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PubMed2005

The immunization data quality audit: verifying the quality and consistency of immunization monitoring systems.

OBJECTIVE: To evaluate the consistency and quality of immunization monitoring systems in 27 countries during 2002-03 using standardized data quality audits (DQAs) that had been launched within the framework of the Global Alliance for Vaccines and Immunization. METHODS: The consistency of reporting systems was estimated by determining the proportion of third doses of diphtheria-tetanuspertussis (DTP-3) vaccine reported as being administered that could be verified by written documentation at health facilities and districts. The quality of monitoring systems was measured using quality indices for different components of the monitoring systems. These indices were applied to each level of the health service (health unit, district and national). FINDINGS: The proportion of verified DTP-3 doses was lower than 85% in 16 countries. Difficulties in verifying the doses administered often arose at the peripheral level of the health service, usually as the result of discrepancies in information between health units and their corresponding districts or because completed recording forms were not available from health units. All countries had weaknesses in their monitoring systems; these included the inconsistent use of monitoring charts; inadequate monitoring of vaccine stocks, injection supplies and adverse events; unsafe computer practices; and poor monitoring of completeness and timeliness of reporting. CONCLUSION: Inconsistencies in immunization data occur in many countries, hampering their ability to manage their immunization programmes. Countries should use these findings to strengthen monitoring systems so that data can reliably guide programme activities. The DQA is an innovative tool that provides a way to independently assess the quality of immunization monitoring systems at all levels of a health service and serves as a point of entry to make improvements. It provides a useful example for other global health initiatives.

Child↗
PubMed1999

A sequential chart for the audit-based evaluation of screening mammogram interpretation.

RATIONALE AND OBJECTIVES: Auditing has received much attention recently as a method for radiologists to use to evaluate their interpretation of screening mammograms. U.S. Food and Drug Administration regulations require that some sort of audit be in place before a mammography screening facility can receive accreditation. Auditing presents a unique opportunity to monitor accuracy continually and identify problems early. Audit data present unique challenges, however, and appropriate methods must be used to control the risk of errors. MATERIALS AND METHODS: This article introduces a simple method for the task of deciding if a radiologist yields an acceptable positive predictive value based on audit. The method is based on "sequential" decision-making techniques that have found wide application in quality control problems. These techniques are developed for diagnostic radiology and embodied in an easy-to-use decision-making chart. RESULTS: Several examples, based on audit data from actual mammography facilities, provide insights into the use of these charts and the influence of (a) the selection of standards, (b) the selection of error risks, and (c) radiologist variability. The examples also serve to demonstrate another important property of this method--that is, it specifies the minimum amount of data that has to be collected before any decision can reliably be made. CONCLUSION: The chart presented in this article provides a method by which audit data can be used objectively to evaluate the accuracy of screening mammogram interpretation. The method controls the risk of either falsely accepting an unqualified radiologist or falsely rejecting a qualified radiologist. It should be a useful tool to radiologists who must evaluate their own practices.

Female↗
PubMed2005

Incidence of epidural blood patch following obstetric regional analgesia in private Australian anaesthetic practice.

BACKGROUND: Collection of audit data about epidural blood patches has traditionally relied on voluntary reporting, which is notoriously incomplete. The records of Medicare-funded Australian private obstetric practice, which represents 30% of all deliveries, allow a novel method of central data collection and retrieval. METHOD: Data relating to all deliveries, epidurals and blood patches in private practice in Australia over a two-year period were retrieved from the Health Insurance Commission. RESULTS: The overall rate of epidural analgesia in labour was estimated at 30% and the proportion of epidurals that progressed to blood patching was 0.35%. The rate of epidural blood patching varied between states from 0.18% to 0.56%. CONCLUSION: Despite certain limitations of our data interpretation, we regard this technique as a useful audit tool capable of generating accurate and robust audit data that might otherwise be unobtainable.

Analgesia, Epidural↗
PubMed1998

Accuracy of centrally recorded OPCS codes for vascular surgery in the United Kingdom.

