Revitalising audit and feedback to improve patient care

Healthcare systems face challenges in tackling variations in patient care and outcomes. Audit and feedback aim to improve patient care by reviewing clinical performance against explicit standards and directing action towards areas not meeting those standards. It is a widely used foundational component of quality improvement, included in around 60 national clinical audit programmes in the United Kingdom. Ironically, there is currently a gap between what audit and feedback can achieve and what they actually deliver, whether led locally or nationally. Several national audits have been successful in driving improvement and reducing variations in care, such as for stroke and lung cancer, but progress is also slower than hoped for in other aspects of care (table 1). Audit and feedback have a chequered past.6 Clinicians might feel threatened rather than supported by top-down feedback and rightly question whether rewards outweigh efforts invested in poorly designed audit. Healthcare organisations have limited resources to support and act on audit and feedback. Dysfunctional clinical and managerial relationships undermine effective responses to feedback, particularly when it is not clearly part of an integrated approach to quality assurance and improvement. Unsurprisingly, the full potential of audit and feedback has not been realised

First Results From the Ionospheric Extension of WACCM-X During the Deep Solar Minimum Year of 2008

New ionosphere and electrodynamics modules have been incorporated in the thermosphere and ionosphere eXtension of the Whole Atmosphere Community Climate Model (WACCM‐X), in order to self‐consistently simulate the coupled atmosphere‐ionosphere system. The first specified dynamics WACCM‐X v.2.0 results are compared with several data sets, and with the Thermosphere‐Ionosphere‐Electrodynamics General Circulation Model (TIE‐GCM), during the deep solar minimum year. Comparisons with Thermosphere Ionosphere Mesosphere Energetics and Dynamics satellite of temperature and zonal wind in the lower thermosphere show that WACCM‐X reproduces the seasonal variability of tides remarkably well, including the migrating diurnal and semidiurnal components and the nonmigrating diurnal eastward propagating zonal wavenumber 3 component. There is overall agreement between WACCM‐X, TIE‐GCM, and vertical drifts observed by the Communication/Navigation Outage Forecast System (C/NOFS) satellite over the magnetic equator, but apparent discrepancies also exist. Both model results are dominated by diurnal variations, while C/NOFS observed vertical plasma drifts exhibit strong temporal variations. The climatological features of ionospheric peak densities and heights (NmF2 and hmF2) from WACCM‐X are in general agreement with the results derived from Constellation Observing System for Meteorology, Ionosphere and Climate (COSMIC) data, although the WACCM‐X predicted NmF2 values are smaller, and the equatorial ionization anomaly crests are closer to the magnetic equator compared to COSMIC and ionosonde observations. This may result from the excessive mixing in the lower thermosphere due to the gravity wave parameterization. These data‐model comparisons demonstrate that WACCM‐X can capture the dynamic behavior of the coupled atmosphere and ionosphere in a climatological sense

Measurement of the Bottom-Strange Meson Mixing Phase in the Full CDF Data Set

We report a measurement of the bottom-strange meson mixing phase \beta_s using the time evolution of B0_s -> J/\psi (->\mu+\mu-) \phi (-> K+ K-) decays in which the quark-flavor content of the bottom-strange meson is identified at production. This measurement uses the full data set of proton-antiproton collisions at sqrt(s)= 1.96 TeV collected by the Collider Detector experiment at the Fermilab Tevatron, corresponding to 9.6 fb-1 of integrated luminosity. We report confidence regions in the two-dimensional space of \beta_s and the B0_s decay-width difference \Delta\Gamma_s, and measure \beta_s in [-\pi/2, -1.51] U [-0.06, 0.30] U [1.26, \pi/2] at the 68% confidence level, in agreement with the standard model expectation. Assuming the standard model value of \beta_s, we also determine \Delta\Gamma_s = 0.068 +- 0.026 (stat) +- 0.009 (syst) ps-1 and the mean B0_s lifetime, \tau_s = 1.528 +- 0.019 (stat) +- 0.009 (syst) ps, which are consistent and competitive with determinations by other experiments.Comment: 8 pages, 2 figures, Phys. Rev. Lett 109, 171802 (2012

Vertebrate Vitellogenin Gene Duplication in Relation to the “3R Hypothesis”: Correlation to the Pelagic Egg and the Oceanic Radiation of Teleosts

The spiny ray-finned teleost fishes (Acanthomorpha) are the most successful group of vertebrates in terms of species diversity. Their meteoric radiation and speciation in the oceans during the late Cretaceous and Eocene epoch is unprecedented in vertebrate history, occurring in one third of the time for similar diversity to appear in the birds and mammals. The success of marine teleosts is even more remarkable considering their long freshwater ancestry, since it implies solving major physiological challenges when freely broadcasting their eggs in the hyper-osmotic conditions of seawater. Most extant marine teleosts spawn highly hydrated pelagic eggs, due to differential proteolysis of vitellogenin (Vtg)-derived yolk proteins. The maturational degradation of Vtg involves depolymerization of mainly the lipovitellin heavy chain (LvH) of one form of Vtg to generate a large pool of free amino acids (FAA 150–200 mM). This organic osmolyte pool drives hydration of the ooctye while still protected within the maternal ovary. In the present contribution, we have used Bayesian analysis to examine the evolution of vertebrate Vtg genes in relation to the “3R hypothesis” of whole genome duplication (WGD) and the functional end points of LvH degradation during oocyte maturation. We find that teleost Vtgs have experienced a post-R3 lineage-specific gene duplication to form paralogous clusters that correlate to the pelagic and benthic character of the eggs. Neo-functionalization allowed one paralogue to be proteolyzed to FAA driving hydration of the maturing oocytes, which pre-adapts them to the marine environment and causes them to float. The timing of these events matches the appearance of the Acanthomorpha in the fossil record. We discuss the significance of these adaptations in relation to ancestral physiological features, and propose that the neo-functionalization of duplicated Vtg genes was a key event in the evolution and success of the teleosts in the oceanic environment