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Cryoballoon ablation has been associated with a significant incidence of phrenic nerve injury (PNI).The purpose of this study was to evaluate whether recordings of diaphragmatic compound motor action potentials (CMAP) on a modified lead I during cryoballoon ablation can predict PNI.Cryoballoon ablation was performed in 109 patients with atrial fibrillation (AF). During ablation of the right-sided pulmonary veins, the phrenic nerve was paced from the superior vena cava. The right and left arm electrodes from a 12-lead ECG were positioned 5 cm above the xiphoid process and 16 cm along the right costal margin. The amplitude of CMAP was recorded on lead I during ablation.Cryoballoon was applied 424 times in 211 right-sided veins. PNI occurred in 7 (6.4%) patients. The average CMAP amplitude did not significantly change in patients without PNI from the initial average CMAP amplitude of 0.34 ± 0.18 mV to 0.32 ± 0.17 mV (P = .58). In patients who developed PNI, there was a significant decrease in the initial average CMAP amplitude during the ablation from 0.33 ± 0.14 mV to 0.09 ± 0.05 mV (P.001). The maximal percent change in the average CMAP amplitude in patients with PNI was higher (70% ± 10%) than in patients without PNI (7.6% ± 7%; P.001). In any patient without PNI, the CMAP amplitude did not decrease more than 35% from baseline.Recording of CMAP amplitude on a modified lead I is reliable and could be early and sensitive method for predicting PNI in patients undergoing cryoballoon ablation for AF.

This bumper issue of London Journal of Primary Care (LJPC) provides a fitting end to its ten years of activity. It signals a PAUSE to prepare for a new stage of translating into practice the ideas ...

[Graphic][1] On 20 December 1952, the British Medical Journal announced the foundation of a college of GPs, now the Royal College of General Practitioners (RCGP).1 The College had a strong vision for general practice. A singular achievement was vocational training.2 Sir James Mackenzie would have been proud of this, as he had himself advocated special training for GPs. There has been immense progress since then. We now have one of the finest systems of general practice in the world: There are also examples of the professionalism of individual GPs up and down the country: the GP who has made that early diagnosis of meningitis in a baby and the GP who deals with the frail older patient with heart failure. ### Concerns about the future There is much to celebrate but we have more work to do. As a practising doctor, I want to do more for my patients. There is much more that we can, and need to do. Take some examples: Mrs Patel is 66, she is distressed, she is crying because she is dying from advanced bladder cancer; her GP failed to diagnose the cancer early enough. Mrs Jones is 86 and has complex multiple medical conditions; her health is declining. She has repeated hospital admissions and multiple referrals without any obvious medical benefit. Actually, she is dying and approaching the end of her life but this goes unrecognised in the health system. People are … [1]: /embed/inline-graphic-1.gif

Clinical governance is the core component of the new quality programme for the NHS (see box on next page) announced in the consultation document A First Class Service .1 It is described as “a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.” It will be the central focus for assuring the quality of care and addressing the issue of providing accountability through the Commission for Health Improvement.2 The activities of the commission will reflect national and local priorities as identified by the National Institute of Clinical Excellence and health improvement programmes respectively. Although A First Class Service included details about the structure and functioning of clinical governance in health service trusts, arrangements for primary care groups were not specified. In this paper, we suggest a possible model for clinical governance in primary care groups. Clinical governance is central to the NHS quality programme, but how it will operate in primary care groups remains unclear Although many activities included in the new concept of clinical governance are already being undertaken, these need to be coordinated A model of governance that addresses the core tasks of defining, accounting for, and improving quality and incorporates evidence on effective methods of changing performance is suggested This model can improve professional, practice, and primary care group performance It shows how groups can introduce and develop clinical governance and how health authorities and the Commission for Health Improvement can monitor progress The model is based on three underlying precepts

The forthcoming white paper is certain to result in changes in primary care, but the nature and effect of the reforms is unclear. We asked some people with an interest in general practice to predict the future What will English primary care look like in 2015? The proposed new white paper on health and community services in England1 will affect all of our futures—public, patients, and health professionals. The future is uncertain, but we can be sure that people will still get sick, or think they may be sick, and then they will value care from a doctor they know and who knows them. We present a vision of a values based, patient centred primary healthcare system that is consistently of high quality, safe, accessible, and accountable. We recognise that our aspiration will require considerable investment, system reform, and support for implementation but believe that it is a much needed yet achievable model to improve patient care. Primary care has been defined as: “The first level contact with people taking action to improve health in a community. In a system with a gatekeeper, all initial (non-emergency) consultations with doctors, nurses or other health staff are termed primary care as opposed to secondary health care or referral services.”2 International comparisons of healthcare systems have shown that the United Kingdom ranks highly on scores of primary care orientation, and countries with good primary care systems show improvement in the health of individuals and populations, together with greater satisfaction with care.3 Within the NHS general practice is a central component of primary care. General practice is defined as: “An academic and scientific discipline, with its own educational content, research base and clinical activity, orientated to primary care and built on fundamental principles.”4 Values …

