Structural approaches to knowledge exchange: comparing practices across five centres of excellence in public health.

Background: In 2008, five UKCRC Public Health Research Centres of Excellence were created to develop a coordinated approach to policy and practice engagement and knowledge exchange. The five Centres have developed their own models and practices for achieving these aims, which have not been compared in detail to date. Methods: We applied an extended version of Saner's model for the interface between science and policy to compare five case studies of knowledge exchanges, one from each centre. We compared these practices on three dimensions within our model (focus, function and type/scale) to identify barriers and facilitators for knowledge exchange. Results: The case studies shared commonalities in their range of activities (type) but illustrated different ways of linking these activities (function). The Centres' approaches ranged from structural to more organic, and varied in the extent that they engaged internal audiences (focus). Each centre addressed policymakers at different geographical levels and scale. Conclusions: This article emphasizes the importance of linking a range of activities that engage policymakers at different levels, intensities and points in their decision-making processes to build relationships. Developing a structural approach to knowledge exchange activities in different contexts presents challenges of resource, implementation and evaluation.

Direct chemical evidence for widespread dairying in prehistoric Britain.

Domesticated animals formed an important element of farming practices in prehistoric Britain, a fact revealed through the quantity and variety of animal bone typically found at archaeological sites. However, it is not known whether the ruminant animals were raised purely for their tissues (e.g., meat) or alternatively were exploited principally for their milk. Absorbed organic residues from pottery from 14 British prehistoric sites were investigated for evidence of the processing of dairy products. Our ability to detect dairy fats rests on the observation that the delta(13)C values of the C(18:0) fatty acids in ruminant dairy fats are approximately 2.3 per thousand lower than in ruminant adipose fats. This difference can be ascribed to (i) the inability of the mammary gland to biosynthesize C(18:0); (ii) the biohydrogenation of dietary unsaturated fatty acids in the rumen; and (iii) differences (i.e., 8.1 per thousand ) in the delta(13)C values of the plant dietary fatty acids and carbohydrates. The lipids from a total of 958 archaeological pottery vessels were extracted, and the compound-specific delta(13)C values of preserved fatty acids (C(16:0) and C(18:0)) were determined via gas chromatography-combustion-isotope ratio mass spectrometry. The results provide direct evidence for the exploitation of domesticated ruminant animals for dairy products at all Neolithic, Bronze Age, and Iron Age settlements in Britain. Most significantly, studies of pottery from a range of key early Neolithic sites confirmed that dairying was a widespread activity in this period and therefore probably well developed when farming was introduced into Britain in the fifth millennium B.C.

The role of myocardial perfusion scanning, heart rate variability and D-dimers in predicting the risk of perioperative cardiac complications after peripheral vascular surgery.

OBJECTIVES: To study the value of a number of proposed prognostic factors in prediction of the risk of perioperative cardiac events after vascular surgery. DESIGN AND METHODS: Two hundred and ninety-seven patients undergoing peripheral vascular surgery were prospectively studied. Patients underwent preoperative 24 h ambulatory electrocardiography, measurement of haemostatic variables, myocardial assessment of perfusion by dipyridamole-thallium scintigraphy and radionuclide ventriculography. The primary endpoint was cardiac death or nonfatal myocardial infarction within 30 days of surgery. A combined endpoint included the primary endpoint plus occurrence of cardiac failure, unstable angina or serious arrhythmias. RESULTS: The primary endpoint occurred in 21 (7%), and the combined endpoint in 41 (14%) of patients. On multivariate analysis, increased age, previous myocardial infarction, aortic surgery, impaired heart rate variability and a positive thallium scan were independent predictors of primary end-points. Preoperative atrial fibrillation and increased fibrin D-dimer were additional predictors of the combined endpoint. Construction of receiver-operator characteristic curves to examine the incremental value of predictive models showed that sensitivity and specificity of clinical data alone for primary endpoints was 71% and 72% respectively, while for the full model (incorporating heart rate variability and thallium data) this rose to 84% and 80% (p=0.0001). CONCLUSIONS: Preliminary screening using clinical data has limited value in risk assessment prior to vascular surgery but preoperative heart rate variability, D-dimers and thallium scanning provide modest incremental predictive value.

Practical and theoretical considerations in the gas chromatography/combustion/isotope ratio mass spectrometry delta(13)C analysis of small polyfunctional compounds.

