Clinical practice guidelines: barriers to durability after effective early implementation

BACKGROUND

Clinical practice guidelines in general (General-CPG) may reduce variation in clinician performance and improve patient outcomes. Short-term evaluation is now routine, but demonstration of early successful implementation does not necessarily ensure longer-term effectiveness.

AIM

To assess adherence to chronic obstructive pulmonary disease (COPD)-CPG recommendations at the Royal Melbourne Hospital (RMH), 2 years after successful implementation. To identify barriers to sustained success of General-CPG.

METHODS

A multi-faceted evaluation was performed to document: (i) current adherence to COPD management recommendations (medical record audit); (ii) awareness of attitudes towards and barriers for the use of COPD-CPG and General-CPG (staff survey, focus groups and key informant interviews) and (iii) access to and quality of available General-CPG (internet review and random sample General-CPG evaluation.

RESULTS

Adherence to COPD-CPG recommendations was highly variable. Adherence was higher in the Emergency Department than the general wards and for specific therapeutic recommendations. It was lower for non-pharmacological therapy and for recommendations relating to processes of care. Most health professionals were in favour of General-CPG. Barriers to use of General-CPG were in keeping with previous literature reports. Organizational issues including high levels of staff turnover and lack of integration of General-CPG into hospital quality frameworks were highlighted as major barriers. Hospital intranet access and presentation of General-CPG identified lack of consistency in terminology and presentation.

CONCLUSION

Short-term effectiveness of COPD-CPG implementation did not ensure sustained success. Departmental organizational behaviours and organizational system barriers are major factors influencing durability.

Vaccines based on the cell surface carbohydrates of pathogenic bacteria

Glycoconjugate vaccines, in which a cell surface carbohydrate from a micro-organism is covalently attached to an appropriate carrier protein are proving to be the most effective means to generate protective immune responses to prevent a wide range of diseases. The technology appears to be generic and applicable to a wide range of pathogens, as long as antibodies against surface carbohydrates help protect against infection. Three such vaccines, against Haemophilus influenzae type b, Neisseria meningitidis Group C and seven serotypes of Streptococcus pneumoniae, have already been licensed and many others are in development. This article discusses the rationale for the development and use of glycoconjugate vaccines, the mechanisms by which they elicit T cell-dependent immune responses and the implications of this for vaccine development, the role of physicochemical methods in the characterisation and quality control of these vaccines, and the novel products which are under development.

Temozolomide Pharmacodynamics in Patients with Metastatic Melanoma: DNA Damage and Activity of Repair EnzymesO6-Alkylguanine Alkyltransferase and Poly(ADP-Ribose) Polymerase-1

PURPOSE

Temozolomide, a DNA methylating agent used to treat melanoma, induces DNA damage, which is repaired by O6-alkylguanine alkyltransferase (ATase) and poly(ADP-ribose) polymerase-1 (PARP-1)-dependent base excision repair. The current study was done to define the effect of temozolomide on DNA integrity and relevant repair enzymes as a prelude to a phase I trial of the combination of temozolomide with a PARP inhibitor.

EXPERIMENTAL DESIGN

Temozolomide (200 mg/m2 oral administration) was given to 12 patients with metastatic malignant melanoma. Peripheral blood lymphocytes (PBL) were analyzed for PARP activity, DNA single-strand breakage, ATase levels, and DNA methylation. PARP activity was also measured in tumor biopsies from 9 of 12 patients and in PBLs from healthy volunteers.

RESULTS

Temozolomide pharmacokinetics were consistent with previous reports. Temozolomide therapy caused a substantial and sustained elevation of N7-methylguanine levels, a modest and sustained reduction in ATase activity, and a modest and transient increase in DNA strand breaks and PARP activity in PBLs. PARP-1 activity in tumor homogenates was variable (828 +/- 599 pmol PAR monomer/mg protein) and was not consistently affected by temozolomide treatment.

CONCLUSIONS

The effect of temozolomide reported here are consistent with those documented in previous studies with temozolomide and similar drug, dacarbazine, demonstrating that a representative patient population was investigated. Furthermore, PARP activity was not inhibited by temozolomide treatment and this newly validated pharmacodynamic assay is therefore suitable for use in a proof-of-principle phase I trial a PARP-1 inhibitor in combination with temozolomide.

