bluuebunny/crossref_metadata_2025 huggingface dataset:
Improving the management of Staphylococcus aureus bacteraemia, including MRSA
Authors: Meyer Claudia , Pett Eleanor
Published: October 2013

Staphylococcus aureus bacteraemia is a serious infection associated with significant complications, including recurrence of bacteraemia, endocarditis and metastatic foci of infection. The management of these patients is often complex, involving appropriate source control, a thorough review and investigations to exclude metastatic foci and infective endocarditis. Additionally, a prolonged course of intravenous antibiotics is often required.

As part of our quality improvement project, the following five aspects were evaluated in 56 patients with S. aureus bacteraemia at two District General Hospitals: 1) adequate and timely removal of the source of bacteraemia, 2) echocardiography to exclude endocarditis, 3) repeat blood culture to prove clearance of bacteraemia, 4) adequate duration and choice of antibiotics and 5) documentation of bacteraemia in the discharge summary.

After an initial review revealed several areas for improvement, we instituted five Plan-Do-Study-Act learning cycles which involved: teaching microbiology trainees and junior doctors, improving clinical liaison and communication between the microbiology team and clinicians, as well as a clinical review of patients by the microbiology team where appropriate.

The post-intervention review evaluated 24 patients with S. aureus bacteraemia between November 2012 and May 2013. The proportion of patients undergoing an echocardiogram improved from 49% to 88%. Another marked improvement was seen in the timely obtaining of clearance blood cultures, with 88% of patients having clearance blood cultures within the 2-4 day window, compared to 56% pre-intervention. 70% of patients with uncomplicated S. aureus bacteraemia received an appropriate antibiotic course post-intervention, compared with 59% pre-intervention. Documentation of the S. aureus bacteraemia in the discharge summary improved from 65% to 75%. The support of the entire microbiology team was pivotal in the successful outcome of the quality improvement project.
Admission avoidance using intramuscular antibiotics for the treatment of borderline foot infections in people with diabetes in a tertiary care foot clinic
Authors: Dhatariya Ketan
Published: October 2013

Several international guidelines exist to help decision making for the infected 'diabetic foot'. However, none consider admissions avoidance. We wanted to develop an antibiotic foot formulary for the empirical treatment of diabetes related foot infections presenting to our service and subsequently to asses the costs associated with the introduction of our protocol. We rationalised our antibiotic protocol. The introduction of our formulary changed the average antibiotic prescribing costs for a 3 week course of treatment from £17.12 to £16.42. In addition, we adapted the Infectious Disease Society of America (IDSA) guideline by introducing a category of ‘moderate infection – borderline admission’ to our classification. This enabled the administration of outpatient intramuscular antibiotics. Over 22 months of follow up, 26 episodes were eligible for treatment with intramuscular antibiotics. Over the same time period, 121 people were admitted directly from the foot clinic. The costs saved as a result of avoided or delayed admission for those 26 episodes was over £76,000. For 12 people who required subsequent admission, their length of hospital stay was significantly shorter than those admitted directly (9.25 days [range 2-25] vs. 16.11 [2-64] p=0.045). In summary, by modifying the IDSA classification and adopting a protocol to administer outpatient oral and intramuscular antibiotics we have led to substantial cost savings, shorter hospital admissions and also have developed a successful admissions avoidance strategy.
Improving e-discharge letters for Permanent pacemaker insertions at Wansbeck General Hospital
Authors: Taylor Christopher
Published: October 2013

670 patients attend Wansbeck General Hospital each year for elective and emergency permanent pacemaker insertion or modification. Elective patients for new devices attend the cardiology department on the day of procedure and are clerked onto the cardiology ward after insertion. Patients are discharged home the following day with a letter typed by a junior doctor.

Prior to October 2011, junior doctors were unaware of any guidelines regarding content of discharge letters due to poor accessibility. Vital information such as pacemaker model and indication for implantation were frequently absent from the typed summaries. In October 2011, the cardiology department reviewed the guidelines establishing the information required in all discharge summaries for pacemaker implantation and these guidelines were published on the ward in an easy to follow proforma for any junior doctor typing letters.

Eight essential criteria should be included in each letter; date and indication for insertion, pacemaker type, make and model, access route, complications, chest x-ray and device check results, and follow-up details. Finally, a copy of the letter was to be sent to the cardiology department for clinic follow-up.

Ten letters were audited prior to the proforma being issued. 0 letters contained 100% of the required information. Main criteria missing in most letters included indication for insertion (50%), make of device (0%), the route of access (10%) and cc to cardiology department (0%). 70 letters were audited in October 2012, one year following introduction of the discharge proforma.100% of letters contained all of the eight essential criteria required by the departmental guidelines. 53% of the letters were also received by the cardiology department.

