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Dry evergreen montane forests in Ethiopia are severely threatened. The status of species composition and structure of forest vegetation are important indicators to understand the trends of threats on local plant communities. In the present study, we examined the floristic composition and structure of the Kibate Forest, Wonchi Highland, Ethiopia along environmental gradients. Sixty-six (30 m × 30 m) plots were established every 100 m interval along altitudinal gradients (2811‒3073 m a.s.l.) in five transect lines for vegetation and environmental data collection. In total, 125 vascular plant species belonging to 104 genera and 52 families were identified. Eighteen species (14%) were endemic to Ethiopia and Eritrea. The two most dominant families, Asteraceae (29 species) and Lamiaceae (eight species) accounted for 30% of the total number of species. The highest number of species (54%) was herbs. Four major community types (viz., Olinia rochetiana-Myrsine melanophloeos, Ilex mitis-Galiniera saxifraga, Erica arborea-Protea gaguedi, and Hagenia abyssinica-Juniperus procera) were identified. The highest species richness, evenness, diversity, and importance value index were in community types 2 and 4. About 82% of the species and all endemic taxa except five were recorded in these two community types. The most dominant woody species were O. rochetiana, E. arborea, Olea europaea subsp. cuspidata, Myrica salicifolia, I. mitis var. mitis, and H. abyssinica with different patterns of population structure. The results show that there was a weak correlation between species richness and altitude. Our findings confirm that environmental variables both with interactions (such as altitude) and without interactions (such as livestock grazing) significantly (p < 0.05) affect species richness. Anthropogenic activities and overgrazing by livestock appear to be the main threat in community types 2 and 3. Urgent management practices and conservation measures such as prohibiting forest clearing and overgrazing and planting indigenous trees through community participation should be considered in community types that are rich in endemic species but are highly threatened. [ABSTRACT FROM AUTHOR]

Rust caused by Uromyces viciae-fabae is a major biotic constraint to field pea (Pisum sativum L.) cultivation worldwide. Deployment of host-pathogen interaction and resistant phenotype is a modest strategy for controlling this intricate disease. However, resistance against this pathogen is partial and influenced by environmental factors. Therefore, the magnitude of environmental and genotype-by-environment interaction was assessed to understand the dynamism of resistance and identification of durable resistant genotypes, as well as ideal testing locations for rust screening through multi-location and multi-year evaluation. Initial screening was conducted with 250 diverse genotypes at rust hot spots. A panel of 23 promising field pea genotypes extracted from initial evaluation was further assessed under inoculated conditions for rust disease for two consecutive years at six locations in India. Integration of GGE biplot analysis and multiple comparisons tests detected a higher proportion of variation in rust reaction due to environment (56.94%) as an interactive factor followed by genotype × environment interaction (35.02%), which justified the requisite of multi-year, and multi-location testing. Environmental component for disease reaction and dominance of cross over interaction (COI) were asserted by the inconsistent and non-repeatable genotypic response. The present study effectively allocated the testing locations into various categories considering their "repeatability" and "desirability index" over the years along with "discrimination power" and "representativeness." "Mega environment" identification helped in restructuring the ecological zonation and location of specific breeding. Detection of non-redundant testing locations would expedite optimal resource utilization in future. The computation of the confidence limit (CL) at 95% level through bootstrapping strengthened the accuracy of the GGE biplot and legitimated the precision of genotypes recommendation. Genotype, IPF-2014-16, KPMR-936 and IPF-2014-13 identified as "ideal" genotypes, which can be recommended for release and exploited in a resistance breeding program for the region confronting field pea rust. [ABSTRACT FROM AUTHOR]

