The Wolfson Prize: designing the hospital of the future

Background

The 2021 Wolfson Economics Prize asked how new hospitals should be designed to radically improve patient experiences, clinical outcomes, staff wellbeing and integration with wider health and social care. With a major programme to rebuild and renew hospitals in England underway, the Prize offered an opportunity to understand current thinking about hospitals and their future place.

Methods

The 41 submissions that were identified as 'most promising' were reviewed and subjected to framework analysis. Emerging themes were identified and discussed iteratively.

Results

Five dominant themes were identified: a calming environment; systems of care; distribution of services; use of technology; and going green. Several tensions and trade-offs were evident across the submissions and a number of gaps were identified in the knowledge base that need to be remedied to ensure that new hospitals are safe and efficient.

Conclusion

The previous approach to building new hospitals, with its over-riding drive to reduce costs, has not served the UK well. New ways of thinking about hospital building and design are urgently needed, especially the funding of research and the creation of a national repository devoted to design solutions and post-build evaluations of new hospitals.

Untangling the Lactifluus clarkeae - Lf. flocktoniae(Russulaceae) species complex in Australasia

The Lactifluus clarkeae complex is a commonly observed, generally brightly coloured, group of mushrooms that are usually associated with Nothofagus or Myrtaceous hosts in Australia and New Zealand. For this study collections labelled as 'Lactarius clarkeae', 'Russula flocktoniae' and 'Lactarius subclarkeae' were examined morphologically and molecularly. Analyses of molecular data showed a high cryptic diversity, with sequences scattered across 11 clades in three subgenera within Lactifluus, and a single collection in Russula. We select epitypes to anchor the currently accepted concepts of Lf. clarkeae s.str. and Lf. flocktoniae s.str. The name Lf. subclarkeae could not be applied to any of the collections examined, as none had a lamprotrichoderm pileipellis. Lactifluus clarkeae var. aurantioruber is raised to species level, and six new species are described, three in subg. Lactifluus: Lf. jetiae, Lf. pagodicystidiatus, and Lf. rugulostipitatus, and three in subg. Gymnocarpi: Lf. albens, Lf. psammophilus, and Lf. pseudoflocktoniae. A new collection of Lf. russulisporus provides a significant range extension for the species. Untangling this complex will enable better identification of species and increase understanding of diversity and specific habitat associations of macrofungi. Citation: Lebel T, Douch J, Tegart L, et al. 2021. Untangling the Lactifluus clarkeae - Lf. flocktoniae (Russulaceae) species complex in Australasia. Persoonia 47: 1-44. https://doi.org/10.3767/persoonia.2021.47.01.

Untangling the Lactifluus clarkeae - Lf. flocktoniae(Russulaceae) species complex in Australasia

The Lactifluus clarkeae complex is a commonly observed, generally brightly coloured, group of mushrooms that are usually associated with Nothofagus or Myrtaceous hosts in Australia and New Zealand. For this study collections labelled as 'Lactarius clarkeae', 'Russula flocktoniae' and 'Lactarius subclarkeae' were examined morphologically and molecularly. Analyses of molecular data showed a high cryptic diversity, with sequences scattered across 11 clades in three subgenera within Lactifluus, and a single collection in Russula. We select epitypes to anchor the currently accepted concepts of Lf. clarkeae s.str. and Lf. flocktoniae s.str. The name Lf. subclarkeae could not be applied to any of the collections examined, as none had a lamprotrichoderm pileipellis. Lactifluus clarkeae var. aurantioruber is raised to species level, and six new species are described, three in subg. Lactifluus: Lf. jetiae, Lf. pagodicystidiatus, and Lf. rugulostipitatus, and three in subg. Gymnocarpi: Lf. albens, Lf. psammophilus, and Lf. pseudoflocktoniae. A new collection of Lf. russulisporus provides a significant range extension for the species. Untangling this complex will enable better identification of species and increase understanding of diversity and specific habitat associations of macrofungi. Citation: Lebel T, Douch J, Tegart L, et al. 2021. Untangling the Lactifluus clarkeae - Lf. flocktoniae (Russulaceae) species complex in Australasia. Persoonia 47: 1-44. https://doi.org/10.3767/persoonia.2021.47.01.

Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study

Background

The increasing number of older, complex patients who require emergency admission to hospital has prompted calls for better models of medical generalist care, especially for smaller hospitals, whose size constrains resources and staffing.

Objective

To investigate the strengths and weaknesses of the current models of medical generalism used in smaller hospitals from patient, professional and service perspectives.

