bluuebunny/crossref_metadata_2025 huggingface dataset:
Study on Mix Proportion Optimization of Manufactured Sand RPC and Design Method of Steel Fiber Content under Different Curing Methods
Authors: Zhong Chunling , Liu Mo , Zhang Yunlong , Wang Jing
Published: June 2019

This study investigated four factors (water/binder ratio, silica fume, fly ash, and sand/binder ratio) using the orthogonal experimental design method to prepare the mix proportions of a manufactured sand reactive powder concrete (RPC) matrix to determine the optimal matrix mix proportions. On this basis, we assessed the compressive and splitting tensile strengths of different steel fiber contents under natural, standard, and compound curing conditions to develop an economical and reasonable RPC for various engineering requirements. A calculation method for the RPC strength of the steel fiber contents was evaluated. The results showed that the optimum steel fiber content for manufactured sand RPC is 4% under natural, standard, and compound curing conditions. Compared with standard curing, compound curing can improve the early strength of manufactured sand RPC but only has a small effect on the enhancement of late strength. Although the strength of natural curing is slightly lower than that of standard curing, it basically meets project requirements and is beneficial for practical applications. The calculation formula of 28-day compressive and splitting tensile strengths of manufactured sand RPC steel fiber at 0%–4% is proposed to meet the different engineering requirements and the flexible selection of steel fiber content.
Monitoring the Performance of Petrochemical Organizations in Saudi Arabia Using Data Envelopment Analysis
Authors: Alidrisi Hisham , Aydin Mehmet Emin , Bafail Abdullah Omer , Abdulal Reda , Karuvatt Shoukath Ali
Published: June 2019

The petrochemical industry plays a crucial role in the economy of the Kingdom of Saudi Arabia. Therefore, the effectiveness and efficiency of this industry is of high importance. Data envelopment analysis (DEA) is found to be more acceptable in measuring the effectiveness of various industries when used in conjunction with non-parametric methods such as multiple regression, analytical hierarchy process (AHP), multidimensional scaling (MDS), and other multiple criteria decision making (MCDM) approaches. In this study, ten petrochemical companies in the Kingdom of Saudi Arabia are evaluated using Banker, Charnes and Cooper (BCC)/Charnes, Cooper, and Rhodes (CCR) models of DEA to compute the technical and super-efficiencies for ranking according to their relative performances. Data were collected from the Saudi Stock Exchange on key financial performance measures, five of which were chosen as inputs and five as outputs. Five DEA models were developed using different input–output combinations. The efficiency plots obtained from DEA were compared with the Euclidean distance scatter plot obtained from MDS. The dimensionality of MDS plots was derived from the DEA output. It was found that the two-dimensional positioning of the companies was congruent in both plots, thus validating the DEA results.
A New Method for Internal Force Detection of Steel Bars Covered by Concrete Based on the Metal Magnetic Memory Effect
Authors: Pang Caoyuan , Zhou Jianting , Zhao Qingyuan , Zhao Ruiqiang , Chen Zhuo , Zhou Yi
Published: June 2019

In this paper, the specimens of steel bars covered by concrete (SBCC) are taken as research objects, and a new method for steel bar internal force detection based on the metal magnetic memory effect is proposed. The variation law of the self-magnetic flux leakage (SMFL) signals on the surfaces of SBCC specimens with loading tension and the variation of the SMFL signals along the axial positions of specimens under different tensile forces are studied. The results show that when the loading tension is about 90% of the yield tension, the tangential component of the SMFL signal has a maximum extreme point. The distribution of the SMFL signals along the axial position shows a smooth curve, where the values at both ends are small while the intermediate values are large. This paper also proposes the use of the “area ratio deviation parameter” to quantitatively calculate the internal forces of the steel bars. This parameter shows a significant linear relationship with the loading tension during the strengthening stage of the specimens. This method can supplement the existing steel bar stress detection methods and has prospective research value.
Optimization of Induction Quenching Processes for HSS Roll Based on MMPT Model
Authors: Liu Ligang , Yu Hui , Yang Zhiqiang , Zhao Chunmei , Zhai Tongguang
Published: June 2019

To improve the comprehensive performance of high speed steel (HSS) cold rolls, the induction hardening processes were analyzed by numerical simulation and experimental research. Firstly, a modified martensitic phase transformation (MMPT) model of the tested steel under stress constraints was established. Then, the MMPT model was fed into DEFORM to simulate the induction quenching processes of working rolls based on an orthogonal test design and the optimal dual frequency of the induction quenching process was obtained. The results indicate that the depth of the roll’s hardened layer increases by 32.5% and the axial residual tensile stress also becomes acceptable under the optimized process. This study provides guidance for studying phase transformation laws under stress constraints and the optimization of complex processes in an efficient manner.
Different Secondary Metabolite Profiles of Phylogenetically almost Identical Streptomyces griseus Strains Originating from Geographically Remote Locations
Authors: Sottorff Ignacio , Wiese Jutta , Lipfert Matthias , Preußke Nils , Sönnichsen Frank D. , Imhoff Johannes F.
Published: June 2019