Lentil rust incited by the fungus Uromyces viciae-fabae is a major impedance to lentil (Lens culinaris Medik.) production globally. Host-plant resistance is the most reliable, efficient and viable strategy among the various approaches to control this disease. In this study, 26 lentil genotypes comprising advanced breeding lines and released varieties along with a susceptible check were evaluated consecutively for rust resistance under natural incidence for two years and at five test locations in India. A heritability-adjusted genotype main effect plus genotype × environment interaction (HA-GGE) biplot program was used to analyse disease-severity data. The results revealed that, among the interactive factors, the GE interaction had the greatest impact (27.81%), whereas environment and genotype showed lower effects of 17.2% and 20.98%, respectively. The high GE variation made possible the evaluation of the genotypes at different test locations. The HA-GGE biplot method identified two sites (Gurdaspur and Pantnagar) as the ideal test environments in this study, with high efficiency for selection of durable and rust-resistant genotypes, whereas two other sites (Kanpur and Faizabad) were the least desirable test environments. In addition, the HA-GGE biplot analysis identified three distinct mega-environments for rust severity in India. Furthermore, the analysis identified three genotypes, DPL 62, PL 165 and PL 157, as best performing and durable for rust resistance in this study. The HA-GGE biplot analysis recognised the best test environments, restructured the ecological zones for lentil-rust testing, and identified stable sources of resistance for lentil rust disease, under multi-location and multi-year trials. [ABSTRACT FROM AUTHOR]

Nearly half of the world cereal production comes from soils low or marginal in plant available zinc, leading to unsustainable and poor quality grain production. Therefore, the effects of nitrogen (N) rate and application time on zinc (Zn) and iron (Fe) concentration in wheat grain were investigated. Wheat (Triticum aestivum var. Krabat) was grown in a growth chamber with 8 and 16 h of day and night periods, respectively. The N rates were 29, 43, and 57 mg N kg-1 soil, equivalent to 80, 120, and 160 kg N ha-1. Zinc and Fe were applied at 10 mg kg-1 growth media. In one of the N treatments, additional Zn and Fe through foliar spray (6 mg of Zn or Fe in 10 ml water/pot) was applied. Micro-analytical localization of Zn and Fe within grain was performed using scanning macro-X-ray fluorescence (MA-XRF) and laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS). The following data were obtained: grain and straw yield pot-1, 1000 grains weight, number of grains pot-1, whole grain protein content, concentration of Zn and Fe in the grains. Grain yield increased from 80 to 120 kg N ha-1 rates only and decreased at 160 kg N ha-1 g. Relatively higher protein content and Zn and Fe concentration in the grain were recorded with the split N application of 160 kg N ha-1. Soil and foliar supply of Zn and Fe (Zn C FesCf), with a single application of 120 kg N ha-1 N at sowing, increased the concentration of Zn by 46% and of Fe by 35%, as compared to their growth media application only. Line scans of freshly cut areas of sliced grains showed co-localization of Zn and Fe within germ, crease and aleurone. We thus conclude that split application of N at 160 kg ha-1 at sowing and stem elongation, in combination with soil and foliar application of Zn and Fe, can be a good agricultural practice to enhance protein content and the Zn and Fe concentration in grain. [ABSTRACT FROM AUTHOR]

A Pd-doped Ni–MgO catalyst was prepared for synthesis gas production by dry reforming of methane (DRM). The catalyst was prepared by a two-step method; first a high surface area MgO support was prepared by a hydrothermal method then Pd and Ni nanoparticles were deposited by sublimation of the precursor salts. The prepared catalysts were characterized by BET-surface area, X-ray diffraction (XRD), transmission electron microscopy (TEM), X-ray photoelectron spectroscopy (XPS), temperature programmed desorption (CO2-TPD), Raman spectroscopy, FT-IR spectroscopy and temperature programmed reduction (H2-TPR) analysis. Both Ni–MgO and Pd/Ni–MgO were highly active for the DRM reaction. Addition of Pd-nanoparticles to the Ni–MgO catalyst decreased the reaction initiation temperature by 90 °C and increased the rate of H2 and CO production during catalysis. The increased activity of the Pd/Ni–MgO catalyst was due to the easily reducible Ni-oxide particles and much smaller Pd-particles, which were active for the DRM reaction at lower temperature. The best feature of the synthesized catalysts was the ability to inhibit the reverse water gas shift (RWGS) reaction, which highly improved the H2/CO ratio. In fact, the Pd/Ni–MgO catalyst almost stopped the RWGS reaction and the presence of water in the reaction product was negligible. A time on stream (TOS) study of both the catalysts showed absolutely no deactivation even after 100 h of reaction at 750 °C. Both catalysts showed production of synthesis gas with a H2/CO ratio of 0.97–0.99 during the TOS study. [ABSTRACT FROM AUTHOR]

