Improved Time to Notification of Impending Brain Death and Increased Organ Donation Using an Electronic Clinical Decision Support System.

Early referral of patients to an organ procurement organization (OPO) may positively affect donation outcomes. We implemented an electronic clinic decision support (CDS) system to automatically notify our OPO of children meeting clinical triggers indicating impending brain death. Medical records of all patients who died in a pediatric critical care unit or were referred for imminent death for 3 years prior to installation of the initial CDS (pre-CDS) and for 1 year after implementation of the final CDS (post-CDS) were reviewed. Mean time to OPO notification decreased from 30.2 h pre-CDS to 1.7 h post-CDS (p = 0.015). Notification within 1 h of meeting criteria increased from 36% pre-CDS to 70% post-CDS (p = 0.003). Although an increase in donor conversion from 50% pre-CDS to 90% post-CDS did not reach statistical significance (p = 0.0743), there were more organ donors post-CDS (11 of 24 deaths) than pre-CDS (seven of 57 deaths; p = 0.002). Positive outcomes were achieved with the use of a fully automated CDS system while simultaneously realizing few false-positive notifications, low costs, and minimal workflow interruption. Use of an electronic CDS system in a pediatric hospital setting improved timely OPO notification and was associated with increased organ donation.

Creatine and low-dose lithium supplementation separately alter energy expenditure, body mass, and adipose metabolism for the promotion of thermogenesis.

Nutraceutical approaches to promote adipose tissue thermogenesis may help to prevent obesity onset. Creatine is a critical regulator of adipose metabolic function and low-dose lithium supplementation has been shown to promote adipose thermogenesis. In the present study, we sought to directly compare the two supplements for their effects on adipose metabolism and thermogenesis. We show that both supplements increase daily energy expenditure (EE) and reduce body mass in male Sprague-Dawley rats. Lithium increased brown adipose tissue (BAT) mitochondrial and lipolytic proteins that are associated with thermogenesis, while creatine increased BAT UCP1 and mitochondrial respiration. The BAT thermogenic findings were not observed in females. White adipose tissue and skeletal muscle markers of thermogenesis were unaltered with the supplements. Together, the data show that low-dose lithium and creatine have diverging effects on markers of BAT thermogenesis and that each increase daily EE and lower body mass in a sex-dependent manner.

Colour Doppler ultrasound of the ocular circulation in patients with systemic lupus erythematosus identifies altered microcirculatory haemodynamics.

We assessed whether quantitative analysis of Doppler flow velocity waveforms is able to identify subclinical microvascular abnormalities in SLE and whether eigenvector analysis can detect changes not detectable using the resistive index (RI). Fifty-four SLE patients with no conventional cardiovascular risk factors, major organ involvement or retinopathy were compared to 32 controls. Flow velocity waveforms were obtained from the ophthalmic artery (OA), central retinal artery (CRA) and common carotid artery (CA). The waveforms were analysed using eigenvector decomposition and compared between groups at each arterial site. The RI was also determined. The RI was comparable between groups. In the OA and CRA, there were significant differences in the lower frequency sinusoidal components (P < 0.05 for each component). No differences were apparent in the CA between groups. Eigenvector analysis of Doppler flow waveforms, recorded in proximity of the terminal vascular bed, identified altered ocular microvascular haemodynamics in SLE. Altered waveform structure could not be identified by changes in RI, the traditional measure of downstream vascular resistance. This analytical approach to waveform analysis is more sensitive in detecting preclinical microvascular abnormalities in SLE. It may hold potential as a useful tool for assessing disease activity, response to treatment, and predicting future vascular complications.

A randomised interventional trial of omega-3-polyunsaturated fatty acids on endothelial function and disease activity in systemic lupus erythematosus.