Readmission patterns in patients with chronic obstructive pulmonary disease, chronic heart failure and diabetes mellitus: an administrative dataset analysis

Comprehensive disease management programmes for chronic disease aim to improve patient outcomes and reduce health-care utilization. Readmission rates are often used as an outcome measure of effectiveness. This study aimed to document readmission rates, and risk for early and late readmission, for patients discharged from the Royal Melbourne Hospital with a disease diagnosis of chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) or diabetes mellitus compared to those with other general medical conditions. Eighty five (8.6%) of patients were readmitted within 28 days and 183 (20.8%) were readmitted between 29 and 180 days. No risk factors for early readmission were identified. Patients with a primary disease diagnosis of CHF and COPD are at increased risk of late readmissions (29-180 days).

Reminiscence therapy for dementia

BACKGROUND

Reminiscence Therapy (RT) involves the discussion of past activities, events and experiences with another person or group of people, usually with the aid of tangible prompts such as photographs, household and other familiar items from the past, music and archive sound recordings. Reminiscence groups typically involve group meetings in which participants are encouraged to talk about past events at least once a week. Life review typically involves individual sessions, in which the person is guided chronologically through life experiences, encouraged to evaluate them, and may produce a life story book. Family care-givers are increasingly involved in reminiscence therapy. Reminiscence therapy is one of the most popular psychosocial interventions in dementia care, and is highly rated by staff and participants. There is some evidence to suggest it is effective in improving mood in older people without dementia. Its effects on mood, cognition and well-being in dementia are less well understood.

OBJECTIVES

The objective of the review is to assess the effects of reminiscence therapy for older people with dementia and their care-givers.

SEARCH STRATEGY

The trials were identified from a search of the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group on 4 May 2004 using the term "reminiscence". The CDCIG Specialized Register contains records from all major health care databases (MEDLINE, EMBASE, PsycLIT, CINAHL) and many ongoing trials databases and is regularly updated. We contacted specialists in the field and also searched relevant Internet sites. We hand-searched Aging and Mental Health, the Gerontologist, Journal of Gerontology, Current Opinion in Psychiatry, Current Research in Britain: Social Sciences, British Psychological Society conference proceedings and Reminiscence database.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomized trials of reminiscence therapy for dementia.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Five trials are included in the review, but only four trials with a total of 144 participants had extractable data. The results were statistically significant for cognition (at follow-up), mood (at follow-up) and on a measure of general behavioural function (at the end of the intervention period). The improvement on cognition was evident in comparison with both no treatment and social contact control conditions. Care-giver strain showed a significant decrease for care-givers participating in groups with their relative with dementia, and staff knowledge of group members' backgrounds improved significantly. No harmful effects were identified on the outcome measures reported.

AUTHORS' CONCLUSIONS

Whilst four suitable randomized controlled trials looking at reminiscence therapy for dementia were found, several were very small studies, or were of relatively low quality, and each examined different types of reminiscence work. Although there are a number of promising indications, in view of the limited number and quality of studies, the variation in types of reminiscence work reported and the variation in results between studies, the review highlights the urgent need for more and better designed trials so that more robust conclusions may be drawn.

Increased calcitonin level in thyroid nodules without medullary carcinoma

Background

Basal calcitonin measurement is routinely performed in patients with a thyroid nodule to detect medullary carcinoma. However, increased calcitonin does not always correlate with medullary carcinoma. The aim of this study was to analyse increased calcitonin levels in patients without medullary carcinoma and to find out whether absence of this carcinoma can be predicted with certainty.

Methods

From 1992 to 2003, 5018 patients with thyroid nodules underwent thyroid surgery. A retrospective analysis of preoperative increased calcitonin levels in 67 of these patients was performed.

