Health service accreditation stimulating change in clinical care and human resource management processes: A study of 311 Australian hospitals.

OBJECTIVE: This study aimed to establish whether longitudinal participation in an accreditation program is translated into improvement in continuity of quality patient care and human resource management (HRM) processes outcomes. MATERIALS AND METHODS: This was a secondary data analysis of accreditation panel data from acute hospitals participating in the Australian Council on Healthcare Standards' Evaluation and Quality Improvement Program (EQuIP). EQuIP criteria data from 311 hospitals were collected by external surveyors across 2003-2006 (Time 1) and 2007-2010 (Time 2). Mandatory accreditation criteria ratings at Time 1 were used to determine hospital performance group membership (1 = below moderate, 2 = moderate, 3 = above moderate). Analysis was undertaken of ratings across continuity of quality patient care and HRM process criteria, at Time 1 and 2. RESULTS: Continuity of quality patient care and HRM processes improved across time in the three performance groups. Lower performing hospitals improved at a greater rate than moderate and higher performing hospitals. The groupings and performance order did not change over time. CONCLUSIONS: An accreditation program is an external driver that facilitates continual and systemic quality improvement changes to sub-systems with an organisation.

Increased Lipocalin 2 level may have important role in thrombotic events in patients with polycythemia vera and essential thrombocythemia.

The aim of our study was to evaluate the possible effect of lipocalin 2 on thrombotic events in polycythemia vera and essential thrombocythemia patients. The samples of 89 patients were collected and RNA based method was used to evaluate the relative gene expression level of lipocalin 2. 74 samples were available for evaluation. Drawing a cut off point at level 30 relative expression rate, 13 patients with elevated lipocalin 2 expression had thrombotic events during the course of their disease. Based on these data high lipocalin 2 expression level seems to have strong positive predictive value on thrombotic events in patients with polycythemia vera and essential thrombocythemia. Lipocalin 2 may be useful in thrombotic risk stratification in these patients.

[Surprise in abrasion diagnostics]. / Überraschung in der Abradatdiagnostik.

Typical localizations of gynecological squamous cell carcinomas are the cervix, vulva and vagina and are therefore not uncommonly diagnosed in curettages. A differentiation from reactive hyperplastic alterations with a possible invasiveness in samples taken from the surface of the special type of well-differentiated verrucous squamous cell carcinoma can be difficult. This pitfall of such a tumor is presented in the case described here with corresponding diagnostic difficulties.

Health service accreditation reinforces a mindset of high-performance human resource management: lessons from an Australian study.

OBJECTIVE: To investigate whether an accreditation program facilitates healthcare organizations (HCOs) to evolve and maintain high-performance human resource management (HRM) systems. DESIGN: Cross-sectional multimethod study. SETTING AND PARTICIPANTS: Healthcare organizations participating in the Australian Council on Healthcare Standards Evaluation and Quality Improvement Program (EQuIP 4) between 2007 and 2011. MAIN OUTCOME MEASURES: Ratings across the EQuIP 4 HRM criteria, a clinical performance measure, surveyor reports (HRM information) and interview data (opinions and experiences regarding HRM and accreditation). RESULTS: Healthcare organizations identified as high performing on accreditation HRM criteria seek excellence primarily because of internal motivations linked to best practice. Participation in an accreditation program is a secondary and less significant influence. Notwithstanding, the accreditation program provides the HCO opportunity for internal and external review and assessment of their performance; the accreditation activities are reflective learning and feedback events. CONCLUSIONS: This study reveals that HCOs that pursue highly performing HRM systems use participation in an accreditation program as an opportunity. Their organizational mindset is to use the program as a tool by which to reflect and obtain feedback on their performance so to maintain or improve their management of staff and delivery of care.

Genetic differentiation in the genus Lithops L. (Ruschioideae, Aizoaceae) reveals a high level of convergent evolution and reflects geographic distribution.

Southern Africa is one of the hot spots for plant biodiversity, with ca. 80% of species endemic to this area. Rapid and recent radiations in Southern African plant genera were triggered by fine-scale differences in climate, topography and geology. The genus Lithops (Ruschioideae, Aizoaceae) contains 37 species and is widely distributed in Southern Africa. Species delimitation within the genus is challenging because the limited number of morphological characters in these reduced succulents varies intensely between populations, presumably as adaptations to local geological environments. We analysed phylogenetic relationships within Lithops using non-coding chloroplast DNA (trnS-trnG intergenic spacer), nuclear ribosomal internal transcribed spacer (nrITS) sequences and AFLP data. Genetic variability of the sequence data was very low, but AFLP data detected nine clades within Lithops that do not fit current morphology-based taxonomy. Two of these clades are separated by their distribution on the northern and eastern border of the distribution area, and four clades are found in the Gariep Centre in the estuary of the Orange River. Morphological similarities, especially colour of leaves, evolved repeatedly within the clades, thus we hypothesise that closely related species became adapted to different soil types in a mosaic-like geological environment. One-third of the species are found in the Gariep Centre, characterised by extremely diverse edaphic habitats.

