Involving older people with multimorbidity in decision-making about their primary healthcare: A Cochrane systematic review of interventions (abridged)

OBJECTIVE

To assess the effects of interventions aimed at involving older people with multimorbidity in decision-making about their healthcare during primary care consultations.

METHODS

Cochrane methodological procedures were applied. Searches covered all relevant trial registries and databases. Randomised controlled trials were identified where interventions had been compared with usual care/ control/ another intervention. A narrative synthesis is presented; meta-analysis was not appropriate.

RESULTS

8160 abstracts and 54 full-text articles were screened. Three studies were included, involving 1879 patient participants. Interventions utilised behaviour change theory; cognitive-behavioural therapy and motivational interviewing; multidisciplinary, holistic patient review and organisational changes. No studies reported the primary outcome 'patient involvement in decision-making about their healthcare'. Patient involvement was evident in the theory underpinning interventions. Certainty of evidence (assessed using GRADE) was limited by small studies and inconsistency in secondary outcomes measured.

CONCLUSION

The evidence base is currently too limited to interpret with certainty. Transparency in design and consistency in evaluation, using validated measures, is required for future interventions involving older patients with multimorbidity in decisions about their healthcare.

PRACTICE IMPLICATIONS

There is a large gap between clinical guidelines for multimorbidity and an evidence base for implementation of their recommendations during primary care consultations with older people.

Financial Neutrality for Living Organ Donors: Reasoning, Rationale, Definitions, and Implementation Strategies

In the United States, live organ donation can be a costly and burdensome undertaking for donors. While most donation-related medical expenses are covered, many donors still face lost wages, travel expenses, incidentals, and potential for future insurability problems. Despite widespread consensus that live donors (LD) should not be responsible for the costs associated with donation, little has changed to alleviate financial burdens for LDs in the last decade. To achieve this goal, the transplant community must actively pursue strategies and policies to eliminate unreimbursed out-of-pocket costs to LDs. Costs should be more appropriately distributed across all stakeholders; this will also make live donation possible for people who, in the current system, cannot afford to proceed. We propose the goal of LD "financial neutrality," offer an operational definition to include the coverage/reimbursement of all medical, travel, and lodging costs, along with lost wages, related to the act of donating an organ, and guidance for consideration of medical care coverage, and wage and other expense reimbursement. The intent of this report is to provide a foundation to inform discussion within the transplant community and to advance initiatives for policy and resource allocation.

Positive impacts on rural and regional workforce from the first seven cohorts of James Cook University medical graduates

INTRODUCTION

The regionally-based James Cook University (JCU) School of Medicine aims to meet its mission to address the health needs of the region by combining selection and curriculum strategies shown to increase rural career recruitment outcomes. The School has graduated 536 students in its first seven cohorts from 2005 to 2011. This paper presents the early career practice locations and the specialty training undertaken by these cohorts, and describes the association between later practice location with both hometown at application and internship location.

METHODS

Hometown at application' data for JCU Bachelor of Medicine, Bachelor of Surgery (MBBS) graduates was retrieved from administrative databases held by the university, while postgraduate location and career data were obtained either from personal contact via email, telephone, Facebook or electronically from the Australian Health Practitioner Regulation Authority website. Practice location was described across Australian Standard Geographical Classification Remoteness Area (RA) categories.

RESULTS

Data for the primary practice location of 536 JCU MBBS graduates across postgraduate years (PGY) 1 to 7 is 99% complete. A total of 65% of JCU graduates undertook their internship in non-metropolitan locations including 20% in RA 2 and 44% in RA 3-5, a pattern of practice different to that of other Australian clinicians. For the internship year, 'non-metropolitan-origin' JCU MBBS graduates predominantly worked in RA 2-5 locations, while 'metropolitan origin' graduates were more likely to work in major cities. However, by PGY 7, the distribution of 'rural' and 'metropolitan' origin JCU graduates across RA categories was similar. The RA category of internship location - either 'metropolitan (RA 1) or 'non-metropolitan' (RA 2-5) - was associated with the location of subsequent practice across PGY 2-7.