Methods

The design was a mixed-methods study. Phase 1 was a scoping and mapping exercise to create a typology of models of care, which was then explored further through 11 case studies. Phase 2 created a classification using the Hospital Episode Statistics of acute medical ‘generalist’ and ‘specialist’ work and described differences in workload and explored the links between case mix, typology and length of stay and between case mix and skill mix. Phase 3 analysed the relationships between models of care and patient-level costs. Phase 4 examined the strengths and weaknesses of the models of care through focus groups, a discrete choice experiment and an exploration of the impact of typology on other outcomes.

Results

In total, 50 models of care were explored through 48 interviews. A typology was constructed around generalist versus specialist patterns of consultant working. Twenty-five models were deployed by 48 hospitals, and no more than four hospitals used any one model of care. From the patient perspective, analysis of Hospital Episode Statistics data of 1.9 million care episodes found that the differences in case mix between hospitals were relatively small, with 65–70% of episodes accounted for by 20 case types. The skill mix of hospital staff varied widely; there were no relationships with case mix. Patients exhibited a preference for specialist care in the discrete choice experiment but indicated in focus groups that overall hospital quality was more important. From a service perspective, qualitative work found that models of care were contingent on complex constellations of factors, including staffing, the local hospital environment and policy imperatives. Neither the model of care nor the case mix accounted for variability in the length of stay (no associations were significant at p < 0.05). No significant differences were found in the costs of the models. Professionally, the preferences of doctors for specialist versus generalist work depended on their experiences of providing care and were associated with a healthy organisational culture and a co-operative approach to managing emergency work. Concepts of medical generalism were found to be complex and difficult to define, with theoretical models differing markedly from models in action.

Limitations

Smaller hospitals in multisite trusts were excluded, potentially leading to sample bias. The rapidly changing nature of the models limited the analysis of typology against outcomes.

Conclusions

The case mix of smaller hospitals was dominated by patients with presentations amenable to generalist approaches to care; however, there was no evidence to support any particular pattern of consultant working. Matching hospital staff to better meet local need and the creation of more collaborative working environments appear more likely to improve care in smaller hospitals than changing models.

Future work

The exploration of the relationships between workforce, measures of hospital culture, models of care, costs and outcomes in both smaller and larger hospitals is urgently required to underpin service reforms.

Study registration

This study is registered as Integrated Research Application System project ID 191393.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 4. See the NIHR Journals Library website for further project information.

The problems of smaller, rural and remote hospitals: Separating facts from fiction

Smaller hospitals internationally are under threat. The narratives around the closure of smaller hospitals, regardless of size and location, are all constructed around three common problems - cost, quality and workforce. The literature is reviewed, demonstrating that there is little hard evidence to support the contention that hospital merger/closure solves these problems. The disbenefits of mergers and closures, including loss of resources, increased pressure on neighbouring organisations, shifting risk from the healthcare system to patients and their families, and the threat hospital closure represents to communities, are explored. Alternative structures, policies and funding mechanisms, based on the evidence, are urgently needed to support smaller hospitals in the UK and elsewhere.

A multistage mixed methods study protocol to evaluate the implementation and impact of a reconfiguration of acute medicine in Ireland's hospitals

BACKGROUND

To address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation.

METHODS

We will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme's outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme's implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme's outcomes can be explained by the level of implementation.

DISCUSSION

This formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.

Antibiotic Review Kit for Hospitals (ARK-Hospital): study protocol for a stepped-wedge cluster-randomised controlled trial

BACKGROUND

To ensure patients continue to get early access to antibiotics at admission, while also safely reducing antibiotic use in hospitals, one needs to target the continued need for antibiotics as more diagnostic information becomes available. UK Department of Health guidance promotes an initiative called 'Start Smart then Focus': early effective antibiotics followed by active 'review and revision' 24-72 h later. However in 2017, < 10% of antibiotic prescriptions were discontinued at review, despite studies suggesting that 20-30% of prescriptions could be stopped safely.

