GP fundholding. Doctor should know better.
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Community Health Nursing↗
Biomedical subjects
R Kline
Publications and source records attributed to R Kline.
Twice as nice.
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Community Health Nursing↗
Discrimination. Right on your side.
The NHS is Europe's largest employer of women. It is also the largest employer of black and ethnic minority people in the UK. Yet race and sex discrimination are rife. Roger Kline describes how trade union representatives can use official guidance and the law to challenge discriminatory employment practices.
Employment↗
Knowledge can be power.
Despite the erosion of many employment rights during the past 15 years, there has been some improvement in the right to information about individual contracts of employment, or for the purposes of collective bargaining. Roger Kline considers how local representatives may obtain some of the information.
Collective Bargaining↗
Immunisation. At the sharp end.
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Clinical Competence↗
Case-mix adjustment using objective measures of severity: the case for laboratory data.
OBJECTIVE: We evaluate the use of routinely gathered laboratory data to subclassify surgical and nonsurgical major diagnostic categories into groups homogeneous with respect to length of stay (LOS). DATA SOURCES AND STUDY SETTING: The source of data is the Combined Patient Experience database (COPE), created by merging data from computerized sources at the University of California San Francisco (UCSF) Medical Center and Stanford University Medical Center for a total sample size of 73,117 patient admissions. STUDY DESIGN: The study is cross-sectional and retrospective. All data were extracted from COPE consecutive admissions; the unit of analysis is an admission. The outcome variable LOS proxies hospital resource utilization for an inpatient stay. Nine (candidate) predictor variables were derived from seven lab tests (WBC, Na, K, C02, BUN, ALB, HCT) by recording the whole-stay minimum or maximum test result. DATA COLLECTION/EXTRACTION METHODS: Patient groups were formed by first assigning to major diagnostic categories (MDCs) all 73,117 admissions. Each MDC was then partitioned into medical and surgical subgroups (sub-MDCs). The 13 sub-MDCs selected for study define a study population of 32,599 patients that represents approximately 45 percent of inpatients. Within each of the 13 sub-MDCs, patients were randomly assigned to one of two data sets in a ratio of 2:1. The first set was used to create, the second to validate, three different LOS predictors. Predictive accuracies of individual DRG classes were compared with those of two alternative classification schemes, one formed by recursive partitioning (the sub-MDC) using only lab test results, the other by partitioning with both lab test results and individual DRGs. PRINCIPAL FINDINGS: For the eight largest sub-MDCs (81 percent of study population), individual DRGs explained 23 percent of the within sub-MDC variance in LOS, laboratory data classes explained 31 percent, and classes derived by considering individual DRGs and laboratory data explained 37 percent. (Each result is a weighted average R2. The average number of LOS classes into which the eight largest sub-MDCs were partitioned were 20, 10, and 10, respectively. Within six of the eight, partitioning on the basis of laboratory data alone explained more within sub-MDC variance than did partitioning into individual DRGs. CONCLUSIONS: Routine lab test data improve the accuracy of LOS prediction over that possible using DRG classes. We note that the improvements do not result from overfitting the data, since the numbers of LOS classes we use to predict LOS are considerably fewer than the numbers of individual DRGs.
California↗
Redundancy. When your number's up.
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Community Health Nursing↗
Skillful mixing.
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Community Health Nursing↗
Fighting for standards.
HVA members have been among the most vocal and effective campaigners against cuts in community nursing services which they believe will damage services to clients. Roger Kline outlines some typical scenarios and the strategies adopted by HVA members to challenge management proposals.
Community Health Nursing↗
Disciplinary procedures. Cautionary tales.
HVA local accredited representatives are reporting an increase in disciplinary cases against field staff. Disciplinary cases can be very stressful for all concerned. They should not be used unless clearly appropriate, as Roger Kline explains.
Community Health Nursing↗
Radiation Therapy Oncology Group: radiosurgery quality assurance guidelines.
A multidisciplinary Radiation Therapy Oncology Group (RTOG) task force has developed quality assurance guidelines for radiosurgery. The purpose of the guidelines are fourfold: (1) To ensure that participating institutions have the proper equipment and appropriate technique(s) to administer radiosurgery; (2) to outline a standard data set for each treated patient to assess protocol compliance; (3) to define minor and major deviations in protocol treatment; and (4) to set forth clinical data necessary to determine treatment efficacy, including failure patterns, and treatment toxicity. These guidelines are being implemented into active and developing radiosurgery protocols.
Brain Neoplasms↗
Acid dissociation of immune complexes improves diagnostic utility of p24 antigen detection in perinatally acquired human immunodeficiency virus infection.
Since acid treatment of serum is known to disrupt immune complexes, the diagnostic utility of the p24 antigen assay was examined after acid treatment of 345 serum samples from 158 children born to women infected with human immunodeficiency virus (HIV). Although the p24 antigen assay after acid treatment was negative in 9 HIV-1-infected children < 1 week old, antigen was detectable at high levels in all 30 samples obtained from infected children 1-9 months old. Overall, antigen was positive in 145 (sensitivity 89.5%) of 162 samples from 47 HIV-1-infected children > or = 1 month old. In contrast, the sensitivity of the p24 antigen assay without acid dissociation was only 18% (P < .001). Among the 76 uninfected children, 132 (specificity 99.2%) of 133 specimens were p24 antigen-negative after acid dissociation. These results demonstrate that acid treatment of serum markedly improves the sensitivity and predictive value of the p24 antigen assay for diagnosis of perinatally acquired HIV-1 infection in children 1 month of age or older.