CONCLUSION

This comprehensive data set provides the first real evidence from one of Australia's new medical schools on actual postgraduate practice location, as compared to 'intent to practice'. The geographic profile by RA of JCU graduates' hometown and patterns of postgraduate practice is different to that of other Australian medical students and doctors. This early evidence supports the JCU model of distributed non-metropolitan medical education, and suggests more regionally-located internship and specialty training places would further increase the medical workforce in northern and/or rural Australia. The workforce impact of the seven cohorts of graduates in this study is starting to be felt in rural and regional Australia, and, if these trends continue, will result in significant workforce improvements over the next decade. These results support further investment in regional and rural medical education.

Similar effectiveness of paroxetine, fluoxetine, and sertraline in primary care: a randomized trial

CONTEXT

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed class of antidepressant, yet it is not known whether one SSRI is more effective than another.

OBJECTIVE

To compare the effectiveness of 3 SSRIs (paroxetine, fluoxetine, and sertraline) in depressed primary care patients.

DESIGN

Open-label, randomized, intention-to-treat trial, with patient enrollment occurring in April-November 1999.

SETTING

Thirty-seven clinics in 2 US primary care research networks.

PATIENTS

A total of 573 depressed adult patients for whom their primary care physician thought that antidepressant therapy was warranted and who completed a baseline interview.

INTERVENTIONS

Patients were randomly assigned to receive paroxetine (n = 189), fluoxetine (n = 193), or sertraline (n = 191) for 9 months. Primary care physicians were allowed to switch patients to a different SSRI or non-SSRI antidepressant if they did not adequately respond to or tolerate the initial SSRI.

MAIN OUTCOME MEASURES

The primary outcome measure was change in the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) Mental Component Summary score (range, 0-100), compared across treatment groups at 1, 3, 6, and 9 months. Secondary outcomes included other depression and psychological measures, multiple measures of social and work functioning, and other domains of health-related quality of life, such as physical functioning, concentration and memory, vitality, bodily pain, sleep, and sexual functioning.

RESULTS

Follow-up interviews were successfully completed in 94% of patients at 1 month, 87% at 3 months, 84% at 6 months, and 79% at 9 months. Responses to the 3 SSRIs were comparable on all measures and at all time points. The mean change in the SF-36 Mental Component Summary score at 9 months was + 15.8 in the paroxetine group, + 15.1 in the fluoxetine group, and + 17.4 in the sertraline group. The drugs were also associated with similar incidences of adverse effects and discontinuation rates.

CONCLUSIONS

The SSRI antidepressants paroxetine, fluoxetine, and sertraline were similar in effectiveness for depressive symptoms as well as multiple domains of health-related quality of life over the entire 9 months of this trial.

Rural initiatives at the James Cook University School of Medicine: a vertically integrated regional/rural/remote medical education provider

Building on the success of the former North Queensland Clinical School/Royal Australian College of General Practitioners collaboration in North Queensland, the James Cook University School of Medicine continues to develop a model of close collaboration with stakeholder groups that provides medical education services to dispersed communities in northern Australia. The flagship themes of the programme (rural & remote, Indigenous and tropical health) are essential to the regional mission to improve the health care of people in northern Australia. Selection processes target regional and rural background students and Aboriginal and Torres Strait Islander students. An innovative curriculum design reinforces interest in and relevance to regional health needs. The present paper provides an overview of the roles and early progress of the new School of Medicine, with the aim of keeping rural doctors informed about the continuing development of a successful 'national standards/local collaboration and control' model of education service delivery.

Cost-effectiveness of the Mpowerment Project, a community-level intervention for young gay men

OBJECTIVES

Previous evaluation demonstrated that the Mpowerment Project community-level intervention for young gay men reduces HIV risk behaviors. The current analysis was undertaken to estimate the intervention's health and economic outcomes.

DESIGN/METHODS

We conducted a retrospective cost-effectiveness analysis. We estimated HIV infections averted, the gain in quality-adjusted life years (QALYs), cost per infection averted, and net cost. Using a population-level model, we portrayed two epidemic scenarios: the first with stable HIV prevalence and the other with rising HIV prevalence. Inputs included behavior change resulting from the intervention and program cost data. Cost was calculated from three perspectives: societal; societal excluding volunteer time; and that of a community-based organization (CBO). Outcomes were calculated for 1, 5 (baseline), and 20 years.

