Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy.

Background:Acute gallstone disease is a high-volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance. Methods:Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods. Results:Of 13 sites invited to join Chole-QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole-QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8-day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals. Conclusion:A surgeon-led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy

Rhythm and Vowel Quality in Accents of English

In a sample of 27 speakers of Scottish Standard English two notoriously variable consonantal features are investigated: the contrast of /m/ and /w/ and non-prevocalic /r/, the latter both in terms of its presence or absence and the phonetic form it takes, if present. The pattern of realisation of non-prevocalic /r/ largely confirms previously reported findings. But there are a number of surprising results regarding the merger of /m/ and /w/ and the loss of non-prevocalic /r/: While the former is more likely to happen in younger speakers and females, the latter seems more likely in older speakers and males. This is suggestive of change in progress leading to a loss of the /m/ - /w/ contrast, while the variation found in non-prevocalic /r/ follows an almost inverse sociolinguistic pattern that does not suggest any such change and is additionally largely explicable in language-internal terms. One phenomenon requiring further investigation is the curious effect direct contact with Southern English accents seems to have on non-prevocalic /r/: innovation on the structural level (i.e. loss) and conservatism on the realisational level (i.e. increased incidence of [r] and [r]) appear to be conditioned by the same sociolinguistic factors

Understanding the influences on successful quality improvement in emergency general surgery: learning from the RCS Chole-QuIC project.

BACKGROUND: Acute gallstone disease is the highest volume Emergency General Surgical presentation in the UK. Recent data indicate wide variations in the quality of care provided across the country, with national guidance for care delivery not implemented in most UK hospitals. Against this backdrop, the Royal College of Surgeons of England set up a 13-hospital quality improvement collaborative (Chole-QuIC) to support clinical teams to reduce time to surgery for patients with acute gallstone disease requiring emergency cholecystectomy. METHODS: Prospective, mixed-methods process evaluation to answer the following: (1) how was the collaborative delivered by the faculty and received, understood and enacted by the participants; (2) what influenced teams' ability to improve care for patients requiring emergency cholecystectomy? We collected and analysed a range of data including field notes, ethnographic observations of meetings, and project documentation. Analysis was based on the framework approach, informed by Normalisation Process Theory, and involved the creation of comparative case studies based on hospital performance during the project. RESULTS: Chole-QuIC was delivered as planned and was well received and understood by participants. Four hospitals were identified as highly successful, based upon a substantial increase in the number of patients having surgery in line with national guidance. Conversely, four hospitals were identified as challenged, achieving no significant improvement. The comparative analysis indicate that six inter-related influences appeared most associated with improvement: (1) achieving clarity of purpose amongst site leads and key stakeholders; (2) capacity to lead and effective project support; (3) ideas to action; (4) learning from own and others' experience; (5) creating additional capacity to do emergency cholecystectomies; and (6) coordinating/managing the patient pathway. CONCLUSION: Collaborative-based quality improvement is a viable strategy for emergency surgery but success requires the deployment of effective clinical strategies in conjunction with improvement strategies. In particular, achieving clarity of purpose about proposed changes amongst key stakeholders was a vital precursor to improvement, enabling the creation of additional surgical capacity and new pathways to be implemented effectively. Protected time, testing ideas, and the ability to learn quickly from data and experience were associated with greater impact within this cohort

Speech rhythm: a metaphor?

Is speech rhythmic? In the absence of evidence for a traditional view that languages strive to coordinate either syllables or stress-feet with regular time intervals, we consider the alternative that languages exhibit contrastive rhythm subsisting merely in the alternation of stronger and weaker elements. This is initially plausible, particularly for languages with a steep ‘prominence gradient’, i.e. a large disparity between stronger and weaker elements; but we point out that alternation is poorly achieved even by a ‘stress-timed’ language such as English, and, historically, languages have conspicuously failed to adopt simple phonological remedies that would ensure alternation. Languages seem more concerned to allow ‘syntagmatic contrast’ between successive units and to use durational effects to support linguistic functions than to facilitate rhythm. Furthermore, some languages (e.g. Tamil, Korean) lack the lexical prominence which would most straightforwardly underpin prominence alternation. We conclude that speech is not incontestibly rhythmic, and may even be antirhythmic. However, its linguistic structure and patterning allow the metaphorical extension of rhythm in varying degrees and in different ways depending on the language, and that it is this analogical process which allows speech to be matched to external rhythms

Rhythm in the speech of a person with right hemisphere damage: Applying the pairwise variability index