Results

Pathology revealed medullary carcinoma in 16 patients (group I), micromedullary carcinoma in 13 (group II) and no medullary carcinoma in 38 (group III). In group III, 30 patients had C-cell hyperplasia. The mean basal calcitonin level was 6250 pg/ml in group I (39–62 500), 109·6 pg/ml in group II (10–728) and 25·5 pg/ml in group III (10·5–145). The mean pentagastrin-stimulated calcitonin level was 1074·1 pg/ml in group II (26–5700) and 67·6 pg/ml in group III (10–205).

Conclusion

There is an overlap of thyroid C-cell pathology for medullary carcinoma, micromedullary carcinoma and C-cell hyperplasia that occurs when basal calcitonin is between 10 and 145 pg/ml and pentagastrin-stimulated calcitonin between 10 and 205 pg/ml. In these patients, since medullary carcinoma cannot be completely excluded, total thyroidectomy should be recommended.

Alexithymia: its prevalence and correlates in a British undergraduate sample

INTRODUCTION

Alexithymia is characterized by a difficulty identifying and describing emotional states, as well as an externally oriented thinking style. This study investigated the prevalence of alexithymia in a British undergraduate sample and assesses its relationship to both parental bonding and dissociation.

METHOD

The Toronto alexithymia scale (TAS-20), the Parental Bonding Instrument (PBI), and the Dissociative Experience Scale (DES) were administered to a sample of 181 male and 190 female undergraduate students from both arts and science subjects.

RESULTS

Rates of alexithymia were comparable with those observed in some other countries. Contrary to predictions, females were found to have higher rates than males, and the highest presence of alexithymia was in female science students. As in previous studies, alexithymia was linked to both dissociation and perceptions of a lack of maternal care, though the degree of association to the latter was small. Dissociative experiences were predicted by both maternal overprotection and difficulties identifying feelings.

DISCUSSION

Some qualified support was found for the relevance of early maternal bonding to later difficulties processing emotions. The presence of greater alexithymia in females, and female science students in particular, was discussed in reference to similar observations elsewhere. There was also an understandable relationship between 'difficulty identifying feelings' (TAS) and both depersonalization/derealization and absorption (DES).

A mobile screening programme for the cardiovascular and microvascular complications of Type 2 diabetes in primary care

The Diabetes National Service framework (NSF), and the quality payments in the new contract for UK General Practitioners, promote regular screening for diabetes complications. The new contract also includes immediate incentives to meet screening and quality targets, but it will be difficult to meet these targets in primary care. We have developed a mobile 'annual review' programme for patients with Type 2 diabetes managed solely in primary care, that screens for cardiovascular disease, hypertension, retinopathy and neuropathy at the patient's general practice, and gives written foot care, dietary advice and level 1 smoking cessation advice to all patients.

Full NMR assignment and revised structure for the capsular polysaccharide from Streptococcus pneumoniae type 15B

The capsular polysaccharide from Streptococcus pneumoniae Type 15B is a component of the 23-valent polysaccharide vaccine against pneumococcal disease. We report full NMR assignments for the native and de-O-acetylated polysaccharide, and confirm that the phosphorylated substituent is glycerol-2-phosphate rather than phosphocholine, located on O-3 of the side chain beta-Galp residue. The polysaccharide is O-acetylated on the terminal alpha-Gal residue, distributed between O-2, O-3, O-4 and O-6 in a ratio of 6:12:12:55, with approximately 15% of the repeat units not O-acetylated.

Mapping herpes simplex virus type 1 latency-associated transcript sequences that protect from apoptosis mediated by a plasmid expressing caspase-8

LAT (latency-associated transcript) is the only herpes simplex virus type 1 (HSV-1) transcript abundantly expressed during neuronal latency. LAT expression is required for the high reactivation phenotype of HSV-1 and this phenotype correlates with LAT's anti-apoptosis properties. LAT nucleotides 1 to 1499 inhibit caspase-8 (death receptor apoptotic pathway), but not caspase-9 (mitochondrial apoptotic pathway), -induced apoptosis as efficiently as larger LAT fragments. LAT sequences important for inhibiting caspase-8-induced apoptosis were also localized. The ability of LAT nucleotides 1 to 1499 to efficiently inhibit caspase-8-induced apoptosis correlates with the high reactivation phenotype of a mutant virus expressing just the first 1.5 kb of LAT (nucleotides 1 to 1499).

