Knowledge-based clinical pathway for medical quality improvement

Clinical pathways have been adopted for various diseases in clinical departments for quality improvement as a result of standardization of medical activities in treatment process. Using knowledge-based decision support on the basis of clinical pathways is a promising strategy to improve medical quality effectively. However, the clinical pathway knowledge has not been fully integrated into treatment process and thus cannot provide comprehensive support to the actual work practice. Therefore this paper proposes a knowledgebased clinical pathway management method which contributes to make use of clinical knowledge to support and optimize medical practice. We have developed a knowledgebased clinical pathway management system to demonstrate how the clinical pathway knowledge comprehensively supports the treatment process. The experiences from the use of this system show that the treatment quality can be effectively improved by the extracted and classified clinical pathway knowledge, seamless integration of patient-specific clinical pathway recommendations with medical tasks and the evaluating pathway deviations for optimization.

Integrated clinical pathway management for medical quality improvement-based on a semiotically inspired systems architecture

Clinical pathway is an approach to standardise care processes to support the implementations of clinical guidelines and protocols. It is designed to support the management of treatment processes including clinical and non-clinical activities, resources and also financial aspects. It provides detailed guidance for each stage in the management of a patient with the aim of improving the continuity and coordination of care across different disciplines and sectors. However, in the practical treatment process, the lack of knowledge sharing and information accuracy of paper-based clinical pathways burden health-care staff with a large amount of paper work. This will often result in medical errors, inefficient treatment process and thus poor quality medical services. This paper first presents a theoretical underpinning and a co-design research methodology for integrated pathway management by drawing input from organisational semiotics. An approach to integrated clinical pathway management is then proposed, which aims to embed pathway knowledge into treatment processes and existing hospital information systems. The capability of this approach has been demonstrated through the case study in one of the largest hospitals in China. The outcome reveals that medical quality can be improved significantly by the classified clinical pathway knowledge and seamless integration with hospital information systems.

Patient and public involvement in healthcare quality improvement: how organizations can help patients and professionals to collaborate

Citizens across the world are increasingly called upon to participate in healthcare improvement. It is often unclear how this can be made to work in practice. This 4- year ethnography of a UK healthcare improvement initiative showed that patients used elements of organizational culture as resources to help them collaborate with healthcare professionals. The four elements were: (1) organizational emphasis on nonhierarchical, multidisciplinary collaboration; (2) organizational staff ability to model desired behaviours of recognition and respect; (3) commitment to rapid action, including quick translation of research into practice; and (4) the constant data collection and reflection process facilitated by improvement methods.

Designing care bundle documentation to support the recognition and treatment of acute kidney injury: a route to quality improvement

The chapter describes development of care bundle documentation, through an iterative, user-centred design process, to support the recognition and treatment of acute kidney injury (AKI). The chapter details stages of user and stakeholder consultation, employed to develop a design response that was sensitive to user experience and need, culminating in simulation testing of a near final prototype. The development of supplementary awareness-raising materials, relating to the main care bundle tool is also discussed. This information design response to a complex clinical decision-making process is contrasted to other approaches to promoting AKI care. The need for different but related approaches to the working tool itself and the tool’s communication are discussed. More general recommendations are made for the development of communication tools to support complex clinical processes.

Nitrate transport in Chalk catchments: monitoring, modelling and policy implications

Rising nitrate levels have been observed in UK Chalk catchments in recent decades, with concentrations now approaching or exceeding legislated maximum values in many areas. In response, strategies seeking to contain concentrations through appropriate land management are now in place. However, there is an increasing consensus that Chalk systems, a predominant landscape type over England and indeed northwest Europe, can retard decades of prior nitrate loading within their deep unsaturated zones. Current levels may not fully reflect the long-term impact of present-day practices, and stringent land management controls may not be enough to avert further medium-term rises. This paper discusses these issues in the context of the EU Water Framework Directive, drawing on data from recent experimental work and a new model (INCA-Chalk) that allows the impacts of different land use management practices to be explored. Results strongly imply that timelines for water quality improvement demanded by the Water Framework directive are not realistic for the Chalk, and give an indication of time-scales over which improvements might be achieved. However, important unresolved scientific issues remain, and further monitoring and targeted data collection is recommended to reduce prediction uncertainties and allow cost effective strategies for mitigation to be designed and implemented. (C) 2007 Elsevier Ltd. All rights reserved.

