, range 51.6-82.8%; CKD 69.0%, range 64.0-81.4%; and COPD 82.0%, range 47.9-95.8%; and DM 58.4%, range 50.3-65.2%.

Conclusions

In this small study compliance with individual QOF-based care bundle components was high, but overall (‘all or nothing’) compliance was substantially lower. Care bundles may provide a more informed measure of care quality than existing methods. However, the acceptability, feasibility and potential impact on clinical outcomes are unknown.

Background

Making health care safer is a key policy priority worldwide. In specialty training, medical educators may unintentionally impact on patient safety e.g. through failures of supervision; providing limited feedback on performance; and letting poorly developed behaviours continue unchecked. Doctors-in-training are also known to be susceptible to medical error. Ensuring that all essential educational issues are addressed during training is problematic given the scale of the tasks to be undertaken. Human error and the reliability of local systems may increase the risk of safety-critical topics being inadequately covered. However adherence to a checklist reminder may improve the reliability of task delivery and maximise harm reduction. We aimed to prioritise the most safety-critical issues to be addressed in the first 12-weeks of specialty training in the general practice environment and validate a related checklist reminder.

Methods

We used mixed methods with different groups of GP educators (n = 127) and specialty trainees (n = 9) in two Scottish regions to prioritise, develop and validate checklist content. Generation and refinement of checklist themes and items were undertaken on an iterative basis using a range of methods including small group work in dedicated workshops; a modified-Delphi process; and telephone interviews. The relevance of potential checklist items was rated using a 4-point scale content validity index to inform final inclusion.

Results

14 themes (e.g. prescribing safely; dealing with medical emergency; implications of poor record keeping; and effective & safe communication) and 47 related items (e.g. how to safety-net face-to-face or over the telephone; knowledge of practice systems for results handling; recognition of harm in children) were judged to be essential safety-critical educational issues to be covered. The mean content validity index ratio was 0.98.

Conclusion

A checklist was developed and validated for educational supervisors to assist in the reliable delivery of safety-critical educational issues in the opening 12-week period of training, and aligned with national curriculum competencies. The tool can also be adapted for use as a self-assessment instrument by trainees to guide patient safety-related learning needs. Dissemination and implementation of the checklist and self-rating scale are proceeding on a national, voluntary basis with plans to evaluate its feasibility and educational impact.

Background

The UK general practitioner (GP) appraisal system is deemed to be an inadequate source of performance evidence to inform a future medical revalidation process. A long-running voluntary model of external peer review in the west of Scotland provides feedback by trained peers on the standard of GP colleagues' core appraisal activities and may 'add value' in strengthening the robustness of the current system in support of revalidation. A significant minority of GPs has participated in the peer feedback model, but a clear majority has yet to engage with it. We aimed to explore the views of non-participants to identify barriers to engagement and attitudes to external peer review as a means to inform the current appraisal system.

Methods

We conducted semi-structured interviews with a sample of west of Scotland GPs who had yet to participate in the peer review model. A thematic analysis of the interview transcriptions was conducted using a constant comparative approach.

Results

13 GPs were interviewed of whom nine were males. Four core themes were identified in relation to the perceived and experienced 'value' placed on the topics discussed and their relevance to routine clinical practice and professional appraisal: 1. Value of the appraisal improvement activity. 2. Value of external peer review. 3. Value of the external peer review model and host organisation and 4. Attitudes to external peer review.

Conclusions

GPs in this study questioned the 'value' of participation in the external peer review model and the national appraisal system over the standard of internal feedback received from immediate work colleagues. There was a limited understanding of the concept, context and purpose of external peer review and some distrust of the host educational provider. Future engagement with the model by these GPs is likely to be influenced by policy to improve the standard of appraisal and contractual related activities, rather than a self-directed recognition of learning needs.

Purpose

Meibomian gland dysfunction (MGD) is a common clinical problem that is often associated with evaporative dry eye disease. Alterations of the lipids of the meibomian glands have been identified in several studies of MGD. This prospective, observational, open label clinical trial documents the improvement in both clinical signs and symptoms of disease as well as spectroscopic behavior of the meibomian gland lipids after therapy with topical azithromycin ophthalmic solution.

Methods

Subjects with symptomatic MGD were recruited. Signs of MGD were evaluated with a slit lamp. Symptoms of MGD were measured by the response of subjects to a questionnaire. Meibum lipid (ML) lipid-lipid interaction strength, conformation and phase transition parameters were measured using Fourier transform infrared spectroscopy (FTIR).