In conclusion, a set of easy to follow guidelines in the form of a published document on the cardiology ward has produced dramatic improvement in the quality of e-discharge letters for patients undergoing permanent pacemaker implantation.
Development of an Integrated Subspecialist Multidisciplinary Neuro-oncology Service
Authors: Price Stephen J , Guilfoyle Mathew , J Jefferies Sarah , Harris Fiona , Oberg Ingela , G Burnet Neil , Santarius Thomas , Watts Colin
Published: October 2013

Traditionally, the poor outcome for patients with malignant brain tumours led to therapeutic nihilism. In turn, this resulted in lack of interest in neurosurgical oncology subspecialisation, and less than ideal patient pathways. One problem of concern was the low rate of tumour resection.

Between 1997 and 2006, 685 treated glioblastomas were identified. In the first four years only 40% of patients underwent tumour resection, rising to 55% in the last four years. Before revision of the pathway, the median length of hospital stay was 8 days, and 35% of patients received the results of their histology outside of a clinic setting.

A pathway of care was established, in which all patients were discussed pre-operatively in an MDT meeting and then directed into a new surgical neuro-oncology clinic providing first point of contact. This limited the number of surgeons operating on adult glioma patients and aided recruitment into research studies.

Now, three consultant neurosurgeons run this service, easily fulfilling IOG requirement to spend >50% of programmed activities in neuro-oncology. Nursing support has been critical to provide an integrated service. This model has allowed increased recruitment to clinical trials.

The introduction of this service led to an increase in patients discussed pre-operatively in an MDT (66% rising to 87%; P=0.027), an increase in the rate of surgical resection (from 40% to 80%) and more patients being admitted electively (from 25% to 80%; P<0.001). There was a reduction in the median length of stay (8 days reduced to 4.5 days; P<0.001). For the cohort of GBM patients that went on to have chemoradiotherapy we improved median survival to 18 months, with 35% of patients alive at two years, comparable to international outcomes.

Implementing a specialist neurosurgical oncology service begins with understanding the patient care pathway. Our patients have benefitted from the culture of subspecialisation and the excellent inter-disciplinary working relationships that have been developed.
From Zero to Hero, the rise of the Trauma and Orthopaedic discharge summary
Authors: Evans Jonathan , Armstrong Alexander
Published: October 2013

Discharge summaries document key information after an in-patient care episode and hand back care to the GP. Locally our orthopaedic department used carbon-copy paper as a discharge document. Anecdotally, these were thought to be inaccurate, illegible and of poor quality. Complaints from GPs became a catalyst in assessing the accuracy and presenting it to the department.

A baseline dataset of inaccuracies was collected. This became a good starting point to develop a new improved system of discharging orthopaedic patients. We proposed to develop a bespoke, electronic, patient centred discharge document. Our aims were to improve patient safety, quality and develop an adaptable document, which could be updated to be in line with local CQUINs. The initial challenges of the resistance to change within the department were overcome by presenting data in an open forum with an agreed trial period.

A multidisciplinary team was formed, including managers, consultants, junior doctors, allied health professionals and IT personnel. This facilitated live decision making, streamlining the processes. We created an adaptable online document, which enabled regular updates. This in-turn improved the overall accuracy of the document, improved prescription of key medications and ensured we were able to fulfil local CQUINs. We highly recommend the use of subspecialty specific electronic discharge summaries.
Making the ward a more efficient place: a qualitative evaluation of the impact of the Vista 90 trolley
Authors: Ahluwalia Nikhil
Published: October 2013

A significant amount of professional time is wasted during a medical ward round retrieving patient notes from the ward trolley. If the efficiency of this non-clinical, non-functional interaction could be improved it would save time, maintain continuity and have financial implications.

One identified constraint was the structure of the traditional ward trolley; a stationary filing tray with vertical sleeves. During ward round, time is spent returning and retrieving each patients notes from outside the patient bay and additional time may be wasted if the notes are misplaced or in use elsewhere. To resolve this, the ‘Vista 90’ trolley with horizontal, transparent trays, is portable and has an ergonomic writing surface was selected as a potential second generation replacement.

An assessment of the impact of the Vista 90 trolley over the traditional trolley in the clinical setting was carried out on Erringham (medical) Ward, Worthing Hospital, West Sussex Hospital Trust, UK. This was by way of qualitative analysis performed by semi-structured interview of 12 doctors and other healthcare professionals who regularly interacted with the Vista 90 and traditional trolley in December 2012.

The audit found that those interviewed preferred using the Vista 90 trolley over its predecessor as it improved the efficiency of the ward round and subsequent clinical work. It’s mobility allowed it to be easily transported with the ward round, reducing disruption during a consultation and between consecutives ones. The ergonomic writing surface was noted to improve legibility of documentation due to greater comfort and if placed appropriately, did not interfere with the doctor-patient interaction. The financial savings of this greater efficiency was found to be of significance and justify the cost of the Vista 90 within two weeks.
Improving Peripherally Inserted Central Catheter (PICC) care on a Trauma and Orthopaedics ward
Authors: Piorkowska Marta , Al-Raweshidy Zahra , Yeong Keefai
Published: October 2013