OBJECTIVE: To determine the clinical effect of dietary supplementation with low-dose omega-3-polyunsaturated fatty acids on disease activity and endothelial function in patients with systemic lupus erythematosus. METHODS: A 24-week randomised double-blind placebo-controlled parallel trial of the effect of 3 g of omega-3-polyunsaturated fatty acids on 60 patients with systemic lupus erythematosus was performed. Serial measurements of disease activity using the revised Systemic Lupus Activity Measure (SLAM-R) and British Isles Lupus Assessment Group index of disease activity for systemic lupus erythematosus (BILAG), endothelial function using flow-mediated dilation (FMD) of the brachial artery, oxidative stress using platelet 8-isoprostanes and analysis of platelet membrane fatty acids were taken at baseline, 12 and 24 weeks. RESULTS: In the fish oil group there was a significant improvement at 24 weeks in SLAM-R (from 9.4 (SD 3.0) to 6.3 (2.5), p<0.001); in BILAG (from 13.6 (6.0) to 6.7 (3.8), p<0.001); in FMD (from 3.0% (-0.5 to 8.2) to 8.9% (1.3 to 16.9), p<0.001) and in platelet 8-isoprostanes (from 177 pg/mg protein (23-387) to 90 pg/mg protein (32-182), p = 0.007). CONCLUSIONS: Low-dose dietary supplementation with omega-3 fish oils in systemic lupus erythematosus not only has a therapeutic effect on disease activity but also improves endothelial function and reduces oxidative stress and may therefore confer cardiovascular benefits.

Vitamin D deficiency is associated with anxiety and depression in fibromyalgia.

Fibromyalgia is a complex problem in which symptoms of anxiety and depression feature prominently. Low levels of vitamin D have been frequently reported in fibromyalgia, but no relationship was demonstrated with anxiety and depression. Seventy-five Caucasian patients who fulfilled the ACR criteria for fibromyalgia had serum vitamin D levels measured and completed the Fibromyalgia Impact Questionnaire (FIQ) and Hospital Anxiety and Depression Score (HADS). Deficient levels of vitamin D was found in 13.3% of the patients, while 56.0% had insufficient levels and 30.7% had normal levels. Patients with vitamin D deficiency (<25 nmol/l) had higher HADS [median, IQR, 31.0 (23.8-36.8] than patients with insufficient levels [25-50 nmol/l; HADS 22.5 (17.0-26.0)] or than patients with normal levels [50 nmol/l or greater; HADS 23.5 (19.0-27.5); Kruskal-Wallis ANOVA on ranks p<0.05]. There was no relationship with global measures of disease impact or musculoskeletal symptoms. Vitamin D deficiency is common in fibromyalgia and occurs more frequently in patients with anxiety and depression. The nature and direction of the causal relationship remains unclear, but there are definite implications for long-term bone health.

Prevalence of vitamin D inadequacy in Belfast following fragility fracture.

BACKGROUND: It is well established that vitamin D levels are sub-optimal in older people and that adults with fragility fracture have low levels of serum vitamin D. OBJECTIVES: To investigate the prevalence of vitamin D inadequacy in an elderly population with fragility fractures and to compare data with previously published work from Glasgow. RESEARCH DESIGN AND METHODS: Two retrospective patient audits were carried out using records from the out-patient Osteoporosis Clinic at Musgrave Park Hospital and from in-patient hip fracture admissions at the Royal Victoria Hospital. RESULTS: There were data for 86 patients with fragility fracture from the Osteoporosis Clinic, 40.7% patients had vertebral fractures and 10.5% multiple fractures. Patients with hip fracture were excluded from the analysis. 69.8% of the patients were women. The mean age at the time of fracture was 65.3 years and 70.9% of patients were aged 60 years or over and 32.6% were aged 75 years or over. At the time of out-patient attendance, 73.3% were receiving supplementation with calcium and vitamin D. The mean vitamin D level was 52.3 nmol/L (21.0 ng/mL), SD = 23.4 (9.4). There were 83.7% of patients who had a vitamin D level < 80 nmol/L, 73.3% < 70 nmol/L and 55.8% < 50 nmol/L. There were no significant differences by patient age or sex. Data were also analysed according to supplementation status, in patients not taking supplements (n = 23) mean vitamin D level was 48.1 nmol/L (19.3 ng/mL), SD = 27.4 (11.0) compared with 53.8 nmol/L (21.6 ng/mL), SD = 21.8 (8.7) in the 63 patients taking supplements. Prevalence of inadequacy was higher in the patients not taking supplements 82.6% versus 67.1% at the 70 nmol/L threshold. There were data for 43 hip fracture patients, 95.3% of the patients were women. The mean age at the time of fracture was 78.3 years, 95.3% of patients were aged 60 years or over and 69.8% were aged 75 years or over. Data were not available on whether these patients were receiving supplementation. The mean vitamin D level was 36.1 nmol/L (14.5 ng/mL), SD = 24.8 (9.9). 90.7% of patients had a vitamin D level < 80 nmol/L, 88.4% < 70 nmol/L ( approximately 28 ng/mL) and 88.4% < 50 nmol/L ( approximately 20 ng/mL). CONCLUSIONS: The levels of vitamin D inadequacy revealed in this audit were similar to those in an earlier audit carried out in Glasgow. Thus studies at two locations in the UK confirm the high prevalence of vitamin D inadequacy, furthermore, the prevalence of inadequacy appears to be higher in those patients with a hip fracture.