METHODS/DESIGN

Antibiotic Review Kit for Hospitals (ARK-Hospital) is a complex 'review and revise' behavioural intervention targeting healthcare professionals involved in antibiotic prescribing or administration in inpatients admitted to acute/general medicine (the largest consumers of non-prophylactic antibiotics in hospitals). The primary study objective is to evaluate whether ARK-Hospital can safely reduce the total antibiotic burden in acute/general medical inpatients by at least 15%. The primary hypotheses are therefore that the introduction of the behavioural intervention will be non-inferior in terms of 30-day mortality post-admission (relative margin 5%) for an acute/general medical inpatient, and superior in terms of defined daily doses of antibiotics per acute/general medical admission (co-primary outcomes). The unit of observation is a hospital organisation, a single hospital or group of hospitals organised with one executive board and governance framework (National Health Service trusts in England; health boards in Northern Ireland, Wales and Scotland). The study comprises a feasibility study in one organisation (phase I), an internal pilot trial in three organisations (phase II) and a cluster (organisation)-randomised stepped-wedge trial (phase III) targeting a minimum of 36 organisations in total. Randomisation will occur over 18 months from November 2017 with a further 12 months follow-up to assess sustainability. The behavioural intervention will be delivered to healthcare professionals involved in antibiotic prescribing or administration in adult inpatients admitted to acute/general medicine. Outcomes will be assessed in adult inpatients admitted to acute/general medicine, collected through routine electronic health records in all patients.

DISCUSSION

ARK-Hospital aims to provide a feasible, sustainable and generalisable mechanism for increasing antibiotic stopping in patients who no longer need to receive them at 'review and revise'.

TRIAL REGISTRATION

ISRCTN Current Controlled Trials, ISRCTN12674243 . Registered on 10 April 2017.

The value of the physical examination in clinical practice: an international survey

A structured online survey was used to establish the views of 2,684 practising clinicians of all ages in multiple countries about the value of the physical examination in the contemporary practice of internal medicine. 70% felt that physical examination was 'almost always valuable' in acute general medical referrals. 66% of trainees felt that they were never observed by a consultant when undertaking physical examination and 31% that consultants never demonstrated their use of the physical examination to them. Auscultation for pulmonary wheezes and crackles were the two signs most likely to be rated as frequently used and useful, with the character of the jugular venous waveform most likely to be rated as -infrequently used and not useful. Physicians in contemporary hospital general medical practice continue to value the contribution of the physical examination to assessment of outpatients and inpatients, but, in the opinion of trainees, teaching and demonstration could be improved.

Investigations into the temporal development of epitheliocystis infections in brown trout: a histological study

Epitheliocystis in Swiss brown trout (Salmo trutta) is a chlamydial infection, mainly caused by Candidatus Piscichlamydia salmonis and Candidatus Clavichlamydia salmonicola. To gain a better understanding of the temporal development of infections in wild brown trout, we investigated epitheliocystis infections during the course of the summer and autumn months of a single year (2015), and compared this to sampling points over the span of the years 2012-2014. The survey focused on tributaries (Venoge and Boiron) of the Rhone flowing in to Lake Geneva. When evaluated histologically, epitheliocystis infections were found throughout the period of investigation with the exception of the month of June. Fifty to 86 animals per sampling were investigated. Highest prevalence and infection intensities were seen in September. A correlation between epitheliocystis infection and water temperatures was not evident. Interyear comparison revealed consistent levels of prevalence and infection intensities in late summer. The absence of infections in June, combined with the consistent interyear results, indicates seasonal fluctuation of epitheliocystis infections in brown trout with a reservoir persisting during winter months from which infections can re-initiate each year. This could either be at levels below detection limits within the brown trout population itself or in an alternative host.

Physician consensus on preventability and predictability of readmissions based on standard case scenarios

BACKGROUND

Policy makers struggle with unplanned readmissions as a quality indicator since integrating preventability in such indicators is difficult. Most studies on the preventability of readmissions questioned physicians whether they consider a given readmission to be preventable, from which conclusions on factors predicting preventable readmissions were derived. There is no literature on the interobserver agreement of physician judgement.

AIM

To assess the degree of agreement among physicians regarding predictability and preventability of medical readmissions.

DESIGN

An online survey based on eight real-life case scenarios was distributed to European physicians.

METHODS

Physicians were requested to rate from the first four (index admission) scenarios whether they expected these patients to be readmitted within 30 days (the predictability). The remaining four cases, describing a readmission, were used to assess the preventability. The main outcome was the degree of agreement among physicians determined using the intra class correlation coefficient (ICC).

RESULTS

526 European medical physicians completed the survey. Most physicians had internal medicine as primary specialism. The median years of clinical experience was 11. ICC for predictability of readmission was 0.67 (moderate to good) and ICC for preventability of readmission was 0.13 (poor).

CONCLUSION

There was moderate to good agreement among physicians on the predictability of readmissions while agreement on preventability was poor. This study indicates that assessing preventability of readmissions based solely on the judgement of physicians is far from perfect. Current literature on the preventability of readmissions and conclusions derived on the basis of physician opinion should be interpreted with caution.

