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Validation of alternative methods for toxicity testing.

Before nonanimal toxicity tests may be officially accepted by regulatory agencies, it is generally agreed that the validity of the new methods must be demonstrated in an independent, scientifically sound validation program. Validation has been defined as the demonstration of the reliability and relevance of a test method for a particular purpose. This paper provides a brief review of the development of the theoretical aspects of the validation process and updates current thinking about objectively testing the performance of an alternative method in a validation study. Validation of alternative methods for eye irritation testing is a specific example illustrating important concepts. Although discussion focuses on the validation of alternative methods intended to replace current in vivo toxicity tests, the procedures can be used to assess the performance of alternative methods intended for other uses.

Animal Testing Alternatives↗

Primary care. Associated benefits.

Results from an associate physician scheme for one region showed improved services for patients, benefits in organisation and management and high retention of doctors in inner cities. The scheme also caused early retirement of two poorly performing principals and uncovered instances of possible fraud. Success depended on the health authorities' commitment and support.

Benchmarking↗

Behavioral facilities solve special needs for restraints.

Representatives from two behavioral health facilities say adhering to restraint and seclusion standards presents unique problems. One facility keeps track of all restraint patients in order to identify trends, and a multidisciplinary committee meets monthly to review the collected data. At another hospital, a performance improvement project ensures that staff members take the least restrictive approach to support the patient's highest level of independence and functioning.

Benchmarking↗

Just shocking!

Electrical shock injuries can be fatal. Rescues of electrical shock victims also can be fatal if not handled correctly. Using "best practices" at work (and at home) will reduce the risk of an event from ever occurring and prevent the injury. Do not attempt to touch someone in contact with an electrical source. Shut off the power first, then attempt the rescue. Immediately call for emergency assistance. Always look for life-threatening conditions first, then treat any wounds. Always look for two external wounds and cover with dry dressing. Continue to monitor the patient for breathing and heart rate. Transport the patient to a medical facility as soon as possible. Each of us has the ability to choose how we perform an assigned task. You do have control over your work environment. Exercise that control and choose wisely to stay alive!

Benchmarking↗

The performance of sample selection estimators to control for attrition bias.

Sample attrition is a potential source of selection bias in experimental, as well as non-experimental programme evaluation. For labour market outcomes, such as employment status and earnings, missing data problems caused by attrition can be circumvented by the collection of follow-up data from administrative registers. For most non-labour market outcomes, however, investigators must rely on participants' willingness to co-operate in keeping detailed follow-up records and statistical correction procedures to identify and adjust for attrition bias. This paper combines survey and register data from a Norwegian randomized field trial to evaluate the performance of parametric and semi-parametric sample selection estimators commonly used to correct for attrition bias. The considered estimators work well in terms of producing point estimates of treatment effects close to the experimental benchmark estimates. Results are sensitive to exclusion restrictions. The analysis also demonstrates an inherent paradox in the 'common support' approach, which prescribes exclusion from the analysis of observations outside of common support for the selection probability. The more important treatment status is as a determinant of attrition, the larger is the proportion of treated with support for the selection probability outside the range, for which comparison with untreated counterparts is possible.

Adult↗

SVM-BALSA: remote homology detection based on Bayesian sequence alignment.

Biopolymer sequence comparison to identify evolutionarily related proteins, or homologs, is one of the most common tasks in bioinformatics. Support vector machines (SVMs) represent a new approach to the problem in which statistical learning theory is employed to classify proteins into families, thus identifying homologous relationships. Current SVM approaches have been shown to outperform iterative profile methods, such as PSI-BLAST, for protein homology classification. In this study, we demonstrate that the utilization of a Bayesian alignment score, which accounts for the uncertainty of all possible alignments, in the SVM construction improves sensitivity compared to the traditional dynamic programming implementation over a benchmark dataset consisting of 54 unique protein families. The SVM-BALSA algorithms returns a higher area under the receiver operating characteristic (ROC) curves for 37 of the 54 families and achieves an improved overall performance curve at a significance level of 0.07.

