Patient cueing, a type of diagnostic error.

Diagnostic failure can be due to a variety of psychological errors on the part of the diagnostician. An erroneous diagnosis rendered by previous clinicians can lead a diagnostician to the wrong diagnosis. This report is the case of a patient who misdiagnosed herself and then led an emergency room physician and subsequent treating physicians to the wrong diagnosis. This mechanism of diagnostic error can be called patient cueing.

Indoor biofuel air pollution and respiratory health: the role of confounding factors among women in highland Guatemala.

BACKGROUND: A number of studies have reported associations between indoor biofuel air pollution in developing countries and chronic obstructive lung disease (COLD) in adults and acute lower respiratory infection (ALRI) in children. Most of these studies have used indirect measures of exposure and generally dealt inadequately with confounding. More reliable, quantified information about this presumed effect is an important pre-requisite for prevention, not least because of the technical, economic and cultural barriers to achieving substantial exposure reductions in the world's poorest households, where ambient pollution levels are typically between ten and a hundred times higher than recommended standards. This study was carried out as part of a programme of research designed to inform the development of intervention studies capable of providing quantified estimates of health benefits. METHODS: The association between respiratory symptoms and the use of open fires and chimney woodstoves ('planchas'), and the distribution of confounding factors, were examined in a cross-sectional study of 340 women aged 15-45 years, living in a poor rural area in the western highlands of Guatemala. RESULTS: The prevalence of reported cough and phlegm was significantly higher for three of six symptom measures among women using open fires. Although this finding is consistent with a number of other studies, none has systematically examined the extent to which strong associations with confounding variables in these settings limit the ability of observational studies to define the effect of indoor air pollution adequately. Very strong associations (P < 0.0001) were found between the type of fire and a number of household and socioeconomic factors including the arrangement of rooms, floor type, and possession of a radio and television. The spouse's economic activity type was also significantly associated (P < 0.05). Thus, while 82% of open fire users had dirt floors and only 18% cement or tile floors, the situation was reversed for plancha users, only 16% of whom had dirt floors. CONCLUSIONS: Confounding presents a substantial problem for observational studies of indoor air pollution and health, although there is a reasonable case for believing that the observed association is causal. Intervention studies are required for stronger evidence of this association, and more importantly, to determine the size of health benefit achievable through feasible exposure reductions.

PIP: The authors investigated the association between respiratory symptoms and the use of open fires and chimney woodstoves, as well as the distribution of confounding factors, in a cross-sectional study of 340 women aged 15-45 years living in a poor rural area in the western highlands of Guatemala, and found a significantly higher prevalence of reported cough and phlegm for 3 of 6 symptom measures among women using open fires. When considering confounding factors, very strong associations were found between the type of fire and a number of household and socioeconomic factors including the arrangement of rooms, floor type, and possession of a radio and television. The spouse's economic activity type was also significantly associated. 82% of open fire users had dirt floors, with the remaining 18% having cement or tile floors, while only 16% of chimney woodstove users had dirt floors.

Comparative evaluation of underlying causes of death processed by the Automated Classification of Medical Entities and the Underlying Cause of Death Selection Systems.

INTRODUCTION: The correct identification of the underlying cause of death and its precise assignment to a code from the International Classification of Diseases are important issues to achieve accurate and universally comparable mortality statistics. These factors, among other ones, led to the development of computer software programs in order to automatically identify the underlying cause of death. OBJECTIVE: This work was conceived to compare the underlying causes of death processed respectively by the Automated Classification of Medical Entities (ACME) and the "Sistema de Seleção de Causa Básica de Morte" (SCB) programs. MATERIAL AND METHOD: The comparative evaluation of the underlying causes of death processed respectively by ACME and SCB systems was performed using the input data file for the ACME system that included deaths which occurred in the State of S. Paulo from June to December 1993, totalling 129,104 records of the corresponding death certificates. The differences between underlying causes selected by ACME and SCB systems verified in the month of June, when considered as SCB errors, were used to correct and improve SCB processing logic and its decision tables. RESULTS: The processing of the underlying causes of death by the ACME and SCB systems resulted in 3,278 differences, that were analysed and ascribed to lack of answer to dialogue boxes during processing, to deaths due to human immunodeficiency virus [HIV] disease for which there was no specific provision in any of the systems, to coding and/or keying errors and to actual problems. The detailed analysis of these latter disclosed that the majority of the underlying causes of death processed by the SCB system were correct and that different interpretations were given to the mortality coding rules by each system, that some particular problems could not be explained with the available documentation and that a smaller proportion of problems were identified as SCB errors. CONCLUSION: These results, disclosing a very low and insignificant number of actual problems, guarantees the use of the version of the SCB system for the Ninth Revision of the International Classification of Diseases and assures the continuity of the work which is being undertaken for the Tenth Revision version.

