Shorter heels are linked with greater elastic energy storage in the Achilles tendon.

Previous research suggests that the moment arm of the m. triceps surae tendon (i.e., Achilles tendon), is positively correlated with the energetic cost of running. This relationship is derived from a model which predicts that shorter ankle moment arms place larger loads on the Achilles tendon, which should result in a greater amount of elastic energy storage and return. However, previous research has not empirically tested this assumed relationship. We test this hypothesis using an inverse dynamics approach in human subjects (n = 24) at speeds ranging from walking to sprinting. The spring function of the Achilles tendon was evaluated using specific net work, a metric of mechanical energy production versus absorption at a limb joint. We also combined kinematic and morphological data to directly estimate tendon stress and elastic energy storage. We find that moment arm length significantly determines the spring-like behavior of the Achilles tendon, as well as estimates of mass-specific tendon stress and elastic energy storage at running and sprinting speeds. Our results provide support for the relationship between short Achilles tendon moment arms and increased elastic energy storage, providing an empirical mechanical rationale for previous studies demonstrating a relationship between calcaneal length and running economy. We also demonstrate that speed and kinematics moderate tendon performance, suggesting a complex relationship between lower limb geometry and foot strike pattern.

Functional outcomes of clinically high-risk prostate cancer patients treated with robot-assisted radical prostatectomy: a multi-institutional analysis.

BACKGROUND: To ascertain 3-year urinary continence (UC) and sexual function (SF) recovery following robot-assisted radical prostatectomy (RARP) for clinically high-risk prostate cancer (PCa). METHODS: Retrospective analyses of a prospectively maintained database for 769 patients with D'Amico high-risk PCa undergoing RARP at two tertiary care centers in the United States and Europe between 2001 and 2014. The association between time since RARP and recovery of UC (defined as 0 pad/one safety liner per day) and SF (defined as sexual health inventory for men (SHIM) score ⩾17) was tested in separate preoperative and post-operative Cox-proportional hazards regression models. Sensitivity analyses were conducted using continence 0 pad per day and erection sufficient for intercourse as end points for UC and SF recovery, respectively. RESULTS: Mean age of the cohort was 62.3 years, and 62.1% harbored ⩾PT3a disease. Nerve sparing (unilateral or bilateral) RARP was performed in 87.7% of patients. Kaplan-Meier estimates of UC recovery at 12, 24 and 36 months after surgery was 85.2%, 89.1% and 91.2%, respectively, while 33.8, 52.3 and 69.0% of preoperatively potent men (preoperative SHIM ⩾17; n=548; 71.3%) recovered SF. Similar results were noted in sensitivity analyses. Patient age and year of surgery were associated with UC and SF recovery; additionally, preoperative SHIM score, degree of nerve sparing, pT3b-T4 disease and surgical margins were associated with SF recovery over the period of observation. CONCLUSIONS: Patients with D'Amico high-risk PCa treated with RARP may continue to recover UC and SF beyond 12 months of surgery and show promising outcomes at 3-year follow-up. Appropriate patient selection and counseling may aid in setting realistic expectations for functional recovery post RARP.

Patient and provider perspectives on quality and health system effectiveness in a transition economy: evidence from Ukraine.

Facing a severe population health crisis due to noncommunicable diseases, Ukraine and other former Soviet republics and Eastern European countries have a pressing need for more effective health systems. Policies to enhance health system effectiveness should consider the perspectives of different stakeholder groups, including providers as well as patients. In addition, policies that directly target the quality of clinical care should be based on objective performance measures. In 2009 and 2010 we conducted a coordinated series of household and facility-level surveys to capture the perspectives of Ukrainian household members, outpatient clinic patients, and physicians regarding the country's health system overall, as well as the quality, access, and affordability of health care. We objectively measured the quality of care for heart failure and chronic obstructive pulmonary disease using CPV(®) vignettes. There was broad agreement among household respondents (79%) and physicians (95%) that Ukraine's health system should be reformed. CPV(®) results indicate that the quality of care for common noncommunicable diseases is poor in all regions of the country and in hospitals as well as polyclinics. However, perspectives about the quality of care differ, with household respondents seeing quality as a serious concern, clinic patients having more positive perceptions, and physicians not viewing quality as a reform priority. All stakeholder groups viewed affordability as a problem. These findings have several implications for policies to enhance health system effectiveness. The shared desire for health system reform among all stakeholder groups provides a basis for action in Ukraine. Improving quality, strengthening primary care, and enhancing affordability should be major goals of new health policies. Policies to improve quality directly, such as pay-for-performance, would be mutually reinforcing with purchasing reforms such as transparent payment mechanisms. Such policies would align the incentives of physicians with the desires of the population they serve.