RESULTS

The Mpowerment Project averted an estimated 2.0 to 2.3 HIV infections in the first year (according to the epidemic scenario), 5.0 to 6.2 over 5 years, and 9.2 to 13.1 over 20 years. The societal cost per HIV infection averted was estimated at between $14,600 and $18,300 over 5 years. Costs per infection averted were 28% lower when excluding volunteer time and 35% lower from the CBO perspective. Net savings were $700,000 to $900,000 over 5 years from the societal perspective.

CONCLUSIONS

The Mpowerment Project is cost-effective compared with many other HIV prevention strategies. The cost per HIV infection prevented is far less than the lifetime medical costs of HIV disease.

Country report: Australia

The last 10 years has been an interesting time for Australian medical education despite reduced funding.

WORKFORCE

There are five main workforce trends: a rural/urban maldistribution, a need for more specialists, public hospital staffing difficulties, increasing female practitioners and under-representation of indigenous practitioners.

ISSUES FACING THE DEANS

Lack of resources is a problem facing Deans, with pressure for clinical service in teaching hospitals. Entrepreneurial activities have been undertaken including the enrollment of overseas students. Medical schools have also responded to important government initiatives.

DEVELOPMENTS IN MEDICAL EDUCATION

Australia's 11 medical schools have undergone significant reform in the last decade. There is a mix of four (graduate), five and six year courses. AUSTRALIA'S NEW MEDICAL SCHOOL: James Cook University opened the first medical school in northern Australia in 2000. The School admits students from rural, northern Australian and indigenous backgrounds. It has a strong regional mission. RURAL AND COMMUNITY-BASED EDUCATION: Government funding to address the maldistribution of the workforce has led to the establishment of rural clubs, Departments of Rural Health and community-based programs.

THE FIRST TWO POSTGRADUATE YEARS

There have been recent moves to improve education in the two years following graduation. This includes the initiation of national projects in curriculum and assessment.

POSTGRADUATE AND CONTINUING MEDICAL EDUCATION

Postgraduate programs in Australia are being reformed to build on the changes in undergraduate education. CME is also under review.

CONCLUSION

Australian medical educators should build on the recent reforms and take on some of the new directions in medical education.

Programmed cell death and patterning in Drosophila

Selective cell death provides developing tissues with the means to precisely sculpt emerging structures. By imposing patterned cell death across a tissue, boundaries can be created and tightened. As such, programmed cell death is becoming recognized as a major mechanism for patterning of a variety of complex structures. Typically, cell types are initially organized into a fairly loose pattern; selective death then removes cells between pattern elements to create correct structures. In this review, we examine the role of selective cell death across the course of Drosophila development, including the tightening of embryonic segmental boundaries, head maturation, refining adult structures such as the eye and the wing, and the ability of cell death to correct for pattern defects introduced by gene mutation. We also review what is currently known of the relationship between signals at the cell surface that are responsible for tissue patterning and the basal cell death machinery, an issue that remains poorly understood.

The accountability of clinical education: its definition and assessment

BACKGROUND

Medical education is not exempt from increasing societal expectations of accountability. Competition for financial resources requires medical educators to demonstrate cost-effective educational practice; health care practitioners, the products of medical education programmes, must meet increasing standards of professionalism; the culture of evidence-based medicine demands an evaluation of the effect educational programmes have on health care and service delivery. Educators cannot demonstrate that graduates possess the required attributes, or that their programmes have the desired impact on health care without appropriate assessment tools and measures of outcome.

OBJECTIVE

To determine to what extent currently available assessment approaches can measure potentially relevant medical education outcomes addressing practitioner performance, health care delivery and population health, in order to highlight areas in need of research and development.

METHODS

Illustrative publications about desirable professional behaviour were synthesized to obtain examples of required competencies and health outcomes. A MEDLINE search for available assessment tools and measures of health outcome was performed.

