Multisite, quality-improvement collaboration to optimise cardiac care in Queensland public hospitals

Objective: To evaluate changes in quality of in-hospital care of patients with either acute coronary syndromes (ACS) or congestive heart failure (CHF) admitted to hospitals participating in a multisite quality improvement collaboration. Design: Before-and-after study of changes in quality indicators measured on representative patient samples between June 2001 and January 2003. Setting: Nine public hospitals in Queensland. Study populations: Consecutive or randomly selected patients admitted to study hospitals during the baseline period (June 2001 to January 2002; n = 807 for ACS, n = 357 for CHF) and post-intervention period (July 2002 to January 2003; n = 717 for ACS, n = 220 for CHF). Intervention: Provision of comparative baseline feedback at a facilitative workshop combined with hospital-specific quality-improvement interventions supported by on-site quality officers and a central program management group. Main outcome measure: Changes in process-of-care indicators between baseline and post-intervention periods. Results: Compared with baseline, more patients with ACS in the post-intervention period received therapeutic heparin regimens (84% v 72%; P < 0.001), angiotensin-converting enzyme inhibitors (64% v 56%; P = 0.02), lipid-lowering agents (72% v 62%; P < 0.001), early use of coronary angiography (52% v 39%; P < 0.001), in-hospital cardiac counselling (65% v 43%; P < 0.001), and referral to cardiac rehabilitation (15% v 5%; P < 0.001). The numbers of patients with CHF receiving β-blockers also increased (52% v 34%; P < 0.001), with fewer patients receiving deleterious agents (13% v 23%; P = 0.04). Same-cause 30-day readmission rate decreased from 7.2% to 2.4% (P = 0.02) in patients with CHF. Conclusion: Quality-improvement interventions conducted as multisite collaborations may improve in-hospital care of acute cardiac conditions within relatively short time frames.

Evolution of plant water relations research in Australia

Ecophysiological research in Australia has focussed, at different times, on the fundamental similarities in function between all plant species, and on the peculiarity of Australian species with respect to their survival in stressful environments. Early work on plant water relations emphasised the differences between species, and indicated that diverse structural and functional attributes occurred in species from the same water-limited environment. Most recent research has emphasised processes that optimise rates of carbon dioxide exchange, but the understanding of functioning in plants with different morphological arrangements is incomplete. Variation in functions between individual plants and geographic populations in wild species has been examined to a lesser extent. The great variety within and between populations of wild plant species warrants further study for both understanding and more effective management of this biological resource.

HPGR model verification and scale-up

This paper summarises test results that were used to validate a model and scale-up procedure of the high pressure grinding roll (HPGR) which was developed at the JKMRC by Morrell et al. [Morrell, Lim, Tondo, David,1996. Modelling the high pressure grinding rolls. In: Mining Technology Conference, pp. 169-176.]. Verification of the model is based on results from four data sets that describe the performance of three industrial scale units fitted with both studded and smooth roll surfaces. The industrial units are currently in operation within the diamond mining industry and are represented by De Beers, BHP Billiton and Rio Tinto. Ore samples from the De Beers and BHP Billiton operations were sent to the JKMRC for ore characterisation and HPGR laboratory-scale tests. Rio Tinto contributed an historical data set of tests completed during a previous research project. The results conclude that the modelling of the HPGR process has matured to a point where the model may be used to evaluate new and to optimise existing comminution circuits. The model prediction of product size distribution is good and has been found to be strongly dependent of the characteristics of the material being tested. The prediction of throughput and corresponding power draw (based on throughput) is sensitive to inconsistent gap/diameter ratios observed between laboratory-scale tests and full-scale operations. (C) 2004 Elsevier Ltd. All rights reserved.

Achieving better in-hospital and after-hospital care of patients with acute cardiac disease

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after hospital care, patient self-care, and hospital-community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included: clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); educational interventions (seminars, academic detailing); regular performance feedback; patient self-management strategies; and hospital-community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before-after study design to assess program impact, significantly more program patients compared with historical controls received: ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and beta-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. CHF. Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, beta-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P=0.06) and from 13.4% to 10.1% (P= 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P= 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.

Validation of assembled nucleic acid-based tests in diagnostic microbiology laboratories

Medical microbiology and virology laboratories use nucleic acid tests (NAT) to detect genomic material of infectious organisms in clinical samples. Laboratories choose to perform assembled (or in-house) NAT if commercial assays are not available or if assembled NAT are more economical or accurate. One reason commercial assays are more expensive is because extensive validation is necessary before the kit is marketed, as manufacturers must accept liability for the performance of their assays, assuming their instructions are followed. On the other hand, it is a particular laboratory's responsibility to validate an assembled NAT prior to using it for testing and reporting results on human samples. There are few published guidelines for the validation of assembled NAT. One procedure that laboratories can use to establish a validation process for an assay is detailed in this document. Before validating a method, laboratories must optimise it and then document the protocol. All instruments must be calibrated and maintained throughout the testing process. The validation process involves a series of steps including: (i) testing of dilution series of positive samples to determine the limits of detection of the assay and their linearity over concentrations to be measured in quantitative NAT; (ii) establishing the day-to-day variation of the assay's performance; (iii) evaluating the sensitivity and specificity of the assay as far as practicable, along with the extent of cross-reactivity with other genomic material; and (iv) assuring the quality of assembled assays using quality control procedures that monitor the performance of reagent batches before introducing new lots of reagent for testing.

