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PubMed2001

Quality assurance and continuing education needs of rural and remote general practitioners: how are they changing?

The Royal Australian College of General Practitioners' (RACGP) 1998 Rural Quality Assurance and Continuing Education (QA & CE) Needs Assessment Project was designed to generate sufficient data to inform strategic planning for rural and remote GPs participating in the College's QA & CE Program. Results indicated that the demand for QA & CE activities has changed over the past 12 years. Three distinct streams of continuing education emerged, where once only one was researched. This reflected a move towards continuing professional development (CPD) rather than purely continuing medical education (CME). However, differences between the CME needs identified suggested that national data could not be reduced to the local level. Data on CME in which rural and remote GPs felt underserviced, proved more useful in relation to other workforce variables such as age, length of service and gender. A broad 'rural set' of CPD topics was established, and the survey yielded information on learning format preferences that will be of use to providers of QA & CE activities for rural GPs across Australia.

Australia↗
PubMed1999

The 0.8% ultraviolet B content of an ultraviolet A sunlamp induces 75% of cyclobutane pyrimidine dimers in human keratinocytes in vitro.

Tanning lamps, emitting predominantly ultraviolet (UV) A, are used widely throughout the U.K. and other countries, but little is known about the long-term risks associated with their use, especially with respect to skin cancer. We have exposed normal human epidermal keratinocytes to a commercial tanning lamp and used the comet assay in association with DNA repair enzymes T4 endonuclease V and endonuclease III to investigate the relative yields of directly formed cyclobutane pyrimidine dimers (CPDs) and indirectly formed types of oxidative DNA damage. To put the risk of using tanning lamps into perspective, the sunbed used in this study (five Philips Performance 80W-R UVA tubes at a distance of 35 cm) was found to be approximately 0.7 times as potent at inducing CPDs as U.K. natural sunlight around noon on a fine summer day. This compares with a relative risk for CPD induction and erythema of 0.8 and 0.7 times, respectively, calculated from the relevant action spectra of tanning lamps and British noontime sunlight. To determine the relative contribution of UVB and UVA to the induction of CPDs and oxidative DNA damage, we modified the spectral output of the tanning lamps with a series of Schott WG UVB filters. The induction of CPDs was more dependent on the UVB component of the sunbed than oxidative types of damage. Schott WG UVB filters with 50% transmission at 305 nm reduced the yield of T4 endonuclease V sites by 42% while there was only a 17% decrease in the yield of endonuclease III sites. CPD induction was not completely abolished after irradiation through WG335 and WG345 nm filters despite there being no detectable UVB. From these data, it was estimated that, although the tanning lamps emitted only 0.8% of their total output in the UVB range, these wavelengths were responsible for the induction of over 75% of CPDs and 50% of the oxidative damage to DNA.

Cells, Cultured↗
PubMed2003

Patterns of nursing: a review of nursing in a large metropolitan hospital.

In this Clinical Practice Development (CPD) project we set out to identify and describe current approaches to the management and delivery of nursing care in an Australian Metropolitan Teaching Hospital. Using a simple descriptive design, data were collected to elicit patterns of care provided by nursing teams. We sought to demonstrate patterns described by nursing teams (interviews) and actual patterns of care (observation). As expected there was a degree of incongruence between the espoused and actual patterns of care. Interview data revealed that most study wards had a view of nursing that emphasizes meeting the total care needs of patients and their families through offering biopsychosocial and educative care. The observational data revealed that a relatively large proportion of time was expended on activities that were not regarded as important by staff when interviewed (e.g. documentation) while relatively small amounts of time were observed to be spent educating patients or communicating with relatives of patients. The identification of this type of gap creates a dissonance in clinicians that can be used to stimulate change through CPD. Clinicians used the information to stimulate discussion and to rewrite team value statements.

Hospitals, Teaching↗
PubMed2002

Chiropractors' attitudes to, and perceptions of, the impact of continuing professional education on clinical practice.

