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Establishing a practice based primary care research network. The University Family Practice Network in South Australia.

BACKGROUND: Practice based research networks enable the study of primary care problems in a primary care setting. To be successful, our experience indicates that a network will need to incorporate a number of key components. In South Australia, a University Family Practice Network has been established to undertake primary health care research and teaching and to contribute to the general practice workforce. The University Family Practice Network is composed of five practices and is managed jointly by the Department of General Practice, Adelaide University and the South Australian Centre for Rural and Remote Health, Adelaide University and the University of South Australia. OBJECTIVE: This article details the successful establishment of the University Family Practice Network in the hope of providing a model for other universities who may be interested in setting up a practice based research network. DISCUSSION: The characteristics of this network include fractional academic positions for general practitioners, computerised medical records, location in rural and urban sites, regular meetings and the appointment of a research fellow. A number of benefits have arisen since the network's establishment that will assist its future development and sustainability. These include collocation with allied health services, development of local expertise and workforce support.

Australia↗

Prolonged hypothermic cardiac storage with University of Wisconsin solution. An assessment with human cell cultures.

Hypothermic storage of cardiac allografts is routinely used for transplantation but is associated with an increased mortality when ischemic times are greater than 4 hours. The ideal storage conditions (solution and temperature) could extend the current limits of cold ischemia. Human endothelial cells and ventricular myocytes were studied to screen various solutions and temperatures for organ preservation. Four solutions (modified Euro-Collins, phosphate-buffered saline, Stanford cardioplegia, and University of Wisconsin) were evaluated. Endothelial cells were evaluated after prolonged hypothermic storage consisting of 0 degree, 4 degrees, and 8 degrees C for 36 hours, and ventricular myocytes were stored at 0 degree and 8 degrees C for 24 hours. Cell viability was determined by morphology (10 dishes per group), and trypan blue exclusion (5 dishes per group) in addition to a cell adhesion assay (endothelial cells 5 dishes per group) and adenine nucleotide analysis with high-performance liquid chromatography techniques (ventricular myocytes 5 dishes per group). Endothelial cell morphology was best preserved by University of Wisconsin solution (p less than 0.001, chi 2) and at 0 degree C (p less than 0.01, chi 2). Endothelial cells stored with University of Wisconsin solution excluded trypan blue better (1.0% +/- 0.5% cells stained, p less than 0.001. Analysis of variance [ANOVA]). Cell adhesion was poorly protected with Stanford cardioplegia (p less than 0.001, ANOVA). Myocyte morphology was preserved best with University of Wisconsin solution at 0 degree C (p less than 0.001, chi 2). According to trypan blue staining, Euro-Collins and University of Wisconsin solutions were superior to Stanford cardioplegia or phosphate-buffered solutions (p less than 0.001, ANOVA). Temperature did not influence the trypan blue results. Adenosine triphosphate was maintained best with University of Wisconsin solution at 0 degree C (p less than 0.01, ANOVA). Myocytes were more sensitive to the effects of prolonged storage compared with endothelial cells by morphologic criteria and trypan blue staining characteristics, irrespective of the shorter preservation times. University of Wisconsin solution was the most effective solution tested. Colder temperatures (0 degree to 4 degrees C) provided better protection than 8 degrees C. Myocytes were more sensitive to prolonged preservation than endothelial cells. Furthermore, the technique used appears helpful as a model of prolonged hypothermic storage and could be expanded to assess other interventions.

Adenosine Diphosphate↗

The role of adenosine in extended myocardial preservation with the University of Wisconsin solution.

The purpose of this study was to determine the role that adenosine plays in enhanced myocardial preservation during cold storage with the University of Wisconsin solution. Hearts from adult rabbits were flushed with University of Wisconsin solution with or without adenosine and stored at 4 degrees C for 24 hours. Interstitial fluid purine levels during the period of cold storage were estimated with cardiac microdialysis probes. In a second series of experiments hearts were flushed with University of Wisconsin solution with or without adenosine or St. Thomas' Hospital cardioplegic solution and stored for 18 hours (4 degrees C). Functional recovery was assessed by reperfusing the hearts on a Langendorff apparatus (100 cm H2O) for 45 minutes with Krebs-Henseleit buffer. During cold storage dialysate adenosine concentrations in hearts flushed with University of Wisconsin solution were 20- to 40-fold greater than adenosine levels in hearts flushed without adenosine. After 45 minutes of reperfusion hearts preserved with University of Wisconsin solution exhibited a rate-pressure product of 11,098 +/- 576 mm Hg/min, significantly greater than that for hearts flushed with University of Wisconsin solution minus adenosine (8106 +/- 780 mm Hg/min) and St. Thomas' Hospital solution (7317 +/- 768 mm Hg/min). These results suggest that adenosine plays a major role in enhanced myocardial preservation with the University of Wisconsin solution, possibly by maintaining elevated interstitial fluid adenosine levels during the period of cold storage.