AIM: Centrally recorded OPCS codes are based upon district returns. The aim of this study is to determine the accuracy of this system with regard to vascular surgery. METHODS: Prospectively recorded audit data for vascular and endovascular procedures were compared with those obtained from the Department of Health and Welsh Office. Five U.K. hospitals were involved in the study. Data were obtained for the twelve months, 1 April 1994-30 March 1995 (these being the most up to date figures available). RESULTS: The total number of arterial reconstructions based on audit data was 1082. Those recorded by the OPCS codes were 743. This represents a discrepancy of -31.3% (range for the five hospitals: -13.1% to -63.8%). When examining specific codes similar discrepancies were seen. For example, in one hospital 38 AAA repairs were carried out but only two were centrally recorded. However, examination of ICD9 codes (relating to hospital admissions) for that hospital showed that 38 patients with AAA were admitted. A similar wide variation was seen when examining iliac and superficial femoral artery endovascular procedures. Despite the discrepancies of audit and OPCS data, the codes for reconstructions did reflect relative workload of the different hospitals. CONCLUSION: This study shows that there is a marked underestimate of vascular workload when comparing central recorded data with that obtained from local audit. Marked variation is seen in the accuracy of data submitted from different hospitals.

Angioplasty, Balloon↗
PubMed2003

Understanding variation in quality improvement: the treatment of sore throats in primary care.

BACKGROUND: In 1988, two practices attempted to improve the prescribing of antibiotics for sore throat. The initiative produced only modest improvements in prescribing practice, a finding the authors found difficult to explain. This paper reanalyses the data from an audit of antibiotic prescribing for sore throat in general practice. OBJECTIVE: Our aim was to demonstrate the use of Shewhart control charts and to obtain fresh insight into the variations in clinical practice revealed in clinical audit data. METHODS: We use Shewhart control charts to explore variation in antibiotic prescribing between GPs and to suggest the action most likely to result in improvement. RESULTS: Using control charts, it is possible to distinguish two categories of GPs: low prescribers of antibiotics and high prescribers of antibiotics. Low prescribers of antibiotics show common cause variation, indicating that their prescribing is a stable process. Among low prescribers, improvement can best be achieved by changing the common underlying process. One high prescriber of antibiotics is affected by special cause variation. Among high prescribers, improvement can best be achieved by investigating the special causes affecting this GP and learning lessons from the findings. CONCLUSION: The original improvement effort took the same action on all GPs in both practices. Our analysis suggests that such an approach was unlikely to be successful and that different actions were needed for high and low prescribers. The control charts provide fresh insights on the original data and guide improvement efforts.

Anti-Bacterial Agents↗
PubMed1987

A computer-assisted emergency department chart audit.

We present a method for a microcomputer-assisted emergency department daily chart audit using a spreadsheet format. Computer technology allows the extraction of a large amount of information from audit data with a minimum of clerical time. The software automatically tabulates, sorts, and updates audit data, and depicts physician performance in a quantitative manner. The software is able to generate a variety of graphics that visually depict physician and departmental performance. The spreadsheet model is flexible, and can be adapted to the needs of various emergency departments or quality assurance activities. The audit has a rapid turnaround time, with charts audited and returned to physicians for feedback within 24 hours of the patient being discharged. Individual physician confidentiality is maintained throughout.

Computer Graphics↗
PubMed2006

Antiepileptic TDM pattern at a tertiary care hospital in India.

Therapeutic drug monitoring, a comparatively new investigational procedure in clinical pharmacology, is considered very beneficial to epilepsy patients though it increase the health care cost. Aim of this study was to determine the pattern of use of antiepileptic drug level monitoring over the last 7 years in our tertiary care centre and to critically comment on its utility. Retrospective data audit of archived data from 1998 to 2004 and age, sex, estimated levels of phenytoin, carbamazepine and phenobarbitone by HPLC were noted down, tabulated and compared. Chi square test was used for analysis. Three thousand five jundred thirty four blood samples of patients requesting for 4213 estimations of phenytoin, phenobarbitone or carbamazepine were received. Among the obtained samples, 44.0% (1058) were of children, 68.0% (2402) were of males, 0.6% (22) patients were getting 3 and 18.0% (635) getting 2, antiepileptic medications. 13.0% (546) samples showed level in the toxic range and 39.0% (1653) in lower range. There was increasing demand observed for estimation of antiepileptic drugs, over the 7 years. The number of abnormal values of phenytoin, phenobarbitone and carbamazepine did not show any significant difference over the years. The pattern was similar to that observed in other countries.

Anticonvulsants↗
PubMedDate not supplied

Building a solid GLP foundation: implementing shared training programs between the QAU and study personnel.