OBJECTIVES: As with other health care professions, there is a need for chiropractors to maintain their clinical competencies through continuing professional education (CPE) and development (CPD). This study set out to evaluate chiropractors' attitudes to, and opinions of, current CPE provision, and their perceived needs for the future. In particular, their perceptions of the impact of CPE on clinical practice were assessed. DESIGN: A survey in which primary quantitative and secondary qualitative data were collected using a self-administered questionnaire. The questionnaire concentrated on four areas: (i) attitudes to CPE; (ii) impact of current CPE on practice; (iii) modes of delivery most likely to change practice; and (iv) future learning needs from continuing education programmes. RESPONDENTS: A random sample of chiropractors registered with the British Chiropractic Association. RESULTS: Overall, chiropractors were positive to CPE and cognisant of the need to keep up to date. However, in spite of several benefits, chiropractors did not perceive current CPE to be instrumental in changing practice. As might be expected, chiropractors perceived clinical updates and hands-on practical workshops to be most effective in changing clinical practice. DISCUSSION: There is currently considerable debate surrounding the ability of CPE and CPD to actually make a difference to the way clinicians practice. This study describes a method of evaluating the impact of CPE/D in changing clinical practice from the viewpoint of the practitioners themselves.

Adult↗
PubMed2000

In vitro properties of red cells prepared from half-strength citrate CPD/RAS-2 (Erythro-sol) donations in PL-146 plastic.

Whole blood donations were collected into 0.5CPD anticoagulant in PL-146 plastic. This was shown to improve the stability of plasma FVIII levels when compared with CPD. RAS-2 was used as additive and this improved the in vitro properties of the red cells, such that post processing 2,3-DPG levels were maintained for 21 days and ATP levels were maintained for 28 days. Whether or not such improvements in red cell properties yield a benefit in clinical use remains to be established.

Anticoagulants↗
PubMed2001

Automated blood-mixing devices still fail to mix at low bleeding rates.

BACKGROUND AND OBJECTIVES: The study evaluated mixing performance for various commercial blood-mixing devices at different flow rates. MATERIALS AND METHODS: A glycerol solution with a density equal to blood was pumped into a blood bag (mounted on a mixer) that contained 70 ml of Toluidin Blue in citrate-phosphate-dextrose (CPD). After 500 ml of glycerol solution had been pumped into the blood bag, the bag was emptied in fractions and the absorbance at 640 nm of each fraction (expressed as percentage of mixture absorbance) was plotted against the fraction number. RESULTS: At a flow rate of 30 ml/min, the curves were very sigmoid, with high initial values that decreased during collection of the fractions. The absorbance values of the fractions collected later (after approximately 250-300 ml) were 10-50% (i.e. percentage of absorbance for complete mixing) for the different mixers, indicating that the CPD solution was incompletely mixed with the incoming solution, resulting in a lower-than-expected 'anticoagulant' content for the fractions collected later. At a flow rate of 50 ml/min the mixing was improved, but only at 75 ml/min did all mixers show relatively good mixing. Manual mixing, by kneading the bag three times/min, gave at all rates an almost ideal mixing curve, 105% initially to 90% in the final fractions. CONCLUSION: At relatively high bleeding rates, all mixers performed well, although complete mixing was only obtained with manual kneading. However, most blood-mixing devices still fail to mix efficiently at normal and low bleeding rates. Although the minimal degree of necessary mixing is unknown, further optimization of mixing devices seems warranted.

Anticoagulants↗
PubMed2001

Autologous platelet-rich plasma isolated using the Haemonetics Cell Saver 5 and Haemonetics MCS+ for the preparation of platelet gel.

BACKGROUND AND OBJECTIVES: We compared three methods of isolating platelet-rich plasma (PRP) using the Haemonetics Cell Saver 5 and one method of isolating PRP by plateletpheresis using the Haemonetics MCS+. PRP contains both platelets and fibrinogen, which are used in the preparation of haemostatic agents. MATERIALS AND METHODS: When the Haemonetics Cell Saver 5 was used, 500 ml of blood from each of 30 normal volunteer donors was collected into 70 ml of citrate-phosphate-dextrose (CPD) anticoagulant. In a further 14 normal volunteers, the Haemonetics MCS+ was used to isolate PRP by plateletpheresis using an acid citrate dextrose (ACD) to blood ratio of 1 : 9. In a separate study, CPD-anticoagulated whole blood from another 30 volunteers was used for measurement of fibrinogen levels in the plasma and cryoprecipitate. RESULTS: A larger volume of PRP can be collected using the Haemonetics Cell Saver 5 than by using the Haemonetics MCS+. The platelet concentration and the total number of platelets were higher in the PRP isolated using the Haemonetics MCS+ than in the PRP isolated by the three methods used with the Haemonetics Cell Saver 5, with differences in platelet concentration and PRP volume among the four methods. The mean fibrinogen level in the plasma was 253 mg % +/- 47 (SD) and in the cryoprecipitate was 1085 mg % +/- 304 (SD). CONCLUSIONS: The most appropriate method of PRP isolation for preparation of platelet gel is dependent upon the specific surgical procedure to be undertaken and the patient's needs.

