Can evidence-based medicine and clinical quality improvement learn from each other?

The considerable gap between what we know from research and what is done in clinical practice is well known. Proposed responses include the Evidence-Based Medicine (EBM) and Clinical Quality Improvement. EBM has focused more on ‘doing the right things’—based on external research evidence—whereas Quality Improvement (QI) has focused more on ‘doing things right’—based on local processes. However, these are complementary and in combination direct us how to ‘do the right things right’. This article examines the differences and similarities in the two approaches and proposes that by integrating the bedside application, the methodological development and the training of these complementary disciplines both would gain

Semi-annual carbon and nitrogen isotope variations in the water column of Lake Bled, NW Slovenia

The variability in the stable isotope signature of carbon and nitrogen in particulate organic matter and dissolved species in the water column of the mesotrophic subalpine Lake Bled in NW Slovenia has been determined. After the algae bloom from August to December in 2008, samples were taken from the deepest part of the lake which develops an anoxic hypolimnion for most of the year. C/N molar ratios and δ¹³C_POC and δ¹⁵N_PN values suggest an autochthonous source for particulate organic matter (POM). According to the isotope model, autochthonous carbon accounted for a major part of the particulate organic carbon (POC), ranging from 86% to 96% in September and October, while in December the proportion of allochthonous carbon was more pronounced, ranging from 57% to 59%. Low δ¹³C_POC and δ¹⁵N_PN values (from −36 to −33‰ and from 0.8 to 1.8‰), observed below 24 m in August and September, indicate the bacterial origin of POM, mainly from methanotrophic bacteria. δ¹⁵N_NO₃ and δ¹⁵N_PN values decreased with depth. The relations between δ¹⁵N_PN and NO₃^- and NH₄⁺ concentrations suggest that NH₄⁺ is the main assimilation species for nitrogen in POM. Nitrification was active between 12 and 18 m deep in September and October, indicated by increased NO₃^- concentrations and decreased δ¹⁵N_NO₃ values. The correlation between nitrate concentrations and δ¹⁵N_NO₃ values suggests active water column denitrification in October 2008. The decrease in δ¹⁵N_NO₃ values observed in December could be explained by degradation of organic matter, followed by nitrification of the degradation products. During our sampling period, there was no evident influence of sewage, agriculture, or atmospheric deposition on the nitrogen balance in the lake

Case study of a fixed network traffic model

In this thesis, we analyse network traffic using a fixed virtual network model for the Administrative Office of Slovenj Gradec. First, we describe different types of traffic distribution and classify components to create a baseline for the model. Second, we summarise the input data regarding home and work users. Third, we divide the settlements into areas, where each area contains a network router and apply the open source simulation tool OMNeT++ in order to characterize every component of the model. Finally, we describe in detail the manner in which we generate network traffic. Furthermore, we analyse three sets of network simulations under different traffic loads according to time of day. Prior to conducting simulations, we described for each set of simulations, the fixed parameters, input data and how home and work users influence on traffic network load. After every set of simulations, we analysed key parameters, such as router processing time, connection bandwidth efficiency and other conditions that effect packet permeability and traffic congestion. We then devise possible solutions and test them in the next set of simulations. Finally, we present and summarise the results for each set of simulations and describe how each solution influences packet permeability and traffic congestion

Sensory Integration of Apparent Motion Speed and Vibration Magnitude

Tactile apparent motion can display directional information in an intuitive way. It can for example be used to give directions to visually impaired individuals, or for waypoint navigation while cycling on busy streets, when vision or audition should not be loaded further. However, although humans can detect very short tactile patterns, discriminating between similar motion speeds has been shown to be difficult. Here we develop and investigate a method where the speed of tactile apparent motion around the user & #x0027;s wrist is coupled with vibration magnitude. This redundant coupling is used to produce tactile patterns from slow & amp;weak to fast & amp;strong. We compared the just noticeable difference (JND) of the coupled and the individual variables. The results show that the perception of the coupled variable can be characterised by JND smaller than JNDs of the individual variables. This allowed us to create short tactile pattens (tactons) for display of direction and speed, which can be distinguished significantly better than tactons based on motion alone. Additionally, most subjects were also able to identify the coupled-variable tactons better than the magnitude-based tactons

