A systems science perspective on the capacity for change in public hospitals

Many types of organisation are difficult to change, mainly due to structural, cultural and contextual barriers. Change in public hospitals is arguably even more problematic than in other types of hospitals, due to features such as structural dysfunctionalities and bureaucracy stemming from being publicly-run institutions. The main goals of this commentary are to bring into focus and highlight the "3 + 3 Decision Framework" proposed by Edwards and Saltman. This aims to help guide policymakers and managers implementing productive change in public hospitals. However, while change from the top is popular, there are powerful front-line clinicians, especially doctors, who can act to counterbalance top-down efforts. Front-line clinicians have cultural characteristics and power that allows them to influence or reject managerial decisions. Clinicians in various lower-level roles can also influence other clinicians to resist or ignore management requirements. The context is further complicated by multi-stakeholder agendas, differing goals, and accumulated inertia. The special status of clinicians, along with other system features of public hospitals, should be factored into efforts to realise major system improvements and progressive change.

The fern cavitation catapult: mechanism and design principles

Leptosporangiate ferns have evolved an ingenious cavitation catapult to disperse their spores. The mechanism relies almost entirely on the annulus, a row of 12-25 cells, which successively: (i) stores energy by evaporation of the cells' content, (ii) triggers the catapult by internal cavitation, and (iii) controls the time scales of energy release to ensure efficient spore ejection. The confluence of these three biomechanical functions within the confines of a single structure suggests a level of sophistication that goes beyond most man-made devices where specific structures or parts rarely serve more than one function. Here, we study in detail the three phases of spore ejection in the sporangia of the fern Polypodium aureum. For each of these phases, we have written the governing equations and measured the key parameters. For the opening of the sporangium, we show that the structural design of the annulus is particularly well suited to inducing bending deformations in response to osmotic volume changes. Moreover, the measured parameters for the osmoelastic design lead to a near-optimal speed of spore ejection (approx. 10 m s(-1)). Our analysis of the trigger mechanism by cavitation points to a critical cavitation pressure of approximately -100 ± 14 bar, a value that matches the most negative pressures recorded in the xylem of plants. Finally, using high-speed imaging, we elucidated the physics leading to the sharp separation of time scales (30 versus 5000 µs) in the closing dynamics. Our results highlight the importance of the precise tuning of the parameters without which the function of the leptosporangium as a catapult would be severely compromised.

Vital signs monitoring and nurse-patient interaction: A qualitative observational study of hospital practice

BACKGROUND

High profile safety failures have demonstrated that recognising early warning signs of clinical and physiological deterioration can prevent or reduce harm resulting from serious adverse events. Early warning scoring systems are now routinely used in many places to detect and escalate deteriorating patients. Timely and accurate vital signs monitoring are critical for ensuring patient safety through providing data for early warning scoring systems, but little is known about current monitoring practices.

OBJECTIVE

To establish a profile of nurses' vital signs monitoring practices, related dialogue, and adherence to health service protocol in New South Wales, Australia.

METHODS

Direct observations of nurses' working practices were conducted in two wards. The observations focused on times of the day when vital signs were generally measured. Patient interactions were recorded if occurring any time during the observation periods. Participants (n=42) included nursing staff on one chronic disease medical and one acute surgical ward in a large urban teaching hospital in New South Wales.

RESULTS

We observed 441 patient interactions. Measurement of vital signs occurred in 52% of interactions. The minimum five vital signs measures required by New South Wales Health policy were taken in only 6-21% of instances of vital signs monitoring. Vital signs were documented immediately on 93% of vitals-taking occasions and documented according to the policy in the patient's chart on 89% of these occasions. Nurse-patient interactions were initiated for the purpose of taking vital signs in 49% of interactions, with nurse-patient discourse observed during 88% of all interactions. Nurse-patient dialogue led to additional care being provided to patients in 12% of interactions.

CONCLUSION

The selection of appropriate vital signs measured and responses to these appears to rely on nurses' clinical judgement or time availability rather than on policy-mandated frequency. The prevalence of incomplete sets of vital signs may limit identification of deteriorating patients. The findings from this study present an important baseline profile against which to evaluate the impact of introducing continuous monitoring approaches on current hospital practice.

