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Concept: Case study


In 1965, the Sugar Research Foundation (SRF) secretly funded a review in the New England Journal of Medicine that discounted evidence linking sucrose consumption to blood lipid levels and hence coronary heart disease (CHD). SRF subsequently funded animal research to evaluate sucrose’s CHD risks. The objective of this study was to examine the planning, funding, and internal evaluation of an SRF-funded research project titled “Project 259: Dietary Carbohydrate and Blood Lipids in Germ-Free Rats,” led by Dr. W.F.R. Pover at the University of Birmingham, Birmingham, United Kingdom, between 1967 and 1971. A narrative case study method was used to assess SRF Project 259 from 1967 to 1971 based on sugar industry internal documents. Project 259 found a statistically significant decrease in serum triglycerides in germ-free rats fed a high sugar diet compared to conventional rats fed a basic PRM diet (a pelleted diet containing cereal meals, soybean meals, whitefish meal, and dried yeast, fortified with a balanced vitamin supplement and trace element mixture). The results suggested to SRF that gut microbiota have a causal role in carbohydrate-induced hypertriglyceridemia. A study comparing conventional rats fed a high-sugar diet to those fed a high-starch diet suggested that sucrose consumption might be associated with elevated levels of beta-glucuronidase, an enzyme previously associated with bladder cancer in humans. SRF terminated Project 259 without publishing the results. The sugar industry did not disclose evidence of harm from animal studies that would have (1) strengthened the case that the CHD risk of sucrose is greater than starch and (2) caused sucrose to be scrutinized as a potential carcinogen. The influence of the gut microbiota in the differential effects of sucrose and starch on blood lipids, as well as the influence of carbohydrate quality on beta-glucuronidase and cancer activity, deserve further scrutiny.

Concepts: Gut flora, Metabolism, Nutrition, Glucose, Triglyceride, Case study, Carbohydrate, Blood lipids


Depression is common in primary care and clinicians are encouraged to screen their patients. Meta-analyses have evaluated the effectiveness of screening, but two author groups consistently reached completely opposite conclusions.

Concepts: Scientific method, Critical thinking, Evaluation methods, Case study


BACKGROUND: Although collaborative team models (CTM) improve care processes and health outcomes, their diffusion poses challenges related to difficulties in securing their adoption by primary care clinicians. The objectives of this study are to understand: (1) how the perceived characteristics of a CTM influenced clinicians' decision to adopt -or not- the model; and (2) the model’s diffusion process. METHODS: We conducted a longitudinal case study based on the Diffusion of Innovations Theory. First, diffusion curves were developed for all 175 primary care physicians (PCPs) and 59 nurses practicing in one borough of Paris. Second, semi-structured interviews were conducted with a representative sample of 40 PCPs and 15 nurses to better understand the implementation dynamics. RESULTS: Diffusion curves showed that 3.5 years after the start of the implementation, 100% of nurses and over 80% of PCPs had adopted the CTM. The dynamics of the CTM’s diffusion were different between the PCPs and the nurses. The slopes of the two curves are also distinctly different. Among the nurses, the critical mass of adopters was attained faster, since they adopted the CTM earlier and more quickly than the PCPs. Results of the semi-structured interviews showed that these differences in diffusion dynamics were mostly founded in differences between the PCPs' and the nurses' perceptions of the CTM’s compatibility with norms, values and practices and its relative advantage (impact on patient management and work practices). Opinion leaders played a key role in the diffusion of the CTM among PCPs. CONCLUSION: CTM diffusion is a social phenomenon that requires a major commitment by clinicians and a willingness to take risks; the role of opinion leaders is key. Paying attention to the notion of a critical mass of adopters is essential to developing implementation strategies that will accelerate the adoption process by clinicians. Key-words: primary care, primary care physician, nurses, chronic disease, collaboration, health service research, diffusion of innovation.

Concepts: Sociology, Diffusion, Adoption, Case study, Innovation, Primary care physician, Diffusion of innovations, Opinion leadership


Bochdalek hernia is the most common type of congenital diaphragmatic hernia. It appears frequently in infants but rarely in adults. We present the case of a 50-year-old female han patient with tremendous left-sided congenital posterolateral diaphragmatic hernia (Bochdalek hernia) who also has a pair of supernumerary breasts and pulmonary hypoplasia of the lower-left lobe. The patient had an experience of misdiagnosis and she was treated for bronchitis for one year until being admitted to our hospital. This case study emphasizes the rare presentation of Bochdalek hernia in adults and the necessity of high clinical attention to similar cases.

