Narrative methods in quality improvement research

This paper reviews and critiques the different approaches to the use of narrative in quality improvement research. The defining characteristics of narrative are chronology (unfolding over time); emplotment (the literary juxtaposing of actions and events in an implicitly causal sequence); trouble (that is, harm or the risk of harm); and embeddedness (the personal story nests within a particular social, historical and organisational context). Stories are about purposeful action unfolding in the face of trouble and, as such, have much to offer quality improvement researchers. But the quality improvement report (a story about efforts to implement change), which is common, must be distinguished carefully from narrative based quality improvement research (focused systematic enquiry that uses narrative methods to generate new knowledge), which is currently none. We distinguish four approaches to the use of narrative in quality improvement research--narrative interview; naturalistic story gathering; organisational case study; and collective sense-making--and offer a rationale, describe how data can be collected and analysed, and discuss the strengths and limitations of each using examples from the quality improvement literature. Narrative research raises epistemological questions about the nature of narrative truth (characterised by sense-making and emotional impact rather than scientific objectivity), which has implications for how rigour should be defined (and how it might be achieved) in this type of research. We offer some provisional guidance for distinguishing high quality narrative research in a quality improvement setting from other forms of narrative account such as report, anecdote, and journalism.

Fluid intake, personality and behaviour in patients with eating disorders

OBJECTIVE

To examine psychological and behavioural variables associated with the disordered fluid intake of 112 eating disorder patients.

METHOD

Fluid intake history for previous seven days, and standardized psychological and behavioural measures of eating disorders, mood, personality and health, were completed on admission to hospital.

RESULTS

Only behaviours associated with eating disorders were associated with fluid intake. Greater amounts of total and energy-free fluids are consumed if patients report overeating, binge eating and dieting between overeating more frequently, drinking more caffeine-containing energy free drinks, vomiting and using laxatives. Energy-containing fluid intake is higher if patients feel their body weight is less important and if they binge eat. There is a significant difference in the amount of fluid drunk (ml or ml/kg) by patients with bulimia nervosa (BN) when compared to patients with no current diagnosis but not compared with anorexia nervosa (AN) or eating disorders not otherwise specified (EDNOS) patients.

DISCUSSION

Fluid intake is associated with eating disorder behaviour rather than personality and psychological variables. Patients eating more drink more.

Duodenal Dcytb and hephaestin mRNA expression are not significantly modulated by variations in body iron homeostasis

BACKGROUND AND AIMS

While the upregulation of duodenal cytochrome b (Dcytb) within duodenal enterocytes is reported in patients with iron deficiency, the expression of hephaestin (Hp) remains controversial in altered iron metabolism states, including HFE associated hereditary hemochromatosis (HH). The effect of iron depletion therapy on the expression of these molecules is unclear. This study examines the duodenal expression of these two molecules in HH patients (prior to and following phlebotomy), in patients with iron deficiency (ID) and in healthy controls.

METHODS

Using quantitative real-time polymerase chain reaction (qRT-PCR), Dcytb and Hp mRNA expression levels were measured in duodenal tissue of C282Y homozygous HH patients, in ID patients negative for the C282Y mutation with a serum ferritin concentration less than 20 mug/l, and in controls negative for C282Y and H63D mutations with normal iron indices.

RESULTS

Dcytb and Hp mRNA expression levels were not significantly different in either non-phlebotomized and phlebotomized HH patients or individuals with iron deficiency when compared with controls. There was no significant correlation between the gene expression levels and their respective serum ferritin or TS% values in any of the investigated groups. In HH patients, there was no significant association between gene expression and the degree of hepatic parenchymal siderosis identified by Perl's iron stain. Dcytb and Hp mRNA levels were significantly correlated to each other when all cohorts were analyzed together and separately.

CONCLUSIONS

These findings demonstrate that the duodenal ferroreductase Dcytb and ferroxidase Hp mRNA expression are not significantly altered by variations in iron homeostasis. The effect of phlebotomy-induced erythropoiesis did not alter either gene transcript mRNA expression.

