The surgical management of cervical carcinoma within the South West of England: progress through an audit loop. Gynaecology Tumour Panel

Objective To define and use a minimum clinical dataset for prospective data collection in order to audit the surgical management of cervical cancer in the South West of England. To compare this data set with a retrospective audit allowing assessment of the quality of care offered to patients.
Design Prospective collection of a defined dataset on paper forms which were put into a computerised database for analysis. Registrations validated against histopathology databases and hospital coding.
Setting All 13 hospitals in the South West of England which participated in the retrospective audit.
Participants One hundred and sixty-five women with cervical cancer diagnosed in 1997.
Main outcome measures Distribution of cases by hospital and surgeon; workload of individual surgeons; adequacy and accuracy of FIGO staging; adequacy of histological information; and adequacy of surgery.
Results There is a trend to centralisation of cancer care and radical surgery in the region. Prospective collection of data has dramatically improved FIGO staging with 92% of all cases staged. For cases greater than Stage la, 98% were staged suggesting that a target of 100% staging is feasible. The histological dimensions of tumours were not measured in a high proportion of cases (20% of tumour diameters and 28% of tumour thicknesses). Apparent inadequacies in surgical management are explored. In 10/165 cases (6%) inappropriate conservative surgery may have been unavoidable, suggesting that a quality standard of 95% for appropriate radical surgical management of cervical cancer can be achieved. An anatomically complete removal of pelvic node-bearing tissue, yielding greater than 10 nodes in more than 95% cases, should be achievable with each surgeon/pathologist achieving a mean of more than 20 nodes.
Conclusion Regional audit of cervical cancer management is feasible. It can be used to improve the quality of information on management and guide improved service provision.     

THE SALIENCE OF FACIAL EXPRESSION FOR AUTISTIC CHILDREN

Autistic and non-autistic retarded children who were matched for verbal ability were shown 'standard' pairs of photographs of people who differed in three, two or one of the following respects: sex, age, facial expression of emotion, and the type of hat they were wearing. When given similar photographs to sort, the majority of non-autistic children sorted according to people's facial expressions before they sorted according to type of hat, but most autistic children gave priority to sorting by type of hat, and many neglected the facial expressions altogether. It is suggested that these results reflect autistic children's insensitivity to other people's facial expressions of emotion.     

Metabolism of 4-fluoroaniline and 4-fluorobiphenyl in the earthworm Eisenia veneta characterized by high-resolution NMR spectroscopy with directly coupled HPLC-NMR and HPLC-MS

1. Little is known about metabolism of xenobiotics by earthworms, despite their importance in soil ecotoxicity testing. Normal earthworms and earthworms treated with antibiotics to ensure inhibition of gut microflora were exposed to two model xenobiotic compounds, 4-fluoroaniline and 4-fluorobiphenyl, to determine which metabolites were produced, and whether the pattern of metabolism was affected by the presence of microbial transformation ability. 2. (19)F-NMR spectroscopy detected the number and relative proportions of metabolites and directly coupled HPLC-(1)H-NMR spectroscopy and HPLC-MS then identified the metabolites. 3. Despite uptake, no metabolism of 4-fluorobiphenyl was observed at any stage, which appears to be a consequence of the lack of oxidative Phase I metabolic activity of the earthworms towards this substrate. In contrast, 4-fluoroaniline exhibited dose-dependent metabolism. At high doses (leading to mortality within 24 h) one predominant metabolite was observed, which was identified as the N-beta-glucoside conjugate. At lower dose levels, the predominant metabolite was the gamma-glutamyl conjugate, although the glucoside and another as yet unidentified metabolite were also detected. 4. The inhibition of gut microflora did not have any influence on metabolism. The study represents the first evidence for glucoside and glutamyl conjugation as a pathway for xenobiotic metabolism in earthworms.     

19F-NMR and directly coupled 19F/1H-HPLC-NMR spectroscopic investigations of the metabolism of the model ecotoxin 3-trifluoromethylaniline in the earthworm species Eisenia veneta

1. The metabolic fate of the model ecotoxin 3-trifluoromethylaniline (3-TFMA) in earthworm was studied by (19)F- and directly coupled (19)F/(1)H-HPLC-NMR spectroscopy. Earthworms of Eisenia veneta spp. were subjected to the ecotoxin during a filter papercontact toxicity test at exposure levels of 1000, 100, 10, 1 and 0.1 micro g cm(-2). A metabolic profile was obtained previously by (19)F-NMR spectroscopy and metabolites were observed at all the exposure levels. 2. Identification of metabolites in individual worm extracts at the (lethal) exposure levels of 1000 and 100 micro g cm(-2) could be achieved on-line without sample preparation by (19)F/(1)H-HPLC-NMR spectroscopy. (19)F-HPLC-NMR spectroscopy was used in the continuous-flow mode, which enabled the HPLC chromatographic retention times (t(R)) of the metabolites to be established in a single analytical step. 3. In total, three (19)F-NMR signals could be detected, of which one was identified as the parent compound. Two earlier eluting metabolites were identified to be alpha- and beta-glucoside conjugates of 3-TFMA. 4. Metabolites at the lower (sublethal) exposure levels of 10, 1 and 0.1 micro g cm(-2) escaped identification by (19)F/(1)H-HPLC-NMR spectroscopy as outlined here and will require concentration prior to analysis.     

Improving the effectiveness of physician participation in local quality improvement efforts

The authors present five success factors for medical students, residents, and fellows to consider when engaged in quality improvement projects: (1) add value, not work; (2) start small and build; (3) move quickly; (4) adapt, innovate, and collaborate; (5) produce understandable results. Using examples from the Veterans Affairs National Quality Scholars Fellowship Program, they describe how these factors were used successfully. While not the only steps to take, these critical success factors proved helpful in defining the problem to be addressed, engaging leadership, and anticipating the resolution of conflict.     

A curriculum for training quality scholars to improve the health and health care of veterans and the community at large

In 1998, the Veterans Health Administration invested in the creation of the Veterans Administration National Quality Scholars Fellowship Program (VAQS) to train physicians in new ways to improve the quality of health care. We describe the curriculum for this program and the lessons learned from our experience to date. The VAQS Fellowship program has developed a core improvement curriculum to train postresidency physicians in the scholarship, research, and teaching of the improvement of health care. The curriculum covers seven domains of knowledge related to improvement: health care as a process; variation and measurement; customer/beneficiary knowledge; leading, following, and making changes in health care; collaboration; social context and accountability; and developing new, locally useful knowledge. We combine specific knowledge about the improvement of health care with the use of adult learning strategies, interactive video, and development of learner competencies. Our program provides insights for medical education to better prepare physicians to participate in and lead the improvement of health care.     

Quality improvement as an investment

Health care organizations are experiencing increasing internal and external pressures to improve the quality of care that they provide. However, there is not a framework that can be used to help understand the value of quality improvement projects and to prioritize competing projects. By understanding the current processes, costs and outcomes of care, enumerating the costs and benefits of change, anticipating the timing of the costs and benefits, and performing a financial analysis, quality improvement efforts can be evaluated as investments. Only by understanding and adapting to the financial environments in which health care organizations operate can continuous quality improvement in health care succeed.