Brief review of dinosaur studies and perspectives in Brazil.

Dinosaur research is developing at very high rates around the world resulting in several new discoveries that are improving our understanding of this terrestrial reptilian clade. Except for the last couple years, the studies of Brazilian dinosaurs have not followed this expansive trend, despite the high potential of several dinosaur localities. So far there are only eight described taxa, four in the last year, representing theropod, sauropod, and one possible prosauropod taxa. Except for footprints, there are no records of ornithischian dinosaurs in the country what is at least partially explainable by the lack of continuous vertebrate fossil collecting program in the country. More funding is necessary to improve the research activities in this field.

High-performance clinical patient data review and consultation system.

Primary care physicians rely on specialists. Specialists are too expensive to be located at every clinical site requiring a practical means for specialists to help without requiring patients or specialists to travel for consultation. To address the challenge of providing primary care physician access to specialists, we are developing a clinical prototype system for the high-speed access and transfer of patient data and images within Radiology Departments, Medical Centers and Health Care Networks. The key components of the system are: a high-bandwidth network (100 Mbit/s upgradeable to ATM); an image server system with a 30-60 day patient image on-line archive ( < 10 sec. recall) coupled with a long term archive; viewing consoles matching existing film display paradigms located within the medical center and clinics providing rapid access to patient data and diagnostic images for house staff (OR/ER/ICU); clinician access to the image archive on a consultation basis in office computers; and image review applications which closely follow the established paradigms used by clinicians. Using our system primary care physicians can rapidly review patient data locally obtaining additional consultation from tertiary sites while the patient is present. Clinics and outlying medical centers gain rapid access to specialists with physicians in different cities discussing patient diagnostic and management issues in a shared environment leading to instantaneous data analysis and diagnosis further reducing health care costs and enhancing patient care.

Acute effects of ranitidine, famotidine and omeprazole on plasma gastrin in the rat.

In the rat, treatment with gastric inhibitory drugs may result in hypergastrinemia, an effect thought to be in response to increased gastric pH caused by inhibition of acid secretion. This study compared 24-hr profiles of plasma gastrin levels associated with three different compounds at equivalent, highly effective antisecretory doses. Ranitidine, famotidine and omeprazole at 60, 20 and 40 mg/kg p.o., respectively, inhibited basal acid secretion of chronic gastric fistula rats by greater than 95% and raised intraluminal pH to above 7.0 for 5 hr. The peak plasma gastrin levels associated with each agent were observed 5 hr after dosing. Ranitidine, famotidine and omeprazole induced statistically significant and distinct peak hypergastrinemic responses of 312 +/- 20, 483 +/- 28 and 616 +/- 27 pg/ml, respectively. After 8 hr ranitidine and famotidine associated gastrin values returned to control levels, whereas those of omeprazole remained substantially above control values until the 12th hr. Differences in peak gastrin levels between compounds disappeared at increased dose levels of 500 mg/kg for ranitidine, 200 or 2000 mg/kg for famotidine and 140 mg/kg for omeprazole. Unlike high dose famotidine, omeprazole (140 mg/kg) maintained peak plasma gastrin levels at 8, 12, and 16 hr after dosing. These studies demonstrate clearly hypergastrinemic responses to single dose administration of ranitidine, famotidine and omeprazole. The differences observed in peak plasma gastrin levels at equivalent antisecretory doses of these agents suggests the presence of luminal acid independent components that effect gastrin release. Moreover, these studies indicate that, in the rat, the most unique aspect of omeprazole-associated hypergastrinemia is the magnitude of its prolonged response.

[Sonography and cytology of cold thyroid nodules]. / Sonographie und Zytologie von kalten Schilddrüsenknoten.

270 patients with a scintigraphically cold thyroid nodule of sonographically increased (n = 34), diminished (n = 72) or neutral (n = 86) echogenity or cystic criteria (n = 78) were subjected to fine needle aspiration biopsy. This revealed unequivocal malignancy in 8 and follicular neoplasia in another 30 patients, 10 of whom proved to have malignomas on further evaluation. A total of 12 papillary and 2 follicular carcinomas, 2 non-Hodgkin lymphomas, 1 sarcoma and the metastasis of a breast carcinoma were diagnosed. The most sensitive criteria for malignancy were diminished echogenity, an inhomogeneous echo pattern and the occurrence of a solitary nodule. The incidence of malignancy was increased among males but not among especially young persons. There was no sonographic feature that would permit omission of fine needle aspiration.