Blood Transfusion, Autologous↗
PubMed2001

Audit of influenza and pneumococcal vaccination uptake in diabetic patients attending secondary care in the Northern Region.

AIMS: To document uptake of influenza and pneumococcal vaccination in diabetic patients attending secondary care in the Northern Region, and to explore influencing factors. METHODS: Diabetic patients attending out-patients in Middlesbrough, Gateshead and Newcastle were questioned from October 1999 to March 2000. Physicians inquired about influenza and pneumococcal vaccination status using a standardized questionnaire. Data collected included age, year of diagnosis, duration of diabetes, type of diabetes, and the presence of other recognized indications for vaccination. RESULTS: Two hundred and sixty-eight diabetic patients, 42% (113/268) with Type 1 diabetes, 34% (91/268) with ischaemic heart disease, 10% (26/268) with chronic pulmonary disease (CPD) and 10% (27/268) with chronic renal disease, were questioned. Thirty-five percent (93/268) of patients received both influenza and pneumococcal vaccines, 24% (64/268) received only influenza vaccine, and none received pneumococcus vaccine alone. Most vaccinees received advice about influenza and pneumococcal vaccination from their general practitioner (90% (142/157) and 87% (81/93), respectively). A large number of non-vaccinees were unaware of the need for influenza and pneumococcal vaccination (69% (76/111) and 91% (159/175), respectively). Using multiple logistic regression co-existing CPD increased the odds of receiving influenza (odds ratio (OR) (95% confidence interval (CI)) = 1.99 (1.07-14.12)) or pneumococcal (OR = 3.77 (1.69-21.76)) vaccination. Furthermore, each 1-year increase in age increased the chance of receiving influenza or pneumococcal vaccination by 22% (OR = 1.22 (1.09-1.67) and 29% (OR = 1.29 (1.07-1.72)), respectively. CONCLUSIONS: Vaccination rates in these diabetic patients are unsatisfactory. Secondary care health professionals might increase rates by raising the topic in consultations. Diabet. Med. 18, 599-603 (2001)

Adolescent↗
PubMed2002

Radiological and manometric diagnosis of cricopharyngeal dysphagia in a Japanese encephalitis survivor.

Japanese encephalitis (JE) is endemic throughout most of the western Pacific region where Taiwan is located. About half the survivors are left with neurological damages. We report a 55-year-old male who survived from JE and was left with sequela of parkinsonism and severe swallowing disorder. Later, it was proved to be cricopharyngeal dysphagia (CPD) using esophagogram and manometry, which disclosed involuntary hypertonic and hyperreflexic cricopharyngeal muscle contraction. CPD, a life-threatening neurological sequel of JE, has never been reported in the JE survivors before and possibly results from disseminated lesions over pyramidal and extrapyramidal systems.

Brain↗
PubMed2002

Temporal detection in human vision: dependence on eccentricity.

Studies of human perception of time-varying luminance often aim to estimate either temporal impulse response shapes or temporal modulation transfer functions (MTFs) of putative temporal processing mechanisms. Previously, temporal masking data have been used to estimate the properties and numbers of these temporal mechanisms in central vision for 1 cycle per degree (cpd) targets [Fredericksen and Hess (1998)]. The same methods have been used to explore how these properties change with stimulus energy [Fredericksen and Hess (1997)] and spatial frequency [Fredericksen and Hess (1999)]. We present here analyses of the properties of temporal mechanisms that detect temporal variations of luminance in peripheral vision. The results indicate that a two-filter model provides the best model for our masking data, but that no multiple filter model provides an acceptable fit across the range of parameters varied in this study. Single-filter modelling shows differences between processing mechanisms at 1 cpd in central vision and those that operate eccentrically. We find evidence that this change is because of differences in relative sensitivities of the mechanisms, and to differences in fundamental mechanism impulse responses.

Electronics↗
PubMedDate not supplied

The kinetic spectrum of APD.

