The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration

As the science of quality improvement in health care advances, the importance of sharing its accomplishments through the published literature increases. Current reporting of improvement work in health care varies widely in both content and quality. It is against this backdrop that a group of stakeholders from a variety of disciplines has created the Standards for QUality Improvement Reporting Excellence, which we refer to as the SQUIRE publication guidelines or SQUIRE statement. The SQUIRE statement consists of a checklist of 19 items that authors need to consider when writing articles that describe formal studies of quality improvement. Most of the items in the checklist are common to all scientific reporting, but virtually all of them have been modified to reflect the unique nature of medical improvement work. This "Explanation and Elaboration" document (E & E) is a companion to the SQUIRE statement. For each item in the SQUIRE guidelines the E & E document provides one or two examples from the published improvement literature, followed by an analysis of the ways in which the example expresses the intent of the guideline item. As with the E & E documents created to accompany other biomedical publication guidelines, the purpose of the SQUIRE E & E document is to assist authors along the path from completion of a quality improvement project to its publication. The SQUIRE statement itself, this E & E document, and additional information about reporting improvement work can be found at http://www.squire-statement.org.

Recent common ancestry of human Y chromosomes: evidence from DNA sequence data

We consider a data set of DNA sequence variation at three Y chromosome genes (SMCY, DBY, and DFFRY) in a worldwide sample of human Y chromosomes. Between 53 and 70 chromosomes were fully screened for sequence variation at each locus by using the method of denaturing high-performance liquid chromatography. The sum of the lengths of the three genes is 64,120 bp. We have used these data to study the ancestral genealogy of human Y chromosomes. In particular, we focused on estimating the expected time to the most recent common ancestor and the expected ages of certain mutations with interesting geographic distributions. Although the geographic structure of the inferred haplotype tree is reminiscent of that obtained for other loci (the root is in Africa, and most of the oldest non-African lineages are Asian), the expected time to the most recent common ancestor is remarkably short, on the order of 50,000 years. Thus, although previous studies have noted that Y chromosome variation shows extreme geographic structure, we estimate that the spread of Y chromosomes out of Africa is much more recent than previously was thought. We also show that our data indicate substantial population growth in the effective number of human Y chromosomes.

Genetic contributions to variation in general cognitive function: a meta-analysis of genome-wide association studies in the CHARGE consortium (N=53949)

General cognitive function is substantially heritable across the human life course from adolescence to old age. We investigated the genetic contribution to variation in this important, health- and well-being-related trait in middle-aged and older adults. We conducted a meta-analysis of genome-wide association studies of 31 cohorts (N=53,949) in which the participants had undertaken multiple, diverse cognitive tests. A general cognitive function phenotype was tested for, and created in each cohort by principal component analysis. We report 13 genome-wide significant single-nucleotide polymorphism (SNP) associations in three genomic regions, 6q16.1, 14q12 and 19q13.32 (best SNP and closest gene, respectively: rs10457441, P=3.93 × 10(-9), MIR2113; rs17522122, P=2.55 × 10(-8), AKAP6; rs10119, P=5.67 × 10(-9), APOE/TOMM40). We report one gene-based significant association with the HMGN1 gene located on chromosome 21 (P=1 × 10(-6)). These genes have previously been associated with neuropsychiatric phenotypes. Meta-analysis results are consistent with a polygenic model of inheritance. To estimate SNP-based heritability, the genome-wide complex trait analysis procedure was applied to two large cohorts, the Atherosclerosis Risk in Communities Study (N=6617) and the Health and Retirement Study (N=5976). The proportion of phenotypic variation accounted for by all genotyped common SNPs was 29% (s.e.=5%) and 28% (s.e.=7%), respectively. Using polygenic prediction analysis, ~1.2% of the variance in general cognitive function was predicted in the Generation Scotland cohort (N=5487; P=1.5 × 10(-17)). In hypothesis-driven tests, there was significant association between general cognitive function and four genes previously associated with Alzheimer's disease: TOMM40, APOE, ABCG1 and MEF2C.