Concepts: Lung, Patient, Case study, Case, Adult, Congenital diaphragmatic hernia, Diaphragmatic hernia, Bochdalek hernia


The impact case studies submitted by UK Higher Education Institutions to the Research Excellence Framework (REF) in 2014 provide a rich resource of text describing impact beyond academia and across all disciplines. Using text mining techniques and qualitative assessment, the 6,679 non-redacted case studies submitted were analysed and the impact described was found to be multidisciplinary, multi-impactful, and multinational. By digging deeper into the data, the health gains from health research in terms of Quality Adjusted Life Years was also estimated. Similar analyses are possible using these case studies, but will require the data to be ’re-purposed' from the original intention (i.e., for assessment purposes) for robust analysis.

Concepts: Scientific method, Research methods, Evaluation methods, Educational psychology, Qualitative research, Thought, Case study, Higher education


Screening the active compounds of herbal medicines is of importance to modern drug discovery. In this work, an integrative strategy was established to discover the effective compounds and their therapeutic targets using Phellodendri Amurensis cortex (PAC) aimed at inhibiting prostate cancer as a case study. We found that PAC could be inhibited the growth of xenograft tumours of prostate cancer. Global constituents and serum metabolites were analysed by UPLC-MS based on the established chinmedomics analysis method, a total of 54 peaks in the spectrum of PAC were characterised in vitro and 38 peaks were characterised in vivo. Among the 38 compounds characterised in vivo, 29 prototype components were absorbed in serum and nine metabolites were identified in vivo. Thirty-four metabolic biomarkers were related to prostate cancer, and PAC could observably reverse these metabolic biomarkers to their normal level and regulate the disturbed metabolic profile to a healthy state. A chinmedomics approach showed that ten absorbed constituents, as effective compounds, were associated with the therapeutic effect of PAC. In combination with bioactivity assays, the action targets were also predicted and discovered. As an illustrative case study, the strategy was successfully applied to high-throughput screening of active compounds from herbal medicine.

Concepts: Pharmacology, Medicine, Cancer, Prostate cancer, Screening, In vitro, Case study, High-throughput screening


The Future of Home Health project sought to support transformation of home health and home-based care to meet the needs of patients in the evolving U.S. health care system. Interviews with key thought leaders and stakeholders resulted in key themes about the future of home health care. By synthesizing this qualitative research, a literature review, case studies, and the themes from a 2014 Institute of Medicine and National Research Council workshop on “The Future of Home Health Care,” the authors articulate a vision for home-based care and recommend a bold framework for the Medicare-certified home health agency of the future. The authors also identify challenges and recommendations for achievement of this framework.

Concepts: Health care, Scientific method, Psychology, Health economics, Medicine, Evaluation methods, Qualitative research, Case study


Proposed causes for increased mortality following weekend admission (the ‘weekend effect’) include poorer quality of care and sicker patients. The aim of this study was to analyse the 7 days post-admission time patterns of excess mortality following weekend admission to identify whether distinct patterns exist for patients depending upon the relative contribution of poorer quality of care (care effect) or a case selection bias for patients presenting on weekends (patient effect).

Concepts: Scientific method, Patient, Hospital, Medical statistics, Physician, Case study, Weekend, Workweek


Patients are increasingly being asked for feedback about their healthcare experiences. However, healthcare staff often find it difficult to act on this feedback in order to make improvements to services. This paper draws upon notions of legitimacy and readiness to develop a conceptual framework (Patient Feedback Response Framework - PFRF) which outlines why staff may find it problematic to respond to patient feedback. A large qualitative study was conducted with 17 ward based teams between 2013 and 2014, across three hospital Trusts in the North of England. This was a process evaluation of a wider study where ward staff were encouraged to make action plans based on patient feedback. We focus on three methods here: i) examination of taped discussion between ward staff during action planning meetings ii) facilitators notes of these meetings iii) telephone interviews with staff focusing on whether action plans had been achieved six months later. Analysis employed an abductive approach. Through the development of the PFRF, we found that making changes based on patient feedback is a complex multi-tiered process and not something that ward staff can simply ‘do’. First, staff must exhibit normative legitimacy - the belief that listening to patients is a worthwhile exercise. Second, structural legitimacy has to be in place - ward teams need adequate autonomy, ownership and resource to enact change. Some ward teams are able to make improvements within their immediate control and environment. Third, for those staff who require interdepartmental co-operation or high level assistance to achieve change, organisational readiness must exist at the level of the hospital otherwise improvement will rarely be enacted. Case studies drawn from our empirical data demonstrate the above. It is only when appropriate levels of individual and organisational capacity to change exist, that patient feedback is likely to be acted upon to improve services.

Concepts: Better, Scientific method, Patient, Focus group, Hospital, Qualitative research, Control theory, Case study


Jim McCambridge and colleagues analyze industry submissions to a Scottish Government consultation on whole-population approaches to alcohol policy.

Concepts: Case study, Scotland