A case study of translating ACGME practice-based learning and improvement requirements into reality: systems quality improvement projects as the key component to a comprehensive curriculum.

BACKGROUND: In 2002, the Accreditation Council for Graduate Medical Education (ACGME) introduced a new requirement: residents must demonstrate competency in Practice-Based Learning and Improvement (PBLI). Training in this domain is still not consistently integrated into programmes, with few, if any, adequately going beyond knowledge of basic content and addressing all components of the requirement. AIM: To summarise the implementation of a PBLI curriculum designed to address all components of the requirement and to evaluate the impact on the practice system. METHODS: A case-study approach was used for identifying and evaluating the steps for delivering the curriculum, along with the Model for Improvement's successive Plan-Do-Study-Act (PDSA) cycles (July 2004-May 2006). DATA SOURCE: Notes from curriculum development meetings, notes and presentation slides made by teams about their projects, resident curriculum exit evaluations curriculum and interviews. RESULTS: Residents reported high levels of comfort by applying PBLI-related knowledge and skills and that the curriculum improved their ability to do various PBLI tasks. The involvement of multiple stakeholders increased. Twelve of the 15 teams' suggestions with practical systems-relevant outcomes were implemented and sustained beyond residents' project periods. While using the traditional PDSA cycles was helpful, there were limitations. CONCLUSION: A PBLI curriculum that is centred around practice-based quality improvement projects can fulfil the objectives of this ACGME competency while accomplishing sustained outcomes in quality improvement. A comprehensive curriculum is an investment but offers organisational rewards. We propose a more realistic and informative representation of rapid PDSA cycle changes.

A case study of translating ACGME practice-based learning and improvement requirements into reality: systems quality improvement projects as the key component to a comprehensive curriculum.

BACKGROUND: In 2002, the Accreditation Council for Graduate Medical Education (ACGME) introduced a new requirement: residents must demonstrate competency in Practice-Based Learning and Improvement (PBLI). Training in this domain is still not consistently integrated into programmes, with few, if any, adequately going beyond knowledge of basic content and addressing all components of the requirement. AIM: To summarise the implementation of a PBLI curriculum designed to address all components of the requirement and to evaluate the impact on the practice system. METHODS: A case-study approach was used for identifying and evaluating the steps for delivering the curriculum, along with the Model for Improvement's successive Plan-Do-Study-Act (PDSA) cycles (July 2004-May 2006). DATA SOURCE: Notes from curriculum development meetings, notes and presentation slides made by teams about their projects, resident curriculum exit evaluations curriculum and interviews. RESULTS: Residents reported high levels of comfort by applying PBLI-related knowledge and skills and that the curriculum improved their ability to do various PBLI tasks. The involvement of multiple stakeholders increased. Twelve of the 15 teams' suggestions with practical systems-relevant outcomes were implemented and sustained beyond residents' project periods. While using the traditional PDSA cycles was helpful, there were limitations. CONCLUSION: A PBLI curriculum that is centred around practice-based quality improvement projects can fulfil the objectives of this ACGME competency while accomplishing sustained outcomes in quality improvement. A comprehensive curriculum is an investment but offers organisational rewards. We propose a more realistic and informative representation of rapid PDSA cycle changes.

The role of lumbar puncture as a diagnostic tool in 2005.

