A new implicit review instrument for measuring quality of care delivered to pediatric patients in the emergency department

BackgroundThere are few outcomes experienced by children receiving care in the Emergency Department (ED) that are amenable to measuring for the purposes of assessing of quality of care. The purpose of this study was to develop, test, and validate a new implicit review instrument that measures quality of care delivered to children in EDs.MethodsWe developed a 7-point structured implicit review instrument that encompasses four aspects of care, including the physician's initial data gathering, integration of information and development of appropriate diagnoses; initial treatment plan and orders; and plan for disposition and follow-up. Two pediatric emergency medicine physicians applied the 5-item instrument to children presenting in the highest triage category to four rural EDs, and we assessed the reliability of the average summary scores (possible range of 5-35) across the two reviewers using standard measures. We also validated the instrument by comparing this mean summary score between those with and without medication errors (ascertained independently by two pharmacists) using a two-sample t-test.ResultsWe reviewed the medical records of 178 pediatric patients for the study. The mean and median summary score for this cohort of patients were 27.4 and 28.5, respectively. Internal consistency was high (Cronbach's alpha of 0.92 and 0.89). All items showed a significant (p < 0.005) positive correlation between reviewers using the Spearman rank correlation (range 0.24 to 0.39). Exact agreement on individual items between reviewers ranged from 70.2% to 85.4%. The Intra-class Correlation Coefficient for the mean of the total summary score across the two reviewers was 0.65. The validity of the instrument was supported by the finding of a higher score for children without medication errors compared to those with medication errors which trended toward significance (mean score = 28.5 vs. 26.0, p = 0.076).ConclusionThe instrument we developed to measure quality of care provided to children in the ED has high internal consistency, fair to good inter-rater reliability and inter-rater correlation, and high content validity. The validity of the instrument is supported by the fact that the instrument's average summary score was lower in the presence of medication errors, which trended towards statistical significance

Increased sporulation underpins adaptation of Clostridium difficile strain 630 to a biologically–relevant faecal environment, with implications for pathogenicity

Abstract Clostridium difficile virulence is driven primarily by the processes of toxinogenesis and sporulation, however many in vitro experimental systems for studying C. difficile physiology have arguably limited relevance to the human colonic environment. We therefore created a more physiologically–relevant model of the colonic milieu to study gut pathogen biology, incorporating human faecal water (FW) into growth media and assessing the physiological effects of this on C. difficile strain 630. We identified a novel set of C. difficile–derived metabolites in culture supernatants, including hexanoyl– and pentanoyl–amino acid derivatives by LC-MSn. Growth of C. difficile strain 630 in FW media resulted in increased cell length without altering growth rate and RNA sequencing identified 889 transcripts as differentially expressed (p < 0.001). Significantly, up to 300–fold increases in the expression of sporulation–associated genes were observed in FW media–grown cells, along with reductions in motility and toxin genes’ expression. Moreover, the expression of classical stress–response genes did not change, showing that C. difficile is well–adapted to this faecal milieu. Using our novel approach we have shown that interaction with FW causes fundamental changes in C. difficile biology that will lead to increased disease transmissibility

M.N.Srinivas: the man and his work

The late prof.Srinivas was quick to see that caste loyalties would be utilised in electoral politics. he pointed out that caste would thus find a new lease of life, that it would not wither away under the impact of modern political institutions but adapt to them

Aging across worlds: examining intergenerational relationships among older adults in two cities in transition

The successful aging model marked by an emphasis on the self has dominated the gerontological tradition in a majority of the western industrialized countries. However, this narrative of active, socially engaged and consumer centric aging is not a contextually homogenized process as experienced by older adults elsewhere, where a “meaningful decline” defines older adults’ renegotiation with familial relationships, expectations, religion and death. Borrowing social-psychological and gerontological perspectives the current study examined the co-existence of these two contrary models-disengagement and successful aging- in two cities that are in transition Ahmedabad (Gujarat, India) and Saskatoon (Saskatchewan, Canada). Drawing from in-depth interviews this study examined intergenerational relationships and expectations around filial ties, emotional bonds, network ties, cultural ideologies and their contribution in forging the aging identity in these two contexts among older Indians in Ahmedabad and those in the transnational setting. Findings suggest that despite the Asian traditional values and expectations surrounding caregiving and support from adult children older Indians in Saskatoon have reconfigured their expectations and are re-negotiating between the two cultural worlds by embracing the successful aging model. In contrast, a structured dependency in terms of economic support and psychological needs is preserved, legitimized and nurtured in the older adult-adult children relationship in Ahmedabad where older parents contribute to household and grandparenting duties while expecting caregiving, support and respect in exchange. By adopting a comparative perspective, the study demonstrates how everyday life of older adults is constructed, lived and produced and role of cultural forces shaping the experience of growing old.by Jagriti Gangopadhya