Search

Background: In some countries, such as the Netherlands and Norway, point-of-care testing (POCT) is more widely implemented in general practice compared to countries such as England and Australia. To comprehend what is necessary to realize the benefits of POCT, regarding its integration in primary care, it would be beneficial to have an overview of the structure of healthcare operations and the transactions between stakeholders (also referred to as value networks). The aim of this paper is to identify the current value networks in place applying to POCT implementation at general practices in England, Australia, Norway and the Netherlands and to compare these networks in terms of seven previously published factors that support the successful implementation, sustainability and scale-up of innovations. Methods: The value networks were described based on formal guidelines and standards published by the respective governments, organizational bodies and affiliates. The value network of each country was validated by at least two relevant stakeholders from the respective country. Results: The analysis revealed that the biggest challenge for countries with low POCT uptake was the lack of effective communication between the several organizations involved with POCT as well as the high workload for general practitioners (GPs) aiming to implement POCT. It is observed that countries with a single national authority responsible for POCT have a better uptake as they can govern the task of POCT roll-out and management and reduce the workload for GPs by assisting with set-up, quality control, training and support. Conclusion: Setting up a single national authority may be an effective step towards realizing the full benefits of POCT. Although it is possible for day-to-day operations to fall under the responsibility of the GP, this is only feasible if support and guidance are readily available to ensure that the workload associated with POCT is limited and as low as possible. [ABSTRACT FROM AUTHOR]

Abstract Background The specificity of clinical questions is gauged by explicit descriptions of four dimensions: subjects, interventions, comparators and outcomes of interest. This study determined whether adding simple instructions and examples on clinical question formulation would increase the specificity of the submitted question compared to using a standard form without instructions and examples. Methods A randomised controlled trial was conducted in an evidence-search and appraisal service. New participants were invited to reformulate clinical queries. The Control Group was given no instructions. The Intervention Group was given a brief explanation of proper formulation, written instructions, and diagrammatic examples. The primary outcome was the change in the proportion of reformulated questions that described each the dimensions of specificity. Results Fifty-two subjects agreed to participate in the trial of which 13 were lost to follow-up. The remaining 17 Intervention Group and 22 Control Group participants were analysed. Baseline characteristics were comparable. Overall, 20% of initially submitted questions from both groups were properly specified (defined as an explicit statement describing all dimensions of specificity). On follow-up, 7/14 questions previously rated as mis-specified in the Intervention Group had all dimensions described at follow-up (p = 0.008) while the Control Group did not show any changes from baseline. Participants in the Intervention Group were also more likely to explicitly describe patients (p = 0.028), comparisons (p = 0.014), and outcomes (p = 0.008). Conclusions This trial demonstrated the positive impact of specific instructions on the proportion of properly-specified clinical queries. The evaluation of the long-term impact of such changes is an area of continued research.

A central function of health technology assessment (HTA) agencies is the production of HTA reports to support evidence-informed policy and decision making. HTA agencies are interested in understanding the mechanisms of HTA impact, which can be understood as the influence or impact of HTA report findings on decision making at various levels of the health system. The members of the International Network of Agencies for HTA (INAHTA) meet at their annual Congress where impact story sharing is one important activity. This paper summarizes four stories of HTA impact that were finalists for the David Hailey Award for Best Impact Story. The methods to measure impact include: document review; claims analysis and review of reimbursement status; citation analysis; qualitative evaluation of stakeholders' views; and review of media response. HTA agency staff also observed changes in government activities and priorities based on the HTA. Impact assessment can provide information to improve the HTA process, for example, the value of patient and clinician engagement in the HTA process to better define the assessment question and literature reviews in a more holistic and balanced way. HTA reports produced by publicly funded HTA agencies are valued by health systems around the globe as they support decision making regarding the appropriate use, pricing, reimbursement, and disinvestment of health technologies. HTAs can also have a positive impact on information sharing between different levels of government and across stakeholder groups. These stories show how HTA can have a significant impact, irrespective of the health system and health technology being assessed. [ABSTRACT FROM AUTHOR]