COMPUTER assisted technologies to enhance CONCURRENce in building DESIGN

Modern organisms are adapted to a wide variety of habitats and lifestyles. The processes of evolution have led to complex, interdependent, well-designed mechanisms of todays world and this research challenge is to transpose these innovative solutions to resolve problems in the context of architectural design practice, e.g., to relate design by nature with design by human. In a design by human environment, design synthesis can be performed with the use of rapid prototyping techniques that will enable to transform almost instantaneously any 2D design representation into a physical three-dimensional model, through a rapid prototyping printer machine. Rapid prototyping processes add layers of material one on top of another until a complete model is built and an analogy can be established with design by nature where the natural lay down of earth layers shapes the earth surface, a natural process occurring repeatedly over long periods of time. Concurrence in design will particularly benefit from rapid prototyping techniques, as the prime purpose of physical prototyping is to promptly assist iterative design, enabling design participants to work with a three-dimensional hardcopy and use it for the validation of their design-ideas. Concurrent design is a systematic approach aiming to facilitate the simultaneous involvment and commitment of all participants in the building design process, enabling both an effective reduction of time and costs at the design phase and a quality improvement of the design product. This paper presents the results of an exploratory survey investigating both how computer-aided design systems help designers to fully define the shape of their design-ideas and the extent of the application of rapid prototyping technologies coupled with Internet facilities by design practice. The findings suggest that design practitioners recognize that these technologies can greatly enhance concurrence in design, though acknowledging a lack of knowledge in relation to the issue of rapid prototyping.

Effect of simulated rainfall during wheat seed development and maturation on subsequent seed longevity is reversible

Poor wheat seed quality in temperate regions is often ascribed to wet production environments. We investigated the possible effect of simulated rain during seed development and maturation on seed longevity in wheat (Triticum aestivum L.) cv. Tybalt grown in the field (2008, 2009) or a polythene tunnel house (2010). To mimic rain, the seed crops were wetted from above with the equivalent of 30mm (2008, 2009) or 25mm rainfall (2010) at different stages of seed development and maturation (17 to 58 DAA, days after 50% anthesis), samples harvested serially, and subsequent air-dry seed longevity estimated. No pre-harvest sprouting occurred. Seed longevity (p50, 50% survival period in experimental hermetic storage at 40°C with c. 15% moisture content) in field-grown controls increased during seed development and maturation attaining maxima at 37 (2008) or 44 DAA (2009); it declined thereafter. Immediate effects of simulated rain at 17-58 DAA in field studies (2008, 2009) on subsequent seed longevity were negative but small, e.g. a 1-4 d delay in seed quality improvement for treatments early in development but with no damage detected at final harvests. In rainfall-protected conditions (2010), simulated rain close to harvest maturity (55-56 DAA) reduced longevity immediately and substantially, with greater damage from two sequential days of wetting than one; again, later harvests provided evidence of recovery in subsequent longevity. In the absence of pre-harvest sprouting, the potentially deleterious effects of rainfall to wheat seed crops on subsequent seed longevity may be reversible in full or in part.

Improvement of link failure restoration utilising multi-protocol label switching (MPLS) as a means to maintain quality of service (QOS)

This paper proposes a practical approach to the enhancement of Quality of Service (QoS) routing by means of providing alternative or repair paths in the event of a breakage of a working path. The proposed scheme guarantees that every Protected Node (PN) is connected to a multi-repair path such that no further failure or breakage of single or double repair paths can cause any simultaneous loss of connectivity between an ingress node and an egress node. Links to be protected in an MPLS network are predefined and a Label Switched path (LSP) request involves the establishment of a working path. The use of multi-protection paths permits the formation of numerous protection paths allowing greater flexibility. Our analysis examined several methods including single, double and multi-repair routes and the prioritization of signals along the protected paths to improve the Quality of Service (QoS), throughput, reduce the cost of the protection path placement, delay, congestion and collision. Results obtained indicated that creating multi-repair paths and prioritizing packets reduces delay and increases throughput in which case the delays at the ingress/egress LSPs were low compared to when the signals had not been classified. Therefore the proposed scheme provided a means to improve the QoS in path restoration in MPLS using available network resources. Prioritizing the packets in the data plane has revealed that the amount of traffic transmitted using a medium and low priority Label Switch Paths (LSPs) does not have any impact on the explicit rate of the high priority LSP in which case the problem of a knock-on effect is eliminated.

