Magnitude of terminological bias in international health services research: a disambiguation analysis in mental health.

AIMS: Health services research (HSR) is affected by a widespread problem related to service terminology including non-commensurability (using different units of analysis for comparisons) and terminological unclarity due to ambiguity and vagueness of terms. The aim of this study was to identify the magnitude of the terminological bias in health and social services research and health economics by applying an international classification system. METHODS: This study, that was part of the PECUNIA project, followed an ontoterminology approach (disambiguation of technical and scientific terms using a taxonomy and a glossary of terms). A listing of 56 types of health and social services relevant for mental health was compiled from a systematic review of the literature and feedback provided by 29 experts in six European countries. The disambiguation of terms was performed using an ontology-based classification of services (Description and Evaluation of Services and DirectoriEs - DESDE), and its glossary of terms. The analysis focused on the commensurability and the clarity of definitions according to the reference classification system. Interrater reliability was analysed using κ. RESULTS: The disambiguation revealed that only 13 terms (23%) of the 56 services selected were accurate. Six terms (11%) were confusing as they did not correspond to services as defined in the reference classification system (non-commensurability bias), 27 (48%) did not include a clear definition of the target population for which the service was intended, and the definition of types of services was unclear in 59% of the terms: 15 were ambiguous and 11 vague. The κ analyses were significant for agreements in unit of analysis and assignment of DESDE codes and very high in definition of target population. CONCLUSIONS: Service terminology is a source of systematic bias in health service research, and certainly in mental healthcare. The magnitude of the problem is substantial. This finding has major implications for the international comparability of resource use in health economics, quality and equality research. The approach presented in this paper contributes to minimise differentiation between services by taking into account key features such as target population, care setting, main activities and type and number of professionals among others. This approach also contributes to support financial incentives for effective health promotion and disease prevention. A detailed analysis of services in terms of cost measurement for economic evaluations reveals the necessity and usefulness of defining services using a coding system and taxonomical criteria rather than by 'text-based descriptions'.

Comparing colon cancer outcomes: The impact of low hospital case volume and case-mix adjustment.

OBJECTIVE: When comparing performance across hospitals it is essential to consider the noise caused by low hospital case volume and to perform adequate case-mix adjustment. We aimed to quantify the role of noise and case-mix adjustment on standardized postoperative mortality and anastomotic leakage (AL) rates. METHODS: We studied 13,120 patients who underwent colon cancer resection in 85 Dutch hospitals. We addressed differences between hospitals in postoperative mortality and AL, using fixed (ignoring noise) and random effects (incorporating noise) logistic regression models with general and additional, disease specific, case-mix adjustment. RESULTS: Adding disease specific variables improved the performance of the case-mix adjustment models for postoperative mortality (c-statistic increased from 0.77 to 0.81). The overall variation in standardized mortality ratios was similar, but some individual hospitals changed considerably. For the standardized AL rates the performance of the adjustment models was poor (c-statistic 0.59 and 0.60) and overall variation was small. Most of the observed variation between hospitals was actually noise. CONCLUSION: Noise had a larger effect on hospital performance than extended case-mix adjustment, although some individual hospital outcome rates were affected by more detailed case-mix adjustment. To compare outcomes between hospitals it is crucial to consider noise due to low hospital case volume with a random effects model.

[Chemoprevention of prostate cancer - a plea]. / Chemoprävention des Prostatakarzinoms - Ein Plädoyer.

The high disease prevalence, the presentation in older age, a frequently slowly progressing course of disease, and high costs make the diagnosis of and therapy for prostate cancer a special challenge for urologists. Effective prevention of the disease may help to improve some of the problems mentioned above. Two randomised, controlled studies have proved that effective chemoprevention of prostate cancer is viable using 5α-reductase inhibitors (finasteride, dutasteride). Furthermore, there is increasing evidence that other compounds, e. g., selective oestrogen receptor modulators (SERMs), NSAIDs and statins might also be effective. This review investigates potential risks and benefits of chemoprevention including a consideration of health economical aspects. The authors conclude that the options of chemoprevention should be investigated in an open and unbiased way.

Is the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) effective for preterm infants with intrauterine growth restriction?

OBJECTIVE: This study investigates the effectiveness of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) on neurobehavioral and electrophysiological functioning of preterm infants with severe intrauterine growth restriction (IUGR). STUDY DESIGN: Thirty IUGR infants, 28 to 33 weeks gestational age, randomized to standard care (control/C=18), or NIDCAP (experimental/E=12), were assessed at 2 weeks corrected age (2wCA) and 9 months corrected age (9mCA) in regard to health, anthropometrics, and neurobehavior, and additionally at 2wCA in regard to electrophysiology (EEG). RESULT: The two groups were comparable in health and anthropometrics at 2wCA and 9mCA. The E-group at 2wCA showed significantly better autonomic, motor, and self-regulation functioning, improved motility, intensity and response thresholds, and reduced EEG connectivity among several adjacent brain regions. At 9mCA, the E-group showed significantly better mental performance. CONCLUSION: This is the first study to show NIDCAP effectiveness for IUGR preterm infants.