As Streptomyces have shown an outstanding capacity for drug production, different campaigns in geographically distant locations currently aim to isolate new antibiotic producers. However, many of these newly isolated Streptomyces strains are classified as identical to already described species. Nevertheless, as discrepancies in terms of secondary metabolites and morphology are possible, we compared two Streptomyces strains with identical 16S rRNA gene sequences but geographically distant origins. Chosen were an Easter Island Streptomyces isolate (Streptomyces sp. SN25_8.1) and the next related type strain, which is Streptomyces griseus subsp. griseus DSM 40236T isolated from Russian garden soil. Compared traits included phylogenetic relatedness based on 16S rRNA gene sequences, macro and microscopic morphology, antibiotic activity and secondary metabolite profiles. Both Streptomyces strains shared several common features, such as morphology and core secondary metabolite production. They revealed differences in pigmentation and in the production of accessory secondary metabolites which appear to be strain-specific. In conclusion, despite identical 16S rRNA classification Streptomyces strains can present different secondary metabolite profiles and may well be valuable for consideration in processes for drug discovery.
Addendum: Cillóniz, C.; Dominedò, C.; Nicolini, A.; Torres, A. PES Pathogens in Severe Community-Acquired Pneumonia. Microorganisms 2019, 7, 49
Authors: Cillóniz Catia , Dominedò Cristina , Nicolini Antonello , Torres Antoni
Published: June 2019

In the article recently published in Microorganisms [...]
Antifungal Effect of Magnolol and Honokiol from Magnolia officinalis on Alternaria alternata Causing Tobacco Brown Spot
Authors: Chen Ya-Han , Lu Mei-Huan , Guo Dong-Sheng , Zhai Ying-Yan , Miao Dan , Yue Jian-Ying , Yuan Chen-Hong , Zhao Ming-Min , An De-Rong
Published: June 2019

In this study, two phenol compounds, magnolol and honokiol, were extracted from Magnolia officinalis and identified by LC-MS, 1H- and 13C-NMR. The magnolol and honokiol were shown to be effective against seven pathogenic fungi, including Alternaria alternata (Fr.) Keissl, Penicillium expansum (Link) Thom, Alternaria dauci f.sp. solani, Fusarium moniliforme J. Sheld, Fusarium oxysporum Schltdl., Valsa mali Miyabe & G. Yamada, and Rhizoctonia solani J.G. Kühn, with growth inhibition of more than 57%. We also investigated the mechanisms underlying the potential antifungal activity of magnolol and honokiol. The results showed that they inhibited the growth of A. alternata in a dose-dependent manner. Moreover, magnolol and honokiol treatment resulted in distorted mycelia and increased the cell membrane permeability of A. alternata, as determined by conductivity measurements. These results suggest that magnolol and honokiol are potential antifungal agents for application against plant fungal diseases.
Annotation and Expression of IDN2-like and FDM-like Genes in Sexual and Aposporous Hypericum perforatum L. accessions
Authors: Basso Andrea , Barcaccia Gianni , Galla Giulio
Published: June 2019

The protein IDN2, together with the highly similar interactors FDM1 and FDM2, is required for RNA-directed DNA methylation (RdDM) and siRNA production. Epigenetic regulation of gene expression is required to restrict cell fate determination in A. thaliana ovules. Recently, three transcripts sharing high similarity with the A. thaliana IDN2 and FDM1-2 were found to be differentially expressed in ovules of apomictic Hypericum perforatum L. accessions. To gain further insight into the expression and regulation of these genes in the context of apomixis, we investigated genomic, transcriptional and functional aspects of the gene family in this species. The H. perforatum genome encodes for two IDN2-like and 7 FDM-like genes. Differential and heterochronic expression of FDM4-like genes was found in H. perforatum pistils. The involvement of these genes in reproduction and seed development is consistent with the observed reduction of the seed set and high variability in seed size in A. thaliana IDN2 and FDM-like knockout lines. Differential expression of IDN2-like and FDM-like genes in H. perforatum was predicted to affect the network of potential interactions between these proteins. Furthermore, pistil transcript levels are modulated by cytokinin and auxin but the effect operated by the two hormones depends on the reproductive phenotype.
Effect of Heating Oxidation on the Surface/Interface Properties and Floatability of Anthracite Coal
Authors: Rong Guoqiang , Xu Mengdi , Wang Dongyue , Gui Xiahui , Xing Yaowen
Published: June 2019

Oxidation processes of coal surfaces are both fundamental and interesting from academic and engineering points of view. In this work, we comprehensively analyzed the mechanism of heating oxidation at 200 °C on the surface/interface characters and the floatability of anthracite coal. The variations of surface/interface characters were studied using SEM (scanning electron microscopy), FTIR (Fourier transform infrared spectroscopy), and XPS (X-ray photoelectron spectroscopy). The floatability was further identified using Induction Time and Bubble-Particle Wrap Angle. It was found that, after heating oxidation at 200 °C, both surface ravines and oxygen-containing groups were increased. The degradation of hydroxyl on anthracite could be neglected during the heating, while the oxidation of hydrocarbon chains dominated the balance of hydrophobicity and hydrophilicity on coal surface. The induction time significantly increased from 200 ms to 1200 ms and 2000 ms after 10 h and 20 h of heating oxidation at 200 °C, respectively. Additionally, raw coal exhibited the fastest kinetics of bubble-particle attachment and the largest wrap angle, directly proving that the floatability decreased after oxidation.
Numerical Determination of RVE for Heterogeneous Geomaterials Based on Digital Image Processing Technology
Authors: Yang Lanlan , Xu Weiya , Meng Qingxiang , Xie Wei-Chau , Wang Huanling , Sun Mengcheng
Published: June 2019