Isotope partitioning between cow milk and farm water: A tool for verification of milk provenance

Rationale: The oxygen and hydrogen isotope compositions of the water component of the milk from nine Italian dairy farms were studied together with the farm water for one year. The aim was to verify the importance of farm water and seasonal temperature variation on milk isotope values and propose mathematical relations as new tools to identify the milk origin. Methods: Milk was centrifuged to separate the solids and then distilled under vacuum to separate water. δ(18O/16O) and δ(2H/1H) analyses of the water molecules were carried out using a water equilibrator online with a mass spectrometer. For oxygen and hydrogen isotope determination, water was equilibrated with pure CO2 for 7.5 h and with pure H2 for 5 h, respectively. The isotope ratio value is indicated with δ (expressed on the VSMOW/SLAP scale) as defined by IUPAC. Results: The average annual isotope value of milk at the different cattle sheds is mostly related to the farm water suggesting that the drinking water is the most important factor influencing the isotopic values of the milk water. The milk/water fractionation factor correlates with the milking time and, thus, the seasonal temperature is best described by a 4th order polynomial regression line. A two-level check model was used to verify the milking provenance. Conclusions: This study shows that it is essential to analyze both milk and farm water to indicate provenance. A two-step verification tool, based on the difference between the measured and calculated δ(18O/16O)M values, and the difference between the calculated and estimated milk-water fractionation factors, allowed the source determination of milk. Both conditions must be met if the milk is considered to be from the Parmigiano-Reggiano production region. Although this approach was developed for this region, it can easily be tested and adapted to other dairy production areas

GripAble: an accurate, sensitive and robust digital device for measuring grip strength

Introduction: Grip strength is a reliable biomarker of overall health and physiological well-being. It is widely used in clinical practice as an outcome measure. This paper demonstrates the measurement characteristics of GripAble, a wireless mobile handgrip device that measures grip force both isometrically and elastically-resisted for assessment and training of hand function. Methods: A series of bench tests were performed to evaluate GripAble's grip force measurement accuracy and sensitivity. Measurement robustness was evaluated through repeated drop tests interwoven with error verification test phases. Results: GripAble's absolute measurement error at the central position was under 0.81 and 1.67 kg (95th percentiles; N = 47) when measuring elastically and isometrically, respectively, providing similar or better accuracy than the industry-standard Jamar device. Sensitivity was measured as 0.062 ± 0.015 kg (mean ± std; 95th percentiles: [0.036, 0.089] kg; N = 47), independent of the applied force. There was no significant performance degradation following impact from 30 drops from a height >1.5 m. Conclusion: GripAble is an accurate and reliable grip strength dynamometer. It is highly sensitive and robust, which in combination with other novel features (e.g. portability, telerehabilitation and digital data tracking) enable broad applicability in a range of clinical caseloads and environments

Mainstreaming quality and safety: a reformulation of quality and safety education for health professions students

The urgent need to expand the ability of health professionals to improve the quality and safety of patient care in the USA has been well documented. Yet the current methods of teaching quality and safety to health professionals are inadequate for the task. To the extent that quality and safety are addressed at all, they are taught using pedagogies with a narrow focus on content transmission, didactic sessions that are spatially and temporally distant from clinical work, and quality and safety projects segregated from the provision of actual patient care. In this article an argument for a transformative reorientation in quality and safety education for health professions is made. This transformation will require new pedagogies in which a) quality improvement is an integral part of all clinical encounters, b) health professions students and their clinical teachers become co-learners working together to improve patient outcomes and systems of care, c) improvement work is envisioned as the interdependent collaboration of a set of professionals with different backgrounds and perspectives skilfully optimising their work processes for the benefit of patients, and d) assessment in health professions education focuses on not just individual performance but also how the care team's patients fared and how the systems of care were improved