Team interventions in acute hospital contexts: a systematic search of the literature using realist synthesis.

BACKGROUND: Research on team effectiveness in healthcare has focussed on whether effective teams yield positive outcomes for patients and on the effectiveness of team interventions to improve performance. Limited understanding exists of what works for whom within an effective team, or how and why the context in which the team operates enables team members both as individuals and as a collective to enact behaviours that promote positive outcomes. METHODS: This realist synthesis of the literature explores the relationship between team interventions, underlying teamwork mechanisms generated by those interventions, and the resultant impact on patient outcomes in an acute hospital context. A systematic search of five healthcare and healthcare management academic databases: PubMed, PsychINFO, CINAHL, ABInform, Emerald Management and three grey literature databases: ERIC, OpenDOAR and Open Grey was undertaken. Five experts in the field were also contacted to source relevant literature. Using PRISMA guidelines, relevant studies published between January 2006 and January 2017 were systematically searched by a team of three people. Drawing on realist methodology, data were synthesised using context, mechanism and outcome configurations as the unit of analysis to identify enablers and barriers to effective team interventions. RESULTS: Out of 3347 papers retrieved, 18 were included in the final synthesis. From these, five contextual enablers were identified: an inter-disciplinary focus and flattened hierarchy; effective communication; leadership support and alignment of team goals with organisational goals; credibility of intervention; and appropriate team composition with physician involvement. Ten recurring mechanisms were identified, the most frequently occurring of which was shared responsibility. CONCLUSIONS: The advantage of using realist synthesis to extrapolate data from the literature is that it considers the context and mechanisms that will impact effectiveness of healthcare team interventions. This methodological approach provides a different perspective to other types of syntheses and offers insight as to why certain contextual elements may yield more success than others. Findings therefore tend to have more practical implications. Specificity of detail in terms of how external drivers impact on healthcare team interventions was limited in the articles extracted for analysis. This broader perspective is therefore an important consideration for future research.

Estimating hourly anaesthetic and surgical reimbursement from private medical insurers' benefit maxima: implications for pricing services and for incentives.

While some speculation surrounds annual private practice incomes of anaesthetists, little is known of the hours of work needed to generate any presumed income (the hourly rate). The benefit maxima of five private medical insurers are published in fee schedules and data on the duration of common operations are now also known. In this study we combined these to generate estimates for hourly rates of reimbursement across 78 common operations in eight surgical subspecialties, for anaesthetists and surgeons. We expected to find significant differences between insurers as a result of market competition, and we expected differences between anaesthetists and surgeons. The median (IQR [range]) rate of reimbursement for anaesthetists was pound167 (132-211 [68-570]).h(-1) with significant variation across subspecialties (p < 0.001); for example, cardiac surgery was best reimbursed at pound283 (257-308 [229-398]).h(-1) and orthopaedics the least at pound146 (133-159 [81-246]).h(-1). Contrary to expectations, the rates of payment to anaesthetists by insurers were similar (p > 0.17). Patterns of reimbursement for surgeons were similar to those for anaesthetists, except that surgeons were reimbursed at about twice the rate. We conclude there is a confluence of insurer reimbursement levels and we discuss potential implications of this finding. Our results also have implications for how incentives between the NHS and private practice, or within a private practice group, might be optimally managed.

Investigations of dynamic amyloid-like structures of the Wnt signalling pathway by solid-state NMR.

We report solid-state Nuclear Magnetic Resonance (ssNMR) studies on amyloid-like protein complexes formed by DIX domains that mediate key protein interactions in the Wnt signalling pathway. Our results provide insight into the 3D fold of the self-associated Axin-DIX domain and identify a potential lipid cofactor.

Relation between direct detection of Chlamydia pneumoniae DNA in human coronary arteries at postmortem examination and histological severity (Stary grading) of associated atherosclerotic plaque.

BACKGROUND: Numerous studies have suggested a link between Chlamydia pneumoniae infection, atherosclerosis, and coronary artery disease. However, it is still unclear whether C pneumoniae plays a causal role in the pathogenesis of these conditions. Accordingly, we have performed a systematic dissection of the 3 coronary arteries on 33 postmortem subjects and studied the relationship in individual artery segments between the presence of C pneumoniae DNA and the severity of associated atherosclerosis. METHODS AND RESULTS: The prevalence of C pneumoniae DNA in arterial segments was determined by polymerase chain reaction (PCR) after controlling for the presence of PCR inhibitors. Atherosclerosis in each arterial segment was graded histologically with the Stary classification. C pneumoniae was detected by PCR in 78.8% of subjects, but there was no association between the presence of this DNA and cause of death or grade of atherosclerosis. When paired mild and severe atherosclerotic lesions within subjects were compared, mild lesions were as likely to be positive for C pneumoniae as severe lesions. CONCLUSIONS: This study demonstrates that C pneumoniae can frequently be detected in atheromatous plaques in coronary arteries. However, its distribution did not correlate with severity or extent of disease.