Detection of Mycobacteria and Chlamydiae in Granulomatous Inflammation of Reptiles: A Retrospective Study

A retrospective study on reptile tissues presenting with granulomatous inflammation was performed to detect the possible presence of mycobacteria and chlamydiae in these lesions. Ninety cases including 48 snakes, 27 chelonians, and 15 lizards were selected. Mycobacteria were detected by Ziehl-Neelsen (ZN) staining and a broad-range polymerase chain reaction (PCR) followed by DNA sequencing. To detect chlamydiae, immunohistochemistry with monoclonal antibodies against chlamydial lipopolysaccharide (LPS) and a Chlamydiales order-specific PCR and sequencing were applied. Acid-fast bacilli were found in 14 cases (15.6%) by ZN staining and in 23 cases (25.6%) by PCR. Sequence analysis revealed the presence of Mycobacteria other than Mycobacterium tuberculosis complex (MOTT). Chlamydial LPS antigen was observed within granulomas from five samples (5.6%), whereas the PCR screen revealed 58 positive cases (64.4%). Of these, 9 cases (10%) showed 98–99% similarity to Chlamydophila ( Cp.) pneumoniae and 49 cases (54.4%) displayed a high similarity (88–97%) to the newly described “Chlamydia-like” microorganisms Parachlamydia acanthamoebae and Simkania negevensis. Results from this study confirm, on the one hand, that MOTT are probably the most important infectious etiology for granulomatous inflammation in reptiles. On the other hand, they indicate that chlamydia infects reptiles and that Cp. pneumoniae should be considered an etiological agent of granulomatous lesions of reptiles. Because both MOTT and Cp. pneumoniae are human pathogens, the potential of zoonotic transmission from reptiles to humans has to be considered. In contrast, the significance of Chlamydia-like isolates remains completely open, and further studies are needed to evaluate their role.

Chlamydia-related abortions in Cattle from Graubunden, Switzerland

In 2001, the first case of bovine chlamydial abortion was reported in canton Graubunden, Switzerland. In this region, Chlamydophila (Cp.) abortus is endemic in small ruminants. Hence, we aimed to investigate the incidence of chlamydia-related abortions in cattle from Graubunden. During breeding seasons of 2003-2004, formalin-fixed and paraffin-embedded placenta specimens ( n = 235) from late-term abortions in cattle were analyzed by histopathology, immunohistochemistry with a Chlamydiaceae-specific monoclonal antibody against chlamydial lipopolysaccharide (LPS), and 2 different polymerase chain reaction (PCR) methods (16 S ribosomal ribonucleic acid [rRNA] PCR, intergenic spacer [IGS-S] PCR), followed by PCR product sequencing. In 149 of 235 cases (63.4%), histopathologic lesions such as purulent and/or necrotizing placentitis were observed. Chlamydial antigen was clearly demonstrated in immunohistochemistry in only 1 of 235 cases (0.4%). Cp. abortus or Cp. psittaci was found in 12 of 235 (5.1%) and 10 of 235 cases (4.2%) by 16 S rRNA PCR and IGS-S PCR, respectively. However, we detected, by 16 S rRNA PCR, 43 of 235 cases (18.3%) to be positive for chlamydia-like organisms. In contrast to the situation in small ruminants in the canton Graubunden, bovine abortion from Cp. abortus seems not to play an important role. Nevertheless, zoonotic potential should be taken into account when handling abortion material from cattle. The significance of chlamydia-like isolates other than Waddlia chondrophila remains an open question in abortion and needs further investigation.

Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital

OBJECTIVES

Reliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge.

SETTING

An acute 400-bedded teaching hospital in London, UK.

PARTICIPANTS

The effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18 months.

INTERVENTIONS

Quality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives.

RESULTS

Statistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients' discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems.

CONCLUSIONS

New processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers.

The Challenges of Conducting Research on the Acute Medical Unit

Conducting research on the Acute Medical Unit (AMU) poses unique challenges; the environment is one that sees a diverse range of patient groups and pathologies and holds the potential for easy patient recruitment to research studies, however is geared towards a specific set of triage and discharge goals. We conducted a study into Stress Hyperglycaemia (SH) on a busy AMU, which involved profiling glycaemic changes using specialist equipment and interventions in patients with unscheduled medical admissions, and experienced a number of challenges. This article discusses these challenges and proposes potential solutions. Conducting research on a busy AMU was complicated by factors including rapid patient and staff turnover, the differing goals of the AMU system and suboptimal staff engagement in labour intensive research. We endeavored to follow patients up in further visits after discharge but found they lacked engagement after the resolution of the acute illness requiring initial admission. In this article, we discuss these issues in more detail and suggest approaches for future AMU researchers.