Endocrine abnormalities in patients with Jacobsen (11q-) syndrome

Jacobsen syndrome (JS), a rare disorder with multiple dysmorphic features, is caused by the terminal deletion of chromosome 11q. Short stature has been reported in this syndrome, however very few of these patients have undergone endocrine evaluation. Serum insulin-like growth factor-1 (IGF-1) levels are an indirect indicator of growth hormone activity and are a useful initial screening tool in the assessment of an individual's growth hormone axis. We studied nine children with JS, eight of whom had short stature. Four out of eight children with short stature (50%) had low IGF-1 values, with three low for age and one low for Tanner stage. Four out of six males (67%) had cryptorchidism, a potential sign of hypogonadism. We conclude that low IGF-1 is common in patients with JS and short stature, and that growth hormone status and possibly hypothalamic-pituitary function should be evaluated in this patient population.

The 11q terminal deletion disorder: a prospective study of 110 cases

We performed a prospective study of 110 patients (75 not previously published) with the 11q terminal deletion disorder (previously called Jacobsen syndrome), diagnosed by karyotype. All the patients have multiple dysmorphic features. Nearly all the patients (94%) have Paris-Trousseau syndrome characterized by thrombocytopenia and platelet dysfunction. In total, 56% of the patients have serious congenital heart defects. Cognitive function ranged from normal intelligence to moderate mental retardation. Nearly half of the patients have mild mental retardation with a characteristic neuropsychiatric profile demonstrating near normal receptive language ability, but mild to moderate impairment in expressive language. Ophthalmologic, gastrointestinal, and genitourinary problems were common, as were gross and fine motor delays. Infections of the upper respiratory system were common, but no life-threatening infections were reported. We include a molecular analysis of the deletion breakpoints in 65 patients, from which genetic "critical regions" for 14 clinical phenotypes are defined, as well as for the neuropsychiatric profiles. Based on these findings, we provide a comprehensive set of recommendations for the clinical management of patients with the 11q terminal deletion disorder.

The Healthgrid White Paper

Over the last four years, a community of researchers working on Grid and High Performance Computing technologies started discussing the barriers and opportunities that grid technologies must face and exploit for the development of health-related applications. This interest lead to the first Healthgrid conference, held in Lyon, France, on January 16th-17th, 2003, with the focus of creating increased awareness about the possibilities and advantages linked to the deployment of grid technologies in health, ultimately targeting the creation of a European/international grid infrastructure for health. The topics of this conference converged with the position of the eHealth division of the European Commission, whose mandate from the Lisbon Meeting was "To develop an intelligent environment that enables ubiquitous management of citizens' health status, and to assist health professionals in coping with some major challenges, risk management and the integration into clinical practice of advances in health knowledge." In this context "Health" involves not only clinical procedures but covers the whole range of information from molecular level (genetic and proteomic information) over cells and tissues, to the individual and finally the population level (social healthcare). Grid technology offers the opportunity to create a common working backbone for all different members of this large "health family" and will hopefully lead to an increased awareness and interoperability among disciplines. The first HealthGrid conference led to the creation of the Healthgrid association, a non-profit research association legally incorporated in France but formed from the broad community of European researchers and institutions sharing expertise in health grids. After the second Healthgrid conference, held in Clermont-Ferrand on January 29th-30th, 2004, the need for a "white paper" on the current status and prospective of health grids was raised. Over fifty experts from different areas of grid technologies, eHealth applications and the medical world were invited to contribute to the preparation of this document.

Overview of programmes for the assessment of risks to the environment from ionising radiation and hazardous chemicals

Within the FASSET project, a review of existing programmes for the assessment of environmental risks from radioactive or hazardous substances was carried out in order to identify appropriate aspects that could be incorporated into the FASSET framework. The review revealed a number of different approaches, arising from the need to balance the information value of the assessment against the availability of data and the need to keep the assessment manageable. Most of the existing assessment programmes fit into a three-phase approach to environmental risk assessment: problem formulation, assessment and risk characterisation. However, the emphasis on particular assessment phases varies between programmes. The main differences between the different programmes are: the degree of specificity to a particular site, the level of detail of the assessment, the point at which a comparison is made between a criterion intended to represent 'what is acceptable' and a measured or predicted quantity, the choice of end-point for the assessment and the relationship between measurement end-points and assessment end-points. The existing assessment programmes are based on a similar general structure, which is suitable for use as a basis for the FASSET framework. However, certain aspects of the assessment of exposure and effects of ionising contaminants, e.g. dosimetry, require further development before incorporation into such a framework.