Quality assurance representatives and study personnel are equally responsible for conducting preclinical studies in compliance with good laboratory practices (GLPs). To provide all employees with a solid understanding of GLP requirements we have implemented a system of shared training programs for the quality assurance unit (QAU) and study personnel. Biologists and chemists complete a three-phase training module that encompasses GLP history, roles and responsibilities of the QAU, and QAU procedures specific to Wildlife International, Ltd. Study directors work with experienced QA trainers and are provided mock auditing assignments, including data, reports, and in-process and facility inspections. QA personnel are in turn trained by qualified study personnel in principal scientific concepts, testing guidelines, and study procedures that will be observed when performing in-process inspections and data audits. Also, as permanent positions become available, selected individuals from the QAU may assume responsibilities in various departments as study directors or laboratory supervisors, and study directors may assume responsibilities as quality assurance representatives. At Wildlife International, Ltd., these shared training programs provide a mutual understanding and knowledge of GLP requirements and their application while promoting respect and harmony between the QAU and study personnel.

Facility Regulation and Control↗
PubMed1993

Bayesian analysis of binary data from an audit of cervical smears.

A large data set of unsatisfactory smear rates from 629 different cervical smear takers is used to illustrate a Bayesian approach to the analysis of medical audit data with a binary outcome. It is shown that this gives more relevant results in terms of characterizing individual smear takers than frequentist methods, and that the full Bayesian analysis is preferable to an empirical Bayes approximation when the number of different smear takers is small and at least one individual smear taker has contributed only a few smears. Plots of Bayesian posterior distributions with 95 per cent confidence sets are suggested as a useful way of feeding back the results to individual clinicians.

Adult↗
PubMed2005

An audit of the use of isolation facilities in a UK National Health Service trust.

To aid the ongoing battle against hospital-acquired infection in the UK, all acute National Health Service (NHS) trusts should have audit data about how dedicated isolation beds within the trust are being used. In a previously published audit, we demonstrated that one-third of patients admitted to a dedicated isolation room in Tayside were not thought to be an infection risk by experienced healthcare staff. Since this audit, Tayside's isolation facilities have moved from a small peripheral 'fever' hospital to a large central teaching hospital site. At the time of this move, and using the above audit data, we designed and implemented a guideline for general practitioners and hospital doctors regarding the admission of patients to an isolation bed. The aim of this study was to compare the use of isolation beds before and after the move to the new facilities, which we anticipated would increase the demand for isolation. The results show that by all three criteria used, the utilization of isolation beds has deteriorated following the move, mainly due to the increased admission of general medical 'boarders' and low-risk infection patients. At a time when hospital-acquired infections are increasing, NHS trusts should ensure that dedicated isolation beds are used appropriately.

Female↗
PubMed2001

Scoring systems and risk assessment for upper gastrointestinal bleeding.

Mortality associated with acute upper gastrointestinal bleeding remains high despite advances in diagnosis and therapy. This was emphasized by the findings of the seminal English National Audit of acute gastrointestinal haemorrhage undertaken by Rockall and associates in the mid-1990s. The apparent lack of progress is largely due to less selective reporting in an ageing population with greater co-morbidity. Thus some deaths will be unavoidable even with exemplary treatment. Managing high risk patients in a dedicated area with close cooperation between medical and surgical gastroenterologists has been shown to improve outcome. The challenge is to select those patients who have most to gain from such a scarce and expensive resource so that their treatment can be optimized. Various risk factors have been identified to help achieve this end. Rockall's national audit data suggest that avoidable deaths remain a problem in most district general hospitals. A simple numerical score was derived from these audit data (Rockall score) to predict rebleeding and mortality. The score is based on five variables: age, shock, co-morbidity, endoscopic diagnosis and stigmata of recent haemorrhage. It has the advantage that pre-endoscopic assessment can be made by inexperienced medical or nursing staff. The system was validated internally in a second audit by Rockall and co-workers, and subsequent external validation has come from New Zealand and the Netherlands. The score is less reliable at predicting rebleeding than death and so is, as yet, an imperfect instrument. The scoring system has also proven valuable in selecting low risk patients for early discharge (resulting in health care economies) and for comparing outcome data from different hospitals or populations. Endoscopic treatment has recently been shown to reduce rebleeding rates and perhaps mortality. These advances in therapy are becoming more widely adopted and may influence the predictive ability of the Rockall score. The study from Edinburgh, in this issue, although small and with wide confidence intervals, supports the ability of the Rockall score to identify high risk cases amongst those given endoscopic treatment. It also suggests that an adjustment of the score may be required in these circumstances to prevent overcalling the risk of rebleeding and death.