Improvement of 3D protein models using multiple templates guided by single-template model quality assessment

Motivation: Modelling the 3D structures of proteins can often be enhanced if more than one fold template is used during the modelling process. However, in many cases, this may also result in poorer model quality for a given target or alignment method. There is a need for modelling protocols that can both consistently and significantly improve 3D models and provide an indication of when models might not benefit from the use of multiple target-template alignments. Here, we investigate the use of both global and local model quality prediction scores produced by ModFOLDclust2, to improve the selection of target-template alignments for the construction of multiple-template models. Additionally, we evaluate clustering the resulting population of multi- and single-template models for the improvement of our IntFOLD-TS tertiary structure prediction method. Results: We find that using accurate local model quality scores to guide alignment selection is the most consistent way to significantly improve models for each of the sequence to structure alignment methods tested. In addition, using accurate global model quality for re-ranking alignments, prior to selection, further improves the majority of multi-template modelling methods tested. Furthermore, subsequent clustering of the resulting population of multiple-template models significantly improves the quality of selected models compared with the previous version of our tertiary structure prediction method, IntFOLD-TS.

Effect of dietary supplementation with selenium-enriched yeast or sodium selenite on selenium tissue distribution and meat quality in beef cattle

The objective was to determine the concentration of total selenium (Se) and the proportion of total Se comprised as selenomethionine (SeMet) and selenocysteine (SeCys) in post mortem tissues of beef cattle offered diets containing graded additions of selenized enriched yeast (SY) [Saccharomyces cerevisae CNCM I-3060]), or sodium selenite (SS). Oxidative stability and tissue glutathione peroxidase (GSH-Px) activity of edible muscle tissue were assessed 10 d post-mortem. Thirty two beef cattle were offered, for a period of 112 d, a total mixed ration which had either been supplemented with SY (0, 0.15 or 0.35 mg Se/kg DM) or SS (0.15 mg Se/kg DM). At enrollment (0 d) and at 28, 56, 84 and 112 d following enrollment, blood samples were taken for Se and Se species determination, as well as whole blood GSH-Px activity. At the end of the study beef cattle were euthanized and samples of heart, liver, kidney, and skeletal muscle (LM and psoas major) were retained for Se and Se species determination. Tissue GSH-Px activity and thiobarbituric acid reactive substances (TBARS) were determined in skeletal muscle tissue (LM only). The incorporation into the diet of ascending concentrations of Se as SY increased whole blood total Se and the proportion of total Se comprised as SeMet, as well as GSH-Px activity. There was also a dose dependant response to the graded addition of SY on total Se and proportion of total Se as SeMet in all tissues and GSH-Px activity in skeletal muscle tissue. Furthermore, total Se concentration of whole blood and tissues was greater in those animals offered SY when compared with those receiving a comparable dose of SS, indicating an improvement in Se availability and tissue Se retention. Likewise, GSH-Px activity in whole blood and LM was greater in those animals offered SY when compared with those receiving a comparable dose of SS. However, these increases in tissue total Se and GSH-Px activity appeared to have little or no effect in meat oxidative stability.

Evaluating the role of environmental quality in the sustainable rural economic development of England

The issue of the sustainable development of rural economies in England has recently received considerable attention. This is because many of the poorest areas in the country are rural, often of high environmental quality, but suffering from high unemployment and a lack of services and facilities. The rapid decline in agricultural incomes and in-migration of affluent urban workers since 1990 has exacerbated economic inequality in such areas. A number of factors have the potential to drive rural development and this paper applies, and considers, the feasibility of a method from the USA for combining economic and environmental variables in a regional growth model to examine the hypothesis that environmental quality is an important determinant of sustainable rural development in England. The model output suggests that, although environmental quality does play a role in sustainable rural development in England there are other, more important, factors driving development. These include business and communications infra-structure, the degree and opportunities for commuting and underlying employment prospects. The robustness and limitations of the method for combining economic and environmental variables is discussed in relation to the spatial interrelatedness of Local Authority Districts in England, and conclusions are drawn about areas for refinement and improvement of the method.

