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Increasingly, ambulance services offer alternatives to transfer to the emergency department (ED), when this is better for patients. The introduction of electronic health records (EHR) in ambulance services is encouraged by national policy across the United Kingdom (UK) but roll-out has been variable and complex.
Electronic Records in Ambulances (ERA) is a two-year study which aims to investigate and describe the opportunities and challenges of implementing EHR and associated technology in ambulances to support a safe and effective shift to out of hospital care, including the implications for workforce in terms of training, role and clinical decision-making skills.
Our study includes a scoping review of relevant issues and a baseline assessment of progress in all UK ambulance services in implementing EHR. These will inform four in-depth case studies of services at different stages of implementation, assessing current usage, and examining context.
The scoping review identified themes including: there are many perceived potential benefits of EHR, such as improved safety and remote diagnostics, but as yet little evidence of them; technical challenges to implementation may inhibit uptake and lead to increased workload in the short term; staff implementing EHR may do so selectively or devise workarounds; and EHR may be perceived as a tool of staff surveillance.
Our scoping review identified some complex issues around the implementation of EHR and the relevant challenges, opportunities and workforce implications. These will help to inform our fieldwork and subsequent data analysis in the case study sites, to begin early in 2017. Lessons learned from the experience of implementing EHR so far should inform future development of information technology in ambulance services, and help service providers to understand how best to maximize the opportunities offered by EHR to redesign care.
This paper analyses the origin of innovation using institutional economic theory. Because of distributed information and fundamental uncertainty, an efficient institutional context for the economic organization of innovation in its early stages is often that of a common pool resource. The theory of the innovation commons draws upon Hayek, Williamson and Ostrom to present the innovation problem as a combined knowledge problem, implicit contracting problem and collective action governance problem. Innovation commons theory also implies that Kirzner's model of entrepreneurial opportunity discovery extends to higher-order groups, suggesting a multilevel selection model of economic evolution.
The general contours of nineteenth-century collegiate development, as found in the histories of American higher education, probably need substantial reexamination and extensive reshaping. Traditionally, colleges associated with various denominations are characterized largely in terms of sect-like religious zeal and are assigned the early nineteenth century as their period of importance. The few monographic studies of late nineteenth-century colleges and the more numerous works on the emergence of universities are correspondingly cast in a framework of increasing secularism in higher education. It seems more likely, however, that the current historical conception of the denominational college more closely coincides with realities of institutional development after rather than before 1850. In terms of support, control, and functions, there is evidence of a strong and increasing denominationalism in a large majority of late nineteenth-century colleges. For most of the institutions with founding dates prior to 1850 this degree of denominationalism is a departure from the primary role played by localism in founding and nurturing these educational enterprises during their earliest years. Although additional research will be necessary to confirm this contrast, there is good reason to anticipate that the traditional generalization concerning a basic trend from sectarianism toward secularism, when applied to American collegiate history during the nineteenth century, will have to be inverted.
The criteria set out by the International Union for Conservation of Nature to identify threatened species requires information on population trends which, for priority lichen species within Scotland, is lacking. Collecting such data is problematic as there is a lack of empirical information on the performance of different sampling designs and survey methodologies. Using Pseudocyphellaria norvegica as an example species, we tested differences in the efficiency of 3 transect patterns and a 20 minute search for surveying 100×100 m cells of potentially suitable habitat. The methods were not intended to census the total population of the cells but, rather, to provide a standardized, repeatable estimate of the population density to allow detection of trends through time. We also tested the repeatability of the methods between surveyors. The results provided no evidence to suggest that controlled survey methodologies using fixed transect patterns were any better in terms of consistency between surveyors or numbers of occupied trees found than 20 minute searches of the areas within each 100×100 m cell deemed suitable for the target species by an experienced surveyor. Given that following the fixed transect patterns took approximately twice as long as a 20 minute search, the search method would clearly be more cost-effective when there are large numbers of cells to survey. For all survey methods variability between surveyors was high, meaning that it would be extremely difficult to detect temporal changes in populations, and hence identify population trends. We also examined the extent to which recording presence/absence at the 1 ha scale might improve consistency between surveyors and found that it reduced, but did not eliminate, the surveyor variability. Recording only presence/absence would allow greater numbers of cells to be surveyed using the same level of resources, but would reduce the amount of information available per cell for use in analysis of population trends. We conclude that controlling inter-surveyor variability while collecting adequate data for population trend analysis is a major issue when planning and implementing any large-scale survey of lichen species.
This patient case-study represents the introduction of radiotherapy in the management of extra-cranial vascular malformations, a topic with virtually no supported literature before our case study. In those patients refractory to established therapies and facing the inevitability of mutilating amputation, radiotherapy may be a viable option to preserve the limb.
Symptoms of attention-deficit hyperactivity disorder (ADHD) are known to
persist into adulthood in the majority of cases.
To determine the prevalence of methylphenidate, dexamfetamine and
atomoxetine prescribing and treatment discontinuation in adolescents and
A descriptive cohort study using the UK General Practice Research
Database included patients aged 15–21 years from 1999 to 2006 with a
prescription for a study drug.
Prevalence of prescribing averaged across all ages increased 6.23-fold
over the study period. Overall, prevalence decreased with age: in 2006,
prevalence in males dropped 95% from 12.77 per 1000 in 15-year-olds to
0.64 per 1000 in 21-year-olds. A longitudinal analysis of a cohort of 44
patients aged 15 years in 1999 demonstrated that no patient received
treatment after the age of 21 years.
The prevalence of prescribing by general practitioners to patients with
ADHD drops significantly from age 15 to age 21 years. The fall in
prescribing is greater than the reported age-related decrease in
symptoms, raising the possibility that treatment is prematurely
discontinued in some young adults in whom symptoms persist.
In September of 2004, we investigated 7 cases of post-myelography meningitis. Streptococcal species were recovered from blood or cerebrospinal fluid in all cases. Our findings suggest that droplet transmission of the oral flora of the clinician performing the procedure was the most likely source of these infections. The Centers for Disease Control and Prevention recommends the use of face masks by those performing myelograms.
Event-related potentials (ERPs) provide a noninvasive
method to evaluate neural activation and cognitive processes
in schizophrenia. The pathophysiological significance of
these findings would be greatly enhanced if scalp-recorded
ERP abnormalities could be related to specific neural circuits
and/or regions of the brain. Using quantitative approaches
in which scalp-recorded ERP components are correlated with
underlying neuroanatomy in schizophrenia, we focused on
biophysical and statistical procedures (partial least squares)
to relate the auditory P300 component to anatomic measures
obtained from quantitative magnetic resonance imaging.
These findings are consistent with other evidence that
temporal lobe structures contribute to the generation of
the scalp-recorded P300 component and that P300 amplitude
asymmetry over temporal recording sites on the scalp may
reflect anatomic asymmetries in the volume of the superior
temporal gyrus in schizophrenia.
A cluster of cerebrospinal fluid Gram's stains showing gram-positive bacilli and of cerebrospinal fluid cultures growing Bacillus species in a large community teaching hospital prompted an epidemiologic and microbiologic investigation. Pseudomeningitis was suspected and confirmed when cultures of uninoculated commercial trypticase soy broth with 5% Fildes enrichment grew Bacillus species. Secondary contamination of the pipettes used for inoculation accounted for the positive cerebrospinal fluid Gram's stains. The costs of this pseudo-outbreak included unnecessary antibiotic therapy, lumbar punctures, and hospitalization. Such adverse effects can be minimized by increased physician awareness of pseudoinfections and by prompt investigation of such occurrences.
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