High-dose mitoxantrone–vinblastine–cyclophosphamide and autologous stem cell transplantation for stage III breast cancer: final results of a prospective multicentre study

BACKGROUND

Stage III breast cancer patients continue to suffer high relapse and death rates despite standard chemotherapy regimens. High-dose alkylator chemotherapy does not further improve outcome. This phase II study evaluated a novel high-dose chemotherapy regimen which combined active breast cancer agents with differing mechanisms of action.

PATIENTS AND METHODS

Eligibility included at least seven involved axillary nodes (AxLNs) for tumours <5 cm, at least four AxLNs for tumours >5 cm or locally advanced breast cancer (LABC). Patients received four cycles of fluorouracil-adriamycin-cyclophosphamide (FAC) followed by one cycle of mitoxantrone 63 mg/m(2)-vinblastine 12.5 mg/m(2)-cyclophosphamide 6 g/m(2) (MVC) with autologous blood stem cell transplantation (ASCT).

RESULTS

Between April 1995 and December 1998, 92 patients aged 21-65 years (median 45 years) were enrolled, of whom 25 were treated preoperatively for LABC and 67 were treated postoperatively. Although there was no early treatment-related mortality, one late death occurred from secondary acute myeloid leukaemia. The 7-year event-free and overall survival rates were 53% (95% confidence interval 42-64%) and 62% (95% CI 52-73%), respectively, with no significant difference between pre- and postoperative groups.

CONCLUSION

FAC followed by MVC-ASCT is feasible and reasonably well tolerated, but does not result in improved survival rates compared with other conventional or high-dose regimens for stage III breast cancer.

Fenestration of the Fontan circuit as treatment for plastic bronchitis

Plastic bronchitis is a rare, potentially life-threatening condition in which protein casts form within and occlude the bronchus, resulting in pulmonary failure, and has been identified as a complication after the Fontan procedure. We present a case of a 5-year-old girl who had undergone an extracardiac fenestrated Fontan repair as a component of staged palliation for tricuspid atresia. Six weeks following surgery, the patient presented with airway obstruction, coughing a bronchial cast. Medical therapies to optimize heart function and attempt to control cast formation were implemented, with little clinical impact. Following cardiac catheterization to stent open the fenestration, the symptoms of plastic bronchitis resolved. Cast expectoration recurred following spontaneous closure of the stented fenestration and again resolved with recreation of the baffle defect. Fenestration of the Fontan circuit alters hemodynamics, thereby providing an additional therapeutic option for this devastating disorder.

Autologous transplantation for primary systemic AL amyloidosis is feasible outside a major amyloidosis referral centre: the Calgary BMT Program experience

Recent reports from large amyloidosis referral centers suggest that primary systemic AL amyloidosis patients treated with high-dose melphalan (HDM) and autologous stem cell transplantation (ASCT) survive longer than historical controls treated with less intensive chemotherapy, despite high transplant-related mortality (TRM) rates of >10%. A retrospective review was conducted to determine if the outcome of ASCT for AL amyloidosis at our institution was similar to that reported at major amyloidosis referral centers. Over a 7 year period, we treated a total of 15 AL amyloidosis patients with ASCT, including four with poor prognosis cardiac or multisystem involvement. No TRM was observed. Overall, 10 patients (67%) achieved a complete hematological response and four patients (27%) achieved a complete organ response. The 4-year event-free and overall survival rates were 60% (95% CI 32-89%) and 75% (95% CI 50-100%), respectively. One patient, who presented with cardiac failure and multiorgan involvement with colonic bleeding currently remains in complete remission 62 months post-ASCT. In conclusion, ASCT for primary AL amyloidosis can safely be performed at experienced transplant centers that are not associated with major amyloidosis referral centers, and is feasible for patients who have multisystem involvement, particularly for motivated patients with good performance status.