Impact of socioeconomic status on the prevalence of dementia in an inner city memory disorders clinic.

BACKGROUND: Socioeconomic status (SES) has been identified as a possible risk factor for the development of dementia, with low SES shown to be associated with a higher prevalence of dementia, increased psychiatric comorbidity and worse baseline cognitive functioning. Few studies have actually looked at the impact of SES within a clinical population using multiple measures of SES and cognition. METHODS: Data on 217 patients seen in an Inner City Memory Disorders Clinic were analyzed with respect to demographic status, clinical status and SES. Correlations were then examined looking at the relationship of SES to clinical variables and neurocognitive status. Regression analysis was undertaken to examine the relative contribution of individual sociodemographic factors to a diagnosis of dementia. RESULTS: In general, there was wide variation in the sample examined with respect to most measures of SES. Approximately one third (36%) of the sample had a diagnosis of dementia, the mean age was 66.1 years and the mean Mini-mental State Examination score was relatively high (25.4). There was a strong association between age, individual annual income range, education, medical comorbidity and a diagnosis of dementia, with increased age and medical comorbidity being the strongest predictors. CONCLUSION: Increased age, low education, high medical comorbidity and low annual income are all associated with a diagnosis of dementia in an inner city setting. Age and medical comorbidity appear to be more strongly associated with a diagnosis of dementia than SES in an inner city setting.

[Functional assessment of cochlear nerve and hearing]. / Exploration fonctionnelle du nerf cochléaire et de l'audition.

BACKGROUND/PURPOSE: Since otoneurosurgical pathologies are being diagnosed increasingly early, the functional prognosis of surgery is gaining in importance. Hearing and cochlear nerve exploration can be carried out using three principal methods: pure-tone and speech audiometry, evoked otoacoustic emissions (EOAEs), and brainstem auditory evoked potentials (BAEPs). The aim of this paper is to present the current knowledge on auditory functional assessment. MATERIALS AND METHODS: The medical and scientific literature from the Pubmed-Medline database was reviewed. Recently published related books were also included. RESULTS/DATA SYNTHESIS: Preoperative audiological evaluation makes it possible to assess pathology consequences on hearing. Depending on auditory status, conservative surgery, including intraoperative auditory monitoring, can be planned. From this perspective, prognostic factors for hearing preservation - such as the speech intelligibility score, the presence of transient EOAEs, and the presence of the BAEPs wave III - were identified. However, several surgical teams argue for a systematic conservative procedure, particularly when EOAEs are present, whatever the patient's preoperative hearing status. Postoperative audiological evaluation provides the opportunity for monitoring: in the short term, to detect complications early, through BAEPs recorded in the nonoperated ear; in the long term, to detect recurrence of the pathology. Moreover, the consequences of surgery on hearing can be assessed and long-term follow-up of auditory function can be carried out. Finally, the comparison of pre- and postoperative audiological status provides inductive feedback on surgery and electrophysiological monitoring, giving the otoneurosurgeon and neurophysiologist the opportunity to improve the entire procedure. CONCLUSION: Auditory functional assessment is essential for optimal care of tumor or functional pathologies involving the cochlear nerve and/or the cerebellopontine angle.

[Socio-economical aspects, quality of life and state of knowledge in hepatitis B patients. Socio-economical aspects in hepatitis B]. / Sozioökonomische Charakteristika, Lebensqualität und Wissensstand bei Patienten mit Hepatitis-B-Virusinfektion in Deutschland. Sozioökonomische Aspekte bei Hepatitis B.