Carbohydrates and proteins are among the most abundant naturally occurring biomolecules and so suitable methods for their reliable stable isotope analysis by gas chromatography/combustion/isotope ratio mass spectrometry (GC/C/IRMS) are required. Due to the non-volatile nature of these compounds they require hydrolytic cleavage to their lower molecular weight subunits and derivatisation prior to GC/C/IRMS analysis. The addition of carbon to the molecules and any kinetic isotopic fractionation associated with derivatisation must be accounted for in order to provide meaningful stable isotope values and estimates of propagated errors. To illustrate these points amino acid trifluoroacetate/isopropyl esters and alditol acetates were prepared from authentic amino acids and monosaccharides, respectively. As predicted from the derivatisation reaction mechanisms, a kinetic isotope effect was observed which precludes direct calculation of delta(13)C values of the amino acids and monosaccharides by simple mass balance equations. This study shows that the kinetic isotope effect associated with derivatisation is both reproducible and robust, thereby allowing the use of correction factors. We show how correction factors can be determined and accurately account for the addition of derivative carbon. As a consequence of the addition of a molar excess of carbon and the existence of a kinetic isotope effect during derivatisation, errors associated with determined delta(13)C values must be assessed. We illustrate how such errors can be quantified (for monosaccharides +/-1.3 per thousand and for amino acids between +/-0.8 per thousand and +/-1.4 per thousand). With the magnitude of the errors for a given delta(13)C value of a monosaccharide or amino acid quantified, it is possible to make reliable interpretations of delta(13)C values, thereby validating the determination of delta(13)C values of amino acids as TFA/IP esters and monosaccharides as alditol acetates.

Prosodic variation across sampling tasks in normal and dysarthric speakers.

Speech assessments are commonly based on structured elicitation tasks. Despite the value of these tasks, the extent to which their results are a valid reflection of natural speech performance is being increasingly questioned. This is particularly warranted in the light of research findings indicating significant differences in normal speech behaviour across sampling tasks. There is, however, a paucity of research into how disordered speakers' performance varies across elicitation tasks. This study investigated ten prosodic parameters in structured and unstructured speech tasks (reading and conversation) in 12 dysarthric and 12 control subjects. The results suggest that the nature of sampling task affected dysarthric speakers differently to the control group. The implications of these findings for the assessment of disordered speakers are addressed.

The British Association of Dermatologists audit of atopic eczema management in secondary care. Phase 3: audit of service outcome.

Service outcome was examined by a preconsultation (part 1) and a 6-week postconsultation (part 2) patient questionnaire in 29 hospital dermatology departments randomly selected from an original sample of 187 centres across the U.K. The outcome measures were: quality of life as measured by the Dermatology Life Quality Index (DLQI) and Children's DLQI (CDLQI), improvement in sleep loss, improvement in worse aspect of skin disease and return to work or school. Three hundred and fifty-two questionnaires (115 adults, 237 children) were completed for part 1, and 235 (67%) replied to part 2. The mean DLQI at initial consultation was 12.5, dropping to 9.7 at 6 weeks (P = 0.001). The mean CDLQI at initial consultation was 10.5, dropping to 8.7 at 6 weeks (P < 0.001). Forty-nine per cent of adults and 44% of children had a > 25% relative improvement in score, which did not meet the 60% working standard. Forty-four per cent of adults and 47% of children had an improvement in sleep loss at 6 weeks, falling short of the 70% working standard. Sixty-one per cent of adults and 59% of children had an improvement in the worst aspect of their skin condition at 6 weeks, falling short of the 80% working standard. Of the 20 adults and eight children off work/school during part 1, 70% of adults and 87.5% of children had returned to work/school by 6 weeks. This met the 80% working standard for children but not for adults. On a national scale, only one of the eight working standards for service outcome was met, although most of the working standards were met by at least one of the 11 National Health Service administrative areas. This study presents the first national data on the outcomes of a representative sample of atopic eczema patients seen in secondary care. Small sample sizes, instruments which may be insensitive to change, as well as local factors such as case-mix, baseline severity and staff to patient ratios need to be taken into account when interpreting these results. Nevertheless, the results of this baseline audit suggest that the outcome of patients with atopic eczema following secondary care consultation may not be as good as some doctors believe. This suggests that an improvement in practice, a re-evaluation of the working standards, or both, is needed and should be examined in future audit cycles.

Effect of surgeon specialty interest on patient outcome after potentially curative colorectal cancer surgery.

