Taking a value based commissioning approach to non-clinical and clinical support services.

Value based healthcare beyond the clinical domain is the focus of this case study. We share NSW Health's experiences in achieving value through a focus on outcomes in non-clinical and clinical support services using examples that demonstrate key aspects across the commissioning cycle. These include: the importance of stakeholder engagement in the planning phase to later success; the critical role of non-clinical services in patient experience; the opportunity to facilitate value by introducing new approaches in business areas such as procurement; and the role of clinical supports such as digital enablement to facilitate outcome-focussed clinical models. Applying a value lens to non-clinical services can increase the potential benefits to patients, clinicians and the system.

Characterization of the Effects of Ligands on Bonding and σ-Aromaticity of Small Pt Nanoclusters.

Nanoclusters, particularly gold nanoclusters, have attracted the attention of researchers due to their potential applications in the medicine and energy fields. Other noble-metal nanoclusters, including Pt, have also been studied, but in lesser detail. Pt is known for its excellent catalytic properties and is a promising candidate for applications in catalysis and biomedicine. In this study, we used density functional theory to elucidate the molecular and electronic structures of small phosphine-ligated Pt nanoclusters. This study is directed at identifying highly stable platinum clusters. Our results show that phosphine-ligated platinum nanoclusters with σ-aromaticity have high stability. In addition, we were able to predict the most stable clusters using an electron counting equation.

An Update on Current Resuscitation Council (UK) Guidelines.

On 15 October 2015, The Resuscitation Council (UK) published new resuscitation guidelines following the review of resuscitation science by the International Liaison Committee on Resuscitation (ILCOR). The 2015 guidelines emphasize the importance of interactions between the emergency medical dispatcher, the bystander who provides cardiopulmonary resuscitation (CPR) and the prompt deployment of an automated external defibrillator (AED); the co-ordination of these three elements is crucial to improving out-of-hospital cardiac arrest survival. Medical emergencies in dental practices are thought to occur on average once every 3−4 years per dentist in primary care. The GDC consider medical emergencies as a highly recommended topic for Continuing Professional Development (CPD) and recommend at least 10 hours in every CPD cycle. Clinical relevance: The publication of the updated guidelines serves as a reminder to the clinical team of the importance of being up to date with recognition and treatment of cardiac arrest and choking and how seamless interaction between members of both the dental and medical teams improves long-term outcomes for patients.

PAS-G supports platelet reconstitution after cryopreservation in the absence of plasma.

BACKGROUND: Platelet (PLT) concentrates frozen in dimethyl sulfoxide (DMSO) can be stored for extended periods at -80°C. PLTs are frozen in a hyperconcentrated state to avoid postthaw washing and minimize residual DMSO. Consequently, PLTs require reconstitution upon thawing. Although plasma, saline, and PLT additive solutions (PASs) have been used to reconstitute frozen PLTs, a comparison to define an optimal solution for PLT recovery has not been performed. STUDY DESIGN AND METHODS: DMSO (5% final concentration) was added to buffy coat-derived PLTs, followed by centrifugation to concentrate and freezing at -80°C. Cryopreserved PLTs (n=12 per group) were thawed at 37°C, reconstituted in a unit of thawed frozen plasma, SSP+, or PAS-G. In vitro PLT quality was examined before freezing, immediately after thawing, and 6 and 24 hours after thawing. RESULTS: After thawing and reconstitution, PLTs in plasma and PAS-G displayed similar recovery (69 and 73%, respectively), while PLT recovery in SSP+ was lower (62%). All PLTs maintained an acceptable pH and metabolic activity during postthaw storage. Frozen PLTs were activated, although the extent differed depending on the reconstitution solution, with PLTs in PAS-G retaining better aggregation responses than PLTs in plasma or SSP+. CONCLUSION: Thawing cryopreserved PLTs in PAS-G, without plasma supplementation, resulted in PLTs with similar recovery and in vitro quality indicators as those suspended in plasma. Importantly, using PAS-G enables the PLTs to be ready for use significantly faster than when having to thaw frozen plasma, which may be beneficial in trauma situations.