Adenosine↗

Differential impact of Carolina rinse and University of Wisconsin solutions on microcirculation, leukocyte adhesion, Kupffer cell activity and biliary excretion after liver transplantation.

This quantitative in vivo fluorescence microscopy study investigated the relative impact of an optimized rinse solution (warm Carolina rinse) and that of an established storage solution (University of Wisconsin solution) on various pathomechanisms of hepatic reperfusion injury after cold storage. Syngeneic orthotopic, arterialized liver transplantation was performed in male Lewis rats after 24 hr of cold ischemia (n = 24). The four experimental groups differed according to the type of preservation/rinse solution used: University of Wisconsin solution/albumin rinse (group 1), autologous blood (just external cooling)/albumin rinse (group 2), blood/Carolina rinse (group 3) and University of Wisconsin solution/Carolina rinse (group 4). Hepatic microvascular perfusion, leukocyte accumulation and phagocytic activity of Kupffer cells were assessed by means of intravital fluorescence microscopy 30 to 90 min after reperfusion. Disturbances of microvascular perfusion were most pronounced in group 2, markedly reduced by University of Wisconsin solution (group 1) and Carolina rinse (group 3) and minimized by combined use of University of Wisconsin solution and Carolina rinse in group 4. Intrahepatic leukocyte-endothelium interaction in sinusoids and postsinusoidal venules was found to depend on the application of Carolina rinse before reperfusion rather than the use of University of Wisconsin solution during cold storage. Activation of phagocytosis by Kupffer cells was most pronounced in group 1, intermediate in groups 2 and 3 and not noticeable in group 4. Hepatocellular excretory function as assessed on the basis of total bile flow and excretion of bile acids during the first 90 min after reperfusion was found to be improved by application of Carolina rinse, both after storage in blood or in University of Wisconsin solution.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenosine↗

A clinical trial of University of Wisconsin solution for pulmonary preservation.

Suboptimal pulmonary preservation with modified Euro-Collins solution (9/90 to 4/91) prompted us to change to University of Wisconsin solution (4/91 to 4/92). Between September 1990 and April 1992, 94 patients received 100 pulmonary allografts (13 heart-lungs, 45 double lungs, 42 single lungs) that were flushed and preserved with either Euro-Collins (n = 30) or University of Wisconsin (n = 70) solution. Selection of donors and procurement and storage of donor lungs were identical. Bilateral single lung transplantation was performed more often in the University of Wisconsin group and resulted in a significantly longer graft ischemic time (University of Wisconsin group; 303 +/- 62 minutes; Euro-Collins group; 260 +/- 62 minutes; p = 0.007, t test). The use of cardiopulmonary bypass was not statistically significantly different. Preservation injury identified by the radiograph on day 1 was more severe (p = 0.036; Mann-Whitney U test) in the Euro-Collins group than in the University of Wisconsin group. In double lung and heart-lung recipients gas exchange of the allografts was evaluated by the arterial/alveolar oxygen tension ratios at nine intervals during the first 72 hours. The mean arterial/alveolar oxygen tension ratio was 0.62 +/- 0.26 in the University of Wisconsin group and 0.46 +/- 0.23 in the Euro-Collins group, but this difference did not reach significance (p = 0.119, analysis of variance). Despite the longer ischemic time, pulmonary preservation achieved by University of Wisconsin solution appears to be comparable with that achieved by Euro-Collins solution.

Adenosine↗

Cardiac storage with University of Wisconsin solution, calcium, and magnesium.

