Low adenoma detection rates (ADRs) at colonoscopy are linked to significantly higher interval cancer rates, and vary between colonoscopists. Studies demonstrate that lesion detection is improved by: ...withdrawal time of ≥ 6 minutes; use of hyoscine butylbromide; position change; and rectal retroflexion. We evaluated the feasibility of implementing the above "bundle" of interventions into colonoscopy practice, and the effect on ADR.
A longitudinal cohort design was used. Implementation combined central training, local promotion, and feedback. The uptake marker was change in hyoscine butylbromide use. Comparisons were between the 3 months before and the 9 months after the implementation phase, globally, by endoscopy unit and by quartile when colonoscopists were ranked according to baseline ADR. Chi-squared or Fisher's tests were used to evaluate significance.
12 units participated. Global and quartile analyses included data from 118 and 68 colonoscopists and 17 508 and 14 193 procedures respectively. A significant increase in hyoscine butylbromide use was observed globally (54.4 % vs. 15.8 %, P < 0.001), in all endoscopy units (P < 0.001) and quartiles (P < 0.001). A significant increase in ADR was observed globally (18.1 % vs. 16.0 %, P = 0.002) and in the lower two colonoscopist quartiles (P < 0.001), with a nonsignificant increase in the upper middle quartile and a significant fall to 21.5 %. in the upper quartile. The significant variations in ADR among the upper three quartiles disappeared.
In routine clinical practice, introduction of a simple, inexpensive, evidence-based "bundle" of measures is feasible and is associated with higher global ADR, driven by improvements amongst the poorest performing colonoscopists.
Systematic reviews are increasingly being viewed as important sources of information for policymakers who need to make decisions on different aspects of the health system, often under tight time ...constraints and with many factors competing for their attention. Unfortunately, a number of misconceptions, or 'myths', stand in the way of promoting their use. The belief that systematic review topics are not relevant to health systems policymaking, that they cannot be found quickly, and that they are not available in formats that are useful for policymakers are but three examples of such myths. This paper uses evidence drawn mainly from Health Systems Evidence, a continuously updated repository of syntheses of health systems research, to counter these and nine other common myths, with the aim of changing the constraining beliefs associated with them, while improving the prospects for the use of systematic reviews in health system policymaking.
Summary Objective We examine the lifetime cost-effectiveness of treatment with fluticasone propionate/salmeterol (500/50 μg) compared with no maintenance treatment in COPD in the US. Methods A ...decision-analytic model was developed to estimate lifetime costs and outcomes associated with fluticasone propionate/salmeterol 500/50 μg treatment, salmeterol 50 μg, and fluticasone propionate 500 μg compared to no maintenance treatment in treating COPD from a third-party US payer perspective. The patient population was similar to that of the TORCH clinical trial. Model structure and inputs were obtained from published literature and clinical trial data. All costs are presented in 2006 US dollars. Outcomes included cost per life year (LY) saved and cost per quality-adjusted life year (QALY) gained. Costs and outcomes were discounted at 3% annually. Univariate and multivariate sensitivity analyses were conducted to assess model robustness. Results Compared to no maintenance treatment, treatment with fluticasone propionate/salmeterol 500/50 μg results in a lifetime incremental cost-effectiveness ratio (ICER) of $33,865/QALY. Treatment with salmeterol 50 μg was found to have an ICER of $20,797/QALY. These results are robust to changes in input parameters. Fluticasone propionate 500 μg was dominated by no treatment, though the results were not robust to changes in parameters. Conclusions Treatment of COPD with fluticasone propionate/salmeterol 500/50 μg appears to be cost-effective (≤$50,000/QALY) compared to no maintenance treatment. Similarly, salmeterol 50 μg may be cost-effective compared to no maintenance treatment. Compared with no maintenance treatment, fluticasone propionate 500 μg was effective in reducing number of exacerbations, but failure to differentiate from no maintenance treatment in mortality resulted in it being dominated in the base case.
To evaluate the implementability of the "2008 Mexican Clinical Practice Guideline for the management of hip and knee osteoarthritis at the primary level of care" within primary healthcare of three ...Mexican regions using the Guideline Implementability Appraisal methodology version 2 (GLIA.v2).
Six family physicians, representing the South, North, and Central Mexico, and one Mexican physiatrist evaluated the 45 recommendations stated by the Mexican guideline. The GLIA.v2 methodology includes the execution of qualitative and semi-quantitative techniques.
Reviewers' agreement was between moderate to near complete in most cases. Sixty-nine percent of the recommendations were considered difficult to implement within clinical practice. Eight recommendations did not have an appropriate format. Only 6 recommendations were judged as able to be consistently applied to clinical practice. Barriers related to the context of one or more institutions/regions were identified in 25 recommendations. These barriers are related to health providers/patients' beliefs, processes of care within each institution, and availability of some treatments recommended by the guideline.
The guideline presented problems of conciseness and clarity that negatively affect its application within the Mexican primary healthcare context. We identified individual, organizational and system characteristics, which are common to the 3 institutions/regions studied and constitute barriers for implementing the guideline to clinical practice. It is recommended that the 2008-Mexican-CPG-OA be thoroughly revised and restructured to improve the clarity of the actions implied by each recommendation. We propose some strategies to accomplish this and to overcome some of the identified regional/institutional barriers.