The Impact of a Health IT Changeover on Medical Imaging Department Work Processes and Turnaround Times: A mixed method study

OBJECTIVES

To assess the impact of introducing a new Picture Archiving and Communication System (PACS) and Radiology Information System (RIS) on: (i) Medical Imaging work processes; and (ii) turnaround times (TATs) for x-ray and CT scan orders initiated in the Emergency Department (ED).

METHODS

We employed a mixed method study design comprising: (i) semi-structured interviews with Medical Imaging Department staff; and (ii) retrospectively extracted ED data before (March/April 2010) and after (March/April 2011 and 2012) the introduction of a new PACS/RIS. TATs were calculated as: processing TAT (median time from image ordering to examination) and reporting TAT (median time from examination to final report).

RESULTS

Reporting TAT for x-rays decreased significantly after introduction of the new PACS/RIS; from a median of 76 hours to 38 hours per order (p<.0001) for patients discharged from the ED, and from 84 hours to 35 hours (p<.0001) for patients admitted to hospital. Medical Imaging staff reported that the changeover to the new PACS/RIS led to gains in efficiency, particularly regarding the accessibility of images and patient-related information. Nevertheless, assimilation of the new PACS/RIS with existing Departmental work processes was considered inadequate and in some instances unsafe. Issues highlighted related to the synchronization of work tasks (e.g., porter arrangements) and the material set up of the work place (e.g., the number and location of computers).

CONCLUSIONS

The introduction of new health IT can be a "double-edged sword" providing improved efficiency but at the same time introducing potential hazards affecting the effectiveness of the Medical Imaging Department.

Design challenges for electronic medication administration record systems in residential aged care facilities: a formative evaluation

INTRODUCTION

Electronic medication administration record (eMAR) systems are promoted as a potential intervention to enhance medication safety in residential aged care facilities (RACFs). The purpose of this study was to conduct an in-practice evaluation of an eMAR being piloted in one Australian RACF before its roll out, and to provide recommendations for system improvements.

METHODS

A multidisciplinary team conducted direct observations of workflow (n=34 hours) in the RACF site and the community pharmacy. Semi-structured interviews (n=5) with RACF staff and the community pharmacist were conducted to investigate their views of the eMAR system. Data were analysed using a grounded theory approach to identify challenges associated with the design of the eMAR system.

RESULTS

The current eMAR system does not offer an end-to-end solution for medication management. Many steps, including prescribing by doctors and communication with the community pharmacist, are still performed manually using paper charts and fax machines. Five major challenges associated with the design of eMAR system were identified: limited interactivity; inadequate flexibility; problems related to information layout and semantics; the lack of relevant decision support; and system maintenance issues. We suggest recommendations to improve the design of the eMAR system and to optimize existing workflows.

DISCUSSION

Immediate value can be achieved by improving the system interactivity, reducing inconsistencies in data entry design and offering dedicated organisational support to minimise connectivity issues. Longer-term benefits can be achieved by adding decision support features and establishing system interoperability requirements with stakeholder groups (e.g. community pharmacies) prior to system roll out. In-practice evaluations of technologies like eMAR system have great value in identifying design weaknesses which inhibit optimal system use.

The role of the nitric oxide pathway in brain injury and its treatment--from bench to bedside

Nitric oxide (NO) is a key signalling molecule in the regulation of cerebral blood flow. This review summarises current evidence regarding the role of NO in the regulation of cerebral blood flow at rest, under physiological conditions, and after brain injury, focusing on subarachnoid haemorrhage, traumatic brain injury, and ischaemic stroke and following cardiac arrest. We also review the role of NO in the response to hypoxic insult in the developing brain. NO depletion in ischaemic brain tissue plays a pivotal role in the development of subsequent morbidity and mortality through microcirculatory disturbance and disordered blood flow regulation. NO derived from endothelial nitric oxide synthase (eNOS) appears to have neuroprotective properties. However NO derived from inducible nitric oxide synthase (iNOS) may have neurotoxic effects. Cerebral NO donor agents, for example sodium nitrite, appear to replicate the effects of eNOS derived NO, and therefore have neuroprotective properties. This is true in both the adult and immature brain. We conclude that these agents should be further investigated as targeted pharmacotherapy to protect against secondary brain injury.

Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm

Despite improvements in the clinical management of aneurysmal subarachnoid haemorrhage over the last decade, delayed cerebral ischaemia (DCI) remains the single most important cause of morbidity and mortality in those patients who survive the initial bleed. The pathological mechanisms underlying DCI are still unclear and the calcium channel blocker nimodipine remains the only therapeutic intervention proven to improve functional outcomes after SAH. The recent failure of the drug clazosentan to improve functional outcomes despite reducing vasoconstriction has moved the focus of research into DCI away from cerebral artery constriction towards a more multifactorial aetiology. Novel pathological mechanisms have been suggested, including damage to cerebral tissue in the first 72 h after aneurysm rupture ('early brain injury'), cortical spreading depression, and microthrombosis. A greater understanding of the significance of these pathophysiological mechanisms and potential genetic risk factors is required, if new approaches to the prophylaxis, diagnosis, and treatment of DCI are to be developed. Furthermore, objective and reliable biomarkers are needed for the diagnosis of DCI in poor grade SAH patients requiring sedation and to assess the efficacy of new therapeutic interventions. The purpose of this article is to appraise these recent advances in research into DCI, relate them to current clinical practice, and suggest potential novel avenues for future research.

The feasibility of Dementia Care Mapping (DCM) on a neurorehabilitation ward

Person-centred care (PCC) is recommended when working with patients with neurological difficulties. Despite this, to date there has been no appropriate methodology for assessing or developing PCC in neurorehabilitation settings. Dementia Care Mapping (DCM) is a well-established tool for assessing and developing PCC in dementia settings and the current study investigated the feasibility of applying DCM on an acute neurorehabilitation ward. DCM procedure and coding required minor adaptations for use in this setting and further recommended adaptations were subsequently identified. It was found that the DCM coding system was generally suitable and could identify strengths, weaknesses and areas for development in ward care. Q-methodology identified that staff views endorsed the feasibility of using DCM in neurorehabilitation, with staff reporting that they found DCM useful and relevant to their work. DCM could be further developed for this setting by amendments to the behaviour coding system, concept and coding of person-centred care, and a population-specific manual. DCM is a promising methodology to develop and promote PCC in neurorehabilitation.

The fern sporangium: a unique catapult

Various plants and fungi have evolved ingenious devices to disperse their spores. One such mechanism is the cavitation-triggered catapult of fern sporangia. The spherical sporangia enclosing the spores are equipped with a row of 12 to 13 specialized cells, the annulus. When dehydrating, these cells induce a dramatic change of curvature in the sporangium, which is released abruptly after the cavitation of the annulus cells. The entire ejection process is reminiscent of human-made catapults with one notable exception: The sporangia lack the crossbar that arrests the catapult arm in its returning motion. We show that much of the sophistication and efficiency of the ejection mechanism lies in the two very different time scales associated with the annulus closure.

Are specialist physicians missing out on the e-Health boat?

BACKGROUND

Nationally health systems are making increasing investments in the use of clinical information systems. Little is known about current computer use by specialist physicians, particularly outside the hospital setting.

AIMS

To identify the extent and reasons physician Fellows of the Royal Australasian College of Physicians (RACP) use computers in their work.

METHODS

A self-administered survey was emailed from the RACP to all practising physicians in 2007 that were living in Australia and New Zealand who had consented to email contact with the College.

RESULTS

The survey was sent to a total of 7445 eligible physicians, 2328 physicians responded (31.3% response rate), but only 1266 responses (21.0%) were able to be analysed. Most 97.5% had access to computers at work and 96.5% used home computers for work purposes. Physicians in public hospitals (72.6%) were more likely to use computers for work (65.6%) than those in private hospitals (12.6%) or consulting rooms (27.3%). Overall physicians working in public hospitals used a wider range of applications with 70.5% using their computers for searching the internet, 53.7% for receiving results and 52.7% used their computers to engage in specific educational activities. Physicians working from their consulting rooms (33.6%) were more likely to use electronic prescribing (11%) compared with physicians working in public hospitals (5.7%).

