Our approach to changing the culture of caring for the acutely unwell patient at a large UK teaching hospital: A service improvement focus on Early Warning Scoring tools.

INTRODUCTION: Early Warning Scoring tools (EWS) play a major role in the detection of the deteriorating ward patient. EWS tools have been in place in Nottingham University Hospitals NHS Trust for over five years but compliance has been low. A service improvement project commenced across all admission wards in 2013, initiated through a financially driven CQUIN. Prior to the project, only one out of five clinical care targets set were achieved. STRATEGY: An established framework for service improvement was used to guide delivery. The approach has consisted of multi-faceted, inter-professional high impact interventions including ward delivered education, human factors training and clinician feedback, combined with regular performance audits. RESULTS: Since introduction of the service improvement team, consistent signs of improvement have been visible across the admission areas in four out of five of the clinical care targets. CONCLUSION: The first 12 months of the project has seen tangible benefits in patient care and staff experience. Personal feedback both to medical and nursing staff has been effective where a top-down approach may not have been.

Experience of implementing an adult educational approach to treating anxiety disorders.

This paper describes the background to the development and delivery of a self-help package for anxiety disorders. Evidence of effectiveness is summarized. The paper outlines the intervention and describes the experience of two mental health nurses, who set out to assess its acceptability, evaluate its outcomes in routine clinical practice and assess the feasibility of its delivery by mental health nurses. Acceptability of the intervention was high, judged by retention and attendance rates. The pilot study produced promising clinical outcomes, especially for people with depression secondary to anxiety. Clinical measures showed significant improvements from pre-course to 6-month follow-up in anxiety, psychological well-being and depression. The outcomes suggest that appropriately trained mental health nurses could deliver the intervention as a routine treatment. The paper concludes by discussing future plans, including a randomized controlled trial and implementation in primary care.

Structure of the native (unligated) mannose-specific bulb lectin from Scilla campanulata (bluebell) at 1.7 A resolution.

The X-ray crystal structure of native Scilla campanulata agglutinin, a mannose-specific lectin from bluebell bulbs and a member of the Liliaceae family, has been determined by molecular replacement and refined to an R value of 0.186 at 1.7 A resolution. The lectin crystallizes in space group P21212 with unit-cell parameters a = 70. 42, b = 92.95, c = 46.64 A. The unit cell contains eight protein molecules of Mr = 13143 Da (119 amino-acid residues). The asymmetric unit comprises two chemically identical molecules, A and B, related by a non-crystallographic twofold axis perpendicular to c. This dimer further associates by crystallographic twofold symmetry to form a tetramer. The fold of the polypeptide backbone closely resembles that found in the lectins from Galanthus nivalis (snowdrop) and Hippeastrum (amaryllis) and contains a threefold symmetric beta-prism made up of three antiparallel four-stranded beta-sheets. Each of the four-stranded beta-sheets (I, II and III) possesses a potential saccharide-binding site containing conserved residues; however, site II has two mutations relative to sites I and III which may prevent ligation at this site. Our study provides the first accurate and detailed description of a native (unligated) structure from this superfamily of mannose-specific bulb lectins and will allow comparisons with a number of lectin-saccharide complexes which have already been determined or are currently under investigation.

Strategies for improving health plan member retention.

Member retention is an increasingly important issue for health plans to address. It costs health plans $75 to $200 to acquire a commercial member and $400 to $800 to acquire a Medicare member. If members leave the plan within the first year or so, up to half of this investment is lost. Health plans should implement several strategies, therefore, to improve member retention. They should communicate the value of retention throughout the organization, use a cross-functional team approach to retention, analyze who is disenrolling and why, improve access to referral providers, and extend the retention effort until a relationship exists, evaluate and strengthen member orientation efforts. Other ways to enhance member retention are to improve access to health and service information, improve provider-staff interaction and communication skills, implement relationship-enhancing communication campaigns, manage expectations about treatment, and create personal relationships at the plan-purchaser level.

Crystallization and preliminary structural studies of Scilla campanulata lectin complexed with alpha1-6 mannobiose.

Recent work has shown that Scilla campanulata agglutinin from bluebell bulbs has a strong affinity for alpha(1,3)- and alpha(1,6)-linked mannosyl residues and possesses moderate antiretroviral activity. This lectin has been crystallized by the hanging-drop method of vapour diffusion complexed with the disaccharide mannose-alpha1,6-D-mannose. The crystals are in the space group P21212 with unit-cell dimensions a = 70.63, b = 92.79 and c = 47.25 A, and with a dimer in the asymmetric unit. The crystals diffract X-rays to beyond 1.5 A resolution at 277 K and are stable in an X-ray beam. Data to 1.6 A resolution have been collected using a MAR image-plate system at a synchrotron source and the structure of the complex has been solved by the molecular replacement method.

Scilla campanulata agglutinin crystallized in complex with the trimannoside alpha-D-man-(1-->6)-[alpha-D-man-(1-->3)]-alpha-D-Man.

The monocot mannose-specific lectin, Scilla campanulata agglutinin (SCA), from bluebell bulbs has a strong affinity for alpha1,3- and alpha1,6-linked mannosyl residues. SCA has been co-crystallized with the trisaccharide alpha-D-mannopyranosyl-(1-->6)-alpha-D-mannopyranosyl-(1-->3)-alpha-D -mannopyranoside ¿alpha-D-Man-(1-->6)-[alpha-D-Man-(1-->3)]-alpha-D-Man¿, the core structure of biantennary N-linked oligosaccharides. Crystals of the complex were obtained by the hanging-drop vapour-diffusion technique. A complete data set to 2.5 A resolution has been collected at 100 K, using a MAR image-plate system at a synchrotron source, from crystals which belong to the space group C2 with unit-cell dimensions a = 99.38, b = 119.86, c = 77.10 A and beta = 105.56 degrees. Use of a CCD detector with cryo-cooled crystals improved the resolution to 2.3 A. A molecular replacement solution, with the 2.5 A data set, using the native SCA as a search model was obtained, with six subunits per asymmetric unit.

