Survey of bulk tank milk in New Zealand for Mycoplasma bovis , using species-specific nested PCR and culture.

AIM: To survey the dairy cattle population in New Zealand for the presence or absence of Mycoplasma bovis. METHODS: A random cross-sectional survey of bulk tank milk from dairy herds in New Zealand based on regionally proportioned sampling, weighted towards herds with a high bulk tank milk somatic cell count (SCC) was used to detect M. bovis at a between-herd prevalence of 2%, with 99% confidence. Bulk tank milk samples collected on-farm were tested using a nested M. bovis PCR, and bacteriological culture employing enrichment in mycoplasma broth and direct plating onto mycoplasma agar. RESULTS: Mycoplasma bovis was not detected in any of the 244 bulk tank milk samples by either PCR or culture. CONCLUSIONS: This survey provides further evidence that M. bovis is not present in the dairy cattle population in New Zealand.

A syndrome of facial paralysis of dairy calves in the Franklin district of New Zealand.

AIM: To determine the aetiology of a syndrome characterised by facial paralysis in calves (facial paralysis syndrome; FPS); describe the epidemiology of the syndrome on an affected case farm; and define the intra-farm prevalence of affected calves, and inter-farm prevalence of affected dairy farms, in the Franklin district of New Zealand. CASE HISTORY AND CLINICAL FINDINGS: An investigation was carried out on a town-supply dairy farm experiencing an outbreak of FPS in calves during the autumn of 2007, following a previous outbreak during the spring of 2006; 21 calves were affected in both outbreaks. Post-mortem examinations of three affected calves revealed no infectious aetiological agent in neurological tissues despite tests for viruses, bacteria and Mycoplasma species. Tests on hepatic tissues for vanadium toxicity were inconclusive. SURVEY OF DAIRY FARMS: Results from a postal survey of 177/325 (54%) farms established the yearly prevalence of affected farms, based on farmer diagnosis, was 11%, and there was a median two (range 1-25) affected calves on those farms. There was no evidence of spatial clustering of affected farms after accounting for the underlying farm density, or of an increase in the number of affected farms between 2003 and 2007. CLINICAL RELEVANCE: Facial paralysis syndrome is an unusual condition that has not been reported in other districts of New Zealand or in other countries. It is probable that this syndrome will continue to occur at a low to moderate prevalence, and have a significant impact on a small number of farms.

A real-time polymerase chain reaction assay for the detection of Mycoplasma agalactiae.

AIM: To develop a real-time PCR for the detection of Mycoplasma agalactiae, using PCR primers targeting the ma-mp81 gene. METHODS: A group of 15 M. agalactiae isolates, 21 other Mycoplasma spp. isolates and 21 other bacterial isolates was used in evaluation of the assay. RESULTS: All M. agalactiae isolates were detected by the assay and none of the non-target isolates was amplified. The analytical detection limit of the assay was 10 fg of purified genomic DNA and 104 cfu/ml milk inoculated with M. agalactiae. When applied to goat-milk samples collected from three herds free of M. agalactiae infection, the assay had a specificity of 100%. CONCLUSIONS: The assay would be useful in a diagnostic laboratory, providing specific, sensitive and rapid detection of M. agalactiae.

Real-time polymerase chain reaction assays for the detection of members of the Mycoplasma mycoides cluster.

AIM: To develop real-time PCR assays for the detection and differentiation of members of the Mycoplasma mycoides cluster. METHODS: Five real-time PCR assays were designed to allow differentiation of members of the M. mycoides cluster: an assay for detection of the M. mycoides subspecies, viz M. mycoides subsp mycoides large colony (MmmLC), M. mycoides subsp capri (Mmc), and M. mycoides subsp mycoides small colony (MmmSC); one for the detection of the M. capricolum subspecies, viz M. capricolum subsp capricolum (Mcc), M. capricolum subsp capripneumoniae (Mccp), and Mycoplasma sp bovine group 7 (BG7); and three for the specific detection of MmmSC, Mccp, and BG7. A panel of 74 Mycoplasma isolates from various geographical origins and a panel of 21 other bacterial isolates were used to evaluate the sensitivity and specificity of the assays. RESULTS: The assays displayed 100% analytical sensitivity in detecting all target Mycoplasma isolates. The analytical detection limit for the assays to detect the M. mycoides subspecies, M. capricolum subspecies, and MmmSC was determined to be 100 fg of genomic DNA, while the Mccp and BG7 assays had a detection limit of 100 fg and 10 fg of genomic DNA, respectively. The M. mycoides subspecies assay had a detection limit of 10(3) (SD 10(2)) cfu/ml milk, 10(4) (SD 10(4)) cfu per swab, and 10(3) (SD 10(3)) cfu/g lung in inoculated samples. The assays displayed 100% specificity when applied to non-target bacterial isolates and to 110 culture-negative milk samples. CONCLUSIONS: The assays were highly sensitive and specific, and provide accurate detection and differentiation of the members of the M. mycoides cluster.

