Clinical governance : a friend or foe to dental care practice in the UK?

This paper presents a literature review of clinical governance and its impact upon dental health care in the UK. Whilst the value of clinical governance is recognised, the findings illustrate that the concept of clinical governance remains challenging to dental care practitioners, illustrated by lack of knowledge and confidence in its application and evaluation. The study also identifies a distinct paucity of research concerning impact and makes recommendations to enhance clinical governance in practice

Mentoring and you

This research based case study explores and illustrates the benefits of mentoring and the place of clinical governance in enhancing dental care practice

Differential stability of expression of similarly specified endogenous and exogenous genes in the sea urchin embryo

The object of these experiments was to determine whether competitive titration in vivo of factors required for expression of the CyIIIa·CAT fusion gene would affect expression of the endogenous CyIIIa gene in the same embryos. Earlier work showed that expression of this fusion gene after injection into sea urchin eggs is stoichiometrically reduced when low molar excesses of DNA fragments containing only its regulatory domain are coinjected. In order to compare endogenous (i.e. CyIIIa) and exogenous (i.e. CyIIIa·CAT) expression simultaneously in embryos bearing excess competitor regulatory DNA, we developed, and here describe, a new procedure for generating transgenic sea urchin embryos in which all of the cells in many embryos, and most in others, bear the exogenous DNA. Such large reduction of mosaicism can be achieved by multiple injection of the exogenous DNA fragments into fertilized eggs. Using this method, we demonstrate that at a level of competitor DNA incorporation which reduces CyIIIa·CAT expression by 85%, endogenous CyIIIa mRNA levels are wholly unaffected. Nor is spatial expression of the endogenous CyIIIa gene disturbed. Since the CyIIIa·CAT genes are properly expressed under control of the CyIIIa regulatory sequences, they must participate in the same set of necessary DNA-protein interactions. However, we infer from the results that we report here that the regulatory complexes in the endogenous CyIIIa gene are greatly stabilized relative to those of the exogenous CyIIIa·CAT genes

Contrasts in China and Soviet reform: sub-national and national causes

Why did reform in China and the former Soviet Union produce drastically different outcomes? Why did some provinces in China embrace faster economic reform than others? This article argues that the state sector and reform initiatives in the sub-national units, reform strategies, entrenchment and maturation of central planning, the size of the defence industry, policy choice and the historical context help explain the differences in Soviet and Chinese reform courses and outcomes. A predominant state sector in the former Soviet republics had stifled local reform initiatives. Gorbachev resorted to democratisation in order to unbolt the gate for popular support for marketisation, yet resulting in the breakup of the Soviet Union and destabilising the economy. In China, some provinces had sizable non-state sectors and were inclined to push forth marketization. Reform resulted in expanding non-state sectors, generating high growth and encouraging the regime to maintain its monopoly of power. China’s reform also benefited from a yet-to-be-entrenched and rudimentary central planning, a small defence sector, popular backlash against past policies, and reformist pragmatic strategy

Adjunctive rifampicin for Staphylococcus aureus bacteraemia (ARREST): a multicentre, randomised, double-blind, placebo-controlled trial.