Do doctors under-provide, over-provide or do both? Exploring the quality of medical treatment in the Philippines.

OBJECTIVE: To assess the quality of medical treatment by disaggregating quality into components that distinguish between insufficient and unnecessary care. DESIGN: Randomly selected doctors were asked how they would treat a sick child. Their responses were disaggregated into how much of an evidence-based essential treatment plan was completed and the number of additional non-essential treatments that were given. Key variables included the expected cost, the health consequences of insufficient and unnecessary care and comparisons between public and private physicians. Responses to 160 clinical performance vignettes (CPVs) were analysed. SETTING: Philippines. PARTICIPANTS: One hundred and forty-three public and private physicians in the Philippines, collected in November 2003-December 2004 and September 2006-June 2007. INTERVENTIONS: CPVs administered to physicians. MAIN OUTCOME MEASURES: Process quality measures (accounting for the possibility of both over-treatment and under-treatment). RESULTS: Based on CPVs, doctors gave both insufficient and unnecessary treatment to under-five children in 69% of cases. Doctors who provided the least sufficient care were also the most likely to give costly or harmful unnecessary care. Insufficient care typically had potentially worse health consequences for the patient than unnecessary care, though unnecessary care remains a concern because of overuse of antibiotics (47%) and unnecessary hospitalization (34%). CONCLUSIONS: Quality of care is complex, but over- and under-treatment coexist and, in our analysis physicians that were more likely to under-treat a sick child were also those more likely to over-treat.

Household CO and PM measured as part of a review of China's National Improved Stove Program.

UNLABELLED: In 2001-2003, a team of researchers from the United States and China performed an independent, multidisciplinary review of China's National Improved Stove Program carried out since the 1980s. As part of a 3500-household survey, a subsample of 396 rural households were monitored for particulate matter less than 4 microm (PM(4)) in kitchens and living rooms over 24 h, of which 159 were measured in both summer and winter. Carbon monoxide was measured in a 40% subsample. The results of this indoor air quality (IAQ) component indicate that for nearly all household stove or fuel groupings, PM(4) levels were higher than - and sometimes more than twice as high as - the national PM(10) standard for indoor air (150 microg PM(10)/m(3)). If these results are typical, then a large fraction of China's rural population is now chronically exposed to levels of pollution far higher than those determined by the Chinese government to harm human health. Further, we observed highly diverse fuel usage patterns in these regions in China, supporting the observations in the household survey of multiple stoves being present in many kitchens. Improved stoves resulted in reduced PM(4) from biomass fuel combinations, but still not at levels that meet standards, and little improvement was observed in indoor pollution levels when other unimproved stoves were present in the same kitchen. As many households change fuels according to daily and seasonal factors, resulting in different seasonal concentrations in living rooms and kitchens, assessing health implications from fuel use requires longitudinal evaluation of fuel use and IAQ levels, combined with accurate time-activity information. PRACTICAL IMPLICATIONS: Leaving aside the difficult issue of enforcement, it is uncertain whether Chinese household IAQ standards represent realistic objectives for current attainment given current patterns of energy consumption in rural China, which rely so heavily on unprocessed solid fuels. Even when used with chimneys, these fuels emit substantial pollution into the household environment. It is probable that low-emission technologies involving gaseous/liquid fuels or high combustion - efficiency biomass stoves need to be promoted in order to achieve these standards for the greater part of the population.

Tuberculosis control in Bolivia, Chile, Colombia and Peru: why does incidence vary so much between neighbors?

SETTING: In 2003, Peru and Bolivia reported the highest annual tuberculosis (TB) incidence rates in the Americas. Neighboring Colombia and Chile had lower annual incidence rates despite their proximity. OBJECTIVE: To determine what factors contribute to differences in TB incidence rates among Chile, Colombia, Bolivia and Peru. DESIGN: Multiple sources of literature dating between 1990 and 2005 were used and World Health Organization TB control guidelines were consulted for policy level comparisons. RESULTS: Comprehensive implementation of the DOTS strategy is the main factor explaining the differences in TB incidence rates, even after considering socio-economic factors. CONCLUSION: Cross-national comparisons suggest ways to improve regional DOTS implementation.