DNA methylation levels in human and murine melanoma cell lines of varying metastatic potential.

DNA methylation levels were measured in a series of murine and human melanoma cell lines consisting of matched variants of low and high experimental metastatic capacity. The percentage of cytosine residues modified to 5-methylcytosine ranged between 2.13-3.92% in these lines. Ten cell lines were established in culture from individual lung tumor nodules produced in nude mice by i.v. injection of DX-3 human melanoma cells. Upon reinjection into groups of nude mice the individual lines manifested marked diversity for lung nodule formation (median number of pulmonary tumor nodules ranging from less than 10/group-greater than 100/group). DNA methylation levels in these lines were also heterogeneous (range 1.59 +/- 0.13 (SD)-4.04 +/- 0.15%) but no correlation was detected between methylation status of the genomic DNA and metastatic capacity.

Self-reactive antibody expression by human carcinoma cells engineered with monoclonal antibody genes.

The purpose of this study was to determine if human colon cancer cells transduced with monoclonal antibody (MAb) genes become sensitive to immune destruction through coexpression of both the MAb and its reactive antigen. Murine retroviral expression vectors were constructed with the heavy or light chain genes of an anti-human colon carcinoma MAb, D612, that mediates antibody-dependent cell-mediated cytotoxicity (ADCC). Transduction of D612 MAb genes into the D612 antigen-positive (> 95%) human colon carcinoma cell line, LS-174T, was carried out by sequential cocultivation with PA317 packaging cells producing infectious virions containing the light or heavy chain expression vectors. Six cultures survived drug selection, two of which were found to have elevated levels of both light and heavy immunoglobulin chain activity in their supernatants. IgG secretion levels (24 h) were 1-2 ng/1 x 10(6) cells. Low but definite antigen reactivity was also present in supernatants obtained from these LS-174T transductants. Immunocytochemical staining of transduced tumor cells revealed that > 95% of the cells were positive for IgG expression. Thus, LS-174T transductants were capable of producing both the D612 MAb and D612-reactive antigen. Analysis of transductants by flow cytometry further revealed that > 95% of the cells had murine immunoglobulin on their surfaces. ADCC mediated by human natural killer cells against nontransduced tumor cells was observed when the latter cells were co-cultivated in the presence of transductants producing both D612 heavy and light chains but not in the presence of tumor cells transduced with light chain only. LS-174T cells transduced with both D612 heavy and light chain genes were more sensitive to cytotoxicity mediated by natural killer cells than were light chain gene only transductants. ADCC contributed to the greater sensitivity of the former transductants to cytotoxicity based on its inhibition by anti-FcR gamma III antibody. Thus, these studies demonstrate that tumor cells transduced with genes encoding for MAbs that can participate in ADCC reactions are able to sensitize nontransduced tumor cells to immune destruction as well as to direct killer cells against themselves. These studies may lead to a new immunotherapeutic approach for the treatment of cancer based on MAb gene therapy.

Damaging effects of fourteen chemotherapeutic drugs on mouse testis cells.

The harmful effects of 14 chemotherapeutic drugs on spermatogenesis in the mouse have been evaluated by studies of testicular cell killing and morphological and genetic damage produced. Male mice were given drugs as single injections at various doses up to the toxic levels. Prednisone and 6-mercaptopurine produced little or no cytotoxicity. All other drugs tested killed differentiated spermatogonia. Of these, methotrexate, cyclohexylchlorethylnitrosourea, cis-platinum, and mechlorethamine did not show significant stem cell killing. Bischlorethylnitrosourea, chlorambucil, 5-fluorouracil, mitomycin C, antinomycin D, and procarbazine showed some stem cell killing. Triethylenethiophosphoramide (thio-TEPA) was the only drug in this group which killed large numbers of stem cells. Only 5-fluorouracil and cis-platinum killed spermatocytes, and only cis-platinum killed spermatids. Several drugs induced chromosome breaks in treated spermatocytes. Thio-TEPA was effective in inducing chromosome translocations in treated spermatocytes and probably also in spermatocytes which originated from surviving treated stem cells. It had been our hypothesis that the cytotoxic effects of these drugs on mouse testicular stem cells would correlate with the duration of azoospermia observed in patients. This was shown not to be the case. Thus, the cytotoxic effects of single injections of single chemotherapeutic agents on the mouse testis did not appear to be predictive of which drugs will cause long-term azoospermia in humans.