The ethics of using quality improvement methods in health care.

Quality improvement (QI) activities can improve health care but must be conducted ethically. The Hastings Center convened leaders and scholars to address ethical requirements for QI and their relationship to regulations protecting human subjects of research. The group defined QI as systematic, data-guided activities designed to bring about immediate improvements in health care delivery in particular settings and concluded that QI is an intrinsic part of normal health care operations. Both clinicians and patients have an ethical responsibility to participate in QI, provided that it complies with specified ethical requirements. Most QI activities are not human subjects research and should not undergo review by an institutional review board; rather, appropriately calibrated supervision of QI activities should be part of professional supervision of clinical practice. The group formulated a framework that would use key characteristics of a project and its context to categorize it as QI, human subjects research, or both, with the potential of a customized institutional review board process for the overlap category. The group recommended a period of innovation and evaluation to refine the framework for ethical conduct of QI and to integrate that framework into clinical practice.

Comparison of a membrane surface adhesion recovery method with an IMS method for use in a polymerase chain reaction method to detect Escherichia coli O157:H7 in minced beef.

In this study, enrichment procedures and two recovery methods, a membrane surface adhesion technique and an immunomagnetic separation (IMS), were compared for use in conjunction with a multiplex polymerase chain reaction (PCR) method with a view to describing a fast (24 h) and economical test for detection of Escherichia coli O157:H7 in meat samples. The study showed no significant difference between three different enrichment media (BHI, E. coli (E.C.) broth+novobiocin, modified tryptone soya broth (mTSB)+novobiocin) or two incubation temperatures (37 or 41.5 degrees C) for growth of E. coli O157:H7 in minced beef. Minced beef samples inoculated with E. coli O157:H7 at 40 cfu g(-1) were incubated at 37 degrees C for 16 h in E.C. broth+novobiocin reaching numbers of (log(10)7.82-8.70). E. coli O157:H7 were recovered by attachment to polycarbonate membranes immersed in the enriched cultures for 15 min or by immunomagnetic separation. Subsequent treatment of recovered membranes or IMS beads with lysis buffer and phenol/chloroform/isoamyl alcohol was used to extract the DNA from the extracted E. coli O157:H7 cells. The results show when E. coli O157:H7 was present at high levels in the enriched meat sample (log(10)9.6-7.5 cfu ml(-1); >16-h enrichment), the membrane and IMS techniques recovered similar levels of the pathogen and the microorganism was detectable by PCR using both methods. At lower levels of E. coli O157:H7 (log(10)6.4), only the IMS method could recover the pathogen but at levels below this neither method could recover sufficient numbers of the pathogens to allow detection. The conclusion of the study is that with sufficient enrichment time (16 h) the membrane surface adhesion membrane extraction method used in combination with multiplex PCR has the potential for a rapid and economical detection method.

Application of real-time PCR and RT-PCR assays for the detection and quantitation of VT 1 and VT 2 toxin genes in E. coli O157:H7.

Real-time PCR assays, based on hybridisation probes and LightCycler technology, were developed for VT 1 and VT 2 genes and applied to the detection and quantitation of DNA and mRNA of Escherichia coli O157:H7. The qualitative consensus PCR assay for the detection of VT 1 and/or VT 2 genes had a detection limit of 100 fg of E. coli O157:H7 genomic DNA and did not detect DNA from 13 non-VTEC isolates. When E. coli O157:H7 was inoculated into minced beef, enriched and recovered by immunomagnetic separation, the real-time consensus PCR assay had a detection limit of log(10)3.5 ml(-1) E. coli O157:H7 cells. Nineteen E. coli O157:H7 isolates, derived from food, bovine samples and human faeces, were analysed and compared for mRNA expression of three genes, VT 1, VT 2 and gapA (housekeeping gene), using quantitative real-time PCR assays. While there was no statistically significant difference for the expression of the VT 1 (p=0.134) or VT 2 (p=0.52) mRNA in the E. coli O157:H7 isolates from food, bovine and human sources, three clinical isolates did show lower expression of VT 2 compared to other isolates in the study. The study indicates that the consensus qualitative real-time PCR assay for VT 1 and VT 2 is rapid and sensitive and that the quantitative assays reported here have the potential to be used as an alternative method to more conventional methods for studying VT 1 and VT 2 virulence gene expression in E. coli O157:H7 with potential application in other pathogenic E. coli species.

Three decades of research on computer applications in health care: medical informatics support at the Agency for Healthcare Research and Quality.