Peripherally Inserted Central Catheter (PICC) blockage rate was audited over a two month period on the Trauma & Orthopaedics ward at our District General Hospital. A 70% (five out of seven) PICC blockage rate was observed. High blockage rates lead to potential treatment complications, delays in delivery of treatment, increase in costs, and reduction in patient satisfaction. The factors contributing to the significant blockage rate include, long and contradictory PICC care guidelines, no information sheets in the patient notes, lack of training and awareness about care of, and flushing of, PICC lines, and lack of accountability for PICC flushing. Our project aimed to achieve a greater rate of PICC patency. We produced one succinct and comprehensive PICC care guideline, carried out staff training sessions, introduced a sticker reminding staff to flush the PICC line after use, and introduced a prescription of weekly heparin saline and PRN saline flushes (for monitoring and accountability). We used questionnaires to assess competency of hospital staff pre-teaching (doctors 6%, nurses 0%), and post-teaching (doctors 70%, nurses 38%). Blockage rate data post-intervention is pending. Education improved awareness of guidelines amongst staff and we anticipate that the proposed interventions will translate into reduced blockage rates, improving patient outcomes and reducing costs.
Strengthening surgical handover: Developing and evaluating the effectiveness of a handover tool to improve patient safety.
Authors: Din Nizar , Ghaderi Shahrzad , O'Connell Rachel , Johnson Tayo
Published: October 2013

The European Working Time Directive and economic challenges have led to a paradigm of shift-work becoming common, and yet the continuation of high-quality patient care remains paramount. Effective and safe transfer of clinical information is critical as emphasised by the Royal College of Surgeons document 'Safe handover: Guidance from the Working Time Directive working party (March 2007)'. The aim of this project was to design and implement a handover proforma in order to deliver a more efficient and safer system for patient care over the weekend. The surgical weekend handover proforma was designed following consultation with nursing and medical colleagues. It included a traffic light scoring system to alert the on-call team of the urgency of clinical review. An educational session was delivered to junior doctors on the surgical rotation to ensure accurate completion of the proforma. All trainee surgical doctors from Foundation Year 1 to Specialist Registrars were asked to complete a pre- and post-intervention questionnaire. Improvement was noted in all categories measured. 85% of the firms were using the new surgical weekend handover sheet. 78% of junior doctors were confident in understanding the patient's condition and executing the clinical jobs faster, with ward rounds lasting less than 3 hours. On average, 20% of patients were discharged per weekend during the trial period. Robust patient handover is vital to maintain patient safety and avoid adverse events. Our findings support the use of a surgical proforma to provide a consistent and structured approach to inpatient handover during the weekend.
Targeting the initial investigation and management in cases of acute pulmonary embolism
Authors: Moore Nicholas , Hawkins Peter
Published: October 2013

It was noted by consultants in our hospital that the early investigation of suspected pulmonary embolism (PE) lacked structure. This was causing delays in definitive diagnosis and early management. The resulting unnecessary use of investigation was also wasting resources. In particular, the inappropriate use of serum d-dimer tests was causing concern. The National Institute of Clinical Excellence (NICE) guidelines recommend use of the 2-level Well's score to target investigation in suspected PE. A baseline audit against the NICE guideline revealed that Well's scores were rarely used (only calculated in 12% of cases) and confirmed the suspicion that early investigation was poorly targeted.

This project intervened using educational talks promoting the use of Well's scores in cases of suspected PE. Well's score proformas were placed in the emergency department and emergency assessment unit for reference. Their availability was advertised.

This significantly increased the use of Well's scores (46% vs 11%, p <0.001). Fewer patients underwent unnecessary d-dimer measurements in cases of likely PE (65% vs 86%). Initial investigation was more targeted in cases where a Well's score had been calculated than in cases without a Well's score. For example, significantly fewer unnecessary d-dimer tests were performed in these cases (45% vs 100%, p < 0.05).

The cost of unnecessary investigation in suspected PE is not only significant financially but also in the resulting delay in definitive diagnosis and management for the patient. The simple intervention used here was effective in addressing this problem.
Look before you LEAPP™: An interprofessional approach to bedside pediatric inpatient procedures
Authors: Botash Ann S , Jeski Michelle , Baish Cameron Colleen , K. Nelsen Elizabeth , Haines Pamela , Bennett Nicholas
Published: October 2013

The Golisano Children’s Hospital at Upstate Medical University is a 71 bed children’s hospital within a hospital, serving nearly two million people in Central New York. Minor procedures occur daily in all children's hospitals, yet team coordination when planning for these procedures is often overlooked. LEAPP™ is a mnemonic for: Listen, Evaluate, Anticipate, Plan, and Proceed. The “Look before You LEAPP™” program was developed by a group of nurses, child life specialists, faculty, a chief resident and a fellow. LEAPP™ is a team-based program providing consistent care to all children undergoing inpatient procedures. It improves patient satisfaction and reduces procedural distress. Through LEAPP™ steps, teams are created at point of care — at the bedside or treatment room of inpatient units. Educational goals are linked to the practical goal of cooperation for good health care.

