Raising awareness of pre-conception care in community pharmacies: a feasibility study

Background

There is growing evidence to support the introduction of pre-conception interventions to optimise the health of mothers and their future children. At present, there is poor awareness regarding the importance of pre-conception care (PCC) amongst healthcare professionals and couples planning a pregnancy. Community pharmacies are ideally placed to reach a range of prospective couples planning a pregnancy and could effectively provide information about PCC.

Methods

This study assessed feasibility of an intervention to raise awareness of PCC in community pharmacies in Northern Ireland over 3 months. Inclusion criteria: women of childbearing age (16–45 years) engaging with services at participating pharmacies. Study resources: campaign posters, information cards, crib sheets for pharmacy staff. A mixed methods approach was employed, including, brief information provision for women, record of staff interactions with customers, customer feedback cards and qualitative interviews with pharmacy staff. Descriptive statistics assessed distribution of study resources and staff interviews were analysed using a thematic analysis framework.

Results

There were eight participating pharmacies, three of which consented to post-study interviews. Three pharmacies chose not to deliver the planned intervention. Distribution of campaign cards (n = 456) varied (0–86%). Analysis of customer feedback cards (n = 9) demonstrated that the majority of respondents were happy to receive information on pre-conception health. Of the women who responded to this question (n = 8), all were ‘extremely likely’ or ‘likely’ to act on the information provided. Four main themes emerged from analysis of staff interviews: (1) training and experience in providing health advice, (2) intervention resources, (3) understanding the aims of the intervention, (4) perceived value of the intervention. Barriers to intervention delivery included non-engagement from pharmacies and need for additional training of staff.

Conclusions

An intervention to raise awareness of PCC within a community pharmacy setting was feasible and acceptable to both women and staff in participating pharmacies. This study indicates that a number of factors must be considered to enhance implementation and effectiveness of PCC interventions in this setting. In particular, better understanding of non-engagement, provision of adequate training and support for staff, and exploring incentives for pharmacies to prioritise PCC.

Predicting Delayed Complications After Esophagectomy in the Current Era of Early Discharge and Enhanced Recovery

BACKGROUND

Enhanced recovery protocols after esophagectomy aim to discharge patients by day 7. A small risk of delayed complications exists. We aimed to assess whether C-reactive protein (CRP) levels on day 7 could help predict delayed complications and assist safe discharge.

METHODS

All consecutive esophagectomies over 3 years were retrospectively reviewed. Patients were categorized on day 7 into (1) those clinically unsafe for discharge; (2) those clinically safe for discharge; and (3) those considered safe for discharge but develop a delayed complication. CRP level on day 7 and the trend in CRP levels between days 3 and 7 were compared.

RESULTS

A total of 140 patients underwent esophagectomy, of which 64 patients (46%) had at least one complication. On day 7, 62 (44%) patients were considered clinically unsafe for discharge; 74 (53%) were considered safe for discharge; and 4 (3%) were safe but developed a delayed complication. No patient with delayed complication had a day 7 CRP level < 84 mg/L. CRP trend did not help predict delayed complications.

CONCLUSIONS

The actual CRP level on day 7 after esophagectomy, rather than the trend, can predict delayed complications. Early discharge after esophagectomy should be desisted if the clinical picture is better than the actual blood results.

Socioeconomic inequalities and the equity impact of population-level interventions for adolescent health: an overview of systematic reviews

OBJECTIVES

Despite robust evidence on health inequalities in adulthood, less attention has been paid to inequalities in adolescence. The aim of this overview was to examine systematic review (SR) evidence on the equity impact of population-level interventions intended to improve health, happiness and wellbeing for adolescents.

STUDY DESIGN

An overview (review of systematic reviews).

METHODS

Eleven electronic databases were systematically searched to identify SRs of population-level interventions for adolescent health. A secondary data analysis of socioeconomic inequality was conducted to identify whether SRs reported on primary studies in terms of disadvantage, by measures of socioeconomic status (SES) and by differential effects.

RESULTS

35,310 review titles were screened; 566 full texts were retrieved and 140 SRs met the predefined selection criteria. Differential intervention effects were considered in 42/140 (30%) SRs, 18/140 (13%) reported primary studies using an SES measure and 16/140 (11%) explicitly reported differential effects. 15/140 SRs (11%) explicitly focused on socioeconomic inequalities; of these 4/15 reported differential intervention effects in more detail, 7/15 concluded there was insufficient primary evidence to identify the impact of interventions on socioeconomic inequalities and 4/15 planned to examine differential effects by SES, but this was not reported further.

CONCLUSIONS

Our overview identifies that there is limited SR evidence on the equity impact of population-level interventions for adolescent health. Strengthening the evidence on whether interventions narrow or widen inequalities for adolescents must be a priority for public health research.

P680The clinical value of CMR in the management of Cardio-Oncology patients - a tertiary centre experience

Background

There is increasing awareness of cardiotoxicity arising from cancer treatments. Early diagnosis and treatment is key, to ensure patients receive optimal oncological management. Cardiovascular magnetic resonance (CMR) offers gold standard measurement of cardiac function, alongside tissue characterisation and myocardial perfusion, thereby potentially providing additive value in the context of cardio-oncology.

Purpose

We sought to understand the clinical value of CMR in cardio-oncology at a tertiary cardio-oncology centre.

Methods

We retrospectively reviewed CMR scans requested in cardio-oncology patients at our institution within a ten-month period. We categorised clinical indications and assessed the impact on clinical management using previously-published criteria.

Results

102 CMR studies were requested in 93 cardio-oncology patients (mean age 56 (range 18 to 82), 49% male) between (March to December 2018). 41% of patients had haematological malignancies, 59% solid tumours.

15% of requests were for risk stratification prior to initiation of cancer therapy, 21% for screening for cardio-toxicity in patients currently receiving cardiotoxic agents (3% anthracyclines, 13% HER2 monoclonal antibodies, 4% fluoropyrimidines), 15% for investigation of patients with cardiac complications during cancer treatment, 35% assessment for late effects post cancer treatment, and 14% for cardiac malignancies/ infiltration.

The most common indications for CMR were monitoring of left ventricular ejection fraction (LVEF) in patients where quantification by echocardiography was non-diagnostic or significantly different between imaging studies (39%) and ischaemia assessment including for patients due to receive fluoropyrimidines (26%). Others were aetiology of LV dysfunction/cardiomyopathy (13%) and tissue characterisation (23%), including assessment for cardiac AL amyloid (11 patients), myocarditis (2), cardiac metastases (1), cardiac masses (6), and cardiac iron loading (1).