Although several aspects of prosody have been studied in speakers with right hemisphere damage (RHD), rhythm remains largely uninvestigated. This study compares the rhythm of an Australian English speaker with right hemisphere damage (due to a stroke, but with no concomitant dysarthria) to that of a neurologically unimpaired individual. The speakers' rhythm is compared using the pairwise variability index (PVI) which allows for an acoustic characterization of rhythm by comparing the duration of successive vocalic and intervocalic intervals. A sample of speech from a structured interview between a speech and language therapist and each participant was analysed. Previous research has shown that speakers with RHD may have difficulties with intonation production, and therefore it was hypothesized that there may also be rhythmic disturbance. Results show that the neurologically normal control uses a similar rhythm to that reported for British English (there are no previous studies available for Australian English), whilst the speaker with RHD produces speech with a less strongly stress-timed rhythm. This finding was statistically significant for the intervocalic intervals measured (t(8) = 4.7, p < .01), and suggests that some aspects of prosody may be right lateralized for this speaker. The findings are discussed in relation to previous findings of dysprosody in RHD populations, and in relation to syllable-timed speech of people with other neurological conditions

Elastic deformation of a fluid membrane upon colloid binding

When a colloidal particle adheres to a fluid membrane, it induces elastic deformations in the membrane which oppose its own binding. The structural and energetic aspects of this balance are theoretically studied within the framework of a Helfrich Hamiltonian. Based on the full nonlinear shape equations for the membrane profile, a line of continuous binding transitions and a second line of discontinuous envelopment transitions are found, which meet at an unusual triple point. The regime of low tension is studied analytically using a small gradient expansion, while in the limit of large tension scaling arguments are derived which quantify the asymptotic behavior of phase boundary, degree of wrapping, and energy barrier. The maturation of animal viruses by budding is discussed as a biological example of such colloid-membrane interaction events.Comment: 14 pages, 9 figures, REVTeX style, follow-up on cond-mat/021242

Mechanisms and in vivo functions of contact inhibition of locomotion

Contact inhibition of locomotion (CIL) is a process whereby a cell ceases motility or changes its trajectory upon collision with another cell. CIL was initially characterized more than half a century ago and became a widely studied model system to understand how cells migrate and dynamically interact. Although CIL fell from interest for several decades, the scientific community has recently rediscovered this process. We are now beginning to understand the precise steps of this complex behaviour and to elucidate its regulatory components, including receptors, polarity proteins and cytoskeletal elements. Furthermore, this process is no longer just in vitro phenomenology; we now know from several different in vivo models that CIL is essential for embryogenesis and in governing behaviours such as cell dispersion, boundary formation and collective cell migration. In addition, changes in CIL responses have been associated with other physiological processes, such as cancer cell dissemination during metastasis

The independent group looks at London's west end

In the early 1950s, British culture was dominated by welfare-state visions of urban reconstruction. These projections of a stable civic society were premised on a particular way of looking at and reading the metropolitan environment. At odds with this project, the Independent Group's discussions and collaborative work developed an alternative urban semiology, which found the city to be already rich in visual resources for fashioning a more profound form of social democracy. Soon, this critical engagement would develop in different directions, represented here by Lawrence Alloway's commentary on Piccadilly Circus in his essay 'City Notes' and the London footage inserted by John McHale into his film for the Smithsons' Berlin Hauptstadt project (both 1959). By the end of the 1950s, members of the erstwhile Independent Group had produced two contrasting critical accounts of how the metropolitan centre should be looked at, which challenged the strictures of post-war reconstruction in distinct and conflicting ways. © The Author(s), 2013

Determinants of impact : towards a better understanding of encounters with the arts

The article argues that current methods for assessing the impact of the arts are largely based on a fragmented and incomplete understanding of the cognitive, psychological and socio-cultural dynamics that govern the aesthetic experience. It postulates that a better grasp of the interaction between the individual and the work of art is the necessary foundation for a genuine understanding of how the arts can affect people. Through a critique of philosophical and empirical attempts to capture the main features of the aesthetic encounter, the article draws attention to the gaps in our current understanding of the responses to art. It proposes a classification and exploration of the factors—social, cultural and psychological—that contribute to shaping the aesthetic experience, thus determining the possibility of impact. The ‘determinants of impact’ identified are distinguished into three groups: those that are inherent to the individual who interacts with the artwork; those that are inherent to the artwork; and ‘environmental factors’, which are extrinsic to both the individual and the artwork. The article concludes that any meaningful attempt to assess the impact of the arts would need to take these ‘determinants of impact’ into account, in order to capture the multidimensional and subjective nature of the aesthetic experience