An automated scoring algorithm for computerized clinical vignettes: evaluating physician performance against explicit quality criteria.

OBJECTIVE: To evaluate the accuracy of an automated algorithm for scoring physicians' responses to open-ended clinical vignettes against explicit, evidence-based quality criteria. METHODS: One hundred sixteen physicians completed a total of 915 computerized clinical vignettes at 4 sites. Each vignette simulated an outpatient primary care visit for one of 8 different clinical cases. The automated algorithm scored disease-specific quality criterion as done or not done by recognizing the presence or absence of predefined patterns in the physician's text response to the vignette. Scores generated by the automated algorithm for each criterion were compared to scores generated by trained human abstractors. Vignette responses were divided into development and test sets. Percentage agreement between automated and manual scores was computed separately for the development and test sets. Sensitivity and specificity were calculated. Costs of automated and manual scoring were compared. RESULTS: Accuracy of the algorithm exceeds 90% for both the development and test sets, and is high for care items that were deemed either necessary or unnecessary, across diverse clinical cases, and for all domains of the outpatient clinical encounter. The sensitivity of the automated scoring algorithm is 89.0%, and specificity is 93.5%. Automated scoring is approximately 84% less expensive than manual scoring. CONCLUSION: Automated scoring of computerized vignettes appears feasible and accurate. Computerized vignettes incorporating accurate automated scoring offer the promise of a highly standardized but relatively inexpensive measurement tool for a wide range of quality assessments within and across health systems.

pT1 substaging in renal cell carcinoma: validation of the 2002 TNM staging modification of malignant renal epithelial tumors.

PURPOSE: Tumor size has been used as one of the criteria to stratify renal cell carcinoma (RCC) into different pathological stages (pT). The recent 2002 UICC/TNM classification of malignant epithelial renal tumors is modified to substratify pT1 RCC into pT1a (less than 4.0 cm) and pT1b (greater than 4.0 but less than 7.0 cm). In this study we ascertained if this stage modification has prognostic relevance. MATERIALS AND METHODS: A total of 259 consecutive radical nephrectomy specimens of organ confined RCC from 1970 to 1997 at 1 institution, including 153 of conventional RCC (CRCC), 71 of papillary RCC, 28 of chromophobe RCC, 1 of collecting duct carcinoma and 6 of RCC not otherwise specified, with a mean clinical followup of 7.5 years (median 6.4) were included in the study. RESULTS: There were 115 pT1a (44.4%), 95 pT1b (36.7%) and 49 pT2 tumors (18.9%). Disease recurrences (DR) and disease specific death occurred in 2 (1.7%) and 0 cases (0%) of pT1a, 7 (7.3%) and 5 (5.3%) of pT1b, and 16 (32.6%) and 12 (24.5%) of pT2. DR for pT1b was higher compared with pT1a (all histological subtypes RR 3.68), although this difference was not statistically significant (p = 0.106). If only CRCCs were analyzed, DR in the pT1b group was statistically higher compared with pT1a (RR 8.54, p = 0.047). Disease specific survival in pT1a could not be evaluated because no deaths occurred in this subgroup. DR and disease specific survival were significantly different between pT1b and pT2 tumors for all histological subtypes (RR 5.51, p = 0.001 and 5.49, p = 0.001) and for the CRCC subtype (RR 5.50, p = 0.001 and 5.18, p = 0.005, respectively). Using size as a continuous variable the logarithmic change in tumor size was a significant predictor of DR (RR 8.82, p = 0.001). All statistical analyses were adjusted for age and sex. CONCLUSIONS: Substaging RCC into pT1a and pT1b yields prognostically important information, validating the 2002 TNM modification for malignant renal epithelial malignancies. The substratification of pT1 is particularly useful in tumors with CRCC histology.

The ethical problem of false positives: a prospective evaluation of physician reporting in the medical record.