CONCLUSIONS

Fellows have not incorporated computers into their consulting rooms over which they have control. This is in contrast to general practitioners who have embraced computers after the provision of various incentives. The rate of use of computers by physicians for electronic prescribing in consulting rooms (11%) is very low in comparison with general practitioners (98%). One reason may be that physicians work in multiple locations whereas general practitioners are more likely to work from one location.

The rate of missed test results in an emergency department: an evaluation using an electronic test order and results viewing system

OBJECTIVES

1) To measure the incidence and impact of missed radiology and microbiology test results in an emergency department with an electronic test order and results viewing system, and 2) to assess the average times from test order to test availability.

METHODS

The study was conducted in the emergency department (ED) of a 370-bed metropolitan teaching hospital in Sydney, Australia. A computerised provider order entry (CPOE) system was used to order all diagnostic tests and view all test results. For microbiology and radiology tests electronic results were then printed for ED patients not admitted to the hospital to allow ED physicians to document follow-up. All radiology (n = 197) and microbiology (n = 66) tests ordered and results received for discharged ED patients were collected for a seven-day period. We measured the: 1) proportion of radiology and microbiology test results without follow-up for discharged patients; 2) impact of non follow-up on patient outcomes; 3) average time from radiological examination and microbiology specimen collection to reporting of results; and 4) average time from reporting of results to follow-up.

RESULTS

Two radiology (1.0%) and two microbiology reports (3.0%), all of which had negative findings, were never followed-up. Review of these patients' medical records indicated there was no impact on patient outcomes or management. The average time from radiological examination to reporting of a result was 1.5 days, and from microbiology specimen collection to reporting was 2.5 days. Eighty-nine percent of radiology and 68% of microbiology results were followed-up on the same day that they were available to physicians.

CONCLUSIONS

Our rates of missed test results are lower than those reported from studies where paper ordering and reporting systems were used. This suggests that the availability of CPOE systems may reduce the risk of these events. Electronic result delivery, with electronic endorsement to allow documentation of follow-up of test results, may provide additional efficiency benefits and further reduce the risk of test results which are not followed up.

The safety and quality of decision support systems

OBJECTIVES

The use of clinical decision support systems (CDSS) can improve the overall safety and quality of health care delivery, but may also introduce machine-related errors. Recent concerns about the potential for CDSS to harm patients have generated much debate, but there is little research available to identify the nature of such errors, or quantify their frequency or clinical impact.

METHODS

A review of recent literature into electronic prescribing systems, as well as related literature in decision support.

RESULTS

There seems to be some evidence for variation in the outcomes of using CDSS, most likely reflecting variations in clinical setting, culture, training and organizational process, independent of technical variables. There is also preliminary evidence that poorly implemented CDSS can lead to increased mortality in some settings. Studies in the US, UK and Australia have found commercial prescribing systems often fail to uniformly detect significant drug interactions, probably because of errors in their knowledge base. Electronic medication management systems may generate new types of error because of user-interface design, but also because of events in the workplace such as distraction affecting the actions of system users. Another potential source of CDSS influenced errors are automation biases, including errors of omission where individuals miss important data because the system does not prompt them to notice them, and errors of commission where individuals do what the decision aid tells to do, even when this contradicts their training and other available data. Errors of dismissal occur when relevant alerts are ignored. On-line decision support systems may also result in errors where clinicians come to an incorrect assessment of the evidence, possibly shaped in part by cognitive decision biases.

CONCLUSIONS

The effectiveness of decision support systems, like all other health IT, cannot be assessed purely by evaluating the usability and performance of the software, but is the outcome of a complex set of cognitive and socio-technical interactions. A deeper understanding of these issues can result in the design of systems which are not just intrinsically 'safe' but which also result in safe outcomes in the hands of busy or poorly resourced clinicians.

