What methods do stakeholders prefer for feeding back performance data: a qualitative study in palliative care.

OBJECTIVE: To investigate the opinions of stakeholders (service commissioners and providers) on how performance data should be presented, in order to develop effective feedback methods to facilitate the use of these data in decision making. DESIGN: A qualitative analysis of semi-structured face-to-face and telephone interviews. League tables and fictional box plots were presented as an illustrative guide. The themes covered in the interviews were the effectiveness of these two feedback formats, their positive and negative characteristics, and ideas for new and improved feedback mechanisms. PARTICIPANTS: Thirty-six stakeholders representing a range of clinical and non-clinical roles within palliative care and the wider health care system across a variety of statutory and non-statutory organizations from London and the West Midlands. RESULTS: Box plots were received more positively than league tables, and qualitative information was considered more appropriate than pictorial feedback. Conventional methods such as league tables and box plots were judged to lack essential information on which important decisions could be based, such as additional contextual information and the methodological assumptions of the instrument. Both feedback methods were considered useful as an impetus to further discussion. There was a consensus that feedback should be constructive and able to be adapted to the organizational realities in which UK health services function. CONCLUSION: Qualitative research was viewed as the right evidence for gaining an understanding of the quality of end of life care. Stakeholders highlighted the importance of the lay perspective, which requires approaches that illuminate the subjective meanings of patient experience.     

Electroencephalography in acute head injury

The established uses of standard and computerized EEG in acute head injury are outlined. Emphasis is placed on EEG correlation with level of consciousness, rostrocaudal deterioration, brainstem lesions, and prognosis. The utility of the standard EEG in seizures and toxic metabolic states accompanying severe head injury is also discussed.     

The strength of surgical repairs of the rotator cuff. A biomechanical study on cadavers.

Using 26 cadaver shoulders, we produced a standard defect in the supraspinatus tendon and performed one of three types of repair. Their strength was found by testing in tension the force required to produce a gap of 3 mm, then 6 mm, and finally total disruption of the repair. The use of a polyethylene patch to spread the forces over the lateral bone surface and of extra sutures to grasp the tendon end raised by 2.6 times the load at which a 3 mm gap in the repair occurred and by 1.7 times the load to failure.     

Evoked potentials in head injury and states of increased intracranial pressure

Recent clinical studies have addressed the utility of sensory evoked potentials (auditory, somatosensory, and visual) in head injury. The clinical significance of evoked potentials in head trauma, states of increased intracranial pressure, and post-traumatic syndrome is discussed. Emphasis is placed on up-to-date studies discussing evoked potential correlation with clinical findings, lesion localization, intracranial pressure, brain herniation, and prognosis.     

Perinatal toxicology screening.

Accurate identification of substance abusing mothers and their infants is critical for appropriate medical management as well as the collection of accurate information on the effects of illicit drug use on perinatal morbidity, mortality, and long-term neurobehavioral outcome in the infants. This study examines the differences found using two methods for urine toxicology screening at the time of obstetrical admission to the hospital. The institution of universal screening identified significantly more women than were previously identified through the use of a risk-directed protocol (P less than .0001). Women identified using either protocol were significantly more likely than toxicology-negative women to have had poor prenatal care and to have smoked and used alcohol during pregnancy (P less than .001). In the population studied, the multiple criteria needed to accurately identify mothers with positive-toxicology screens would also include screening over one half of the toxicology-negative mothers.     

Lipoprotein macroaggregates in bronchoalveolar lavage fluid from patients with diffuse interstitial lung disease: comparison with idiopathic alveolar lipoproteinosis.

Lipoprotein macroaggregates were present in cytocentrifuge preparations of bronchoalveolar lavage fluid from four patients with diffuse lung diseases other than idiopathic alveolar lipoproteinosis. In three patients the primary diagnosis was cryptogenic fibrosing alveolitis and in one sarcoidosis. We confirmed the presence of large multilamellar aggregates of lipoprotein by ultrastructural examination in patients with both interstitial lung disease and idiopathic alveolar lipoproteinosis. The small lamellar bodies and amorphous debris found in idiopathic alveolar lipoproteinosis were rare in the patients with interstitial lung disease. The lavage fluid from patient with interstitial lung disease did not show the substantial alterations in phospholipid composition that were seen in lavage fluid in idiopathic alveolar lipoproteinosis. These ultrastructural and biochemical features may help to distinguish idiopathic from other causes of alveolar lipoproteinosis, particularly at an early stage, when differential diagnosis may be difficult.     