OBJECTIVE: To determine if the medical record might overestimate the quality of care through false, and potentially unethical, documentation by physicians. DESIGN: Prospective trial comparing two methods for measuring the quality of care for four common outpatient conditions: (1) structured reports by standardised patients (SPs) who presented unannounced to the physicians' clinics, and (2) abstraction of the medical records generated during these visits. SETTING: The general medicine clinics of two veterans affairs medical centres. PARTICIPANTS: Twenty randomly selected physicians (10 at each site) from among eligible second and third year internal medicine residents and attending physicians. MAIN MEASUREMENTS: Explicit criteria were used to score the medical records of physicians and the reports of SPs generated during 160 visits (8 cases x 20 physicians). Individual scoring items were categorised into four domains of clinical performance: history, physical examination, treatment, and diagnosis. To determine the false positive rate, physician entries were classified as false positive (documented in the record but not reported by the SP), false negative, true positive, and true negative. RESULTS: False positives were identified in the medical record for 6.4% of measured items. The false positive rate was higher for physical examination (0.330) and diagnosis (0.304) than for history (0.166) and treatment (0.082). For individual physician subjects, the false positive rate ranged from 0.098 to 0.397. CONCLUSIONS: These data indicate that the medical record falsely overestimates the quality of important dimensions of care such as the physical examination. Though it is doubtful that most subjects in our study participated in regular, intentional falsification, we cannot exclude the possibility that false positives were in some instances intentional, and therefore fraudulent, misrepresentations. Further research is needed to explore the questions raised but incompletely answered by this research.

A comparison of the outcomes of neonates treated with two different natural surfactants.

OBJECTIVE: Our purpose was to determine whether there exists a mortality difference between neonates treated with Infasurf (surfactant A [SA], ONY, Inc, Amherst, NY) and Survanta (surfactant B [SB], Ross Products Division, Abbott Laboratories, Columbus, OH). METHODS: We evaluated 114 different neonatal units' records, between January 1, 2000, and December 31, 2000, of neonates < or = 36 weeks' estimated gestational age who were admitted for neonatal intensive care and reported to have been treated with SA or SB. We used stepwise logistic regression analysis to determine whether the type of surfactant was associated with increased incidence of neonatal death, severe intraventricular hemorrhage, or necrotizing enterocolitis independent of estimated gestational age, birth weight, sex, method of delivery, use of antenatal steroids, or place of birth. RESULTS: We studied the records of 5169 neonates; 1115 (22%) received SA and 4054 (78%) received SB. The most important variables associated with neonatal death, intraventricular hemorrhage and necrotizing enterocolitis were birth weight and estimated gestational age. Logistic regression showed that the type of surfactant did not significantly influence any of these 3 outcomes. Neither overall mortality (8.3% vs 8.5%) or birth weight-specific mortality was different between the 2 groups. CONCLUSION: The differences in mortality previously reported are not present in a larger, more contemporary data set.

Are very low birth weight infants born at high altitude at greater risk for adverse outcomes?

OBJECTIVE: To determine if neonatal intensive care at higher altitudes was associated with any variation in mortality or morbidity. METHODS: We reviewed demographic and outcome data on 5450 neonates with birth weights between 500 and 1500 g cared for in 76 different level II and III neonatal intensive care units (NICUs). The altitude break point of 4300 feet was prospectively chosen. Care was provided at 63 NICUs located below 4300 feet, "low-altitude," (n = 4534 neonates) and at 13 NICUs at or above 4300 feet, "high-altitude" (n = 916 neonates). RESULTS: Compared with neonates cared for at low altitude, neonates cared for at high altitude were more often non-Hispanic white and exposed to prenatal steroids. Neonates born at high altitude were more often treated with surfactant (60% vs 53%, P <.01). At 28 days of age, neonates cared for at high altitude were less often in room air (33% vs 50%, P <.01) compared with neonates cared for at low altitude. However, when corrected for barometric pressure, the calculated partial pressure of inspired oxygen at 28 days of age was lower for neonates cared for at high altitude compared with low altitude (165 +/- 80 vs 183 +/- 57, P <.01). There were no differences in the rates of mortality, severe intraventricular hemorrhage (grades 3 and 4), severe retinopathy of prematurity (stages 3 and 4), or necrotizing enterocolitis requiring surgical treatment. CONCLUSIONS: Being cared for at NICUs located above 4300 feet above sea level was not associated with any increase in adverse events compared with NICUs located below 4300 feet.