BACKGROUND: Previous investigations from this institution and others support the role of University of Wisconsin solution for prolonged hypothermic cardiac storage. Modification of the divalent cation concentrations has been beneficial for cardioplegic investigations and may enhance cardiac recovery after extended preservation. METHODS: To investigate this hypothesis, isolated rodent hearts were obtained from Sprague-Dawley rats and mounted on a Langendorff apparatus. Rat hearts were flushed (15 ml/kg) and stored (30 ml) for 8 hours at 0 degree C in unmodified University of Wisconsin solution (n = 16/group) or University of Wisconsin solution with calcium concentrations of 0.025 to 10 mmol/L or magnesium concentrations of 10 to 20 mmol/L (six to eight hearts/group). Finally, combinations of calcium and magnesium were examined. Rat hearts were studied before storage and after 45 minutes of reperfusion with an intraventricular balloon. RESULTS: Developed pressure (mean +/- standard deviation) was increased with calcium 0.1 mmol/L (University of Wisconsin solution: 69.2% +/- 7.0%; Ca++ 0.1 mmol/L: 78.9% +/- 6.1%, p < 0.05), whereas only the addition of the highest calcium concentration (10 mmol/L) was significantly harmful (developed pressure: 58.3% +/- 8.4%, p < 0.05; creatine kinase release: 408 +/- 200 versus 170 +/- 104 IU/gm, p < 0.05; lactate dehydrogenase release: 103 +/- 43 versus 37 +/- 26 IU/gm, p < 0.05). Coronary flow recovered to control values with magnesium 15 mmol/L, which was significantly greater than that achieved with unmodified University of Wisconsin solution (97.1% +/- 14.6% versus 72.1% +/- 8.4%, p < 0.05). Of the calcium-magnesium combinations tested, developed pressure was increased compared with unmodified University of Wisconsin solution with calcium 0.1 and magnesium 20 mmol/L (76.8% +/- 6.4%, p < 0.05). Diastolic function was reduced in all groups (p < 0.0001) and not significantly different between groups. CONCLUSIONS: The experiments indicated that recovery after storage with University of Wisconsin solution is enhanced with the addition of calcium and magnesium. The addition of high concentrations of calcium (> or = 2.5 mmol/L) appears harmful.

Adenosine↗

Critical limits (alert values) for physician notification: universal or medical center specific limits?

The concept of critical limits (alert values), defined as an imminent life threatening laboratory result requiring immediate physician notification, has been widely adopted as a standard of good laboratory practice. Although virtually all laboratories have tests with critical limits, surveys have shown that there is no universal alert value list. Recently, nine VA medical centers in the New England region, which now constitute one consolidated entity, were surveyed with the objective of summarizing critical limits. Universal (100 percent) critical limit tests for clinical chemistry were: Calcium; mean low/high, 6.5/12.4 mg/dL: Glucose 48/432 mg/dL: Potassium 2.8/6.1 mmol/L: Sodium 121/159 mmol/L. Universal hematology tests included: Hematocrit 22.2/59.7 percent: Platelet count 61K/983K: white blood count 1.9K/29K. Although there was universal agreement that abnormal coagulation tests (PT, PTT) should be included on the hematology critical limit list, there was wide variation in the reporting of coagulation tests (seconds and INR) and patient therapeutic status (anticoagulant or no-anticoagulant). Universal alert values for microbiology were: Positive blood culture: Positive cerebral spinal fluid (CSF) culture: Positive CSF Gram stain. There was no universal agreement regarding critically high (potentially toxic) therapeutic drugs, with two medical centers declining to notify physicians of any abnormally high therapeutic drug level. No other qualitative critical limits for other laboratory sections, such as physician notification of an unexpected malignancy (surgical pathology) were universal. Medical center specific critical limits, designed to meet the clinical needs of each facility, are the norm in the nine medical centers. Laboratories do need periodically to review their critical limit lists with appropriate clinical input to avoid including critical limits for laboratory tests not required for urgent physician notification and patient evaluation and treatment.

Chemistry, Clinical↗

Knowledge and practice of universal precaution in a tertiary health facility.