CMR findings had clinical impact in 61% of patients and assisted in adjudicating a new diagnosis in 29% of patients. 88% of patients were able to continue anthracycline/anti-HER2 therapies based on CMR findings of stable LVEF (93% of whose echocardiograms had suggested reductions). LVEF had reduced significantly in 12% of patients meaning chemotherapy was held/discontinued. 3 patients were recommended to receive non-fluoropyrimidine chemotherapy based on perfusion CMR (pCMR) findings, with one patient permitted to receive capecitabine following normal pCMR.

Conclusion

CMR provides a comprehensive assessment of myocardial structure and function with utility within the context of cardio-oncology for risk stratification pre-chemotherapy, screening for cardiotoxicity during treatment and investigation of cardiac complications of cancer treatment. The additional information derived from CMR generally provides reassurance enabling administration of optimal cancer therapies.

Childhood adversity, mental health and suicide (CHASE): a methods protocol for a longitudinal case-control linked data study

Introduction

Suicide is a tragic outcome with devastating consequences. In 2018, Scotland experienced a 15% increase in suicide from 680 to 784 deaths. This was marked among young people, with an increase of 53% in those aged 15-24, the highest since 2007. Early intervention in those most at risk is key, but identification of individuals at risk is complex, and efforts remain largely targeted towards universal suicide prevention strategies with little evidence of effectiveness.

Recent evidence suggests childhood adversity is a predictor of subsequent poor social and health outcomes, including suicide. This protocol reports on methodology for harmonising lifespan hospital contacts for childhood adversity, mental health, and suicidal behaviour. This will inform where to 1) focus interventions, 2) prioritise trauma-informed approaches, and 3) adapt support avenues earlier in life for those most at risk.

Methods

This study will follow a case-control design. Scottish hospital data (physical health SMR01; mental health SMR04; maternity/birth record SMR02; mother’s linked data SMR01, SMR04, death records) from 1981 to as recent as available will be extracted for people who died by suicide aged 10-34, and linked on Community Health Index unique identifier. A randomly selected control population matched on age and geography at death will be extracted in a 1:10 ratio. International Classification of Disease (ICD) codes will be harmonised between ICD9-CM, ICD9, ICD10-CM and ICD10 for childhood adversity, mental health, and suicidal behaviour.

Results

ICD codes for childhood adversity from four key studies are reported in two categories, 1) Maltreatment or violence-related codes, and 2) Codes suggestive of maltreatment. ‘Clinical Classifications Software’ ICD codes to operationalise mental health codes are also reported. Harmonised lifespan ICD categories were achieved semi-automatically, but required labour-intensive supplementary manual coding. Cross-mapped codes are reported.

Conclusion

There is a dearth of evidence about touchpoints prior to suicide. This study reports methods and harmonised ICD codes along the lifespan to understand hospital contact patterns for childhood adversity, which come to the attention of hospital practitioners.

Key words

Childhood Adversity, Adverse Childhood Experiences, Mental Health, Self-harm, Suicide, Suicidality, Violence, Hospital episodes, Routine Data, Data Linkage, Study Protocol

Enhancing the get healthy information and coaching service for Aboriginal adults: evaluation of the process and impact of the program

BACKGROUND

Non-communicable chronic diseases in Australia contribute to approximately 85% of the total burden of disease; this proportion is greater for Aboriginal communities. The Get Healthy Service (GHS) is effective at reducing lifestyle-based chronic disease risk factors among adults and was enhanced to facilitate accessibility and ensure Aboriginal cultural appropriateness. The purpose of this study is to detail how formative research with Aboriginal communities was applied to guide the development and refinement of the GHS and referral pathways; and to assess the reach and impact of the GHS (and the Aboriginal specific program) on the lifestyle risk factors of Aboriginal participants.

METHODS

Formative research included interviews with Aboriginal participants, leaders and community members, healthcare professionals and service providers to examine acceptability of the GHS; and contributed to the redesign of the GHS Aboriginal program. A quantitative analysis employing a pre-post evaluation design examined anthropometric measures, physical activity and fruit and vegetable consumption of Aboriginal participants using descriptive and chi square analyses, t-tests and Wilcoxon signed-rank tests.

RESULTS

Whilst feedback from the formative research was positive, Aboriginal people identified areas for service enhancement, including improving program content, delivery and service promotion as well as ensuring culturally appropriate referral pathways. Once these changes were implemented, the proportion of Aboriginal participants increased significantly (3.2 to 6.4%). There were significant improvements across a number of risk factors assessed after six months (average weight loss: 3.3 kg and waist circumference reduction: 6.2 cm) for Aboriginal participants completing the program.

CONCLUSIONS

Working in partnership with Aboriginal people, Elders, communities and peak bodies to enhance the GHS for Aboriginal people resulted in an enhanced culturally acceptable and tailored program which significantly reduced chronic disease risk factors for Aboriginal participants. Mainstream telephone based services can be modified and enhanced to meet the needs of Aboriginal communities through a process of consultation, community engagement, partnership and governance.

Protocol-developing meta-ethnography reporting guidelines (eMERGe)

Background

Designing and implementing high-quality health care services and interventions requires robustly synthesised evidence. Syntheses of qualitative research studies can provide evidence of patients’ experiences of health conditions; intervention feasibility, appropriateness and acceptability to patients; and advance understanding of health care issues. The unique, interpretive, theory-based meta-ethnography synthesis approach is suited to conveying patients’ views and developing theory to inform service design and delivery. However, meta-ethnography reporting is often poor quality, which discourages trust in, and use of, meta-ethnography findings. Users of evidence syntheses require reports that clearly articulate analytical processes and findings. Tailored research reporting guidelines can raise reporting standards but none exists for meta-ethnography. This study aims to create an evidence-based meta-ethnography reporting guideline articulating the methodological standards and depth of reporting required to improve reporting quality.

Methods/design

The mixed-methods design of this National Institute of Health Research-funded study (http://www.stir.ac.uk/emerge/) follows good practice in research reporting guideline development comprising: (1) a methodological systematic review (PROSPERO registration: CRD42015024709) to identify recommendations and guidance in conducting/reporting meta-ethnography; (2) a review and audit of published meta-ethnographies to identify good practice principles and develop standards in conduct/reporting; (3) an online workshop and Delphi studies to agree guideline content with 45 international qualitative synthesis experts and 45 other stakeholders including patients; (4) development and wide dissemination of the guideline and its accompanying detailed explanatory document, a report template for National Institute of Health Research commissioned meta-ethnographies, and training materials on guideline use.