Perinatal factors associated with severe intracranial hemorrhage.

OBJECTIVE: The purpose of this study was to assess the incidence of perinatal factors that are associated with severe intracranial hemorrhage in a large and recent multicenter experience. STUDY DESIGN: Retrospective analyses of nonanomalous newborns who were admitted to 100 neonatal intensive care units from 23 to 34 6/7 weeks' gestation were analyzed by multiple regression. RESULTS: There were 12,578 premature newborns with a mean (+/- SD) gestational age of 31.3 +/- 2.9 weeks and a birth weight of 1685 +/- 571 g, respectively. The overall incidence of severe intracranial hemorrhage was 2.9%; in 4575 newborns who weighed < or = 1500 g the incidences of intracranial hemorrhage was 7.1%. Factors with positive and negative associations with severe intracranial hemorrhage are listed in order of decreasing statistical significance: gestational age (negative), surfactant (positive), antenatal indomethacin (positive), neonatal transport (positive), cesarean birth (negative), poor prenatal care (positive), 5-minute Apgar score of < 7 (positive), chorioamnionitis (positive), antenatal terbutaline (negative), preterm premature rupture of fetal membranes (negative), and abruption (positive). CONCLUSION: The incidence of severe intracranial hemorrhage has dramatically declined over the past 2 decades. Antenatal steroids were not associated with reductions in severe intracranial hemorrhage.

Home apnea monitor use in preterm infants discharged from newborn intensive care units.

PURPOSE: To identify current factors associated with home apnea monitor use in preterm infants and to determine whether home monitor use was associated with a shorter length of hospital stay. SETTING: We evaluated neonates who were < or =34 weeks' estimated gestational age and admitted for neonatal intensive care. We excluded neonates with congenital anomalies, neonates transferred out before discharge, and neonates who died. METHODS: Using a database created with a computer-assisted tool that generates hospital notes, we reviewed the epidemiology of monitor use. Differences between neonates sent home with an apnea monitor and those who were not were evaluated by using stepwise logistic regression analysis to identify which factors were independently associated with a neonate being discharged with a monitor. RESULTS: We studied 14,532 neonates; 1588 (11%) were sent home with monitors and 12,944 (89%) were not. The most important variables associated with being discharged with a monitor were site of care and a diagnosis of apnea. Site variation remained significant when adjusted for gestational age, diagnosis of apnea, and a history of use of methylxanthines. When corrected for gestational age, monitor use was not associated with shorter hospital stays. CONCLUSION: The data suggest that monitor use is more dependent on physician preference than medical indication and is not associated with earlier hospital discharge.

Predictive modeling techniques in prostate cancer.

A number of new predictive modeling techniques have emerged in the past several years. These methods can be used independently or in combination with traditional modeling techniques to produce useful tools for the management of prostate cancer. Investigators should be aware of these techniques and avail themselves of their potentially useful properties. This review outlines selected predictive methods that can be used to develop models that may be useful to patients and clinicians for prostate cancer management.

Genetic adaptive neural network to predict biochemical failure after radical prostatectomy: a multi-institutional study.

BACKGROUND AND PURPOSE: Despite many new procedures, radical prostatectomy remains one of the commonest methods of treating clinically localized prostate cancer. Both from the physician's and the patient's point of view, it is important to have objective estimation of the likelihood of recurrence, which forms the foundation for treatment selection for an individual patient. Currently, it is difficult to predict the probability of biochemical recurrence (rising serum prostate specific antigen [PSA] concentration) in an individual patient, and approximately 30% of the patients do experience recurrence. Tools predicting the recurrence will be of immense practical utility in the treatment selection and planning follow up. We have utilized preoperative parameters through a computer based genetic adaptive neural network model to predict recurrence in such patients, which can help primary care physicians and urologists in making management recommendations. PATIENTS AND METHODS: Fourteen hundred patients who underwent radical prostatectomy at participating institutions form the subjects of this study. Demographic data such as age, race, preoperative PSA, systemic biopsy based staging and Gleason scores were used to construct a neural network model. This model simulated the functioning of a trained human mind and learned from the database. Once trained, it was used to predict the outcomes in new patients. RESULTS: The patients in this comprehensive database were representative of the average prostate cancer patients as seen in USA. Their mean age was 68.4 years, the mean PSA concentration before surgery was 11.6 ng/mL, and 67% patients had a Gleason sum of 5 to 7. The mean length of follow-up was 41.5 months. Eighty percent of the cancers were clinical stage T2 and 5% T3. In our series, 64% of patients had pathologically organ-confined cancer, 33% positive margins, and 14% had seminal vesicle invasion. Lymph node positive patients were not included in this series. Progression as judged by serum PSA was noted in 30.6%. With entry of a few routinely used parameters, the model could correctly predict recurrence in 76% of the patients in the validation set. The area under the curve was 0.831. The sensitivity was 85%, the specificity 74%, the positive predictive value 77%, and the negative predictive value of 83%. CONCLUSION: It was possible to predict PSA recurrence with a high accuracy (76%). Physicians desiring objective treatment counseling can use this model, and significant cost savings are anticipated because of appropriate treatment selection and patient-specific follow-up protocols. This technology can be extended to other treatments such as watchful waiting, external-beam radiation, and brachytherapy.

