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.

Grain yield components of pearl millet under optimum conditions can be used to identify germplasm with adaptation to and zones

There is evidence that high-tillering, small-panicled pearl millet landraces are better adapted to the severe, unpredictable drought stress of the and zones of NW India than are low-tillering, large-panicled modern varieties, which significantly outyield the landraces under favourable conditions. In this paper, we analyse the relationship of and zone adaptation with the expression, under optimum conditions, of yield components that determine either the potential sink size or the ability to realise this potential. The objective is to test whether selection under optimal conditions for yield components can identify germplasm with adaptation to and zones in NW India, as this could potentially improve the efficiency of pearl millet improvement programs targeting and zones. We use data from an evaluation of over 100 landraces from NW India, conducted for two seasons under both severely drought-stressed and favourable conditions in northwest and south India. Trial average grain yields ranged from 14 g m(-2) to 182 g m(-2). The landraces were grouped into clusters, based on their phenology and yield components as measured under well-watered conditions in south India. In environments without pre-flowering drought stress, tillering type had no effect on potential sink size, but low-tillering, large-panicled landraces yielded significantly more grain, as they were better able to realise their potential sink size. By contrast, in two low-yielding and zone environments which experienced pre-anthesis drought stress, low-fillering, large-panicled landraces yielded significantly less grain than high-tillering ones with comparable phenology, because of both a reduced potential sink size and a reduced ability to realise this potential. The results indicate that the high grain yield of low-tillering, large-panicled landraces under favourable conditions is due to improved partitioning, rather than resource capture. However, under severe stress with restricted assimilate supply, high-tillering, small-panicled landraces are better able to produce a reproductive sink than are large-panicled ones. Selection under optimum conditions for yield components representing a resource allocation pattern favouring high yield under severe drought stress, combined with a capability to increase grain yield if assimilates are available, was more effective than direct selection for grain yield in identifying germplasm adapted to and zones. Incorporating such selection in early generations of variety testing could reduce the reliance on random stress environments. This should improve the efficiency of millet breeding programs targeting and zones. (c) 2005 Elsevier B.V. All rights reserved.