Generation and characterization of a recombinant/chimeric B72.3 (human gamma 1).

We report here the generation and characterization of a recombinant/chimeric construct of murine gamma 1 monoclonal antibody (MAb) B72.3, containing the murine variable region and a human gamma 1 constant region [designated cB72.3(gamma i)]. cB72.3(gamma 1) was generated by first isolating functionally rearranged VH and VL genes of B72.3 from partial genomic libraries in phage vectors. Construction of mouse-human chimeric heavy and light chain genes was performed by inserting restriction fragments carrying VL and VH regions of B72.3 into unique sites of expression vectors which contains sequences encoding constant regions of human kappa and gamma 1, respectively. The expression constructs were subsequently electroporated into SP2/0 cells. The transfected SP2/0 murine cell line has been shown to synthesize cB72.3(gamma 1) at a level of 10-20 micrograms/ml. Reciprocal competition radioimmunoassays demonstrated that cB72.3(gamma 1), a previously described cB72.3(gamma 4), and native B72.3 (designated nB72.3) competed similarly. A rat anti-idiotype MAb made against nB72.3 was shown to bind equally well to cB72.3(gamma 1) and to the nB72.3. Immunochemical studies of the nB72.3, cB72.3(gamma 4), and cB72.3(gamma 1) revealed slight differences in size among the three MAb forms on sodium dodecyl sulfate gels and revealed a higher isoelectric point for the cB72.3(gamma 1). Antibody-dependent cell-mediated cytotoxicity experiments using human lymphokine-activated killer effector cells indicated better tumor cell killing by the cB72.3(gamma 1) than the nB72.3 or cB72.3(gamma 4). Dual label studies of coinjected cB72.3(gamma 1) and nB72.3 revealed that both MAbs could efficiently localize human tumor xenografts in athymic mice. Pharmacokinetic studies, analyzing the blood clearance of cB72.3(gamma 1), cB72.3(gamma 4), and nB72.3 in mice, showed that the nB72.3 beta phase of clearance was slower than that of other MAb forms. However, when the pharmacokinetic patterns of these three MAbs forms were analyzed in monkeys, the cB72.3(gamma 1) and the nB72.3 showed similar clearance curves, while the cB72.3(gamma 4) showed a much slower plasma clearance. In view of the binding properties of nB72.3 and its ability to localize a range of carcinomas in clinical trials, the studies reported here demonstrate that the cB72.3(gamma 1) may serve as a potentially useful diagnostic and/or therapeutic reagent.

Effectiveness of centre-based childcare interventions in increasing child physical activity: a systematic review and meta-analysis for policymakers and practitioners.

CONTEXT: The review describes the effectiveness of physical activity interventions implemented in centre-based childcare services and (i) examines characteristics of interventions that may influence intervention effects; (ii) describes the effects of pragmatic interventions and non-pragmatic interventions; (iii) assesses adverse effects; and (iv) describes cost-effectiveness of interventions METHODS: Data sources were Cochrane Central Register of Controlled trials, MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, SCOPUS and SPORTDISCUS. Studies selected included randomized controlled trials conducted in centre-based childcare including an intervention to increase objectively measured physical activity in children aged less than 6 years. Data were converted into standardized mean difference (SMD) and analysed using a random effects model. RESULTS: Overall interventions significantly improved child physical activity (SMD 0.44; 95% confidence interval [CI]: 0.12-0.76). Significant effects were found for interventions that included structured activity (SMD 0.53; 95% CI: 0.12-0.94), delivery by experts (SMD 1.26; 95% CI: 0.20-2.32) and used theory (SMD 0.76; 95% CI: 0.08-1.44). Non-pragmatic (SMD 0.80; 95% CI: 0.12-1.48) but not pragmatic interventions (SMD 0.10; 95% CI:-0.13-0.33) improved child physical activity. One trial reported adverse events, and no trials reported cost data. CONCLUSIONS: Intervention effectiveness varied according to intervention and trial design characteristics. Pragmatic trials were not effective, and information on cost and adverse effects was lacking. Evidence gaps remain for policymakers and practitioners regarding the effectiveness and feasibility of childcare-based physical activity interventions.

