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General practices as emergent research organizations: a qualitative study into organizational development.

BACKGROUND: An increasing proportion of research in primary care is locally undertaken in designated research practices. Capacity building to support high quality research at these grass roots is urgently needed and is a government priority. There is little previously published research on the process by which GP practices develop as research organizations or on their specific support needs at organizational level. METHODS: Using in-depth qualitative interviews with 28 key informants in 11 research practices across the UK, we explored their historical accounts of the development of research activity. We analysed the data with reference to contemporary theories of organizational development. RESULTS: Participants identified a number of key events and processes, which allowed us to produce a five-phase model of practice development in relation to research activity (creative energy, concrete planning, transformation/differentiation, consolidation and collaboration). Movement between these phases was not linear or continuous, but showed emergent and adaptive properties in which specific triggers and set-backs were often critical. CONCLUSION: This developmental model challenges previous categorical taxonomies of research practices. It forms a theory-driven framework for providing appropriate support at the grass roots of primary care research, based on the practice's phase of development and the nature of external triggers and potential setbacks. Our findings have important implications for the strategic development of practice-based research in the UK, and could serve as a model for the wider international community.

Family Practice↗

Poor hospital infection control practice in venepuncture and use of tourniquets.

Previous studies have indicated that tourniquets may act as reservoirs of pathogenic organisms and could therefore pose a risk to patients through cross-infection. In this study, 200 tourniquets were sampled from health professionals working in a large teaching hospital. A parallel survey of control of infection was also undertaken. Staphylococcus aureus was isolated from 10 (5%) of the tourniquets sampled. Methicillin-resistant S. aureus was not isolated. Seventy-five (37.5%) of the tourniquets sampled had visible blood stains; house officers (72.7%) and laboratory phlebotomists (69.2%) had the highest proportion of blood-stained tourniquets. Tourniquets were owned on average for 1.86 years, with most respondents only obtaining a new tourniquet when the old tourniquet was lost. Three percent of respondents used a separate tourniquet for patients with known infective risk factors, e.g. HIV, MRSA. Twenty-seven percent of respondents did not wear gloves for venepuncture or did so only occasionally. Only 42% washed their hands both before and after venepuncture. Our survey reveals poor infection control practice, but a relatively low frequency of S. aureus contamination of tourniquets.

Blood-Borne Pathogens↗

Achieving research-based nursing practice.

The literature suggests that nurses may be failing to achieve research-based practice. A range of reasons why nurses fail to use research findings in practice has been highlighted in previous studies. The overall aim of this study was to identify the self-perceived research skills needs of trained nurses with the view to organizing workshops to meet these needs. Six hundred trained nurses in six different health authorities were surveyed using self-administered questionnaires. These nurses worked in clinical areas, in hospitals, the community and education. The results indicated that 93% (n = 398) of nurses were not satisfied with their research skills. Other factors emerging indicated the self-perceived skills deficit were those of an elementary nature, including locating research reports, reading and evaluating reports and application of results to practice, amongst others. This may be an indication of why research-based practice is still not a reality.

Clinical Competence↗

An outbreak of antibiotic multiresistant Klebsiella at the Neonatal Intensive Care Unit, Kaplan Hospital, Rehovot, Israel, November 1991 to April 1992.

From November 1991 through April 1992, 8 infants developed systemic infections due to antibiotic multiple resistant Klebsiellaa (MRK). All were premature and 6 of the 8 weighed less than 1100 g; 7 of the 8 had received previous antibiotic therapy. Five infections occurred during the first week of life. MRK were isolated from blood (8 cases), tracheal secretions (TS-6), stool (3), and CSF (1). All Klebsiella blood isolates were resistant to ampicillin, mezlocillin, and cefotaxime, 7 of 8 to ceftazidime and amikacin, and 4 of 7 to aztreonam; all isolates were sensitive to quinolones and imipenem. Four infants died. In all 4 of the isolates, they were sensitive only to quinolones and imipenem, and the empiric therapy used for suspected sepsis proved to be inappropriate. The outbreak was terminated by temporary closure of NICU in May 1992. Strict hand washing practices were reemphasized, and the previous empiric antibiotic protocol used for suspected sepsis (mezlocillin plus amikacin, and lately ceftazidime plus amikacin) was changed to imipenem and amikacin in the risk population. At closure, 5 additional infants had MRK in stools and/or tracheal suction specimens. Development of MRK organisms should dictate a rational use of empiric antibiotics for neonatal infections in NICU.