Using standardized patients to measure quality: evidence from the literature and a prospective study.

BACKGROUND: Use of standardized patients for evaluating the clinical skills of medical students and medical trainees is commonplace. This has encouraged the use of standardized patients to evaluate the quality of physician practice in outpatient settings. However, there may be substantive differences between observing student performance and evaluating whether the provision of care meets defined quality criteria. OBJECTIVES: This study had two primary objectives: (1) to review studies that use standardized patients to evaluate physician performance and (2) to ascertain directly whether standardized patients could be useful in assessing quality of outpatient care. METHODS: A comprehensive literature review of studies that used standardized patients to assess physician performance was conducted. A prospective study that included 20 physicians at two outpatient settings and 27 actor patients assessed quality of care using eight clinical cases divided into five clinical domains, each of which had explicit criteria checklists based on widely accepted guidelines. RESULTS: The literature review identified five important issues: developing scenarios, selecting explicit criteria, standardizing standardized patient training, creating subterfuges, and ensuring reliability and validity of measures. In the study, trained standardized patients were able to assess physician practice accurately for common medical conditions, using proven criteria linked to health outcomes. The detection rate was 3%. There was no performance variation between actors for seven of the eight cases. CONCLUSIONS: Using standardized patients to measure the quality of care is practical and feasible. The major methodological challenge is incorporating observable evidence-based criteria into realistic scripts and objective checklists. The major logistical challenge is obtaining and maintaining undetected entry into physicians' offices.

Measuring compliance with preventive care guidelines: standardized patients, clinical vignettes, and the medical record.

OBJECTIVE: To determine how accurately preventive care reported in the medical record reflects actual physician practice or competence. DESIGN: Scoring criteria based on national guidelines were developed for 7 separate items of preventive care. The preventive care provided by randomly selected physicians was measured prospectively for each of the 7 items. Three measurement methods were used for comparison: (1) the abstracted medical record from a standardized patient (SP) visit; (2) explicit reports of physician practice during those visits from the SPs, who were actors trained to present undetected as patients; and (3) physician responses to written case scenarios (vignettes) identical to the SP presentations. SETTING: The general medicine primary care clinics of two university-afflliated VA medical centers. PARTICIPANTS: Twenty randomly selected physicians (10 at each site) from among eligible second- and third-year general internal medicine residents and attending physicians. MEASUREMENTS AND MAIN RESULTS: Physicians saw 160 SPs (8 cases x 20 physicians). We calculated the percentage of visits in which each prevention item was recorded in the chart, determined the marginal percentage improvement of SP checklists and vignettes over chart abstraction alone, and compared the three methods using an analysis-of-variance model. We found that chart abstraction underestimated overall prevention compliance by 16% (P < .01) compared with SP checklists. Chart abstraction scores were lower than SP checklists for all seven items and lower than vignettes for four items. The marginal percentage improvement of SP checklists and vignettes to performance as measured by chart abstraction was significant for all seven prevention items and raised the overall prevention scores from 46% to 72% (P < .0001). CONCLUSIONS: These data indicate that physicians perform more preventive care than they report in the medical record. Thus, benchmarks of preventive care by individual physicians and institutions that rely solely on the medical record may be misleading, at best.