A generalized kinetic model to quantify the efficiency of cycler (CPD) and tidal peritoneal dialysis (TPD) is used to examine the relative efficiency of these techniques over a wide range of tidal volumes, drain profile characteristics, and hourly dialysate flow rates. In the patient with good catheter function, there is little difference in efficiency between CPD and TPD. In patients with long drain times or nonlinear drain profiles, greatly improved efficiency may theoretically be achieved with small tidal volume TPD. A generalized solution of the continuous flow PD (CFPD) kinetic model is used to demonstrate and contrast the kinetics of automated PD (APD) and CFPD.

Automation↗
PubMedDate not supplied

Viability of gynecological malignant cultured cells after 4 degrees C storage in citrate-phosphate-dextrose solution.

For the surgery of gynecological malignant tumors, a predeposit type of autologous blood transfusion has been widely used. However, using molecular biologic techniques, malignant cells have been found in the peripheral blood of cancer patients. Therefore, to evaluate the utility of presurgical blood deposits, we studied the survival of gynecological malignant cultured cells after 4 degrees C storage in citrate-phosphate-dextrose solution. Ten cultured cell lines derived from gynecological malignant tumors were used. Mixtures of 1 x 105 cells, culture medium, and citrate-phosphate-dextrose (CPD) solution were stored at 4 degrees C. After 0, 1, 4, 8, 15, or 22 days of storage, cells were placed in 96-well microtiter plates in culture medium with 1 x 104 cells/100 micro l/well. After 24 h culture in the incubator, the survival rate was calculated from the optical density by 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H tetrazolium bromide (MTT) assay. More than 10% of surviving cells were seen in nine cell lines after 4 days of storage, in seven cell lines after 8 days, in three cell lines after 15 days, and in two cell lines after 22 days. Cancer cells in presurgical blood deposits may survive a 3-week storage period at 4 degrees C in CPD solution.

Blood Preservation↗
PubMedDate not supplied

Simplification of the methods for adding and removing glycerol during freeze-preservation of human red blood cells with the high or low glycerol methods: biochemical modification prior to freezing.

Simple methods have been developed for adding and removing glycerol during freeze-preservation with 20 per cent W/V glycerol at minus 150 C, or with 40 per cent W/V glycerol at minus 80 C. A one-step method with a 35 per cent W/V glycerol solution is used to prepare 20 per cent W/V glycerolized red blood cells, and a two-step method with a 57 per cent W/V glycerol solution is used to prepare 40 per cent W/V glycerolized red blood cells. The systems for washing glycerolized red blood cells have been simplified. This method consists of dilution of the thawed glycerolized red blood cells prior to recovery, followed by on-line dilution of these red blood cells with wash solutions during continuous flow centrifugation. This can be done in any of three commercially available washing systems, and they all use the same sodium chloride solutions. For the 40 per cent W/V glycerolized red blood cells, this process takes about 30 minutes and uses 2.2 to 3.2 liters of the sodium chloride solutions, whereas the 20 per cent W/V glycerolized red blood cells can be processed in about 20 minutes using 1.5 to 2.5 liters. After storage in CPD for three days at 4 C, red blood cells can be freeze-preserved with 40 per cent W/V glycerol at minus 80 C or with 20 per cent W/V glycerol at minus 150 C. When the thawed red blood cells are washed in the Fenwal Elutramatic, the IBM Blood Processor, or the Haemonetics Blood Processor and stored at 4 C in sodium chloride-glucose-phosphate for at least 24 hours before transfusion, they have excellent posttransfusion survival values and normal or slightly decreased oxygen transport function. Alternatively, these red blood cells can be rejuvenated before freeze-preservation so that their 2,3-DPG levels are increased and their affinity for oxygen is reduced. Red blood cells that are stored in CPD at 4 C for as long as 28 days can be rejuvenated with a solution containing pyruvate, inosine, glucose, phosphate, and adenine (PIGPA, Solution A) before freeze-preservation with 40 per cent W/V glycerol at minus 80 C. Any one of the above systems can be used to wash these red blood cells and they can be stored at 4 C in a sodium.

Adenine↗
PubMedDate not supplied

The quality of over- and undercollected blood for transfusion.

Whole blood was collected in increments varying from 100 g to 600 g into plastic containers intended for 450 ml collections. In order to determine the clinical usefulness of over and undercollected bloods, red blood cell survival studies were performed after 21 and 28 days of storage and in vitro measurements were performed weekly throughout the storage period. The red blood cell survival of 21-day-old CPD bloods was acceptable if as little as 300 g of blood were collected whereas a minimum of 400 g of blood was necessary to provide normal survival after 21 days storage in ACD solution. If as much as 600 g of whole blood were collected into a standard ACD or CPD blood pack, the red blood cell survival was within normal limits after 21 days of storage. These data demonstrate the limits to which over- and undercollected units can be utilized in transfusion therapy.