BACKGROUND: The increased risk of health workers to contract HIV, hepatitis B and C viruses in their work place led to the development of universal precaution or infection control policy. This policy where applied, has been found to reduce the risk of contracting these infections in the work place. The aim of this study is to determine the knowledge and practice of this policy in University of Nigeria Teaching Hospital (UNTH), Enugu. METHODS: This study was cross-sectional in design. Subjects were health workers likely to be exposed to body fluid. The study tool was a self administered pre-tested questionnaire. Statistical analysis was done using SPSS version 11.5 software. RESULTS: Two hundred and forty six health workers participated in the study, consisting of 150 females and 96 males. The male to female ratio was 1: 1.6. Majority of the respondents were between ages 20-49 years. One hundred and twenty four (50.4%) of the respondents were aware of universal precaution, while 88 (35.8%) knew the correct definition of universal precaution. Thirty four (13.8%) had received training on universal precaution however no ward attendant was trained. On multiple regression (P = 0.049) and training (P = 0.006) were the variables that were predictive of correct definition of universal precaution. Hands gloves were used by 86.6% of the respondents, 32.9% did not re-sheath needles and 43.9% practiced appropriate hand washing. CONCLUSION: The level of knowledge and compliance with precaution by health workers in UNTH Enugu is low. Low level of training and unequal training exposure among the various occupations contributes to this.

Adult↗

Differences in prostate size between patients from University and Veterans Affairs Medical Center populations.

BACKGROUND: Numerous studies on prostatic disease have been performed at Veterans Affairs (VA) Medical Centers. Recent investigations evaluating early detection of prostate cancer provide insight that the average prostate volume may be different between patients with similar clinical findings who are from different hospital settings. The objective of this study was to compare prostate size between men from University and VA Medical Centers. METHODS: Patients were enrolled retrospectively from 1989-1996 from the Urology Clinics at a University and a VA Medical Center. All men underwent transrectal ultrasound-guided sextant biopsy of the prostate owing to either an elevated prostate-specific antigen (PSA) level and/or abnormal digital rectal examination (DRE) detected prior to biopsy. Prostate volume was calculated using the ellipsoid three-diameter formula based on transrectal ultrasound measurements. RESULTS: There were 1,311 men included in the analysis: 717 were from the VA, and 594 were from the University. The average prostate volume was significantly smaller among VA patients both for men with cancer (P = 0.0004) and for men with no evidence of malignancy (P < 0.0001). Overall, the average prostate volume was 38.5 cm3 (median, 32.5 cm3) among men from the VA compared to 46.8 cm3 (median, 39.3 cm3) among men from the University Medical Center. Men from the VA were older (mean +/- SD = 68 +/- 7.3) than men from the University (mean +/- SD = 66 +/- 7.7) (P = 0.004) and there was no significant difference in PSA levels between the two groups of patients (P = 0.11). Intriguingly, the incidence of cancer was significantly lower at the VA (24.5%) compared to the University (35.9%) (P < 0.0001). CONCLUSIONS: The variance in prostate size suggests that there are significant differences between the two patient populations. Proposed factors leading to this discrepancy include differences in socioeconomic factors, environmental factors, and changes in hormonal milieu related to alcohol and tobacco use. These results may have significant implications regarding the interpretation and extrapolation of results from previous studies performed at a single hospital setting.

Black or African American↗

An alternative to foster care for victims of child abuse/neglect: a university-based program.

Two central forces dominated the conception and development of the Parents and Children Together (PACT) project: the need for provision of an in-home alternative to foster care for abuse and/or neglect families and the prevention of further abuse and/or neglect in the family. Wayne State University in Detroit is the site for Parents and Children Together (PACT) project, a contractual service of the Michigan Department of Social Services (DSS). Graduate students provide in-home services to referred families who, due to child abuse or neglect, would otherwise have their child(ren) removed from the home. This family-based work is a one-year cooperative education experience for students interested in professions in the human services. This report discusses the PACT project as a grant operated through the university, the specification of course work associated, and the attraction of students to graduate study with "hands-on" experience. All of these program attributes, as well as the resource of the project for research, make it an important effort for the university. Further, the university has an additional meaningful role with community residents. Beyond university and student opportunities, the DSS and its clients benefit by having broad-based expertise brought into homes on a weekly basis. Annual success rates of keeping children out of foster care are cited along with cost effectiveness. The university's role in levels of prevention in a highly coordinated community effort is indicated.

Child↗

Industry-university collaborations: a necessity for the future.