Heterogeneity in the biosynthesis of mucin O-glycans from Trypanosoma cruzi tulahuen strain with the expression of novel galactofuranosyl-containing oligosaccharides

Sialoglycoprotein from Trypanosoma cruzi strains participates in important biological functions in which the O-linked glycans play a pivotal role, and their structural diversity may be related to the parasite's virulence pattern. To provide supporting evidence for this idea, we have determined the structure of novel linear and branched alpha-O-GlcNAc-linked oligosaccharides present on the mucins of the T. cruzi Tulahuen strain. The O-glycans were isolated as oligosaccharide alditols by reductive beta-elimination, purified, and characterized by nuclear magnetic resonance spectroscopy and methylation analysis. Two core families were synthesized by the parasite: the Galfbeta1-->4GlcNAc and Galpbeta1-->4GlcNAc. The Galfbeta1-->4GlcNAc core yields three series of O-chain structures. In the first, the Galf residue is nonsubstituted, while in the other series it is elongated by the activity of galactopyranosyl or galactofuranosyl transferases giving rise to Galp-beta-(1-->2)-Galf-beta-(1-->4) or Galf-beta-(1-->2)-Galf-beta-(1-->4) substructures not previously observed. The three series can arise by further galactopyranosylation of the GlcNAc O-6 arm. Sialylation was the only observed elaboration of the Galpbeta1-->4GlcNAc core family. Thus the determination of the structures of the O-glycans from T. cruzi Tulahuen mucins confirms the strain specificity of the glycosylation and predicts a relationship between it and parasite pathogenicity and the epidemiology of Chagas' disease.

Expression of ATM, p53, and the MRE11-Rad50-NBS1 complex in myoepithelial cells from benign and malignant proliferations of the breast

AIMS

To analyse the expression of proteins involved in DNA double strand break detection and repair in the luminal and myoepithelial compartments of benign breast lesions and malignant breast tumours with myoepithelial differentiation.

METHODS

Expression of the ataxia telangiectasia (ATM) and p53 proteins was immunohistochemically evaluated in 18 benign and malignant myoepithelial tumours of the breast. Fifteen benign breast lesions with prominent myoepithelial compartment were also evaluated for these proteins, in addition to those in the MRE11-Rad50-NBS1 (MRN) complex, and the expression profiles were compared with those seen in eight independent non-cancer (normal breast) samples and in the surrounding normal tissues of the benign and malignant tumours examined.

RESULTS

ATM expression was higher in the myoepithelial compartment of three of 15 benign breast lesions and lower in the luminal compartment of eight of these lesions compared with that found in the corresponding normal tissue compartments. Malignant myoepithelial tumours overexpressed ATM in one of 18 cases. p53 was consistently negative in benign lesions and was overexpressed in eight of 18 malignant tumours. In benign breast lesions, expression of the MRN complex was significantly more reduced in myoepithelial cells (up to 73%) than in luminal cells (up to 40%) (p=0.0005).

CONCLUSIONS

Malignant myoepithelial tumours rarely overexpress ATM but are frequently positive for p53. In benign breast lesions, expression of the MRN complex was more frequently reduced in the myoepithelial than in the luminal epithelial compartment, suggesting different DNA repair capabilities in these two cell types.

Cognitive behaviour therapy for schizophrenia

BACKGROUND

Cognitive behavioural therapy (CBT) is now a recommended treatment for people with schizophrenia. This approach helps to link the person's feelings and patterns of thinking which underpin distress.

OBJECTIVES

To review the effects of CBT for people with schizophrenia when compared to standard care, specific medication, other therapies and no intervention.