Improving acute care for adolescents and young adults on medical admission units: The interventions that matter

It had become a familiar routine. My seventh admission with diabetic ketoacidosis (DKA) in a year. Each time I was admitted it was the same; a DKA protocol, a diabetes specialist nurse visit, and a few questions from the doctors checking if "everything is okay?" On each admission, I would be discharged home after a couple of days. We all knew I'd be back again within a month or two.

Clinical Research Abstracts of the British Equine Veterinary Association Congress 2015

REASONS FOR PERFORMING STUDY

Injury to the superficial digital flexor tendon (SDFT) is common in equids, with a high risk of re-injury associated with changes in tendon stiffness. In vivo measurement of limb stiffness has been shown to correlate with tendon stiffness after injury [1] but requires kinematic analysis which is impractical in a clinical setting. We have developed a simple system for measuring limb stiffness statically, which could be used as a tool for monitoring SDFT healing.

OBJECTIVES

To validate a goniometric measurement of limb stiffness.

STUDY DESIGN

Cross sectional study.

METHODS

Initially, forelimb stiffness indices were determined at the walk for 6 equids using a validated kinematic analysis [1]. Limb stiffness indices were then calculated using portable floor scales to record ground reaction force (GRF), and an electrogoniometer to record metacarpophalangeal joint angle. Goniometric limb stiffness indices were subsequently measured in 11 horses ranging from 2 to 20 years of age, with no clinical evidence of SDFT injury. Strength and significance of correlation and agreement between the measurement methods was assessed and association between limb stiffness, limb (left vs. right), weight and age of horse and were calculated.

RESULTS

There were strong positive correlations between GRF and joint angle (R(2) = 0.98) and between the static and kinematic methods (R = 0.78, P<0.01). There was a positive correlation between limb stiffness and weight (R(2) = 0.85, P<0.01), but no association with age or limb.

CONCLUSIONS

This study validated the measurement of limb stiffness in a clinical setting. The positive correlation of limb stiffness and weight supports the theory of an optimised limb spring [2] for energy-efficient cursorial locomotion which may, in turn, provide a clinically-relevant measure of running efficiency and therefore the quality of tendon healing post injury. Ethical animal research: Owner consent was obtained.

SOURCE OF FUNDING

None. Competing interests: None declared.

Overcrowding in emergency department: an international issue

Overcrowding in the emergency department (ED) has become an increasingly significant worldwide public health problem in the last decade. It is a consequence of simultaneous increasing demand for health care and a deficit in available hospital beds and ED beds, as for example it occurs in mass casualty incidents, but also in other conditions causing a shortage of hospital beds. In Italy in the last 12-15 years, there has been a huge increase in the activity of the ED, and several possible interventions, with specific organizational procedures, have been proposed. In 2004 in the United Kingdom, the rule that 98 % of ED patients should be seen and then admitted or discharged within 4 h of presentation to the ED ('4 h rule') was introduced, and it has been shown to be very effective in decreasing ED crowding, and has led to the development of further acute care clinical indicators. This manuscript represents a synopsis of the lectures on overcrowding problems in the ED of the Third Italian GREAT Network Congress, held in Rome, 15-19 October 2012, and hopefully, they may provide valuable contributions in the understanding of ED crowding solutions.

Adolescents and young adults on the acute medical unit: how might we do it better?

It is a common perception that young people do not become ill and do not pose a challenge in the unscheduled healthcare setting. The research, however, increasingly suggests that young adults and adolescents (YAAs) are a highly vulnerable group, with poorer outcomes than either older adults or children, and distinct healthcare needs. The acute medical unit (AMU) setting poses particular challenges to the care of this patient group. To improve care and patient experience, adult clinicians need to look critically at their services and seek to adapt them to meet the needs of YAAs. This requires cooperation and linkage with local paediatric and emergency services, as well as the input of other relevant stakeholder groups. Staff on AMUs also need to develop the knowledge, skills and attitudes to communicate effectively and address the developmental and health needs of YAAs and their parents/carers at times of high risk and stress.

Safety in numbers: lack of evidence to indicate the number of physicians needed to provide safe acute medical care

Patient safety in hospital is dependent on a multitude of factors. Recent reports into the failings of healthcare organisations in the UK have highlighted low staffing levels as a significant factor. There is research into the impact of nurse-to-patient ratios on patient safety, but our literature search found little published data that would allow healthcare providers to define a minimum number of physician staff and skills mix that would assure safety in the largest hospital specialty: unscheduled (acute) medicine. Future work should focus on the evaluation of existing data on hospital mortality rates and physician staffing levels as well as on empirical time and motion studies to ascertain the resources required to undertake safe medical care at times of peak demand.