OBJECTIVES: The aim of this discussion document is to consider the potential benefits of collaborations between universities and industry. Universities and industry now exist in a harsh and competitive economic climate. Indeed, their very survival depends increasingly on their ability and willingness to adapt to an unprecedented pace of change. There are a number of compelling reasons for universities and industry to undertake collaborative research. The costs of research have escalated. Universities, of necessity, are increasingly seeking financial support from industry as conventional sources of funding have been systematically reduced. Companies can no longer be self sufficient in terms of the science and technology needed for success. The strength of universities is their science base, and industry recognizes that the rapid exploitation of scientific advances is the key to its survival. Both organizations can benefit from collaborative research programmes. Universities are able to make additional staff appointments which add to their intellectual resource and reputation. In addition the purchase of equipment enhances their infrastructure. CONCLUSIONS: Industry has the opportunity to recognize the potential relevance and value of funded research and must harness and commercially exploit new knowledge as rapidly as possible. Ultimately such collaboration will give rise to new approaches to the prevention, diagnosis and treatment of dental diseases with benefits to all concerned.

Capital Financing↗

Are universal precautions realistic?

In concluding whether universal precautions are necessary, it certainly appears that we need something to reduce the significant problem of HIV transmission to health-care providers. As occupational risk goes, it exceeds the occupational risk of a number of other high-risk professions. Unfortunately, we do not know if universal precautions are effective. We also do not know the true compliance rate in use of universal precautions, nor whether they have an impact on transmission even if effectively used. What are the alternatives? They are not great, but some have not been adequately explored or implemented. Re-engineering around needle use in the hospital is clearly the most likely area to produce concrete results, because needlesticks are overwhelmingly the greatest source of infection, but this has not been encouraged to the degree it could be, even with systems already developed. Universal testing does not appear to be a viable alternative, for numerous reasons already discussed. Finally, are universal precautions more important for other pathogens than HIV? I would say yes. Hepatitis B, hepatitis C, and nosocomial infections are more important both as public health issues and as health-care provider prevention issues. If universal precautions are effective in reducing any of these, they are worthwhile.

HIV Infections↗

Effectiveness of computer-assisted instruction in increasing the rate of universal precautions--related behaviors.

BACKGROUND: With widespread noncompliance to universal precautions well established, an experimental study was designed to compare the rate of universal precautions--related behaviors between nurses who participate in computer-assisted instruction. This study also explored the relationship between rates of universal precautions--related behaviors and subjects' demographic and experiential characteristics and history of occupational blood-borne exposure. METHODS: Data were collected by using a questionnaire to elicit information as to subjects' demographic and experiential characteristics and history of occupational blood-borne exposure. The Universal Precautions Assessment Tool was used to gather data on rates of universal precautions--related behaviors on two groups of registered nurses with 30 subjects per group. RESULTS: By using analysis of variance, the null hypothesis was rejected. The intervention used in this study did increase universal precautions--related behaviors. Multiple regression was used to analyze the research question and none of the variables were significant. Forty (67.8%) subjects reported receiving a needlestick or cut caused by a needle or sharp that was actually or potentially contaminated with blood or body fluids. Of these exposures, only one patient was known to be HIV antibody positive. CONCLUSION: Replication studies using computer-assisted instruction interventions are needed as are studies aimed at exploring other potentially effective interventions.

Adult↗

Do schizophrenic patients who managed to get to university have a non-developmental form of illness?

BACKGROUND: Many people who develop schizophrenia have impairments in intellectual and social functioning that are detectable from early childhood. However, some patients do not exhibit such deficits, and this suggests that they may have suffered less neurodevelopmental damage. We hypothesized that the aetiology and form of schizophrenia may differ in such patients. We therefore studied a group of schizophrenic patients who were functioning well enough to enter university prior to illness onset. METHODS: The casenotes of 46 university-educated patients and 48 non-university-educated patients were rated on several schedules including the OPCRIT checklist, and the two groups were compared using univariate statistical techniques. Principal components analysis was then performed using data from all patients, and the factor scores for each principal component were compared between groups. RESULTS: Univariate analyses showed the university-educated patients had an excess of depressive symptoms, and a paucity of core schizophrenic symptoms. Four principal components emerged in the principal components analysis: mania, biological depression, schizophrenic symptoms, and a reactive depression. University-educated patients scored significantly higher on the reactive depression principal component, and lower on the schizophrenic symptoms principal component, than the non-university-educated patients.