Circulating Chlamydia pneumoniae DNA as a predictor of coronary artery disease.

OBJECTIVE: To determine whether current vascular Chlamydia pneumoniae (CPn) infection as diagnosed by circulating CPn DNA is more common in subjects with coronary artery disease (CAD). BACKGROUND: Serological, pathological and animal studies have associated CPn with CAD and preliminary trials suggest antibiotics may prevent adverse coronary events. C. pneumoniae is thought to disseminate systemically within macrophages. We therefore detected CPn DNA in blood to determine whether its presence was a predictor of CAD. METHODS: One thousand, two hundred and five subjects attending for diagnostic and interventional coronary arteriography were recruited. The mononuclear cell layer and platelets were separated from collected blood and the polymerase chain reaction (PCR) was used to detect CPn DNA. RESULTS: Circulating CPn DNA was found in 8.8% of 669 men with CAD compared with 2.9% of 135 men with normal coronary arteries (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.1-8.9). In men with CAD, those with CPn DNA had higher mean platelet counts than those without CPn DNA. Monocyte counts and indirect fibrinogen levels were also raised but not significantly so. By contrast, no association of circulating CPn DNA and CAD was seen in women. CONCLUSIONS: Circulating CPn DNA is a predictor of CAD in men. Unlike serology, it is a specific indicator of current infection and is a means of identifying subjects who may potentially benefit from antichlamydial therapy.

The prevalence of Chlamydia pneumoniae in atherosclerotic and nonatherosclerotic blood vessels of patients attending for redo and first time coronary artery bypass graft surgery.

OBJECTIVES: To determine if Chlamydia pneumoniae (C. pneumoniae) is more prevalent in atherosclerotic compared with normal blood vessels of patients requiring redo and first time coronary artery bypass graft surgery (CABG). BACKGROUND: Serological and pathological studies have associated atherosclerosis with C. pneumoniae infection. As atherosclerosis is one of the causes of graft failure following CABG, then it may be expected that the prevalence of the organism in failed grafts and diseased native vessels should be greater than in the new grafts. METHODS: Endarterectomy specimens and failed and new grafts were collected from 49 patients with late graft failure. Endarterectomy specimens and new grafts were also collected from nine patients having first time CABG. The presence of C. pneumoniae DNA was then checked for using a nested polymerase chain reaction. RESULTS: The prevalence of C. pneumoniae DNA in failed venous grafts (38.2%) was similar to that in endarterectomy specimens from native coronary arteries (38.5%) and greater than that in new saphenous vein grafts (11.8%). However, it was similar to that in new internal mammary artery grafts (30.0%). Also, the interval between surgery in redo patients was the same regardless of whether C. pneumoniae was present or not. CONCLUSIONS: Cross sectional studies cannot determine whether C. pneumoniae is a cause of atherosclerosis since they do not show whether infection precedes or follows its development. However, our results suggest that the organism is not an important factor in graft failure or atherosclerosis.

A reappraisal of the role of Pityrosporum orbiculare in pityriasis versicolor and the significance of extracellular lipase.

Pityrosporum orbiculare is an obligate lipophilic yeast in vitro, which suggests it possesses an extracellular lipase crucial for nutrition. If present in vivo, the enzyme would enable the yeast to utilize skin surface lipids, which may therfore play an important role in the pathogenesis of pityriasis versicolor. Cultured P. orbiculare and biopsy material from patients with pityriasis versicolor were investigated for the presence of lipase by electron microscope histochemistry. At sites of lipase activity, fatty acid hydrolyzed from Tween 80 substrate reacts with Ca++ ions to form an insoluble Ca++ soap. Exchange of Ca++ with Pb++ enables the sites of lipase activity to be visualized as electron dense deposits of insoluble lead soap. Surface lipase activity was apparent when the technique was applied to P. orbiculare grown on lipid containing medium and its specificity confirmed by removal of substrate and inhibition by di-isopropyl fluorophosphate and quinine hydrochloride, but not by sodium fluoride. When the same technique was applied to stratum corneum infected with Pityrosporum furfur (Malassez), no reaction product could be detected. It is postulated that lipase, although critical for fungal nutrition in vitro, is unlikely to be of importance in vivo. Skin surface lipids are therefore probably not relevant to the pathogenesis of pityriasis versicolor.