Discussion

Meta-ethnography, devised in the field of education, is now used widely in other disciplines. Methodological advances relevant to meta-ethnography conduct exist. The extent of discipline-specific adaptations of meta-ethnography and the fit of any adaptions with the underpinning philosophy of meta-ethnography require investigation. Well-reported meta-ethnography findings could inform clinical decision-making. A bespoke meta-ethnography reporting guideline is needed to improve reporting quality, but to be effective potential users must know it exists, trust it and use it. Therefore, a rigorous study has been designed to develop and promote a guideline. By raising reporting quality, the guideline will maximise the likelihood that high-quality meta-ethnographies will contribute robust evidence to improve health care and patient outcomes.

Overexpression of the ros1 gene in primary human gliomas may contribute to malignant progression

Gliomas are malignant brain tumors thought to arise through multi-step tumorigenesis, involving both the activation of oncogenes and the loss of tumor suppressor genes. The ros1 gene encodes a proto-oncogenic protein which has been implicated, by in vitro studies, in the pathogenesis of several types of cancer, including gliomas. Northern blot analysis revealed expression of ros1 mRNA in 3 (30%) of 10 primary glioma specimens. In situ hybridization localized ros1 mRNA transcripts to GFAP positive tumor cells and pericytes around capillaries. Immunohistochemistry using an antibody specific for ros1 demonstrated strong positivity amongst neoplastic glial cells in the same glioma samples. No ros1 mRNA or protein was detected in 5 normal brain specimens. These data provide the first evidence for the overexpression of ros1 mRNA and protein in primary human gliomas, and are consistent with a proposed oncogenic role of ros1 in these tumors.

Cell-cycle regulator cyclin D1 mRNA and protein overexpression occurs in primary malignant gliomas

Gliomas are malignant brain tumors thought to arise through multi-step tumorigenesis, involving both the activation of oncogenes and the loss of tumor suppressor genes. The cyclin D1 gene encodes a proto-oncogenic cell cycle regulator implicated in the pathogenesis of several types of cancer, including gliomas. Northern blot analysis revealed expression of cyclin D1 mRNA in 7 (47%) of 15 primary glioma specimens. Immunohistochemistry using an antibody specific for cyclin D1 showed strong positivity amongst neoplastic glial cells in the same glioma samples. No cyclin D1 mRNA or protein was detected in 5 normal brain specimens. Cyclin B, which has not been linked to tumorigenesis and serves as a marker for cellular proliferation, was expressed in all tumor, but not control, samples. These data provide the first evidence for the overexpression of cyclin D1 mRNA and protein in primary human gliomas, and are consistent with a proposed oncogenic role of cyclin D1 in these tumors. It is suggested that excessive levels of cyclin D1 with or without several other D-type cyclin proteins may lead to deregulation of G(1) control in subsets of human gliomas. These results are further discussed in the context of putative functional redundancy of D-type cyclins and the role of the D-type cyclin/p16-ink4/pRB pathway in tumorigenesis.

Suicide methods in Europe: a gender-specific analysis of countries participating in the "European Alliance Against Depression"

OBJECTIVE

To identify the most frequent gender-specific suicide methods in Europe.

DESIGN

Proportions of seven predominant suicide methods utilised in 16 countries participating in the European Alliance Against Depression (EAAD) were reported in total and cross-nationally. Relative risk (RR) relating to suicide methods and gender was calculated. To group countries by pattern of suicide methods, hierarchical clustering was applied.

SETTING AND PARTICIPANTS

Data on suicide methods for 119,122 male and 41,338 female cases in 2000-4/5 from 16 EAAD countries, covering 52% of European population were obtained.

RESULTS

Hanging was the most prevalent suicide method among both males (54.3%) and females (35.6%). For males, hanging was followed by firearms (9.7%) and poisoning by drugs (8.6%); for females, by poisoning by drugs (24.7%) and jumping from a high place (14.5%). Only in Switzerland did hanging rank as second for males after firearms. Hanging ranked first among females in eight countries, poisoning by drugs in five and jumping from a high place in three. In all countries, males had a higher risk than females of using firearms and hanging and a lower risk of poisoning by drugs, drowning and jumping. Grouping showed that countries might be divided into five main groups among males; for females, grouping did not yield clear results.

CONCLUSIONS

Research on suicide methods could lead to the development of gender-specific intervention strategies. Nevertheless, other approaches, such as better identification and treatment of mental disorders and the improvement of toxicological aid should be put in place.

The Sentence Completion and Three Wishes tasks: windows into the inner lives of people with intellectual disabilities

BACKGROUND

Measuring the self-perceptions, thoughts, hopes and inner lives of persons with intellectual disabilities (ID) has long been a research challenge. Unlike objective or projective tests, semi-projective tasks may provide persons with ID with just enough structure or cues to convey their self-perceptions in a spontaneous and unbiased manner.

METHODS

Sentence Completion and Three Wishes tasks were individually administered to 128 persons with ID aged 5-50 years (mean = 18.75 years). Participants had Prader-Willi, Williams or Down syndromes. Content analyses resulted in 19 codes that were used to reliably score both tasks by independent raters who achieved excellent levels of inter-rater agreement. Participants also received IQ testing, and their parents or care providers completed the Child Behavior Checklist (CBCL).

RESULTS

Frequent themes across both tasks included activities, positive affect, desired objects, and relationships with family and pets. No gender or IQ effects were found, and just a few codes showed modest age effects. Several responses, including dating, friends, food, and positive or negative self-appraisals, were significantly related to either syndrome status or CBCL maladaptive behaviour.

CONCLUSIONS

Although not widely used, the Sentence Completion and Three Wishes tasks are useful semi-projective techniques for garnering otherwise hard-to-access self-perceptions and associations of people with ID. Implications are discussed for practice and research.

Weight cycling in a very low-calorie diet programme has no effect on weight loss velocity, blood pressure and serum lipid profile

BACKGROUND

Many dieters lose and regain weight many times. It is unclear whether weight cycling is associated with adverse metabolic alterations or becomes more difficult with each attempt.