Pathogen reduction treatment of buffy coat platelet concentrates in additive solution induces proapoptotic signaling.

BACKGROUND: Pathogen reduction technology (PRT) can potentially reduce the risk of transfusion-transmitted infections. However, PRT treatment of platelet (PLT) concentrates also results in reduced PLT quality and increased markers of apoptosis during storage. The aim of this study was to investigate changes to the expression and activation of proteins involved in apoptosis signaling. STUDY DESIGN AND METHODS: Samples from riboflavin and ultraviolet light PRT-treated and untreated (control) buffy coat-derived PCs in 70% SSP+ and 30% plasma were taken on Days 1, 5, and 7 of storage. Phosphatidylserine (PS) exposure, expression of Bcl-2 family proteins, cytochrome c release, and cleavage of caspase-3 and caspase-3 substrates were analyzed using flow cytometry and Western blotting. RESULTS: Compared to untreated controls, markers of apoptosis signaling were increased after PRT and subsequent storage. PS exposure on the PLT outer membrane was significantly higher after PRT on Days 5 and 7 of storage (p < 0.05). Expression of proapoptotic Bak and Bax was higher after PRT and subsequent storage. Cytochrome c release and caspase-3 cleavage were also greater and occurred earlier in the PRT-treated PLTs. The cleavage of caspase-3 substrates gelsolin and ROCK I were also increased after PRT, compared to untreated controls. CONCLUSIONS: This study demonstrated an increase in proapoptotic signaling during PLT storage, which was exacerbated by PRT. Many of these differences emerged outside the current 5-day storage period. These changes may not currently influence PLT transfusion quality, but will need to be carefully evaluated when considering extending PLT storage beyond 5 days.

A prospective trial assessing the safety and efficacy of collecting up to 840 mL of plasma in conjunction with saline infusion during plasmapheresis.

BACKGROUND: The demand for plasma for manufacturing intravenous immunoglobulin and other plasma derivatives is increasing. A prospective study was conducted to determine whether up to 840 mL of plasma could be safely and effectively collected in conjunction with saline infusion during plasmapheresis. STUDY DESIGN AND METHODS: Ninety-one plasma donors were enrolled in a modified 3 × 3 crossover study to assess the equivalence of three plasma collection methods: 750 mL of plasma with no saline (control, Method 1), 840 mL of plasma with a 250-mL saline infusion during and at the end of the donation (Method 2), and 800 mL of plasma with a 500-mL saline infusion at the end of the donation (Method 3). The primary efficacy endpoint was the total protein concentration of the collected plasma. Secondary efficacy endpoints were immunoglobulin (Ig)G and Factor (F)VIII plasma concentration and donors' acceptance of the new procedures. Safety was determined from the adverse event (AE) rate. RESULTS: The total protein, IgG, and FVIII concentrations in plasma collected under Methods 2 and 3 were significantly lower than those in plasma collected under Method 1 (p < 0.0001). These variables were also significantly lower in plasma collected under Method 2 compared to Method 3. During the study, 75 AEs were recorded, 73 of which were mild to moderate. Significantly more donors (31%) preferred Method 2 compared to Method 3 (p = 0.006). CONCLUSIONS: Saline infusion during plasmapheresis led to hemodilution of plasma proteins. However, the benefits to donor safety and satisfaction are compelling reasons to implement saline infusion during plasmapheresis.

Evaluation of the automated collection and extended storage of apheresis platelets in additive solution.

BACKGROUND: Collecting apheresis platelets (PLTs) into additive solution has many potential benefits. The new Trima software (Version 6.0, CaridianBCT) allows automated addition of PLT additive solution (PAS) after collection, compared to Trima Version 5.1, which only collects PLTs into plasma. The aim of this study was to compare PLT quality during extended storage, after collection with the different Trima systems. STUDY DESIGN AND METHODS: Apheresis PLTs were collected using both Trima Accel apheresis systems. The test PLT units (n = 12) were collected using the new Trima Version 6.0 into PLT AS (PAS-IIIM), while the control units (n = 8) were collected into autologous plasma using Trima Version 5.1. All units were stored for 9 days, and in vitro cell quality variables were evaluated during this time. RESULTS: PLTs collected in PAS-IIIM maintained a stable pH between 7.2 and 7.4, whereas plasma-stored apheresis units exhibited significantly increased acidity during storage, due to lactate accumulation and bicarbonate exhaustion. Plasma-stored PLTs also demonstrated a more rapid consumption of glucose. However, there was little difference in PLT activation or cytokine secretion between PAS-IIIM and control PLTs. CONCLUSION: These data indicate that apheresis PLT concentrates collected in PAS-IIIM, using Trima Version 6.0 software, maintained acceptable PLT metabolic and cellular characteristics until Day 9 of storage.

