Collaborative working within UK NHS secondary care and across sectors for COPD and the impact of peer review : qualitative findings from the UK National COPD Resources and Outcomes Project

Introduction: We investigated the effects on collaborative work within the UK National Health Service (NHS) of an intervention for service quality improvement: informal, structured, reciprocated, multidisciplinary peer review with feedback and action plans. The setting was care for chronic obstructive pulmonary disease (COPD). Theory and methods: We analysed semi-structured interviews with 43 hospital respiratory consultants, nurses and general managers at 24 intervention and 11 control sites, as part of a UK randomised controlled study, the National COPD Resources and Outcomes Project (NCROP), using Scott’s conceptual framework for action (inter-organisational, intra-organisational, inter-professional and inter-individual). Three areas of care targeted by NCROP involved collaboration across primary and secondary care. Results: Hospital respiratory department collaborations with commissioners and hospital managers varied. Analysis suggested that this is related to team responses to barriers. Clinicians in unsuccessful collaborations told ‘atrocity stories’ of organisational, structural and professional barriers to service improvement. The others removed barriers by working with government and commissioner agendas to ensure continued involvement in patients’ care. Multidisciplinary peer review facilitated collaboration between participants, enabling them to meet, reconcile differences and exchange ideas across boundaries. Conclusions: The data come from the first randomised controlled trial of organisational peer review, adding to research into UK health service collaborative work, which has had a more restricted focus on inter-professional relations. NCROP peer review may only modestly improve collaboration but these data suggest it might be more effective than top-down exhortations to change when collaboration both across and within organisations is required

Measurements of the light-absorbing material inside cloud droplets and its effect on cloud albedo

Most of the measurements of light-absorbing aerosol particles made previously have been in non-cloudy air and therefore provide no insight into aerosol effects on cloud properties. Here, researchers describe an experiment designed to measure light absorption exclusively due to substances inside cloud droplets, compare the results to related light absorption measurements, and evaluate possible effects on the albedo of clouds. The results of this study validate those of Twomey and Cocks and show that the measured levels of light-absorbing material are negligible for the radiative properties of realistic clouds. For the measured clouds, which appear to have been moderately polluted, the amount of elemental carbon (EC) present was insufficient to affect albedo. Much higher contaminant levels or much larger droplets than those measured would be necessary to significantly alter the radiative properties. The effect of the concentrations of EC actually measured on the albedo of snow, however, would be much more pronounced since, in contrast to clouds, snowpacks are usually optically semi-infinite and have large particle sizes

Eligibility of patients with advanced non-small cell lung cancer for phase III chemotherapy trials

<p>Abstract</p> <p>Background</p> <p>Evidence that chemotherapy improves survival and quality of life in patients with stage IIIB & IV non small cell lung cancer (NSCLC) is based on large randomized controlled trials. The purpose of this study was to determine eligibility of patients with advanced NSCLC for major chemotherapy trials.</p> <p>Methods</p> <p>Physicians treating stage IIIB/IV NSCLC at Sydney Cancer Centre assessed patient eligibility for the E1594, SWOG9509 and TAX326 trials for patients presenting from October 2001 to December 2002. A review of the centre's registry was used to obtain missing data.</p> <p>Results</p> <p>199 patients with advanced NSCLC were registered during the 14-month period. Characteristics of 100 patients were defined prospectively, 85 retrospectively: 77% males, median age 68 (range 32–88), 64% stage IV disease. Only 35% met trial eligibility for E1594 and 28% for SWOG9509 and TAX326. Common reasons for ineligibility were: co-morbidities 75(40%); ECOG Performance Status ≥2 72(39%); symptomatic brain metastasis 15(8%); and previous cancers 21(11%). Many patients were ineligible by more than one criterion.</p> <p>Conclusion</p> <p>The majority of patients with advanced NSCLC were ineligible for the large chemotherapy trials. The applicability of trial results to advanced lung cancer populations may be limited. Future trials should be conducted in a more representative population.</p

Inflammatory (B) symptoms are independent predictors of myelosuppression from chemotherapy in Non-Hodgkin Lymphoma (NHL) patients – analysis of data from a British National Lymphoma Investigation phase III trial comparing CHOP to PMitCEBO

