A new tool for measurement of process-based performance of multispecialty tertiary care hospitals

There is an increasing need of a model for the process-based performance measurement of multispecialty tertiary care hospitals for quality improvement. Analytic hierarchy process (AHP) is utilized in this study to evolve such a model. Each step in the model was derived by group-discussions and brainstorming sessions among experienced clinicians and managers. This tool was applied to two tertiary care teaching hospitals in Barbados and India. The model enabled identification of specific areas where neither hospital performed very well, and helped to suggest recommendations to improve those areas. AHP is recommended as a valuable tool to measure the process-based performance of multispecialty tertiary care hospitals. © Emerald Group Publishing Limited.

Genetic characterization of clinical isolates of Clostridium difficile using an optimized RAPD protocol and PCR ribotyping reveals strain diversity between two tertiary referral Trusts in the West Midlands, UK

Epidemiological investigations of Clostridium difficile often focus on differences between separate geographical areas. In this investigation, two populations of C. difficile recovered from separate tertiary referral Trusts within the West Midlands, UK, were characterized using both PCR ribotyping and an optimized RAPD (random amplification of polymorphic DNA) protocol. The PCR ribotyping and RAPD methodologies identified differences between the two C. difficile populations, in both the prevalence and the diversity of types identified. The use of PCR ribotyping in conjunction with RAPD further categorized different types within defined PCR ribotypes, identifying different types within the same PCR ribotype and therefore providing a greater discriminatory power than either of the methods when used alone. The differences observed in this study between the two Trusts in the distribution of both RAPD 'type' and PCR ribotype demonstrate the diversity that is present amongst isolates of C. difficile within a relatively small geographical area and warrants a need for further investigation into the local epidemiology of C. difficile.

Adapting an apprenticeship model to the needs of English-medium education at the tertiary level in Turkey

Despite the difficulties that we have regarding the use of English in tertiary education in Turkey, we argue that it is necessary for those involved to study in the medium of English. Furthermore, significant advances have been made on this front. These efforts have been for the most part language-oriented, but also include research into needs analysis and the pedagogy of team-teaching. Considering the current situation at this level of education, however, there still seems to be more to do. And the question is, what more can we do? What further contribution can we make? Or, how can we take this process further? The purpose of the study reported here is to respond to this last question. We test the proposition that it is possible to take this process further by investigating the efficient management of transition from Turkish-medium to English-medium at the tertiary level of education in Turkey. Beyond what is achieved by only the language orientation of the EAP approach, and moving conceptually deeper than what has been achieved by the team-teaching approach, the research undertaken for the purpose of this study focuses on the idea of the discourse community that people want to belong to. It then pursues an adaptation of the essentially psycho-social approach of apprenticeship, as people become aspirants and apprentices to that discourse community. In this thesis, the researcher recognises that she cannot follow all the way through to the full implementation of her ideas in a fully-taught course. She is not in a position to change the education system. What she does here is to introduce a concept and sample its effects in terms of motivation, and thereby of integration and of success, for individuals and groups of learners. Evaluation is provided by acquiring both qualitative and quantitative data concerning mature members' perceptions of apprenticed-neophytes functioning as members in the new community, apprenticed-neophytes' perceptions of their own membership and of the preparation process undertaken, and the comparison of these neophytes' performance with that of other neophytes in the community. The data obtained provide strong evidence in support of the potential usefulness of this apprenticeship model towards the declared purpose of improving the English-medium tertiary education of Turkish students in their chosen fields of study.

Complementary methods to investigate the development of clogging within a horizontal sub-surface flow tertiary treatment wetland

A combination of experimental methods was applied at a clogged, horizontal subsurface flow (HSSF) municipal wastewater tertiary treatment wetland (TW) in the UK, to quantify the extent of surface and subsurface clogging which had resulted in undesirable surface flow. The three dimensional hydraulic conductivity profile was determined, using a purpose made device which recreates the constant head permeameter test in-situ. The hydrodynamic pathways were investigated by performing dye tracing tests with Rhodamine WT and a novel multi-channel, data-logging, flow through Fluorimeter which allows synchronous measurements to be taken from a matrix of sampling points. Hydraulic conductivity varied in all planes, with the lowest measurement of 0.1 md1 corresponding to the surface layer at the inlet, and the maximum measurement of 1550 md1 located at a 0.4m depth at the outlet. According to dye tracing results, the region where the overland flow ceased received five times the average flow, which then vertically short-circuited below the rhizosphere. The tracer break-through curve obtained from the outlet showed that this preferential flow-path accounted for approximately 80% of the flow overall and arrived 8 h before a distinctly separate secondary flow-path. The overall volumetric efficiencyof the clogged system was 71% and the hydrology was simulated using a dual-path, dead-zone storage model. It is concluded that uneven inlet distribution, continuous surface loading and high rhizosphere resistance is responsible for the clog formation observed in this system. The average inlet hydraulic conductivity was 2 md1, suggesting that current European design guidelines, which predict that the system will reach an equilibrium hydraulic conductivity of 86 md1, do not adequately describe the hydrology of mature systems.

Whither human capital? The woeful tale of transition to tertiary education in India

In this article, we examine the issue of high dropout rates in India which has adverse implications for human capital formation and hence for the country's long-term growth potential. Using the 2004–2005 National Sample Survey (NSS) employment–unemployment data, we estimate transition probabilities of moving from a number of different educational levels to higher educational levels using a sequential logit model. Our results suggest that the overall probability of reaching tertiary education is very low. Further, even by the woeful overall standards, women are significantly worse off, particularly in rural areas.

