Feedback GAP: pragmatic,cluster-randomized trial of goal setting and action plans to increase the effectiveness of audit and feedback interventions in primary care

Background

Audit and feedback to physicians is a commonly used quality improvement strategy, but its optimal design is unknown. This trial tested the effects of a theory-informed worksheet to facilitate goal setting and action planning, appended to feedback reports on chronic disease management, compared to feedback reports provided without these worksheets.

Methods

A two-arm pragmatic cluster randomized trial was conducted, with allocation at the level of primary care clinics. Participants were family physicians who contributed data from their electronic medical records. The ‘usual feedback’ arm received feedback every six months for two years regarding the proportion of their patients meeting quality targets for diabetes and/or ischemic heart disease. The intervention arm received these same reports plus a worksheet designed to facilitate goal setting and action plan development in response to the feedback reports. Blood pressure (BP) and low-density lipoprotein cholesterol (LDL) values were compared after two years as the primary outcomes. Process outcomes measured the proportion of guideline-recommended actions (e.g., testing and prescribing) conducted within the appropriate timeframe. Intention-to-treat analysis was performed.

Results

Outcomes were similar across groups at baseline. Final analysis included 20 physicians from seven clinics and 1,832 patients in the intervention arm (15% loss to follow up) and 29 physicians from seven clinics and 2,223 patients in the usual feedback arm (10% loss to follow up). Ten of 20 physicians completed the worksheet at least once during the study. Mean BP was 128/72 in the feedback plus worksheet arm and 128/73 in the feedback alone arm, while LDL was 2.1 and 2.0, respectively. Thus, no significant differences were observed across groups in the primary outcomes, but mean haemoglobin A1c was lower in the feedback plus worksheet arm (7.2% versus 7.4%, p<0.001). Improvements in both arms were noted over time for one-half of the process outcomes.

Discussion

Appending a theory-informed goal setting and action planning worksheet to an externally produced audit and feedback intervention did not lead to improvements in patient outcomes. The results may be explained in part by passive dissemination of the worksheet leading to inadequate engagement with the intervention.

Trial registration

ClinicalTrials.gov NCT00996645

     

Link Clustering Reveals Structural Characteristics and Biological Contexts in Signed Molecular Networks

Many biological networks are signed molecular networks which consist of positive and negative links. To reveal the distinct features between links with different signs, we proposed signed link-clustering coefficients that assess the similarity of inter-action profiles between linked molecules. We found that positive links tended to cluster together, while negative links usually behaved like bridges between positive clusters. Positive links with higher adhesiveness tended to share protein domains, be associated with protein-protein interactions and make intra-connections within protein complexes. Negative links that were more bridge-like tended to make interconnections between protein complexes. Utilizing the proposed measures to group positive links, we observed hierarchical modules that could be well characterized by functional annotations or known protein complexes. Our results imply that the proposed sign-specific measures can help reveal the network structural characteristics and the embedded biological contexts of signed links, as well as the functional organization of signed molecular networks.     

Do Chinese Readers Follow the National Standard Rules for Word Segmentation during Reading?

We conducted a preliminary study to examine whether Chinese readers’ spontaneous word segmentation processing is consistent with the national standard rules of word segmentation based on the Contemporary Chinese language word segmentation specification for information processing (CCLWSSIP). Participants were asked to segment Chinese sentences into individual words according to their prior knowledge of words. The results showed that Chinese readers did not follow the segmentation rules of the CCLWSSIP, and their word segmentation processing was influenced by the syntactic categories of consecutive words. In many cases, the participants did not consider the auxiliary words, adverbs, adjectives, nouns, verbs, numerals and quantifiers as single word units. Generally, Chinese readers tended to combine function words with content words to form single word units, indicating they were inclined to chunk single words into large information units during word segmentation. Additionally, the “overextension of monosyllable words” hypothesis was tested and it might need to be corrected to some degree, implying that word length have an implicit influence on Chinese readers’ segmentation processing. Implications of these results for models of word recognition and eye movement control are discussed.     

Mab_3168c,a Putative Acetyltransferase,Enhances Adherence,Intracellular Survival and Antimicrobial Resistance of Mycobacterium abscessus

Mycobacterium abscessus is a non-tuberculous mycobacterium. It can cause diseases in both immunosuppressed and immunocompetent patients and is highly resistant to multiple antimicrobial agents. M. abscessus displays two different colony morphology types: smooth and rough morphotypes. Cells with a rough morphotype are more virulent. The purpose of this study was to identify genes responsible for M. abscessus morphotype switching. With transposon mutagenesis, a mutant with a Tn5 inserted into the promoter region of the mab_3168c gene was found to switch its colonies from a rough to a smooth morphotype. This mutant had a higher sliding motility but a lower ability to form biofilms, aggregate in culture, and survive inside macrophages. Results of bioinformatic analyses suggest that the putative Mab_3168c protein is a member of the GCN5-related N-acetyltransferase superfamily. This prediction was supported by the demonstration that the mab_3168c gene conferred M. abscessus and M. smegmatis cells resistance to amikacin. The multiple roles of mab_3168c suggest that it could be a potential target for development of therapeutic regimens to treat diseases caused by M. abscessus.     