Prevalence of atrial fibrillation and eligibility for anticoagulants in the community

BACKGROUND

Anticoagulants are effective in the prevention of stroke in atrial fibrillation and flutter (AF). We aimed to find out the prevalence of AF in the UK and to estimate the proportion of patients with AF who might benefit from anticoagulation.

METHODS

We screened with electrocardiography a random sample of 4843 people from the community aged 65 years and older for AF. Participants with AF had further investigations to identify risk factors for stroke and contraindications to anticoagulants. We used three sets of criteria to assess risk and eligibility for anticoagulation.

FINDINGS

228 (4.7%) participants had AF. According to analyses derived from risk stratifications based on the Stroke Prevention in Atrial Fibrillation (SPAF) study 61% of these patients would have benefited from anticoagulation, 49% according to pooled analysis of trial results, and 41% according to the inclusion criteria for the SPAF 3 study. Anticoagulants were used by 1114 (23%) of all patients and were least used among elderly women, who may be the most likely to benefit. Echocardiography would be useful to assess the need for anticoagulation only in patients younger than 75 years with no contraindications to treatment and no clinical risk factors for stroke.

INTERPRETATION

Anticoagulants seem to be underused and misdirected in treatment of AF, according to various criteria. Efforts to promote and support wider and more appropriate use of anticoagulants would seem to be justified, and should decrease the incidence of stroke amongst elderly patients.

Bifidobacterial supplementation reduces the incidence of necrotizing enterocolitis in a neonatal rat model

BACKGROUND & AIMS

Neonatal necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of premature infants partly caused by intestinal bacterial proliferation. Because bifidobacteria are thought to reduce the risk for intestinal disturbances associated with pathogenic bacterial colonization, we hypothesized that exogenous bifidobacterial supplementation to newborn rats would result in intestinal colonization and a reduction in the incidence of neonatal NEC.

METHODS

Newborn rat pups were given Bifidobacterium infantis (10(9) organisms per animal daily), Escherichia coli, or saline control and exposed to the NEC protocol consisting of formula feeding (Esbilac; 200 cal. kg(-1). day(-1)) and asphyxia (100% N(2) for 50 seconds followed by cold exposure for 10 minutes). Outcome measures included stool and intestinal microbiological evaluation, gross and histological evidence of NEC, plasma endotoxin concentration, intestinal phospholipase A(2) expression, and estimation of intestinal mucosal permeability.

RESULTS

Bifidobacterial supplementation resulted in intestinal colonization by 24 hours and appearance in stool samples by 48 hours. Bifidobacteria-supplemented animals had a significant reduction in the incidence of NEC compared with controls and E. coli-treated animals (NEC, 7/24 B. infantis vs. 19/27 control vs. 16/23 E. coli; P < 0.01). Plasma endotoxin and intestinal phospholipase A(2) expression were lower in bifidobacteria-treated pups than in controls, supporting the role of bacterial translocation and activation of the inflammatory cascade in the pathophysiology of NEC.

CONCLUSIONS

Intestinal bifidobacterial colonization reduces the risk of NEC in newborn rats.

Variability in patient preferences for participating in medical decision making: implication for the use of decision support tools

While there is an increasing emphasis on patient empowerment and shared decision making, evidence suggests that many patients do not wish to be involved in decisions about their own care. Previous research has found patient preferences for involvement in decision making to vary with age, socioeconomic status, illness experience, and the gravity of the decision. Furthermore, there is evidence that certain patients may experience disutility from being involved in decision making about the treatment of their health problems. We discuss the implications of these findings for the use of decision support tools and the difficulties of targeting their use towards those patients most likely to benefit. We argue that patients may be ill informed about what participation in decision making actually entails and unaware of the benefits they stand to gain by articulating their preferences to their clinician. Furthermore, clinicians are not good at accurately assessing patients' preferences, while patients may have unrealistic expectations about their clinician's ability to "know what is best" for them. Further research is required to understand variations in patients' preferences for information and involvement in decision making, and the factors that influence them.

Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports

INTRODUCTION

Falls in hospital inpatients are common, with reported rates ranging from 3 to 14 per 1,000 bed days. They cause physical and psychological harm, are associated with impaired rehabilitation, increased length of stay and excess cost, and lead to complaints and litigation, making them a crucial area for risk management. A National Reporting and Learning System (NRLS) for patient safety incidents in England and Wales was utilised to examine frequency of falls in hospitals specialising in acute care, rehabilitation and mental health; related harm; timing; age and gender of patients who fell; and to draw general lessons from this which might inform fall-prevention strategies.

METHODS

The NRLS database was searched retrospectively for slips, trips and falls occurring between 1 September 2005 and 31 August 2006. Organisations were classified as "regularly reporting" if they returned reports at least monthly and with at least 100 patient safety incidents per month for acute trusts and 50 per month for community and mental health trusts. Falls rates were standardised as number of falls per 1,000 occupied bed days. Reporting hospitals used standardised categories for degree of harm from incidents, and injury rates were calculated as the percentage of injuries by severity per fall. Key word searches combined with free text scrutiny were conducted to identify specific injuries. Specific falls rates for time of day, gender and age were also compared, with age and gender adjusted for bed occupancy rates from Hospital Episode Statistics (HES) data. Most data were used descriptively, though 95% confidence intervals were used to facilitate comparisons between groups and where samples are generalised to the data set as a whole.

RESULTS

Reports of 206,350 falls were received from a total of 472 organisations. Falls incidents accounted for 32.3% of all reported patient safety incidents. 152,069 (73.7%) reports were from acute hospitals, 28,198 (13.7%) from community hospitals, and 26,083 (12.6%) from mental health units. Only 102 of these could be classified as "regularly reporting" organisations, and in these the mean standardised rates of falls per 1,000 bed days were 4.8 in acute hospitals, 2.1 in mental health units and 8.4 in community hospitals. 133,417 falls (64.7%) resulted in "no harm," 64,144 (31.1%) in "low harm," 7,506 (3.6%) in "moderate harm," and 1230 (0.6%) in "severe harm," with 26 reported deaths. The proportions of falls resulting in some degree of harm varied significantly across the care settings: mental health units (44.5%; 95% CI 43.9 to 45.1), community hospitals (37.0%; 95% CI 36.4 to 37.6) and acute hospitals (33.4%; 95% CI 33.2 to 33.7). Patients aged 85-89 years had a higher-than-expected likelihood of falling relative to bed days. Males accounted for 50.8% (95% CI 50.5 to 51.1) of falls and females 49.2% (95% CI 48.9 to 49.5). (Occupied bed days were 45.5% male and 54.4% female.) The proportion of falls varied considerably with time, with a peak occurring between 10:00 and 11:59.

DISCUSSION

This paper describes the largest retrospective study of hospital falls incidents and draws on data from almost 500 institutions of varying types. It describes wide variations in falls recording and reporting, and in recorded falls rates between institutions of different types and between institutions of ostensibly similar case-mix. As falls are the commonest reported patient safety incident, there is a pressing need for improvements in local reporting, recording and focused analysis of incident data, and for these data to be used at local and national level better to inform and target falls prevention, as well as to explore the reasons for large apparent differences in falls rates between institutions.

Decision analysis and guidelines for anticoagulant therapy to prevent stroke in patients with atrial fibrillation

BACKGROUND

Clinical guidelines are needed on whether or not to use anticoagulant therapy to prevent stroke in patients with non-valvular atrial fibrillation. We did a Markov decision analysis to model decision-making with regard to warfarin treatment in patients with atrial fibrillation, and used the model to develop evaluative guidelines.

METHODS

The decision analysis involved a systematic literature review supplemented by patients' estimates of the quality of life associated with different states of health, secondary analysis of stroke-registry data, and estimation of service costs; it also incorporated a sensitivity analysis. The derived guidelines were subsequently applied to a cohort of patients with atrial fibrillation.