BACKGROUND: Little is known about socio-economical consequences and information status of patients with chronic hepatitis B virus (HBV) infection. AIMS AND METHODS: The present study prospectively analyzed questionnaires about socio-economical consequences and information status including the SF12 quality-of-life analysis in HBV-infected subjects. Overall 1500 questionnaires were distributed by clinics, practioners, patient support groups and internet; 255 questionnaires were sent back. Results were compared with a recent study in 714 HCV infected patients (Z Gastroenterol 2006; 44: 305-317). RESULTS: HBV-infected patients were younger (mean 46 vs. 52 years), more likely to be male (62 vs. 44%) and to come from abroad (30 vs. 9%) when compared with HCV-infected subjects. Only 1 and 4% of HBV- and HCV-infected subjects, respectively, considered the public information about hepatitis as good or very good, 73 and 77%, however, as bad or very bad. Mental and physical quality-of-life (SF12) was better in HBV- than in HCV-infected subjects, but reduced when compared with a sex- and age-matched general population (p < 0.001). Quality-of-life decreased with increases in HBV-DNA, fibrosis and inflammation. In both HBV- and HCV-infected subjects there were information deficits concerning the risks for infection; some of these were more pronounced in HBV-infected subjects when compared to HCV-infected ones. German subjects with HBV and HCV infection are in general well informed about their infection (73-87% knew ALT and histology results); however, HBV-infected subjects are less well informed in particular about viral load and HBeAg (59 and 30%) when compared with HCV infected subjects who knew HCV-RNA and genotype in 80-85%. CONCLUSIONS: The information deficits about viral load are of concern for HBV-infected subjects because these data are more important in HBV than in HCV infection. This lack of information likely reflects a lack of attentiveness towards HBV-DNA levels by the patients' physician. Both HBV- and HCV-infected subjects have problems at work and with various insurances; both have a reduced quality-of-life which correlates with viral load and degree of inflammation and fibrosis. Both populations consider the public information status about viral hepatitis to be bad.

Haplotype sharing analysis using mantel statistics.

OBJECTIVE: The potential value of haplotypes has attracted widespread interest in the mapping of complex traits. Haplotype sharing methods take the linkage disequilibrium information between multiple markers into account, and may have good power to detect predisposing genes. We present a new approach based on Mantel statistics for spacetime clustering, which is developed in order to improve the power of haplotype sharing analysis for gene mapping in complex disease. METHODS: The new statistic correlates genetic similarity and phenotypic similarity across pairs of haplotypes for case-only and case-control studies. The genetic similarity is measured as the shared length between haplotypes around a putative disease locus. The phenotypic similarity is measured as the mean-corrected cross-product based on the respective phenotypes. We analyzed two tests for statistical significance with respect to type I error: (1) assuming asymptotic normality, and (2) using a Monte Carlo permutation procedure. The results were compared to the chi(2) test for association based on 3-marker haplotypes. RESULTS: The results of the type I error rates for the Mantel statistics using the permutational procedure yielded pointwise valid tests. The approach based on the assumption of asymptotic normality was seriously liberal. CONCLUSION: Power comparisons showed that the Mantel statistics were better than or equal to the chi(2) test for all simulated disease models.

Development status of miltefosine as first oral drug in visceral and cutaneous leishmaniasis.

An oral treatment for visceral and cutaneous leishmaniasis has been searched for over the last decades. An oral drug would facilitate treatment and lower costs. Oral miltefosine (Zentaris/ASTA Medica AG, Germany), an alkylphosphocholine, is under clinical development for treatment of leishmaniasis. Phase I, II and III clinical trials have been performed in visceral leishmaniasis in India; the overall response rate with 100 mg/day over 4 weeks is 96%. A first clinical trial in New World cutaneous leishmaniasis has shown a final cure rate of 94% at a dose of 150 mg/day over 3 or 4 weeks. Side effects are mainly gastrointestinal (vomiting, diarrhoea). Furthermore, transient elevation of transaminases or urea/creatinine has been observed. The clinical results suggest that miltefosine is the first oral therapy that is effective and safe in visceral and cutaneous leishmaniasis.

Collaborative, individualized assessment.

Collaborative, individualized assessment is an approach to psychological assessment in which the assessor and the client work together to develop productive understandings. Collaboration is a means of individualizing the assessment--its process, resulting suggestions, and written accounts. In this approach, life events are regarded as primary data. Test scores, categories, and related research are used as bridges into a particular life and as tools for then exploring that life. This article, an invited Master Lecture presented at the 1999 Society for Personality Assessment (SPA) meeting, presents examples of contextualizing, intervening, describing in life-world terms, and writing individualized reports with suggestions. Historical struggles to promote individualized assessment and current openness to its practices, especially within SPA, are mentioned. A hermeneutic approach to impression formation is described.

The search for cost-effective prevention of postoperative nausea and vomiting in the child undergoing reconstructive burn surgery: ondansetron versus dimenhydrinate.