The approach uses an online educational module for residents, students and nurses to introduce an innovative protocol and a planning tool.1 Pocket cards, promotional pens, and logo door-clings, purchased through grant funds (The Foundation for Upstate Medical University) were initially used to encourage participation. Pre/post observations of procedural planning and performance of the nurse, caregiver, physician, child-life specialist and independent observer included patient and family preparation, pain and anxiety, staffing and supplies, and satisfaction. Fifty procedures were assessed pre-implementation and 28 post implementation. Although satisfaction with procedures improved between pre and post LEAPP™ implementation, there were overall differences in satisfaction with procedural management and pain/anxiety control by physicians, caregivers, and staff that remained statistically significant. Interdisciplinary bedside teamwork can be used to support interprofessional education and this education can similarly be used to support improved patient outcomes.
Improving the transport of urgent specimens to an off-site laboratory using a novel sticker-tracker
Authors: Sepahzad Afsoon , Ejiofor Florence , Giles Susan , Klaber Robert
Published: October 2013

Obtaining results for urgent microbiology specimens in an efficient manner is imperative to ensure that patients receive appropriate antibiotic therapy. A previous audit carried out in the Paediatric department of a central teaching hospital and a number of clinical incidents, highlighted a delay in transport of specimens (exceeding eight hours) and 'missing' specimens. This results in empirical antibiotic treatment of infection, with delay in confirming microbiology result and unnecessary, distressing repeat investigation. As an initial step we sought staff opinion to further explore the problem. A sticker was designed for the microbiology specimen bag to assign accountability, track each step in the transport process and to raise awareness of the problem. The sticker required the member of staff responsible at each stage of the process to time, date and sign it, to allow tracking of potential delays. The new sticker tracking system was promoted and launched in the Paediatric department. Initial challenges included lack of awareness of the protocol and lack of pods for sending urgent specimens. The team met regularly and completed stickers were analysed weekly to identify on-going issues and to devise solutions. Consequently total transport time was reduced to an average of 69 minutes by September (within four hr target). Our intervention improved the efficiency and reliability of urgent specimen transport. This is likely to result in safer antibiotic use and avoid the need for repeat investigation. The system is now also used in the Neonatal department and has lead to the development of a new 'Central Specimens Reception'.
Improving medical SHO weekend handover at a tertiary referral centre
Authors: Curtis Olivia , Fisher Rachel
Published: October 2013

The GMC states that, 'You must be satisfied that, when you are off duty, suitable arrangements have been made for your patients' medical care...including effective hand-over procedures' [1].

The medical weekend handover system at this tertiary referral centre involved multiple pieces of paper with no clear list of tasks, and no way to identify critically unwell patients. Patients could be missed from the ward round or could be difficult to identify under pressure. The authors felt this process could pose a threat to patient safety so decided to improve it.

A questionnaire was distributed to all 11 medical SHOs with 100% response rate. Results showed that 72% thought the process was unstructured, 81% did not think the process was always safe, and 100% thought it could be improved. After discussions with senior medical management and with the approval of the trust audit committee, a new weekend handover proforma was designed, taking into consideration the results and comments from the questionnaire.

The new proforma is accessible through a shared drive, which can be accessed by all medical SHOs in the hospital. Each team is able to copy their patients onto the combined ward-based list. There are columns for specific weekend jobs and registrar/SHO reviews. Any potentially unwell patients are highlighted in bold and discussed with the on-call SHO on Friday.

All medical SHOs were given a post-implementation questionnaire after the new handover process had been in place for two months. Results of this showed that 100% of SHOs felt an improvement had been made, with 100% stating that the new system was more structured (64% always, 36% most of the time). The SHO's perception of patient safety increased from 81% generally unsafe, to 100% generally safe. The new handover has been well received and supported by the current SHO cohort. Improvements in the structure of handover have been made with perceived improvements in patient safety. Due to the success of the system, the handover proforma is being implemented in the trust's sister hospital.
Using a screening tool to improve timely referral of patients from acute oncology-haematology to palliative care services
Authors: Begum Akhtari
Published: October 2013

This project was done at specialist cancer hospital in Qatar. At a haematology-oncology inpatient department most patients were not getting access to palliative care unless they were at the very end stages of life. Data collected from 2008-2011 showed significant numbers of patients were dying within one month of their transfer to palliative care. There was no standard measure to identify the prospective palliative care patients. A multidisciplinary team developed a Palliative care referral screening tool based on the National Cancer Care Network guideline. Retrospective medical record review done from January to April 2012 showed a mean of 68% of patients who scored more than five were not consulted, 32% of patients who scored more than seven were not transferred to palliative care and seven percent died without any referral. The team used various kinds of quality planning, analysis and improvement tools in the form of process mapping, value analysis, Fish Bone diagrams, stakeholders’ analysis and communication, physician survey, "Pareto’s principal" (80 / 20 rule, the law of vital few) and other data collection tools.