METHODS

From 1988 to 2000, 2474 obese patients enrolled in our outpatient weight loss programme using a very low-calorie diet. Caloric intake consisted of meal replacement supplying 700-800 cal/day.

RESULTS

Our search distinguished 480 patients who had restarted the weight reduction programme at least once and up to four times (restarts). All subjects remained on the programme for 2 weeks or more each time. Mean initial weight loss was 21.3 kg for women and 28.8 kg for men. Rate of weight loss on first restart was not different from initial weight loss for women [1.6 vs. 1.4 kg/week; not significant (NS)] or for men (2.2 vs. 2.1 kg/week; NS). Of the 480 patients, 85 women and 51 men entered the programme three times. Rate of weight loss was similar for all three entries (1.4, 1.6 and 2.1 kg/week for first, second and third entry in women, NS; 2.1, 2.1 and 2 kg/week for men, NS). Only 20 women and 18 men entered the programme four times. The rate of weight loss was again similar for both men (NS) and women (NS) during each re-entry. Cardiovascular risk factors including lipid profile and blood pressure were not adversely affected by weight cycling. In fact, lipid levels were lower at each restart.

CONCLUSIONS

The present study refutes the hypothesis that repeated dieting makes further dieting efforts more difficult.

Persistent organochlorine pesticide levels in bovine fat from Mexico

Organochlorine pesticides have been used in Mexico in agriculture as a seed dresser, in sanitation, in malaria control programmes and in livestock to combat ectoparasites. The pesticides applied drift to areas where cattle graze and plants grow. Because of their chemical stability, they accumulate in the lipid-rich tissues of the body. In the body, they circulate throughout all compartments and accumulate in adipose fat. The aim was to monitor the organochlorine pesticide levels in bovine muscle fat and kidney fat from cows living in an endemic malaria zone, where the environmental contamination can be suspected as being higher. Two hundred samples (100 muscle fat, 100 kidney fat) were analysed by gas chromatography. From the pesticides, only hexachlorobenzene (HCB), beta-hexachlorocyclohexane (HCH), gamma-HCH, pp'-1.1.1-trichloro-2,2-bis(4-chlorophenyl)ethane (DDT), op'-DDT and pp'-DDE, were detected frequently and at levels above the detection limits. The HCB mean level was low at 0.009 mg kg(-1) on a fat basis. From the HCH isomers, beta-HCH mean concentration was 0.039 mg kg(-1) and gamma-HCH was 0.025 mg kg(-1) on a fat basis. Among DDTs, pp'-DDT was the major constituent (0.032 mg kg(-1) on a fat basis) followed by pp'-DDE (0.025 mg kg(-1) on a fat basis) and op'-DDT (0.023 mg kg(-1) on a fat basis). The DDT total (sigma DDT) level was 0.067 mg kg(-1) on a fat basis. Comparing the previous study (1994) and the present one (2002-03), organochlorine pesticide levels were decreased. HCB decreased 3.7 times from 0.033 to 0.009 mg kg(-1) on a fat basis; beta-HCH decreased 3.8 times from 0.149 to 0.039 mg kg(-1) on a fat basis; pp'-DDE did not reveal a significant difference at 0.026 versus 0.025 mg kg(-1) on a fat basis. However, pp'-DDT decreased substantially, 6.7 times from 0.215 to 0.032 mg kg(-1) on a fat basis. The DDT total decreased 3.5 times from 0.236 to 0.067 mg kg(-1) on a fat basis. The tendency for reduced concentrations in organochlorine pesticide levels in Mexican cows is caused by their substitution with pyrethroids used in agriculture and by the Mexican Ministry of Health in sanitary programmes.

Psychological interventions for women with metastatic breast cancer

BACKGROUND

There have been conflicting results from systematic reviews of psychological interventions for patients with cancer, some showing benefits for patients and others not. One early study appeared to show significant survival benefits as well as psychological benefits from a psychological intervention given to women with metastatic breast cancer. Some further studies have been undertaken, again with conflicting results.

OBJECTIVES

To assess the effects of psychological interventions (educational, individual cognitive behavioural or psychotherapeutic, or group support) on psychological and survival outcomes for women with metastatic breast cancer.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group Trials Register (September 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), MEDLINE (1966-October 2003), CancerLit (1983-2000), CINAHL (1982-October 2003), PsycInfo (1974-November 2003), and SIGLE (1980-November 2003).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of psychological interventions for women with metastatic breast cancer. Studies were included even if they were not 'intention to treat', owing to the nature of the patient group under study and the likely high loss of follow-up data.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. Data about the nature and setting of the intervention, and the relevant outcome data were extracted, along with items relating to methodological quality.

MAIN RESULTS

Five primary studies were identified, all group psychological interventions. Two of these were cognitive behavioural interventions and three evaluated support-expressive group therapy. The five studies of group psychological therapies for women with metastatic breast cancer showed very limited evidence of benefit arising from these interventions. Although there was evidence of short-term benefit for some psychological outcomes, in general these were not sustained at follow-up. A clearer pattern of psychological outcomes could not be discerned as a wide variety of outcome measures and durations of follow-up were used in the included studies. The possible longer survival times in women allocated to receive psychological intervention in the early study have not been replicated in the subsequent four studies (including one by members of the first study group), and overall the effects of these interventions on survival are not statistically significant (for example, odds ratio for 5 year survival 0.83 (95% confidence interval [CI] 0.53 - 1.28).

REVIEWERS' CONCLUSIONS

There is insufficient evidence to advocate that group psychological therapies (either cognitive behavioural or supportive-expressive) should be made available to all women diagnosed with metastatic breast cancer. Any benefits of the interventions are only evident for some of the psychological outcomes and in the short term. The possibility of the interventions causing harm is not ruled out by the available data.

Preliminary study of joint disease in poultry by the analysis of synovial fluid

Samples of synovial fluid and synovial membrane were obtained from the hock joints of several groups of broilers, including lame birds and two strains of broilers raised on different feeding regimens and given different drug treatments (carprofen or placebo). There were more significant differences between the groups on the basis of the analysis of the synovial fluid samples than the synovial membrane samples. Experimental birds fed ad libitum had the highest median red blood cell counts and median ghost cell counts of all of the groups, but there were no differences between the groups in the thickness of the synovial lining cell layer or the degree of cellular infiltrate in the synovial membrane. The synovial fluid from the broilers and lame birds fed ad libitum was more turbid, suggestive of intra-articular pathology, and the large numbers of heterophils in samples from the lame birds indicated an inflammatory arthropathy. The birds fed ad libitum which were treated with carprofen had more cells in the synovial fluid than the birds given the placebo. A large number of the samples of synovial fluid from the ad libitum-fed broilers contained blood.