The Agency for Healthcare Research and Quality and its predecessor organizations-collectively referred to here as AHRQ-have a productive history of funding research and development in the field of medical informatics, with grant investments since 1968 totaling $107 million. Many computerized interventions that are commonplace today, such as drug interaction alerts, had their genesis in early AHRQ initiatives. This review provides a historical perspective on AHRQ investment in medical informatics research. It shows that grants provided by AHRQ resulted in achievements that include advancing automation in the clinical laboratory and radiology, assisting in technology development (computer languages, software, and hardware), evaluating the effectiveness of computer-based medical information systems, facilitating the evolution of computer-aided decision making, promoting computer-initiated quality assurance programs, backing the formation and application of comprehensive data banks, enhancing the management of specific conditions such as HIV infection, and supporting health data coding and standards initiatives. Other federal agencies and private organizations have also supported research in medical informatics, some earlier and to a greater degree than AHRQ. The results and relative roles of these related efforts are beyond the scope of this review.

Developing BSN leaders for the future: the Fuld Leadership Initiative for Nursing Education (LINE).

The Helene Fuld Leadership Initiative in Nursing Education (LINE) program was designed to enhance beginning leadership competencies of baccalaureate nursing students. Given the increasing need for strong and effective leadership throughout the health care system, and the demands new graduates encounter as they move into practice, the LINE program is built on the premise that leadership skills must be instilled at the undergraduate level. The program achieves its goal through an intensive 5-day institute focused on assessing and developing the leadership competencies of nurse educators and their clinical partners to enable them to be effective agents of curriculum change in their home institutions. The institute also assists participants to redesign their baccalaureate nursing (BSN) curricula to ensure that students learn to: (1) work effectively within and across complex, integrated organizational and institutional boundaries; (2) think and act from the perspective of a system; and (3) communicate, negotiate, lead, and facilitate change within health care organizations. D. Goleman's (1998) framework of emotional intelligence, which addresses both personal competence (managing oneself) and social competence (handling one's relationships with others) provides the framework for operationalizing leadership in the BSN curriculum. To date, 26 BSN programs and their clinical partners have participated in the LINE program, which has the potential to influence the beginning leadership development of more than 2,400 BSN students. Program outcomes reveal that education-practice collaboration, professional networking, individual leadership development of nurse educators and their clinical partners as change agents, and the integration of leadership experiences at all levels of the BSN curriculum are important in developing beginning leadership competencies in BSN students.

Cutting to the chase: what physician executives need to know about HIPAA.

All health care providers, plans, and clearinghouses will be affected by the federally mandated uniform standards for administrative transactions. This article presents distilled core information about the Health Insurance Portability and Accountability Act (HIPAA) legislation--the standards, penalties for violations, and status of final rules. It also raises several key unsolved issues of which clinicians, executives, and health care providers must be aware so they can prepare and plan for the upcoming changes. HIPAA is intended to improve the efficiency and effectiveness of the health care system, as well as to increase the protection and confidentiality of individually identifiable health information. The costs of making the transition to the legislated standards and processes remain a worrisome factor. Although there are two years before these standards must be implemented, and cost and compliance issues resolved, work has already begun in many health institutions to identify and address them.

A new twist in US health care data standards development: adoption of electronic health care transactions standards for administrative simplification.

To reduce the costs of common administrative transactions, health plans, payers and providers encouraged the US Congress to legislate administrative simplification of specific electronic health data transactions. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 created incentives for a public-private partnership to develop and implement standards for the uniformity of health care data used in electronic administrative health transactions and standards for the privacy and security of individually identifiable health information. The standards' requirements of HIPAA and how they have been met by the US government hold promise for accelerating the uniform adoption of standards developed by accredited standards developing organizations. The transactions designated by Congress, the process of choosing the standards in the Department of Health and Human Services, the principles that guided these choices, and the actual choices, are presented here. A successful partnership for administrative health data standards can pave the way for success in clinical health data standards and their application in computer-based patient record systems.

Barriers and facilitators to the utilization of nursing research.

The nurse in clinical practice must demonstrate a scientific base for practice grounded in research findings. The purpose of this study was to explore the nurse's perception of the barriers and facilitators to using research findings in nursing practice. A survey methodology was used, and a sample of 356 practicing registered nurses responded. Data were collected using a scale that rated the barriers and facilitators to research utilization. The greatest barriers were insufficient time on the job to implement new ideas, lack of knowledge of nursing research findings, and inaccessibility of relevant literature. The advanced practice nurse is in a pivotal position to decrease the barriers to research utilization.

Evaluation of a decision support system for pressure ulcer prevention and management: preliminary findings.