The palliative care referral process was standardised by preparing and implementing an objective scoring tool based on international best practice. It changed the referral culture and helped manage the psychological barriers of patients, families and caregivers. Extensive orientation and education of all key stakeholders was implemented. Monthly auditing of patient records was carried out. The aim has been achieved, exceeded and sustained, and we reduced the percentage of patients who scored more than five without palliative consultation from a mean of 68% to 16% and those who scored more than seven without palliative care transfer from a mean of thirty two percent to three percent, after four months of the project's implementation.

Standardising the referral process and creating an objective referral tool is needed to facilitate safe, collaborative, continuous and patient centered care. Timely referral of cancer patients to palliative care minimises patient and caregiver distress, ensures better quality of life, and provides an appropriate measure for end of life care.
Improving documentation and use of ultrasound for suprapubic catheter insertions.
Authors: Day Nigel
Published: October 2013

The British Association of Urological Surgeons (BAUS) published recommendations for the safe insertion of suprapubic catheters (SPCs) in January 2011. They identified a number of parameters surrounding the insertion and maintenance of catheters that should be identified, implemented and documented on each insertion. One such recommendation was the use of ultrasound, if available and appropriate, to aid insertion and improve patient safety. A previous review of our documentation showed that in 2009, ultrasound imaging was not utilised in any of the 19 SPC insertions.

We retrospectively collected data for 36 SPC insertions between April 2010 and December 2011. The information collated was the same as that collected for the BAUS national SPC insertion audit. This quality improvement project identified a significant increase in the use of ultrasound during SPC insertion since 2009 with 17 out of the 36 (47%) cases using this imaging modality. Despite this increase, there was still substantial room for improvement. We also identified some areas of documentation that needed improving, particularly with regard to insertion technique and indication for insertion. As a result, a proforma was designed to be used on each SPC insertion ensuring that all required data is easily identifiable and clearly documented. This proforma is now being used as standard mandatory clinical practice within our Trust.
Improving transmission rates of electronic discharge summaries to GPs
Authors: Barr Rory , Chin Kuen Yeow , Yeong Keefai
Published: October 2013

Discharge summaries are a vital tool to communicate information from Hospital to Primary Care teams; updating GPs about what happened during an admission, and handing over care detailing any follow up care required. Historically, Discharge Summaries have been posted to hospitals, increasing costs for hospitals, creating administrative work for GP practices receiving the letters, and resulting in some letters being lost or delayed in reaching the GP, with implications for patient safety if follow up requests are not received and acted upon.

In an effort to improve patient care, the Clinical Commissioning Group in Surrey drew up a contract with Ashford and St Peter's Foundation Trust, aiming to increase the percentage of discharge summaries sent electronically from the rate of 9% sent within 24 hours, to over 75%. This contract set targets of 50% in May, 65% in June, and 80% in July. Financial penalties would be imposed if targets were not achieved, starting in June 2013.

The Trust set up a working group comprising of doctors, IT personnel and ward PAs to devise a multi-pronged solution to achieve this target. The electronic discharge summary system was reviewed and improvements were designed and developed to make the process of signing off letters easier, and transmission of signed off letters became automated rather than requiring manual transmission by ward PAs. Presentations and leaflets to explain the importance of prompt completion and transmission of discharge summaries were given to Doctors to improve compliance using the revised IT system. Figures on transmission rates were automatically emailed to key stakeholders every day (Ward PAs, Divisional Leads) showing performance on each ward. This helped identify areas requiring more intervention. Areas (e.g. Day Surgery) that had not used electronic discharge summaries were engaged with, and persuaded to take part.

As a result, transmission rates of Discharge Summaries within 24 hours of patient discharge increased from 9% on May 11th 2013, to 76% by June 29th 2013. This has improved communication with GPs, led to more reliable handover of care, and reduced costs for the Trust (both in processing and postage costs, and by avoiding fines).
Improving patient discharge process using electronic medication input tool and on-line guide to arranging follow-ups
Authors: Barr Rory , Chin Kuen Yeow , Yeong Keefai
Published: October 2013

Complete, accurate and timely discharge summaries (TTOs) enable effective communication between hospital teams and GPs. It can prevent adverse events and reduce hospital readmission rates (1). If the discharge summary does not contain important information (e.g. follow-up arrangements, accurate discharge medication list), or if follow-up arrangements are not made, then patient care and outcome can be adversely affected (2,3).

An electronic Medication Input Wizard was developed to improve the quality and reduce the error rates of TTOs. The Wizard makes entering drug information faster; prompts for reasons medication changes; provides examples for Controlled Drug (CD) prescribing; and prompts to refer patients taking warfarin to anticoagulation clinic. An on-line guide was developed which explains how to arrange investigations and appointments. Retrospective studies of TTOs were carried out before and after these interventions, analysing documentation of medication and completion of intended follow-up arrangements.

A baseline audit found 65% of medication changes on TTOs were not clearly documented, and only 8% with changes documented reasons. 40% of prescriptions for CDs were incorrect delaying discharge by 4.9 hours per patient. 80% of intended follow-ups actually happened.

After intervention, TTOs written using the Wizard had 100% of medication changes documented, and 75% were documented with reasons. CD errors decreased to 28% (76% of errors were done without using the Wizard). Follow-up arrangements that occurred increased to 86%. A survey showed 78% of Doctors reported the Wizard was faster than typing the details in separate textboxes, and 94% believed it was beneficial.