Representative volume element (RVE) is an important parameter in numerical tests of mechanical properties of heterogeneous geomaterials. For this study, a digital image processing (DIP) technology was proposed for estimating the RVE of heterogeneous geomaterials. A color image of soil and rock mixture (SRM) with size of 400 × 400 mm2 taken from a large landslide was used to illustrate the determination procedure of the SRM. Six sample sizes ranging from 40 × 40 mm2 to 240 × 240 mm2 were investigated, and twelve random samples were taken from the binarized image for each sample size. A connected-component labeling algorithm was introduced to identify the microstructure. After establishing the numerical finite difference models of the samples, a set of numerical triaxial tests under different confining pressures were carried out. Results show that the size of SRM sample affects the estimation of the mechanical properties, including compressive strength, cohesion, and internal friction angle. The larger the size of the samples, the less variability of the estimated mechanical properties. The coefficient of variation (CV) was applied to measure the variability of mechanical properties, and the RVE of the SRM was determined easily with a predefined acceptance threshold of the CV. The results show that a DIP-based modeling method is an effective method got the RVE determination of heterogeneous geomaterials.
Manufacturing Process, In Vivo and In Vitro Digestibility Assessment of an Enteral Feeding Product Hydrolyzed from Locally Available Ingredients Using Commercial Enzymes
Authors: Quynh Hoa Nguyen Thi , Ngan Tam Luu , Thien Phu Luu Van , Van Thai Than , Nguyen Duy Chinh , Anh Dao Dong Thi
Published: June 2019

A ready-for-use enteral feeding product was manufactured based on energy standard mixing using hydrolyzed products from local foods (i.e., loin pork, carrot, pumpkin, soybean, rice, and potato). When compared to enteral foods based on defined ingredients, the manufactured product is more cost-effective, appropriately functional and has similar physicochemical properties. Relative protein digestibility for in vitro value was tested by using enzyme pepsin, pH-drop and pH-stat method with three different enzymes. The product was shown to be easily digested with an in vivo digestibility value of 89.7%. Molecule sizes of components in the product ranged from 3.5 to 8.5 kDa, determined by SDS-PAGE, and the average molecular weight was 1.52 kDa, determined by Gel Permeation Chromatography (GPC) method. In terms of nutritional value, the product achieved a caloric density of 1 kcal/mL, dietary fibers of 1.48 g per 100 mL and provided both oligomeric and monomeric forms of protein. In addition, the product has the leucine: isoleucine: valine ratio of 2:1:1, thus facilitating the absorption of the protein. In conclusion, the manufactured enteral feeding product has been shown to be appropriate for providing nutritional support for patients.
A Computationally Efficient Semantic SLAM Solution for Dynamic Scenes
Authors: Wang Zemin , Zhang Qian , Li Jiansheng , Zhang Shuming , Liu Jingbin
Published: June 2019

In various dynamic scenes, there are moveable objects such as pedestrians, which may challenge simultaneous localization and mapping (SLAM) algorithms. Consequently, the localization accuracy may be degraded, and a moving object may negatively impact the constructed maps. Maps that contain semantic information of dynamic objects impart humans or robots with the ability to semantically understand the environment, and they are critical for various intelligent systems and location-based services. In this study, we developed a computationally efficient SLAM solution that is able to accomplish three tasks in real time: (1) complete localization without accuracy loss due to the existence of dynamic objects and generate a static map that does not contain moving objects, (2) extract semantic information of dynamic objects through a computionally efficient approach, and (3) eventually generate semantic maps, which overlay semantic objects on static maps. The proposed semantic SLAM solution was evaluated through four different experiments on two data sets, respectively verifying the tracking accuracy, computational efficiency, and the quality of the generated static maps and semantic maps. The results show that the proposed SLAM solution is computationally efficient by reducing the time consumption for building maps by 2/3; moreover, the relative localization accuracy is improved, with a translational error of only 0.028 m, and is not degraded by dynamic objects. Finally, the proposed solution generates static maps of a dynamic scene without moving objects and semantic maps with high-precision semantic information of specific objects.
Joint Formation Control with Obstacle Avoidance of Towfish and Multiple Autonomous Underwater Vehicles Based on Graph Theory and the Null-Space-Based Method
Authors: Pang Shi-kun , Li Ying-hui , Yi Hong
Published: June 2019