RESULTS

There are extensive tools for assessing clinical skills and knowledge. Some work has been done on the use of professional judgement for assessing professional behaviours; scholarship; and multiprofessional team working; but much more is needed. Very little literature exists on assessing group attributes of professionals, such as clinical governance, evidence-based practice and workforce allocation, and even less on examining individual patient or population health indices.

CONCLUSIONS

The challenge facing medical educators is to develop new tools, many of which will rely on professional judgement, for assessing these broader competencies and outcomes.

A review of the evaluation of clinical teaching: new perspectives and challenges

PURPOSE

This article discusses the importance of the process of evaluation of clinical teaching for the individual teacher and for the programme. Measurement principles, including validity, reliability, efficiency and feasibility, and methods to evaluate clinical teaching are reviewed.

CONTEXT

Evaluation is usually carried out from the perspective of the learner. This article broadens the evaluation to include the perspectives of the teacher, the patient and the institutional administrators and payers in the health care system and recommends evaluation strategies.

RESULTS

Each perspective provides specific feedback on factors or attributes of the clinical teacher's performance in the domains of medical expert, professional, scholar, communicator, collaborator, patient advocate and manager. Teachers should be evaluated in all domains relevant to their teaching objectives; these include knowledge, clinical competence, teaching effectiveness and professional attributes.

CONCLUSIONS AND IMPLICATIONS

Using this model of evaluation, a connection can be made between teaching and learning about all the expected roles of a physician. This can form the basis for systematic investigation into the relationship between the quality of teaching and the desired outcomes, the improvement of student learning and the achievement of better health care practice. It is suggested that the extent of effort and resources devoted to evaluation should be commensurate with the value assigned to the evaluation process and its outcomes.

Interpractitioner communication: telephone consultations between rural general practitioners and specialists

The results of a study that sought to investigate the utility of and satisfaction with telephone consultations from the perspective of general practitioners and specialists are reported. Semi-structured interviews with rural general practitioners and specialists were used to elicit information about their most recent telephone consultations. The telephone was found to be an important means of communication for rural practitioners, primarily in terms of organising referrals. General practitioners tended to called specialists who they knew and appeared to have fairly well-formed networks of specialists who they called for most of their concerns. Trust is an important element of interpractitioner communication as it increases understanding and confidence in the reliability of the information exchanged. Good working relationships ensure that rural general practitioners have an accessible source of acceptable specialist support.

An educational intervention to improve diagnosis and management of suspicious skin lesions

BACKGROUND

Family physicians have an important clinical role in assessment and management of suspicious skin lesions. As a result of a previous needs assessment study, an educational intervention based on audit and feedback with opportunity for reflection on practice was introduced to 46 family physicians randomly allocated to either an intervention (23) or control group (23). As an educational tool, audit allows doctors to systematically review their practice and establish the quality of care they provide. When combined with feedback and comparison of clinical performance with peers or standards, it has been shown to increase learning and change behavior.

METHODS

Data based on their own patients, on the correlation between clinical and histologic diagnosis, and excisions of skin lesions were collated and reported to the intervention group.

RESULTS

Despite randomization of the doctors, the patient population of doctors in the intervention and control groups were significantly different in key characteristics, including the types of skin lesions treated. The intervention group of doctors showed improved performance in providing clinical information on pathology requests and in adequate surgical excision of skin lesions. Diagnostic performance did not improve significantly, but physicians' certainty of diagnosis did.

IMPLICATIONS

This study design has highlighted the difficulty in balancing the use of evidence-based educational strategies in an equivalent setting to normal practice with evaluation of performance using measures that include characteristics of practitioners' patients that cannot be controlled.

Community participation in the recruitment and retention of rural doctors: methodological and logistical considerations

Two Queensland rural communities with histories of poor general practitioner (GP) recruitment and retention participated in a process aimed at developing broadly based community action plans to recruit and retain GPs. Despite their very different physical and social characteristics, the two communities developed many similar objectives and strategies, which had the possibility of being implemented more widely. The community participation process can be both time- and cost-effective if consideration is given to a variety of methodological and logistical issues. The process is a means by which communities, Divisions of General Practice, government, academic institutions and others can work together to recruit and retain medical practitioners.