FINDINGS

We constructed decision tables for 12 age and sex groups. For most risk combinations, warfarin treatment would have decreased health-care costs and increased quality-of-life years, although the clinical decision was sensitive to patients' preferences and to the estimate of warfarin's effectiveness. 97% of women with atrial fibrillation older than 75 years, and 69% aged 65-74 would have been recommended for treatment; for men, the corresponding figures would have been 75% and 53%. With the upper quartile for the loss of quality of life associated with being on warfarin treatment (1.00), all but two of the 116 patients without contraindications would have been treated, whereas with the lower quartile (0.92), only 27 of 116 would have been treated.

INTERPRETATION

Decision analysis is useful in the incorporation of complex probabilistic data into informed decision-making, the identification of factors influencing such decisions, and the subsequent development of evaluative guidelines.

Sexual behaviour of young people in international tourist resorts

BACKGROUND/OBJECTIVES

Increasingly, young people travel abroad to experience nightlife in international resorts. Although media coverage of such resorts suggests high levels of sexual activity, little empirical data are currently available. We have measured: 3 year trends in sexual behaviour of young people visiting Ibiza, levels of sexual risk taking, and their relation to substance use. Additionally, in 2002 we identified levels of homosexual sex and sexual interactions between UK residents and individuals from other countries.

METHODS

Data were collected from visitors to Ibiza between 2000 and 2002 just before they left the island. Information on sexual health was surveyed using a short anonymous questionnaire.

RESULTS

Over half of individuals (56.0%) visiting Ibiza had sex with at least one person, with 26.2% of males and 14.5% of females having sex with more than one individual. However, of those arriving without sexual partners (75.5%) just under half (47.5%) have sex in Ibiza and most of these (62.4%) always used condoms. Having any sex abroad was associated with using illicit drugs and having more sexual partners in the 6 months before visiting Ibiza. However, having unprotected sex or sex with more than one person was associated with smoking as well as having higher numbers of sexual partners before their visit. Overall, 8.6% of individuals had sex with a non-UK resident in Ibiza although such individuals were no more likely to have sex without condoms.

CONCLUSIONS

Substantial numbers of individuals visiting international nightlife resorts have unprotected sex with people they meet while abroad. This poses an increasing threat to the sexual health of UK residents but as yet little attention has been paid to developing interventions that might reduce sexual risk taking among young people holidaying abroad.

HTLV-associated myelopathy in a cohort of HTLV-I and HTLV-II-infected blood donors. The REDS investigators

OBJECTIVE

HTLV-I-associated myelopathy (HAM) is a slowly progressive spastic paraparesis caused by infection with human T-lymphotropic virus type I (HTLV-I). The prevalence of HAM among those infected with HTLV-I is poorly defined, and the association of a similar myelopathy with HTLV-II infection has not been confirmed.

DESIGN

Cross-sectional examination of HTLV-I, HTLV-II, and control subjects from the baseline visit of a cohort study. SETTING/ SUBJECTS: Persons testing HTLV seropositive at the time of blood donation at five U.S. blood centers, their seropositive sex partners, and a matched control group of HTLV seronegative blood donors.

MEASUREMENTS

HTLV-I and HTLV-II were differentiated by serology and/or polymerase chain reaction. All subjects received systematic neurologic screening examinations.

RESULTS

A diagnosis of myelopathy was confirmed in four of 166 HTLV-I subjects (2.4%, 95% confidence interval 0.7%, 6.1%) and in one of 404 HTLV-II subjects (0.25%, 95% confidence interval 0.0%, 0.6%). None of the 798 controls had a similar myelopathy, although one had longstanding typical multiple sclerosis.

CONCLUSIONS

Our data also suggest that HAM occurs more frequently among HTLV-I-infected subjects than reported by previous studies. The HTLV-II infected myelopathy patient identified in this cohort, together with three other case reports in the literature, implies a pathogenic role for this human retrovirus. The diagnosis of HTLV-associated myelopathy should be considered in cases of spastic paraparesis or neurogenic bladder when risk factors for HTLV-I or HTLV-II infection are present.