Gemfibrozil reduces plasma prothrombin fragment F1 + 2 concentration, a marker of coagulability, in patients with coronary heart disease.

The effects of gemfibrozil on several indices of haemostatic activity were explored in male patients with coronary heart disease (CHD). Sixty-three of 71 patients completed a crossover study in which gemfibrozil 1,200 mg/day and matching placebo were each taken in randomised order for 2 months in a double-blind manner, separated by a 2-month washout period. Serum cholesterol decreased by an average (95% confidence interval) of 12 (9 to 15)% and non-fasting triglyceride concentration by 43 (34 to 51)% during active treatment. Plasma prothrombin fragment F1 + 2 concentration, a marker of the in vivo rate of generation of thrombin, was 25 (12 to 37)% lower on average while on gemfibrozil than during the placebo phase. Factor VII coagulant activity (VIIc) and antigen concentration, and fibrinopeptide A concentration were not influenced by gemfibrozil in the group overall. However, the VIIc response appeared to be dependent upon the untreated cholesterol level. Hypercholesterolaemic men (cholesterol greater than 6.5 mmol/l) experienced a significant reduction in VIIc averaging 6% of standard during active therapy. Other effects of gemfibrozil were a 5 (2 to 9)% increase in plasma fibrinogen by a gravimetric method, an 11 (8 to 13)% increase in platelet count, and a 6 (2 to 10)% reduction in white cell count. The reduced incidence of CHD following gemfibrozil therapy in hyperlipidaemic patients may arise in part through a reduction in procoagulant activity and thus the risk of an occlusive coronary thrombosis.     

No evidence for a direct vasodilatory effect of celiprolol on human vasculature in vivo or in vitro

Celiprolol is reported to be a new cardioselective beta blocker with novel ancillary properties including vasodilator effects. The purpose of this study was to investigate whether celiprolol possesses a direct vasodilatory effect on human vasculature in vivo and in vitro. We studied the in vivo effects of intra-arterial celiprolol (1-100 micrograms/min i.a.) on forearm blood flow (FBF). Forearm blood was measured by venous occlusion plethysmography. Possible vasorelaxant actions of celiprolol on human vascular smooth muscle were studied using segments of isolated human saphenous vein in vitro. The effect of celiprolol was investigated on resting tone or noradrenaline induced tone. Possible alpha 2-adrenoceptor antagonist effects of celiprolol were assessed using celiprolol as an antagonist of BHT933 induced constriction. Celiprolol was without significant effect on FBF and failed to relax isolated saphenous vein segments preconstricted with noradrenaline. The weak alpha 2-adrenoceptor antagonist action of celiprolol was demonstrable in human saphenous vein. This study does not provide evidence for a direct vasodilatory effect of celiprolol on human vasculature.     

Uterine artery resistance and anxiety in the second trimester of pregnancy.

OBJECTIVE: To investigate the association between maternal anxiety and uterine artery resistance index (RI) at 20 weeks of gestation. METHODS: Uterine artery blood flow was assessed using color Doppler ultrasound and maternal anxiety was measured using the Hospital Anxiety and Depression (HAD) scale in 96 healthy primigravid women attending consecutively for their routine 20-week anomaly scan. RESULTS: The mean uterine artery RI was 0.54 (95% confidence interval, 0.52-0.56) and the median HAD anxiety score was 6 (range, 0-20). There was no association between RI and anxiety scores (r = 0.09, P = 0.36). Women scoring as definite cases of anxiety did not have a significantly elevated uterine artery RI or increased frequency of waveform notching compared to women with doubtful or no anxiety. CONCLUSIONS: The data of this study do not suggest a significant association between maternal anxiety and uterine artery RI at 20 weeks of gestation in healthy primigravid women with normally developing pregnancies. A prospective cohort study would be useful to determine the nature of the relationship between maternal anxiety, alteration in uterine artery blood flow and abnormal pregnancy outcome.