Analysis of cerebrospinal fluid (CSF) obtained by lumbar puncture (LP) is fundamental to the management of inflammatory disease of the central nervous system (CNS), particularly that due to infection. This review summarises the role of lumbar puncture, anatomy and pathophysiology of CSF, techniques of obtaining CSF, indications, contraindications and complications of LP, methods of analysis and some of the implications of specific changes in CSF. The CNS is protected by unique immunological barriers, and has some unique responses to processes that breach these barriers. While clues in the epidemiology, history and clinical features of potential CNS inflammatory disease may be important in guiding early empirical treatment which may obviate adverse outcomes, many pathological processes cannot be distinguished or appropriately treated without analysis of CSF. When appropriate assessments are made of the indications, risks and potential to alter management, LP is a relatively safe procedure with a high diagnostic yield. Optimal performance and use of LP requires individual skill and judgment, and often benefits from close liaison with several disciplines, including emergency, intensive care, diagnostic laboratory, clinical imaging, neurology and infectious/ communicable diseases specialists. Understanding of the sensitivity, specificity and variation of CSF testing is critical to its effective use. Some CSF testing is sensitive, specific and timely, but other CNS disease processes will generate obscure and ambiguous results, and interpretation may benefit from liaison with experienced specialists in several fields. Polymerase chain reaction (PCR) testing has changed the practice of LP and is likely to generate further evolution. Some findings on CSF analysis may have implications beyond the individual patient - the consequences of the diagnosis of meningococcal meningitis, emerging pathogens such as West Nile virus or Nipah virus, and the identification of anthrax meningitis in the USA may be quite profound on both a local and global scale.

Quality of the caregiver--care recipient relationship: does it offset negative consequences of caregiving for family caregivers?

This study examined whether relationship quality mediates, moderates, or both mediates and moderates the associations between caregiving stressors (e.g., disability and behavioral problems) and negative consequences associated with caregiver well-being (overload, role captivity, and depression). Data on family (spouses and children) caregivers (n = 118) came from a longitudinal study of a representative sample of disabled older people and their primary caregivers. Relationship quality mediated the linkages between the presence of problem behaviors and the outcomes of role captivity and depression. That is, when problem behaviors were present, they related to higher levels of captivity and depression because quality of the relationship suffered. Relationship quality moderated the linkage between disability and overload. Specifically, for those with a higher quality of relationship, increased disability was related to higher levels of perceived overload.

Intensity and correlates of fear of falling and hurting oneself in the next year: baseline findings from a Roybal Center fear of falling intervention.

Fear of falling is highly prevalent and associated with restricted activity. To help inform design of interventions, the authors examined the correlates of this fear. Data came from baseline information on subjects in a community-based falls intervention study (N = 392). In a multivariate model, lower levels of fear of falling and hurting oneself in the next year were related to being younger, having higher levels of dysfunction, and having lower levels of perceived ability to manage falls, with the last two remaining significant even after controlling for generalized fearfulness. When analyzing specific domains of dysfunction, higher levels of fear of falling and hurting oneself in the next year were associated with higher levels of physical dysfunction. The findings lend support to the expanding awareness that fear of falling may imperil quality of life and suggest the importance of interventions aimed at enhancing ability to manage falls.

Do proxy evaluations of health status predict mortality?

The ability of self-evaluations of health to predict mortality remains despite efforts to explain their contribution. To further the understanding of global evaluations, this study investigated whether proxy evaluations of health status also predict mortality. Data from the Longitudinal Study of Aging were used. For men and women, the unadjusted odds ratios for proxy evaluations exhibited a monotone relationship to 3-year and 7-year mortality rates and were predictive of 7-year mortality. This monotone relationship remained even after controlling for other factors when predicting 7-year mortality rates. However, only the fair and poor evaluations were significant, and only for men. The adjusted relationship when predicting 3-year mortality was not completely monotone, although good and poor proxy evaluations were significant. This suggests that proxy evaluations are useful, and that there are aspects of health status that are currently unmeasured but that should lend themselves to being quantified.

Subject-caregiver response comparability on global health and functional status measures for African American, Puerto Rican, and Caucasian elders and their primary caregivers.

Ethnic differences in response comparability and bias were evaluated for elderly African American, Puerto Rican, and non-Hispanic Caucasian elderly subjects with some degree of disability and their caregivers. Responses were compared for items assessing basic and instrumental activities of daily living, memory problems, confusion, and global health status. In general, for all ethnic groups, response comparability, based on kappa, was only poor to fair, with the lowest agreement found for items assessing memory problems and confusion. When disagreements occurred, caregivers tended to overestimate impairment relative to the elderly subjects, regardless of ethnicity. However, there were very few significant differences between the response patterns of the caregivers of these different ethnic groups. Thus, although three may be bias in the responses of caregivers relative to elderly persons, in general further bias is not introduced by ethnic differences in comparability of caregiver responses for elders with some degree of disability.