In this study, a new joint formation combined with a two-part underwater towed vehicle (towfish) with multiple autonomous underwater vehicles (AUVs) was investigated. A triangular structure formation was established based on graph theory, in which the main point is the secondary towed vehicle acting as the “leader,” and the other two points are AUVs acting as “followers.” The excellent real-time performance and high flexibility of the towfish is highlighted, and the communication delay and fixed routine of AUVs can be avoided simultaneously. As to the obstacle avoidance, the null-space-based behavioral approach is proposed. On the basis of this approach, the formation task moving to the target is decomposed into different subtasks, and the obstacle avoidance subtask is set as the highest priority. The vector of the low-level task is projected to the null space of the high-level task vector, and the integrated task output is used as the final output function. The low-level task is partially or completely accomplished while handling the higher task; therefore, the mutual conflict between different level targets can be avoided. Moreover, the corresponding task functions are designed in accordance with different subtask priorities. The comprehensive output function of formation motion is deduced and established to ensure that obstacles can be avoided effectively. Furthermore, simulation results demonstrate the effectiveness and feasibility of the proposed method in a complex underwater environment with obstacles.
Building Relationships with Customer 4.0 in the Era of Marketing 4.0: The Case Study of Innovative Enterprises in Poland
Authors: Wereda Wioletta , Woźniak Jacek
Published: June 2019

(1) Background: Contemporary enterprises are putting more and more emphasis on shaping lasting and effective relationships with clients. This is not an easy task, especially in the conditions of Marketing 4.0, which imposes on enterprises the need to holistically consider the needs as well as the skills and inventiveness of customers. It can be assumed that Clients 4.0 require both changes in the scope of business processes and shaping communication with their environment. That is why it is important today to skillfully and correctly determine the complexity of communication with Clients 4.0, as well as to determine the importance of communication with clients for the development of enterprises—especially those operating in innovative industries. (2) Methods: Empirical research was carried out on a sample of 100 innovative enterprises listed on the NewConnect market in Poland. The respondents were managers at various levels. Two indicators were constructed based on these assessments: Customer Relationships Importance Index (CRII) and Customer Communication Complexity Index (CCCI). (3) Results: It was determined that the complexity of communication of innovative enterprises with customers is at a high level. What is more, the importance of relationships with Customers 4.0 for the development of innovative enterprises is at a high level. It was also indicated that there is no correlation between the level of complexity of relationships with Customers 4.0 and the importance of these relationships for the development of innovative enterprises. (4) Conclusions: Based on the survey, it can be assumed that the relations with Clients 4.0 have the greatest share in shaping the development of innovative enterprises in the areas of minimizing the number of complaints, financial liquidity and efficiency of core business processes. It is also important that, in shaping the complexity of communication with Clients 4.0, enterprises mainly consider traditional phone calls and email account.
O processo penal constitucional e a questão do mandado de busca e apreensão coletivo
Authors: Spinelli Paciello Antonella , Ziesemer Henrique Da Rosa
Published: June 2019

O objetivo geral do presente artigo é debater a inviolabilidade constitucional do domicílio, estimando direitos e garantias fundamentais previstas na Constituição da República Federativa do Brasil. Para tal, serão descritos os direitos e garantias fundamentais, definindo ainda o mandado de busca e apreensão e o mandado de busca e apreensão coletivo. Será discutido, por fim, o crime organizado e seu combate, mencionando a recente intervenção federal decretada no Rio de Janeiro e o suposto conflito entre direitos individuais e a segurança pública. O escopo será o de atingir uma conclusão a respeito da constitucionalidade do mandado de busca e apreensão genérico, ante o embate aparente entre direitos individuais e coletivos.
Risk prediction models that use routinely collected electronic health data: generalisable and useful in heterogeneous settings?
Authors: Li Yan , Sperrin Matthew , Belmonte Miguel , Pate Alexander , Ashcroft Darren , Van Staa Tjeerd
Published: June 2019

Background

Healthcare sites (practices) may vary in quality of data recording and populations. Risk predictions models that use routinely collected data do not test generalisability to heterogeneous practices.

Aim

To assess the extent of variability between practices on individual patients’ risk of cardiovascular disease (CVD) that is not taken into account by the risk prediction model QRISK3.

Method

A longitudinal cohort study from 1 Jan 1998 to Jan 2015 in 392 general practices (including 3.6 million patients) from the Clinical Practice Research Datalink (CPRD). This was a shared frailty model to incorporate QRISK3 predictors, practice variability, and simulations to measure random variability.

Results

There was considerable variation in data recording between general practices. Practices on 5th percentile of missingness of body mass index have 18.7% patients with missing values and 60.1% on the 95th percentile. The crude incidence rates also varied considerably between practices (from 0.4 to 1.3 CVD events per 100 patient-years, respectively). The estimates of individual CVD risks with the random effect model were inconsistent with the estimated QRISK3 risk. For patients with a QRISK3 CVD risk of 10%, the 95% range of predicted risks were between 7.2% and 13.7% with the random effects model. Random variability only explained a small part of this. The random effects model was similar to QRISK3 for discrimination and calibration.