Morphine pharmacokinetics after pulmonary administration from a novel aerosol delivery system.

BACKGROUND: Successful pharmacotherapy of pain often depends on the mode of drug delivery. A novel, unit dose, aqueous aerosol delivery system (AERx Pulmonary Drug Delivery System) was used to examine the feasibility of the pulmonary route for the noninvasive systemic administration of morphine. METHODS: The study had two parts: (1) a dose-ranging study in four subjects with three consecutive aerosolized doses of 2.2, 4.4, and 8.8 mg (nominal) morphine sulfate pentahydrate at 40-minute intervals, and (2) a crossover study, on separate days, in six subjects with 4.4 mg (nominal) aerosolized morphine sulfate administered over 2.1 minutes on three occasions and intravenous infusions of 2 and 4 mg over 3 minutes. Subjects were healthy volunteers from 19 to 34 years old. Arterial blood was sampled for a total of 6 hours and plasma morphine concentrations were measured by gas chromatography-mass spectrometry. RESULTS: In part 1, plasma morphine concentrations were proportional to dose. In part 2, the mean +/- SD peak plasma concentration (Cmax) occurred at 2.7 +/- 0.8 minutes after the aerosol dose, with mean values for Cmax of 109 +/- 85, 165 +/- 22, and 273 +/- 114 ng/ml for the aerosol and 2 and 4 mg intravenous doses, respectively. The bioavailability [AUC(0-360 min)] of aerosol-delivered morphine was approximately 100% relative to intravenous infusion, with similar intersubject variability in AUC for both routes (coefficient of variation < 30%). CONCLUSION: The time courses of plasma morphine concentrations after pulmonary delivery by the AERx system and by intravenous infusions were similar. This shows the utility of the pulmonary route in providing a noninvasive method for the rapid and reproducible systemic administration of morphine if an appropriate aerosol drug delivery system is used.

Molecular cloning and sequence analysis of a developmentally regulated cysteine-rich outer membrane protein from Chlamydia trachomatis.

Two overlapping genomic fragments have been cloned from Chlamydia trachomatis serovar L1 DNA. Sequence determination of 2530 bp has revealed two open reading frames coding for 'cysteine-rich' (Cr) proteins. One of these proteins was confirmed, by analysis of the inferred amino acid sequence, as the 60-kDa Cr outer membrane protein associated with differentiation of reticulate bodies (RBs) into elementary bodies (EBs). The other smaller 15-kDa protein contained a high percentage of methionine and cysteine and may correspond to a reported smaller and co-ordinately synthesised Cr outer-membrane protein also associated with RB to EB differentiation. Sequencing showed three potential stem-loop structures within the 5', 3' and intergenic regions of the cloned fragment. Southern-blot analysis revealed that the cloned fragment is conserved in ten serovars of C. trachomatis and that a strongly cross-hybridising fragment is also present in Chlamydia psittaci.

Sulfur-rich proteins of Chlamydia trachomatis: developmentally regulated transcription of polycistronic mRNA from tandem promoters.

RNA was extracted at various times from cells infected with Chlamydia trachomatis serovar L1. Northern-blot analysis showed that transcription of the CrP gene encoding the 60-kDa cysteine-rich outer membrane protein (CrP) produces a temporally controlled polycistronic mRNA. Primer extension analysis indicated the presence of tandem promoters separated by 66 nt with transcriptional start points (tsp) located 577 and 643 nt upstream from the start codon of the mature 60-kDa CrP. Nucleotide (nt) sequencing of this region revealed a small open reading frame (SORF) with coding potential for an 88-amino acid protein containing 13 cysteine residues. This SORF is transcribed as both a polycistronic 2300-nt mRNA together with the CrP gene, and as a separate 480-nt mRNA. Analysis of the upstream sequences, around the tsp for these mRNAs, revealed the presence of three inverted repeat structures that might act as binding domain(s) for a regulatory protein.

Celiac disease and spinocerebellar degeneration with normal vitamin E status.

We studied a 47-year-old man with spinocerebellar degeneration and malabsorption due to celiac enteropathy; the serum vitamin E level was normal. The neurologic disorder initially deteriorated despite improvement of small bowel histology on a gluten-free diet and vitamin E therapy, but later stabilized. The etiology of the neurologic disorder in adult celiac disease has not been identified and does not appear to be vitamin E deficiency.

Regulation of baseline vascular resistance in the canine diaphragm by nitric oxide.