Objectives: Intra-organizational communication is mostly interpersonal. Synchronous interruptive communication is recognized as a primary source of inefficiency and error in healthcare, and there is much potential for information and communication technology (ICT) to improve such communication. As recently suggested, however, due to communication failures ICT can also compound medical errors. In this paper we analyze factors that restrict the role of ICT in improving interpersonal healthcare communication and suggest solutions.Methods: We critically analyzed the literature from a selection of diverse scientific disciplines. These were related to interpersonal communication, to the role and place of standardization and computerization in its improvement, and to reducing medical errors.Results: Four possible scenarios were defined on how ICT can serve healthcare communication. Two differing conceptual frameworks about communication in healthcare were discussed. Considering "information space" as a part of "communication space" allows the recognition and control of the source of the semantic gaps in conventional standardization and an enhancement of the role of ICT in improving intra-organizational communication. Moreover, cognitive, social, and organizational dimensions of complexity in interpersonal communication can be managed. Three approaches to control the variability in those dimensions and to promote the role of ICT in intra-organizational communication were discussed.Conclusion: A multi-dimensional approach is required to promote the role of ICT in intra-organizational communication in healthcare. Parallel to conventional standardization, at least three dimensions need to be addressed: controlling the effect of the social context, developing standard information processing skills, and most importantly, controlling variations in care practices' performance. [ABSTRACT FROM AUTHOR]

Aims: Rice ( Oryza sativa L.), wheat ( Triticum aestivum L.) and common bean ( Phaseolus vulgaris L.) are major staple food crops consumed worldwide. Zinc (Zn) deficiency represents a common micronutrient deficiency in human populations, especially in regions of the world where staple food crops are the main source of daily calorie intake. Foliar application of Zn fertilizer has been shown to be effective for enriching food crop grains with Zn to desirable amounts for human nutrition. For promoting adoption of this practice by growers, it is important to know whether foliar Zn fertilizers can be applied along with pesticides to wheat, rice and also common bean grown across different soil and environmental conditions. Methods: The feasibility of foliar application of zinc sulphate (ZnSO.7HO) to wheat, rice and common bean in combination with commonly used five fungicides and nine insecticides was investigated under field conditions at the 31 sites-years of seven countries, i.e., China, India, Pakistan, Thailand, Turkey, Brazil and Zambia. Results: Significant increases in grain yields were observed with foliar Zn/foliar Zn + pesticide (5.2-7.7 % of wheat and 1.6-4.2 % of rice) over yields with no Zn treatment. In wheat, as average of all experiments, higher grain Zn concentrations were recorded with foliar Zn alone (41.2 mg kg) and foliar Zn + pesticide (38.4 mg kg) as compared to no Zn treatment (28.0 mg kg). Though the magnitude of grain Zn enrichment was lesser in rice than wheat, grain Zn concentrations in brown rice were significantly higher with foliar Zn (24.1 mg kg) and foliar Zn + pesticide (23.6 mg kg) than with no Zn (19.1 mg kg). In case of common bean, grain Zn concentration increased from 68 to 78 mg kg with foliar Zn alone and to 77 mg kg with foliar Zn applied in combination with pesticides. Thus, grain Zn enrichment with foliar Zn, without or with pesticides, was almost similar in all the tested crops. Conclusions: The results obtained at the 31 experimental site-years of seven countries revealed that foliar Zn fertilization can be realized in combination with commonly-applied pesticides to contribute Zn biofortification of grains in wheat, rice and common bean. This agronomic approach represents a useful practice for the farmers to alleviate Zn deficiency problem in human populations. [ABSTRACT FROM AUTHOR]