Oxidized Low Density Lipoprotein Induced Caspase-1 Mediated Pyroptotic Cell Death in Macrophages: Implication in Lesion Instability?

Background

Macrophage death in advanced lesion has been confirmed to play an important role in plaque instability. However, the mechanism underlying lesion macrophage death still remains largely unknown.

Methods and Results

Immunohistochemistry showed that caspase-1 activated in advanced lesion and co-located with macrophages and TUNEL positive reaction. In in-vitro experiments showed that ox-LDL induced caspase-1 activation and this activation was required for ox-LDL induced macrophages lysis, IL-1β and IL-18 production as well as DNA fragmentation. Mechanism experiments showed that CD36 and NLRP3/caspase-1/pathway involved in ox-LDL induced macrophage pyroptosis.

Conclusion

Our study here identified a novel cell death, pyroptosis in ox-LDL induced human macrophage, which may be implicated in lesion macrophages death and play an important role in lesion instability.     

Epidemiological Characteristics of Lower Extremity Cellulitis after a Typhoon Flood

Objective

The flood after a typhoon may lead to increase in patients with cellulitis of lower limbs. However, the microbiological features of these cases are rarely reported. We conducted a study of patients with lower extremity cellulitis after a typhoon followed in southern Taiwan to study the risk factors of cellulitis and the bacteriological features of the patients.

Methods

We reviewed all the medical records of cellulitis at emergency departments of two teaching hospitals in southern Taiwan 30 days before and after the landing of Typhoon Morakot and collected data on the demographic and bacteriological characteristics. In addition, we evaluated the relationship between the daily number of patients and the rainfall in the Tainan area.

Results

The number of cellulitis patients increased from 183 to 344 during the 30-day period after the typhoon. The number peaked in the third and fourth days and lasted for 3 weeks. The proportion of patients with water immersion of the affected limb was higher after the typhoon (6% vs. 37%, odds ratio [OR]: 9.0, 95% Confidence interval [CI]: 4.7–17.2). We found cultures from the infected limbs with immersion had more polymicrobial (73% vs. 26%, OR: 7.8, 95% CI: 3.2–19.2) and Gram-negative bacilli infection (86% vs. 34%, OR: 11.8, 95% CI: 4.1–34.5).

Conclusions

Flood arose from Typhoon Morakot caused increases in cellulitis patients, which lasted for 3 weeks. Antibiotic treatment that were effective to both Gram-positive cocci and Gram-negative bacilli are recommended for patients with limbs emerged in the water.     

A Novel Cell-Penetrating Peptide Derived from Human Eosinophil Cationic Protein

Cell-penetrating peptides (CPPs) are short peptides which can carry various types of molecules into cells; however, although most CPPs rapidly penetrate cells in vitro, their in vivo tissue-targeting specificities are low. Herein, we describe cell-binding, internalization, and targeting characteristics of a newly identified 10-residue CPP, denoted ECP^32–41, derived from the core heparin-binding motif of human eosinophil cationic protein (ECP). Besides traditional emphasis on positively charged residues, the presence of cysteine and tryptophan residues was demonstrated to be essential for internalization. ECP^32–41 entered Beas-2B and wild-type CHO-K1 cells, but not CHO cells lacking of cell-surface glycosaminoglycans (GAGs), indicating that binding of ECP^32–41 to cell-surface GAGs was required for internalization. When cells were cultured with GAGs or pre-treated with GAG-digesting enzymes, significant decreases in ECP^32–41 internalization were observed, suggesting that cell-surface GAGs, especially heparan sulfate proteoglycans were necessary for ECP^32–41 attachment and penetration. Furthermore, treatment with pharmacological agents identified two forms of energy-dependent endocytosis, lipid-raft endocytosis and macropinocytosis, as the major ECP^32–41 internalization routes. ECP^32–41 was demonstrated to transport various cargoes including fluorescent chemical, fluorescent protein, and peptidomimetic drug into cultured Beas-2B cells in vitro, and targeted broncho-epithelial and intestinal villi tissues in vivo. Hence this CPP has the potential to serve as a novel vehicle for intracellular delivery of biomolecules or medicines, especially for the treatment of pulmonary or gastrointestinal diseases.     

Tangshenosides from Codonopsis lanceolata roots

A new symmetrical phenylpropanoid glycoside, tangshenoside VIII (1), together with six known tangshenosides (2–7) were isolated from the roots of Codonopsis lanceolata (Campanulaceae). Their structures were established on the basis of spectroscopic data, including two-dimensional NMR analyses. Tangshenosides have chemotaxonomic significance.