1. The role played by nitric oxide (NO) in the regulation of blood flow to the canine isolated hemidiaphragm was evaluated by determining (a) the effects of the L-arginine analogues NG-nitro-L-arginine methyl ester (L-NAME), NG-nitro-L-arginine (L-NOARG), and argininosuccinic acid (ArgSA) on baseline vascular resistance and of the latter two agents on endothelium-dependent (acetylcholine, ACh) and endothelium independent (sodium nitroprusside, SNP) vasodilatation; (b) the effects of L- and D-arginine on baseline vascular resistance; and (c) the effects of L-glutamine, an inhibitor of intracellular recycling of L-citrulline to L-arginine, on baseline resistance and on the response to ACh and SNP. 2. L-NAME, L-NOARG and ArgSA (6 x 10(-4) M final concentration) increased baseline diaphragmatic vascular resistance to a similar extent (28.6 +/- 4.2%, 26.7 +/- 4.3% and 32.8 +/- 4.6% respectively). L-NOARG and ArgSA reversed the vasodilator effect of ACh but not of SNP. 3. L- and D-arginine had no effect on vascular resistance. 4. L-Glutamine (10(-3) M) increased baseline vascular resistance by 10 +/- 1.9% (P < 0.05) but did not alter responses to either ACh or SNP. 5. Basal NO release plays a role in the regulation of baseline diaphragmatic vascular resistance. L-Arginine analogues tested potently and specifically inhibited this process. Moreover, extracellular L-arginine appears to have no effect on baseline diaphragmatic vascular resistance.

The immunobiology and immunopathology of chlamydial infections.

Chlamydiae are obligate intracellular bacterial pathogens of eukaryotic cells responsible for a wide variety of important human and animal infections. In humans, chlamydial infections are generally localised to superficial epithelial or mucosal surfaces, are frequently asymptomatic and may persist for long periods of time if untreated, inducing little protective immunity. Nevertheless, neutralising antibodies of limited efficacy are produced against the main chlamydial outer envelope protein, while gamma interferon (IFN gamma) is chlamydiastatic and paradoxically may play a role both in chlamydial persistence and in protective immunity. Delayed hypersensitivity responses to chlamydiae caused by repeated or persistent infection are thought to be important in the development of the severe scarring sequelae characteristic of cicatricial trachoma and of chronic salpingitis. Chlamydial heat shock proteins bearing close homology with their human equivalents may be major targets for immunopathological responses and their expression is upregulated in IFN gamma induced persistent infection. C. pneumoniae, a common cause of acute respiratory infection in humans, may persist in coronary arteries and is strongly implicated as a risk factor in atherosclerosis and in acute myocardial infarction. This paper reviews the immunology and immunopathology of chlamydial infections in the context of the unique biology of this fascinating but challenging group of organisms.

Analysis of the household distribution of trachoma in a Gambian village using a Monte Carlo simulation procedure.

Studies on the household distribution of trachoma have reached conflicting conclusions. This paper describes a cross-sectional survey of endemic trachoma in a Gambian village. Cases of active trachoma were mapped, and the compound and household distribution of the disease analysed by a Monte Carlo simulation procedure which takes into account differences in the size and age distribution within individual households. Significant clustering of active trachoma cases both by village compound (p less than 0.0001) and bedroom (less than 0.05) were detected supporting the concept that intra-familial transmission of trachoma is important. There was no evidence of spatial clustering of rooms with higher than expected prevalence of trachoma. Clustering of disease in space or time provides important evidence of infectious aetiology and route of transmission. The methods discussed here are generally applicable in the study of other infectious diseases.

Quantitative assessment of bed rise difficulty in young and elderly women.

OBJECTIVE: To describe the motions which occur during rising from bed, specifically the motions that appeared to characterize difficulty in rising from a bed in older adults. DESIGN: Development of a Mobility assessment tool. SETTING: Retirement center and two university laboratories. PARTICIPANTS: Three groups of female volunteers: young controls (n = 17, mean age 24), community-dwelling older adults (n = 12, mean age 71), and retirement center-dwelling older adults who admitted to difficulty in rising from a bed (n = 15, mean age 86). INTERVENTION: Videotaping of motions occurring during controlled rises from a supine to sitting position. MAIN OUTCOME MEASURES: These motions were rated on the specially developed Bed Rise Difficulty (BRD) scale, a scale designed to measure movements that characterize difficulty in rising from a bed in older adults. Subject groups were compared in total BRD score, individual BRD item score, and total time to rise. Item relationships and scale reliability were also assessed. RESULTS: Older adults with no apparent difficulty in rising based on total time to rise or on the BRD score nevertheless showed differences in upper extremity use when compared to young controls. Older adult subjects with difficulty in rising from a bed, when compared to other older adults with no apparent difficulty, differed more often in their upper extremity and leg use to facilitate the rise. Five BRD scale items, including use of extremity pushes, discontinuity of trunk and leg motion, multiple shoulder/pelvic adjustments, multiple leg adjustments, and poor vertical heel clearance may have best indicated true bed rise difficulty. CONCLUSIONS: These data provide a reliable and valid method to characterize difficulty in rising from a bed and provide the basis for biomechanical analyses of the strength and joint ranges of motion required to rise from a bed.