Anti-Bacterial Agents↗

Malnutrition in hospital patients: where does it come from?

This article provides a comprehensive overview of malnutrition in hospital patients. It explores the issues surrounding nutrition and investigates factors that contribute to the malnutrition seen in patients within the community and to the malnutrition that develops while patients are in hospital. It proposes that although patients are at risk of malnutrition in the community, malnutrition can develop while the patient is in hospital, as the result of changes in diet, nutrition not being seen as a high priority, common hospital practices, and lack of knowledge of patients' previous nutritional state.

Diet↗

Health practices of male Department of Defense health care beneficiaries: a follow-up on prostate cancer screening in the national capital area.

The purpose of this study was to assess screening for prostate cancer (PC) of male Department of Defense health care beneficiaries in the national capital area. This study was a follow-up of a previous research of African-American men's PC screening practices. In the previous study, 85% of African-American men screened for PC and the determinants of screening were men's perceived "benefits" of PC testing, age, and education. This follow-up study was conducted on 234 men age 52 years and over regardless of ethnicity using a questionnaire and convenience sampling similar to the prior study. Results showed 96% screened for PC; no statistical differences in PC screening and ethnicity; and men's perceived "self-efficacy" and "benefits" were predictors of PC screening. More men screened for PC when advised by their health care providers and 94% of men stated "trust" in health care providers, indicating the importance of a "trusting-informative health care milieu" for men's self-efficacy to screen for PC.

Age Factors↗

Effects of environmental demands, stress, and mood on health practices.

The present study examined how environmental demands, stress, and positive and negative affect were related to health practices. College undergraduates (N = 79) completed measures of stress, mood, and health practices during periods of low and high academic demands. Positive affect was positively related to exercise, nutrition, self-care practices, and overall health practices at two measurement points. Levels of stress (daily hassles, perceived stress, academic stress) increased over time, but increases in daily hassles and perceived stress were unrelated to health practices. Increases in academic demands completed in the previous week were associated with improvements in nutrition and self-care practices, greater drug avoidance, and greater overall health practices. This pattern indicates that a "rebound effect" may occur after high demand periods, during which individuals engage in more health-promoting activities. The results also suggest that the determinants of positive health practices may differ from those of negative health practices.

Adolescent↗

The use of pulse oximetry in the prevention of hyperoxaemia in preterm infants.

UNLABELLED: When deciding an appropriate upper limit for pulse oxygen saturation (SpO2) in preterm infants the usefulness of current data is limited by the fact that previous studies have examined a population of more mature infants and children or have applied various exclusion criteria which produce results unrepresentative of clinical practice. We tested the hypothesis of previous workers that maintaining the SpO2 below 98% would ensure an arterial oxygen tension (PaO2) less than 12kPa. A total of 477 simultaneous measurements of PaO2 and SpO2 were made using Ohmeda Biox oximeters on 43 infants who were less than 33 weeks gestation and receiving supplementary oxygen. Of 435 measurements performed when the SpO2 was 97% or less, 26 (6%) had a PaO2 greater than 12kPa. Further examination of the data showed that of 108 estimations performed when the SpO2 was less than 94%, none had a PaO2 greater than 12kPa. CONCLUSION: When using Ohmeda Biox pulse oximeters an upper limit of 97% for SaO2 is not effective in preventing hyperoxaemia; however, a limit of 93% is likely to maintain the PaO2 below 12kPa.

Acidosis↗

Disclosure of diagnostic errors: the death knell of retrospective pathology reviews?