Comparative analysis of population genetic structure in Athyrium distentifolium (Pteridophyta) using AFLPs and SSRs from anonymous and transcribed gene regions

To examine the performance and information content of different marker systems, comparative assessment of population genetic diversity was undertaken in nine populations of Athyrium distentifolium using nine genomic and 10 expressed sequence tag (EST) microsatellite (SSR) loci, and 265 amplified fragment length polymorphism (AFLP) loci from two primer combinations. In range-wide comparisons (European vs. North American populations), the EST-SSR loci showed more reliable amplification and produced more easily scorable bands than genomic simple sequence repeats (SSRs). Genomic SSRs showed significantly higher levels of allelic diversity than EST-SSRs, but there was a significant correlation in the rank order of population diversities revealed by both marker types. When AFLPs, genomic SSRs, and EST-SSRs are considered, comparisons of different population diversity metrics/markers revealed a mixture of significant and nonsignificant rank-order correlations. However, no hard incongruence was detected (in no pairwise comparison of populations did different marker systems or metrics detect opposingly significant different amounts of variation). Comparable population pairwise estimates of F(ST) were obtained for all marker types, but whilst absolute values for genomic and EST-SSRs were very similar (F(ST) = 0.355 and 0.342, respectively), differentiation was consistently higher for AFLPs in pairwise and global comparisons (global AFLP F(ST) = 0.496). The two AFLP primer combinations outperformed 18 SSR loci in assignment tests and discriminatory power in phenetic cluster analyses. The results from marker comparisons on A. distentifolium are discussed in the context of the few other studies on natural plant populations comparing microsatellite and AFLP variability.

Pre- and postoperative developmental attainment in sagittal synostosis

AIMS

To investigate whether sagittal synostosis (SS) has consequences for children's mental and psychomotor development, and whether surgery has any impact on this.

METHODS

The study involved 28 children with SS who underwent corrective surgery at a mean age of 8.0 (SD 7.16) months, and 28 normal controls. All the children with SS were assessed pre- and postoperatively using the Griffiths Mental Development Scales. The controls were assessed on one occasion, at an age matched with individuals in the patient group at the time of the preoperative assessment. A further control group consisted of 13 children with SS, who had received developmental assessment on two or more occasions without surgical intervention.

RESULTS

The data indicated that children with SS have significantly poorer gross locomotor function than the normal controls. Following surgical intervention the deficit was shown to have resolved; consistent with this a lesser improvement in eye-hand coordination and performance skills was shown. Overall developmental attainment also improved postoperatively. The children with SS who did not receive surgery did not show any improvement in development.

CONCLUSIONS

The study shows improved developmental attainment following surgical correction of SS, which may therefore be more than a cosmetic procedure.

Myocardial contraction is 5-fold more economical in ventricular than in atrial human tissue

OBJECTIVE

Cardiac energetics and performance depend on the expression level of the fast (alpha-) and slow (beta-) myosin heavy chain (MHC) isoform. In ventricular tissue, the beta-MHC isoform predominates, whereas in atrial tissue a variable mixture of alpha- and beta-MHC is found. In several cardiac diseases, the slow isoform is upregulated; however, the functional implications of this transition in human myocardium are largely unknown. The aim of this study was to determine the relation between contractile properties and MHC isoform composition in healthy human myocardium using the diversity in atrial tissue.

METHODS

Isometric force production and ATP consumption were measured in chemically skinned atrial trabeculae and ventricular muscle strips, and rate of force redevelopment was studied using single cardiomyocytes. MHC isoform composition was determined by one-dimensional SDS-gel electrophoresis.

RESULTS

Force development in ventricular tissue was about 5-fold more economical, but nine times slower, than in atrial tissue. Significant linear correlations were found between MHC isoform composition, ATP consumption and rate of force redevelopment.

CONCLUSION

These results clearly indicate that even a minor shift in MHC isoform expression has considerable impact on cardiac performance in human tissue.