Campylobacter infections in the United States. Results of an 11-state surveillance.

In January 1982, 11 states (Alabama, Arizona, Georgia, Illinois, Minnesota, New Mexico, Oregon, Texas, Vermont, Washington, and Wisconsin) began reporting monthly their isolations of Campylobacter to the Centers for Disease Control in Atlanta. The information reported included the species of Campylobacter organisms, the week of the report, the site from which the organism was isolated, and the age and sex of the infected person. A total of 3,966 isolates were reported in 1982, of which 3,900 were Campylobacter jejuni. Campylobacter isolations exceeded Salmonella in two of the three states (Oregon and Wisconsin) that require reporting. The eight other states with lower rates of isolation had variable reporting practices. Rates of Campylobacter isolations were highest in June through August. Age-specific rates of Campylobacter infections peaked in the 1- to 2-year and 20- to 29-year age groups. Fifty-five percent of all isolates were from male patients. Campylobacter infections seem to be at least as common as Salmonella infections in states in which the reporting practices are comparable.

From data to policy ... to politics. The Minnesotans health care plan for universal access to care.

Calls for major reform of the health care delivery system have been sounded at both the state and federal level. However, given the lack of consensus on health care reform at a federal level, more than half of the states are developing initiatives for universal access to care. In 1989, the Minnesota legislature created the Health Care Access Commission to develop a blueprint for universal access in Minnesota. To assist this effort, we studied the extent and nature of uninsurance and underinsurance within the state. In this article we report the findings of that study and discuss how the findings were first used to develop recommendations for universal access legislation. We then describe the fate of the legislation. Finally, we describe the veto and the creation of HealthRight, the recently enacted plan for health care reform bill in Minnesota. This plan simultaneously expands access to care and aims to contain health care costs.

Head kinematics during shaking associated with abusive head trauma.

Abusive head trauma (AHT) is a potentially fatal result of child abuse but the mechanisms of injury are controversial. To address the hypothesis that shaking alone is sufficient to elicit the injuries observed, effective computational and experimental models are necessary. This paper investigates the use of a coupled rigid-body computational modelling framework to reproduce in vivo shaking kinematics in AHT. A sagittal plane OpenSim computational model of a lamb was developed and used to interpret biomechanical data from in vivo shaking experiments. The acceleration of the head during shaking was used to provide in vivo validation of the associated computational model. Results of this study demonstrated that peak accelerations occurred when the head impacted the torso and produced acceleration magnitudes exceeding 200ms(-)(2). The computational model demonstrated good agreement with the experimental measurements and was shown to be able to reproduce the high accelerations that occur during impact. The biomechanical results obtained with the computational model demonstrate the utility of using a coupled rigid-body modelling framework to describe infant head kinematics in AHT.

Predictors of cognitive and functional progression in patients with probable Alzheimer's disease.

We followed 65 patients with probable Alzheimer's disease, who were initially mildly to moderately impaired, with semiannual assessments of cognitive and functional performance for up to 4 years. Scores on the Mini Mental State Examination and a combination of instrumental and self-maintenance scale of activities of daily living were regressed on time of examination (measured in 6-month increments) to estimate cognitive and functional progression rates in individual patients. Lower scores on the verbal neuropsychological tests at the time of study entry, more aggressive behavior, and sleep disturbance during the first year of observation predicted faster cognitive progression. Faster functional progression was predicted by paranoid behavior, hallucinations and activity disturbances during the first year and the presence of extrapyramidal signs and lower scores on nonverbal neuropsychological tests at the time of entry into the study. Hallucinations occurred independently of cognitive severity and may identify a distinct subgroup of patients with rapid functional progression. Because of the greater significance of functional progression for caregivers' ability to manage patients, the presence of specific behavior problems early in the disease course may help to identify individuals who will experience greater functional decline and be at risk for earlier institutionalization.

Capitated Medicaid and the process of care of elderly hypertensives and diabetics: results from a randomized trial.

PURPOSE: To measure the quality of care for hypertensive and diabetic elderly Medicaid beneficiaries enrolled in managed care versus fee-for-service (FFS) plans. METHODS: Individuals enrolled in the Medicaid Demonstration Project in Hennepin County, Minnesota, were randomly assigned to receive their care either in one of seven managed care health plans in which the Medicaid payment for their care was capitated or in an FFS plan. Two hundred ninety-one hypertensives and 96 diabetics who were aged 65 years or over at the beginning of the evaluation were interviewed at baseline and followed for 1 year. Drug and nondrug therapy, monitoring, monthly medication costs, and access to medications were assessed. RESULTS: The prepaid and FFS did not differ in drug or nondrug therapy, with the exception that slightly more FFS enrollees were on human insulin after 1 year. Mean monthly medication costs and access to medications were similar for both groups. CONCLUSIONS: In this randomized trial, we were unable to detect differences in the process of care for hypertensive and diabetic Medicaid enrollees.