Immunohistochemical Expression Study of Proapoptotic BH3-Only Protein Bad in Canine Nonneoplastic Tissues and Canine Lymphomas

The BH3-only protein Bad is a proapoptotic Bcl-2 family member that acts as a sensitizer in intrinsic apoptosis by inactivating antiapoptotic members through heterodimer formation. Bad has been shown to contribute to tumorigenesis, including lymphoma formation in humans and mice, through alteration in expression or functional status. Here, its immunohistochemical expression was analyzed in canine nonneoplastic and lymphoma tissues using tissue microarrays. Bad was expressed in the cytoplasm of a wide range of nonneoplastic tissues, especially epithelial cells. Nonneoplastic lymph nodes displayed weak immunostaining in the follicular germinal centers only. Immunoblotting supported these observations but also revealed presence of nonspecific labeling in some organs. Of 81 lymphomas, 29 (35.8%) displayed moderate to strong immunohistochemical Bad labeling, and a significant expression increase was found in lymphomas (especially B cell and double negative) compared to nonneoplastic lymph nodes. These findings warrant further investigations of the functional status, the involvement of partner proteins, and a possible impact of Bad on prognosis in canine lymphoma.

'August is always a nightmare': results of the Royal College of Physicians of Edinburgh and Society of Acute Medicine August transition survey

An electronic survey was used to assess perceptions of the disruption caused by the August transition and explore support for possible solutions. In total, 763 responses from members and fellows of the Royal College of Physicians of Edinburgh and the Society of Acute Medicine were received. The majority perceived the August transition to have a negative impact on patient care (93.1%), patient safety (90.4%) and training (57.8%) for a period of up to one month. In total 680/737 respondents wished to shift away from a single changeover day, with strong support for a staggered changeover by grade. Changes to consultant working practices were felt to be beneficial, especially the cancellation of outpatient clinics (75%) and the restriction of leave (69.9%). Further use of shadowing (74.1%) and online induction (37%) was supported. This paper concludes that there is a high degree of support for structured change to the current provisions for junior doctor changeover.

Phone calls to a hospital medicines information helpline: analysis of queries from members of the public and assessment of potential for harm from their medicines

OBJECTIVE

To find out what questions the public ask of pharmacists on a hospital medicines information helpline, and to assess the potential for improving individuals' management of medicines through telephone helpline support.

METHODS

We analysed consecutive phone calls made by members of the public over 6 months to a hospital pharmacy medicines information helpline. Calls were coded for type of medicine, reason for phoning and any error revealed in the call. We also looked at which medicines were associated with harm and/or potential for harm had the caller not enquired about appropriate action to take.

KEY FINDINGS

Five hundred of the 923 consecutive calls to the helpline were from members of the public (including discharged hospital patients). Antimicrobial agents, analgesics and cardiovascular medicines accounted for approximately half of all calls. The reason for phoning was most often to ask about interactions (22%), directions for use (21%) or advice on adverse effects (15%). In a third of calls it is possible an error had occurred (including patient error and directions missing from a dispensed item). Forty-eight per cent of calls were concerned with harm or judged to have potential for harm had professional information not been available. Four of these cases (0.8%), one of which was patient error and three of which were adverse effects reported by the caller, were categorised as Harm Index category F, defined as requiring intervention and referral.

CONCLUSIONS

Our medicines information helpline appears to be a valuable resource for discharged patients and public and the advice given may be expected to improve safety with medicines and reduce harm. Our results reveal gaps in patient education about their medicines, some of which could be addressed by dispensing staff or the pharmacist at discharge. The data provide a baseline for measuring improvements in medicines management and will be useful in identifying patients who may benefit from follow-up call support from pharmacists.

Novel Chlamydiales associated with epitheliocystis in a leopard shark Triakis semifasciata

The Chlamydiales is a diverse order of obligate intracellular gram-negative bacteria that are known to cause a wide range of diseases in terrestrial animals, including humans. Molecular analyses have revealed that these organisms are also associated with epitheliocystis in teleost fish species, highlighting the suspected deep evolutionary origin of members of this bacterial order. However, our knowledge of their fish host range and of the diversity of the bacteria themselves is still very limited. In this study, we provide molecular evidence for a novel member of the Order Chlamydiales in a nonteleost species, the leopard shark Triakis semifasciata. Based on phylogenetic analysis of the 16S rRNA gene, this novel organism appears to represent a unique lineage in the Order Chlamydiales despite appearing histologically similar to epitheliocystis-causing organisms in other fish species. A greater understanding of the genetic diversity of marine Chlamydiales will assist our attempts to manage and control epitheliocystis outbreaks and to understand the evolution of this unique obligate intracellular pathogen.