PIP: Problems in collecting data on causes of death are examined by comparing data collected in two different programs in Brazil, the Automated Classification of Medical Entities (ACME) and the Sistema de Selecao de Causa Basica de Morte (SCB). The data concern 129,104 death certificates recorded in the state of Sao Paulo in 1993. The analysis revealed 3,278 differences in the causes of death between the two systems, primarily due to failure to record the necessary information, deaths associated with HIV for which there was no provision for recording the appropriate information, and coding or keying errors. The relatively low and insignificant number of problems recorded indicates the high quality of the data collected, particularly in the SCB system.

Measuring condom use among sex workers in the Dominican Republic.

The purpose of this paper is to assess the internal consistency of self-reported condom use among sex workers in Puerto Plata and Santo Domingo, Dominican Republic. We examined the responses to questions about condom use among 4 cross-sectional samples of sex workers. We compared measures based on: (1) questions using always-to-never scales; (2) questions about use with the past 5 clients; and (3) questions about use in the past week obtained from a retrospective coital log. In each sample, more women reported 'always' using condoms with clients than with each of the past 5 clients. In 3 of the 4 samples, only about half of the women who reported 'always' using condoms used condoms with the most recent 5 clients and with all clients in the past week. Internal consistency was significantly higher when the comparison was limited to use with the most recent 5 clients and use in the past week. Self-reported measures of condom use can be difficult to interpret. Assessing the internal consistency of several measures of use provides insight into the strengths and weaknesses of each measure.

PIP: Although evaluations of interventions to curtail the spread of HIV rely, to a large extent, on self-reported changes in behavior, the validity of self-reported condom use is difficult to assess. The internal consistency of self-reported condom use was investigated among four convenience samples of commercial sex workers in Puerto Plata (n = 408) and Santo Domingo (n = 604), Dominican Republic, interviewed before and after targeted HIV/AIDS educational programs. Three measures of condom use were assessed: 1) a measure based on reported frequency of use with new clients and regular clients using an always-to-never scale, 2) a measure of use with the most recent 5 clients, and 3) a measure based on a retrospective coital log of use with clients in the past 7 days. In each sample, more women reported "always" using condoms with clients than with each of the past 5 clients. The largest discrepancy was found in the second Puerto Plata sample, where 153 women (76%) reported always using condoms with clients, but only 96 women (47.5%) reported using condoms with each of the past 5 clients. "Sometimes" users were significantly more consistent in their responses than "always" users. Internal consistency was significantly improved (83-89%) when the comparison was limited to use with the most recent 5 clients and use in the past week.

[Using System DIA software for the detection and automatic correction of errors in the data compiled using the basic questionnaire from the 1991 population census]. / Uso do Sistema DIA para a deteccao e correcao automatica de erros nos dados do questionario basico do censo demografico de 1991.

PIP: "This paper deals with aspects of the application of the generalized data editing and imputation software named DIA to the 1991 Population Census [of Brazil] Basic Questionnaire. This software, developed by the Spanish National Statistical Institute, handles editing and imputation of categorical data in one processing cycle and provides comprehensive information to control and assess the automatic correction process. The analysis reveals the data quality and efficiency of the software adopted, which ensures data consistency while preserving basic distribution properties." (EXCERPT)^ieng

[Maternal mortality in Mexico: measurement based on vital statistics]. / Mortalidad materna en Mexico: medicion a partir de estadisticas vitales.

PIP: "Vital statistics are the most comprehensive source of information on maternal mortality in Mexico.... It is clear that maternal mortality has decreased throughout the twentieth century and will continue to do so. There are signs of a higher underestimation of mortality [due to] abortion. And there are regional differentials of maternal mortality.... Professional and/or institutional attention during childbirth has a great impact on maternal mortality decline. There are also socio-economic differentials by marital status, milieu, and schooling...." (EXCERPT)^ieng

Delayed birth registration (DBR) in Sao Paulo State: an attempt at correcting underregistration.