Relationship between stair ambulation with and without a handrail and centre of pressure velocities during stair ascent and descent.

INTRODUCTION: Stair ambulation is one of the most challenging and hazardous types of locomotion for older adults and often requires the adoption of compensatory strategies such as increased handrail use to mitigate disability and increase stability. Centre of pressure velocity (VCOP) describes the neuromuscular response to shifts of the body's centre of mass and serves as an indicator of stability. Knowledge of VCOP may provide some understanding of strategies to improve measured and perceived stability during stair negotiation. The aim of this study was to compare VCOP during stair ascent and descent with and without a handrail in young, older and older adults with a fear of falling (FOF) populations. METHODS: COP velocities of 23 young adults (23.7±3.0 yrs), 26 older adults (66.4±8.3 yrs), and 3 older adults with FOF (80.2±8.0 yrs) were analyzed while they ascended and descended a custom 4-step staircase. VCOP were obtained using a force plate mounted on concrete blocks centered on the second step of the staircase. RESULTS: During stair ascent and descent with and without a handrail, the VCOP between young and older adults were comparable. The three adults with FOF demonstrated reduced VCOP during ascent and descent without the handrail and even slower VCOP when ascending and descending stairs with the handrail. These results suggest that handrail use does not increase biomechanical stability for healthy, older adults. However, in the presence of fear of falling the use of the handrail enhances dynamic stability, particularly during stair descent. CONCLUSIONS: This study provides the first detailed description of dynamic stability during stair ambulation with and without a handrail. Observations from those with FOF aid in understanding the nature of compensations to improve actual and perceived stability.

Characterisation and relevance of CD138-negative plasma cells in plasma cell myeloma.

INTRODUCTION: The use of CD138 to isolate CD138(+) plasma cells (PCs) from plasma cell myeloma (PCM) patients' bone marrow samples has been used extensively in myeloma research. We sought to highlight the problem with this selection process, by demonstrating that a subpopulation of CD138⁻ plasma cells exists which is not included in these analyses. METHODS: Retrospective analysis of a patient database was carried out on all PCM patient bone marrow biopsies taken between 4/9/07 and 18/2/09 (n = 218). CD138(+) and CD138⁻ cell populations were separated using flow cytometry cell sorter then analyzed for percentage of cells in S phase using plasma cell labeling index as an indicator of proliferation. RESULTS: Database results indicated a CD138⁻ PC population in all PCM patient samples which also had a significantly increased (r = 0.53; P < 0.0001) CD45 expression, an indicator or immaturity. Flow cytometric analysis demonstrated the presence of a more immature, higher proliferating CD138⁻ PC population through a significantly (t = 3.26; P < 0.02) higher number of CD138⁻ PCs in S phase compared with the CD138(+) cells. CONCLUSION: We have characterised the CD138⁻ PCs as more immature and with a significantly higher proliferative potential. The current trend to ignore this more immature and proliferative subpopulation of malignant PCs may have serious implications when determining gene expression, classifications and drug sensitivity of the malignancy.

Differentiation of young and older adult stair climbing gait using principal component analysis.