<p>Abstract</p> <p>Background</p> <p>Toxicity from chemotherapy is highly variable, unpredictable and results in substantial morbidity and increased healthcare costs. New predictors of toxicity are required to improve the safety and efficacy of chemotherapy. Inflammatory or B symptoms in lymphoma are associated with elevated plasma inflammatory markers and predict worse treatment response and survival. Recent data suggest that systemic inflammation results in reduced hepatic drug metabolism and increased toxicity from chemotherapy. We investigated whether B symptoms were associated with greater toxicity in patients treated for non-Hodgkin lymphoma (NHL).</p> <p>Methods</p> <p>The British National Lymphoma Investigation compared two chemotherapy regimens in older patients with aggressive NHL. Approximately 50% of patients had B symptoms. Demographic and toxicity data on 664 patients were analysed to identify predictors of toxicity by multivariate analysis, with particular reference to B symptoms.</p> <p>Results</p> <p>Using univariate analyses, severe (grades 3–4) leucopenia, anaemia, thrombocytopenia, nausea and vomiting and diarrhoea occurred more frequently in patients with B symptoms. The associations between B symptoms and severe leucopenia (OR 1.7, p = 0.005) and anaemia (OR 2.3, p = 0.025) persisted after adjustment for other prognostic factors in multivariate analyses. The use of granulocyte colony stimulating factor reduced neutropenia in patients with both A and B symptoms.</p> <p>Conclusion</p> <p>For the first time and in a large NHL cohort we have shown that inflammatory symptoms are independent predictors for myelosuppression from chemotherapy. These data will enable improved prognostication for toxicity and provide individualisation of therapy in NHL and other tumours. These findings also create the potential for strategies used prior to chemotherapy aimed at reducing systemic inflammation in order to improve drug metabolism and reduce treatment-related toxicity.</p> <p>Trial registration number</p> <p>ISRCTN98741793</p

Reducing the Environmental Impacts of Garments through Industrially Scalable Closed-Loop Recycling: Life Cycle Assessment of a Recycled Wool Blend Sweater

Wool recycling has been practiced commercially for more than 200 years. This study used data from established, commercial processes with the aim of determining the environmental impacts of a recycled wool blend garment and the contribution of recycling to reducing impacts on the market for wool sweaters, in comparison to other emission reduction approaches relating to garment use. A cradle-to-grave life cycle assessment showed impacts of 0.05 kg CO2-e, 0.63 MJ, 0.58 L H2O-e and 0.95 L per wear of a recycled wool blend sweater for climate change, fossil energy demand, water stress and freshwater consumption, respectively. Impacts predominantly arose from garment manufacturing and consumer practices (retail and garment care). When a recycled wool blend sweater was maintained with best practice garment use and care, impacts were reduced by 66–90% relative to standard maintenance of a virgin pure wool sweater. Increasing the closed-loop recycling rate to 50% had the potential to reduce impacts for the wool sweater market 7–24%, depending on the impact category. Brands and consumers hold the key to increasing recycling rates and reducing environmental impacts via increased donation of garments for recycling and increased adoption of garments containing recycled wool

Longitudinally and circumferentially directed movements of the left ventricle studied by cardiovascular magnetic resonance phase contrast velocity mapping

OBJECTIVE: Using high resolution cardiovascular magnetic resonance (CMR), we aimed to detect new details of left ventricular (LV) systolic and diastolic function, to explain the twisting and longitudinal movements of the left ventricle. METHODS: Using CMR phase contrast velocity mapping (also called Tissue Phase Mapping) regional wall motion patterns and longitudinally and circumferentially directed movements of the left ventricle were studied using a high temporal resolution technique in healthy male subjects (n = 14, age 23 +/- 3 years). RESULTS: Previously undescribed systolic and diastolic motion patterns were obtained for left ventricular segments (based on the AHA segmental) and for basal, mid and apical segments. The summation of segmental motion results in a complex pattern of ventricular twisting and longitudinal motion in the normal human heart which underlies systolic and diastolic function. As viewed from the apex, the entire LV initially rotates in a counter-clockwise direction at the beginning of ventricular systole, followed by opposing clockwise rotation of the base and counter-clockwise rotation at the apex, resulting in ventricular torsion. Simultaneously, as the entire LV moves in an apical direction during systole, the base and apex move towards each other, with little net apical displacement. The reverse of these motion patterns occur in diastole. CONCLUSION: Left ventricular function may be a consequence of the relative orientations and moments of torque of the sub-epicardial relative to the sub-endocardial myocyte layers, with influence from tethering of the heart to adjacent structures and the directional forces associated with blood flow. Understanding the complex mechanics of the left ventricle is vital to enable these techniques to be used for the evaluation of cardiac pathology