Chondro-osseous respiratory epithelial adenomatoid hamartoma of the nasal cavity: a case report

Chondro-osseous respiratory epithelial adenomatoid hamartoma (COREAH) of the nasal cavity is an exceedingly rare benign lesion of the nasal cavity. We report a case arising in an 11-year-old male patient, who presented with a 6-month history of right-sided nasal obstruction. Examination revealed a large fleshy, tender polyp in the right nasal cavity. Computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the large mass in the anterior nasal cavity extending superiorly to the cribriform plate on the right hand side. The polyp was resected endoscopically and confirmed histologically as a COREAH. The clinical differential diagnosis includes cartilaginous tumours and other hamartomatous lesions. Local resection should be curative.

Pine microsatellite markers allow roots and ectomycorrhizas to be linked to individual trees

Linking roots and ectomycorrhizas (EcM) to individual host trees in the field is required to test whether individual trees support different ectomycorrhizal communities. Here we describe a method that identifies the source of EcM roots by PCR of polymorphic pine nuclear microsatellite loci using fluorescently labelled primers and high-throughput fragment analysis. ITS-PCR can also be performed on the same EcM DNA extract for fungal identification. The method was tested on five neighbouring Scots pine (Pinus sylvestris var scotica) trees in native woodland. Successful host tree identification from DNA extracts of EcM root tips was achieved for 93% of all root fragments recovered from soil cores. It was estimated that each individual mature pine sampled was colonised by between 15 and 19 EcM fungi. The most abundant fungal species were found on all five trees, and within the constraints of the sampling scheme, no differences between trees in EcM fungal community structure or composition were detected.

Cemented fixation with PMMA or Bis-GMA resin hydroxyapatite cement: effect of implant surface roughness

Implant surface roughness is an important parameter governing the overall mechanical properties at the implant-cement interface. This study investigated the influence of surface roughness using polymethylmethcrylate (PMMA) and a Bisphenol-a-glycidylmethacyrlate resin-hydroxyapatite cement (CAP). Mechanical fixation at the implant-cement interface was evaluated in vitro using static shear and fatigue loading with cobalt chrome alloy (CoCr) dowels with different surface roughness preparations. Increasing surface roughness improved the mechanical properties at the implant-cement interface for both types of cement. CAP cement fixation was superior to PMMA under static and dynamic loading.

Fine-scale estimation of outcrossing in western redcedar with microsatellite assay of bulked DNA

Western redcedar (Thuja plicata, Cupressaceae) is a self-fertile conifer with a mixed mating system and significant variation for outcrossing among populations. In this paper, we conducted a fine-scale study of mating system variation to identify correlates of outcrossing in natural populations. We examined variation for outcrossing within and among individual trees, and describe a new method to estimate outcrossing using bulked DNA samples. Bulking (assaying DNA tissues from several individuals simultaneously) increases the experimental power without increasing the experimental effort. We sampled 80 trees from four natural populations in southwestern British Columbia. From each tree, we sampled from up to six crown positions (three heights and inner vs outer branches). From each position, two samples of three seedlings each were bulked before DNA extractions. Using four microsatellite loci, we obtained outcrossing rates for each tree and for each of the six crown positions. We found individual tree selfing rates to increase with tree height in all four populations, but selfing rates did not differ among crown positions. The higher selfing rate of larger trees is probably due to their greater proportional contribution to local pollen clouds. Individual tree outcrossing rates ranged from 22 to 100% and the population outcrossing rates from 66 to 78%. Missed alleles due to bulking and the estimation method used both cause a downward bias in outcrossing rates, so that these estimates are probably lower than the actual outcrossing rates. Nevertheless, the trends we observed are not affected by systematic biases of estimation.

Studies with cytotoxic agents suggest that apoptosis is not a major determinant of clonogenic death in neuroblastoma cells

We have previously reported the selection of a radioresistant human neuroblastoma cell line, Clone F, from IMR32 cells. We have shown that clonogenic radioresistance in these cells is accompanied by a reduced level of radiation-induced apoptosis [Cancer Res 55 (1995) 4915]. Here, we measured the response of these lines to several cytotoxic agents, in terms of clonogenicity and apoptosis. In the clonogenic assay, the radioresistant line was also resistant to cisplatin, melphalan and doxorubicin, but not to perillyl alcohol. However, all these agents produced less apoptosis in the Clone F cells, except cisplatin, which failed to induce any apoptosis in either cell line. Reduced apoptosis cannot be the cause of the Clone F cells' resistance to cisplatin. By extension, the Clone F cells' resistance to radiation and other agents cannot be due to diminished apoptosis either. Based on these results, apoptosis may not be a useful surrogate for clonogenic outcome.