Functional and prognostic implications of left ventricular contractile reserve in patients with asymptomatic severe mitral regurgitation

Objective: To evaluate contractile reserve (CR) determined by exercise echocardiography in predicting clinical outcome and left ventricular (LV) function in asymptomatic severe mitral regurgitation (MR). Design: Cohort study. Setting: Regional cardiac centre. Patients and outcome measures: LV volumes and ejection fraction (EF) were measured at rest and after stress in 71 patients with isolated MR. During follow up (mean (SD) 3 (1) years), EF and functional capacity were serially assessed and cardiac events ( cardiac death, heart failure, and new atrial fibrillation) were documented. Results: CR was present in 45 patients (CR+) and absent in 26 patients (CR-). Age, resting LV dimensions, EF, and MR severity were similar in both groups. Mitral surgery was performed in 19 of 45 (42%) CR+ patients and 22 of 26 (85%) CR2 patients. In patients undergoing surgery, CR was an independent predictor of follow up EF (p = 0.006) and postoperative LV dysfunction (EF < 50%) persisted in five patients, all in the CR2 group. Event-free survival was lower in surgically treated patients without CR (p = 0.03). In medically treated patients, follow up EF was preserved in those with intact CR but progressively deteriorated in patients without CR, in whom functional capacity also deteriorated. Conclusions: Evaluation of CR by exercise echocardiography may be useful for risk stratification and may help to optimise the timing of surgery in asymptomatic severe MR.

Modelling, nitrogen dynamics in sugarcane systems: Recent advances and applications

Substantial amounts of nitrogen (N) fertiliser are necessary for commercial sugarcane production because of the large biomass produced by sugarcane crops. Since this fertiliser is a substantial input cost and has implications if N is lost to the environment, there are pressing needs to optimise the supply of N to the crops' requirements. The complexity of the N cycle and the strong influence of climate, through its moderation of N transformation processes in the soil and its impact on N uptake by crops, make simulation-based approaches to this N management problem attractive. In this paper we describe the processes to be captured in modelling soil and plant N dynamics in sugarcane systems, and review the capability for modelling these processes. We then illustrate insights gained into improved management of N through simulation-based studies for the issues of crop residue management, irrigation management and greenhouse gas emissions. We conclude by identifying processes not currently represented in the models used for simulating N cycling in sugarcane production systems, and illustrate ways in which these can be partially overcome in the short term. (c) 2005 Elsevier B.V. All rights reserved.

Phylogeography of the scarab beetle Antitrogus parvulus Britton (Coleoptera : Scarabaeidae) in south-eastern Queensland, Australia

This study surveys the population genetic structure of Childers canegrub, Antitrogus parvulus, to elucidate its population dynamics and gene flow. Antitrogus parvulus is a pest of sugarcane in the Bundaberg region and this knowledge can be used to optimise integrated pest management practices. Here, base-pair differences in the cytochrome oxidase II gene (COII) were used to characterise haplotypic diversity, infer levels of gene flow, and phylogenetic relationships of alleles and their phylogeographical structure. There were 28 unique haplotypes among the 70 sequenced individuals from the seven locations. All three variance components (among regions, among populations, within populations) are highly significant, with highest genetic diversity among regions and lowest among populations within regions. A positive correlation between migration rates and geographical distance and significant phylogeographical structure between four main geographical regions. The main implication of these findings for pest management is that if a grower can eliminate an existing infestation within a field, then reinvasion will be slow and further outbreaks within that field are unlikely to occur. The low dispersal ability of females also means that any resistance to insecticides that develops is likely to remain localised, but will rapidly become dominant within the affected population.

Identifying critical components during information security evaluations

Electronic communications devices intended for government or military applications must be rigorously evaluated to ensure that they maintain data confidentiality. High-grade information security evaluations require a detailed analysis of the device's design, to determine how it achieves necessary security functions. In practice, such evaluations are labour-intensive and costly, so there is a strong incentive to find ways to make the process more efficient. In this paper we show how well-known concepts from graph theory can be applied to a device's design to optimise information security evaluations. In particular, we use end-to-end graph traversals to eliminate components that do not need to be evaluated at all, and minimal cutsets to identify the smallest group of components that needs to be evaluated in depth.