Endoscopy, Gastrointestinal↗
PubMed2000

Regional variation in varicose vein operations in England 1989-1996.

AIM: To determine accuracy of Office of Population Censuses and Surveys (OPCS) codes for varicose vein (VV) operations and differences in regional activity over 7 years. METHODS: OPCS codes were obtained for VV operations (L85, L87) for the 8 English regions 1989/90-1995/96. Data were also obtained for the 4 districts of the old Oxford Region. Centrally collected codes for one hospital were compared with audit data from the same hospital. RESULTS: There was a marked inter-regional variation in VV activity, e.g. in 1995/96 the range of operations/100,000 population was 102 (Anglia & Oxford) to 138 (West Midlands). There was a gradual increase in the number of operations carried out nationally from 98/100,000 in 1989/90 to 121/100,000 in 1995/96. The numbers peaked in 1991/92, coinciding with a 'waiting list initiative'. When compared with audit data, accuracy of coding improved throughout the study period. There was a 55% inaccuracy in 1989/90 compared with 2% in 1995/96. In each year, codes overestimated the volume of work actually carried out. CONCLUSION: OPCS codes broadly reflect VV activity. Difference in VV activity in different parts of the country are apparent.

Documentation↗
PubMed2006

Variations in clinical audit collection: a survey of plastic surgery units across the British Isles.

INTRODUCTION: Clinical audit is a requirement of good medical and surgical practice and is central to the UK Government's plans to modernise the NHS. MATERIALS AND METHODS: A survey was conducted to assess clinical audit data collection and collation within plastic surgery departments across the UK. The survey identified a variety of different data collection and collation methods, with extensive differences between plastic surgery departments. Those responsible for data collection and its funding were also identified by the survey. RESULTS: Results were obtained from 45 plastic surgery departments. Of the 45 departments surveyed, 12 collect data prospectively, whereas 26 units collect data retrospectively. The remaining departments collect data using a combination of methods. Of the units surveyed, 28 collect data on paper-based systems, with only 13 units using electronic applications. The personnel responsible for data collection were identified as being junior doctors. Departments collecting data prospectively do so from a greater number of sources than those collecting data retrospectively. CONCLUSIONS: This survey has focused on plastic surgery. The authors believe that similar results would be obtained from a survey of other surgical specialties. A huge variation in all parameters relating to the collection and collation of clinical audit data is seen. There are few standards within this specialty for data collection. Much work must be done in order to reach targets set by the UK Government.

Data Collection↗
PubMed2001

A laboratory based intervention to improve appropriateness of lipid tests and audit cholesterol lowering in primary care.

PROBLEM: A need exists to reduce inequalities in lipid testing, to provide relevant, individual, patient based interpretation for users, and to audit lipid lowering in primary care. DESIGN: Model to compare laboratory activity between different general practices; construction of computer based strategies to define the lipid tests to be done and to interpret results for primary and secondary coronary prevention patients; introduction of the strategies into routine use; monitoring of any change after the intervention; and investigation of the potential of the strategies to produce audit data for primary care groups. BACKGROUND AND SETTING: Hospital clinical laboratory serving 22 general practices covering 150 000 patients in Bishop Auckland area County Durham. Key measurements for improvement: Reduction in differences in testing for the different serum lipids in coronary prevention. Production of usable audit data for the primary care groups involved. STRATEGIES FOR CHANGE: Four different categories of coronary prevention patient, with, for each category, the defined lipid tests to be done and advice to be given (based on the results), using the computer based strategies. EFFECTS OF CHANGE: Standardised test activity and the qualitative profile of the tests performed changed significantly. The strategies were readily adopted (median use 78%) within six months of introduction. LESSONS LEARNT: Computer based strategies can correct qualitative and quantitative differences in test requesting, provide interpretative guidance in accordance with national guidelines, and offer a cost effective model to monitor results of cholesterol lowering in general practice.

Cholesterol, HDL↗
PubMed1991

[Audit of clinical trials in Argentina. Assessment of standardized operational procedures in 12 centers].