Conclusion

Risk prediction models that use routinely collected electronic health data can have limited generalisability and accuracy in predicting individual patient risks in heterogeneous settings. They need to be based on more robust evidence on causal risk factors.
Measuring the effectiveness of embedding social workers in integrated primary health care teams working with older adults with complex needs
Authors: Bailey Di , Mutale Gabriella
Published: June 2019

Background

Despite the policy agenda for health and social care collaboration currently focused on integrated care systems, there is limited evidence that examines whether embedding social workers in integrated primary health and social care teams working with older adults is effective.

Aim

The study aimed to establish whether embedding social workers in integrated primary care teams (IPCTs) for older adults in Nottinghamshire was cost-effective.

Method

A mixed methods approach collected quantitative and qualitative data that was triangulated using a TRI-Q model. Cost and care quality data were collected from patients in receipt of social worker involvement in three different IPCTs. Patients with similarly complex needs, who were receiving involvement from social work only district teams in the same localities acted as a comparator group. Interviews were conducted with patients and carers and with social workers and GPs working in the IPCTs. Seven focus groups were conducted with IPCT members representing social work and health disciplines.

Results

The cost data were analysed using ANCOVA to identify any significant differences in costs across the teams. The result showed costs in two of the IPCTs were significantly lower than controls. Care quality indicators were also greater in these IPCTs. Thematic analysis highlighted the important of knowledge exchange that arose from social work embeddedness as indicative of the optimal conditions for effective integrated working and care delivery to be achieved.

Conclusion

The findings suggested that embedding social workers in IPCTs offers both higher quality and more cost-effective care for older people if the optimum conditions for integration are met.
Evaluation of a countywide alternative to QOF, aimed at improving person-centred coordinated care
Authors: Close James , Fosh Ben , Byng Richard , Blackwell Richard , Witts Louise , Hall Louise , Lloyd Helen
Published: June 2019

Background

The Quality Outcomes Framework (QOF) for general practice is one of the largest pay-for-performance schemes in the world. The scheme, however, is sometimes viewed as anachronistic, with recent proposals for a slimmed down QOF. Over the last few years, Somerset have been trialling a system with national implications: 55 GP practices in Somerset established the Somerset Quality Practice Scheme (SPQS) — a de-incentivisation of QOF — with the goal of redirecting resources towards improved Person Centred Coordinated Care (P3C), especially for those with long-term conditions.

Aim

An evaluation of the SPQS scheme to establish benefits (for example in provision of P3C) or disbenefits (for example in emergency admissions).

Method

A longitudinal evaluation from 55 SPQS practices and 17 regional controls. Patient experiences (2363 patients), staff experiences (127 professionals), and organisational data (for SPQS and control practices) were collected. Emergency admission data was analysed for ambulatory-sensitive conditions across Somerset.

Results

Discretion from QOF resulted in time savings in the majority of practices. Organisational data revealed a significant increase in P3C. Care delivery was improved via stronger federation-level agreements and informal networks, increased multidisciplinary working, reallocation of resources for other healthcare professionals and changes to the structure and timings of GP appointments. Patient and practitioner experiences were similar in SPQS versus control practices. No disbenefits were detected in admissions data.

Conclusion

The SPQS scheme leveraged time savings and reduced administrative burden via discretionary removal of QOF, enabling participating practices to engage in a number of schemes aimed at improving care for people with LTCs.
Do South Asian Communities ‘Act FAST’?
Authors: Coleby Dawn , Taub Nick , Mistri Amit , Turner Andy , Coad Jane , Wark Petra , Bhatti Krishna , Chahal Kusminder , Teo Wei-Peng
Published: June 2019

Background

Rapid medical assessment and treatment of patients with transient ischemic attack (TIA) or stroke significantly reduces the risk of recurrent stroke. Previous research has shown that delays to initial medical assessment are due to lack of an urgent response to symptoms. In comparison to other communities living within the UK, South Asians have a higher risk of stroke/TIA. Therefore, it is critically important to explore stroke/TIA knowledge and anticipated response to symptoms, within this community.

Aim

This study aims to provide preliminary evidence of stroke knowledge and awareness of the relaunched ‘Act FAST’ campaign in the South Asian community and to provide evidence of successful participant recruitment from ‘hard to engage’ groups.

Method

A pilot mixed methods study, incorporating focus group discussions and a short ‘tick box’ style paper survey, designed to assess and explore participant knowledge of stroke/TIA symptoms, and awareness of the relaunched ‘Act FAST’ campaign. Barriers and facilitators to stroke education and the suitability of mass-media campaigns are also discussed during the focus groups. All participants were recruited from places of worship.

Results

The authors will present highlights from the ‘on-going’ study including; the recruitment strategy, barriers and facilitators to recruitment in Sikh temples and preliminary findings from 68 completed surveys. Highlights from the focus group discussions will be presented, alongside participant suggested methods to improve stroke/TIA knowledge in Indian communities.