Accessible summary Overall, the four collaboratives lead to significant improvement in most objective outcomes, such as health, loneliness, and clients' problem areas., With respect to perceived effectiveness significant differences between the four collaboratives were found. Team members participating in the Social Psychiatric Care collaborative scored significantly lower than team members in the other three collaboratives. The Recovery-Oriented Care collaborative scored weakly higher., Multilevel regression analyses indicated that innovation attributes, appropriate measures, usable data collection tools, and an innovative team culture could explain variation in perceived effectiveness., The results supported the notion that a layered approach is necessary to achieve improvements in quality of care., Abstract This multiple case study evaluates four quality improvement collaboratives (QICs) in long-term mental health care focusing on social psychiatric care, recovery oriented care, social participation and somatic co-morbidity of psychiatric patients. The aim is to explore (1) effectiveness in terms of objective outcome indicators and impact of changes as perceived by team members; and (2) associations between collaborative-, organizational- and team-level factors and perceived effectiveness. Most objective outcomes, such as health, loneliness and clients' problem areas, showed significant improvement. Because of the diversity in content no single measure for objective effectiveness could be computed across the four collaboratives. Perceived effectiveness of team members was used as an indicator of the overall impact. In all, 55 of the 94 participating team leaders and 117 remaining team members completed a written survey at the end of each quality improvement collaborative. Multilevel regression analyses indicated that innovation attributes, appropriate measures, usable data collection tools and an innovative team culture could explain variation in perceived effectiveness. In conclusion, overall positive changes for clients were realized as demonstrated by objective outcomes and team members' perceptions of improvements in care processes. The results supported the notion that a layered approach is necessary to achieve improvements in quality of care. [ABSTRACT FROM AUTHOR]

This paper reports on an evaluation of a 'social participation' improvement project in a mental health care and care for the intellectually disabled setting. The main research question is how sociality (i.e. clients' social lives) was constructed and what consequences this had for the project and for the clients. We undertook a dual approach: investigating the predefined outcomes and analysing the improvement processes in terms of how these processes construct sociality. As to the predefined outcomes, clients' social networks were not widened, but clients felt significantly less lonely at the end of the project. In a bottom-up analysis of data gathered on the improvement processes, we articulated two ways of constructing sociality: individualization, in which clients had to verbalize their wishes (verbalization) and to act upon them more actively (enterprising); and normalization, in which a good social life was one embedded in 'normal' community. We argue that this (explorative) way of conceptualizing change corresponds with some of the quantitative findings but also brings to light aspects that would have gone unnoticed by using only the predefined outcomes. Therefore, a mixed methods approach in studying effectiveness is a fruitful addition to the quality improvement literature. [ABSTRACT FROM AUTHOR]

Objectives: To assess the impact of a CPOE system on medication-related communication of nurses and physicians.Methods: In six internal medicine wards of an academic medical center, two questionnaires were used to evaluate nurses' attitudes toward the impact of a paper-based medication system and then a CPOE system on their communication in medication-related-activities (medication work). The questionnaires were analyzed using t-tests, followed by Bonferroni correction. Nine nurses and six physicians in the same wards were interviewed after the implementation to determine how their communication and their work have been impacted by the system.Results: The total response rates were 54% and 52% for pre- and post-implementation questionnaires. It was shown that after implementation, the legibility and completeness of prescriptions were significantly improved (P <.001) and the administration system had a more intelligible layout (P <.001), with a more reliable overview (P <.001). The analysis of the interviews supported and confirmed the findings of the surveys. Moreover, they showed communication problems that caused difficulties in integrating medication work of nurses into physicians'. To compensate for these, nurses and physicians devised informal interactions and practices (workarounds), which often represented risks for medication errors.Conclusion: The introduction of CPOE system with paper-based medication administration system improved prescription legibility and completeness but introduced many workflow impediments and as a result error-inducing conditions. In order to prevent such an effect, CPOE systems have to support the level of communication which is necessary to integrate the work of nurses and physicians. [ABSTRACT FROM AUTHOR]

The article presents a study which evaluates the effects of computerized physician order entry (CPOE) system on medication-related communication and interoperability between the physician and the nurse. It notes that survey and interview methodologies were employed in gathering data from six internal medicine wards of an academic medical center. It also discusses the impacts of the system in the safety of the patients and occurrence of medical errors, as well as the means to improve the system.