Background: Emergency front of neck access in a "can't intubate can't oxygenate" scenario in pediatrics is rare. Ideally airway rescue would involve the presence of an ear, nose, and throat surgeon. If unavailable however, responsibility lies with the anesthesiologist and accurate identification of anterior neck structures is essential for success. Aim: We assessed anesthesiologists' accuracy in identification of the pediatric cricothyroid membrane by digital palpation in three predefined age groups (37 weeks to <1 year old, 1‐8 years old, and 9‐16 years old) and whether accuracy improved with repetition. We also investigated a novel hypothetical vertical skin incision strategy to successfully expose the cricothyroid membrane. Methods: We asked anesthesiologists to identify the location of the cricothyroid membrane of anesthetized children in the extended neck position. Accuracy was defined as a mark made within the margins of the cricothyroid membrane using ultrasound as a reference standard. The position of the cricothyroid membrane relative to the neck midpoint, between the suprasternal notch and mentum, was defined for each child. Using this neck midpoint, we determined the hypothetical vertical skin incision lengths required to successfully expose the cricothyroid membrane ("midpoint incision"). Results: Ninety‐seven patients were included in this study. There were 14, 58, and 25 patients recruited across the three predefined groups. Accurate anesthesiologist identification of the location of the cricothyroid membrane occurred in 29.4%, 28.6%, and 38.2% of attempts, respectively. The majority of inaccurate assessments (64.1%) were below the cricothyroid membrane. There was no improvement in accuracy with repetition. Hypothetical "midpoint incision" lengths of 20, 30, and 35 mm were required. Conclusion: Significant anesthesiologist inaccuracy exists in locating the cricothyroid membrane in children of all ages. This has implications for the technical approach to emergency front of neck access and how we teach the management of "can't intubate can't oxygenate" in pediatric practice. [ABSTRACT FROM AUTHOR]

Arterial matrix proteoglycans (PG) are necessary for the maintenance of viscoelastic properties of the vessel wall, but excess levels, particularly of versican and biglycan in primary and restenotic intimal thickenings, are correlated with increased tissue volume and with atherogenicity. There is good evidence that the primary stimulus to increased PG synthesis, including versican and biglycan, is transforming growth factor-β[sub 1] (TGF-β[sub 1] ). The aim of this study was to determine the effects of reducing endogenous TGF-β[sub 1] on rates and patterns of PG synthesis and on versican, biglycan and decorin accumulation in vivo. Rabbit common carotid arteries subjected to balloon catheter injury were treated with a TGF-β[sub 1] antisense phosphorothioate oligonucleotide applied in a pluronic gel to the adventitia. Control animals received a nonsense oligonucleotide or gel alone. TGF-β[sub 1] antisense (1) significantly (p < 0.005) inhibited, at day 2, the balloon catheter-induced increase in TGF-β[sub 1] mRNA relative to β-actin mRNA; (2) inhibited intimal thickening at 23 days by ∼40% (p < 0.05); (3) inhibited (p < 0.05) PG synthesis, measured by autoradiographic detection of [[sup 3] H]glucosamine, in the media of day 2 ballooned carotids and in the subendothelial zone of day 23 neointima, and (4) decreased immunostaining intensity for versican (p < 0.03) and TGF-β[sub 1] (p < 0.001) in the neointima. Biglycan was reduced to a lesser extent but not significantly and decorin was not affected. Proliferating cell nuclear antigen indices were variable and not significantly changed. These findings confirm a role for TGF-β[sub 1] in developing neointima and demonstrate a specific effect on the synthesis, distribution, and accumulation of matrix PG, particularly versican.Copyright © 2000 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Using immunohistochemistry and quantitative in vitro autoradiography, the present study was undertaken to examine whether co-expression of pro-atherosclerotic factors, ACE, the AT(1) receptor, and iNOS, is increased in early and advanced atherosclerotic lesions of human coronary arteries. In normal coronary arteries, ACE and eNOS were strongly co-expressed in endothelial cells (ECs), whereas the AT(1) receptor was expressed in medial smooth muscle cells (SMCs). By contrast, iNOS was not expressed in ECs and SMCs. In early atherosclerotic lesions and atheromatous plaques, ACE, the AT(1) receptor and iNOS immunostaining were primarily co-localized in infiltrated macrophages and SMCs adjacent to macrophages. eNOS expression was lower in ECs than in normal arteries, and absent in accumulated macrophages and SMCs. In fibrosclerotic plaques, ACE, the AT(1) receptor, and iNOS immunostaining were still positive in macrophages as well as new microvessels within the plaques. Interestingly, SMCs in vasa vasorum of the adventitia in atheromatous and fibrosclerotic plaques were also strongly positive for AT(1) receptor and iNOS, while ECs of the vasa vasorum were positive for ACE and eNOS. The present study demonstrates that multiple pro-atherosclerotic factors ACE, AT(1) receptor and iNOS are co-localized almost exclusively in infiltrated macrophages and SMCs that have accumulated in or adjacent to early and advanced atherosclerotic plaques, while the anti-atherosclerotic enzyme eNOS is reduced in ECs. These data therefore suggest that increased formation of Ang II and iNOS in infiltrated macrophages and medial SMCs might well play important roles in the development and progression of human coronary atherosclerosis.