Postoperative nausea and vomiting (PONV) is a common and unpleasant problem for children with burns who are undergoing reconstructive burn surgery. Ondansetron and dimenhydrinate have been found to be effective for the prevention of PONV in other patient populations, but they have not been directly compared in the pediatric population. A prospective, randomized, double-blind, placebo-controlled comparison of ondansetron and dimenhydrinate was performed. One hundred patients with a mean age of 11.8 years who were undergoing reconstructive burn surgery with general anesthesia were randomly assigned to receive either a placebo, 0.1 mg/kg of ondansetron, or 0.5 mg/kg of dimenhydrinate. The 3 groups were well matched for all demographic and procedural variables. The study drugs were given twice, first at the end of surgery and again 4 hours later, to ensure adequate blood levels during the 8-hour study period. Postoperatively, on the basis of the presence and amount of PONV experienced, all patients were assigned a PONV score by a blinded investigator. Statistically significant reductions in the incidence of PONV in the patients who received ondansetron or dimenhydrinate were found, as compared with the results of patients who received placebo. Postoperative vomiting was reduced from 61% in the placebo group to 29% and 40% in the ondansetron and dimenhydrinate groups, respectively, and PONV was similarly reduced from 69% to 47% and 40%, respectively. The differences between ondansetron and dimenhydrinate were not significant. The average cost to our pharmacy for the prescribed dose of ondansetron was $19.34; the cost for dimenhydrinate was $0.90. In this patient population, dimenhydrinate was as effective as ondansetron for the prevention of PONV and postoperative vomiting, and it was much less expensive.

MRI assessment of the anatomy of optic radiations after temporal lobe epilepsy surgery.

OBJECTIVE: The aim of this study was to determine the course of the temporal optic radiations. MATERIAL AND METHODS: Eighteen patients were included in this prospective study. All of them underwent a temporal lobectomy for epilepsy, including the mesial temporal structures and a variable extent of lateral neocortex (from 2 to 7 cm behind the temporal tip). An MRI was performed 2 months postoperatively, allowing assessment of the extent of lateral resection. Postoperative visual fields were determined by automatic static perimetry (ASP). RESULTS: (1) No patient complained of a disabling visual field deficit. (2) ASP, a highly sensitive technique, however, detected postoperative visual field deficits in 83% of patients, confined to the superior homonymous field contralateral to the resection. (3) A strong correlation was found between the presence of a visual field deficit and the extent of laterotemporal resection. (4) The smallest anteroposterior resection resulting in a field defect was limited to 20 mm from the temporal tip. CONCLUSION: (1) This study confirms a strong correlation between postoperative visual field deficits and the extent of lateral neocortical temporal resection. (2) The anterior limit of Meyer's loop is likely to be located more rostrally than previously believed. (3) Despite this, lateral resection remains useful in some cases for seizure control.

Simultaneous assessment of the intravenous and oral disposition of the enantiomers of racemic nimodipine by chiral stationary-phase high-performance liquid chromatography and gas chromatography/mass spectroscopy combined with a stable isotope technique.

An enantioselective method of high specificity and sensitivity for the determination of the enantiomers of two racemic 1,4-dihydropyridine compounds after simultaneous oral (po) and intravenous (iv) administration is reported. The method is suitable for the simultaneous administration by two different routes of a racemic drug labeled with stable isotopes and unlabeled racemate. For workup, an internal racemic standard labeled with a different number of stable isotopes is added. After separation of the enantiomers by chiral stationary-phase high-performance liquid chromatography and subsequent analysis by gas chromatography/mass spectroscopy (GC/MS) with selected ion detection, the R and S enantiomer concentrations arising from i.v. and p.o. administration can be precisely measured because of their mass difference. This method has been applied to assess the disposition of the R and S enantiomers of nimodipine and nitrendipine after simultaneous i.v. and p.o. administration. The assay is highly specific and sensitive, with a limit of quantification per enantiomer of 0.1 ng/mL after extraction of 0.5 mL of human serum samples and monitoring the M- ions in the electron capture, negative ion chemical ionization mode. The calibration curve was linear in the range 0.1-100 ng/mL. Within- and between-day precision were satisfactory (coefficient of variation, < 10%). Enantiomeric excess in the range 0-100% could be accurately determined. Comparison of the enantioselective method with the achiral method (GC/MS only) gave good agreement.

Variables associated with the assessment of systemic tumor necrosis factor alpha levels during hemodialysis.