Lymphoid aggregates that resemble tertiary lymphoid organs define a specific pathological subset in metal-on-metal hip replacements

Aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) has been used to describe the histological lesion associated with metal-on-metal (M-M) bearings. We tested the hypothesis that the lymphoid aggregates, associated with ALVAL lesions resemble tertiary lymphoid organs (TLOs). Histopathological changes were examined in the periprosthetic tissue of 62 M-M hip replacements requiring revision surgery, with particular emphasis on the characteristics and pattern of the lymphocytic infiltrate. Immunofluorescence and immunohistochemistry were used to study the classical features of TLOs in cases where large organized lymphoid follicles were present. Synchrotron X-ray fluorescence (XRF) measurements were undertaken to detect localisation of implant derived ions/particles within the samples. Based on type of lymphocytic infiltrates, three different categories were recognised; diffuse aggregates (51%), T cell aggregates (20%), and organised lymphoid aggregates (29%). Further investigation of tissues with organised lymphoid aggregates showed that these tissues recapitulate many of the features of TLOs with T cells and B cells organised into discrete areas, the presence of follicular dendritic cells, acquisition of high endothelial venule like phenotype by blood vessels, expression of lymphoid chemokines and the presence of plasma cells. Co-localisation of implant-derived metals with lymphoid aggregates was observed. These findings suggest that in addition to the well described general foreign body reaction mediated by macrophages and a T cell mediated type IV hypersensitivity response, an under-recognized immunological reaction to metal wear debris involving B cells and the formation of tertiary lymphoid organs occurs in a distinct subset of patients with M-M implants. © 2013 Mittal et al.

Geology of the tertiary coal basins of Thailand

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Anisotropic characterization of crack growth in the tertiary flow of asphalt mixtures in compression

Asphalt mixtures exhibit primary, secondary, and tertiary stages in sequence during a rutting deterioration. Many field asphalt pavements are still in service even when the asphalt layer is in the tertiary stage, and rehabilitation is not performed until a significant amount of rutting accompanied by numerous macrocracks is observed. The objective of this study was to provide a mechanistic method to model the anisotropic cracking of the asphalt mixtures in compression during the tertiary stage of rutting. Laboratory tests including nondestructive and destructive tests were performed to obtain the viscoelastic and viscofracture properties of the asphalt mixtures. Each of the measured axial and radial total strains in the destructive tests were decomposed into elastic, plastic, viscoelastic, viscoplastic, and viscofracture strains using the pseudostrain method in an extended elastic-viscoelastic correspondence principle. The viscofracture strains are caused by the crack growth, which is primarily signaled by the increase of phase angle in the tertiary flow. The viscofracture properties are characterized using the anisotropic damage densities (i.e., the ratio of the lost area caused by cracks to the original total area in orthogonal directions). Using the decomposed axial and radial viscofracture strains, the axial and radial damage densities were determined by using a dissipated pseudostrain energy balance principle and a geometric analysis of the cracks, respectively. Anisotropic pseudo J-integral Paris' laws in terms of damage densities were used to characterize the evolution of the cracks in compression. The material constants in the Paris' law are determined and found to be highly correlated. These tests, analysis, and modeling were performed on different asphalt mixtures with two binders, two air void contents, and three aging periods. Consistent results were obtained; for instance, a stiffer asphalt mixture is demonstrated to have a higher modulus, a lower phase angle, a greater flow number, and a larger n1 value (exponent of Paris' law). The calculation of the orientation of cracks demonstrates that the asphalt mixture with 4% air voids has a brittle fracture and a splitting crack mode, whereas the asphalt mixture with 7% air voids tends to have a ductile fracture and a diagonal sliding crack mode. Cracks of the asphalt mixtures in compression are inclined to propagate along the direction of the external compressive load. © 2014 American Society of Civil Engineers.

Methicillin-resistant Staphylococcus aureus bacteremia:epidemiology, outcome, and laboratory characteristics in a tertiary referral center in the UK

Objective: To analyze the recent epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in a UK tertiary referral center. Methods: We collected epidemiological and laboratory data on all cases of MRSA bacteremia from September 1, 2005 to December 31, 2007. Results: There were 195 clinically significant episodes. Most were hospital-acquired. Only one episode occurred in patients without a history of hospital admission in the previous 12 months. An intravascular device was the most common focus of infection (37%), with no identifiable source found in 35% of episodes. Twenty-eight percent of patients died within 30 days of bacteremia. Mortality was significantly higher in the absence of an identifiable focus. Failure to include an antibiotic active against MRSA in the empirical treatment was only significantly associated with death in patients showing signs of hemodynamic instability (p < 0.001). No isolates had a minimum inhibitory concentration to vancomycin above 1.5. mg/l and no heteroresistance to glycopeptide antibiotics (heteroresistant vancomycin-intermediate Staphylococcus aureus; hVISA) was detected. All isolates were sensitive to daptomycin, tigecycline, and linezolid. Conclusions: Despite improvement in infection control measures, medical devices remain the most common source of infection. Inappropriate empirical antibiotic usage is associated with a poor outcome in patients with signs of severe sepsis. Susceptibility to glycopeptides and newer antibiotics remains good. © 2010 International Society for Infectious Diseases.