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The article presents a study on the use of intra-organizational communication in healthcare. It states that synchronous interruptive communication is identified as a primary source of error and inefficiency in healthcare. Relative to this, it is mentioned that there is much possibility of information and communication technology (ICT) to enhance such communication. It is identified that a multi-dimensional approach is necessitated to promote the role of ICT in intra-organizational communication in healthcare.

Transient outward currents were characterized with twin electrode voltage clamp techniques in isolated F76 and D1 neuronal membranes (soma only) of Helix aspersa subesophageal ganglia. In this study, in addition to the transient outward current (A-current, I(A)) described by Connor and Stevens (1971b), another fast outward current, referred to as I(Adepol) here, is described for the first time. This is similar to the current component characterized in Aplysia (Furukawa, Kandel & Pfaffinger, 1992). The separation of these two current components was based on activation and steady-state inactivation curves, holding potentials and sensitivity to 4-aminopyridine (4-AP). In contrast to I(A), I(Adepol) did not require hyperpolarizing conditioning pulses to remove inactivation; it was evoked from a holding potential of -40 mV, at which I(A) is completely inactivated. I(Adepol) shows noticeable activation at around -5 mV, whereas I(A) activates at around -50 mV. The time courses of I(Adepol) activation and inactivation were similar but slower than I(A). It was found that I(Adepol) was more sensitive than I(A) to 4-AP. 4-AP at a concentration of 1 mm blocked I(Adepol) completely, whereas 5-6 mm 4-AP was needed to block I(A) completely. This current is potentially very important because it may, like other A currents, regulate firing frequency but notably, it does not require a period of hyperpolarization to be active. [ABSTRACT FROM AUTHOR]

Transient outward currents were characterized with twin electrode voltage clamp techniques in isolated F76 and D1 neuronal membranes (soma only) of Helix aspersa subesophageal ganglia. In this study, in addition to the transient outward current (A-current, IA) described by Connor and Stevens (1971b), another fast outward current, referred to as IAdepol here, is described for the first time. This is similar to the current component characterized in Aplysia (Furukawa, Kandel & Pfaffinger, 1992). The separation of these two current components was based on activation and steady-state inactivation curves, holding potentials and sensitivity to 4-aminopyridine (4-AP). In contrast to IA, IAdepol did not require hyperpolarizing conditioning pulses to remove inactivation; it was evoked from a holding potential of -40 mV, at which IA is completely inactivated. IAdepol shows noticeable activation at around -5 mV, whereas IA activates at around -50 mV. The time courses of IAdepol activation and inactivation were similar but slower than IA. It was found that IAdepol was more sensitive than IA to 4-AP. 4-AP at a concentration of 1 mm blocked IAdepol completely, whereas 5–6 mm 4-AP was needed to block IA completely. This current is potentially very important because it may, like other A currents, regulate firing frequency but notably, it does not require a period of hyperpolarization to be active. [ABSTRACT FROM AUTHOR]

Twin-electrode voltage-clamp techniques were used to study the effect of calcium and calcium channel blockers on the transient outward current in isolated F76 and D1 neurones of Helix aspersa subesophageal ganglia in vitro (soma only preparation with no cell processes). On lowering extracellular Ca(2+) concentration from 10 to 2 mm or removing extracellular calcium from the bathing medium, the threshold for this current shifted in a negative direction by 11. 5 and 20 mV, respectively. On the other hand, increasing the extracellular Ca(2+) concentration from 10 to 20 and to 40 mm shifted the steady-state inactivation curves in positive directions on the voltage axis by 7 and 15 mV, respectively. Upon application of calcium channel blockers, Co(2+), La(3+), Ni(2+) and Cd(2+), transient potassium current amplitude was reduced in a voltage-dependent manner, being more effective at voltages close to the threshold. The current was elicited even at a holding potential of -34 mV. The specific calcium channel blockers, amiloride and nifedipine did not shift the activation and steady-state inactivation curves and did not reduce the transient outward current amplitude. It was concluded that the transient outward current is not dependent on intracellular Ca(2+) but that it is modulated by Ca(2+) and di- and trivalent ions extracellularly. The effects of these ions are very unlikely to be due to a surface charge effect because the addition of La(3+) (200 microm) completely reverses the shift in a hyperpolarizing direction when the extracellular Ca(2+) concentration was reduced from 10 to 1 mm and additionally shifts the kinetics further still in a depolarizing direction. The responses seen here are consistent with a specific effect of di- and trivalent ions on the transient outward current channels leading to a modification of gating. [ABSTRACT FROM AUTHOR]

