Subspecialisation in cardiology care and outcome: should clinical services be redesigned, again?

BACKGROUND: Inpatient management of cardiac patients by cardiologists results in reduced mortality and hospitalisation. With increasing subspecialisation of the field because of growing management complexity and use of technological innovations, the impact of sub-specialisation on patient outcomes is unclear. AIM: To investigate whether management by subspecialty cardiologists impacts the outcomes of patients with subspecialty-specific diseases. METHODS: All patients admitted to a tertiary centre over nine years with a diagnosis of heart failure, acute coronary syndrome (ACS) or primary arrhythmia were reviewed. The outcomes of these patients managed by cardiologists subspecialised in their admission diagnosis (heart failure specialists, interventionalists and electrophysiologists) were compared with those treated by general cardiologists. RESULTS: Heart failure was diagnosed in 1704 patients, ACS in 7763 and arrhythmia in 4398. There was no difference in length of stay (LOS) (P = 0.26), mortality (P = 0.57) or cardiovascular readmissions (P = 0.50) in heart failure patients treated by general cardiologists compared with subspecialists. In ACS patients, subspecialty management was associated with reduced LOS, cardiovascular readmissions and mortality (all P < 0.05). This reduction in mortality was seen mainly in lower risk patients (P < 0.05). There was a reduction in LOS and cardiovascular readmissions in arrhythmia patients receiving subspecialty management (both P < 0.05) but no difference in mortality (P = 0.14). ACS patients managed by interventionalists were more likely to undergo coronary intervention (P < 0.05). Electrophysiologists more frequently referred patients for catheter ablation and pacemaker implantation than general cardiologists (P < 0.05). CONCLUSIONS: The benefits of subspecialty care seem attributable to the appropriate selection of patients who would benefit from technological innovations in care. These results suggest that the development of healthcare systems which align cardiovascular disease with the subspecialist may be more effective.

'Healthy gums do matter': A case study of clinical leadership within primary dental care.

The Health and Social Care Act 2012 heralded wide reaching reforms intended to place clinicians at the heart of the health service. For NHS general dental practice, the conduits for this clinical leadership are the NHS England local professional networks. In Greater Manchester, the local professional network has developed and piloted a clinician led quality improvement project: 'Healthy Gums DO Matter, a Practitioner's Toolkit'. Used as a case study, the project highlighted the following facilitators to clinical leadership in dentistry: supportive environment; mentoring and transformational leadership; alignment of project goals with national policy; funding allowance; cross-boundary collaboration; determination; altruism; and support from wider academic and specialist colleagues. Barriers to clinical leadership identified were: the hierarchical nature of healthcare, territorialism and competing clinical commitments.

NHS Health Checks in a primary care dental setting - an opportunity for the profession to maximise uptake for public health partners?

This opinion piece considers an opportunity for primary dental care practitioners to work in partnership with public health teams to maximise the uptake of the NHS Health Check. Public Health England and Local Authority partners remain committed to offering the NHS Health Check to those aged 40-74 years old. The programme previously explored alternative points of delivery - such as community pharmacists. This piece discusses and reflects on the efforts within Manchester to use skill mix in primary dental care services and widen access to target individuals eligible for an NHS Health Check. The pilot schemes in Manchester illustrated the willingness and enthusiasm for primary care dentists to embrace change and work alongside new partners to deliver patient benefit beyond the provision of dental care. However, substantial barriers to implementation prevented the desired level of progress.

A qualitative evaluation of a Local Professional Network programme "Baby Teeth DO Matter".

OBJECTIVE: The objective of this study was to use a qualitative approach to examine the perceptions of dentists who led a health promotion programme entitled "Baby Teeth DO Matter". BASIC RESEARCH DESIGN: Semi-structured interviews were undertaken with a variety of participants in a health promotional programme facilitated by a shadow Local Professional Network. These were then recorded and transcribed verbatim. The transcripts were line numbered and subjected to thematic analysis to develop a coding frame. Overarching themes were developed from the coded transcripts by organising them into clusters based on the similarity of their meaning and checked against the coded extracts and the raw data. CLINICAL SETTING: General Dental Practice. PARTICIPANTS: General Dental Practitioners. INTERVENTIONS: A Greater Manchester-wide prevention programme entitled "Baby teeth DO Matter". MAIN OUTCOME MEASURES: To determine the perceptions of involved clinicians and whether "clinically owned and clinically led" services add value. RESULTS: Eight codes were generated: "Success of the project", "Down-stream to up-stream", "Importance of clinically led and clinically owned", "Keeping the approach simple", "Importance of networking", "Importance of Dental Public Health", "Importance of task and finish" and "Threats to the future of the Local Professional Network". These were organised into three over-arching themes. CONCLUSIONS: "Clinically Led and Clinically Owned" projects appear to empower local practitioners and add value. They encourage community-facing practitioners, build capacity and develop personal skills;--all in accordance with the fundamental principles of the Ottawa Charter. Distributed leadership was seen to be effective and Dental Public Health input, "Task and Finishing", resources and clarity of communication were all considered to be of critical importance.