Polyglutamine expansions cause decreased CRE-mediated transcription and early gene expression changes prior to cell death in an inducible cell model of Huntington's disease

Huntington's disease (HD) is one of 10 known diseases caused by a (CAG)(n) trinucleotide repeat expansion that is translated into an abnormally long polyglutamine tract. We have developed stable inducible neuronal (PC12) cell lines that express huntingtin exon 1 with varying CAG repeat lengths under doxycycline (dox) control. The expression of expanded repeats is associated with aggregate formation, caspase-dependent cell death and decreased neurite outgrowth. Post-mitotic cells expressing mutant alleles were more prone to cell death compared with identical cycling cells. To determine early metabolic changes induced by this mutation in cell models, we studied changes in gene expression after 18 h dox induction, using Affymetrix arrays, cDNA filters and adapter-tagged competitive PCR (ATAC-PCR). At this time point there were low rates of inclusion formation, no evidence of mitochondrial compromise and no excess cell death in the lines expressing expanded compared with wild-type repeats. The expression profiles suggest novel targets for the HD mutation and were compatible with impaired cAMP response element (CRE)-mediated transcription, which we confirmed using CRE-luciferase reporter assays. Reduced CRE-mediated transcription may contribute to the loss of neurite outgrowth and cell death in polyglutamine diseases, as these phenotypes were partially rescued by treating cells with cAMP or forskolin.

Wild type Huntingtin reduces the cellular toxicity of mutant Huntingtin in mammalian cell models of Huntington's disease

OBJECTIVES

Recent data suggest that wild type huntingtin can protect against apoptosis in the testis of mice expressing full length huntingtin transgenes with expanded CAG repeats. It is not clear if this protective effect was confined to particular cell types, or if wild type huntingtin exerted its protective effect in this model by simply reducing the formation of toxic proteolytic fragments from mutant huntingtin.

METHODS

We cotransfected neuronal (SK-N-SH, human neuroblastoma) and non-neuronal (COS-7, monkey kidney) cell lines with HD exon 1 (containing either 21 or 72 CAG repeats) construct DNA and either full length wild type huntingtin or pFLAG (control vector).

RESULTS

Full length wild type huntingtin significantly reduced cell death resulting from the mutant HD exon 1 fragments containing 72 CAG repeats in both cell lines. Wild type huntingtin did not significantly modulate cell death caused by transfection of HD exon 1 fragments containing 21 CAG repeats in either cell line.

CONCLUSIONS

Our results suggest that wild type huntingtin can significantly reduce the cellular toxicity of mutant HD exon 1 fragments in both neuronal and non-neuronal cell lines. This suggests that wild type huntingtin can be protective in different cell types and that it can act against the toxicity caused by a mutant huntingtin fragment as well as against a full length transgene.

Developing a 'consultation quality index' (CQI) for use in general practice

BACKGROUND

The core values of general practice include holism and patient-centredness. None of the measures of quality of care in general practice presently capture the expression of these values at routine consultations.

OBJECTIVES

The aim of the present study was to construct a 'consultation quality index' (CQI) which reflects the core values of general practice, using as proxies 'consultation length' and how well patients 'know the doctor' as process measures and 'patient enablement' as an outcome measure.

METHODS

The CQI was constructed from data collected from 23 799 adult English-speaking patients consulting 221 doctors in four demographically contrasting areas of the UK during 2 weeks of March/April 1998. A total of 171 doctors who entered 50 qualifying consultations were allocated scores for the three component variables, and a total CQI was calculated.

RESULTS

CQI scores were in the range 4-18. Validity was examined by looking at high and low scorers in greater detail and by searching for correlates with case mix, patient age and gender, and the deprivation scores of the practices concerned. Particular attention was paid to how registrars and doctors new to their practices scored. The scores of different doctors in the same practice were also noted. The results had strong face validity and were independent of case mix and deprivation. Reliability was gauged by examining similar work from a previous study which had collected information on consultation length and enablement over three time periods. High CQI scores were associated with smaller overall practice list sizes.

CONCLUSIONS

We have outlined possible uses for the CQI as part of the packages assessing quality of care by doctors and practices. The measure may also have a part to play in recognizing poorly performing doctors. We suggest how CQI scores could contribute to an incentive scheme to reward good consulting practice. Further work is in hand to compare doctors' CQI scores with scores based on performance indicators constructed from routine NHS data on prescribing and preventive medicine.

Expanding indications for the Ross procedure

The pulmonary autograft procedure has been shown to provide excellent hemodynamic results in young patients with aortic pathology. However, the use of this procedure in those with more complex aortic disease has not been extensively evaluated. The purpose of this report is to present the application of the Ross procedure in a 21-year-old man with extensive acquired aortic root pathology, both subannular and supraannular, and prosthetic valve dysfunction after two previous procedures.

Quality at general practice consultations: cross sectional survey

OBJECTIVES

To measure quality of care at general practice consultations in diverse geographical areas, and to determine the principal correlates associated with enablement as an outcome measure.

DESIGN

Cross sectional multipractice questionnaire based study.

SETTING

Random sample of practices in four participating regions: Lothian, Coventry, Oxfordshire, and west London.

PARTICIPANTS

25 994 adults attending 53 practices over two weeks in March and April 1998.

MAIN OUTCOME MEASURES

Patient enablement, duration of consultation, how well patients know their doctor, and the size of the practice list.

RESULTS

A hierarchy of needs or reasons for consultation was created. Similar overall enablement scores were achieved for most casemix presentations (mean 3.1, 95% confidence interval 3.1 to 3.1). Mean duration of consultation for all patients was 8.0 minutes (8.0 to 8.1); however, duration of consultation increased for patients with psychological problems or where psychological and social problems coexisted (mean 9.1, 9.0 to 9.2). The 2195 patients who spoke languages other than English at home were analysed separately as they had generally higher enablement scores (mean 4.5, 4.3 to 4.7) than those patients who spoke English only despite having shorter consultations (mean 7.1 (6. 9 to 7.3) minutes. At individual consultations, enablement score was most closely correlated with duration of consultation and knowing the doctor well. Individual doctors had a wide range of mean enablement scores (1.1-5.3) and mean durations of consultation (3. 8-14.4 minutes). Doctors' ability to enable was linked to the duration of their consultation and the percentage of their patients who knew them well and was inversely related to the size of their practice. At practice level, mean enablement scores ranged from 2.3 to 4.4, and duration of consultation ranged from 4.9 to 12.2 minutes. Correlations between ranks at practice level were not significant.