The status of structural genomics defined through the analysis of current targets and structures

Structural genomics--large-scale macromolecular 3-dimenional structure determination--is unique in that major participants report scientific progress on a weekly basis. The target database (TargetDB) maintained by the Protein Data Bank (http://targetdb.pdb.org) reports this progress through the status of each protein sequence (target) under consideration by the major structural genomics centers worldwide. Hence, TargetDB provides a unique opportunity to analyze the potential impact that this major initiative provides to scientists interested in the sequence-structure-function-disease paradigm. Here we report such an analysis with a focus on: (i) temporal characteristics--how is the project doing and what can we expect in the future? (ii) target characteristics--what are the predicted functions of the proteins targeted by structural genomics and how biased is the target set when compared to the PDB and to predictions across complete genomes? (iii) structures solved--what are the characteristics of structures solved thus far and what do they contribute? The analysis required a more extensive database of structure predictions using different methods integrated with data from other sources. This database, associated tools and related data sources are available from http://spam.sdsc.edu.

Effects of Buddleja globosa leaf and its constituents relevant to wound healing

An aqueous extract of Buddleja globosa leaves, used traditionally in Chile for wound healing, was tested for the ability to stimulate growth of fibroblasts in vitro and for antioxidant activity in the same fibroblast cell system challenged with hydrogen peroxide. Low concentrations of the extract gave an increase in fibroblast growth which was not statistically significant but cytotoxicity was observed at concentrations greater than 50 microg/ml. The extract showed strong antioxidant effect and fractionation led to the isolation of three flavonoids and two caffeic acid derivatives, each of which was shown to contribute to the antioxidant effect at concentrations below 10 microg/ml. These activities would accelerate the healing of wounds.

Miniature radio-frequency mobility analyzer as a gas chromatographic detector for oxygen-containing volatile organic compounds, pheromones and other insect attractants

A high electric field, radio-frequency ion mobility spectrometry (RF-IMS) analyzer was used as a small detector in gas chromatographic separations of mixtures of volatile organic compounds including alcohols, aldehydes, esters, ethers, pheromones, and other chemical attractants for insects. The detector was equipped with a 2 mCi 63Ni ion source and the drift region for ion characterization was 5 mm wide, 15 mm long and 0.5 mm high. The rate of scanning for the compensation voltages was 60 V s(-1) and permitted four to six scans to be obtained across a capillary chromatographic elution profile for each component. The RF-IMS scans were characteristic of a compound and provided a second dimension of chemical identity to chromatographic retention adding specificity in instances of co-elution. Limits of detection were 1.6-55 x 10(-11) g with an average detection limit for all chemicals of 9.4 x 10(-11) g. Response to mass was linear from 2-50 x 10(-10) g with an average sensitivity of 4 pA ng(-1). Separations of pheromones and chemical attractants for insects illustrated the distinct patterns obtained from gas chromatography with RF-IMS scans in real time and suggest an analytical utility of the RF-IMS as a small, advanced detector for on-site gas chromatographs.

A national comparison of health information management students' career expectations and anticipated involvement in professional activities

The aim of this paper is to present the results of a survey of Australian health information management students relating to their career aspirations and expectations and anticipated involvement in professional activities following graduation. To explain reasons for the differences in results between states and student years, interviews were conducted with academic staff and other health information management educators. Three hundred and sixty three students completed the questionnaire in 1996, which represented a response rate of 86%. It was found that the majority of students thought they had made the correct career choice and were confident they would find full-time employment within six months of graduation. A high percentage of students also indicated that they would undertake continuing education after graduation. There was less support for involvement in the activities of their professional association, particularly at a national level. Students in New South Wales and Queensland indicated that they would be significantly less likely to work in the field of health information management for the rest of their careers. They also reported they would be significantly less likely to conduct research in an area related to health information management. Victorian students were significantly more likely to present a paper at a conference than students from Queensland, New South Wales or Western Australia. Western Australian students were significantly more likely to report that they would undertake postgraduate studies compared to students from the other three states.

The PDB data uniformity project

The Protein Data Bank (PDB; http://www.rcsb.org/pdb/) is the single worldwide archive of structural data of biological macromolecules. This paper describes the data uniformity project that is underway to address the inconsistency in PDB data.

The Protein Data Bank and the challenge of structural genomics

The PDB has created systems for the processing, exchange, query, and distribution of data that will enable many aspects of high throughput structural genomics.

Upregulation of the Bcl-2 family of proteins in end stage heart failure

OBJECTIVES

To elucidate the pattern of expression of four members of the Bcl-2 family of proteins and to correlate this with terminal deoxynucleotidyl transferase [TdT]-mediated dUTP nick end labelling (TUNEL) and DNA fragmentation.