Wheat is the most important widely cultivated crops in the world. Its yield is greatly influenced by both biotic and abiotic stresses. Therefore, an evaluation of different species belonging to Triticum and Aegilops species for seedling traits was attempted. All the traits i.e. root length, shoot length and coleoptile length showed high heritability in broad sense and root length showed significantly positive correlation with coleoptile length under both moisture non- stress (E1) and moisture stress (E2) environments. All the traits showed a decreasing trend under moisture stress conditions in all the species and the reduction for all the traits were more pronounced in wild species than the cultivated species. [ABSTRACT FROM AUTHOR]

The concept of patient career as applied to chronic illness has gained substantial popularity. This is especially true for career as it is developed in the trajectory framework from Corbin and Strauss. The theoretical status of the framework is somewhat ambivalent. Although the framework i8 based on interactionist theorizing, the metaphor of illness work as "normal" work gives it a definite instrumentalistic flavour. As a result, the framework could be classified as a theory and a practice ideology at the same time In addition, the framework does not specify an organizational model and is ambivalent on issues of power and dependency. A main criticism, however, is its indistinctness on the role of the patient. When the metaphor of 5zor,nal" work is elaborated upon, the operational specificity of the framework could be enhanced. Especially relevant for continuity of care is the observation that the network where illness work is being accomplished needs the function of a broker. Also, elements of standard career planning and development could easily be applied to the framework. The implications of the elaboration on the work" metaphor for the theoretical status of the framework will be discussed. [ABSTRACT FROM AUTHOR]

Background: Gene expression profile analysis on mammalian cell lines and animal models after exposure to botulinum neurotoxin (BoNT) has been investigated in several studies in recent years. Microarray analysis provides a powerful tool for identifying critical signaling pathways involved in the biological and inflammatory responses to BoNT and helps determine the mechanism of the function of botulinum toxins. One of the pivotal clinical characteristics of BoNT is its prolonged on-site effects. The role of BoNT on the blockage of neurotransmitter acetylcholine release in the neuromuscular junction has been well established. However, the effects of the treatment time of BoNT on the human cellular model and its potential mechanism remain to be defined. Methods: This study aimed to use gene microarray technology to compare the two physiological critical time points of BoNT type A (BoNT/A) treatment of human neuroblastoma cells and to advance our understanding of the profound biological influences that toxin molecules play in the neuronal cellular system. SH-SY5Y neuroblastoma cells were treated with BoNT/A for 4 and 48 h, which represent the time needed for the entrance of toxin into the cells and the time necessary for the initial appearance of the on-site effects after BoNT application, respectively. Results: A comparison of the two time points identified 122 functional groups that are significantly changed. The top five groups are alternative splicing, phosphoprotein, nucleus, cytoplasm, and acetylation. Furthermore, after 48 h, there were 744 genes significantly up-regulated, and 624 genes significantly down-regulated (p‹ 0.01). These genes fell into the following neurological and biological annotation groups: Nervous system development, proteinaceous extracellular matrix, signaling pathways regulating pluripotency of stem cells, cellular function and signal transduction, and apoptosis. We have also noticed that the up-regulated groups contained neuronal cell development, nervous system development, and metabolic processes. In contrast, the down-regulated groups contained many chromosomes and cell cycle categories. Conclusions: The effects of BoNT/A on neuronal cells extend beyond blocking the neurotransmitter release, and that BoNT/A is a multifunctional molecule that can evoke profound cellular responses which warrant a more in-depth understanding of the mechanism of the toxin's effects after administration. [ABSTRACT FROM AUTHOR]