Full disclosure of medical errors to patients is now widely seen as an essential component of error management, although its update into daily clinical practice is variable. Laboratory diagnostic errors are discovered in retrospective reviews of previous surgical and cytopathology cases. This quality assurance practice is a valuable tool of practice audit and change for both cytotechnologists and pathologists. Presently, these diagnostic errors are only reported to the clinician and patient if the new finding affects current patient management. Mandatory full disclosure of all diagnostic errors discovered in the retrospective review process would have a significant adverse impact on cytotechnologists, pathologists, the laboratory, the clinic, the institution, and insurers. Retrospective pathology review would become so burdensome that its survival would be in jeopardy-unless measures are undertaken to ameliorate the anticipated adverse consequences.

Diagnostic Errors↗

Opposing gates model for voltage gating of gap junction channels.

Gap junctions are intercellular channels that link the cytoplasm of neighboring cells. Because a gap junction channel is composed of two connexons docking head-to-head with each other, the channel voltage-gating profile is symmetrical for homotypic channels made of two identical connexons (hemichannels) and asymmetric for the heterotypic channels made of two different connexons (i.e., different connexin composition). In this study we have developed a gating model that allows quantitative characterization of the voltage gating of homotypic and heterotypic channels. This model differs from the present model in use by integrating, rather than separating, the contributions of the voltage gates of the two member connexons. The gating profile can now be fitted over the entire voltage range, eliminating the previous need for data splicing and fusion of two hemichannel descriptions, which is problematic when dealing with heterotypic channels. This model also provides a practical formula to render quantitative several previously qualitative concepts, including a similarity principle for matching a voltage gate to its host connexon, assignment of gating polarity to a connexon, and the effect of docking interactions between two member connexons in an intact gap junction channel.

Algorithms↗

Electromagnetic navigation during flexible bronchoscopy.

BACKGROUND: Flexible bronchoscopy is routinely utilized in the diagnosis and treatment of various lung diseases. Nondiagnostic bronchoscopy leads to more invasive interventions, such as transthoracic needle aspiration, mediastinoscopy or even thoracotomy. Electromagnetic navigation is a novel technology that facilitates approaching peripheral lung lesions, which are difficult to sample by conventional means. The navigation system involves creating an electromagnetic field around the chest and localizing an endoscopic tool using a microsensor overlaid upon previously acquired CT images. OBJECTIVES: To determine the practicality, accuracy and safety of real-time electromagnetic navigation, coupled with previously acquired 3D CT images, in locating artificially created peripheral lung lesions in a swine model. METHODS: Peripheral lung lesions were created in four swine models by insertion of a metal tube (1 x 10 mm) via a transthoracic approach. An electromagnetic field was created by placing the animal on an electromagnetic location board. A position sensor incorporated into the distal tip of a dedicated tool was used to navigate to the various target lesions. Information gathered in real time during bronchoscopy was presented on a monitor simultaneously by displaying previously acquired CT images. Upon reaching the target lesion, biopsies were performed and the functionality and safety of the superDimension/Bronchus System was observed and documented. RESULTS: The registration accuracy expressed by the fiducial target registration error, expressing both the registration quality and the stability of fiducial (registration) points, was 4.5 mm on average. No adverse effects, such as pneumothorax or internal bleeding, were encountered in any of the animals in this study. CONCLUSIONS: Real-time electromagnetic positioning technology coupled with previously acquired CT images is an accurate technology added to standard bronchoscopy to assist in reaching peripheral lung lesions and performing biopsies.

Animals↗

Chronic upper airway cough syndrome secondary to rhinosinus diseases (previously referred to as postnasal drip syndrome): ACCP evidence-based clinical practice guidelines.