OBJECTIVE: There are significant differences in patient outcome after potentially curative surgery for colorectal cancer that relate to the surgeon performing the procedure. The reasons for these differences remain obscure. The aim of this study was to examine the effect of the surgeon's specialty on patient outcome after potentially curative colorectal cancer surgery and to identify factors that may help explain differences in outcome among specialty groups. METHODS: Between 1990 and 1993, 378 patients underwent potentially curative surgery for colorectal cancer by surgeons with different specialty interests, vascular or transplant, general, and colorectal surgeons, in a large teaching hospital. Information on operative details, including the length of the resection specimen, resection margins, whether the tumor was removed with en bloc resection of adjacent clinically involved organs, number of lymph nodes removed, and stage was collected. Factors affecting both local and overall recurrence rates were analyzed using logistic regression analysis at both univariate and multivariate levels. RESULTS: At a median follow-up of 45 months the only factors associated with a significantly reduced local recurrence rate were the length of the resection specimen (odds ratio, 0.56; 95 percent confidence interval, 0.31-0.99) and colorectal specialty (P = 0.04). Patients operated on by a general surgeon were 3.42 times (95 percent confidence interval, 1.32-8.9) more likely to develop a local recurrence than those operated on by a colorectal surgeon. For overall recurrence, early stage disease (P < 0.0001), absence of vascular invasion (0.005), and colorectal specialty (0.025) were the only factors associated with significantly improved outcome at multivariate analysis. CONCLUSIONS: These data show that surgeons with an interest in colorectal cancer achieve lower local and overall recurrence rates compared with vascular or transplant or general surgeons. Differences in local recurrence rates seem to be predominantly related to the extent of resection performed and demonstrate the need to remove an adequate specimen when performing potentially curative colorectal cancer surgery.

The British Association of Dermatologists audit of atopic eczema management in secondary care. Phase 2: audit of service process.

An audit of atopic eczema management, conducted on behalf of the British Association of Dermatologists, examined service structure (phase 1), process (phase 2) and outcome (phase 3). In phase 2, an on-site case-note audit was conducted in 19 hospital dermatology departments randomly selected from the original sample of 187 centres across the U.K. In total, 630 sets of notes were examined for completeness of: (i) information given to general practitioners (GPs) in clinic letters and (ii) facts relevant to the management of atopic eczema recorded in the patients' notes. In general, the information given to GPs in the clinic letters was good, with the recording of diagnosis, treatment and follow-up approaching the 100% working standard. Factual information such as site and severity of eczema (83% and 74%), and presence or absence of asthma (53%) were better recorded than quality of life issues such as sleep loss secondary to itching (21%) and effect on school, work or social life (6%). On average, only 51% of all audit measures were recorded across all centres, with slight variation between centres (41-61%). The centre with the best recording had a purpose-designed data sheet for doctors to complete when seeing new patients with atopic eczema. Such data sheets may help improve case-note recording. Similar data sheets for patients to complete may be more time-efficient.

Is lipoprotein(a)-cholesterol a better predictor of vascular disease events than total lipoprotein(a) mass? A nested case control study from the West of Scotland Coronary Prevention Study.

The clinical utility of a new assay for plasma lipoprotein(a)-cholesterol (Lp(a)-C) was assessed in parallel with our routine Lp(a) mass measurements in a nested-case control study of subjects within the placebo arm of the West of Scotland Coronary Prevention Study (WOSCOPS). A total of 238 control patients and 108 patients who had suffered a serious vascular event during the course of the WOSCOPS were examined. Lp(a) mass was assessed within 2 years of sampling by an ELISA method on baseline EDTA plasma samples which had been stored at -70 degrees C. Subsequently, the Lp(a) mass was re-measured by an immunoturbidimetric assay approximately 8 years after sampling. On the same stored aliquot the Lp(a)-C was measured. These analyses allowed us to assess whether the Lp(a)-C assay could provide any additional information over and above that which would be obtained from our Lp(a) mass assays. In addition the apo(a) isoform sizes of these subjects were measured using a high resolution immunoblotting system. The Lp(a)-C and Lp(a) mass measurements provided exactly the same information in the study, as they were equally non-discriminatory between cases and controls. The only difference between the two patient groups was the percentage of 'null' apo(a) alleles (control: 25.6% versus cases: 19.4%). We conclude that these results reinforce the concordance of the two assay systems and confirm that the Lp(a)-C assay provides no added information over and above that gained from traditional Lp(a) mass assays, which may be faster and less expensive.

The British Association of Dermatologists audit of atopic eczema management in secondary care. Phase 1: audit of service structure.