"The aim of this paper is to analyze the pattern of delayed birth registration [in Brazil] and to establish a relationship with the total and registered births in order to estimate a mathematical function that quantifies birth underregistration."

[Correction of underregistration of general mortality]. / Correccion del subregistro de mortalidad general.

PIP: The authors evaluate the underregistration of mortality in Latin America, using the example of Ecuador. Underregistration by province, age groups, sex, and cause of death is investigated.^ieng

[Participatory observation in the 1995 count of population and housing. An anthropological experience]. / La observacion participante en el Conteo de Poblacion y Vivienda 1995. Una experiencia antropologica.

PIP: "The experience of an anthropologist who participated as enumerator in [Mexico's] Conteo de Poblacion y Vivienda 1995 is analyzed in this paper. The author describes briefly the methodology...for each stage of the enumeration; she systematically points [out] the circumstances and reasons that determine why the different groups involved in the process do not follow the rules. She [examines] the questions that the informers usually avoid answering, or the ones they answer hardly and imprecisely." (EXCERPT)^ieng

[International record linkage of Dutch immigrants in the United States in the nineteenth century]. / Cruzamiento internacional de registros de inmigrantes holandeses en los Estados Unidos en el siglo XIX.

PIP: "Nominative sources both at origin (Netherlands' emigration records) and at destination (U.S. Ship Passenger Customs Lists) [in the 1800s] are compared on a nominal basis and thus the omission in each series evaluated. The results show both an underestimation of immigration figures and a bias in international migration statistics. Single, young working-class males prevail in nonlinked records, probably corresponding to clandestine emigration. In other respects, however, the passenger manifests seem reasonably reliable, since social structural biases are minimal in this source." (EXCERPT)^ieng

The migration of women: measuring the impact.

PIP: The following recommendations from an INSTRAW report are excerpted in this article on the migration of women. 1) Data collection should include detailed information on smaller areas below the state or provincial level and gender. Short distance migrants should be included in counts. 2) Specialized surveys are needed for expanding current understanding of the migration process, the effects on the social and economic welfare of migrants, and the links between migration and fertility, marital status, and social stability. 3) Data collection should include gender-specific information on temporary, short-term migration for education or employment reasons or for temporary work. 4) Gender blind surveys should be conducted that include all family members. 5) Data collection should include data disaggregated by sex and by broad demographic factors and other determinants of migration. 6) Data collection should use appropriate comparison groups. 7) Marriage migration should not be overlooked. 8) The consequences of migration should not be ignored. Migration may have negative or positive impacts for migrants, which may vary by places of origin and destination. Little information is available on female migration. The economic and social context of female migration is overlooked, particularly for women traveling alone. Women are subject to physical and mental abuse. This article identifies some of policy needs for data pertaining to internal migration. One flaw in data is the use of birth registration and census data for identifying gender specific moves. A change of residence does not provide information on "why" the move is made or "when." Movement is limited to moves across major political or administrative boundaries, when most moves are over shorter distances within boundaries. Statistics focus on rural to urban migration, when in developing countries, most migration is rural to rural. Data collection uses heads of households as the sources of information. When data focuses only on "working" migrants, women may be excluded. Female domestics living in the household may be excluded. Migrant data should include reasons for leaving, marital status, age, children, employment history, migration partners, status of family members left behind, and employment status at destination.^ieng

[A preliminary analysis of unmarried mothers who were heads of households in Brazil during 1970 and 1980]. / Analisis preliminar acerca de las madres solteras, jefas de hogar, en Brasil durante 1970 y 1980.

"This paper reports on an attempt to use census data from Brazil in 1970 and 1980 to investigate a rise in household headship by unmarried mothers 15-49.... Demographic analysis can be useful in decomposing the change into that due to a changed propensity of women 15-49 years of age to be unmarried, to have children if unmarried, and to head their own household if an unmarried mother. This was further analyzed in terms of age, marital status (whether single, divorced/separated or widowed), region of residence, and urban-rural status....However, the research encountered data problems that make firm conclusions impossible...." This is a translation of a paper originally presented at the 1992 Annual Meeting of the Population Association of America. (SUMMARY IN ENG)

[The indigenous population in Latin American censuses]. / La poblacion indigena en los censos de America Latina.