Adjustment Disorders↗

Universal vs. selective services: the case of British health visiting.

AIMS: This paper discusses whether there should be universal or selective provision of health visiting services. The aim is to show the central relevance of the work of the late epidemiologist, Geoffery Rose, to arguments advocating the retention of a universal health visiting service. BACKGROUND: In the United Kingdom (UK), health visiting moved, in the early years of the twentieth century, from being focused on the needs of poor families to becoming a universally provided service. Recent debates about the future of British health visiting have again raised the issue of whether health visiting remains a universal service, or should be targeted only on the most needy. STRUCTURE: Following an exposition of Rose's work, two kinds of problems with which health visitors are concerned, depression and child abuse, are used to illustrate the ways in which Rose's approach can be applied to health visiting. CENTRAL THESIS: Rose argued that the bulk of problems in society arise in the many who are not at especially high risk, rather than in the few who are at high risk. This is because of a very large number of people who are not at especially high risk. Consequently, following Rose, this paper argues that in relation to such problems as depression or child abuse, to target health visiting services only on those at high risk would be to leave untouched a vast burden of health and social problems. In the context of identifying people who are at greatest risk, Rose argued that no screening instrument can ever be sufficiently precise to accurately identify those most likely to suffer problems. In corroboration of Rose's argument, this paper illustrates the pitfalls of health visitors' attempts to screen for families at greatest risk through the use of such instruments as checklists of risk factors. CONCLUSIONS: It is concluded that it is neither possible to screen accurately for those at greatest risk, nor desirable to target services only on those at greatest risk. Therefore, it is advocated that health visiting should remain a universal service. However, it is recognized that within a universally provided service, some clients will require a greater intensity of input than others. In assessing the need for services, it is argued that the professional judgements of health visitors are crucial.

Child↗

Conflict of interest and the university.

This essay provides an analysis of conflicts of interest (COIs) that arise in university relationships with private industry and articulates the concept of an "institutional" COI. It compares personal and institutional COIs in order to shed some light on the difficulties universities face in managing their own COIs. The essay discusses some proposed strategies for responding to institutional COIs, such as developing independent boards to monitor and oversee the university's COIs, building firewalls between various parts of the university to prevent financial interests from affecting university functions, creating independent research institutes, and prohibiting some types of university investments.

Conflict of Interest↗

Designing a low-cost pollution prevention plan to pay off at the University of Houston.

The University of Houston is located just south of downtown Houston, TX. Many different chemical substances are used in scientific research and teaching activities throughout the campus. These activities generate a significant amount of waste materials that must be discarded as regulated hazardous waste per U.S. Environmental Protection Agency (EPA) rules. The Texas Commission on Environmental Quality (TCEQ) is the state regulatory agency that has enforcement authority for EPA hazardous waste rules in Texas. Currently, the University is classified as a large quantity generator and generates >1000 kg per month of hazardous waste. In addition, the University has experienced a major surge in research activities during the past several years, and overall the quantity of the hazardous waste generated has increased. The TCEQ requires large quantity generators to prepare a 5-yr Pollution Prevention (P2) Plan, which describes efforts to eliminate or minimize the amount of hazardous waste generated. This paper addresses the design and development of a low-cost P2 plan with minimal implementation obstacles and strong payoff potentials for the University. The projects identified can be implemented with existing University staff resources. This benefits the University by enhancing its environmental compliance efforts, and the disposal cost savings can be used for other purposes. Other educational institutions may benefit by undertaking a similar process.

Conservation of Natural Resources↗

Capital investment for the future of biomedical research: a university chief financial officer's view.

The author explores the subject of capital needs in university biomedical research. Three main topics are covered: the universities' need for capital (which is great and growing fast); the sources of capital for universities (private donations, state and federal governments, institutional funds, and debt); and a review of federal policy, to determine whether the federal government is part of the problem of meeting universities' capital needs or part of the solution. For each topic, important assumptions, questions, and possible future trends and dangers are reviewed. The author calls for the university research community to face the difficult issues he has raised and consolidate their thinking in order to avoid potential dangers and to ensure the health of university science into the 21st century.

Capital Expenditures↗