Systems should be optimised to encourage better documentation of medication details and reduce prescribing errors. Guides that explain how to make follow-up arrangements should be accessible to Doctors, to make sure follow-ups are organised correctly.
Efficacy of Integrated Rehabilitation Techniques of Traditional Chinese Medicine for Ischemic Stroke: A Randomized Controlled Trial
Authors: Zhang Yong , Jin He , Ma Dayong , Fu Yuanbo , Xie Yanming , Li Zongheng , Zou Yihuai
Published: October 2013

This study aimed to determine the efficacy of Integrated Rehabilitation Techniques of Traditional Chinese Medicine (IRT-TCM) on patients with ischemic stroke as an alternative therapy to conventional rehabilitation techniques. Sixty-nine patients with ischemic stroke were randomly assigned to receive either IRT-TCM (intervention group, n = 46) or conventional rehabilitation techniques (control group, n = 23). The IRT-TCM consisted of a sequential combination of acupuncture and massage techniques. The Fugl-Meyer Assessment (FMA), National Institutes of Health Stroke Scale (NIHSS), Barthel index (BI) and modified Rankin Scale (mRS) were measured on day 0 (baseline, before treatment), day 21, and day 90. We observed that the scores in FMA and BI were increased, and NIHSS were decreased in both groups on day 21 and 90, compared with the baseline (day 0). Furthermore, significantly better scores in FMA of lower limbs and NIHSS were found in patients treated with IRT-TCM on day 21 and 90. For mRS, the percentage of patients ranking 0 and 1 in the intervention group presented a striking contrast to the control group on day 90 but with no significant difference. The results indicated that, as a feasible alternative therapy, IRT-TCM is beneficial for patients with ischemic stroke. Further research with larger sample size, long-term observation, and strict blinding are still in need to confirm the efficacy of IRT-TCM.
Characteristics of Female and Male Visitors to Practitioners of Acupuncture in the HUNT3 Study
Authors: Løhre Audhild , Steinsbekk Aslak , Rise Marit By
Published: October 2013

Characteristics of female and male visitors to practitioners of acupuncture were investigated in a large cross-sectional adult population in Central Norway. A total population health survey, HUNT3, conducted in 2008 with 50,827 respondents provided the data. Demographic variables, lifestyle, health, and use of conventional medicine were analyzed using multivariable logistic regression models. The one year prevalence of visiting a practitioner of acupuncture was 5.7% for females and 2.2% for males. Visitors of both genders were five times more likely to have had somatic complaints in the preceding year and were 2–3 times more likely to report poor global health than female or male non-visitors. Also, visitors of both genders were more likely to do hard physical activities every week, and they were less likely to live alone or be daily smokers. Further, female visitors were characterized by having higher education and were more likely to have a paid job than other females. Corresponding differences were not seen among males. Age showed limited associations with being a visitor, and for females only. Valid for both genders, our findings draw a picture of visitors to acupuncture treatment as persons who actively contribute to promoting their health through lifestyle choices of physical activity and non-smoking while simultaneously having worse global health and higher burdens of somatic complaints than other adults. In contrast to males, it is suggested that females may be more dependent on personal income, as indicated by higher education and being in a paid job, in choosing acupuncture treatment in addition to conventional medicine.
Systematic Review and Meta-Analysis of Traditional Chinese Medicine in the Treatment of Migraines
Authors: Zhou Liang , Chen Pinyi , Liu Ling , Zhang Yanqi , Liu Xiaoyu , Wu Yazhou , Jiang Lei , Cheng Dixiang , Huang Wenquan , Pettigrew Julia Christine , Yi Dong
Published: October 2013

Migraine is a chronic disorder characterized by recurrent moderate to severe headaches often in association with a number of autonomic nervous system symptoms. It is a common disease and incidence has increased yearly. Chinese medical treatments are popularly used in Asian countries, although they vary in effectiveness. In this study, we applied a systematic review method and combined meta-regression with meta-subgroup analysis to explore heterogeneity of clinical therapeutic efficacy upon meta-analysis of randomized controlled Chinese medical treatments for migraine. We also aimed to provide a more effective Chinese prescription and to advance the knowledge in evaluating validity of preventing or alleviating migraine symptoms with Chinese medical treatments. Twenty randomized migraine control trails, including 2246 patients, were collected from online databases: PubMed, MEDLINE, EMBASE, CENTRAL of Cochrane Library, CBM, integrated version of CMCI/CMCC, TCM online, CDFD, and CMFD from January 2000 to December 2011. The results showed that the major factors influencing therapeutic efficacy were either the specific medicine form of or its prescription type (p < 0.05). The use of TCM decoctions, especially those that condition the viscera, treat from the perspective of "wind", and target the Shaoyang gateway, could be the best migraine treatment in clinical TCM practice (RR > 1.30).
GABA-Mimetic Actions ofWithania somniferaon Substantia Gelatinosa Neurons of the Trigeminal Subnucleus Caudalis in Mice
Authors: Yin Hua , Cho Dong Hyu , Park Soo Joung , Han Seong Kyu
Published: October 2013