The purpose of these audits was to ensure the quality, integrity and validity of investigational data. Audits were performed by control of compliance to standard operational procedures (SOPs) for Good Clinical Practice (GCP). Guidelines were proposed and established by the Food and Drug Administration (FDA) in 1977-1979 and adopted by several countries of the European Community in 1987-1989 and 1990. In Argentina, 12 on site audits of clinical trials performed between 1987 and 1990, were carried out. Basic data of GCP, audited in 58 out of 153 patients included in 12 different centers, were: protection of individual rights, compliance to standard operational procedures, adverse event reports, access to original investigational data and source document archives. The analysis of all audited data showed that patient case reports form recorded findings are credible and reliable and that researchers and monitors had conducted the study with an acceptable level in accordance to SOPs of good clinical practice. Otherwise, several in need of change to obtain better clinical data were identified: ethical committees, written informed consent, protocol adherence, data record, drug accountability, document source archives and the necessity of a thorough theorical and practical training on SOPs for GCP for researchers and monitors of clinical trials.

Argentina↗
PubMed1992

Cost of urology: financial audit in a clinical department.

OBJECTIVES: To cost a clinical unit over one month in 1991, to cost treatment of individual patients from audit data, and to compare this costing method with the hospital charging system. DESIGN: A financial breakdown was obtained for one month's work. Ward stay, operating time, investigations, and outpatient visits were costed and a formula (episode = days on ward+hours of operating+investigations+outpatient visits) was used to cost patient episodes from audit data. SETTING: The adult urology unit in a teaching hospital. MAIN OUTCOME MEASURES: Costs for each part of patients' treatment. RESULTS: Total cost was 147,796 pounds for 159 admissions, 738 inpatient days, 131 operations in 29 operating lists, and 615 outpatient visits. An uncomplicated transurethral prostatectomy cost 1140 pounds but complications increased this to 1500 pounds in another patient. The costs of diagnostic cystoscopy were 130 pounds in outpatients, 240 pounds in day surgery, and 430 pounds in inpatients. Hospital charges do not reflect the individual costs of treatment, charges being greater than costs for some patients and lower than costs for others. CONCLUSIONS: Clinicians can produce a financial analysis of their work and cost their patients' treatment. Audit is strongly advocated as a resource planning tool.

Adult↗
PubMed1988

NTP Toxicology and Carcinogenesis Studies of Trichloroethylene (CAS No. 79-01-6) in Four Strains of Rats (ACI, August, Marshall, Osborne-Mendel) (Gavage Studies).