Consumers' after hours health care decisions. Comparison between those who did and those who did not seek care in an Australian provincial city

OBJECTIVE

To compare the demographic and illness characteristics of people who sought after hours care with those who did not, to identify differences that might be exploited in patient education regarding 'appropriate' use of after hours care.

METHOD

Structured telephone interview survey of randomly selected householders in Townsville.

RESULTS

An 88% response rate was achieved (1227/1402). A total of 10.8% (133/1227) of respondents had sought after hours care for themselves in the 3 months before interview. A further 10.9% (134/1227) had decided against seeking care during that period. The two groups were demographically similar, except in terms of health care training and perceived travel time to after hours care. Self reported conditions varied only for ICPC general, musculoskeletal and skin chapters. Symptom related issues were most important in the decision to seek care, while self care procedures were the most common reason for not seeking care, followed by access related issues.

CONCLUSIONS

The decision to seek care is an individual process that cannot be reliably predicted by demographic characteristics. Broad scale community education programs aimed at reducing 'inappropriate' use of after hours services would need to find a balance between increasing knowledge for self care of minor conditions and emphasising the importance of being alert to signs and symptoms of life threatening conditions.

Patterning of Drosophila leg sensory organs through combinatorial signaling by hedgehog, decapentaplegic and wingless

During development, global patterning events initiate signal transduction cascades which gradually establish an array of individual cell fates. Many of the genes which pattern Drosophila are expressed throughout development and specify diverse cell types by creating unique local environments which establish the expression of locally acting genes. This process is exemplified by the patterning of leg microchaete rows. hairy (h) is expressed in a spatially restricted manner in the leg imaginal disc and functions to position adult leg bristle rows by negatively regulating the proneural gene achaete, which specifies sensory cell fates. While much is known about the events that partition the leg imaginal disc and about sensory cell differentiation, the mechanisms that refine early patterning events to the level of individual cell fate specification are not well understood. We have investigated the regulation of h expression along the dorsal/ventral (D/V) axis of the leg adjacent to the anterior/posterior (A/P) compartment boundary and have found that it requires input from both D/V and A/P patterning mechanisms. Expression of the D/V axis h stripe (D/V-h) is controlled by dorsal- and ventral-specific enhancer elements which are targets of Decapentaplegic (Dpp) and Wingless (Wg) signaling, respectively, but which are also dependent on Hedgehog (Hh) signaling for activation. D/V-h expression is lost in smoothened mutant clones and is specifically activated by exogenously supplied Cubitus interruptus (Ci). D/V-h expression is also lost in clones deficient for Dpp and Wg signaling, but ectopic activation of D/V-h by Dpp and Wg is limited to the A/P compartment boundary where endogenous levels of full-length Ci are high. We propose that D/V-h expression is regulated in a non-linear pathway in which Ci plays a dual role. In addition to serving as an upstream activator of Dpp and Wg, Ci acts combinatorially with them to activate D/V-h expression.

National standards for general practice

A set of standards for Australian general practices has been developed through a 4 year project conducted by The Royal Australian College of General Practitioners. An orderly, iterative process was adopted to ensure comprehensive consultation with general practitioners, other health professionals, consumers and governments. The draft standards were field tested in 199 randomly selected urban and rural practices. Results of this field testing showed that the standards have content validity, that they can be measured reliably and that the practice visit protocol is feasible. The standards are calibrated to define the minimum acceptable features of general practices expected for the mid 1990s. The standards have been adopted by Australian General Practice Accreditation Limited as the basis for a voluntary system of practice accreditation.

In-training assessment in postgraduate training for general practice

Assessment within general practice training curricula is necessary to both guide learning and to make certification decisions about competence to practise without supervision in the community, but there is a risk that the two roles could become confused. This paper proposes a conceptual framework that explains the relationship between formative assessment, in-training assessment and end-point assessment, as adopted by the Royal Australian College of General Practitioners Training Programme. The literature is reviewed to suggest assessment formats that could provide a means of making decisions about progress through training without harming the important role of providing feed-back to guide learners.