BACKGROUND

Apoptosis has been implicated as a possible mechanism in the development of heart failure. However, the mechanisms involved remain unclear.

METHODS

We have studied the expression of four members of the Bcl-2 family that are involved in the regulation of apoptosis and analyzed DNA fragmentation as a marker of apoptosis and as a biochemical criterion to distinguish between apoptosis and necrosis in dilated cardiomyopathy (DCM), ischemic heart disease (IHD) and normal donors.

RESULTS

Western blot analysis and immunocytochemistry of the proapoptotic and antiapoptotic Bcl-2 proteins demonstrated significantly higher levels of all these proteins in the diseased groups compared with normal donors. Additionally, Bax was significantly higher in the IHD group compared with DCM. Terminal deoxynucleotidyl transferase [TdT]-mediated dUTP nick end labelling analysis demonstrated a significantly higher percentage of TUNEL-positive cells in the diseased groups compared with the control. Genomic DNA extraction of ventricular myocardial tissue showed no demonstrable DNA laddering for any of the groups.

CONCLUSIONS

The significant increases in the levels of the proapoptotic proteins Bak and Bax and the higher percentage of TUNEL-positive cells in both diseased groups suggests the presence of ongoing apoptosis. However, increases in the antiapoptotic proteins, Bcl-2 and Bcl-xL, suggest a possible concomitant, compensatory antiapoptotic mechanism in patients with heart failure.

The Protein Data Bank

The Protein Data Bank (PDB; http://www.rcsb.org/pdb/ ) is the single worldwide archive of structural data of biological macromolecules. This paper describes the goals of the PDB, the systems in place for data deposition and access, how to obtain further information, and near-term plans for the future development of the resource.

The Protein Data Bank

The Protein Data Bank (PDB; http://www.rcsb.org/pdb/ ) is the single worldwide archive of structural data of biological macromolecules. This paper describes the goals of the PDB, the systems in place for data deposition and access, how to obtain further information, and near-term plans for the future development of the resource.

The quality of burns coding. Compliance with standards and the effects on clinical data

Coded burns cases in two NSW public acute care facilities were reviewed to determine 1. the degree of compliance with Australian Coding Standards (ACS) relating to burns separations 2. the relationship between coding errors and poor quality documentation and 3. the impact of coding errors on ANDRG allocation. Despite high compliance with specific aspects of the ACS, coding errors occurred in 89% of cases. The ANDRG changed in 9% of total cases as a result of recoding. While some cases changed to a higher weighted ANDRG, overall the hospitals would have lost $98,445 after recoding. Significant associations were found between coding errors and poor quality documentation. The results indicate that while the ACS are adhered to, a high degree of coding variation still exists. This is largely due to inadequacies in medical record documentation. Clinicians and coders need to work together to ensure that coding variation is kept to a minimum.

The Nucleic Acid Database: A resource for nucleic acid science

The Nucleic Acid Database (NDB) distributes information about nucleic acid-containing structures. Here the information content of the database as well as the query capabilities are described. A summary of how the technology developed by this project has been used to develop other macromolecular databases is given.

Why is it difficult for staff to discuss advance directives with chronic dialysis patients?

