Process, structural, and outcome quality indicators to support perioperative opioid stewardship: a rapid review.

Opioids are effective analgesics but can cause harm. Opioid stewardship is key to ensuring that opioids are used effectively and safely. There is no agreed set of quality indicators relating to the use of opioids perioperatively. This work is part of the Yorkshire Cancer Research Bowel Cancer Quality Improvement programme and aims to develop useful quality indicators for the improvement of care and patient outcomes at all stages of the perioperative journey.A rapid review was performed to identify original research and reviews in which quality indicators for perioperative opioid use are described. A data tool was developed to enable reliable and reproducible extraction of opioid quality indicators.A review of 628 abstracts and 118 full-text publications was undertaken. Opioid quality indicators were identified from 47 full-text publications. In total, 128 structure, process and outcome quality indicators were extracted. Duplicates were merged, with the final extraction of 24 discrete indicators. These indicators are based on five topics: patient education, clinician education, pre-operative optimization, procedure, and patient-specific prescribing and de-prescribing and opioid-related adverse drug events.The quality indicators are presented as a toolkit to contribute to practical opioid stewardship. Process indicators were most commonly identified and contribute most to quality improvement. Fewer quality indicators relating to intraoperative and immediate recovery stages of the patient journey were identified. An expert clinician panel will be convened to agree which of the quality indicators identified will be most valuable in our region for the management of patients undergoing surgery for bowel cancer.

Multi-technique comparison of source and primary transfer soil samples: an experimental investigation.

The comparison of soil samples is of long-standing and increasing interest in forensic science. Routine comparisons should involve the use of several techniques in combination. A wide range of analytical techniques can be used, choice being dependent on several factors including sample size and character, time constraints and cost limitations. In this paper results are presented for experiments carried out to test the effectiveness of four of the available analytical techniques (spectro-photometric colour determination, laser diffraction particle size analysis, stable isotope analysis and chemical element analysis) used to compare single source and primary transfer soil samples. Four soil types and five footwear types were used. All four techniques showed excellent precision and good resolving power between soil types. Only relatively small differences were obtained between source and transferred soil samples in terms of colour, stable carbon and nitrogen isotope ratios and elemental chemistry. Slight but significant differences were found in grain size, indicating that the primary transfer process is to some extent grain size selective.

Innovative approaches to educating medical students for practice in a changing health care environment: the National UME-21 Project.

In today's continually changing health care environment, there is serious concern that medical students are not being adequately prepared to provide optimal health care in the system where they will eventually practice. To address this problem, the Health Resources and Services Administration (HRSA) developed a $7.6 million national demonstration project, Undergraduate Medical Education for the 21st Century (UME-21). This project funded 18 U.S. medical schools, both public and private, for a three-year period (1998-2001) to implement innovative educational strategies. To accomplish their goals, the 18 UME-21 schools worked with more than 50 organizations external to the medical school (e.g., managed care organizations, integrated health systems, Area Health Education Centers, community health centers). The authors describe the major curricular changes that have been implemented through the UME-21 project, discuss the challenges that occurred in carrying out those changes, and outline the strategies for evaluating the project. The participating schools have developed curricular changes that focus on the core primary care clinical clerkships, take place in ambulatory settings, include learning objectives and competencies identified as important to providing care in the future health care system, and have faculty development and internal evaluation components. Curricular changes implemented at the 18 schools include having students work directly with managed care organizations, as well as special demonstration projects to teach students the knowledge, skills, and attitudes necessary for successfully managing care. It is already clear that the UME-21 project has catalyzed important curricular changes within 12.5% of U.S. medical schools. The ongoing national evaluation of this project, which will be completed in 2002, will provide further information about the project's impact and effectiveness.

Diagenesis of US Gulf Coast shales.

The burial diagenesis of mudstones is of major interest in petroleum geology1-3. Key questions which remain incompletely answered include the relative importance of temperature, time, changes in pore-water chemistry and organic maturation as driving mechanisms, and the relationship between diagenesis in mudstones and neighbouring sandstones4-7. We reconsider here the nature and timing of diagenesis in Gulf Coast Tertiary mudstones using data obtained by backscattered electron microscopy (BSEM) and energy-dispersive X-ray analysis (EDS) of cuttings from two Texas wells. Our observations confirm the mineralogical trends with depth reported by Hower et al.1 and suggest new evidence concerning the timing and causes of the changes. The most important mineralogical changes occurred in the zone of organic matter decarboxylation (zone IV8). We show that the sequence of burial diagenetic events can be established quickly and reliably by BSEM examination of shale cuttings, and demonstrate the use of foram tests and their authigenic mineral infillings as indicators of diagenesis in soft, fine-grained shales.