Results

In subjects with clinical evidence of MGD changes in ordering of the lipids and resultant alteration of phase transition temperature were identified. Topical therapy with azithromycin relieved signs and symptoms and restored the lipid properties of the meibomian gland secretion towards normal.

Conclusions

Improvement in phase transition temperature of the meibomian gland lipid with the determined percent trans rotomer composition of the lipid strongly suggests that the ordering of the lipid molecules is altered in the disease state (MGD) and that azithromycin can improve that abnormal condition toward normal in a manner that correlates with clinical response to therapy.

Background

GP appraisal is currently considered inadequate because it lacks robustness. Objective assessment of appraisal evidence is needed to enable judgements on professional performance to be made.

Aim

To determine GP appraisers' views of the acceptability, feasibility, and educational impact of external peer feedback received on three core appraisal activities undertaken as part of this study.

Design of study

Independent peer review and cross-sectional postal questionnaire study.

Setting

NHS Scotland.

Method

One of three core appraisal activities (criterion audit, significant event analysis, or video of consultations) was undertaken by GP appraisers and subjected to peer review by trained colleagues. A follow-up postal questionnaire elicited participants' views on the potential acceptability, feasibility, and educational impact of this approach.

Results

Of 164 appraisers, 80 agreed to participate; 67/80 (84%) submitted one of three appraisal materials for peer review and returned completed questionnaires. For significant event analyses (n = 44), most responders believed the peer feedback method was feasible (100%) and fair (92.5%) and would add value to appraisal (95.5%). Peer feedback on criterion audits (n = 15) was believed to be acceptable and fair (93.3%) and it was thought it would be a useful educational tool (100%). Completing a consultation video (n = 8) was perceived to be feasible as part of normal general practice (n = 5). It was unanimously agreed that assessment of videos by peers has educational impact and would help improve appraisal.

Conclusion

This group of GP appraisers strongly supported the role of external and independent feedback by trained peers as one approach to strengthening the existing appraisal process.

The polyomavirus JC (JCV) is the etiologic agent of progressive multifocal leukoencephalopathy(PML) and of JCV granule cell neuronopathy(JCV GCN). We present an HIV-negative patient who developed multiple cortical lesions, aphasia and progressive cognitive decline after chemotherapy for non-small-cell lung cancer. Brain biopsy and CSF PCR demonstrated JCV and she had a rapidly fatal outcome. Post-mortem analysis showed diffuse cortical lesions and areas of necrosis at the gray-white junction. Immunostaining revealed a productive JCV-infection of cortical pyramidal neurons, confirmed by electron microscopy, with limited demyelination. This novel gray matter syndrome expands the scope of JCV clinical presentation and pathogenesis.

High-impact biological invasions often involve establishment and spread in disturbed, high-resource patches followed by establishment and spread in biotically or abiotically stressful areas. Evolutionary change may be required for the second phase of invasion (establishment and spread in stressful areas) to occur. When species have low genetic diversity and short selection history, within-generation phenotypic plasticity is often cited as the mechanism through which spread across multiple habitat types can occur. We show that trans-generational plasticity (TGP) can result in pre-adapted progeny that exhibit traits associated with increased fitness both in high-resource patches and in stressful conditions. In the invasive sedge, Cyperus esculentus, maternal plants growing in nutrient-poor patches can place disproportional number of propagules into nutrient-rich patches. Using the invasive annual grass, Aegilops triuncialis, we show that maternal response to soil conditions can confer greater stress tolerance in seedlings in the form of greater photosynthetic efficiency. We also show TGP for a phenological shift in a low resource environment that results in greater stress tolerance in progeny. These lines of evidence suggest that the maternal environment can have profound effects on offspring success and that TGP may play a significant role in some plant invasions.

Background

Significant event analysis (SEA) is promoted as a team-based approach to enhancing patient safety through reflective learning. Evidence of SEA participation is required for appraisal and contractual purposes in UK general practice. A voluntary educational model in the west of Scotland enables general practitioners (GPs) and doctors-in-training to submit SEA reports for feedback from trained peers. We reviewed reports to identify the range of safety issues analysed, learning needs raised and actions taken by GP teams.

Method

Content analysis of SEA reports submitted in an 18 month period between 2005 and 2007.