Protection of spermatogonial survival and testicular function by WR-2721 against high and low doses of radiation.

The radioprotection of normal cells with WR-2721 at doses of radiation extending down to less than 1 Gy was investigated using testicular cells. Survival of stem spermatogonia after single doses of radiation was measured by counts of repopulating tubules and by sperm head counts, with consistent results obtained for both endpoints. Protection factors (PF) obtained by injection of 400 mg/kg WR-2721 at 15 min prior to irradiation decreased from about 1.4 at radiation doses above 10 Gy to 1.0 at 2 Gy. Similarly, the radioprotection by 300 mg/kg WR-2721 was reduced from a PF of about 1.35 when the drug was given prior to a single high dose of radiation to 1.0-1.1 when the drug was given prior to each of 5 daily fractions of 2 Gy. Thus, less protection of testicular stem cells by WR-2721 was observed at lower doses of radiation. This lowered protection may be explained, at least in part, by a direct cytotoxic effect of WR-2721 on testicular stem cells. Protection of differentiated spermatogonia was observed with 400 mg/kg WR-2721; the PF was 1.4 at 1 Gy and decreased at lower doses. The protection of testicular function by WR-2721, as assayed by the return of fertility and the maximum recovered level of sperm production, was compared to the protection of stem cell survival. At about 8 Gy the PF with 400 mg/kg WR-2721 for both functional endpoints was about 1.5, which was not significantly different from the value of 1.3 obtained using the stem cell assays.

Cytotoxic effects of WR-2721 on mouse testicular cells.

WR-2721 (S-2-(3-aminopropylamino)ethylphosphorothioic acid) has been demonstrated to be cytotoxic to stem spermatogonia in the mouse. Five and 10 injections of 300 mg/kg killed sufficient numbers of stem cells to reduce sperm production 56 days after treatment by 16 and 43%, respectively. Single injections of 300 or 400 mg/kg of WR-2721 given 15 min after irradiation produced negligible toxicity to stem cells as measured by counts of repopulated tubules; 600 mg/kg reduced stem cell survival by 47%. Four daily injections of 300 mg/kg given 4, 3, 2, and 1 days prior to irradiation (with or without a fifth injection 15 min after irradiation) reduced stem cell survival by about 60%. The cytotoxic effects of WR-2721 on testicular stem cells at least partially explains the reduced protection factors observed in the testis with low doses of radiation and during fractionated treatments involving multiple injections of drug.

Differences in valuation of functional status components among consumers and professionals in Europe and the United States.

The ratings of the importance of functional status items among geriatric experts and consumers in Europe and the United States differed in many cases between experts and consumers in both countries; the differences were more frequent among the U.S. samples. The overall correlation between consumer and expert rankings was .82 for both groups. In general consumers, rated instrumental activities of daily living (IADL) items more highly, whereas the experts rated the most dysfunctional activities of daily living (ADL) items higher than did consumers. This study suggests the gap in doctor-patient communication. As function is increasingly used as a clinical outcome, agreement is needed on how to weight the components. The differences uncovered in this study suggest a need for more dialogue about what ends are truly sought by various parties.

Developing a new metric for ADLs.

BACKGROUND: Most ADL summary measures add up the number of dependencies. They assume an equal weighting among items and require an arbitrary definition of dependency. METHODS: A panel of experts in geriatrics was asked to rate a set of ADL and IADL components in terms of the contribution of each to overall dependency using a magnitude estimation (ME) technique. The ratings were done for both domains and for levels of function within each domain. The resultant scores were compared with the usual dependency count approach. RESULTS: The distribution of weighted items appears to have face validity. The pattern of dependency traced by the ME model was intermediate between those created by simple counts with two different definitions of dependency. The ME approach has stronger statistical properties than the ordinal scoring approach. CONCLUSIONS: The ME approach appears to be a reasonable and workable method for creating a measure that permits meaningful statements about the mean value of functional dependencies. This result can be used for any comparison of means, such as across individuals, across aggregates of individuals, or across time.