Conflicting results have been published concerning the systemic induction of the cytokine tumor necrosis factor alpha (TNF alpha) during hemodialysis (HD). We therefore evaluated in vitro TNF alpha production in whole blood as well as in vivo variability of TNF alpha levels in patients on long-term HD. Whole blood was incubated at room temperature (RT) with or without exogenously added endotoxin (ET), and plasma-TNF alpha was measured after 5, 30, 120, 240, and 960 min by specific enzyme immunoassay. Additionally, plasma-TNF alpha before and after 120 and 240 min HD was studied longitudinally once a week over a period of 4 weeks in 36 patients on Cuprophan (CU, n = 23) or polysulfone-F60 (PSu, n = 13) HD. Mean plasma TNF alpha levels in vitro rose from (mean) 8 pg/ml after 5 min to 12 pg/ml (120') and 32 pg/ml (960') even without ET addition, and to 18 pg/ml (after 120') and 88 pg/ml (after 960') when 0.1 microgram/ml ET were added. Pre-dialytic as well as intra-dialytic TNF alpha levels in patients showed high intra-individual variability. A substantial (> 100%) increase in plasma TNF alpha was observed during only 14 out of 84 treatments with CU and 20 out of 47 with PSu, however, the increase in TNF alpha was not statistically significant in either group. We conclude that the sampling procedure, if not carefully standardized, is a potential source of artifacts with regard to "systemic" TNF alpha levels. The high intra and inter-individual variability of plasma TNF alpha suggests that results of cross-sectional studies are questionable.

Intravascular ultrasound assessment of lumen size and wall morphology in normal subjects and patients with coronary artery disease.

BACKGROUND: Necropsy studies demonstrate that coronary artery disease (CAD) is frequently complex and eccentric. However, angiography provides only a silhouette of the vessel lumen. Intravascular ultrasound is a new tomographic imaging method for evaluation of coronary dimensions and wall morphology. Few data exist regarding intravascular ultrasound in patients with CAD, and no data exist for subjects with normal coronaries. METHODS AND RESULTS: We used a multielement 5.5F, 20-MHz ultrasound catheter to examine eight normal subjects and 43 patients with CAD. We assessed the safety of coronary ultrasound and the effect of vessel eccentricity on comparison of minimum luminal diameter by angiography and ultrasound. Normal and atherosclerotic wall morphology and stenosis severity were also evaluated by intravascular ultrasound. The only untoward effect was transient coronary spasm in five patients. At 33 sites in normal subjects, the lumen was nearly circular, yielding a close correlation between angiographic and ultrasonic minimum diameter (r = 0.92). At 90 sites in patients with CAD, ultrasound demonstrated a concentric cross section; correlation was also close (r = 0.93). However, at 72 eccentric sites, correlation was not as close (r = 0.77). For 41 stenoses, correlation between angiography and ultrasound for area reduction was moderate (r = 0.63). In normal subjects, wall morphology revealed a thin (0.30 mm or less) intimal leading edge and subadjacent sonolucent zone (0.20 mm or less). Patients with CAD exhibited increased thickness and echogenicity of the leading edge, thickened sonolucent zones, and/or attenuation of ultrasound transmission. CONCLUSIONS: These data establish that intravascular ultrasound is feasible and safe and yields luminal measurements that correlate generally with angiography. Differences between angiographic and ultrasound measures of lumen size in eccentric vessels probably reflect the dissimilar perspectives of tomographic and silhouette imaging techniques. Intravascular ultrasound provides detailed images of normal and abnormal wall morphology not previously possible in vivo.

Breast-feeding policies and routines among Arizona hospitals and nursery staff: results and implications of a descriptive study.

In 1988, Arizona's 61 hospitals providing obstetrical services were canvased with regard to hospital routines that favor either breast-feeding or bottle-feeding. Forty-five hospitals provided responses that were used in the survey. Practices favoring breast-feeding, which were reported by a majority of the hospitals (more than 50%), were demand feeding, staff assessment for "latch-on" (the action of nipple presentation and sucking initiation) and positioning, "rooming-in" (the practice of minimal mother-infant separation), and information about follow-up support services. Hospital practices suggested to promote bottle-feeding were the provision of pacifiers and supplemental water or glucose, issuance of formula packs at discharge, and a first feed of sterile water. A positive significant relationship was identified for policies advocating breast-feeding and the prevalence of breast-feeding encouragement from professional staff. Of 44 respondents, 41 indicated that their hospital's policies endorse breast-feeding as the ideal method of feeding healthy newborns. Hospital staff perceived that they encourage mothers to breast-feed and offer support to those who initiate breast-feeding. On the basis of this information, we conclude that dietetics practitioners should evaluate current breast-feeding practices and integrate policies supportive of breast-feeding into the health care system.

Microtuboplasty as an outpatient procedure.

Fifteen cases of microtuboplasty were done as outpatient procedures at low cost and with increased patient convenience. Advances in outpatient surgery at free-standing surgery centers have allowed many new patient care innovations, and microsurgery should now be considered an outpatient procedure for gynecologic patients. Outpatient microtuboplastic surgery is not only feasible but perhaps preferable to that done as an inpatient procedure.