OBJECTIVE: To review the literature on postnasal drip syndrome (PNDS)-induced cough and the various causes of PNDS. Hereafter, PNDS will be referred to as upper airway cough syndrome (UACS). METHODS: MEDLINE search (through May 2004) for studies published in the English language since 1980 on human subjects using the medical subject heading terms "cough," "causes of cough," "etiology of cough," "postnasal drip," "allergic rhinitis," "vasomotor rhinitis," and "chronic sinusitis." Case series and prospective descriptive clinical trials were selected for review. Also, any references from these studies that were pertinent to the topic were obtained. RESULTS: In multiple prospective, descriptive studies of adults, PNDS due to a variety of upper respiratory conditions has been shown either singly or in combination with other conditions, to be the most common cause of chronic cough. The symptoms and signs of PNDS are nonspecific, and a definitive diagnosis of PND-induced cough cannot be made from the medical history and physical examination findings alone. Furthermore, the absence of any of the usual clinical findings does not rule out a response to treatment that is usually effective for PND-induced cough. The differential diagnosis of PNDS-induced cough includes allergic rhinitis, perennial nonallergic rhinitis, postinfectious rhinitis, bacterial sinusitis, allergic fungal sinusitis, rhinitis due to anatomic abnormalities, rhinitis due to physical or chemical irritants, occupational rhinitis, rhinitis medicamentosa, and rhinitis of pregnancy. Because of a high prevalence of upper respiratory symptoms associated with gastroesophageal reflux disease (GERD), GERD may occasionally mimic PNDS. A crucial unanswered question is whether the conditions listed above actually produce cough through a final common pathway of PND or whether, in fact, in some circumstances they cause irritation or inflammation of upper airway structures that directly stimulate cough receptors and produce cough independently of or in addition to any associated PND. CONCLUSION: PNDS (ie, UACS) secondary to a variety of rhinosinus conditions is the most common cause of chronic cough. Because it is unclear whether the mechanisms of cough are the PND itself or the direct irritation or inflammation of the cough receptors located in the upper airway, the guideline committee has decided that, pending further data that address this difficult question, the committee unanimously recommends that the term upper airway cough syndrome be used in preference to postnasal drip syndrome when discussing cough associated with upper airway conditions.

Chronic Disease↗

Idiopathic interstitial pneumonias: a re-appraisal of idiopathic pulmonary fibrosis.

Over the last 30 years the clinical and histopathological definitions of the diffuse lung diseases have evolved considerably. Initially pathological entities were defined in parallel with clinico-radiological diagnoses, but these have more recently become consolidated into a more meaningful combined classification. These refinements have impacted on the diffuse lung diseases in particular, and have defined individual diseases more precisely than in previous classifications in which a number of distinct entities had been grouped together and mistaken for idiopathic pulmonary fibrosis, resulting in much confusion. The American Thoracic and European Respiratory Societies' committees, charged with the task of defining the idiopathic interstitial pneumonias, have recently published a statement on idiopathic pulmonary fibrosis, and a statement on the other idiopathic interstitial pneumonias should follow this year. Of these diseases, idiopathic pulmonary fibrosis is the most lethal, and this review deals with the impact that the changes in the nomenclature will have on our understanding of this and the other diseases with which idiopathic pulmonary fibrosis was previously confused and explores the implications of our new understanding on clinical practice. It also attempts to highlight areas of previous dogma in the literature that now need to be re-considered in the context of these more recent statements.

Anti-Inflammatory Agents↗

Evolution of clinical practice guidelines: evidence supporting expanded use of medicines.

Previous studies have shown that the primary factor underlying increased spending on pharmaceuticals has been the rising utilization of medications, rather than increases in unit drug price. This study examined the evolution of clinical practice guidelines to assess possible reasons for the rising drug volume. Clinical practice guidelines from 1970 to the present were reviewed for the six most prevalent treatable medical conditions/risk factors listed as priority areas by the Institute of Medicine. We searched the National Guidelines Clearinghouse, PubMed and Medline databases, and Web sites of relevant national organizations for US clinical practice guidelines published through January 2005. Information pertaining to the therapeutic regimen (eg, the frequency and duration of recommended treatment, when treatment should be initiated, the patient population for whom the guideline was intended) was abstracted and entered into evidence tables. Changes in guidelines were distributed across three themes that recommended evidence-based increases in medication use, including: (1) changes in the size of the treatable population; (2) changes in the number and type of recommended pharmaceutical therapeutic options, including movement from monotherapy to combination therapy, treatment of comorbidities, and use of newer types of medicines; and (3) changes in the therapeutic regimen, including a shift from episodic care to preventive and chronic care. Many of these changes point to an important, but not often noticed, addition of secondary prevention of disease effects to the objectives of medical care. These trends are likely to continue with important economic, clinical, and policy ramifications.