Trichloroethylene is an industrial solvent used primarily for vapor degreasing and cold cleaning. It was selected for study because of its industrial use and for potential for human exposure. (An estimated 3.5 million workers are exposed to trichloroethylene.) In an earlier study trichloroethylene (stabilized with epichlorohydrin and 1,2-epoxybutane) administered by gavage caused hepatocellular carcinomas in male and female B6C3F1 mice. Trichloroethylene administration did not increase the incidence of tumors in male or female Osborne-Mendel rats. However, the survival of dosed rats was reduced, thereby compromising the sensitivity of the study to detect a carcinogenic effect. The studies described in this report were conducted to compare the sensitivities of four strains of rats (ACI, August, Marshall, and Osborne-Mendel) to diisopropylamine-stabilized trichloroethylene. The results of the present studies demonstrate that long-term administration of trichloroethylene produces nephrotoxicity in four strains of rats and that the susceptibilities of these strains to the nephrotoxic effects of the chemical are similar. Because of chemically induced toxicity, reduced survival, and incomplete documentation of the experimental data, the studies are considered inadequate for either comparing or assessing trichloroethylene-induced carcinogenesis in these strains of rats. Toxicology and carcinogenesis studies of trichloroethylene (more than 99% pure, stabilized with 8 ppm diisopropylamine) were conducted by administering the chemical in corn oil gavage at doses of 0, 500, or 1,000 mg/kg per day, 5 day per week, for 103 weeks to groups of 50 male and 50 female ACI, August, Marshall, and Osborne-Mendel rats. The doses were selected on the basis of results from 13-week gavage studies in which groups of 10 male and 10 female ACI, August, and Marshall rats received daily doses or trichloroethylene (male: 125-2,000 mg/kg; female: 63-1,000 mg/kg). Doses for Osborne-Mendel rats were selected to conform with doses used in an earlier carcinogenicity study in that strain (TR-2). In the 13-week studies, male ACI and August rats receiving 2,000 mg/kg trichloroethylene and male and female Marshall rats receiving 1,835 mg/kg had final mean body weights 12%-17% lower than those of the vehicle controls. All other dose groups had body weights comparable to those of the vehicle controls. Three male August rats dosed with 2,000 mg/kg died. Histopathologic evaluation of tissues revealed no lesions attributable to trichloroethylene administration in the 13-week studies. This absence of histopathologic findings did not accurately predict the nephrotoxic effects of long-term administration of trichloroethylene to rats. Body Weight and Survival in the Two-Year Studies: In the 2-year studies, all dosed groups exhibited some reduction in mean body weights relative to the vehicle controls. Survival relative to vehicle controls was significantly reduced in 7/16 dosed groups (see page 6 of the Technical Report). Also, the survival of high dose male Marshall rats was reduced by a large number of accidental deaths. Nephrotoxicity, reduced survival, and central nervous system toxicity (characterized by sedation, loss of consciousness, tremors, and convulsions) showed that the doses of trichloroethylene selected for the 2-year studies were too high. Renal Effects in the Two-Year Studies: Trichloroethylene caused tubular cell cytomegaly in 82%-100% of all dosed animals. In addition, trichloroethylene produced toxic nephropathy (which was distinguishable from age-related nephropathy) in 17%-80% of the dosed animals. Cytomegaly, karyomegaly, or toxic nephropathy was not found in untreated or vehicle control animals. Trichloroethylene administration was also associated with increased incidences of renal tubular cell adenomas and adenocarcinomas. The incidences of renal lesions are shown in the following table (see page 7 of Technical Report). Other Pathologic Effects in the Two-Year Studies: An increased incidence of interstitial cell tumors of the testis was observinterstitial cell tumors of the testis was observed in high dose male Marshall rats (untreated control, 16/46; vehicle control, 17/46; low dose, 21/48; high dose, 32/48; P=0.002). The incidences of pheochromocytomas of the adrenal gland were significantly reduced in male ACI, female August, female Marshall, and male and female Osborne-Mendel rats. Genetic Toxicology: Trichloroethylene did not cause mutations in Salmonella typhimurium strains TA98, TA100, TA1535, or TA1537 with or without metabolic activation. In Chinese hamster ovary cells, trichloroethylene did not induce chromosomal aberrations; the results for sister chromatid exchanges were considered positive. Trichloroethylene was mutagenic to mouse L5178Y lymphoma cells in the presence of rat liver S9. Data Audit: Audits of the experimental data for these 2-year studies of trichloroethylene were conducted by the National Toxicology Program (see Appendix Q of the Technical Report). The results of the audits revealed evidence that the doses of trichloroethylene were too high. In addition, there was insufficient documentation of animal breeding, clinical observations, environmental conditions, and analytical chemistry data. Also, individual animal identification was not always verifiable. Conclusions: Under the conditions of these 2-year gavage studies of trichloroethylene in male and female ACI, August, Marshall, and Osborne-Mendel rats, trichloroethylene administration caused renal tubular cell cytomegaly and toxic nephropathy in both sexes of the four strains. However, these are considered to be inadequate studies of carcinogenic activity because of chemically induced toxicity, reduced survival, and deficiencies in the conduct of the studies. Despite these limitations, tubular cell neoplasms of the kidney were observed in rats exposed to trichloroethylene and interstitial cell neoplasms of the testis were observed in Marshall rats exposed to trichloroethylene. Synonyms: acetylene trichloride; 1-chloro-2,2-dichloroethylene; 1,1-dichloro-2-chloroethylene; ethinyl trichloride; ethylene trichloride; 1,1,2-trichloroethylene; trichloroethene Trade names of formulations: Algylen; Anamenth; Benzinol; Blacosolv; Blancosolv; Cecolene; Chlorilen; Chlorylea; Chorylen; Circosolv; Crawhaspol; Densinfluat; Dow-Tri; Dukeron; Fleck-Flip; Flock Flip; Fluate; Gemalgene; Germalgene; Lanadin; Lethurin; Narcogen; Narkogen; Narkosoid; Nialk; Perma-A-Chlor; Perm-A-Clor; Petzinol; Philex; Threthylen; Threthylene; Trethylene; Tri; Triad; Trial; Triasol; Trichloran; Trichloren; Triclene; Tri-Clene; Trielene; Trielin; Triklone; Trilen; Trilene; Triline; Trimar; Triol; TRI-plus; TRI-plus M; Vestrol; Vitran; Westrosol Target Organs & Incidences from 2-year Studies

Journal Article↗