A cluster randomized controlled trial aimed at implementation of local quality improvement collaboratives to improve prescribing and test ordering performance of general practitioners: Study Protocol

<p>Abstract</p> <p>Background</p> <p>The use of guidelines in general practice is not optimal. Although evidence-based methods to improve guideline adherence are available, variation in physician adherence to general practice guidelines remains relatively high. The objective for this study is to transfer a quality improvement strategy based on audit, feedback, educational materials, and peer group discussion moderated by local opinion leaders to the field. The research questions are: is the multifaceted strategy implemented on a large scale as planned?; what is the effect on general practitioners' (GPs) test ordering and prescribing behaviour?; and what are the costs of implementing the strategy?</p> <p>Methods</p> <p>In order to evaluate the effects, costs and feasibility of this new strategy we plan a multi-centre cluster randomized controlled trial (RCT) with a balanced incomplete block design. Local GP groups in the south of the Netherlands already taking part in pharmacotherapeutic audit meeting groups, will be recruited by regional health officers. Approximately 50 groups of GPs will be randomly allocated to two arms. These GPs will be offered two different balanced sets of clinical topics. Each GP within a group will receive comparative feedback on test ordering and prescribing performance. The feedback will be discussed in the group and working agreements will be created after discussion of the guidelines and barriers to change. The data for the feedback will be collected from existing and newly formed databases, both at baseline and after one year.</p> <p>Discussion</p> <p>We are not aware of published studies on successes and failures of attempts to transfer to the stakeholders in the field a multifaceted strategy aimed at GPs' test ordering and prescribing behaviour. This pragmatic study will focus on compatibility with existing infrastructure, while permitting a certain degree of adaptation to local needs and routines.</p> <p>Trial registration</p> <p>Nederlands Trial Register ISRCTN40008171</p

Vacuolar organization in the nodule parenchyma is important for the functioning of pea root nodules

Different models have been proposed to explain the operation of oxygen diffusion barrier in root nodules of leguminous plants. This barrier participates in protection of oxygen-sensitive nitrogenase, the key enzyme in nitrogen fixation, from inactivation. Details concerning structural and biochemical properties of the barrier are still lacking. Here, the properties of pea root nodule cortical cells were examined under normal conditions and after shoot removal. Microscopic observations, including neutral red staining and epifluorescence investigations, showed that the inner and outer nodule parenchyma cells exhibit different patterns of the central vacuole development. In opposition to the inner part, the outer parenchyma cells exhibited vacuolar shrinkage and formed cell wall infoldings. Shoot removal induced vacuolar shrinkage and formation of infoldings in the inner parenchyma and uninfected cells of the symbiotic tissue, as well. It is postulated that cells which possess shrinking vacuoles are sensitive to the external osmotic pressure. The cells can give an additional resistance to oxygen diffusion by release of water to the intercellular spaces

A case-control study of sporadic Creutzfeldt-Jakob disease in Switzerland: analysis of potential risk factors with regard to an increased CJD incidence in the years 2001-2004

BACKGROUND: In 2001, the observed annual mortality from Creutzfeldt-Jakob disease (CJD) in Switzerland increased from less than 1.5 to 2.6 per million inhabitants. An underlying cause could not be identified. METHODS: To analyse potential risk factors for sCJD in Switzerland, close relatives of 69 sCJD-patients and 224 frequency age-matched controls were interviewed in a case-control study using a standardised questionnaire. 135 potential risk factors including socio-demographics, medical history, occupation and diet were analysed by logistic regression adjusting for age, sex and education. RESULTS: sCJD patients were more likely to have travelled abroad, worked at an animal laboratory, undergone invasive dental treatment, orthopaedic surgery, ophthalmologic surgery after 1980, regular GP visits, taken medication regularly, and consumed kidney. No differences between patients and controls were found for residency, family history, and exposure to environmental and other dietary factors. CONCLUSION: Although some factors were significantly more frequent among sCJD-cases, this study did not reveal specific explanations for the increased incidence of deaths due to sporadic CJD observed in Switzerland since 2001. Results have to be interpreted with caution due to multiple testing and possible recall bias in association with a long incubation period. The most plausible reason for the increase in Swiss sCJD cases after 2000 is an improved case ascertainment. Therefore, underreporting of cases might well have occurred before the year 2001, and the "real" yearly incidence of sCJD might not be lower than, but rather above 2 per million inhabitants

Tension lines of the skin

Skin tension lines are natural lines of tension that occur within the skin as a result of growth and remodeling mechanisms. Researchers have been aware of their existence and their surgical implications for over 150 years. Research in the twentieth century showed clearly, through destructive mechanical testing, that the orientation of skin tension lines greatly affects the mechanical response of skin in situ. More recent work has determined that this anisotropic response is, at least in part, due to the structural arrangement of collagen fibres within the dermis. This observation can be incorporated into mathematical and mechanical models using the popular Gasser-Ogden-Holzapfel constitutive equation. Advances in non-invasive measurement techniques for the skin, such as those based on elastic wave propagation, have enabled patient-specific identification of skin tension lines in an accurate and rapid manner. Using this technique on humans, we show that there is considerable variation in the level of anisotropy as the skin ages. Furthermore, we identify that both the structural arrangement of fibres and the in vivo levels of pre-strain play a significant role in the anisotropic behavior of skin.Peer reviewed2021-05-2

Tension lines of the skin

Skin tension lines are natural lines of tension that occur within the skin as a result of growth and remodeling mechanisms. Researchers have been aware of their existence and their surgical implications for over 150 years. Research in the twentieth century showed clearly, through destructive mechanical testing, that the orientation of skin tension lines greatly affects the mechanical response of skin in situ. More recent work has determined that this anisotropic response is, at least in part, due to the structural arrangement of collagen fibres within the dermis. This observation can be incorporated into mathematical and mechanical models using the popular Gasser-Ogden-Holzapfel constitutive equation. Advances in non-invasive measurement techniques for the skin, such as those based on elastic wave propagation, have enabled patient-specific identification of skin tension lines in an accurate and rapid manner. Using this technique on humans, we show that there is considerable variation in the level of anisotropy as the skin ages. Furthermore, we identify that both the structural arrangement of fibres and the in vivo levels of pre-strain play a significant role in the anisotropic behavior of skin.Peer reviewed2021-05-2