CONCLUSIONS

It may be time to reward doctors who have longer consultations, provide greater continuity of care, and both enable more patients and enable patients more.

Synthesis and serotonergic activity of substituted 2, N-benzylcarboxamido-5-(2-ethyl-1-dioxoimidazolidinyl)-N, N-dimethyltryptamine derivatives: novel antagonists for the vascular 5-HT(1B)-like receptor

The synthesis and vascular 5-HT(1B)-like receptor activity of a novel series of substituted 2, N-benzylcarboxamido-5-(2-ethyl-1-dioxoimidazolidinyl)-N, N-dimethyltryptamine derivatives are described. Modifications to the 5-ethylene-linked heterocycle and to substituents on the 2-benzylamide side chain have been explored. Several compounds were identified which exhibited affinity at the vascular 5-HT(1B)-like receptor of pK(B) > 7.0, up to 100-fold selectivity over alpha(1)-adrenoceptor affinity and 5-HT(2A) receptor affinity, and which exhibited a favorable pharmacokinetic profile. N-Benzyl-3-[2-(dimethylamino)ethyl]-5-[2-(4,4-dimethyl-2, 5-dioxo-1-imidazolidinyl)ethyl]-1H-indole-2-carboxamide (23) was identified as a highly potent, silent (as judged by the inability of angiotensin II to unmask 5-HT(1B)-like receptor-mediated agonist activity in the rabbit femoral artery), and competitive vascular 5-HT(1B)-like receptor antagonist with a plasma elimination half-life of approximately 4 h in dog plasma and with good oral bioavailability. The selectivity of compounds from this series for the vascular 5-HT(1B)-like receptors over other receptor subtypes is discussed as well as a proposed mode of binding to the receptor pharmacophore. It has been proposed that the aromatic ring of the 2, N-benzylcarboxamide group can occupy an aromatic binding site rather than the indole ring. The resulting conformation allows an amine-binding site to be occupied by the ethylamine nitrogen and a hydrogen-bonding site to be occupied by one of the hydantoin carbonyls. The electronic nature of the 2,N-benzylcarboxamide aromatic group as well as the size of substituents on this aromatic group is crucial for producing potent and selective antagonists. The structural requirement on the 3-ethylamine side chain incorporating the protonatable nitrogen is achieved by the bulky 2, N-benzylcarboxamide group and its close proximity to the 3-side chain.

Renal cell carcinoma: a rare source of cauda equina metastasis. Case report

The authors present the case of a patient in whom intradural metastasis from renal cell carcinoma spread to the cauda equina. To the authors' knowledge, this is only the second report of its kind. This male patient had undergone nephrectomy for the treatment of renal cell carcinoma for 5 years and was diagnosed as having metastatic lung disease 1 year prior to admission. The patient presented with lower back pain that radiated to both legs, but he exhibited no sensorimotor deficits. The majority of cauda equina tumors are primary tumors, and metastases are very rare. The literature is reviewed with reference to current molecular genetic paradigms of metastatic renal cell carcinoma.

Functional transplantation of the rat pituitary gland

OBJECTIVE

These studies evaluated the ability of transplanted pituitary cells to restore pituitary function in hypophysectomized rats.

METHODS

The pituitary glands of neonatal Lewis rats were rapidly removed, enzymatically dispersed, and stereotactically introduced into the third ventricle of hypophysectomized adult male Lewis rats. Four weeks after implantation, plasma levels of anterior pituitary hormones in implanted animals were compared with those of sham-transplanted control animals.

RESULTS

Plasma levels of prolactin, growth hormone, thyroid-stimulating hormone, and beta-endorphin were below the range of detection in 14 sham-operated animals. In implanted animals, restitution of serum prolactin occurred in 100% of the animals tested, with levels of 2.6 +/- 1.0 ng/ml (mean +/- standard error of the mean; normal, 2-4 ng/ml). Growth hormone was assayable in 71% of the animals, with a mean value of 29 +/- 13 ng/ml over all animals (normal, 1-100 ng/ml); thyroid-stimulating hormone was restored in 68%, with mean resting levels of 79 +/- 13 ng/ml (normal, 100-400 ng/ml); luteinizing hormone levels were found in 53%, with mean levels over all animals of 0.2 +/- 0.1 ng/ml (normal, 0.5-1.0 ng/ml); and beta-endorphin was restored in 45% to high resting levels of 163 +/- 31 pg/ml (normal, 20-30 pg/ml). A challenge with hypothalamic releasing factor and a cold stress test were performed on the animals that had received transplants. Positive hormone responses to both of these tests suggested sensitivity of the pituitary grafts to both endogenous and exogenous sources of stimulation. Histological sections of paraformaldehyde-fixed brains from implanted animals clearly demonstrated survival of clusters of grafted pituitary cells. Positive immunohistochemical staining for adrenocorticotropic hormone and thyroid-stimulating hormone was demonstrated in sections of the grafted tissue.

CONCLUSION

These data suggest survival of neonatal pituitary transplants in the third ventricle of adult hypophysectomized rats with concomitant restoration of anterior pituitary hormone function.

Cellular localization of PDGF mRNAs in developing human forebrain

Platelet-derived growth factor (PDGF) has been implicated in the processes regulating gliogenesis in the CNS. Conflicting in vivo data in rodents have variously implicated either glia or neurons as being the primary source of PDGF. We have used in situ hybridization and immunocytochemical analysis to study the in vivo expression and cellular localization of PDGF-A, sis/PDGF-B, together with the two PDGF receptors alpha and beta, in developing human forebrain. In this study we demonstrate the strong expression of mRNA and protein of both PDGF chains, A and B, and their receptors, alpha and beta, in human embryonic glial cells. The neurons, in contrast to glial cells, expressed lower levels of PDGF and PDGF-receptor mRNAs and protein. Identification of the cell types expressing the PDGF and PDGF-receptor mRNAs was achieved by counterstaining with antibodies specific for glial cells (GFAP) and neurons (NF). The predominant glial-specific expression of both PDGF-A and PDGF-B, together with the coexpression of their receptors alpha and beta, suggests an important role for the PDGF isoforms in the development of human embryonic glial cells and neurons in vivo.

