A case study in healthcare quality management: a practical methodology for auditing total patient X-ray dose during a diagnostic procedure

The healthcare industry is adopting many of the best practices familiar to the manufacturing sector. For example the need for ISO 9000 registration is now seen as an important business driver, indeed, BSI offers specific advice for Healthcare organisations seeking to gain ISO 9001:2000 approval. Accompanying the integration of quality systems into the healthcare business is the need to find practical measures of quality that may be used as part of an overall process to deliver improved performance. The manufacturing industry has a rich array of techniques such as JIT (Just In Time), 6 Sigma, SPC (Statistical Process Control), TQM (Total Quality Management) which may all now be found cited in conjunction with the healthcare industry. This paper focuses on the legislatively driven need to locally audit and minimise the diagnostic X-ray dose received by patients during a Barium Enema procedure. This procedure was selected as it has been shown by other authors to have a reasonably narrow spread of total patient dose levels and therefore might be relatively easy to draw statistically significant inferences for management purposes. The Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER) and Health Service Circular on Clinical Governance (HSC1999/065) state that Clinical Audit should be performed to identify and monitor the issues leading to quality improvement and best practice. This is a statement of requirement, which delegates the responsibility of implementation to the local level. The IRMER Regulation also require the setting of local Diagnostic Reference Levels (DRLs). These are levels of radiation dose for individual examinations which under normal circumstances should not be exceeded. Producing a meaningful audit and DRLs in small departments raises many issues: data availability and capture may be time consuming especially if records are kept on paper-based systems; analysis of the data may present a steep learning curve in statistical techniques; a high degree of statistical confidence in the results is required along with sensitivity in their presentation and dissemination to ensure that they become part of a process of continuous improvement (rather than part of a blame culture). This paper presents a practical approach to delivering a meaningful audit of locally collected data using readily available software tools (Excel Spreadsheet), in conjunction with a relatively simple numerical statistical analysis technique called ‘bootstrapping’. Bootstrapping enabled us to set the local DRL for this procedure with an estimate of statistical confidence. An analysis was performed on the data to determine factors contributing to total patient dose

drav_cov_est_ucln_yule_no_burnin.trees.zip from A Bayesian phylogenetic study of the Dravidian language family

The Dravidian language family consists of about 80 varieties (Hammarström H. 2016 <i>Glottolog 2.7</i>) spoken by 220 million people across southern and central India and surrounding countries (Steever SB. 1998 In <i>The Dravidian languages</i> (ed. SB Steever), pp. 1–39: 1). Neither the geographical origin of the Dravidian language homeland nor its exact dispersal through time are known. The history of these languages is crucial for understanding prehistory in Eurasia, because despite their current restricted range, these languages played a significant role in influencing other language groups including Indo-Aryan (Indo-European) and Munda (Austroasiatic) speakers. Here, we report the results of a Bayesian phylogenetic analysis of cognate-coded lexical data, elicited first hand from native speakers, to investigate the subgrouping of the Dravidian language family, and provide dates for the major points of diversification. Our results indicate that the Dravidian language family is approximately 4500 years old, a finding that corresponds well with earlier linguistic and archaeological studies. The main branches of the Dravidian language family (North, Central, South I, South II) are recovered, although the placement of languages within these main branches diverges from previous classifications. We find considerable uncertainty with regard to the relationships between the main branches

drav_cov_est_ucln_yule.mcct.trees from A Bayesian phylogenetic study of the Dravidian language family

The Dravidian language family consists of about 80 varieties (Hammarström H. 2016 <i>Glottolog 2.7</i>) spoken by 220 million people across southern and central India and surrounding countries (Steever SB. 1998 In <i>The Dravidian languages</i> (ed. SB Steever), pp. 1–39: 1). Neither the geographical origin of the Dravidian language homeland nor its exact dispersal through time are known. The history of these languages is crucial for understanding prehistory in Eurasia, because despite their current restricted range, these languages played a significant role in influencing other language groups including Indo-Aryan (Indo-European) and Munda (Austroasiatic) speakers. Here, we report the results of a Bayesian phylogenetic analysis of cognate-coded lexical data, elicited first hand from native speakers, to investigate the subgrouping of the Dravidian language family, and provide dates for the major points of diversification. Our results indicate that the Dravidian language family is approximately 4500 years old, a finding that corresponds well with earlier linguistic and archaeological studies. The main branches of the Dravidian language family (North, Central, South I, South II) are recovered, although the placement of languages within these main branches diverges from previous classifications. We find considerable uncertainty with regard to the relationships between the main branches