Results

191 SEA reports were reviewed. 48 described patient harm (25.1%). A further 109 reports (57.1%) outlined circumstances that had the potential to cause patient harm. Individual 'error' was cited as the most common reason for event occurrence (32.5%). Learning opportunities were identified in 182 reports (95.3%) but were often non-specific professional issues not shared with the wider practice team. 154 SEA reports (80.1%) described actions taken to improve practice systems or professional behaviour. However, non-medical staff were less likely to be involved in the changes resulting from event analyses describing patient harm (p < 0.05)

Conclusion

The study provides some evidence of the potential of SEA to improve healthcare quality and safety. If applied rigorously, GP teams and doctors in training can use the technique to investigate and learn from a wide variety of quality issues including those resulting in patient harm. This leads to reported change but it is unclear if such improvement is sustained.

Background

Heterokont algae form a monophyletic group within the stramenopile branch of the tree of life. These organisms display wide morphological diversity, ranging from minute unicells to massive, bladed forms. Surprisingly, chloroplast genome sequences are available only for diatoms, representing two (Coscinodiscophyceae and Bacillariophyceae) of approximately 18 classes of algae that comprise this taxonomic cluster.

A universal challenge to chloroplast genome sequencing studies is the retrieval of highly purified DNA in quantities sufficient for analytical processing. To circumvent this problem, we have developed a simplified method for sequencing chloroplast genomes, using fosmids selected from a total cellular DNA library. The technique has been used to sequence chloroplast DNA of two Heterosigma akashiwo strains. This raphidophyte has served as a model system for studies of stramenopile chloroplast biogenesis and evolution.

Results

H. akashiwo strain CCMP452 (West Atlantic) chloroplast DNA is 160,149 bp in size with a 21,822-bp inverted repeat, whereas NIES293 (West Pacific) chloroplast DNA is 159,370 bp in size and has an inverted repeat of 21,665 bp. The fosmid cloning technique reveals that both strains contain an isomeric chloroplast DNA population resulting from an inversion of their single copy domains. Both strains contain multiple small inverted and tandem repeats, non-randomly distributed within the genomes. Although both CCMP452 and NIES293 chloroplast DNAs contains 197 genes, multiple nucleotide polymorphisms are present in both coding and intergenic regions. Several protein-coding genes contain large, in-frame inserts relative to orthologous genes in other plastids. These inserts are maintained in mRNA products. Two genes of interest in H. akashiwo, not previously reported in any chloroplast genome, include tyrC, a tyrosine recombinase, which we hypothesize may be a result of a lateral gene transfer event, and an unidentified 456 amino acid protein, which we hypothesize serves as a G-protein-coupled receptor. The H. akashiwo chloroplast genomes share little synteny with other algal chloroplast genomes sequenced to date.

Conclusion

The fosmid cloning technique eliminates chloroplast isolation, does not require chloroplast DNA purification, and reduces sequencing processing time. Application of this method has provided new insights into chloroplast genome architecture, gene content and evolution within the stramenopile cluster.

Background

The objective of this paper is to estimate the amount of cost-savings to the Australian health care system from implementing an evidence-based clinical protocol for diagnosing emergency patients with suspected pulmonary embolism (PE) at the Emergency department of a Victorian public hospital with 50,000 presentations in 2001–2002.

Methods

A cost-minimisation study used the data collected in a controlled clinical trial of a clinical protocol for diagnosing patients with suspected PE. Thenumber and type of diagnostic tests in a historic cohort of 185 randomly selected patients, who presented to the emergency department with suspectedPE during an eight month period prior to the clinical trial (January 2002 -August 2002) were compared with the number and type of diagnostic tests in745 patients, who presented to the emergency department with suspected PE from November 2002 to August 2003. Current Medicare fees per test were usedas unit costs to calculate the mean aggregated cost of diagnostic investigation per patient in both study groups. A t-test was used to estimate the statistical significance of the difference in the cost of resources used for diagnosing PE in the control and in the intervention group.

Results

The trial demonstrated that diagnosing PE using an evidence-based clinical protocol was as effective as the existing clinical practice. The clinical protocol offers the advantage of reducing the use of diagnostic imaging, resulting in an average cost savings of at least $59.30 per patient.

Conclusion

Extrapolating the observed cost-savings of $59.30 per patient to the wholeof Australia could potentially result in annual savings between $3.1 million to $3.7 million.

Forty-eight patients successfully completed a six-week, double blind, placebo controlled trial of ranitidine hydrochloride 200mg twice daily for active duodenal ulceration. Following endoscopy 68% of the patients taking ranitidine had healed, compared to 35% of those who were taking placebo. Nineteen of the patients who had not healed then took a further six weeks of open active treatment; of these, 14 were successfully treated. Thirty-one of the patients who had healed duodenal ulcers then took ranitidine hydrochloride 100mg at night as a maintenance treatment for one year: 71% remained endoscopically and symptomatically in remission. No serious side effects were encountered.