A comparison of three methods of setting prescribing budgets, using data derived from defined daily dose analyses of historic patterns of use

BACKGROUND

Prescribing matters (particularly budget setting and research into prescribing variation between doctors) have been handicapped by the absence of credible measures of the volume of drugs prescribed.

AIM

To use the defined daily dose (DDD) method to study variation in the volume and cost of drugs prescribed across the seven main British National Formulary (BNF) chapters with a view to comparing different methods of setting prescribing budgets.

METHOD

Study of one year of prescribing statistics from all 129 general practices in Lothian, covering 808,059 patients: analyses of prescribing statistics for 1995 to define volume and cost/volume of prescribing for one year for 10 groups of practices defined by the age and deprivation status of their patients, for seven BNF chapters; creation of prescribing budgets for 1996 for each individual practice based on the use of target volume and cost statistics; comparison of 1996 DDD-based budgets with those set using the conventional historical approach; and comparison of DDD-based budgets with budgets set using a capitation-based formula derived from local cost/patient information.

RESULTS

The volume of drugs prescribed was affected by the age structure of the practices in BNF Chapters 1 (gastrointestinal), 2 (cardiovascular), and 6 (endocrine), and by deprivation structure for BNF Chapters 3 (respiratory) and 4 (central nervous system). Costs per DDD in the major BNF chapters were largely independent of age, deprivation structure, or fundholding status. Capitation and DDD-based budgets were similar to each other, but both differed substantially from historic budgets. One practice in seven gained or lost more than 100,000 Pounds per annum using DDD or capitation budgets compared with historic budgets. The DDD-based budget, but not the capitation-based budget, can be used to set volume-specific prescribing targets.

CONCLUSIONS

DDD-based and capitation-based prescribing budgets can be set using a simple explanatory model and generalizable methods. In this study, both differed substantially from historic budgets. DDD budgets could be created to accommodate new prescribing strategies and raised or lowered to reflect local intentions to alter overall prescribing volume or cost targets. We recommend that future work on setting budgets and researching prescribing variations should be based on DDD statistics.

A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations

OBJECTIVES

We aimed to compare a new primary care outcome measure-the Patient Enablement Instrument (PEI)-against two established satisfaction measures [the Medical Interview Satisfaction Scale (MISS) and the Consultation Satisfaction Questionnaire (CSQ)]. Specifically, we sought (i) to test whether enablement and satisfaction are related or separate concepts; and (ii) to assess whether the internal consistency of the PEI might be enhanced by the inclusion of items from the satisfaction instruments.

METHODS

Questionnaire forms containing the three instruments in a variety of combinations were distributed to a total of 818 patients attending for routine surgery consultations in three urban general practices of varying socio-economic mix. The main outcome measures were: scores on the PEI; scores on the CSQ, the MISS and their individual components; rank correlations between scores on the PEI and scores on the CSQ, the MISS and their component subscales; and Cronbach's alpha coefficient for the PEI.

RESULTS

Overall mean scores, expressed as percentages of maximum scores attainable, were 44.1% for the PEI, 76.9% for the CSQ and 77.6% for the MISS. Rank correlations between PEI scores and scores for the complete CSQ and MISS instruments were 0.48 (P < 0.01) and 0.47 (P < 0.01), respectively. Correlations of PEI scores with individual component scores on the CSQ were generally lower and ranged from 0.14 to 0.53; correlations of PEI scored with MISS component scores were also generally lower and ranged from 0.21 to 0.53. Internal consistency of the PEI items (assessed by Cronbach's alpha coefficient) was lowered when items from the CSQ or MISS were added.

CONCLUSIONS

The study shows that 'enablement' is a primary care outcome measure which is related to but is different from general satisfaction.

Familial meningioma: analysis of expression of neurofibromatosis 2 protein Merlin. Report of two cases

Meningiomas are primarily benign brain tumors thought to arise through multistep tumorigenesis, involving both the activation of oncogenes and the loss of tumor suppressor genes. The recently isolated neurofibromatosis 2 (NF2) tumor suppressor gene has been found to be mutated in a large proportion of meningiomas. Almost all cases of familial meningioma occur in association with NF2. Familial meningioma in isolation from NF2 (sporadic) is exceedingly rare, with only 14 reports since 1959. The authors report the existence of a family lacking any stigmata of NF2, in which two members had spinal meningiomas. Tumor specimens were subjected to immunocytochemical analysis for the NF2 protein product Merlin, which has been implicated in the tumorigenesis of meningioma. Merlin immunoreactivity was present in both tumor specimens, implying that the NF2 tumor suppressor gene was not deleted in these tumors. This supports the hypothesis that a second tumor suppressor gene locus, other than NF2, acts in the formation of familial sporadic meningioma. The results are discussed in the context of putative oncogenic mechanisms of familial meningiomas.

Chest tube removal after cardiac surgery

Prompt remove of chest tubes by RNs has allowed earlier and more aggressive ambulation of our patients and, along with other interventions, has decreased length of stay by 1.5 days while improving quality of care. Proper education, both didactic and clinical, is the key component in preparing RNs to safely and effectively perform this procedure.

Measuring quality in general practice. Pilot study of a needs, process and outcome measure

1. As part of the Scottish Shadow Fundholding Evaluation (1990-92), quality of care was assessed in 6 practices with 49 general practitioners using a pre-consultation health needs questionnaire, consultation length as a process measure (previously shown to be a proxy measure for quality) and a post-consultation satisfaction/outcome measure which contained a subset of six questions assessing whether patients felt enabled by their consultation. This report describes secondary analysis of the available dataset undertaken to explore whether the approach used to evaluate quality of care for patients with specific clinical problems could be extended to the generality of general practice consultations. 2. Chapters 1 and 2 of the report describe earlier work developing both the concepts and instruments used in the Shadow Evaluation, and general findings already reported. The reliability and the construct validity of the measure of enablement are examined and found to be satisfactory. 3. Strong correlations between more time at consultations and more enablement for more patients are found at population level for patients with psychological problems, with social problems and with physical problems. More complex problems require more time to achieve equal benefit. 4. Mean consultation length and mean enablement score correlate well with each other and can be used as summary statistics of quality. Where trends require explanation or exploration, other measures of the use of time and the level of benefit gained are more helpful; both sets of analyses can be derived from the same datasets (Chapter 3). 5. Analyses at practice level show that practices which spend more time at consultations enable patients more whatever the nature of problems presented. The rank orders of time spent at consultation and of enablement are highly correlated (Chapter 4). 6. Analyses at doctor level show that doctors who spend more time at consultations enable patients more and that those who spend less time enable patients less. The numbers of patients available for study were not sufficient to explore this association within subgroups of clinical presentations. As in previous studies, we found that doctors who take longer time are likely to be more patient centred, and those who take less time are likely to be less patient centred. Case-mix varies between doctors, but seems to be independent of whether a doctor is more or less patient centred (Chapter 5). 7. The methods developed in this study give useful insights into the definition and delivery of quality of care in general practice (Chapter 6). The measures now need to be tested in different clinical, cultural and organizational settings and results compared with those found using routinely available NHS data on prescribing and achievement of other clinical and management targets (Chapter 7).