General experience and reported data show that a substantial number of patients, at least 10% in many surveys, eventually choose to withdraw from chronic dialysis. There are additional studies suggesting that discussing and completing advance directives (AD) can promote more acceptance and less acrimony for patients, families, and staff when patients die. Even so, surprisingly few AD are completed, and dialysis staff often shun discussion of AD with patients. Thus, in this study, a survey of approximately 400 dialysis staff from 12 representative Michigan dialysis facilities was undertaken both to determine the beliefs, attitudes, and life experiences that might influence such discussions, as well as to guide future strategies aimed at encouraging the discussion and meaningful execution of AD. More than 50% (210) of the distributed questionnaires were completed. Overall results show that respondents report having discussed AD with only 30% of patients on average and that as many as 40% of respondents report never having done so. Among the professional disciplines responding to this survey, social workers report the largest percentage of patients with whom they discussed AD (60%), physicians a smaller percentage (38%), licensed practical (30%) and registered (25%) nurses even fewer patients, and dialysis technicians (20%) and dietitians (4%) the least. Across all disciplines, staff reported discussing AD with a larger percentage of patients when staff had experienced significant losses within their own personal lives, discussed such issues with friends or family, or had prepared their own AD. In rating specific barriers that correlated strongly with reported discussion of AD, each professional discipline had characteristic responses reflecting the approach of the discipline to addressing AD. The survey results suggest that the interdisciplinary variations observed are attributable to: (1) important differences not only in training, but also in the customary roles taken by each discipline; (2) inherent cultural differences, suggested by the findings among nonwhite staff of a lower reported frequency of having discussed AD with patients and of more concern over the barriers to doing so; and (3) a lack of support from supervisory and physician staff within the dialysis team. In conclusion, this survey shows, not surprisingly, that personal experiences and intrinsic cultural differences influence the attitudes of dialysis staff toward discussing AD with patients. The results of this survey underscore important differences between individual professional disciplines that affect both the perceived barriers to, as well as the likelihood of, discussing AD with patients. It seems that emotional issues such as death and dying stress interdisciplinary team interaction and amplify discomfort. However, it may be possible to increase the level of comfort in talking to patients about AD for each professional discipline by addressing the findings from this study (role differences and barriers) through focused interventions and by facilitating mutual support among the distinct members of the dialysis staff.

Nucleic acid crystallography: a view from the nucleic acid database

What are the future directions of the field of nucleic acid crystallography? Although there have been many duplex structures determined, the sample is still relatively small. This is especially true if one wants to derive enough information about the relationships between sequence and structure. Indeed, there are data for all the possible 10 dimer steps, but for some steps it is very limited. If the structural code resides in trimers or tetrad steps then there is simply not enough data to do meaningful statistical analyses. So the first direction that needs to be explored is the determination of more structures with more varied sequences. The other noticeable thing about the data is the shortness of the strands. While it is probably true that attempts to crystallize very long sequences will not meet with success, the idea of crystallizing sequences engineered to fit together via sticky ends such as has been done for the CAP-DNA complex (Schultz et al., 1990) should give data about the behavior of much longer stretches of DNA. The question of the effects of environment on the structure of DNA continues to be a very important one to address since DNA is rarely alone. The preliminary data we have analysed from the current sample shows that the conformation of some steps are very sensitive to packing type. Numerous studies of the hydration around DNA shows that there is a real synergy between the hydration structure and the base conformation. More data will allow further quantitation of these observations. RNA structure is the next very exciting frontier. The emerging structures of duplexes with internal loops, the two hammerhead ribozyme structures and the group I intron ribozyme have given us a glimpse of the complexity and elegance of this class of molecules. With the technology now in place to allow the determination of the structures of these molecules, the expectation is that now we will see a large increase in the number of these structures in the NDB.

America's health care reforms

President Bill Clinton is currently proposing the most sweeping changes to American social policy since the New Deal by Roosevelt in the 1930s. Major concerns about escalating health care costs, a mushrooming health care bureaucracy and a growing proportion of the American population who can no longer afford adequate health care insurance coverage have motivated Clinton's plan for health care reform. Ideas about telemedicine, the electronic medical record and more comprehensive and advanced information systems are already being canvassed during the course of the debate. Australian clinicians and policy makers are following the American debate closely. So too, should health information managers. America watching should prove interesting, stimulating and professionally rewarding.

Gastric carcinoma in children

Primary gastric carcinoma accounts for only 0.05% of pediatric gastrointestinal malignancies. The pattern, presentation, and location of childhood gastric carcinoma are similar to those of adult gastric carcinoma. Diagnosis is based on a high index of suspicion in children who present with symptoms mimicking acid peptic disease. Delay in diagnosis is common and avoided by early upper gastrointestinal radiography and endoscopy with biopsy. Surgical therapy alone may prolong survival but thus far it has proven only palliative. The role of chemotherapy and radiation in gastric carcinoma is still not well defined, although some new studies in adults may support the use of etoposide, doxorubicin, and cisplatin as primary therapy or combined with surgery and radiation. Long-term survival in children is rare. We present the case of a 3-year survivor, free of disease, treated with resection and chemotherapy.