Disentangling the disablement process.

A model was proposed to assess the premise that functional limitations are an intermediary stage between risk factors (e.g., sex and frequency of walking a mile), pathology/impairments (e.g., musculoskeletal problems), and the onset and course of Instrumental Activities of Daily Living (IADL) disability. Analyses were based on two random subsamples (each with n = 524) of Longitudinal Study of Aging respondents who were nondisabled at baseline (1984) and reinterviewed in 1988 and 1990. The model's central premise was supported in two ways. The main influence of age, frequency of walking, and musculoskeletal problems was on the onset of functional limitations, rather than the onset of IADL disability. And, onset of lower body functional limitations influenced future disability (1990) through its relationship with disability in 1988 and functional limitations in 1990. The results underscore the value of clinical trials which focus on minimizing functional limitations as a strategy for preventing disability.

The structure of physical health status. Comparing proxies and self-respondents.

Because gerontological studies often need to rely on the use of proxy respondents, the comparability of proxy and self-respondents is of particular interest. However, it is often impossible to evaluate response agreement between proxy and self-respondents because the necessary data are not available. This study addresses the problem by using a model of health status to evaluate differences between proxy and self-respondents regarding the conceptualization of health status. The model included three dimensions of physical health: chronic illness, functional limitations, and subjective health. Three groups of respondents who differ regarding proxy status and/or physical health status were compared. A subset of matched self-respondents (n = 146) was selected to be comparable in objective health status to respondents who have proxies (n = 140). The third group consisted of physically healthier self-respondents (n = 1,425). Data came from the Study of Well-Being of Older People in Cleveland, OH. No support was found for the expectation that proxies and self-respondents would weight objective health information differently when providing summary statements of subjective health. The results suggest that proxies rely on a conceptualization similar to self-respondents when providing information about another person's health.

Eicosapentaenoic acid modulates neutrophil leukotriene B4 receptor expression in cystic fibrosis.

In patients with cystic fibrosis (CF), high intrapulmonary concentrations of the neutrophil chemotaxin leukotriene B4 (LTB4) are associated with specific reduction of LTB4-induced chemotaxis of circulating neutrophils. The chemotactic abnormality is partially corrected by dietary supplementation with eicosapentaenoic acid (EPA). LTB4-induced neutrophil chemotaxis is mediated by specific, high-affinity, cell surface LTB4 receptors. The hypotheses that neutrophil LTB4 receptors are down-regulated in CF, and that EPA normalizes receptor expression, were tested by measuring the number (Rmax) and affinity (Kd) of LTB4 receptors on neutrophils from eight CF patients before and after EPA (6 weeks of 2.7 g/day), and from nine normal individuals. High-affinity receptor Rmax was depressed in CF patients (0.6 +/- 0.2 x 10(4)/cell (mean +/- s.d.) versus 1.8 +/- 0.7 x 10(4)/cell in normals), but corrected to normal (2.0 +/- 1.9 x 10(4)/cell) after EPA. High-affinity receptor Kd was depressed in CF patients (0.4 +/- 0.3 nM versus 1.4 +/- 0.5 nM in normals), and also corrected to normal with EPA (1.4 +/- 1.2 nM). Low-affinity receptors were depressed, but did not change significantly with EPA. These results indicate that neutrophil responses in chronic inflammatory lung disease can be influenced directly by LTB4 receptor modulation, and that this effect of EPA predominates over alterations in neutrophil signal transduction in situations of chronic exposure to LTB4.

Pseudomonas aeruginosa bacteraemia. Is pancreatobiliary disease a risk factor?