"On reviewing the information about the indigenous population in the [Latin American] census data, clear discrepancies can be found. The main problem lies in the various definitions of indigenous population....The greatest difficulty arises from the multiple dimensionality of socio-cultural elements.... Existing estimates on indigenous population for the whole region largely vary and, in most cases, seem to be determined by strong emotions or, at least, based on highly subjective criteria. In spite of the strong criticism about the estimates taken from the population censuses, this source is generally one of the few with a real base." (SUMMARY IN ENG)

[Levels of infant mortality and fertility in Mexico by state, 1990]. / Niveles de mortalidad infantil y fecundidad en Mexico, por entidad federativa, 1990.

PIP: The authors present estimates of infant mortality in Mexico by state, using survey and census data for the 1970s and 1980s. They use an alternative method of calculating infant mortality which suggests that previous calculations have underestimated the level of both fertility and infant mortality. (SUMMARY IN ENG)^ieng

Analysis of maternal mortality in Nicaragua.

PIP: The Women's Collective in Matagalpa, Nicaragua, Sanitaria VI region estimated maternal mortality rates for 1989 and 1990 to be 309 and 239/100,000 live births, respectively. The majority of births took place at home, assisted by untrained midwives, and in 68% of cases the place and attendant(s) were not listed. National figures for maternal mortality are 49.4 and 159/per 100,000 in 1989. Thus the proportion of unreported maternal mortality is probably high in Nicaragua. The Collective believers that health workers give substandard prenatal care and fail to refer high risk cases to higher levels of care. They recommend that women mount a permanent campaign, insist on training programs for health workers that focus on women's situation, that more data be collected, and that women themselves take action.^ieng

The problem of under-registration of infant deaths in Jamaica.

PIP: Infant mortality rate (IMR) is an important indicator of a country's socioeconomic development. While IMR has declined among most developing countries over the past 3 decades, under-registration of infant deaths remains a serious problem. In the case of Jamaica, IMR declined from 102/1000 in 1945 to 32/1000 in 1970 to 13/1000 by 1984. This 1984 rate is comparable to those enjoyed in the US, Austria, UK, Spain, and Australia. Significant under-registration of infant births and deaths, however, render suspect the validity of Jamaica's IMR of 13/1000. One study found 34% of infant deaths to be unregistered, while another found 9.0% of 10,249 live births to be also be unregistered. Under-registration of this magnitude is the result of faulty hospital procedures and recording systems, a lack of standardization of related terminology, and the under-registration of live births. Inaccurate IMR adversely affects development and health planning. Efforts should therefore be made with the active support of the Ministry of Health to strengthen the registration system by increasing the numbers of registrars of births and deaths and training all personnel involved in registration.^ieng

Jamaican measles surveillance system.

PIP: In 1991, the Ministry of Health and technical consultants from PAHO evaluated the measles surveillance system in Jamaica. This system consisted of the notification system, the sentinel sites system, active hospital surveillance, laboratory reporting, and special surveys. The team concentrated their efforts on the system's ability to detect and investigate suspected cases of measles. The team visited sentinel sites including health centers, hospitals, or a physician in all 13 parishes. 44 sites operated at the time. It spoke with medical Officers and Senior Public Health Nurses and evaluated written records. The notification system had recently classified measles as a Class I disease to encourage a rapid public health response and to secure investigation records. The major weakness of the notification system was case investigation. In 1991, health workers investigated only 6 (3%) of 208 suspected cases within 48 hours and eventually investigated only 76 (36.5%). 23 cases were confirmed as measles. Serology tests revealed that most suspected cases were actually rubella. This indicated a need to include serological testing for confirmation. The team found that the notification system underreported cases. Each sentinel site was required to collect each week a count of the number of cases of measles and other conditions to monitor trends. 87% reported the counts weekly. The sites consistently reported measles bas ed on clinical suspicion. Public health staff visited hospitals weekly to review cases of target disease including measles. They visited at least 1 hospital regularly in each parish. Hospital records did not contain consistent measles data. For example, only 10 of 13 visit reports included patient's name, age, sex, and address and only 7 included outcome. Detailed information was only available on 13 of the 208 suspected cases so the team was only able to evaluate them.^ieng

[Maternal death: an avoidable tragedy]. / Morte materna: uma tragedia evitavel.