Asthma↗

"Never again" stories of nurses: dilemmas in nursing practice.

The authors describe significant turning points immanent in "never again" stories that practicing nurses, having participated in previously, vowed not to allow to recur during future, similar situations. Nurses submitted written accounts of critical, "never again" situations. The authors used critical incident technique and employed Colaizzi's approach to reveal the essential structure. Patient outcomes were fatal, close calls, dehumanizing, or isolating. Never again stories incorporated ethical dilemmas, deficits in nurses' knowledge, lack of confidence in clinical abilities, and failure to act correctly. Patients' welfare was the center of accounts. Circumstances threatened patients' and family members' trust in nurses and other providers. Patients' wishes were denied because of haste, providers' arrogance, or providers' desire not to be inconvenienced. Nurses' emotions mirrored a sense of failed responsibility for patients. Regret was tempered by nurses' pledges. Critical incidents revealed dilemmas in which nurses' autonomous clinical practice was constrained by feelings of powerlessness.

Ethics, Nursing↗

Effects of pindolol, or a pindolol/clopamide combination preparation, on plasma lipid levels in essential hypertension. Hunter Hypertension Research Group.

In an open study that was conducted in general practice, 22 patients with previously-untreated mild hypertension received an average daily dose of 11.7 mg of pindolol over a 50-week study period. The total cholesterol, high-density lipoprotein fraction and plasma triglyceride levels showed no significant change from baseline values at the conclusion of this period. A separate group of 18 patients were treated with 10 mg of pindolol a day for 12 weeks, to which regimen was added 5 mg of clopamide for the succeeding 38 weeks. A small rise in total plasma cholesterol levels in this group of patients at both 12 and 50 weeks did not achieve statistical significance, and no change was observed in either the high-density lipoprotein fraction or the plasma triglyceride levels. These results which were obtained in general practice and over a prolonged period of time accord with the general view that the treatment of hypertension with pindolol, a beta-receptor blocking drug with partial agonist activity, is not associated with either the increases in total plasma cholesterol levels or the falls in the high-density lipoprotein fraction that have been reported with other beta-blocking compounds.

Adult↗

Assessing treatment outcomes for a graduate orthodontics program: follow-up study for the classes of 2001-2003.

INTRODUCTION: Based on an initial 3-year study (1998-2000) of clinical outcomes, specific changes were made in the clinical protocol in the orthodontic clinic at Indiana University, Indianapolis, Ind. To evaluate these adjustments, a follow-up study with the same methods assessed the clinical outcomes for the next 3 years (2001-2003). METHODS: The 3 changes introduced in 2000 were assessment of prefinish records, education of residents about previous outcomes, and more frequent practice evaluations by the program director. The American Board of Orthodontics (ABO) objective grading system (OGS) and a supplemental comprehensive clinical assessment (CCA) were used to evaluate the results for all patients completed by the classes of 2001 through 2003 (n = 437). RESULTS: The mean ABO OGS, CCA, and combined scores were 25.19 +/- 11.16, 4.38 +/- 2.74, and 29.57 +/- 13.01, respectively. A progressive improvement was noted from 2001 to 2003. The ABO OGS and the combined scores were significantly (P <.001) improved in 2001 through 2003 compared with 1998 through 2000. The CCA score tended to improve, but it was not significantly different. Significant improvements were seen for maxillary and mandibular first order, mandibular second order, mandibular third order, overjet, occlusal contacts, occlusal relationships, and root angulations (P <.001). As with the previous study, excessive treatment times correlated with worse clinical outcomes. CONCLUSIONS: Changes implemented by the graduate program were effective for improving treatment outcomes. Cast scores were more amenable to improvement than other more comprehensive outcomes.

Adolescent↗