Molecular evidence for chlamydial infections in the eyes of sheep

Ocular infections by chlamydiae are associated with ocular disease manifestations such as conjunctivitis and keratitis in humans and animals. Limited evidence exists that members of the order Chlamydiales can also cause ocular disease in sheep. In the current study, the prevalence of chlamydiae in the eyes of sheep was investigated by using PCR methods. Data obtained in sheep by broad-range 16S rRNA order Chlamydiales-specific PCR were compared to the prevalence of antibodies against chlamydiae detected by a competitive enzyme-linked immunosorbent assay (cELISA). Flocks tested included a clinically healthy flock and two flocks suffering from ocular disease and with histories of Ovine Enzootic Abortion (OEA). PCR detected DNA of Chlamydophila (Cp.) abortus and Cp. pecorum in the eyes of both healthy and sick animals but also identified Chlamydia (C.) suis and a variety of uncultured chlamydia-like organisms. Good correlation was found between the presence of Cp. abortus DNA in sheep conjunctival samples and seropositivity detected by cELISA. Despite these findings, no association was found between the presence of chlamydial DNA in the sheep conjunctival samples and the onset of clinical disease. These results suggest that the biodiversity of chlamydiae in the eyes of sheep is greater than that previously thought. Further investigations are needed to determine whether a causal relationship between infection by chlamydiae and ocular disease exists in these animals.

Breeding soundness evaluation of bulls by semen analysis, testicular fine needle aspiration cytology and trans-scrotal ultrasonography

The aim of this study was to evaluate the usefulness of trans-scrotal ultrasonography and testicular fine needle aspiration cytology in assessing bulls for breeding suitability. These two techniques were also compared with semen analysis. Bulls presented for breeding soundness evaluation were assessed using all three techniques. The findings of each technique were compared. There was agreement in classification of fertile bulls using all three techniques, suggesting that the combined use of these techniques enhances routine breeding soundness examination. Use of the three techniques also enhances detailed investigation of suspected sub-fertile bulls while accurately identifying testicular cause(s) of sire sub-fertility.

Intensively kept pigs pre-disposed to chlamydial associated conjunctivitis

In the present study, ocular chlamydial infections in pigs that originate from two different farming systems were investigated. In particular, the aim was to test pigs with and without clinical ocular symptoms for the presence of Chlamydiaceae and for linked infections with Acanthamoebae spp. possibly acting as vectors for Chlamydia or Chlamydia-like organisms. In a total of 181 pigs, 102 from Germany (GER), representing the intensively kept animals and 79 from Switzerland (CH), which were kept extensively, were screened for the presence of different pathogens by PCR, including a new Chlamydiaceae-specific intergenic spacer rRNA gene PCR. Additionally, results of clinical examination and cytology were compared between the symptomatic and asymptomatic pigs of the two groups. Ocular symptomatic pigs showed a high prevalence of Chlamydia suis in both groups: CH 79%, GER 90%. Only 23% asymptomatic pigs from CH, but 88% asymptomatic pigs from GER were positive for C. suis by PCR. DNA of Chlamydia-like organisms were detected in 19% CH, but only in 2% GER pigs, whereas only 4% CH and 1% GER pigs were also positive for Acanthamoebae spp. A co-infection of Acanthamoebae spp. and C. suis was present in only 3% of the CH but 28% of the GER pigs. In general, the intensively kept pigs in our study seemed to be pre-disposed to ocular chlamydial infection and associated conjunctivitis. Infections with Chlamydia-like organisms alone and in combination with Acanthamoebae played no role for clinical findings within the tested pig groups, whereas a co-infection of Acanthamoebae and C. suis was able to cause serious ocular manifestations in half of the cases of intensively kept pigs being positive for these microorganisms.