Conclusion

Preliminary findings suggest awareness of stroke symptoms in the Indian community, but less awareness of TIA. Non-English speakers may be less aware of ‘Act FAST’.
University of Limerick — Graduate Entry Medical School, General Practice Quality Assurance Initiative
Authors: Culhane Aidan , O’Dwyer Patrick , O’Regan Andrew , Glynn Liam
Published: June 2019

Background

At 18 weeks duration, University of Limerick — Graduate Entry Medical School (UL–GEMS) has the longest general practice clinical attachment for medical students in Ireland and fulfils the educational criteria for a Longitudinal Integrated Clerkship (LIC).The longer the clinical placement the greater the imperative to see that these practices achieve satisfactory educational standards.

Aim

This project describes a quality assurance initiative of general practices that participate in the education of medical students at GEMS.

Method

A literature review of previous quality assurance initiatives in relation to general practices that teach medical students was performed. Information gained from this process was then compared with UL-GEMS own criteria for teaching general practices. A set of criteria by for assessing teaching general practices was devised. The assessment process included a combination of self-assessment by the GP tutors and practice visits by the UL-GEMS teaching staff.

Results

Nearly 100% of teaching practices had the correct teaching facilities, such as own room for the student or own computer. Suggested teaching methods, such as parallel consulting, as advised by the Department of General Practice were carried by 100% of practices. Use of the two-way feedback form and the GP/Student manual was poor. GP tutors requested more regular visits form the GP teaching staff as well as more guidance on content for formal tutorials so that a consistency teaching approach could be achieved.

Conclusion

This was the first quality assurance initiative on an extended clinical placement. The knowledge gained will lead to a more inclusive standard setting process for teaching medical students in general practice settings.
Impact of a diagnostic decision support system on GP clinical documentation
Authors: Tracey Chris , Delaney Brendan , Kostopoulou Olga
Published: June 2019

Background

Kostopoulou and colleagues designed and evaluated a diagnostic decision support system (DSS) that presented GPs with differential diagnoses to consider at the start of the consultation. The DSS was integrated with the electronic health record (EHR) and evaluated in simulated consultations (34 GPs consulting with 12 actors), where it was found to improve diagnostic accuracy.

Aim

To evaluate the impact of the DSS on GP clinical documentation.

Method

Secondary data analysis. The analysis dataset consisted of all data items that the 34 GPs recorded during their consultations with the 12 actors (408 consultations). Each GP had conducted six consultations with the EHR alone, and six with the integrated DSS. The 12 patient scenarios had a pre-defined set of clinical cues and differential diagnoses. For each patient scenario, a Delphi panel of five GPs identified which cues were consistent with each differential diagnosis. The data items recorded, either in free text or code, were counted. These were referenced against the Delphi panel’s matrix of cues and diagnoses. For each GP, it was estimated what proportion of the recorded data was consistent with the diagnosis that they finally gave.

Results

Using the DSS increased the total amount of information documented (b = 3.58 [95% confidence interval {CI} = 2.81 to 4.35] P<0.001) and reduced the proportion of documentation that was consistent with the GP’s final diagnosis (b = −0.08 [95% CI = −0.11 to −0.05] P<0.001), suggesting less bias.

Conclusion

Using the DSS led to more complete and less biased documentation. This has implications for the use of routine EHR data to create clinical prediction rules.
Evaluating the use of CKD trigger tools across practices in east London: a qualitative study in primary care
Authors: Rajabzadeh Vian , Thomas Nicola , Hull Sally
Published: June 2019

Background

Early identification of people with chronic kidney disease (CKD) in primary care, enables proactive clinical management. CKD trigger tools designed as patient safety tools, alert GP practices when falling estimated glomerular filtration rates (eGFR) are identified from the patient record. The tool’s aim is to alert clinicians to possible CKD progression, and invites written reflection by the GP of the ‘referral’ or ‘non-referral’ outcomes of patients identified.

Aim

To evaluate how the CKD trigger tool is used across practices in east London. To examine how the differences in the practitioner use and perceived value of the tool is characterised by interview transcripts, compared with the written reflections.

Method

Eight semi-structured interviews were undertaken with six GPs, one pharmacist, and one practice manager. The reflection free-text data were organised into categories, of ‘yes’ and ‘no’ referrals, dividing further each category by ‘young’ and ‘old’ cases. Thematic analysis was applied to the interview transcripts. Arising themes were supplemented by the descriptive analysis of the reflection.

Results

In total 1921 reflection comments were examined, 1770 ‘No’ referrals (935 aged <60 years) and 151 ‘Yes’ referrals (81 aged <60 years), covering a 2-year period. Four themes emerged from the interviews: ‘Getting started …’, ‘Workflow’, ‘Trigger tool as a learning tool’, and ‘Patient safety’.

Conclusion

The study highlights that administratively well organised practices found that the tool could be readily embedded into their workflow. Reflection data highlighted cases of poorly controlled diabetes and/or hypertension for the ‘yes–young’ referrals. Generally, ‘No’ referrals emphasised the implementation of a clinical management plan.
Home-based rehabilitation for heart failure with reduced ejection fraction: the REACH HF multicentre RCT
Authors: Dalal Hasnain , Taylor Rod
Published: June 2019

Background

Cardiac rehabilitation (CR) improves health-related quality of life (HRQOL) and reduces hospitalisations in patients with heart failure (HF), but international uptake of CR for HF remains low.