Estimating the need for dental sedation. 4. Using IOSN as a referral tool.

OBJECTIVE: In this article we report on the use of the IOSN as a referral tool in primary care and the need for sedation in the referred patient population (as determined by the IOSN score). SETTING: Four centres in the North West of England (primary care) accepting referrals for treatment with the aid of sedation participated in this study. DESIGN: A service evaluation. SUBJECTS (MATERIALS) AND METHODS: The four were provided with IOSN referral forms, operator and patient questionnaires. The centres distributed IOSN forms to referrers as a means of recommending patients for sedation. All patients receiving treatment under sedation (having been referred for treatment through the IOSN form) were asked to complete the patient questionnaire. The individual operator who undertook the treatment under sedation was asked to complete the operator questionnaire. Data were entered into SPSS and the IOSN score noted. Statistical analyses of the data utilised descriptives and comparisons between groups using the Chi Squared test. RESULTS: Seventy-eight percent of the patients (n = 140) in this study were receiving treatment with sedation appropriately according to the principals of the IOSN. Patients deemed by the IOSN tool to have a low need for sedation were less likely to cancel their appointment if sedation had not been given. The majority of patients were female (70%) and the majority of operators and patients reported the IOSN forms acceptable for use. CONCLUSIONS: This study provides support for using the IOSN as a tool for organising sedation referral. The majority of operators and patients reported the IOSN forms acceptable for use.

Introducing care pathway commissioning to primary dental care: measuring performance.

Care pathways have been used in a variety of ways: firstly to support quality improvement through standardising clinical processes, but also for secondary purposes, by purchasers of healthcare, to monitor activity and health outcomes and to commission services. This paper focuses on reporting a secondary use of care pathways: to commission and monitor performance of primary dental care services. Findings of a project involving three dental practices implementing a system based on rating patients according to their risk of disease and need for care are outlined. Data from surgery-based clinical databases and interviews from commissioners and providers are reported. The use of both process and outcome key performance indicators in this context is discussed, as well as issues which arise such as attributability of outcome measures and strategic approaches to improving quality of care.

Estimating the need for dental sedation. 1. The Indicator of Sedation Need (IOSN) - a novel assessment tool.

While the control of pain and anxiety is fundamental to the practice of dentistry, the use of conscious sedation in dentistry is very variable among dentists. The need for conscious sedation could be considered by assessing and ranking a combination of information on patient anxiety, medical history and the complexity of the anticipated clinical treatment. By undertaking this systemtic assessment an indication of sedation need may be developed which would act as an aide to decision making and, potentially, referral management. Such a tool could also be used by commissioners who need to identify patients who need conscious sedation for dental treatment in order to plan, commission and deliver appropriate sedation services.

Estimating the need for dental sedation. 2. Using IOSN as a health needs assessment tool.

AIM: This service evaluation assessed the need for sedation in a population of dental attenders (n = 607) in the North West of England. METHODS: Using the novel IOSN tool, three clinical domains of sedation need were assessed: treatment complexity, medical and behavioural indicators and patient reported anxiety using the Modified Dental Anxiety Scale. RESULTS: The findings suggest that 5% of the population are likely to require a course of treatment under sedation at some time. All three clinical domains contributed to the IOSN score and indication of treatment need. Females were 3.8 times more likely than males to be placed within the high need for sedation group. Factors such as age, deprivation and practice location were not associated with the need for sedation. CONCLUSIONS: Primary care trusts (PCTs) need health needs assessment data in order to commission effectively and in line with World Class Commissioning guidelines. This study provides both an indicative figure of need as well as a tool by which individual PCTs can undertake local health needs assessment work. Caution should be taken with the figure as a total need within a population as the study has only included those patients that attended dental practices.

Improving oral health among schoolchildren - which approach is best?