BACKGROUND: Staphylococcus aureus bacteraemia is a common cause of severe community-acquired and hospital-acquired infection worldwide. We tested the hypothesis that adjunctive rifampicin would reduce bacteriologically confirmed treatment failure or disease recurrence, or death, by enhancing early S aureus killing, sterilising infected foci and blood faster, and reducing risks of dissemination and metastatic infection. METHODS: In this multicentre, randomised, double-blind, placebo-controlled trial, adults (≥18 years) with S aureus bacteraemia who had received ≤96 h of active antibiotic therapy were recruited from 29 UK hospitals. Patients were randomly assigned (1:1) via a computer-generated sequential randomisation list to receive 2 weeks of adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) versus identical placebo, together with standard antibiotic therapy. Randomisation was stratified by centre. Patients, investigators, and those caring for the patients were masked to group allocation. The primary outcome was time to bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomisation to 12 weeks, adjudicated by an independent review committee masked to the treatment. Analysis was intention to treat. This trial was registered, number ISRCTN37666216, and is closed to new participants. FINDINGS: Between Dec 10, 2012, and Oct 25, 2016, 758 eligible participants were randomly assigned: 370 to rifampicin and 388 to placebo. 485 (64%) participants had community-acquired S aureus infections, and 132 (17%) had nosocomial S aureus infections. 47 (6%) had meticillin-resistant infections. 301 (40%) participants had an initial deep infection focus. Standard antibiotics were given for 29 (IQR 18-45) days; 619 (82%) participants received flucloxacillin. By week 12, 62 (17%) of participants who received rifampicin versus 71 (18%) who received placebo experienced treatment failure or disease recurrence, or died (absolute risk difference -1·4%, 95% CI -7·0 to 4·3; hazard ratio 0·96, 0·68-1·35, p=0·81). From randomisation to 12 weeks, no evidence of differences in serious (p=0·17) or grade 3-4 (p=0·36) adverse events were observed; however, 63 (17%) participants in the rifampicin group versus 39 (10%) in the placebo group had antibiotic or trial drug-modifying adverse events (p=0·004), and 24 (6%) versus six (2%) had drug interactions (p=0·0005). INTERPRETATION: Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S aureus bacteraemia. FUNDING: UK National Institute for Health Research Health Technology Assessment

A history and analysis of the Salisbury Street Foundation in Christchurch

The Salisbury Street Foundation (SSF) currently operates as a Residential Community Centre in Christchurch, New Zealand. The history of this programme, however, dates back over 23-years to its inception in 1979. Due to its extensive past, SSF has the ability to provide a valuable contribution to literature surrounding community corrections in New Zealand. As little has been previously published about SSF, this thesis offers the most comprehensive document compiled regarding the Foundation. It explores the history of SSF and then analyses the programme in terms of rehabilitation, and organisation and management. In the completion of this research, an extensive search of archival material relating to SSF as well as 13 semi-structured interviews was undertaken. When obtaining information on SSF from these sources, a focus on five main areas of interest was maintained. These were (1) the personality of each programme director and the influence he/she had on the running of the programme; (2) operational philosophies and strategies; (3) the role of the Board of Trustees; (4) the effect of legislative changes; and (5) the impact of critical events and incidents. Overall, my findings diverge from previous studies which largely measure the success of rehabilitative programmes solely in terms of reducing recidivism. Instead, I suggest that the success and longevity of SSF has had more to do with the organisation and management of the programme, than its ability to reform every individual whom attends. Therefore, while some observations can be made in relation to recidivism at SSF, the Foundation more importantly provides a valuable example of what works in the management of nonprofit, community-based residential programmes, and what does not

Implementation, interrupted: Identifying and leveraging factors that sustain after a programme interruption

Many implementation efforts experience interruptions, especially in settings with developing health systems. Approaches for evaluating interruptions are needed to inform re-implementation strategies. We sought to devise an approach for evaluating interruptions by exploring the sustainability of a programme that implemented diabetes mellitus (DM) screening within tuberculosis clinics in Uganda in 2017. In 2019, we conducted nine interviews with clinic staff and observed clinic visits to determine their views and practices on providing integrated care. We mapped themes to a social ecological model with three levels derived from the Consolidated Framework for Implementation Research (CFIR): outer setting (i.e. community), inner setting (i.e. clinic), and individuals (i.e. clinicians). Respondents explained that DM screening ceased due to disruptions in the national supply chain for glucose test strips, which had cascading effects on clinics and clinicians. Lack of screening supplies in clinics limited clinicians’ opportunities to perform DM screening, which contributed to diminished self-efficacy. However, culture, compatibility and clinicians’ beliefs about DM screening sustained throughout the interruption. We propose an approach for evaluating interruptions using the CFIR and social ecological model; other programmes can adapt this approach to identify cascading effects of interruptions and target them for re-implementation