Blood Banks↗
PubMedDate not supplied

The opsonic activity of stored blood.

Experiments were performed to measure the stability of opsonins during storage of whole blood collected in CPD solution and stored at 4 C. Three units were collected, and aliquots removed and recalcified on days 0, 3, 7, 14, 21, and 28. Reconstituted serum was immediately frozen and stored at -70 C. The ability to opsonize Escherichia coli 075 and Pseudomonas aeruginosa immunotype 1, both of which require activation and utilization of the alternative pathway of complement for opsonization, were performed simultaneously for each organism and for each unit. Results showed that there was a slight but insignificant reduction in opsonic strength during storage for up to 28 days. The results indicate that standard collection and storage conditions using CPD as the anticoagulant retains functional activity of the alternative pathway. C3 measured by radial immunodiffusion using antisera against the B antigenic determinant showed that C3 had not been converted during storage.

Blood Preservation↗
PubMedDate not supplied

Antigenic determinants of C3 and C4 complement components on washed erythrocytes from normal persons.

Well-washed erythrocytes from normal persons were agglutinated by antisera to C3, C3d, and C4, and this agglutination was specifically inhibited by the corresponding C3 or C4 protein. C3 and C4 antigenic determinants were present on the red blood cells of freshly shed blood promptly anticoagulated with EDTA, heparin, ACD, or CPD, and no significant changes in degree of agglutination were observed on storage of EDTA or CPD blood for two weeks at 4 C. Marked differences in degree of agglutination by anti-C3, anti-C3d, and anti-C4 were observed when erythrocytes of 16 normal persons were assayed, and significant correlations were obtained when the quantitative results with any two antisera were compared. Anti-C3c did not agglutinate erythrocytes from normal persons, suggesting that the C3 antigens detected on normal cells are carried by the C3d fragment. To avoid significant agglutination of the erythrocytes from some normal persons, very dilute preparations of anti-C3, -C3d, and -C4 had to be used for instrumented diagnostic direct antiglobulin tests. Stronger reagents could be used for indirect antiglobulin tests when the result of a suitable control could be subtracted.

Animals↗
PubMedDate not supplied

Di-2-ethylhexyl phthalate (DEHP) and mono-2-ethylhexyl phthalate (MEHP) accumulation in whole blood and red cell concentrates.

Plasma DEHP concentrations were measured weekly in whole blood and red cell concentrates (RCC) during 21 days of storage in standard CPD within PL-130 blood bags. In addition, DEHP and MEHP accumulation patterns were investigated in blood stored for 42 days in modified CPD with adenine within PL-146 and BB-69 storage containers. Total per-unit plasma DEHP of RCC units was 49 to 71 per cent of the total in plasma of whole blood units (PL-130). From 28 to 42 days, mean DEHP levels were 12 to 19 per cent higher in whole blood stored in PL-146 than in BB-69. Although MEHP was not found in any blood bag plastic, MEHP accumulated in plasma during whole blood storage. MEHP concentrations were 2.8 to 3.8 times higher in plasma stored in BB-69 than in PL-146. It is postulated that MEHP arises from hydrolysis of DEHP by plasma lipase, even in frozen plasma sample, and that the rate of this reaction is influenced by blood bag plastic surface characteristics.

Blood Preservation↗
PubMedDate not supplied

Blood preservation 42: improvement of ascorbate's ability to maintain 2,3-DPG with inosine.

Inosine and ascorbate have been shown to maintain normal 2,3-DPG levels during three to four weeks of blood storage. With the introduction of CPD-adenine, which allows five weeks of storage, the desire for 2,3-DPG maintenance may receive new emphasis. Red blood cell 2,3-DPG remained at normal or higher levels for six weeks whenever 10 or 15 mM inosine and 10 mM vitamin C (L-ascorbate) or D-ascorbate were present in the CPD-adenine preservative. Provision by inosine of a five-carbon sugar for 2,3-DPG synthesis, bypassing the rate-limiting phosphofructokinase reaction, may allow NADH oxidation by ascorbate to provide an increased supply of substrate for the Rappoport-Luebering shunt, thus affecting the net increase and maintenance of 2,3-DPG.

Ascorbic Acid↗