This opinion piece considers the focus of the coalition government on improving the dental health of schoolchildren. It shows how oral health improvement teams have moved on from approaches which involve the education of children alone. More modern interventions are selected from a palette of evidence-informed options to suit the needs of the local population. Such options should ensure a multilevel approach. A plea is made for any new guidance to be informed by dental public health specialists who have practical experience to ensure that outdated methods are not re-introduced.

Introducing care pathway commissioning to primary dental care: the concept.

Care pathways are defined as 'a methodology for the mutual decision making and organisation of care for a well-defined group of patients during a well-defined period'. Although most often used in Europe as a tool to improve the quality of care and to aid the continuity of care between disciplines and settings, care pathways also have an application in underpinning the commissioning process. This paper describes the development of a new model of commissioning for general dental practice services based on a need and risk assessment linked to specified care pathways for preventive care. In this system dentists are monitored on adherence to care protocols based on nationally accepted guidelines for preventive care interventions as well as recommended recall intervals for routine dental examinations. A traffic light system to distinguish between patients with different levels of need and risk of disease is being used.

Development of immunoassay for detection of meat and bone meal in animal feed.

An immunoassay system was developed for efficient detection of prohibited meat and bone meal (MBM) in animal feed. Monoclonal antibodies (MAbs) were raised against bovine smooth muscle autoclaved at 130 degrees C for 20 min. Among the 1,500 supernatants of hybridoma cells screened, MAbs 3E1, 1G3, and 3E10 were selected and characterized in this study. The first set of MAbs produced, 3E1 and 1G3, had stronger reactivity against MBM than against smooth muscle that was heat treated at 90 degrees C for 10 min. However, reactivity gradually increased against smooth muscle that was autoclaved at 130 degrees C for up to 1 h. The enzyme-linked immunosorbent assay for detection of MBM in animal feed was optimized with the MAb 3E10 because of its superior performance. MAb 3E10 diluted to 100-fold was used to differentiate bovine MBM from that of other species in ingredients used for commercial animal feeds and could detect down to 0.05% MBM mixed in animal feed.

A scheme to recruit Pakistani and Bangladeshi trainee dental nurses in a multiethnic area of Greater Manchester.

The primary dental care services in Oldham, Greater Manchester have established an innovative scheme to encourage diversity in primary dental care services. The scheme involves the recruitment of bilingual trainee dental nurses in order to improve accessibility and appropriateness of the services and to improve communication with Pakistani and Bangladeshi patients. The scheme has raised a number of issues for trainees, existing staff and management. However all groups evaluated the scheme as worthwhile. Achievements of the scheme include better communication, better understanding of different ethnic communities among the staff and increased confidence and employability of trainees. It is recommended that similar schemes be adopted for primary dental care and other health services in areas with significant ethnic minority populations.

Production of monoclonal antibody for the detection of meat and bone meal in animal feed.

For the detection of prohibited meat and bone meal (MBM) in animal feed, monoclonal antibodies (MAbs) were raised against heat-stable h-caldesmon purified from bovine intestinal smooth muscle. The obtained hybridoma cells were screened against extracts of the bovine MBM and heat-treated smooth muscle, and MAb 5E12 was identified as having the best performance. Antibody 5E12 did not react with animal feed, milk product, plant proteins, and other ingredients used for commercial animal feed except for the gelatin. This antibody diluted to 100-fold was able to detect MBM mixed in animal feed at 0.05% in an ELISA, and it showed strong affinity toward bovine smooth muscle autoclaved at 130 degrees C. Therefore, this antibody can be used in the ELISA system for field testing of the presence of MBM in animal feed.

Appropriateness of a Resuscitation Council (UK) advanced life support course for primary care dentists.

OBJECTIVES: To investigate whether a standard Resuscitation Council (UK) ALS course is appropriate for primary care dentists or whether a course should be specifically designed for dentists. DESIGN: Opinions canvassed by pre-course expectation and post-course evaluation questionnaires. SUBJECTS: 23 West Pennine primary care dentists providing a general anaesthetic or conscious sedation service who attended an ALS course. RESULTS: Knowledge and skills were rated on a 5-point scale from 1 (not important at all) to 5 (extremely important). Basic airway management (mean = 5) and anaphylaxis (mean = 4.9) scored the highest on the 'expectation' questionnaire. Rhythm recognition (P < 0.001), defibrillation (P = 0.007) and arrest algorithms (P = 0.047) were rated as significantly more important after the course than before. Knowledge about rhythm disorder management, cardiac pacing, post-resuscitation care, blood gas interpretation and bereavement were not considered to be so important either before or after the course. CONCLUSIONS: Despite rating some aspects as unimportant, all dentists stated that this course had been appropriate. They did not want a specially designed ALS course for dentistry. Taking exactly the same recognised course and assessments as other healthcare professionals and gaining the same certification was felt to be important to this group of dentists.