Revalidation is a summative assessment and must be seen as separate fromappraisal and clinical governance The General Medical Council's proposals for recertifying doctors in the United Kingdom every five years have been thrown into confusion. A recent judicial inquiry into the case of Harold Shipman, who murdered at least 215 patients, found that the method for revalidating doctors based on regular appraisal would not detect poorly performing doctors.1 The government suspended plans for revalidation and ordered an urgent review led by the chief medical officer.2 This article gives a proposal for a way forward. Although the article is from general practice, the framework described is applicable to other specialties. The GMC's proposal for revalidation requires doctors to keep a portfolioshowing participation in appraisals and completion of an agreed personal development plan. They also have to provide a statement of “no concerns” fromtheir primary care organisation and evidence of probity and health. To understand the problems with the current model, we have to be clear about the definitions of appraisal, clinical governance, and revalidation (box 1). The three methods of assessing performance overlap.5 This overlap has advantages and disadvantages. On the one hand, data collected for appraisal can be used for revalidation, thus reducing the burden of assessment. On the other hand, a summative process such as revalidation could hijack a formative process such as appraisal. A fundamental observation of the Shipman report was that although appraisal and clinical governance inform revalidation, they are not sufficient to evaluate a doctor's practice. The current proposals therefore give an “illusion of protection,” particularly as patient safety and reassurance of the publicare important functions of revalidation. What can be done to overcome this fundamental shortcoming? My proposal for successful revalidation is based on 10 guiding principles (box 2). Below, I describe …

Use of Intracardiac Echocardiography for Early Detection of Phrenic Nerve Injury. Cryoballoon catheter ablation has recently emerged as an effective tool to achieve pulmonary vein isolation (PVI). Right-sided PVI with cryoballoon ablation has been associated with a significant incidence of phrenic nerve palsy. Multiple modalities are currently utilized to monitor phrenic nerve function during ablation. We describe a novel approach toward monitoring and diagnosing phrenic nerve palsy using intracardiac echocardiography (ICE) during cryoballoon ablation of the right pulmonary veins. This technique of monitoring has the advantage of continuous direct diaphragmatic visualization without the use of fluoroscopy, hence significantly minimizing radiation to both the patient and the operator. In addition, this technique does not require extra personnel to monitor the diaphragm using manual palpation. Further prospective studies of our and other methods for prevention of phrenic nerve palsy are required. (J Cardiovasc Electrophysiol, Vol. 23, pp. 874-876, August 2012)

People suffering from brain injuries or progressive conditions need to communicate their preferences in dying well before they reach the end of life, when it may be too late.

There was a report in the Times of 19 October that I found inspirational, despite the sad circumstances. Surgeons in Australia, struggling to treat someone who was critically injured in the Bali bombing, made a frantic call to the British Library in London at 3 am. One of the surgeons had remembered reading an article in a medical journal about treating severe blast victims but could not track down a copy. Within 20 minutes library staff had scanned the document and sent it to the team in Australia. Our approach tends to be unsystematic I found this a powerful and moving example of the value of knowledge in modern medical practice. Wouldn't it be wonderful if a national newspaper featured a story like this involving a general practitioner or a practice nurse. But it probably would not hit the headlines—after all, we are not often in life and death situations. However, we make hundreds of clinical decisions each week that in the long run can …

Mary, who is 85, has been my patient for about six years. In 1957 she had had a gastroenterostomy and vagotomy for a peptic ulcer. Shortly afterwards, she had developed diarrhoea, which became chronic—she had been referred to many clinics and had been extensively investigated. No formal diagnosis seemed to have been made although malabsorption, bile acid reflux, postvagotomy diarrhoea, and dumping syndrome had been considered at one time or another. She had trials of a fat free diet, pancreatic supplements, antibiotics, codeine, and bulking agents, but her bowels never improved. She was told that diarrhoea was something …

EDITOR,—We agree with Huw T O Davies and Iain K Crombie's comments about the difficulties sometimes encountered in identifying and using outcome measures for assessing the quality of care, and we too advocate the selective use of process measures.1 This, however, begs the question of how high quality process measures should be developed. Review criteria (audit criteria) are “systematically developed statements that can be used …