Chest tube removal after cardiac surgery

Prompt remove of chest tubes by RNs has allowed earlier and more aggressive ambulation of our patients and, along with other interventions, has decreased length of stay by 1.5 days while improving quality of care. Proper education, both didactic and clinical, is the key component in preparing RNs to safely and effectively perform this procedure.

Expression of cyclin D1 proto-oncogene mRNA in primary meningiomas may contribute to tumorigenesis

Meningiomas are benign brain tumors thought to arise by multi-step tumorigenesis, involving both the activation of oncogenes and the loss of tumor suppressor genes. The cell cycle regulator proto-oncogene cyclin D1 has been implicated in the pathogenesis of several types of cancer. Northern blot analysis revealed expression of cyclin D1 mRNA in 8 (53%), and cyclin B mRNA in 12 of 14 (86%), primary meningiomas. Immunocytochemistry using an antibody specific for cyclin D1 showed strong positivity amongst meningeal cells in the same meningioma samples. No cyclin D1 mRNA was detected in a sample of normal pachymeninges. Cyclin B, which has not yet been linked to tumorigenesis and serves as a marker for cellular proliferation, was expressed in a higher proportion of meningioma samples. These data provide the first evidence for the overexpression of cyclin D1 and B mRNA and protein in primary human meningiomas, and are consistent with a proposed oncogenic role of cyclin D1 in tumorigenesis. Excessive levels of the cyclin D1 proto-oncogene may lead to deregulation of G1 control in a proportion of arachnoid cap cells leading to tumorigenesis.

Coexpression of EGF receptor and TGF alpha mRNA and protein occurs in primary meningiomas

Meningiomas are benign brain tumors thought to arise by multi-step tumorigenesis, involving both the activation of proto-oncogenes and the loss of tumor suppressor genes. The EGFR gene encodes a protooncogenic tyrosine kinase growth factor receptor implicated in the pathogenesis of several types of cancer, including gliomas. TGF alpha, the ligand for EGFR, is thought to act through autocrine stimulation of EGFR present on the same and adjacent cells. Northern blot analysis revealed expression of EGFR mRNA in 9 of 11 (82%), and TGF alpha mRNA in 2 of 11 (18%), primary meningioma specimens. III situ hybridization verified EGFR and TGF alpha gene expression by meningioma cells. Immunocytochemistry using specific antibodies for EGFR and TGF alpha showed strong positivity amongst meningeal cells in the same meningioma samples. No EGFR or TGF alpha protein was detected in a sample of normal meninges. These data indicate that the autocrine coexpression of EGFR and TGF alpha mRNA and protein may occur in only a small proportion of primary meningiomas.

Synthesis of inositol 2-phosphate-quercetin conjugates

The antiproliferative flavonoid, quercetin, is limited in its pharmacological utility by its low water solubility. In this paper, we describe the synthesis of two quercetin analogues prepared by linking the hydroxyl group at the 3- or 5-position of the flavonoid to the 1-hydroxyl group of myo-inositol-2-phosphate via a succinate diester linkage. The resulting conjugates were found to have dramatically enhanced water solubility relative to quercetin; the 5-linked quercetin analogue 2 had a water solubility of > 300 mg/mL at 20 degrees C. Comparison of the in vitro cytotoxicity and antiproliferative activity of conjugate 2 with those of quercetin toward cultured human colon adenocarcinoma (SW480) and human glioblastoma (U87MG) cells indicated that this modification of quercetin does not significantly diminish its activity in these assays.

Mechanisms of heading perception in primate visual cortex

When we move forward while walking or driving, what we see appears to expand. The center or focus of this expansion tells us our direction of self-motion, or heading, as long as our eyes are still. However, if our eyes move, as when tracking a nearby object on the ground, the retinal image is disrupted and the focus is shifted away from the heading. Neurons in primate dorso-medial superior temporal area responded selectively to an expansion focus in a certain part of the visual field, and this selective region shifted during tracking eye movements in a way that compensated for the retinal focus shift. Therefore, these neurons account for the effect of eye movements on what we see as we travel forward through the world.

Language codes and sense-making among deaf schoolchildren

There are at least two languages (American Sign Language [ASL], English) and three modalities (sign, speech, print) in most deaf individuals' lives. Mixing of ASL and English in utterances of deaf adults has been described in various ways (pidgins, diglossia, language contact, bilingualism), but children's mixing usually is treated as the 'fault' of poor input language. Alternatively, how might language mixing serve their communication goals? This article describes code variations and adaptations to particular situations. Deaf children were seen to exhibit a wide variety of linguistic structures mixing ASL, English, Spanish, signing, and speaking. Formal lessons supported a recoding of English print as sign and speech, but the children who communicated English speech were the two who could hear speech. The children who communicated ASL were those who had deaf parents communicating ASL or who identified with deaf houseparents communicating ASL. Most language produced by the teacher and children in this study was mixed in code and mode. While some mixing was related to acquisition and proficiency, mixing, a strategy of many deaf individuals, uniquely adapts linguistic resources to communication needs. Investigating deaf children's language by comparing it to standard English or ASL overlooks the rich strategies of mixing that are central to their communication experience.

Clinical benchmarking: results into practice

Describes the way benchmarking data are used in a district general hospital to influence clinical practice. Wirral Hospital Trust is a site for the Electronic Patient Record Project; as such there is a large amount of patient based data available for research and internal benchmarking. Includes working examples of internal benchmarking which have been used by both clinicians and hospital management to improve hospital effectiveness. Discusses the ways in which this information is being used to develop initiatives such as clinical pathway development.