INTRODUCTION: Principal component analysis (PCA) has been used to reduce the volume of gait data and can also be used to identify the differences between populations. This approach has not been used on stair climbing gait data. Our objective was to use PCA to compare the gait patterns between young and older adults during stair climbing. METHODS: The knee joint mechanics of 30 healthy young adults (23.9 + or - 2.6 years) and 32 healthy older adults (65.5 + or - 5.2 years) were analyzed while they ascended a custom 4-step staircase. The three-dimensional net knee joint forces, moments, and angles were calculated using typical inverse dynamics. PCA models were created for the knee joint forces, moments and angles about the three axes. The principal component scores (PC scores) generated from the model were analyzed for group differences using independent samples t-tests. A stepwise discriminant procedure determined which principal components (PCs) were most successful in differentiating the two groups. RESULTS: The number of PCs retained for analysis was chosen using a 90% trace criterion. Of the scores generated from the PCA models nine were statistically different (p < .0019) between the two groups, four of the nine PC scores could be used to correctly classify 95% of the original group. CONCLUSIONS: The PCA and discriminant function analysis applied in this investigation identified gait pattern differences between young and older adults. Identification of stair gait pattern differences between young and older adults could help in understanding age-related changes associated with the performance of the locomotor task of stair climbing.

Knee biomechanics of alternate stair ambulation patterns.

PURPOSE: This study compared the kinematics and kinetics of the knee joint during traditional step-over-step (SOS) and compensatory step-by-step lead-leg (SBSL) and trail-leg (SBST) stair ambulation patterns. METHODS: Seventeen (M:9) healthy adults completed five trials of ascent and descent using three different stepping patterns: 1) SBSL, 2) SBST, and 3) SOS. Kinematics and kinetics were collected with an optoelectronic motion-tracking system and a force plate embedded into a four-step staircase. An inverse-dynamics link-segment model (QGAIT system) was used to calculate the net joint kinetics. RESULTS: During stair ascent, different peak anteroposterior (AP) forces were observed across all three stepping patterns (SOS > SBSL > SBST, P < 0.05). During ascent, the flexion moments of SOS (0.96 N x m x kg(-1)) and SBSL (0.97 N x m x kg(-1)) patterns were similar and much larger than the SBST moments (0.14 N x m x kg(-1)). In the descent conditions, the initial AP peak force for SOS was larger than that of SBSL and SBST. However, the second peak force for SOS (4.92 N x kg(-1)) and SBST (4.68 N x kg(-1)) were larger than SBSL (1.57 N x kg(-1)). During descent, the initial peak flexion moment for the SOS pattern was larger than SBSL and SBST, whereas during the second peak, SOS (1.05 N x m x kg(-1)) and SBST (1.11 N x m x kg(-)) were no different and larger than SBSL (0.18 N x m x kg(-1)). CONCLUSION: Overall, SBSL during ascent and SBST during descent had the highest loads. These results increase our understanding of alternative stepping patterns and have important clinical (reduction of loading on injured/diseased leg) and rehabilitation implications.

The influence of gait pattern on signs of knee osteoarthritis in older adults over a 5-11 year follow-up period: a case study analysis.

There is evidence that joint load is a factor in the development of osteoarthritis (OA) and, while altered gait profiles have been linked with OA, it is unknown if abnormal gait is a cause or effect of the disease. While the knee's adduction moment has been implicated in the development and progression of knee OA, it is also known that shearing forces are detrimental to the health of cartilage. The purpose of this pilot study was to examine the adduction moment and gait shear forces to determine if they may lead to signs of knee OA in older adults as they age. Knee gait kinetics, standardized radiographs and a questionnaire were collected on 28 older adults (M:13) during an initial visit, and 5 to 11 years later. Radiographic score increased (knees became more osteoarthritic in 15 of 28 subjects) over time. However, gait time-distance measures remained constant in disease free participants. Two returning participants developed symptoms and radiographic evidence of knee OA. The subject with the largest adduction moment developed signs of medial OA while the subject with the smallest adduction moment developed signs of lateral OA. In addition, there was a strong correlation between the magnitudes of the adduction moment and lateral-medial shear force that needs to be investigated further. Results suggest that gait can remain stable over time in older adults. Also, the medial and lateral OA case study findings suggest that the extreme gait profiles seen in these two participants may be important in explaining cartilage breakdown and the development of OA. This longitudinal study would suggest that perhaps it is the abnormal gait pattern that leads to the development of OA, although a much larger study would be needed to confirm this finding.