Rapid model quality assessment for protein structure predictions using the comparison of multiple models without structural alignments

MOTIVATION: The accurate prediction of the quality of 3D models is a key component of successful protein tertiary structure prediction methods. Currently, clustering or consensus based Model Quality Assessment Programs (MQAPs) are the most accurate methods for predicting 3D model quality; however they are often CPU intensive as they carry out multiple structural alignments in order to compare numerous models. In this study, we describe ModFOLDclustQ - a novel MQAP that compares 3D models of proteins without the need for CPU intensive structural alignments by utilising the Q measure for model comparisons. The ModFOLDclustQ method is benchmarked against the top established methods in terms of both accuracy and speed. In addition, the ModFOLDclustQ scores are combined with those from our older ModFOLDclust method to form a new method, ModFOLDclust2, that aims to provide increased prediction accuracy with negligible computational overhead. RESULTS: The ModFOLDclustQ method is competitive with leading clustering based MQAPs for the prediction of global model quality, yet it is up to 150 times faster than the previous version of the ModFOLDclust method at comparing models of small proteins (<60 residues) and over 5 times faster at comparing models of large proteins (>800 residues). Furthermore, a significant improvement in accuracy can be gained over the previous clustering based MQAPs by combining the scores from ModFOLDclustQ and ModFOLDclust to form the new ModFOLDclust2 method, with little impact on the overall time taken for each prediction. AVAILABILITY: The ModFOLDclustQ and ModFOLDclust2 methods are available to download from: http://www.reading.ac.uk/bioinf/downloads/ CONTACT: l.j.mcguffin@reading.ac.uk.

Differential effects of temperature on fruit development and bean quality of contrasting genotypes of cacao (Theobroma cacao)

The effects of temperature and light integral on fruit growth and development of five cacao genotypes (Amelonado, AMAZ 15/15, SCA 6, SPEC 54/1 and UF 676) were studied in semi-controlled environment glasshouses in which the thermal regimes of cacao-growing regions of Brazil, Ghana and Malaysia were simulated. Fruit losses because of physiological will (cherelle will) were greater at higher temperatures and also differed significantly between genotypes, reflecting genetic differences in competition for assimilates between vegetative and reproductive components. Short-term measurements of fruit growth indicated faster growth rates at higher temperatures. In addition, a significant negative linear relationship between temperature and development time was observed. There was an effect of genotype on this relationship, such that time to fruit maturation at a given temperature was greatest for the clone UF 676 and least for AMAZ 15/15. Analysis of base temperatures, derived from these relationships indicated genetic variability in sensitivity of cacao fruit growth to temperature (base temperatures ranged from 7.5 degrees C for Amelonado and AMAZ 15/15 to 12.9 for SPEC 54/1). Final fruit size was a positive function of beam number for all genotypes and a positive function of light integral for Amelonado in the Malaysia simulated environment (where the temperature was almost constant). In simulated environments where temperature was the main variable (Brazil and Ghana) increases in temperature resulted in a significant decrease in final pod size for one genotype (Amelonado) in Brazil and for two genotypes (SPEC 54/1 and UF 676) in Ghana. It was hypothesised that pod growth duration (mediated by temperature), assimilation and beam number are all determinants of final pod size but that under specific conditions one of these factors may override the others. There was variability between genotypes in the response of beam size and beam lipid content to temperature. Negative relationships between temperature and bean size were found for Amelonado and UF 676. Lipid concentration was a curvilinear function of temperature for Amelonado and UF 676, with optimal temperatures of 23 degrees C and 24 degrees C, respectively. The variability observed here of different cacao genotypes to temperature highlights the need and opportunities for appropriate matching of planting material with local environments.

Artichoke leaf extract reduces symptoms of irritable bowel syndrome and improves quality of life in otherwise healthy volunteers suffering from concomitant dyspepsia: a subset analysis

Objectives: Does artichoke leaf extract (ALE) ameliorate symptoms of Irritable bowel syndrome (IBS) in otherwise healthy volunteers suffering concomitant dyspepsia? Methods: A subset analysis of a previous dose-ranging, open, postal study, in adults suffering dyspepsia. Two hundred and eight (208) adults were identified post hoc as suffering with IBS. IBS incidence, self-reported usual bowel pattern, and the Nepean Dyspepsia Index (NDI) were compared before and after a 2-month intervention period. Results: There was a significant fall in IBS incidence of 26.4% (p<0.001) after treatment. A significant shift in self-reported usual bowel pattern away from "alternating constipation/diarrhea" toward "normal" (p<0.001) was observed. NDI total symptom score significantly decreased by 41% (p<0.001) after treatment. Similarly, there was a significant 20% improvement in the NDI total quality-of-life (QOL) score in the subset after treatment. Conclusion: This report supports previous findings that ALE ameliorates symptoms of IBS, plus improves health-related QOL.