The soybean NRAMP homologue, GmDMT1, is a symbiotic divalent metal transporter capable of ferrous iron transport

Iron is an important nutrient in N2-fixing legume root nodules. Iron supplied to the nodule is used by the plant for the synthesis of leghemoglobin, while in the bacteroid fraction, it is used as an essential cofactor for the bacterial N2-fixing enzyme, nitrogenase, and iron-containing proteins of the electron transport chain. The supply of iron to the bacteroids requires initial transport across the plant-derived peribacteroid membrane, which physically separates bacteroids from the infected plant cell cytosol. In this study, we have identified Glycine max divalent metal transporter 1 (GmDmt1), a soybean homologue of the NRAMP/Dmt1 family of divalent metal ion transporters. GmDmt1 shows enhanced expression in soybean root nodules and is most highly expressed at the onset of nitrogen fixation in developing nodules. Antibodies raised against a partial fragment of GmDmt1 confirmed its presence on the peribacteroid membrane (PBM) of soybean root nodules. GmDmt1 was able to both rescue growth and enhance 55Fe(II) uptake in the ferrous iron transport deficient yeast strain (fet3fet4). The results indicate that GmDmt1 is a nodule-enhanced transporter capable of ferrous iron transport across the PBM of soybean root nodules. Its role in nodule iron homeostasis to support bacterial nitrogen fixation is discussed.

Male-to-female transmission of human T-cell lymphotropic virus types I and II: association with viral load. The Retrovirus Epidemiology Donor Study Group

SUMMARY

Risk factors for male-to-female sexual transmission of human T-lymphotropic virus types I and II (HTLV-I/II) were investigated among HTLV-seropositive volunteer blood donors and their long-term (> or = 6 month) sex partners. Direction of transmission in concordantly seropositive pairs was assessed by analyzing risk factors for HTLV infection. Donors and their partners were also questioned regarding sexual behaviors during their relationships; HTLV antibody titers and viral load were determined for specimens from male partners. Among 31 couples in whom HTLV-infected men likely transmitted infection to their partners (11 HTLV-I and 20 HTLV-II) and 25 male-positive, female-negative couples (8 HTLV-I and 17 HTLV-II), HTLV transmitter men had been in their relationships longer (mean 225 months vs. 122 months) and had higher viral loads (geometric mean 257,549 vs. 2,945 copies/300,000 cells for HTLV-I; 5,541 vs. 118 copies/300,000 cells for HTLV-II) than non-transmitters (P = 0.018 and P = 0.001 for duration of relationship and viral load, respectively, logistic regression analysis). Transmitter men also tended to have higher antibody titers against various env and whole virus proteins than non-transmitters. The identification of high viral load and duration of relationship as risk factors provides a biologically plausible framework in which to assess risk of sexual transmission of the HTLVs.

An epistemology of patient safety research: a framework for study design and interpretation. Part 2. Study design

This is the second in a four-part series of articles detailing the epistemology of patient safety research. This article concentrates on issues of study design. It first considers the range of designs that may be used in the evaluation of patient safety interventions, highlighting the circumstances in which each is appropriate. The paper then provides details about an innovative study design, the stepped wedge, which may be particularly appropriate in the context of patient safety interventions, since these are expected to do more good than harm. The unit of allocation in patient safety research is also considered, since many interventions need to be delivered at cluster or service level. The paper also discusses the need to ensure the masking of patients, caregivers, observers and analysts wherever possible to minimise information biases and the Hawthorne effect. The difficulties associated with masking in patient safety research are described and suggestions given on how these can be ameliorated. The paper finally considers the role of study design in increasing confidence in the generalisability of study results over time and place. The extent to which findings can be generalised over time and place should be considered as part of an evaluation, for example by undertaking qualitative or quantitative measures of fidelity, attitudes or subgroup effects.