Aim

To compare the REACH-HF (Rehabilitation EnAblement EnAblement in CHronic Heart Failure) intervention: a facilitated self-care and home-based CR programme to usual care (UC) for adults with HF with reduced ejection fraction (HFrEF) and to assess the long-term cost-effectiveness of the intervention. The primary hypothesis was that the addition of the REACH-HF intervention to UC would improve disease-specific HRQOL (Minnesota Living with Heart Failure questionnaire [MLHFQ]) at 12 months compared with UC alone.

Method

Multicentre randomised trial.

Results

There were 216 participants: 78% male, average age 70 years, and mean left ventricular ejection fraction of 34%. Overall, 185 (86%) participants provided data for the primary outcome. At 12 months, there was a significant and clinically meaningful between-group difference in the MLHFQ score of −5.7 points (95% CI = −10.6 to −0.7) in favour of the REACH-HF intervention group (P = 0.025). The mean cost of the REACH-HF intervention was £418 per participant, which was associated with a per patient mean quality-adjusted life year (QALY) gain of 0.23 and an increased mean cost of £400 compared with usual care, resulting in a cost per QALY gained of £1720.

Conclusion

The REACH-HF facilitated intervention was clinically superior in disease-specific HRQoL at 12 months and economic modelling shows that it is cost-effective. REACH-HF offers an affordable alternative to traditional centre-based programmes to address current low CR uptake rates for HF.
MEDREV: feasibility study of a combined pharmacy–health psychology intervention to improve care for people with dementia with behaviour that challenges in care homes
Authors: Maidment Ian
Published: June 2019

Background

‘Behaviour that Challenges’ is common in older people with dementia in care homes and treated with antipsychotics. Policy is focused on reducing the use of antipsychotics in people with dementia and therefore reducing harm. This submission reports results on a NIHR-funded feasibility study MEDREV.

Aim

To assess the feasibility of medication review by a specialist dementia care pharmacist combined with staff training with the objective of limiting the inappropriate use of psychotropics.

Method

Care homes were recruited. People meeting the inclusion (dementia; medication for behaviour that challenges), or their personal consultee, were approached. A specialist dementia care pharmacist reviewed medication and made recommendations. Care staff received a 3-hour training session promoting person-centred care and GPs’ brief training. Data were collected on recruitment and retention, and implementation of recommendations. Other outcomes included the Neuropsychiatric Inventory-Nursing Home version, quality of life (EQ-5D/DEMQoL), cognition (sMMSE), and health economic (CSRI). Qualitative interviews explored expectations and experiences.

Results

Medication reviews were conducted in 29 of 34 residents recruited and the pharmacist recommended reviewing medication in 21 of these. Fifteen (71.4%) of these were antidepressants: 57.1% (12 of 21) of recommendations were implemented and implementation took a mean of 98.4 days. Non-implementation themes for will be presented. One hundred and sixty-four care staff received training (care homes = 142; primary care = 22). Twenty-one participants (care home managers = 5; GPs = 3; nurses = 2; care staff = 11) were interviewed.

Conclusion

The study was feasible, although the approach would need modification to improve the uptake of reviews and reduce the delay in implementation. Most of the recommendations related to antidepressants.
The Safer Prescription of Opioids Tool (SPOT) — a novel clinical decision support digital health platform for opioid conversion in palliative and end-of-life care: a single centre pilot study
Authors: Flint Roger , Jamieson Scott , Buchanan Dean , Botros S , Forbes Joanna , Cuschieri Alfred , George J
Published: June 2019

Background

Opioid conversion is complex and currently performed manually using tables of approximate equivalence, often in high pressure clinical situations. Apps that offer opioid dose conversion are available but there are concerns about their accuracy, reliability, and clinical validation.

Aim

The study evaluated a novel opioid dose conversion app, The Safer Prescription of Opioids Tool (SPOT), as a clinician decision support (CDS) platform. The secondary objective was to use SPOT to describe patterns of opioid dose conversion in palliative and end-of-life care.

Method

This prospective clinical utility single-centre pilot study followed a mixed methods design. Prescribers completed an initial survey exploring their current opioid prescribing practice. Thereafter prescribers used SPOT for opioid dosage conversions in parallel to their usual clinical practice. Lastly, prescribers evaluated SPOT through a survey and focus group. SPOT was evaluated using clinical data across primary, secondary and tertiary care in palliative care and end of life care settings at a Scottish Health Board in both out-of-hours and in-hours.

Results

SPOT correctly matched the Gold Standard result in 258 of 268 (96.3%) calculations. Users had a statistically significant increase in confidence in prescribing opioids after using SPOT. A majority (62%) of conversions were for cancer pain. Focus group feedback highlighted perceived benefits in Quality Improvement and Safety when using SPOT.