SEARCH STRATEGY

This 2004 update built on past work by searching the Cochrane Schizophrenia Groups' Register of Trials (January 2004). We inspected all references of the selected articles for further relevant trials.

SELECTION CRITERIA

All relevant clinical randomised trials of cognitive behaviour therapy for people with schizophrenia-like illnesses.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected and assessed for methodological quality. Two reviewers, working independently, extracted data. We analysed dichotomous data on an intention-to-treat basis and continuous data with 65% completion rate are presented. Where possible, for dichotomous outcomes, we estimated a relative risk (RR) with the 95% confidence interval (CI) along with the number needed to treat/harm (NNT/H).

MAIN RESULTS

30 papers described 19 trials. CBT plus standard care did not reduce relapse and readmission compared with standard care (long term 4 RCTs, n=357, RR 0.8 CI 0.5 to 1.5), but did decrease the risk of staying in hospital (1 RCT, n=62, RR 0.5 CI 0.3 to 0.9, NNT 4 CI 3 to 15). CBT helped mental state over the medium term (2 RCTs, n=123, RR No meaningful improvement 0.7 CI 0.6 to 0.9, NNT 4 CI 3 to 9) but after one year the difference was gone (3 RCTs, n=211, RR 0.95 CI 0.6 to 1.5). Continuous measures of mental state (BDI, BPRS, CPRS, MADRS, PAS) do not demonstrate a consistent effect. When compared with supportive psychotherapy, CBT had no effect on relapse (1 RCT, n=59, RR medium term 0.6 CI 0.2 to 2; 2 RCTs, n=83, RR long term 1.1 CI 0.5 to 2.4). This also applies to the outcome of 'No clinically meaningful improvements in mental state' over the same time periods (1 RCT, n=59, RR medium term 0.8 CI 0.6 to 1.1; 2 RCT, n=100, RR long term 0.9 CI 0.8 to 1.1). When CBT was combined with a psychoeducational approach there was no significant reduction of readmission rates relative to standard care alone (1 RCT, n=91, RR 0.9 CI 0.6 to 1.4).

REVIEWERS' CONCLUSIONS

CBT is a promising but under evaluated intervention. Currently, trial-based data supporting the wide use of CBT for people with schizophrenia or other psychotic illnesses are far from conclusive. More trials are justified, especially in comparison with a lower grade supportive approach. These trials should be designed to be both clinically meaningful and widely applicable.

Measurement of the generalized forward spin polarizabilities of the neutron

The generalized forward spin polarizabilities gamma(0) and delta(LT) of the neutron have been extracted for the first time in a Q2 range from 0.1 to 0.9 GeV2. Since gamma(0) is sensitive to nucleon resonances and delta(LT) is insensitive to the Delta resonance, it is expected that the pair of forward spin polarizabilities should provide benchmark tests of the current understanding of the chiral dynamics of QCD. The new results on delta(LT) show significant disagreement with chiral perturbation theory calculations, while the data for gamma(0) at low Q2 are in good agreement with a next-to-leading-order relativistic baryon chiral perturbation theory calculation. The data show good agreement with the phenomenological MAID model.

Nitrogen-fixing bacterium Burkholderia brasiliensis produces a novel yersiniose A-containing O-polysaccharide

Burkholderia brasiliensis, a Gram-negative diazotrophic endophytic bacterium, was first isolated from roots, stems, and leaves of rice plant in Brazil. The polysaccharide moiety was released by ammonolysis from the B. brasiliensis lipopolysaccharide (LPS), allowing the unambiguous characterization of a 3,6-dideoxy-4-C-(1-hydroxyethyl)-D-xylo-hexose (yersiniose A), an uncommon feature for Burkholderia LPS. The complete structure of the yersiniose A-containing O-antigen was identified by sugar and methylation analyses and NMR spectroscopy. Our results show that the repeating oligosaccharide motif of LPS O-chain consists of a branched tetrasaccharide with the following structure:-->2-alpha-d-Rhap-(1-->3)-[alpha-YerAp-(1-->2)]-alpha-D-Rhap-(1-->3)-alpha-D-Rhap-(1-->.