OBJECTIVE: To review changes in the epidemiology, course, and outcome of bacteraemia caused by Pseudomonas aeruginosa. DESIGN AND SETTING: A retrospective, descriptive study of consecutive cases of P. aeruginosa bacteraemia occurring at a university teaching hospital. PATIENTS AND METHODS: Between January 1980 and December 1989, 164 patients were admitted to Westmead Hospital with P. aeruginosa bacteraemia. Patients in whom there was no clinical evidence of sepsis were excluded from analysis leaving a cohort of 152 patients. Hospital records were reviewed and details of demography, clinical features, therapy, and outcome were recorded. RESULTS: One hundred and fifty-five episodes of P. aeruginosa bacteraemia were recorded at an average rate of 0.39 per 1000 admissions per year. The respiratory and pancreatobiliary tracts were the most common sources of the bacteraemia. Pancreatobiliary disease, independent of an underlying malignancy or immunosuppression, emerged as a previously undescribed risk factor for pseudomonal bacteraemia (incidence of 3.0 episodes per 1000 hospital admissions for patients with this disease). The crude mortality rate was 52%; 35% was attributable to pseudomonal bacteraemia. Factors identified as being independently associated with an increased mortality included hypotension, age of 60 years or older, and the presence of an underlying malignancy. Combination therapy with an antipseudomonal penicillin and an aminoglycoside confers a significant survival advantage independent of underlying neutropenia. CONCLUSIONS: Bacteraemia caused by P. aeruginosa remains an important cause of morbidity and mortality. Pancreatobiliary disease represents a new risk factor for P. aeruginosa bacteraemia, independent of an underlying malignancy or immunosuppression. It may be prudent to consider P. aeruginosa as a cause of sepsis in these circumstances, especially if there has been instrumentation of the biliary tree. Hypotension, age of 60 years or older, and the presence of an underlying malignancy were independently associated with significantly increased mortality. Appropriate antibiotic therapy consisting of an antipseudomonal beta-lactam in addition to an aminoglycoside resulted in a significant decrease in mortality compared with the use of an aminoglycoside alone, not only in the study population as a whole, but also in patients without neutropenia.

Decreased polymorphonuclear leucocyte chemotactic response to leukotriene B4 in cystic fibrosis.

Evidence that leukotriene B4 (LTB4) is a significant inflammatory mediator in chronic pseudomonal respiratory disease was sought in adolescents and young adults with cystic fibrosis. Specific chemotaxis of peripheral blood polymorphonuclear leucocytes (PMN) was used as an indirect measure of remote in vivo exposure to LTB4. PMN from 17 patients showed a significant decrease in chemotaxis to 10(-7)-10(-9) M LTB4, but normal responses to 10(-8) M n-formyl-methionyl-leucyl-phenylalanine and 4 mg/ml casein, when compared with 17 healthy age- and sex-matched controls. This result is consistent with chronic production of LTB4, and specific deactivation of circulating PMN receptors for LTB4 in patients with cystic fibrosis. Pharmacologic inhibition of LTB4 production in vivo may help elucidate its role in the pathogenesis of lung damage in cystic fibrosis.

Perceived intergenerational solidarity and psychological distress among older Mexican Americans.

A model separating and relating dimensions of intergenerational solidarity with measures of psychological distress was investigated for older Mexican Americans. Solidarity consisted of measures of similarity, affection, and association. Measures of psychological distress were somatic/retarded symptoms, depressed affect, and positive affect. To evaluate whether emotional closeness with a particular child modified the linkages, the model was analyzed separately based on whether or not the elderly participant reported that the child included in the intergenerational study was her or his closest child. The findings indicated that the impact of affection and association was a function of the particular dimension of distress and the emotional closeness of the child. Although the proposed model needs expanding, it provides some support for the expectation that family solidarity has important consequences for elderly Mexican Americans.

Cellulitis due to Pseudomonas putrefaciens: possible production of exotoxins.

Pseudomonas putrefaciens has been described as a rare cause of both lower-limb cellulitis and septicemic illness with significant morbidity. We report a case of P. putrefaciens infection in a patient with refractory lower-limb cellulitis and ulceration complicated by thrombocytopenia, hypotension, and mental obtundation in the apparent absence of bacteremia. This scenario raises the possibility of significant production of exotoxins by P. putrefaciens in vivo.

Appropriateness of composites in structural equation models.