This first comprehensive study of atopic eczema management describes an audit of service structure (phase 1), process (phase 2) and outcome (phase 3) in the U.K. This paper describes the phase 1 results. Service structure was audited by a single-page questionnaire containing 10 questions on outpatient facilities. This was sent to the lead dermatologist at 187 dermatology centres throughout the U.K., and a final response rate of 98% was achieved. Although the percentage of centres reporting the presence of recommended facilities did not reach the 100% working standard for any one specific criterion, about half of the recommended items, such as provision of height and weight measuring facilities, access to a dietician, patch testing and photochemotherapy, was reported in over 90% of centres. Areas of service structure which were infrequently reported to be in place were issuing of new appointment letters asking patients to bring their treatment details to clinic (52% of centres) and access to nurses with dermatology experience on paediatric wards (57% of centres). Some audit measures, e.g. access to counselling services, showed wide regional variation (range 33-94% of centres), and these variations could not be explained simply in terms of provision of specialists. Some of the elements of service structure, such as access to nurses with dermatology experience on paediatric wards, may be difficult to change in the short term because of funding and staffing constraints, but others, such as provision of growth charts, are easy to change at little cost. This preliminary audit serves as a framework for future audits of atopic eczema management.

Health promotion in the Scottish workplace: a case for moving the goalposts.

The workplace provides an important opportunity for health promotion, both in terms of allowing access to a large proportion of the adult population and encouraging developments within the workplace structure to improve health. This paper reports on the findings of a survey of Scottish workplaces carried out in 1996 for the Health Education Board for Scotland to assess the state of health promotion activity in the Scottish workplace setting. The results echo those from previous surveys in that most health promotion effort was centred around health and safety, smoking, and alcohol issues, particularly for the smaller and less well-resourced businesses. Under one-fifth of businesses surveyed addressed areas such as stress and mental health, which are being seen as increasingly important in terms of their contribution to the well-being of the employee and the organization. The main implication of these findings is that it is smaller businesses who potentially have the most to gain from workplace health promotion. In this context, the construction of relevant and sustainable health promotion programmes requires an organizational development perspective in order to encourage such businesses to regard workplace health promotion as part of good business practice.

Analysis of pill knowledge amongst oral contraceptive users in Scotland according to client characteristics.

OBJECTIVES: The primary objective of this study was to investigate the relationship between various client characteristics and knowledge of oral contraceptives amongst pill users. METHOD: This was a subanalysis of the data from the national audit of Scottish family planning clinics. RESULTS: There were significant differences in knowledge about many different criteria according to the characteristics of the client group. Low educational attainment, unemployment and more rural residence produced greater significant differences in contraception knowledge than social deprivation according to postcode (zipcode). Age and duration of use affected different criteria to varying degrees, but teenagers scored relatively poorly compared to the general population and knowledge did not significantly improve overall with duration of use. CONCLUSION: Client characteristics do affect levels of pill knowledge. Clinicians must reflect on how to communicate more effectively with all types of pill users. They should take the opportunity of clinic visits for repeat pill prescriptions to improve knowledge levels.

Nationwide audit of pill knowledge amongst family planning users in Scotland.

OBJECTIVES: The primary objective of this study was to estimate knowledge about oral contraceptives amongst oral contraceptive users within family planning clinics in Scotland and to ascertain if this was due to clinicians not attempting to convey certain information or to a lack of understanding of teaching. METHOD: This was a criterion-based audit using three separate questionnaires to estimate the agreement of senior staff with criteria set by a multi-disciplinary expert panel, actual routine clinical practice and user knowledge. RESULTS: Senior clinical staff within family planning clinics in Scotland agreed with 12 out of 15 criteria set by a multidisciplinary panel in over 85% of cases. For six out of 15 criteria, there was a discrepancy of more than 30% in what clinicians did in practice compared to what senior staff thought they ought to do. For a further two criteria, there was a deficiency of over 30% between the number of clients who understood the criteria and the number of clients the clinicians thought they had taught. Most importantly, these latter criteria included the rules for safe and effective pill taking. CONCLUSION: An improvement in user knowledge is required to achieve effective and reliable use of oral contraceptives. Methods of doing this, such as staff and client prompts, should be further explored.

A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia.