Education for health: case studies of two multidisciplinary MPH/MSc public health programmes in the UK

Amidst the winds of change that are blowing across the UK public health (PH) landscape in relation to the essential abilities and national standards that are required for the 'art and science' of PH, the preparation for a new cadre of 'PH professionals' is already underway. Several postgraduate masters programmes in public health (MPH) have taken on board the challenge of addressing the requisite sets of skills and expertise as a guide to their content and delivery. Although there are recommendations regarding teaching PH to undergraduate medical students, little consensus seems to exist on teaching postgraduate PH to non-medically qualified professionals, health managers and administrators. Employing a case study approach, this article analyses the methods used, philosophies and processes, structure and organization, outcomes to date, and lessons learnt from MPH programmes implemented at two institutions in the UK. The programmes have been initiated recently, and have had the opportunity to take on board the recent national guidelines about training standards. The findings indicate that preparatory work of the programmes, and the challenges and strengths in meeting the recent policy developments in PH training are pertinent points. The MPH programmes highlight key issues in interprofessional education and its purpose, its process and its outcomes in relation to multidisciplinary specialist practice. These programmes provide a variety of models for others wishing to develop or restructure their postgraduate PH teaching programmes. The finalization of the national standards for specialist practice in PH in the UK is encouraged, along with clearer working definitions of the domains of expertise required. Collectively, attention to these measures can ensure that the processes which teaching programmes embrace to refine their content and delivery will equip tomorrow's professionals with PH knowledge and skills.

Micrometastases in apheresis products predict shorter progression-free and overall survival in patients with breast cancer undergoing high-dose chemotherapy (HDCT) and autologous blood stem cell transplantation (ABSCT)

The presence of cancer cells in autografts of breast cancer patients has been described to have prognostic value or directly lead to relapse. Previously, we demonstrated that apheresis products (APs) collected after induction chemotherapy have a significantly lower likelihood of tumor cell contamination. Here, we examine the prognostic value of micrometastases in autografts. Data from 83 patients with breast cancer treated with autologous blood stem cell transplantation were analyzed. Pan-cytokeratin-FITC conjugated antibodies were used to detect contaminating breast cancer cells in the APs. Progression and survival data analyzed on the basis of three or fewer cancer cells showed no significant differences in outcomes. Of the 83 patients, 11 had more than three cancer cells detectable in their APs. In total, 72 patients were shown to have less than three cells detectable. When patients with more than three cells were compared to patients with 0-3, we found statistically significant differences in progression-free survival. We also found a significant difference in overall survival (OS) between the two groups. No difference was observed in OS since the time of diagnosis. We conclude that patients with more than three contaminating cells in their APs have micrometastases and represent a poor prognosis group.

Diagnosis and management of type 1 laryngeal cleft

Posterior laryngeal clefts have been reported as exceptionally rare congenital anomalies. We demonstrate that type 1 posterior laryngeal clefts are more common than previously described, by reporting a series of 12 type 1 posterior laryngeal clefts diagnosed at our institution over a 12-month period. Typically, type 1 posterior laryngeal clefts are managed conservatively. In our series, 75% of the clefts were treated successfully with endoscopic repair, following failure of conservative management. This suggests surgical repair may be warranted in a greater number of type 1 posterior laryngeal clefts in an attempt to prevent associated morbidity, secondary to aspiration, pneumonia and respiratory distress. We highlight the importance of educating other paediatric specialities in maintaining a high index of suspicion for the presence of a posterior laryngeal cleft when treating patients with suggestive symptoms. This leads to early referral and diagnosis.