Conclusion

SPOT is a safe, reliable and validated CDS that has significant potential to reduce harms from opioid dosing errors, particularly in primary care, including rural primary care, and the out-of-hours setting.
Learning from diagnostic error when primary care services are located in or alongside emergency departments: a theory generating mixed-methods study
Authors: Cooper Alison , Carson-Stevens Andrew , Siriwardena Niro , Edwards Adrian
Published: June 2019

Background

New healthcare service models are being introduced to help manage increasing demand on emergency healthcare systems including the provision of primary care services in or alongside emergency departments. There is little research evidence to guide decisions about how service models can be most effective and safe.

Aim

Focusing on diagnostic error, the aim was to learn why errors occur to identify priority interventions.

Method

Two data sources were used to identify diagnostic error reports including: coroners’ reports to prevent future deaths; and the National Reporting and Learning System (NRLS). A cross-sectional, mixed-methods theory-generating study which used a multi-axial PISA classification system based on the recursive model for incident analysis, was carried out.

Results

Nine Coroners’ reports (from a total of 1347 community and hospital reports, 2013–2018) and 217 NRLS reports (from 13 million, 2005–2015) were identified describing diagnostic error with learning relevant to primary care services in or alongside emergency departments. Clinical presentations included musculoskeletal injuries; unwell infants; headaches; and chest pains. Findings highlighted a difficulty identifying appropriate patients for the primary care service; underinvestigation; misinterpretation of diagnostic tests; underuse of safeguarding protocols; and inadequate communication and referral pathways between the services.

Conclusion

Priority areas to minimise risk of diagnostic error when primary care services are located in or alongside emergency departments include clinical decision support to triage and stream patients to the appropriate care setting; contextualised, workplace-based education and training for primary care staff; and standardised computer systems, communication and referral pathways between emergency and primary care services.
C-reactive protein testing reduces antibiotics prescription in a community setting
Authors: Burahee Abdus , Hibberd Owen , Malladi Aneja
Published: June 2019

Background

Overuse of antimicrobials and the threats posed by resistance are concerning. Most patients in primary care with respiratory tract symptoms are prescribed antibiotics, amounting between 80–90% of all prescriptions. The National Institute for Health and Care Excellence (NICE) recommends point-of-care (POC) testing of C-reactive protein (CRP) where there is uncertainty about prescribing antibiotics. Studies evaluating the use of POC CRP to reduce antibiotic prescribing for self-limiting respiratory illness in primary care have demonstrated heterogeneity in their results.

Aim

To evaluate the impact of POC CRP testing on antibiotic prescribing.

Method

A retrospective case analysis was undertaken at a GP practice. Alere Afinion AS100 was used for POC CRP testing. Data were collected on patients presenting with cough or sore throat who had POC CRP testing used in their clinical decision making. Eighty-four cases were selected for inclusion. NICE clinical guideline CG191 was used as a standard comparator for antibiotic prescribing and patients were followed up over a 2-month period.

Results

Patients presented with cough (n = 56) and sore throat (n = 28). At initial presentation 23/84 (27.4%) of patients were prescribed antibiotics. Over the 2-month follow-up period 15/84 (17.8%) of patients had at least one further consultation related to their initial respiratory complaint with 6/84 (7.1%) being prescribed antibiotics. The overall effect was a reduction of antibiotic prescriptions by 65.5%.

Conclusion

The use of POC CRP testing helped GPs reduce the rate of antibiotic prescription and improve antimicrobial stewardship by being an addition to their diagnostic armoury. It has also shown potential role in patient reassurance and modifying health seeking behaviour.
Management of type 2 diabetes in general practice in Ireland: effect of the ‘Cycle of Care’ programme
Authors: O’Connor Raymond , O’Driscoll Rory , O’Doherty Jane , O’Neill Aoife , Teljeur Conor , O’Regan Andrew
Published: June 2019

Background

Diabetes is a major cause of death and disability worldwide and is associated with vascular complications, which are reduced by control of risk factors. The introduction of the diabetes ‘cycle of care’ pay-for-performance programme in Ireland in January 2016 means that GPs have been resourced to provide structured care to patients with type 2 disease.

Aim

To examine the effectiveness of the ‘cycle of care’ programme.

Method

A computerised search was developed for diabetes data. Forty-one practices returned data for a 12-month period before (2014) and after (2017) the introduction of the ‘cycle of care’. International guidelines informed the analysis.

Results

In total, 3189 patients were examined from 41 practices for the years 2014 and 2017. Nine practices were located in an urban setting (22%), 16 rural (39%), and 16 in a mixed location (39%); 1781 males (55.8%) and 1408 females (44.2%). In 2017, the mean age of participants was 68.5 years (standard deviation [SD] = 12.3) and 2277 (71.4%) patients had clinical data provided for both 2017 and 2014, 875 (27.4%) for 2017 only, 5 (0.2%) for 2014 only, and 32 (1.0%) for neither year. Substantial improvements in rates of recording and in levels of missing data were shown for HbA1c, lipids, renal function, blood pressure, and body mass index. Rates of foot review, retinopathy screening, treatment review, influenza immunisation, and patient education were recorded for the first time in 2017.

Conclusion

The ‘cycle of care’ programme has resulted in substantial improvements in type 2 diabetes care in Ireland, supporting pay for performance.