Background: In the Netherlands, disease management programs (DMPs) are used to treat chronic diseases. Their aim is to improve care and to control the rising expenditures related to chronic diseases. A bundled payment was introduced to facilitate the implementation of DMPs. This payment is an all-inclusive price per patient per year for a pre-specified care package. However, it is unclear to which extent the costs of developing and implementing DMPs are included in this price. Consequently, the organizations providing DMPs bear financial risk because the development and implementation (D&I) costs may be substantial. The aim of this paper is to investigate the variability in and drivers of D&I costs among 22 DMPs and highlight characteristics that impact these. Methods: The data was analyzed using a mixed methods approach. Descriptive statistical analysis explored the variability in D&I costs as measured by a self-developed costing instrument and investigated the drivers. In addition, qualitative research, including document analysis and interviews, was conducted to explain the possible underlying reasons of cost variability. Results: The development costs varied from €5,891 to €274,783 and the implementation costs varied from €7,278 to €387,879 across DMPs. Personnel costs were the main component of development. Development costs were strongly correlated with the implementation costs (p = 0.55), development duration (p = 0.74), and number of FTEs dedicated DMP development. Organizations with large size and high level of care prior to the implementation of a DMP had relatively low development costs. These findings were in line with the cross-case qualitative comparison where programs with a longer history, more experienced project leadership, previously established ICT systems, and less complex patient populations had lower D&I costs. Conclusions: There is wide variation in D&I costs of DMPs, which is driven primarily by the duration of the development phase and the staff needed to develop and implement a DMP. These drivers are influenced by the attributes of the DMP, characteristics of the target population, project leadership, and ICT involved. There are indications of economies of scale and economies of scope, which may reduce D&I costs. Lessons learned for research development: D&I costs of DMPs are substantial and should be incorporated in economic evaluation studies. In addition, the case-mix of patients included in a DMP is associated with the D&I costs. Limitations: The costs that facilitated the DMP development and occurred prior to it were not available. Future research: should investigate whether the D&I costs per patient decrease in the longer term due to the broader inclusion of patients in DMPs. [ABSTRACT FROM AUTHOR]

We describe a case of Caroli syndrome (Caroli's disease and congenital hepatic fibrosis) in a 10-year-old boy with bilobar involvement and numerous renal cysts. Liver transplantation offers the only hope for such patients. [ABSTRACT FROM AUTHOR]

Intestinal volvulus causing obstruction is an unusual complication of ventriculoperitoneal shunts. There are no clear guidelines on the management of this problem. In our patient exteriorization of the shunt with subsequent reinsertion at a different site led to an uneventful recovery. The extreme rarity of this complication and its challenging management are discussed. [ABSTRACT FROM AUTHOR]

Objectives Understanding non-adherence to guidelines in patients with co-morbidities by supplementing quantitative data through patient-centred qualitative research. It is hypothesised that clinical constraints and patient-related factors explain the vast proportion of non-adherence. Design Mixed-method case study. Setting Primary and secondary acute care hospital, Department for Internal Medicine. Participants All consecutive patients having chronic heart failure (CHF) being hospitalised within a 2-year period. Results Quantitative drug prescribing analysis in 348 patients with CHF confirms moderate guideline adherence: the guideline adherence index (GAI) corresponds to 0.7 for the three most important drug classes indicated for CHF and to 0.6 for all five recommended drug classes. Corrections with regard to the most important clinical contraindication (renal insufficiency) for these drugs raise the GAI to 0.8 in both categories. Semistructured interviews in 50 consecutive patients show relevant reasons for non-adherence in half of the remaining patients with non-adherence to guidelines and raise the adjusted GAI to 0.9. Up to 75% of de jure non-adherence can thus be explained by clinical constraints. Conclusion Quantitative data analysis of treatment regimens in patients with CHF is an inaccurate method for measuring guideline adherence. Combining quantitative prescribing data with semistructured interviews shows a 90% match concerning guideline adherence compared to an only 60% match based on quantitative data alone. Thus, neither quality nor economical assessments of the treatment strategy in patients with chronic diseases should be solely based on quantitative analysis. Understanding non-adherence is crucial for defining and improving quality of care. [ABSTRACT FROM PUBLISHER]