An investigation of the effects on children of tooth extraction under general anaesthesia in general dental practice.

OBJECTIVE: To describe the morbidity related to general anaesthesia provided in general dental practices for the extraction of teeth in school children. DESIGN: Observational study supported by structured questionnaires and interviews. SETTING: Three general dental practices in a Lancashire health district and children's homes. SUBJECTS: 80 children aged 5-15 years undergoing extractions under general anaesthesia. MAIN OUTCOME MEASURES: Observed demeanour of the children prior to, during and immediately after the surgical procedures. Reported morbidity during the following 24 hours and 1 month later. RESULTS: 92% of the children complained of symptoms associated with the surgery under general anaesthesia. Distress was noted in 16 (20%) patients during the induction of 26 (33%) during recovery. Continued crying was reported for 24 (39%) during the journey home and for 23 (37%) once home had been reached. Other symptoms included nausea, vomiting, sickness and prolonged bleeding. Six reported psychological trauma 1 month after; three had nightmares, two had continuing bad memories and one was depressed for several days. CONCLUSION: Morbidity following extractions under general anaesthesia in general dental practice is common and has distressing consequences for the young patients and their carers.

Immunohistochemical diagnosis of Toxoplasma gondii: potential for cross-reactivity with Neospora caninum.

A monoclonal antibody (MAB 3F5) was compared with a commercial polyclonal antibody for specificity for Toxoplasma gondii and cross-reactivity with Neospora caninum in paraffin-embedded tissue sections. Both antibody preparations reliably recognized T. gondii tachyzoites (RH isolate) in animal tissues but did not always label tissue cysts (ME-49 isolate). The commercial antibody strongly cross-reacted with N. caninum tachyzoites, but MAB 3F5 did not when the immunoperoxidase, immunofluorescence, or immunogold procedures were employed, nor did it cross-react with other apicomplexans, e.g., Isospora suis, Eimeria bovis. Sarcocystis cruzi, Hammondia hammondi, or Caryospora bigenetica. Immumoelectron microscopy revealed that MAB 3F5 bound to dense granules in extracellular T. gondii tachyzoites. In western blots of T. gondii tachyzoites, a major band at 38 kDa and a minor band at 32 kDa were labeled by MAB 3F5, but no labeling of the proteins of N. caninum tachyzoites or uninfected host cells occurred at the ultrastructural level or in immunoblots.

A new fallout prediction model.

The standard method for the calculation of nuclear weapon fallout radiation doses and dose rates in operational type studies for the last 20 yr has been the computer algorithm known as WSEG-10. WSEG-10 uses empirical functions rather than numerical analyses and computes fallout dose (rates) in seconds or less on modern computers. WSEG-10 has long been criticized for its inability to allow for variations in the activity-particle size distribution of the fallout, for its inability to account for fractionation and for the absence of realistic settling rates. At the other end of the scale, the Defense Land Fallout Information Code, DELFIC, is currently used for research work and as a comparison standard. DELFIC produces fallout footprints on the ground by numerical integration, employing discrete cells in space, time and particle size. A new fallout prediction method is presented here which, unlike WSEG-10, does allow variations in activity with particle size, does account for fractionation and does model variable settling rates. This new model, like WSEG-10 but unlike DELFIC, computes in seconds or less. Some results are presented and compared to DELFIC and to WSEG results. Additionally, this new model will treat the far-field problem of interest in a massive strategic attack which cannot be easily done using DELFIC.

Viral contamination of bovine fetal lung cultures and bovine fetal serum.

Commercial bovine fetal serum (BFS) and bovine fetal lung (BFL) cells were tested for viruses. The only virus detected in any samples was noncytopathogenic bovine viral diarrhea virus (BVDV). Of 37 BFL cultures initiated, 34 were negative for BVDV, 1 was positive, and 2 were suspicious in that the source of BVDV contamination was not certain. Of 9 lots of irradiated sera tested, 1 (10%) was positive for BVDV; of 21 lots of nonirradiated sera tested, 13 (62%) were positive for BVDV. As judged by intensity of fluorescence in infected cultures, some cell strains were much more susceptible to BVDV than other strains. Heat inactivation of serum at 56 C for 30 minutes was found to be an unreliable method of eliminating BVDV from sera.