Guidelines on anticoagulant treatment in atrial fibrillation in Great Britain: variation in content and implications for treatment

OBJECTIVE

To describe the content of guidelines on the use of anticoagulant treatment in patients with atrial fibrillation and the impact of variations in guidelines on treatment.

DESIGN

Postal survey of guidelines, semistructured interview with lead developers of guidelines, and application of guidelines to patient sample.

SUBJECTS

15 lead developers of the 20 guidelines identified in the postal survey were interviewed. 100 patients over 65 with atrial fibrillation to whom the guidelines were applied.

MAIN OUTCOME MEASURES

Evaluation of guidelines and the methods of dissemination, implementation, review, and evaluation; proportion of patients recommended for anticoagulant treatment by each guideline; and level of agreement between guidelines.

RESULTS

There was considerable variation in whether anticoagulant treatment was recommended for subjects (range 13% to 100%, kappa = 0.12). Guidelines varied greatly in advice on treatment by age, the use of echocardiography, and the target value or range of the international normalised ratio (8 of the 20 guidelines included values unlikely to be effective). Development was unsystematic; evidence based approaches were rarely used, 9 of the 15 lead developers had developed the guidelines themselves, and the 6 guidelines developed by groups relied on informal consensus. Methods to support effective dissemination, implementation, and evaluation were limited.

CONCLUSION

The widespread non-systematic production of guidelines has led to considerable variation with implications for the quality of care and clinical decision making. There is a need for a central, well funded programme of guideline development to ensure that valid guidelines are produced and disseminated.

Sesame seed products contaminated with Salmonella: three outbreaks associated with tahini

In November 2002, the first of three outbreaks of Salmonella Montevideo infection in Australia and New Zealand was identified in New South Wales, Australia. Affected persons were interviewed, and epidemiologically linked retail outlets inspected. Imported tahini was rapidly identified as the source of infection. The contaminated tahini was recalled and international alerts posted. A second outbreak was identified in Australia in June-July 2003 and another in New Zealand in August 2003. In a total of 68 S. Montevideo infections, 66 cases were contacted. Fifty-four (82%) reported consumption of sesame seed-based foods. Laboratory analyses demonstrated closely related PFGE patterns in the S. Montevideo isolates from human cases and sesame-based foods imported from two countries. On the basis of our investigations sesame-based products were sampled in other jurisdictions and three products in Canada and one in the United Kingdom were positive for Salmonella spp., demonstrating the value of international alerts when food products have a wide distribution and a long shelf life. A review of the controls for Salmonella spp. during the production of sesame-based products is recommended.

False-positive HIV-1 test results in a low-risk screening setting of voluntary blood donation. Retrovirus Epidemiology Donor Study

CONTEXT

Persons at risk of human immunodeficiency virus 1 (HIV-1) infection, have been classified incorrectly as HIV infected because of Western blot results, but the frequency of false-positive Western blot results is unknown.

OBJECTIVES

To determine the frequency of false-positive HIV-1 Western blot results in US blood donors and to make projections to other screened populations. Secondarily, to validate an algorithm for evaluating possible false-positive cases.

DESIGN

A retrospective cohort study of HIV-1 enzyme immunoassay (EIA) and Western blot results from large blood donor screening programs in which donors with suspected false-positive Western blot results underwent HIV-1 RNA polymerase chain reaction (PCR) testing and follow-up HIV-1 serology.

SETTING

Five US blood centers participating in the Retrovirus Epidemiology Donor Study.

PARTICIPANTS

More than 5 million allogeneic and autologous blood donors who successfully donated blood at 1 of the 5 participating centers from 1991 through 1995.

MAIN OUTCOME MEASURES

Rate of false positivity by Western blot and true HIV-1 infection status as determined by HIV-1 RNA PCR and by serologic follow-up of blood donors more than 5 weeks after donation.

