How to identify when a performance indicator has run its course

The official published version can be found at the link below.Increasing numbers of countries are using indicators to evaluate the quality of clinical care, with some linking payment to achievement. For performance frameworks to remain effective the indicators need to be regularly reviewed. The frameworks cannot cover all clinical areas, and achievement on chosen indicators will eventually reach a ceiling beyond which further improvement is not feasible. However, there has been little work on how to select indictors for replacement. The Department of Health decided in 2008 that it would regularly replace indicators in the national primary care pay for performance scheme, the Quality and Outcomes Framework, making a rigorous approach to removal a priority. We draw on our previous work on pay for performance and our current work advising the National Institute for Health and Clinical Excellence (NICE) on the Quality and Outcomes Framework to suggest what should be considered when planning to remove indicators from a clinical performance framework

Dayside convection and auroral morphology during an interval of northward interplanetary magnetic field

International audienceWe investigate the dayside auroral dynamics and ionospheric convection during an interval when the interplanetary magnetic field (IMF) had predominantly a positive Bz component (northward IMF) but varying By. Polar UVI observations of the Northern Hemisphere auroral emission indicate the existence of a region of luminosity near local noon at latitudes poleward of the dayside auroral oval, which we interpret as the ionospheric footprint of a high-latitude reconnection site. The large field-of-view afforded by the satellite-borne imager allows an unprecedented determination of the dynamics of this region, which has not previously been possible with ground-based observations. The location of the emission in latitude and magnetic local time varies in response to changes in the orientation of the IMF; the cusp MLT and the IMF By component are especially well correlated, the emission being located in the pre- or post-noon sectors for By By > 0 nT, respectively. Simultaneous ground-based observations of the ionospheric plasma drift are provided by the CUTLASS Finland HF coherent radar. For an interval of IMF By \approx 0 nT, these convection flow measurements suggest the presence of a clockwise-rotating lobe cell contained within the pre-noon dayside polar cap, with a flow reversal closely co-located with the high-latitude luminosity region. This pattern is largely consistent with recent theoretical predictions of the convection flow during northward IMF. We believe that this represents the first direct measurement of the convection flow at the imaged location of the footprint of the high-latitude reconnection site

A fluorophore attached to nicotinic acetylcholine receptor beta M2 detects productive binding of agonist to the alpha delta site

To study conformational transitions at the muscle nicotinic acetylcholine (ACh) receptor (nAChR), a rhodamine fluorophore was tethered to a Cys side chain introduced at the beta-19' position in the M2 region of the nAChR expressed in Xenopus oocytes. This procedure led to only minor changes in receptor function. During agonist application, fluorescence increased by (Delta-F/F) approximate to 10%, and the emission peak shifted to lower wavelengths, indicating a more hydrophobic environment for the fluorophore. The dose-response relations for Delta-F agreed well with those for epibatidine-induced currents, but were shifted approximate to 100-fold to the left of those for ACh-induced currents. Because (i) epibatidine binds more tightly to the alpha-gamma-binding site than to the alpha-delta site and (ii) ACh binds with reverse-site selectivity, these data suggest that Delta-F monitors an event linked to binding specifically at the alpha-delta-subunit interface. In experiments with flash-applied agonists, the earliest detectable Delta-F occurs within milliseconds, i.e., during activation. At low [ACh] (less than or equal to 10 muM), a phase of Delta-F occurs with the same time constant as desensitization, presumably monitoring an increased population of agonist-bound receptors. However, recovery from Delta-F is complete before the slowest phase of recovery from desensitization (time constant approximate to 250 s), showing that one or more desensitized states have fluorescence like that of the resting channel. That conformational transitions at the alpha-delta-binding site are not tightly coupled to channel activation suggests that sequential rather than fully concerted transitions occur during receptor gating. Thus, time-resolved fluorescence changes provide a powerful probe of nAChR conformational changes

First simultaneous observations of flux transfer events at the high-latitude magnetopause by the cluster spacecraft and pulsed radar signatures in the conjugate ionosphere by the CUTLASS and EISCAT radars

Cluster magnetic field data are studied during an outbound pass through the post-noon high-latitude magnetopause region on 14 February 2001. The onset of several minute perturbations in the magnetospheric field was observed in conjunction with a southward turn of the interplanetary magnetic field observed upstream by the ACE spacecraft and lagged to the subsolar magnetopause. These perturbations culminated in the observation of four clear magnetospheric flux transfer events (FTEs) adjacent to the magnetopause, together with a highly-structured magnetopause boundary layer containing related field features. Furthermore, clear FTEs were observed later in the magnetosheath. The magnetospheric FTEs were of essentially the same form as the original “flux erosion events” observed in HEOS-2 data at a similar location and under similar interplanetary conditions by Haerendel et al. (1978). We show that the nature of the magnetic perturbations in these events is consistent with the formation of open flux tubes connected to the northern polar ionosphere via pulsed reconnection in the dusk sector magnetopause. The magnetic footprint of the Cluster spacecraft during the boundary passage is shown to map centrally within the fields-of-view of the CUTLASS SuperDARN radars, and to pass across the field-aligned beam of the EISCAT Svalbard radar (ESR) system. It is shown that both the ionospheric flow and the backscatter power in the CUTLASS data pulse are in synchrony with the magnetospheric FTEs and boundary layer structures at the latitude of the Cluster footprint. These flow and power features are subsequently found to propagate poleward, forming classic “pulsed ionospheric flow” and “poleward-moving radar auroral form” structures at higher latitudes. The combined Cluster-CUTLASS observations thus represent a direct demonstration of the coupling of momentum and energy into the magnetosphere-ionosphere system via pulsed magnetopause reconnection. The ESR observations also reveal the nature of the structured and variable polar ionosphere produced by the structured and time-varying precipitation and flow

A comparison of velocity measurements from the CUTLASS Finland radar and the EISCAT UHF system

International audienceThe CUTLASS Finland radar, which comprises an integral part of the SuperDARN system of HF coherent radars, provides near continuous observations of high-latitude plasma irregularities within a field-of-view which extends over some four million square kilometres. Within the Finland radar field-of-view lie both the EISCAT mainland and EISCAT Svalbard incoherent scatter radar facilities. Since the CUTLASS Finland radar commenced operation, in February 1995, the mainland EISCAT UHF radar has been run in common programme 1 and 2 modes for a total duration exceeding 1000 h. Simultaneous and spatially coincident returns from these two radars over this period provide the basis for a comparison of irregularity drift velocity and F-region ion velocity. Initial comparison is limited to velocities from four intervals of simultaneous radar returns; intervals are selected such that they exhibit a variety of velocity signatures including that characteristic of the convection reversal and a rapidly fluctuating velocity feature. Subsequent comparison is on a statistical basis. The velocities measured by the two systems demonstrate reasonable correspondence over the velocity regime encountered during the simultaneous occurrence of coherent and incoherent scatter; differences between the EISCAT UHF measurements of F-region ion drift and the irregularity drift velocities from the Finland radar are explained in terms of a number of contributing factors including contamination of the latter by E-region echoes, a factor which is investigated further, and the potentially deleterious effect of discrepant volume and time sampling intervals