Introducing a nationally shared electronic patient record: Case study comparison of Scotland,England, Wales and Northern Ireland

AimTo compare the experience of the four UK countries in introducing nationally accessible electronic summaries of patients’ key medical details, intended for use in emergency and unscheduled care episodes, and generate transferable lessons for other countries.MethodSecondary analysis of data collected previously on all four schemes; cross-case comparison using a framework derived from diffusion of innovations theory.Main findingsWhilst all four programmes shared a similar vision, they differed widely in their strategy, budget, implementation plan, approach to clinical and public engagement and approach to evaluation and learning. They also differed, for various reasons, in stakeholder alignments, the nature and extent of resistance to the programme and the rate at which records were created. A nationally shared, widely accessible electronic record has powerful symbolic meaning; it may or may not be perceived as improving the quality and safety of care or (alternatively) as threatening patient confidentiality or the traditional role of the doctor or nurse. ‘Hard’ project management oriented to achieving specific milestones and deadlines sometimes appeared counterproductive when it cut across the ‘softer’ aspects of the programmes.ConclusionWhen designing and implementing complex technologies with pervasive implications, policymakers must consider not only technical issues but also the personal, social and organisational aspects of the programme. A judicious blend of ‘hard’ and ‘soft’ management appears key to managing such programmes.     

Adult-derived liver stem cells acquire a cardiomyocyte structural and functional phenotype ex vivo

We examined the differentiation potential of an adult liver stem cell line (WB F344) in a cardiac microenvironment, ex vivo. WB F344 cells were established from a single cloned nonparenchymal epithelial cell isolated from a normal male adult rat liver. Genetically modified, WB F344 cells that express beta-galactosidase and green fluorescent protein or only beta-galactosidase were co-cultured with dissociated rat or mouse neonatal cardiac cells. After 4 to 14 days, WB F344-derived cardiomyocytes expressed cardiac-specific proteins and exhibited myofibrils, sarcomeres, and a nascent sarcoplasmic reticulum. Further, rhythmically beating WB F344-derived cardiomyocytes displayed calcium transients. Fluorescent recovery after photobleaching demonstrated that WB F344-derived cardiomyocytes were coupled with adjacent neonatal cardiomyocytes and other WB F344-derived cardiomyocytes. Fluorescence in situ hybridization experiments suggested that fusion between WB F344 cells and neonatal mouse cardiomyocytes did not take place. Collectively, these results support the conclusion that these adult-derived liver stem cells respond to signals generated in a cardiac microenvironment ex vivo acquiring a cardiomyocyte phenotype and function. The identification ex vivo of microenvironmental signals that appear to cross germ layer and species specificities should prove valuable in understanding the molecular basis of adult stem cell differentiation and phenotypic plasticity.     

De novo intraepidermal epithelioid melanocytic dysplasia as a marker of the atypical mole phenotype -- a clinical and pathological study of 75 patients

BACKGROUND: We encountered a distinctive pattern of dysplastic intraepidermal melanocytic proliferation, which defies classification as a dysplastic melanocytic nevus, but in which the morphologic features fall short of a diagnosis of melanoma in situ. We designate such lesions as de novo intraepidermal epithelioid melanocytic dysplasia. METHODS: From 75 patients, 82 skin biopsies were encountered that showed this distinctive morphology. Hematoxylin- and eosin-stained histologic sections were studied and the features were correlated with personal and family histories of dysplastic nevi and melanoma. RESULTS: The diagnosis of de novo melanocytic dysplasia was made in 27 male patients and 48 female patients (mean age: 44 years). The histologic hallmark was a pagetoid (single-cell) array of moderately to severely atypical epithelioid melanocytes within the epidermis. Seventy-three lesions were located on sun-exposed skin and nine on sun-protected skin. In 41 patients, there was an atypical mole phenotype, whereas 20 patients had a prior or subsequent diagnosis of melanoma with five of 16 patients questioned revealing a family history of melanoma. CONCLUSIONS: De novo intraepidermal epithelioid melanocytic dysplasia is a distinct entity associated with an atypical mole phenotype and a personal and/or family history of melanoma.     

Muscle inhibition following tendon stimulation is reduced in chronic stroke

ObjectiveElectrical tendon stimulation elicits reflex inhibition in the homonymous muscle that is thought to be mediated by group III afferents. The study goals were to: evaluate group III-mediated reflex inhibition in people with post-stroke hemiparesis; determine the presence of heteronymous group III pathways; investigate the relevance of reflex inhibition to arm function.MethodsReflex responses were recorded in wrist, elbow, and shoulder muscles following stimulation of the extensor carpi radialis (ECR) tendon in 16 people with post-stroke hemiparesis and 16 control subjects. In control subjects, reflex inhibition also was compared between static and dynamic muscle activation.ResultsReflex inhibition following ECR tendon stimulation was present in heteronymous muscles of most, but not all, stroke and control subjects. The level of reflex inhibition was significantly reduced in stroke subjects. In the controls, reflex inhibition was greater during dynamic activation of elbow muscles compared to static activation.ConclusionsEvidence that reflex inhibition projects to heteronymous muscles and is modulated during movement suggests a role for the reflex in multi-joint coordination. The reflex is impaired in post-stroke hemiparesis.SignificanceAbnormalities in the regulation of group III-mediated muscle inhibition in the stroke population may contribute to impaired muscle activation patterns during movement.     

An assessment of parental satisfaction with mode of delivery of specialist advice for paediatric cardiology: face-to-face versus videoconference

Comparisons of parental satisfaction were made after specialist paediatric cardiology consultations were conducted either by conventional face-to-face delivery or telemedicine. Satisfaction statements were rated by 100 parents: 20 who experienced telemedicine; 56 with new children seen in the outreach clinics; 24 with children on review whose next appointment was at the specialist centre. There was general satisfaction with both types of consultations, but significant differences were noted. Those who had videoconferences felt that they had received an explanation about how the specialist advice would be obtained, and that they could see the pictures being discussed clearly. Those who had experienced telemedicine believed that teleconsultations could save them travelling time and money and they found the technical aspects of sound and picture quality acceptable. They were not discomforted by the technology and felt reassured by the consultation with the specialist. However, there was some ambivalence towards the statements suggesting that teleconsultations could take the place of conventional face-to-face consultations.     

Magnetic resonance imaging for investigation of the knee joint: a clinical and economic evaluation

OBJECTIVES: The aim of the study reported here was to investigate whether the use of magnetic resonance imaging (MRI) impacts on the clinical management of patients presenting with chronic knee problems, reduces costs, and improves patient outcome. METHODS: A single-center randomized controlled trial was conducted. Patients attending with knee problems in whom surgery was being considered were randomized either to investigation using an MRI scan or to investigation using arthroscopy. The study investigated benefits in terms of avoidance of surgery and patient health-related quality of life (using SF-36 and EQ-5D). Costs were assessed from the perspectives of the National Health Service and patients. All analyses were by intention to treat. RESULTS: The trial recruited 118 patients. No statistically significant differences were found between groups in terms of health outcome. However, the use of MRI was associated with a positive diagnostic/therapeutic impact: a significantly smaller proportion of patients in the MRI group underwent surgery (MRI = 0.41, No-MRI = 0.71; p value = .001). There was a similar mean overall cost for both groups. CONCLUSIONS: The use of MRI in patients with chronic knee problems, in whom surgery was being considered, did not increase costs overall, was not associated with worse outcomes, and avoided surgery in a significant proportion of patients.