The plant Withania somnifera (WS), also known as Ashwagandha, has been used widely in traditional medicine systems in India and Nepal (Ayurveda), and has been accepted to cure various ailments. In this study, the whole-cell patch clamp technique was performed to examine the mechanism of action of WS on the SG neurons of the Vc from mouse brainstem slices. In whole-cell patch clamp mode, methanol extract of Withania somnifera (mWS) induced short-lived and repeatable inward currents in all SG neurons tested (31.3±8.51 pA, n = 7) using a high chloride pipette solution. The mWS-induced inward currents were concentration dependent and maintained in the presence of tetrodotoxin (TTX), a voltage gated Na+channel blocker, CNQX, a non-NMDA glutamate receptor antagonist, AP5, an NMDA receptor antagonist and strychnine, a glycine receptor antagonist. The mWS induced currents were blocked by picrotoxin, a GABAAreceptor antagonist. These results show that mWS has an inhibitory effects on SG neurons of the Vc through GABAAreceptor-mediated activation of chloride ion channels, indicating that mWS contains compounds with sedative effects on the central nervous system. These results also suggest that mWS may be a potential target for modulating orofacial pain processing.
Mitochondrial Protective Effects of Myrica rubra Extract Against Acetaminophen-Induced Toxicity
Authors: Gou Wenwen , Xu Lizhi , Wang Yucai , Yu Wen , Zhong Zengtao , Gao Jing , Chen Huimei , Wang Yaping
Published: October 2013

The present study investigates the hepatoprotective activity of Myrica rubra Sieb. et Zucc. extract (MCE) against acetaminophen (AAP)-induced liver damage and elucidates the possible mechanisms behind the hepatoprotection observed. Serum alanine aminotransferase and serum aspartate aminotransferase activities were detected and liver histopathology was observed. Mitochondrial swelling, mitochondrial membrane potential, and voltage-dependent anion channel (VDAC) gene transcription were also investigated. The results showed that 50, 150, and 450 mg/kg MCE could restore AAP-induced changes in mice liver in a dose-dependent manner. The mechanisms behind the hepatoprotective effects of MCE may be related to the mitochondrial protection of liver cells, especially of VDAC, an important protein on the outer membrane of the mitochondria.
Anti-Inflammatory Effects ofDanshenon Human Vascular Endothelial Cells in Culture
Authors: Stumpf Christian , Fan Quiaoling , Hintermann Christian , Raaz Dorette , Kurfürst Ingrid , Losert Sigrid , Pflederer Wolfgang , Achenbach Stephan , Daniel Werner G. , Garlichs Christoph D.
Published: October 2013

Inflammation plays a crucial role in the pathophysiology of atherosclerosis. Besides cytokines, chemokines and cell adhesion molecules, CD40 and P-selectin play important roles as key regulators of the inflammatory process in atherosclerosis. Danshen (DS) is commonly used in traditional Chinese medicine for therapy of cardiovascular diseases such as coronary artery disease. The aim of the present study was to evaluate the protective effects of DS with respect to possible anti-inflammatory effects. Human umbilical vein endothelial cells as well as platelets were incubated with an extract of DS or one of its major ingredients salvianolic acid B (Sal B), tanshinone IIA (Tansh) and protocatechuic acid (Protoc) under tumor necrosis factor (TNF)-α or ADP stimulation. Expression of CD40 and cellular adhesion molecules (VCAM-1/ICAM-1) were assessed via flow cytometry. Levels of interleukin (IL)-6, IL-8, monocyte-chemoattractant-protein (MCP)-1 as well as soluble VCAM1 and ICAM-1 in the supernatants were examined via luminex based analysis. Treatment with DS attenuated TNF-α induced expression of CD40. Furthermore, the expression of VCAM-1 and ICAM-1 as well as the release of soluble VCAM-1 and ICAM-1 were downregulated. In the cell supernatants we also observed a significant reduction of IL-6, IL8 and MCP-1. DS and its major ingredients, Sal B and Protoc, significantly inhibited TNF-induced expression and release of adhesion molecules, cytokines and chemokines as well as ADP-induced expression of platelet P-selectin. Because of the key roles of inflammatory mediators in the etiology of atherosclerosis, this work provides useful insight in understanding the pharmacological efficacy of Chinese herbal medicine.
Novel Effect of Paeonol on the Formation of Foam Cells: Promotion of LXRα-ABCA1–Dependent Cholesterol Efflux in Macrophages
Authors: Zhao Jin-Feng , Jim Leu Shr-Jeng , Shyue Song-Kun , Su Kuo-Hui , Wei Jeng , Lee Tzong-Shyuan
Published: October 2013