Acids↗
Mechanisms whereby lytic granules from cytotoxic T lymphocytes damage guinea pig ventricular myocytes.
During immunological rejection of the transplanted heart, cytotoxic T lymphocytes (CTL) infiltrate the myocardium and by damaging the myocytes contribute to loss of function. To address one important aspect of heart transplant rejection, we investigated in guinea pig ventricular myocytes how CTL-derived lytic granules containing the pore-forming protein perforin reduce the membrane potential (VM) and cause cell damage. The reduction in VM was biphasic; within 8.4 +/- 1.9 min VM was reduced from a control value of -78.4 +/- 1.9 mV to -69.9 +/- 3.5 mV. Subsequently, within 6.7 +/- 2.1 min VM declined to -3.4 +/- 1.2 mV, associated with a progressive contracture. Under whole cell voltage clamp, in myocytes held at their resting potential (VM = -76.2 +/- 0.9 mV), granules induced discrete inward current steps (resembling 'single channel' activity), with a mean amplitude of -86.8 +/- 1.4 pA and open times lasting from seconds up to several minutes. The mean conductance and reversal potential calculated from the linear regression analysis of the I-V relations were 1390 pS and -6.8 mV, respectively. The probable non-selectivity of these 'channels' and the resultant loss of membrane K+ selectivity can account for the reduction in VM. At the same time, opening of these pores leads to Ca2+ overload, resulting in contracture and cell damage.
Animals↗
Novel preservation solution permits 24-hour preservation in rat and baboon cardiac transplant models.
BACKGROUND: Cardiac preservation for transplantation disrupts normal vascular homeostatic mechanisms. Hypoxia and reoxygenation increase endothelial cell permeability, induce procoagulant activity, and alter endothelial cell/leukocyte interactions, with a parallel reduction in endothelial cAMP and nitric oxide levels. Because hypoxia/reoxygenation simulates a significant component of the global ischemia/reperfusion of cardiac transplantation, we hypothesized that preservation failure may be related to these perturbations. This work focuses on repleting the intercellular/intracellular second messengers nitric oxide/cGMP and cAMP in the donor heart to enhance cardiac preservation for transplantation. METHODS AND RESULTS: A heterotopic rat heart transplant model was used to compare lactated Ringer's (LR) and University of Wisconsin (UW) solutions to a novel storage solution (Columbia University solution, CU), which contains a cAMP analogue (dibutyryl cAMP) and nitroglycerin (to enhance nitric oxide-related mechanisms). By 24 to 28 hours of preservation, no LR hearts survived (n = 9), 35% of UW hearts survived (n = 20), and 88% of CU-preserved hearts survived (n = 8; P < .05) versus LR or UW). The viability of preserved hearts was explored by determining whether CU preservation enabled myocytes to maintain resting membrane potentials and preserve their ability to generate an action potential in response to a field stimulus. Of 24 sites explored with a microelectrode in UW-preserved hearts, only 4% were able to generate an action potential, compared with 75% of 36 sites in CU-preserved hearts (P < .001), with corresponding preservation of resting membrane potential in the CU-preserved hearts (-13 mV for UW versus -54 mV for CU, P < .001). Orthotopic baboon cardiac transplantation performed after 24-hour simple hypothermic preservation demonstrated that no UW-preserved heart (n = 4) survived the perioperative period; in contrast, four of five hearts stored for 24 hours in CU solution sustained the recipient with minimal inotropic support, and two animals survived long-term. CONCLUSIONS: Sustaining higher levels of intercellular/intracellular second messengers cAMP and nitric oxide/cGMP provides a new approach to enhancing cardiac preservation.
Adenosine↗
TUPE. Safe transfer.
The NHS and Community Care Act protected the pay and conditions of NHS staff transferred from health authority employment to trust. But with the advent of GP fundholding and moves by health care purchasers to 'play' the NHS internal market, HVA members will need the protection of TUPE: the Transfer of Undertakings (Protection of Employment) regulations 1981, as Roger Kline explains.
Community Health Nursing↗
Retiring in style.
The NHS pension scheme is widely regarded by pensions experts as one of the best. It offers a more generous deal than other, private sector schemes for the equivalent contributions. However it is not yet open to nurses employed in general practice and there are a number of issues of which health visitors and school nurses working in the NHS should be aware.
Community Health Nursing↗
Measuring down: PRP pitfalls.
Within the next three years many NHS staff will be on a performance related pay (PRP) scheme, writes ROGER KLINE. PRP, together with job evaluation (see May Health visitor) is likely to become the main means of determining NHS staff pay. Already many senior NHS managers are on PRP and many trusts see it as one of their goals.
Employee Performance Appraisal↗
Recognition. When the music stops.
Trade unions can no longer expect NHS employers automatically to recognise their role in negotiating employment terms and conditions on behalf of their members. NHS self-governing trusts are now free to set their own terms and conditions of employment--and to choose with whom they wish to negotiate. Roger Kline outlines the importance of recognition agreements.
Collective Bargaining↗