RESULTS

Of 421 donors who were positive for HIV-1 by Western blot, 39 (9.3%) met the criteria of possible false positivity because they lacked reactivity to p31. Of these, 20 (51.3%) were proven by PCR not to be infected with HIV-1. The false-positive prevalence was 4.8% of Western blot-positive donors and 0.0004% (1 in 251000) of all donors (95% confidence interval, 1 in 173000 to 1 in 379000 donors).

CONCLUSIONS

A false diagnosis of HIV-1 infection can result from the combination of EIA and Western blot testing in blood donor and other HIV-1 screening programs. Individuals with a positive Western blot result lacking the p31 band should be counseled that, although they may be HIV infected, there is uncertainty about this conclusion. These individuals should be further evaluated by RNA PCR testing (if feasible) and HIV serologic analysis on a follow-up sample.

Cross-infection between animals and man: possible feline transmission of Staphylococcus aureus infection in humans?

An outbreak of epidemic methicillin-resistant Staphylococcus aureus occurred on a rehabilitation geriatric ward. Intensive screening of patients and staff revealed an unusually high carriage rate in the nursing staff (38%), thought to be related to a ward cat which was heavily colonized from the environment. Infection control measures and removal of the cat led to rapid resolution of the outbreak.

Variability in patient preferences for participating in medical decision making: implication for the use of decision support tools

While there is an increasing emphasis on patient empowerment and shared decision making, evidence suggests that many patients do not wish to be involved in decisions about their own care. Previous research has found patient preferences for involvement in decision making to vary with age, socioeconomic status, illness experience, and the gravity of the decision. Furthermore, there is evidence that certain patients may experience disutility from being involved in decision making about the treatment of their health problems. We discuss the implications of these findings for the use of decision support tools and the difficulties of targeting their use towards those patients most likely to benefit. We argue that patients may be ill informed about what participation in decision making actually entails and unaware of the benefits they stand to gain by articulating their preferences to their clinician. Furthermore, clinicians are not good at accurately assessing patients' preferences, while patients may have unrealistic expectations about their clinician's ability to "know what is best" for them. Further research is required to understand variations in patients' preferences for information and involvement in decision making, and the factors that influence them.

Phase I/II study of vaccination with dendritic-like leukaemia cells for the immunotherapy of acute myeloid leukaemia

Twenty-two patients with acute myeloid leukaemia were recruited into a phase I/II clinical trial investigating the vaccination of patients in complete remission (CR) with autologous dendritic-like leukaemia cells (DLLC). At trial entry, leukaemia cells were harvested and tested for their ability to undergo cytokine-induced dendritic cell differentiation. Patients were then treated with intensive chemotherapy. Five patients achieved both CR and had leukaemia cells that successfully underwent differentiation and therefore proceeded to vaccination. Four escalating doses of DLLC were administered weekly by subcutaneous injection. Vaccination was generally well tolerated although one patient developed extensive eczema and an increased antinuclear factor titre possibly indicating induction of autoimmunity. Development of anti-leukaemic T-cell responses was assessed by enzyme-linked immunospot analysis of gamma-interferon secreting T lymphocytes and by human leucocyte antigen tetramer analysis for WT1-specific T cells. Increases in anti-leukaemic T-cell responses were demonstrated in four patients, but only two of the five remained in remission more than 12 months postvaccination. The study has demonstrated that generation of DLLC is feasible in only a subgroup of patients and is currently neither broadly applicable or clinically effective.

An epistemology of patient safety research: a framework for study design and interpretation. Part 3. End points and measurement

This article builds on the previous two articles in this series, which focused on an evaluation framework and study designs for patient safety research. The current article focuses on what to measure as evidence of safety and how these measurements can be undertaken. It considers four different end points, highlighting their methodological advantages and disadvantages: patient outcomes, fidelity, intervening variables and clinical error. The choice of end point depends on the nature of the intervention being evaluated and the patient safety problem it has been designed to address. This paper also discusses the different methods of measuring error, reviewing best practice and paying particular attention to case note review. Two key issues with any method of data collection are ensuring construct validity and reliability. Since no end point or method of data collection is infallible, the present authors advocate the use of multiple end points and methods where feasible.