Effects of testosterone replacement with a nongenital, transdermal system, Androderm, in human immunodeficiency virus-infected men with low testosterone levels

Although weight loss associated with human immunodeficiency virus (HIV) infection is multifactorial in its pathogenesis, it has been speculated that hypogonadism, a common occurrence in HIV disease, contributes to depletion of lean tissue and muscle dysfunction. We, therefore, examined the effects of testosterone replacement by means of Androderm, a permeation-enhanced, nongenital transdermal system, on lean body mass, body weight, muscle strength, health-related quality of life, and HIV-disease markers. We randomly assigned 41 HIV-infected, ambulatory men, 18-60 yr of age, with serum testosterone levels below 400 ng/dL, to 1 of 2 treatment groups: group I, two placebo patches (n = 21); or group II, two testosterone patches designed to release 5 mg testosterone over 24 h. Eighteen men in the placebo group and 14 men in the testosterone group completed the 12-week treatment. Serum total and free testosterone and dihydrotestosterone levels increased, and LH and FSH levels decreased in the testosterone-treated, but not in the placebo-treated, men. Lean body mass and fat-free mass, measured by dual energy x-ray absorptiometry, increased significantly in men receiving testosterone patches [change in lean body mass, +1.345 +/- 0.533 kg (P = 0.02 compared to no change); change in fat-free mass, +1.364 +/- 0.525 kg (P = 0.02 compared to no change)], but did not change in the placebo group [change in lean body mass, 0.189 +/- 0.470 kg (P = NS compared to no change); change in fat-free mass, 0.186 +/- 0.470 kg (P = NS compared to no change)]. However, there was no significant difference between the 2 treatment groups in the change in lean body mass. The change in lean body mass during treatment was moderately correlated with the increment in serum testosterone levels (r = 0.41; P = 0.02). The testosterone-treated men experienced a greater decrease in fat mass than those receiving placebo patches (P = 0.04). There was no significant change in body weight in either treatment group. Changes in overall quality of life scores did not correlate with testosterone treatment; however, in the subcategory of role limitation due to emotional problems, the men in the testosterone group improved an average of 43 points of a 0-100 possible score, whereas those in the placebo group did not change. Red cell count increased in the testosterone group (change in red cell count, +0.1 +/- 0.1 10(12)/L) but decreased in the placebo group (change in red cell count, -0.2 +/- 0.1 10(12)/L). CD4+ and CD8+ T cell counts and plasma HIV copy number did not significantly change during treatment. Serum prostate-specific antigen and plasma lipid levels did not change in either treatment group. Testosterone replacement in HIV-infected men with low testosterone levels is safe and is associated with a 1.35-kg gain in lean body mass, a significantly greater reduction in fat mass than that achieved with placebo treatment, an increased red cell count, and an improvement in role limitation due to emotional problems. Further studies are needed to assess whether testosterone supplementation can produce clinically meaningful changes in muscle function and disease outcome in HIV-infected men.

The development of general practice standards in Australia. Royal Australian College of General Practitioners

The Royal Australian College of General Practitioners has spent 4 years developing a set of entry standards which define the minimum features of general practices expected for the mid-1990s. The project design followed a slow, iterative process, with several opportunities for wide consultation with professional, consumer and Government groups. The draft standards were piloted in 25 volunteer practices, modified and then field-tested in 200 randomly selected practices representing urban and rural practices. Results of this field testing showed that the standards had content validity and that reliable measures were possible using triangulation from several data sources. The current version of the standards has been distributed widely for voluntary application in Australian general practices from early 1997.

The dose-response relation of intrathecal fentanyl for labor analgesia

BACKGROUND

This study determined the dose-response relation of intrathecal fentanyl for labor analgesia and described the onset, duration, and quality of analgesia when used as the sole analgesic.

METHODS

Eighty-four parturients in active labor who requested analgesia were randomized to one of seven treatment groups. They received 5-45 microg intrathecal fentanyl as part of a combined spinal-epidural technique. Visual analog pain scores were recorded before and at intervals after injection patients requested additional analgesia. The occurrence and severity of pruritus, nausea, and vomiting were also recorded. Maternal blood pressure was recorded before injection and at intervals after injection. Fetal heart rate was recorded before and 30 min after injection.