The appropriateness of using composites instead of multiple indicators in a structural model of physical health was evaluated. Liang's (1986) specification of self-reported physical health is a relatively complex multiple indicators model which may not be practical in actual application. To simplify this formulation, a two-stage strategy was used. First, reliability was estimated for each composite to fix the measurement error variance and the regression of the composite on the latent variable. Second, the model was reestimated by constraining these parameters. Regression analyses were undertaken to assess the impact of using composites instead of multiple indicators. Parameter estimates for causal linkages and residual error variances based on multiple indicators approach were closely reproduced by using composites, thus providing justification for the proposed strategy.

Structural integration of the Affect Balance Scale and the Life Satisfaction Index A: race, sex, and age differences.

In this research we examined race, sex, and age differences in the factorial structure of Liang's (1985) model of subjective well-being that integrates the Affect Balance Scale and the Life Satisfaction Index A. In particular, we viewed the covariance structure of the items as a function of several parameter matrices. We analyzed the factorial invariance by testing hypotheses involving the equivalence constraints of one or more parameter matrices with regard to the following: White and Black subsamples, men and women, and the young-old and the old-old. Data for the research came from the 1974 Harris National Council on Aging Survey, Myths and Reality of Aging in America. Analysis of covariance structures, or LISREL, was used to assess the factorial invariance. Replicated race differences were found in the factorial structure, but sex and age differences were not found. Consistent race differences were found for the second-order factor loadings for negative affect.

Race differences in factorial structures of two measures of subjective well-being.

This research examines race differences in the factorial structure of two popular measures of psychological well-being: the Philadelphia Geriatric Center (PGC) Morale Scale and the Life Satisfaction Index A (LSIA). In particular, we view the covariance structure of the items of each scale as a function of several parameter matrices. We analyzed the factorial invariance by testing hypotheses involving the equivalence constraints of one or more parameter matrices in the White and the Black samples. Data for the research came from the 1968 National Senior Citizens Survey and the 1974 Harris National Council on Aging Survey, Myths and Reality of Aging in America. Analysis of covariance structures, or LISREL, was used to assess the factorial invariance of both the PGC Morale Scale and the LSIA. Race differences were found in the factorial structure of the PGC Morale Scale, but not in the structure of LSIA. In particular, consistent race differences in measurement error variances were found for two items of the PGC Morale Scale.

Age differences in the structure of the Philadelphia Geriatric Center Morale Scale.

In this research we examined age differences in the factorial structure of the Philadelphia Geriatric Center (PGC) Morale Scale. In particular, we viewed the covariance structure of the PGC Morale Scale items as a function of several parameter matrices. We analyzed the factorial invariance by testing hypotheses involving the equivalence constraints of one or more parameter matrices in the young-old (65-74) and the old-old (75 and over) populations. Data for this research came from the 1968 National Senior Citizens Survey. Analysis of covariance structures, or LISREL, was used to assess the factorial invariance of the PGC Morale Scale. Although there are some statistically significant age differences in the factorial structure, substantively they are less important.

Sterols of Delphinium ajacis; production and metabolic relationships in whole plants and callus tissue.

Sterols from whole nonsterile Delphinium ajacis plants and from sterile tissue cultures (callus) were identified and determined quantitatively. The major sterols in the whole plant tissues were sitosterol, campesterol and stigmasterol, whereas those in the callus tissue were stigmastanol, 24-ethylidenelophenol and Delta (7)-stigmastanol. Of the 21 compounds identified in callus tissue, 5 were not present in the whole plant, most notably Delta (7)-stigmastanol. For both sources of tissue, the sterol predominating in one was a minor component in the other (whole plant/tissue cultures: sitosterol 57%/5%; stigmastanol 2%/35%). On a tissue dry-weight basis, the amount of sterols isolated from callus tissue culture was ten to twenty times that obtained from the whole plant. Qualitatively the sterols from both sources fit into a metabolic scheme which proceeds from cycloartenol through 4,4-dimethylsterols and 4-methylsterols to sterols. A proposed metabolic pathway shows the differences in accumulation of sterols in the two types of tissue. The increase in sterol production in cultured cells, especially when favored by growth conditions, has promise for industrial application and in organic synthesis.