Early detection of Chlamydia trachomatis using fluorescent, DNA binding dyes.

HeLa 229 cells were infected with genital tract strains of Chlamydia trachomatis. After incubation for varying times the infected cells were fixed and stained with the fluorescent DNA binding dyes Hoechst 33258 or DAPI for comparison with conventional Giemsa stain. Fluorochrome-treated preparations were examined by incident ultraviolet fluorescence microscopy and the Giemsa-stained preparations by dark-ground light microscopy. Chlamydial inclusion bodies could be identified unambiguously as early as 18 hours after infection of HeLa 229 cells using either Hoechst 33258 or DAPI but not until some 48 hours in Giemsa-stained preparations. The DNA rich chlamydial elementary bodies in infected egg yolk suspension were readily detected using Hoechst 33258. The fluorescent dye technique was simpler and more rapid than Giemsa staining. Using Hoechst 33258 it is possible to speed up the identification of chlamydial isolates growing in tissue culture.

Human antibody response to lipopolysaccharides from Neisseria gonorrhoeae.

Red cells coated with lipopolysaccharides from three different strains of Neisseria gonorhoeae have been used as antigens in a haemagglutination test for gonococcal antibodies. For each strain the geometric mean titre in sera from 50 male and 25 female patients was significantly higher than that in 50 normal controls. The most useful smooth strain, G1, picked out 84% of females and 46% of males from a group of patients known to have gonorrhoea, but only gave 2% positives among controls. The rough strain, G2, gave 10% positives in controls and 31% in patients. The results suggest that the method is worth developing further as a diagnostic test and that strain differences are important. False positives were probably due to cross-reacting antibodies.

The preservation of gonococci in liquid nitrogen.

Gonococci suspended in 1% proteose peptone containing 8% glycerol can be snap frozen in liquid nitrogen without detectable loss on thawing. This recovery rate has allowed the use of frozen organisms as the starting inoculum for the bulk growth of gonococci and to preserve gonococci both in urethral pus and after primary subculture for use in studies on gonococcal virulence. The method described for freezing urethral pus on charcoal swabs should make it possible to transport infected specimens from areas lacking adequate laboratory facilities.

Chlamydial and gonococcal antibodies in sera of infertile women with tubal obstruction.

Sera from 48 infertile women with tubal pathology and from 77 infertile women with normal fallopian tubes were tested by enzyme linked immunosorbent assay (ELISA) using Chlamydia trachomatis and Neisseria gonorrhoeae antigens. Control sera were obtained from women undergoing abortion, sterilisation, and from women practising barrier contraception. The results of ELISA for antibodies to chlamydiae were in close agreement with results published previously of an immunofluorescence test on these sera. Antibodies to C trachomatis were found in 73% of the infertile women with tubal pathology, significantly more than in any of the control groups. Only a very low prevalence (2-5%) of antibodies to gonococcal pili was found in all groups, except women undergoing abortion (16%).

The species specificity of the microimmunofluorescence antibody test and comparisons with a time resolved fluoroscopic immunoassay for measuring IgG antibodies against Chlamydia pneumoniae.

AIMS: To examine the species specificity of the microimmunofluorescence test (MIF) and assess a time resolved fluoroscopic immunoassay (TRIA) for measuring IgG antibodies to C pneumoniae. METHODS: Sera from 1020 subjects were tested by MIF for IgG, IgM, and IgA antibodies to C pneumoniae, C trachomatis, and C psittaci; 501 serum samples were also tested by TRIA for IgG antibodies to C pneumoniae. RESULTS: C pneumoniae antibody titres as measured by MIF were correlated with those for C psittaci and trachomatis. It was estimated that on average, one third of the twofold dilution steps that make up the final C pneumoniae antibody titre may be due to cross reacting genus specific antibody. The results of TRIA correlated well with those of MIF. In 75% of cases, the TRIA result predicted a three titre range within which the actual MIF result would fall. CONCLUSIONS: MIF does not appear to be as species specific as claimed. TRIA is unlikely to be as specific but as it is completely objective, easier to perform, amenable to automation, and gives reproducible results, it is a rapid and useful method for comparing populations.