CD8+ T cell-mediated control of distant tumours following local photodynamic therapy is independent of CD4+ T cells and dependent on natural killer cells

Cancer survival rates decrease in the presence of disseminated disease. However, there are few therapies that are effective at eliminating the primary tumour while providing control of distant stage disease. Photodynamic therapy (PDT) is an FDA-approved modality that rapidly eliminates local tumours, resulting in cure of early disease and palliation of advanced disease. Numerous pre-clinical studies have shown that local PDT treatment of tumours enhances anti-tumour immunity. We hypothesised that enhancement of a systemic anti-tumour immune response might control the growth of tumours present outside the treatment field. To test this hypothesis we delivered PDT to subcutaneous (s.c.) tumours of mice bearing both s.c. and lung tumours and monitored the growth of the untreated lung tumours. Our results demonstrate that PDT of murine tumours provided durable inhibition of the growth of untreated lung tumours. The inhibition of the growth of tumours outside the treatment field was tumour-specific and dependent on the presence of CD8⁺ T cells. This inhibition was accompanied by an increase in splenic anti-tumour cytolytic activity and by an increase in CD8⁺ T cell infiltration into untreated tumours. Local PDT treatment led to enhanced anti-tumour immune memory that was evident 40 days after tumour treatment and was independent of CD4⁺ T cells. CD8⁺ T cell control of the growth of lung tumours present outside the treatment field following PDT was dependent upon the presence of natural killer (NK) cells. These results suggest that local PDT treatment of tumours lead to induction of an anti-tumour immune response capable of controlling the growth of tumours outside the treatment field and indicate that this modality has potential in the treatment of distant stage disease.

Chlamydiae in free-ranging and captive frogs in Switzerland

A total of 210 frog samples originating either from a mass mortality (1991/1992) or from routine postmortem investigations of the years 1990 to 2004 were examined retrospectively for a possible involvement of Chlamydiae. For a prevalence study of Chlamydia in a selected Swiss amphibian population, 403 samples from free-ranging Rana temporaria were examined. Histopathology, immunohistochemistry using a monoclonal antibody against chlamydial lipopolysaccharide, and a 16S rRNA polymerase chain reaction (PCR) followed by DNA sequencing were performed on the formalin-fixed and paraffin-embedded tissues. Using PCR, 8 of 54 (14.8%) frog samples from the mass mortality (1991/1992) were positive for Chlamydia suis S45. A control group of healthy Xenopus laevis had 3 of 38 positive samples, sequenced as C suis S45 (2/3) and an endosymbiont of Acanthamoeba species UWE1 (1/3). Chlamydophila pneumoniae TW-183 was detected from exotic frogs kept in a zoo. Of the frogs collected for the prevalence study, 6 of 238 (2.5%) tested positive, 1 each for C suis S45, Cp pneumoniae TW-183, and uncultured Chlamydiales CRG22, and the remaining 3 revealed Chlamydophila abortus S26/3. In immunohistochemistry, there were 2 positive labeling reactions, 1 in intestine and the other in the epithelium coating the body cavity, both testing positive for Cp pneumoniae TW-183 in PCR. Histologically there were no lesions recorded being characteristic for Chlamydia. Although there is a prevalence of Chlamydia in Swiss frogs, no connection to a mass mortality (1991/1992) could be established. For the first time, C suis S45 and Cp abortus S26/3 were detected in frog material.

Chlamydiales in guinea-pigs and their zoonotic potential

The aim was to detect and characterize chlamydial infections in guinea-pigs (GP) with ocular disease, study their pathogenicity and zoonotic potential and to test for the presence of Acanthamoebae spp. in GP eyes and to investigate whether they could act as vectors for Chlamydia-like organisms. Overall 126 GP, of which 77 were symptomatic, were screened by clinical examination, cytology, gross pathology, histology, immunohistochemistry, polymerase chain reaction (PCR) and bacteriology. A new Chlamydiaceae-specific intergenic spacer rRNA gene PCR, designed to amplify this segment linking the 16S and 23S regions, was performed. DNA samples were also received from one owner including samples of his cat and rabbit. Guinea-pigs: 48 of 75 symptomatic, but only 11 of 48 asymptomatic GP were positive by PCR for Chlamydophila caviae guinea-pig inclusion conjunctivitis (GPIC) (P < 0.0001). Eighteen of 75 or 15/48, respectively, were positive for DNA from Chlamydia-like organisms. Acanthamoebae-DNA could be found in two GP, of which one was symptomatic. Owner, cat and rabbit: Samples of all three species were positive by PCR for C. caviae GPIC and the owner's one-day disposable contact lenses showed a positive PCR result for the Chlamydia-like organism Parachlamydia acanthamoebae. No Acanthamoebae-DNA could be detected. This study is the first to describe Chlamydia-like organisms in GP and to detect C. caviae GPIC in human, cat and rabbit. Therefore, C. caviae GPIC could pose a zoonotic potential. We believe that the finding of C. caviae GPIC in species other than GP is probably not unique.