A comparison of expectations for selected physician and managed health care services between Medicare-eligible and the next Medicare-eligible generation.

The year 1998 marks the beginning of a major turning point in the composition of the Medicare-eligible population, making the next few years a significant watershed for those concerned with the provision of health care to seniors. For approximately the next 12 years, those seniors entering the Medicare-eligible health care market, the so-called Swing generation, will have different characteristics and expectations from those generations that precede or follow it. Through standard survey methods, this study explores and compares the differences in selected health services expectations between the current generation of Medicare-eligible seniors and the next Medicare-eligible generation. Significant differences were found between the two groups on variables related to wait time, medical preparedness, communication, and expectations of managed care coverage. The authors discuss the implications of the findings for health care service providers and managed care organizations.

Crystallization and preliminary X-ray analysis of a novel plant lectin from Calystegia sepium.

A mannose-specific lectin from Calystegia sepium has been crystallized by the hanging-drop vapour-diffusion method using ammonium sulfate as precipitant. The needle-shaped crystals are orthorhombic, space group C222(1) with cell dimensions a = 55.2(1), b = 55.9 (1), c = 196.1 (1) A. Fresh crystals diffract to 1.9 A resolution on a synchrotron radiation source. The asymmetric unit contains a dimer of two identical 16 kDa subunits with a packing density of 2.36 A(3) Da(-1). Intensity data have been observed beyond 2.0 A, but reasonable statistics restricted the usable range to 2.0 A.

X-ray structure solution of amaryllis lectin by molecular replacement with only 4% of the total diffracting matter.

It is often the case that analogous proteins from different species crystallize in a different form. These structures can usually be easily solved by the molecular-replacement (MR) technique, as the protein folding is very often conserved. However, the results from MR become more uncertain as the proportion of diffracting matter decreases as a result of multimericity and/or absence of some of the atoms in the model. In this paper results are presented on the structure solution of amaryllis lectin (109 residues per monomer) containing two protein molecules in the asymmetric unit. The structure was solved by MR using the Calpha coordinates of one monomer from snowdrop lectin which has 85% amino-acid sequence identity to amaryllis lectin. This represents only 6% of the non-H atoms of the protein molecule to be used for structure determination and it is a major improvement on previous reports. Further calculations were carried out in order to establish the minimum number of atoms which could be included in the model before a clear solution to the MR problem was revealed. This study showed that the structure of amaryllis lectin could still have been solved easily with 3.85% of the model, which even in the most favourable cases, will probably constitute a minimum for molecular-replacement structure solution.

Purification, crystallization and preliminary X-ray analysis of a mannose-binding lectin from bluebell (Scilla campanulata) bulbs.

Crystals have been grown of a mannose-specific lectin from bluebell (Scilla campanulata) bulbs in a form suitable for X-ray diffraction studies. The crystals, which diffract to high resolution, grew in hanging drops by vapour diffusion, equilibrating with a solution of 70% saturated ammonium sulfate at pH 4.7-4.8 at 293 K, in the absence of any mannose saccharides. Crystals are orthorhombic, P2(1)2(1)2, with unit-cell dimensions a = 70.78, b = 93.69, c = 46.92 A. The functional lectin molecule is organized as a tetramer of four identical 14 kDa subunits, with only two subunits in the asymmetric unit. Data to 1.86 A resolution have been recorded and the structure determined by the molecular replacement method.

Using research for successful Medicare and Medicaid risk marketing.

Medicare/Medicaid risk marketing is a vital business challenge, one that countless managed care organizations are facing right now. Early entry into new markets and aggressive participation in existing markets are essential to meet competitive pressures. Health plans intent on success in government risk programs should conduct research to learn the medical needs, wants, and desires of older persons in the geographic area they serve. Original, market-specific research yields critical marketing and clinical data that can be used to improve care and member satisfaction along with customer loyalty and retention.

Crystallization and preliminary X-ray studies on the mannose-specific lectin from Amaryllis bulbs.

Affinity-purified amaryllis lectin was used to grow single crystals using the hanging-drop method. The space group was found to be C2 with unit-cell dimensions a = 73.4 (1), b = 100.3 (1), c = 62.2 (1) A and beta = 137.3 (2) degrees. Data to 2.25 A resolution have been recorded and solution of the structure is currently underway by means of molecular-replacement techniques.

Identification and treatment of retinopathy of prematurity: an update and review.

The risk of retinopathy of prematurity (ROP) is higher in infants with a birth weight less than 1501 g (3 lb 5 oz). Identification programs coupled with refined treatment procedures can reduce visual impairment in infants with ROP. Physicians providing in-hospital care to these infants should ensure that ophthalmologic referral has been established before hospital discharge. Physicians examining these infants for their 6-week checkups are also vital safeguards in the ROP screening and referral process.

Two team synchronous esophagectomy.

A modification of the Lewis esophagectomy for carcinoma of the intrathoracic esophagus is described herein. With the patient in the semilateral position, two surgical teams operate simultaneously. The abdominal team mobilizes the stomach while the thoracic team removes the esophagus. Esophagogastric anastomosis is performed by stapling at the apex of the thorax. The procedure was performed upon 50 patients. There were two anastomotic leaks and one death occurred in the hospital. The two team synchronous approach avoids changes in the position of the patient, shortens operating time and may contribute to lower morbidity rates for patients undergoing esophagectomy.