Paeonol, a phenolic component purified from Paeonia suffruticosa (Cortex Moutan), is used in traditional Chinese medicine to treat inflammatory diseases. However, little is known about the effect of paeonol on cholesterol metabolism. We investigated the efficacy of paeonol on cholesterol metabolism and the underlying mechanism in macrophages and apolipoprotein E deficient (apoE-/-) mice. Treatment with paeonol markedly attenuated cholesterol accumulation induced by oxidized LDL in macrophages, which was due to increased cholesterol efflux. Additionally, paeonol enhanced the mRNA and protein expression of ATP-binding membrane cassette transport protein A1 (ABCA1) but did not alter the protein level of ABCG1 or other scavenger receptors. Inhibition of ABCA1 activity with a pharmacological inhibitor, neutralizing antibody or small interfering RNA (siRNA), negated the effects of paeonol on cholesterol efflux and cholesterol accumulation. Furthermore, paeonol induced the nuclear translocation of liver X receptor α (LXRα) by increasing its activity. siRNA knockdown of LXRα abolished the paeonol-induced upregulation of ABCA1, promotion of cholesterol efflux and suppression of cholesterol accumulation. Moreover, atherosclerotic lesions, hyperlipidemia and systemic inflammation were reduced and the protein expression of ABCA1 was increased in aortas of paeonol-treated apoE-/- mice. Paeonol may alleviate the formation of foam cells by enhancing LXRα-ABCA1–dependent cholesterol efflux.
ROCKING AND SLIDING OF ANCIENT TEMPLE COLUMNS UNDER EARTHQUAKE EXCITATIONS
Authors: MICHALTSOS GEORGE T. , RAFTOYIANNIS IOANNIS G.
Published: October 2013

This paper deals with the rocking and sliding behavior of a monolithic stone block or a system of stone blocks under earthquakes, a problem commonly observed for ancient temples in Greece and Southern Italy. The analysis for the above monolithic or multi-drum columns is conducted by a simple process based on generally accepted simplifications. The effects of column geometry, earthquake characteristics and restitution ratio due to impact are also studied herein. Furthermore, an analytical approach for the solution of the complete nonlinear equations of motion (including the one for the vertical earthquake excitation) for the subject considered is proposed. Finally, characteristic representative examples are presented with useful conclusions drawn. It was found that the stability criteria based on static conditions are reliable, while the corresponding dynamic criteria may lead to erroneous results.
CO-INNOVATION BY KIBS IN ENVIRONMENTAL SERVICES — A KNOWLEDGE-BASED PERSPECTIVE
Authors: CASTALDI CAROLINA , FABER JAN , KISHNA MAIKEL J.
Published: October 2013

This paper investigates the ability of knowledge intensive business firms (KIBS) to engage in co-innovation with client firms. Co-innovation is related to the competitive advantage of KIBS as knowledge creators and sources of innovation. We apply a knowledge-based perspective where knowledge-related resources and learning capabilities explain why certain KIBS firms are able to co-innovate. We couple our theoretical expectations with qualitative evidence on three best practices in the Dutch market for environmental services.
STRATEGIES OF SUSTAINABLE MANAGEMENT AND BUSINESS PERFORMANCE: AN ANALYSIS IN INNOVATIVE COMPANIES
Authors: GOMES CLANDIA MAFFINI , SCHERER FLÁVIA LUCIANE , GONÇALVES DE MENEZES UIARA , DA LUZ NETO ROBERTO , KRUGLIANSKAS ISAK
Published: October 2013

The main objective of the study was to understand how sustainable business strategies relate to business performance considering different sectors, sizes and levels of international integration. Thus, we identified the major social and environmental management practices of Brazilian companies and the leading indicators that make up the performance of the companies surveyed. The research was characterised as a quantitative research. Among the main aspects highlighted in the analysis one should mention the supremacy of the environmental variable in the relationship with the business performance. With less intensity arise the variable reputation/image, showing that this variable is among the priorities in the socio-environmental agenda of companies. The social variable seems to be among the least concerns of firms, or it is not yet seen by managers as a strategic element to their business competitiveness. The methodological procedures adopted allow us to confirm the existence of a relationship between socio-environmental management practices and business performance.
Ferroelectric ceramic materials of the Aurivillius family
Authors: Peláiz-Barranco A. , González-Abreu Y.
Published: October 2013

Ferroelectric ceramics are important materials with a wide range of industrial and commercial applications. Since the discovery of the phenomenon of ferroelectricity, they have been the heart and soul of several multibillion dollar industries, ranging from high-dielectric-permittivity capacitors to developments in piezoelectric transducers, pyroelectric sensors, medical diagnostic transducers, electro-optical devices, etc. Materials based on barium titanate and lead zirconate titanate have dominated the field throughout their history. Actually, the ferroelectric ceramics from the Aurivillius family receive great attention due to their large remanent polarization, lead-free nature, relatively low processing temperatures, high Curie temperatures and excellent piezoelectric properties, which made them good candidates for multiple applications. This review presents a general overview of the progress in the studies on the ferroelectric ceramics from the Aurivillius family. The progress includes several aspects: (i) structural studies, (ii) dielectric and electric behavior, (iii) piezoelectricity, and (iv) pyroelectricity.