RESULTS

By 5 min after injection, pain scores were significantly different among groups (P < 0.001). Mean duration of analgesia increased to 89 min as the dose increased to 25 microg. Maternal diastolic blood pressure was significantly lower 10 and 30 min after injection. There was no difference among groups in the incidence of pruritus; nausea and vomiting were uncommon. Fetal heart rates did not change after injection. A dose-response curve indicates that the median effective dose of intrathecal fentanyl for labor analgesia is 14 microg (95% confidence interval, 13-15 microg).

CONCLUSIONS

Intrathecal fentanyl produces rapid, profound labor analgesia with minimal side effects. These data indicate that there is little benefit to increasing the dose beyond 25 microg when it is used as the sole agent for intrathecal labor analgesia.

Wingless signaling generates pattern through two distinct mechanisms

wingless (wg) and its vertebrate homologues, the Wnt genes, play critical roles in the generation of embryonic pattern. In the developing Drosophila epidermis, wg is expressed in a single row of cells in each segment, but it influences cell identities in all rows of epidermal cells in the 10- to 12-cell-wide segment. Wg signaling promotes specification of two distinct aspects of the wild-type intrasegmental pattern: the diversity of denticle types present in the anterior denticle belt and the smooth or naked cuticle constituting the posterior surface of the segment. We have manipulated the expression of wild-type and mutant wg transgenes to explore the mechanism by which a single secreted signaling molecule can promote these distinctly different cell fates. We present evidence consistent with the idea that naked cuticle cell fate is specified by a cellular pathway distinct from the denticle diversity-generating pathway. Since these pathways are differentially activated by mutant Wg ligands, we propose that at least two discrete classes of receptor for Wg may exist, each transducing a different cellular response. We also find that broad Wg protein distribution across many cell diameters is required for the generation of denticle diversity, suggesting that intercellular transport of the Wg protein is an essential feature of pattern formation within the epidermal epithelium. Finally, we demonstrate that an 85 amino acid region not conserved in vertebrate Wnts is dispensable for Wg function and we discuss structural features of the Wingless protein required for its distinct biological activities.

Methods for quality assessment in general practice

BACKGROUND AND OBJECTIVES

There is now a wide variety of methods available to general practitioners who want to engage in quality assessment, quality assurance, or quality improvement activities in their practices. These methods require some kind of performance review, or at least the collection of some performance-related data. As in traditional research, the choice of methods depends on what research questions one wants to address. This paper elaborates on some key concepts related to the choice of methods, making a distinction between whether any method actually covers performance (what a doctor does in daily practice) or competence (what a doctor is capable of doing) as well as a distinction between whether a method is direct (patient-doctor contact is observable) or is indirect.

METHOD

An overview frame will be presented of the methods most commonly used for data collection within quality assessment. These methods are discussed on their validity, reliability, feasibility and acceptability. Direct methods aimed at recording performance are assumed to hold the highest validity, but practical, economic and logistic factors may favour less ambitious methods for audit or quality improvement activities.

CONCLUSIONS

One crucial element in all methods is creating a set of empirical data, as a basis for comparisons, reflection, dialogue and discussions among colleagues.

Preferential targeting of oxidative base damage to internucleosomal DNA

The structure of nuclear chromatin may limit the accessibility of carcinogenic agents to DNA. In the case of oxidative DNA strand cleavage mediated by the physiologically relevant iron chelate, iron-ADP, histone-associated nucleosomal DNA is protected while internucleosomal DNA is susceptible to damage. We now find that the distribution of iron-ADP-generated 8-hydroxydeoxyguanosine, a potentially mutagenic oxidative base change, shows relative targeting to internucleosomal sites (3.5-fold increased oxidative modification of internucleosomal compared with nucleosomal DNA as the minimal degree of enrichment). In contrast, iron-EDTA, which generates hydroxyl radical in the 'fluid phase', does not target internucleosomal DNA. Thus, physiologic iron chelates may promote site-specific damage and thereby be relevant to mechanisms of iron-dependent oxidative mutagenesis and carcinogenesis.

Publishing pointers

Communication among general practitioners is a necessary part of current medical practice and written communication is the most popular medium. The first attempt to write a paper is usually the hardest. This paper provides practical advice about how to start.