[Detection of immune complexes in intrauterine retardation]. / Nachweis von Immunkomplexen bei intrauteriner Retardierung.

We tried to find an additional diagnostic parameter for intrauterine growth retardation. The immune complex estimations were carried out by means of precipitation of immune complexes with Polyethylenglykol 6.000 in 203 primi and multiparae suspected for intrauterine growth retardation. The control group (y = 0.073 X + 0.372; r = 0.459) showed an increase of immune complex concentrations towards the end of pregnancy. A possibility for interpretation is the daily penetration of fetal material in to the maternal circulation. Women with suspicion of intrauterine growth retardation (y = -0.045 X + 1.61; r = -0.053) showed a decrease of immune complex concentration at the end of pregnancy. This course is contrary to that one of immune complex concentrations in the control group. The distribution of immunglobulins in the precipitate is corresponding to the proportions in serum. We found mainly IgG and IgM, but also high molecular serumproteins as Alpha-2-Makroglobulin and Orosomucoid. A discreet correlation between intrauterine growth retardation and pathological immune complex values may be present.

Hepatitis B vaccine in medical staff of hemodialysis units: efficacy and subtype cross-protection.

We evaluated the efficacy of hepatitis B vaccine (Heptavax-B) containing only the ad subtype in a randomized, placebo-controlled, double-blind trial among 865 staff members of 43 hemodialysis units in the United States. Surface antibody developed in 92.6 per cent of the subjects after two doses of vaccine and in 96 per cent after the six-month booster. The incidence of infections with hepatitis B virus (with or without hepatitis) was 9.9 per cent in placebo recipients and 2.2 per cent in vaccine recipients (P less than 0.01). The two cases of hepatitis B among vaccine recipients did not occur in subjects in whom antibody had developed. In 81 per cent of the hepatitis events, the virus was of the ay subtype. The indicence of ay virus was 8.2 per cent among placebo recipients and 1.2 per cent among vaccine recipients (P less than 0.005). We conclude that these data confirm the efficacy of the vaccine and demonstrate subtype cross-protection.

A controlled clinical trial of the efficacy of the hepatitis B vaccine (Heptavax B): a final report.

A controlled, randomized, double-blind trial in 1,083 homosexual men from New York confirmed that a highly purified, formalin-inactivated vaccine against hepatitis B prepared from HBsAg positive plasma, is safe immunogenic, and highly efficacious. Over 95% of vaccinated subjects developed antibody against the surface antigen. Vaccine-induced antibody persisted for the entire 24-month follow-up period. The attack rate of all hepatitis B virus infections (excluding conversions of anti-HBc alone) was 3.2% in vaccine recipients compared with 25.6% in placebo recipients (p less than 0.0001). In those who received all three doses of vaccine, of 40 micrograms each, the protective efficacy rate was close to 100%. The vaccine protects against acute hepatitis B, asymptomatic infection, and chronic antigenemia. There is reason to assume that the vaccine is also partially effective when given postexposure.

Hepatitis B vaccine: demonstration of efficacy in a controlled clinical trial in a high-risk population in the United States.

We assessed the efficacy of an inactivated hepatitis B vaccine in a placebo-controlled, randomized, double-blind trial in 1083 homosexual men known to be at high risk for hepatitis B virus infection. The vaccine was found to be safe and the incidence of side effects was low. Within two months, 77% of the vaccinated persons had high levels of antibody against the hepatitis B surface antigen. This rate increased to 96% after the booster dose and remained essentially unchanged for the duration of the trial. For the first 18 months of follow-up, hepatitis B or subclinical infection developed in only 1.4 to 3.4% of the vaccine recipients as compared with 18 to 27% of placebo recipients (P < 0.0001). The reduction of incidence in the vaccinees was as high as 92.3%; none of the vaccinees with a detectable immune response to the vaccine had clinical hepatitis B or asymptomatic antigenemia. A significant reduction of incidence was already seen within 75 days after randomization; this observation suggests that the vaccine may be efficacious even when given after exposure.

A new type of congenital nephrotic syndrome.

Description of a newborn male suffering from hydrops fetalis of unknown cause. Placenta showed multiple chorioangiomata. Coincidence of chorioangiomata of the placenta and hydrops fetalis has not been previously reported. The authors suggest a new kind of glomerulopathy as a cause of congenital nephrotic syndrome.