A decision support system for prevention and management of pressure ulcers was developed based on AHCPR guidelines and other sources. The system was implemented for 21 weeks on a 20-bed clinical care unit. Fifteen nurses on that unit volunteered as subjects of the intervention to see whether use of the system would have a positive effect on their knowledge about pressure ulcers and on their decision-making skills related to this topic. A similar care unit was used as a control. In addition, the system was evaluated by experts for its instructional adequacy, and by end users for their satisfaction with the system. Preliminary results show no effect on knowledge about pressure ulcers and no effect on clinical decision making skills. The system was rated positively for instructional adequacy, and positively for user satisfaction. User interviews related to satisfaction supplemented the quantitative findings. A discussion of the issues of conducting experiments like this in today's clinical environment is included.

A knowledge-based decision support system for prevention and treatment of pressure ulcers.

As part of a research project intended to provide problem-based knowledge to clinicians at the point of care, we have developed a system that supports the nurse's development of patient-specific, guideline-based treatment plans for patients who have pressure ulcers or are at risk for developing them. The system captures coded data about assessment, diagnosis and interventions using a point-and-click interface. Knowledge is accessible to the user via: 1) hypertext links from the data entry screens; 2) explicit entry into an indexed version of the guideline; 3) imbedded knowledge-based rules that critique the diagnosis and offer guidance for treatment; and 4) explicit entry into interactive algorithms. The system has been implemented experimentally on one care unit at our hospital, where its impact will be assessed in comparison with a control unit. Data on 113 patients were entered during the 21-week experimental period. The system is being evaluated for its instructional adequacy, its impact on clinicians' decision-making and knowledge, and on processes of care. Users' perceptions of the system are also being evaluated. Dissemination issues in the context of today's health care environment are addressed.

Planned NLM/AHCPR large-scale vocabulary test: using UMLS technology to determine the extent to which controlled vocabularies cover terminology needed for health care and public health.

The National Library of Medicine (NLM) and the Agency for Health Care Policy and Research (AHCPR) are sponsoring a test to determine the extent to which a combination of existing health-related terminologies covers vocabulary needed in health information systems. The test vocabularies are the 30 that are fully or partially represented in the 1996 edition of the Unified Medical Language System (UMLS) Metathesaurus, plus three planned additions: the portions of SNOMED International not in the 1996 Metathesaurus Read Clinical Classification, and the Logical Observations Identifiers, Names, and Codes (LOINC) system. These vocabularies are available to testers through a special interface to the Internet-based UMLS Knowledge Source Server. The test will determine the ability of the test vocabularies to serve as a source of controlled vocabulary for health data systems and applications. It should provide the basis for realistic resource estimates for developing and maintaining a comprehensive "standard" health vocabulary that is based on existing terminologies.

A decision support system for prevention and treatment of pressure ulcers based on AHCPR guidelines.

We have developed a Pressure Ulcer Prevention and Management System to assist clinicians with patient-specific decision making. The system captures coded data about assessment, diagnosis and interventions using a point-and-click interface. Guideline-based knowledge is imbedded into the system, and is accessible in several ways: 1) via hypertext links from the data entry screens; 2) via explicit entry into an indexed version of the guideline; 3) via imbedded knowledge-based rules that critique the diagnosis and offer guidance for treatment; and 4) via explicit entry into interactive algorithms. The system has been implemented experimentally on one care unit at our hospital, where its impact will be assessed in comparison with a control unit. Preliminary usage data are provided. Issues with rendering guideline material useful for patient-specific decision support are discussed. In our setting, these issues had to do with a) incongruity with local standards; b) insufficient specificity; and 3) insufficient comprehensiveness. Issues of use and dissemination in the context of today's health care environment are also addressed.

Evaluation of a problem-based access knowledge system using triangulation methods.

A microcomputer-based system designed to provide nurses and physicians access to expert synthesized knowledge in the area of pulmonary arterial waveform troubleshooting has been developed and implemented. Evaluation using triangulation methods show that there was a substantive increase in knowledge in both nurses and physicians.¿.

Health care data standards are required for medically effective use of workstations.

Uniform, accurate, and longitudinal patient care data is needed for greater quality and efficiency in institutional and ambulatory care. Further, the knowledge to be gained from medical effectiveness research methods, applied to large quantities of such clinical data about the practice of medicine in the community, is immense. National standards for the coding, content, and electronic transfer of patient care data are needed to achieve uniformity and accuracy. These standards are slow in developing because no single private organization can capture sufficient benefit. Yet, the general public can benefit substantially. Consequently, there may be a role for the Federal Government to work with the private sector to accelerate needed health care data standards. This paper suggests activities that help to define this role.

User evaluation: PA catheter waveforms troubleshooting system.

This paper reports on a user satisfaction survey of a system for consultation and education in troubleshooting pulmonary artery catheter waveforms. The twelve-item End-User Computing Satisfaction Questionnaire was used to assess users' ratings in four areas. On a scale of 1-5 (with 1 the lowest), the ratings were: Content, 3.5; Accuracy, 4.5; Format, 4.2; Ease of Use, 4.4, and Timeliness, 4.1. Comparison with ratings in a survey that included a variety of applications and settings is provided.