Hydraulic tests conducted to improve the design of a centrifugal air stripper, (used in this instance to remove volatile organic compounds of a jet fuel from contaminated groundwater) are described. ...The stripper comprised a torus filled with packing materials, rotating within a fixed housing, the water admitted at the inner circumference of the torus being driven by centrifugal force through the packing and contacting air admitted under pressure between the outer circumference of the packing and the housing. Alternative packing materials of similar surface area per m3 were used, one a spongy metallic material of nickel and chromium, the other a wire gauze. The rotation speed and the rates of water and air injection were adjusted until the on-line hydrocarbon analyser gave a constant reading for 30 minutes. The hydraulic capacity of the unit, determined by the depth of the packing, was varied in 3 steps and the rotational speed varied until flooding of the packing, arising when the gravitational force on the water exceeded the centrifugal, occurred. The data collected suggested that the Sherwood flooding formula, previously used to determine this limit, had over-estimated the rotational speed at which it occurred and should be modified to take account of the specific surface area of the packing. Some fouling of the packing, identified as iron, was experienced and water treatment for iron removal is recommended as a pre-treatment.
To evaluate the implementability of the “2008 Mexican Clinical Practice Guideline for the management of hip and knee osteoarthritis at the primary level of care” within primary healthcare of three ...Mexican regions using the Guideline Implementability Appraisal methodology version 2 (GLIA.v2).
Six family physicians, representing the South, North, and Central Mexico, and one Mexican physiatrist evaluated the 45 recommendations stated by the Mexican guideline. The GLIA.v2 methodology includes the execution of qualitative and semi-quantitative techniques.
Reviewers’ agreement was between moderate to near complete in most cases. Sixty-nine percent of the recommendations were considered difficult to implement within clinical practice. Eight recommendations did not have an appropriate format. Only 6 recommendations were judged as able to be consistently applied to clinical practice. Barriers related to the context of one or more institutions/regions were identified in 25 recommendations. These barriers are related to health providers/patients’ beliefs, processes of care within each institution, and availability of some treatments recommended by the guideline.
The guideline presented problems of conciseness and clarity that negatively affect its application within the Mexican primary healthcare context. We identified individual, organizational and system characteristics, which are common to the 3 institutions/regions studied and constitute barriers for implementing the guideline to clinical practice. It is recommended that the 2008-Mexican-CPG-OA be thoroughly revised and restructured to improve the clarity of the actions implied by each recommendation. We propose some strategies to accomplish this and to overcome some of the identified regional/institutional barriers.
Evaluar las barreras de implementación de la guía de práctica clínica para el manejo de osteoartritis de cadera y rodilla en el primer nivel de atención 2008 dentro de la práctica clínica de 3 regiones mexicanas, usando la metodología Guideline Implementability Appraisal version 2 (GLIA v2).
Seis médicos familiares, representantes del sur, norte y centro de México, y un médico rehabilitador mexicano evaluaron las 45 recomendaciones propuestas en la guía de práctica clínica. La metodología GLIA v2 incluye la ejecución de técnicas cualitativas y semicuantitativas.
En su mayoría, el acuerdo entre revisores fue de moderado a casi completo. El 69% de las recomendaciones fueron consideradas como difíciles de implementar en la práctica clínica. Ocho recomendaciones no tienen un formato apropiado. Únicamente 6 recomendaciones pueden ser aplicadas consistentemente en la práctica clínica. En 25 recomendaciones, se detectaron barreras de implementación relacionadas al contexto de una o más de las instituciones/regiones exploradas. Estas barreras se relacionan con las creencias de proveedores de salud y pacientes, procesos de atención en cada institución y disponibilidad de algunos de los tratamientos recomendados en la guía.
La guía contiene recomendaciones poco claras y concisas, lo que afecta negativamente a su aplicación dentro del primer nivel de atención mexicano. Identificamos características individuales, organizacionales y sistemáticas, comunes a las 3 instituciones/organizaciones estudiadas, que significan barreras para implementar la guía en México. Se recomienda que esta guía sea revisada y reestructurada con el fin de mejorar la claridad de sus recomendaciones. Proponemos algunas estrategias para hacer esto y atacar algunas de las barreras identificadas relacionadas dentro de las regiones exploradas.
The second largest mining sector in the world, South Africa has a rich geological history that is responsible for the country's wealth of gems, metals and other minerals. The country's mining ...industry can be traced back to ancient iron and copper mining and smelting operations.
A strong association between the absence of the granule-bound starch synthase (GBSS) protein for the 4A chromosome of wheat and Japanese Udon noodle quality has been previously described. The aim of ...this study was to identify a molecular marker linked to the GBSS 4A locus which could be used to identify wheat with the desired texture for Udon noodles. PCR primers were designed to target this gene which gave a 440 bp PCR band, corresponding to the presence or absence of the 4A GBSS gene. Of the 268 genotypes screened with these primers, 267 were correctly identified using the PCR primers. The remaining genotype was shown to be heterogeneous for the marker. The PCR marker test developed has advantages over existing methods used to screen for Udon noodle starch quality as it enables high throughput, accurate tests to be carried out on leaves of young seedlings or mature seed and identify breeding lines that are heterogeneous for the 4A allele which will allow for reselections. Application of this PCR test will speed up selection for Udon noodle quality genotypes and reduce breeding costs for production of noodle wheat varieties. Abbreviations: CTAB, cetyltrimethlammonium bromide; FSV, flour swelling volume; GBSS, granule-bound starch synthase; IEF, isoelectric focusing; PCR, polymerase chain reaction; SDS-PAGE, sodium dodecyl sulfate-polyacrylamide-gel electrophoresis.
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