Forty-five patients diagnosed as having nonorganic dysphonia were assigned in rotation to 1 of 3 groups. Patients in group 1 received no treatment and acted as a control group. Patients in groups 2 and 3 received a program of indirect therapy and direct with indirect therapy, respectively. A range of qualitative and quantitative measures were carried out on all patients before and after treatment to evaluate change in voice quality over time. Results revealed a significant difference between the 3 treatment groups in the amount of change for the voice severity, electrolaryngograph, and shimmer measurements and on ratings provided by a patient questionnaire (P<0.05). However, other measures failed to show significant differences between the 3 groups. Most of the patients (86%) in group 1 showed no significant change on any of the measures. Some patients in treatment group 2 (46%) showed significant change in voice quality. Fourteen out of 15 patients (93%) in treatment group showed significant changes in voice quality.

Predictors of plasma lipoprotein(a) concentration in the West of Scotland Coronary Prevention Study cohort.

An elevated plasma lipoprotein(a) (Lp(a)) concentration is an independent risk factor for coronary heart disease (CHD). Plasma Lp(a) levels are believed to be predominantly controlled by the APO(a) gene, which encodes the apo(a) glycoprotein moiety of the Lp(a) particle. However, other parameters in the lipoprotein profile as well as co-existing disease states or personal traits have been proposed as co-varieties. In order to examine these potential controlling factors in greater detail than previously possible, 1760 unrelated Caucasian subjects were studied, from which were identified 907 with a single expressing APO(a) allele. This strategy was followed to obviate the difficulty in dealing with the co-expression of different apo(a) isoforms and the resulting compound plasma Lp(a) level. After cube-root transformation of the plasma Lp(a) levels to normalise their distribution, a series of correlates were computed. There was no good correlation between Lp(a) concentration and any other measured lipid or lipoprotein in the lipid profile or with any other variable examined, with the important exception of the length of the expressed apo(a) isoform (r = -0.491, P = 0.0001). We conclude that in this population the plasma Lp(a) concentration is not predicted by the plasma lipid profile, alcohol intake, or smoking status but is predicted, albeit incompletely, by the length polymorphism of the APO(a) gene.

The effectiveness of voice therapy for patients with non-organic dysphonia.

Forty-five patients diagnosed as having non-organic dysphonia were assigned in rotation to one of three groups. Patients in one group received no treatment and acted as a control group. Patients in the other two groups received a programme of either 'indirect' therapy or 'direct with indirect' therapy, respectively. A self-report questionnaire of vocal performance, observed ratings of voice quality, and computer-derived acoustic measurements (signal-to-noise ratio, pitch perturbation and amplitude perturbation) were carried out on all patients before and after treatment to evaluate the changes in voice quality over time. There was a significant difference between the three groups on the self-report questionnaire, voice quality ratings and pitch perturbation measurements (P = < 0.05). Thirteen out of 15 control patients showed no significant change on any of the measures. Seven patients who received indirect treatment showed significant improvement in voice quality following treatment. Fourteen out of 15 patients who received direct treatment showed significant improvement in voice quality.

Phonetic variation in dysarthric speech as a function of sampling task.

Previous studies have demonstrated a number of ways in which normal speakers' phonetic performance varies across reading and spontaneous speech tasks. This study set out to investigate whether similar differences across speech sampling tasks were found in a mixed group of dysarthric subjects. A selection of segmental and prosodic parameters were investigated acoustically in the performance of five mild dysarthric speakers and five matched control subjects. The results demonstrated that breath-pause position, unstressed vowel duration and voice-onset time were subject to variation across sampling task in the speech produced by different types of dysarthric speaker. The results suggest that read material produced by dysarthric speakers may not be wholly representative of those speakers' spontaneous speech. Preliminary implications for clinical practice are discussed. The findings point to the need for further research to investigate the extent of such differences and their implications for dysarthria assessment, which up to the present has relied predominantly on read material.

The Vale of Leven health promotion project.

A two stage health promotion programme is in progress in the Vale of Leven in Dunbartonshire. The first stage has been completed within a local factory (Polaroid UK Limited), the largest private employer in the district. A total of 1205 employees, representing 87% of the workforce, took part in the programme and were initially screened for coronary artery risk factors. Blood pressure, serum cholesterol, body composition and aerobic fitness were measured and smoking habits determined. Aspects of lifestyle were assessed by questionnaire. All employees whose initial cholesterol concentration was greater than 6.5 mM were given simple dietary advice and their cholesterol concentration thereafter remeasured. Eighty-two per cent of these men and 72% of these women succeeded in reducing their cholesterol, the men by a mean of 1.3 mM, the women by a mean of 0.7 mM. The health initiatives undertaken within the factory at the same time as screening are also described in this paper.