PIP: Although statistics show that maternal mortality has declined during this century, high levels persist in the developing world. There are 100 to 1000 maternal deaths per 100,000 live births in developing countries, compared to 7 to 15 deaths per 100,000 live births in developed countries. Most of these deaths in developing countries are avoidable by effective maternal care interventions. A book edited by Unicamp on maternal mortality has made an important contribution to the debate that has been going on in scientific circles and among planners and health professionals. The quality of data for analysis of maternal mortality is implicated also because of erroneous classification of maternal deaths as nonmaternal, imprecision in the death certification, and omission of the status of pregnancy associated with illegal abortion. The identification of these errors means that medical files, hospital registers, family interviews, and autopsies have to be consulted. Research carried out in Sao Paulo demonstrated that at the end of the 1980s the maternal mortality rate was in fact 99.5/100,000 live births, whereas original records showed only 44.5/100,000 live births. Even in the United States during 1980-85, 33% of maternal deaths were underreported. In England the level of underreporting amounted to 41% during 1970-72. The World Health Organization has encouraged the formation of committees to study the prevention of maternal mortality. Two such committees were started in the state of Sao Paulo with the objectives of making professionals aware of the importance of accurate death records; immediate notification of maternal deaths to the regional committee; means from the proper authorities for the correction of deficiencies detected; and continuous evaluation of maternal mortality rates. The committee of Marilia, in the interior of the state of Sao Paulo, demonstrated that 72% of maternal deaths during 1986-88 were avoidable by medical-obstetrical means, prenatal care, or social assistance. 61% of deaths were attributed to cesarean section, which indicates the major risk of surgical complications.^ieng

Unbiased sex ratios among the Bari: an evolutionary interpretation.

PIP: The Bari, a group of Indians living in a South American rainforest, were studied in order to determine whether there were any differences in the proportions of sons and daughters at birth and/or later ages, and whether costs associated with offspring of each sex differed with unequal rates of survival as predicted by Fisher's hypothesis. Predictions derived from the Trivers and Willard model, where parents favor offspring of the sex requiring greater parental investment, were also tested. During 1988 and 1989, various Bari villages in Venezuela were visited. A total of 59 people (32 women and 27 men) thought to be in their mid-forties or older were interviewed asked to recount their life histories by questions on numbers and names of spouses and children. The dataset was complemented with genealogical and demographic information including a census taken in 1982 and information from birth records. Data were used to reconstruct the reproductive histories of 110 adults (55 women: 32 interviewed and 23 whose spouses were interviewed, and 5 men: 27 interviewed and 28 from spouses' interviews) of post-reproductive ages presumably born more than 40-50 years ago. The sex ratio at birth was approximately 1, and the relative proportions of male and female children alive were similar at ages starting at birth and ending at 15 years of age. When miscarriages and stillbirths were added to the number of live births, the proportions continued to be similar. During the prenatal stage a G-test of goodness of fit indicated that boys were more likely to die than girls. A trend, though not statistically significant, was found for higher male mortality during the 1st year of life. Sons and daughters were equally costly. Sex ratios at the end of the period of dependence were slightly biased toward daughters, confirming Fisher's hypothesis. On the other hand, no support was found for the Trivers-Willard model of sex ratios.^ieng

Child survivorship estimation: methods and data analysis.

"The past 20 years have seen extensive elaboration, refinement, and application of the original Brass method for estimating infant and child mortality from child survivorship data. This experience has confirmed the overall usefulness of the methods beyond question, but it has also shown that...estimates must be analyzed in relation to other relevant information before useful conclusions about the level and trend of mortality can be drawn.... This article aims to illustrate the importance of data analysis through a series of examples, including data for the Eastern Malaysian state of Sarawak, Mexico, Thailand, and Indonesia. Specific maneuvers include plotting completed parity distributions and 'time-plotting' mean numbers of children ever born from successive censuses. A substantive conclusion of general interest is that data for older women are not so widely defective as generally supposed."