SI_2017_09_29.docx from A Bayesian phylogenetic study of the Dravidian language family

Supplementary Materials containing additional Figures and analysis, as well as a literature review on the 20 sampled Dravidian language

drav_cov_est_ucln_yule.xml from A Bayesian phylogenetic study of the Dravidian language family

BEAST 2 xml file that was used for the best-supported analysis, relaxed covarion model with relative mutation rates estimated

drav_cov_est_ucln_yule.xml from A Bayesian phylogenetic study of the Dravidian language family

BEAST 2 xml file that was used for the best-supported analysis, relaxed covarion model with relative mutation rates estimated

SI_2017_09_29.docx from A Bayesian phylogenetic study of the Dravidian language family

Supplementary Materials containing additional Figures and analysis, as well as a literature review on the 20 sampled Dravidian language

Sustained Isoprostane E2 Elevation, Inflammation and Fibrosis after Acute Ischaemia-Reperfusion Injury Are Reduced by Pregnane X Receptor Activation

<div><p>Liver grafts donated after cardiac death are increasingly used to expand the donor pool but are prone to ischaemic-type biliary lesions. The anti-inflammatory effects of the activated pregnane X receptor have previously been shown to be beneficial in a number of inflammatory liver conditions. However, its role in reducing peri-portal inflammation and fibrosis following ischaemia-reperfusion injury has not been investigated. Hepatic injury and its response to pregnane X receptor activation was examined after partial hepatic ischaemia-reperfusion injury induced by surgically clamping the left and middle lobar blood vessels in rats. Molecular and pathological changes in the liver were examined over the following 28 days. Ischaemia-reperfusion injury resulted in transient cholestasis associated with microvillar changes in biliary epithelial cell membranes and hepatocellular injury which resolved within days after reperfusion. However, in contrast to chemically-induced acute liver injuries, this was followed by sustained elevation in isoprostane E2, peri-portal inflammation and fibrosis that remained unresolved in the ischaemic reperfused lobe for at least 28 days after clamping. Administration of pregnenolone-16α-carbonitrile—a rodent-specific pregnane X receptor activator—resulted in significant reductions in cholestasis, hepatic injury, ischaemic lobe isoprostane E2 levels, peri-portal inflammation and fibrosis. Hepatic ischaemia-reperfusion injury therefore results in inflammatory and fibrotic changes that persist well beyond the initial ischaemic insult. Drug-mediated activation of the pregnane X receptor reduced these adverse changes in rats, suggesting that the pregnane X receptor is a viable drug target to reduce ischaemic-type biliary lesions in recipients of liver transplants donated after cardiac death.</p></div

IRI results in progressive fibrosis.

<p><b>(A)</b> α-SMA immunohistochemistry—typical views from the indicated treatment group post and time point (upper panels) and quantification of α-SMA immunohistochemistry staining, scale bar represents 100μm. (<b>B)</b> quantification of α-SMA staining. <b>(C)</b> Sirius red staining–typical views from the indicated treatment group post and time point (upper panels) and quantification of Sirius red staining, scale bar represents 100μm. (<b>D</b>) quantification of Sirius red staining. <b>(E-F)</b> qRT-PCR analysis in ischaemic and sham ischaemic lobes. Data are the mean and standard deviation from 3 separate animals at each time point and treatment, *Significantly different compared to sham IRI group, p<0.05.</p

PCN treatment results in hepatic Cyp3a1 induction, reduced oxidative stress and reduced cholestasis in IRI.

<p><b>(A)</b> Quantification of Cyp3a1 mRNA levels as determined by qRT-PCR RNA was isolated from whole liver as outlined in the methods section. (<b>B)</b> Western blot of Cyp3a1 expression in whole liver homogenates on day 1 and 10 in IRI+PCN and IRI+vehicle groups. (<b>C)</b> Liver MDA levels on day 1 post clamp release. (<b>D)</b> Comparison of bile flow in the IRI+PCN and IRI+vehicle groups. (<b>E)</b> Serum bile acid levels. Data are the mean and standard deviation from 5 separate animals at each time point and treatment, *Significantly different compared to sham IRI group, p<0.05.</p