Bayes Theorem↗

Cost-minimization analysis of pegylated liposomal doxorubicin versus topotecan for the treatment of ovarian cancer in Italy.

BACKGROUND: Ovarian cancer is the most prevalent gynecologic cancer in women. Unfortunately for patients whose cancer is resistant to first-line therapies (platinum and paclitaxel), only a few second-line regimens have both significant efficacy and minimal treatment-related toxicity. Furthermore, the use of these agents increases treatment costs due to adverse events (AEs) related to tolerability and toxicity. OBJECTIVE: The aim of the present study was to assess the comparative patient-specific treatment costs associated with 2 second-line therapies, both benchmark therapies used to treat ovarian cancer patients in Italy: pegylated liposomal doxorubicin (PLD) and topotecan, which appear to have similar efficacy but different tolerability and toxicity profiles. METHODS: A cost-minimization analysis was performed in line with the point of view of Italy's National Health Service. Data on treatment efficacy and the number and types of AEs associated with drug toxicity were taken from a recent Phase III clinical trial comparing PLD with topotecan for the treatment of ovarian cancer. Resource-use estimates for each AE were based on the opinions of a panel of experts (Delphi method). Unit costs were drawn from national sources and a sensitivity analysis was performed. RESULTS: The mean total per-patient cost in the PLD arm was 8812 euro(minimum, 8281 euro; maximum, 9314 euro) compared with 15,788 euro in the topotecan arm (minimum 12,014 euro; maximum 18,847 euro). The higher acquisition cost of PLD offset the higher cost of managing the AEs related to treatment with topotecan. CONCLUSIONS: The present analysis suggested the net cost-saving capability of PLD compared with topotecan. PLD required fewer ambulatory care-center visits for treatment administration and was associated with fewer severe AEs than topotecan.

Antineoplastic Agents↗

Lattice Boltzmann simulations of droplet formation in a T-shaped microchannel.

We investigated the formation of a droplet from a single pore in a glass chip, which is a model system for droplet formation in membrane emulsification. Droplet formation was simulated with the lattice Boltzmann method, a method suitable for modeling on the mesoscale. We validated the lattice Boltzmann code with several benchmarks such as the flow profile in a rectangular channel, droplet deformation between two shearing plates, and a sessile drop on a plate with different wetting conditions. In all cases, the modeling results were in good agreement with the benchmark. A comparison of experimental droplet formation in a microchannel glass chip showed good quantitative agreement with the modeling results. With this code, droplet formation simulations with various interfacial tensions and various flow rates were performed. All resulting droplet sizes could be correlated quantitatively with the capillary number and the fluxes in the system.

Journal Article↗

Detection and clinical significance of occult tumour cells in colorectal cancer.

BACKGROUND: A variety of techniques have been employed for the detection of occult tumour cells in the blood, bone marrow and lymph nodes of patients with colorectal cancer. This review examines the methods used, results obtained and the clinical significance of studies in this field. METHODS: A Medline literature search was performed using the terms colorectal cancer, minimal residual disease, micrometastasis, polymerase chain reaction, reverse transcriptase polymerase chain reaction and immunocytochemistry; further references were obtained from key articles. RESULTS: Immunocytochemical examination of bone marrow is the benchmark for detecting clinically significant occult disease. Larger standardized studies are required to confirm the prognostic significance of molecular assays for the detection of tumour cells in blood and bone marrow. The prognostic significance of lymph node tumour cells detected by either immunohistochemical or molecular methods awaits further affirmation. CONCLUSION: Standardization of terminology and techniques used, combined with large prospective clinical studies, is required if detection of occult residual disease is to become a prognostic marker for recurrence in colorectal cancer.

Biomarkers, Tumor↗

Coupled-cluster with active space selected higher amplitudes: performance of seminatural orbitals for ground and excited state calculations.

The active space approach for coupled-cluster models is generalized using the general active space concept and implemented in a string-based general coupled-cluster code. Particular attention is devoted to the choice of orbitals on which the subspace division is based. Seminatural orbitals are proposed for that purpose. These orbitals are obtained by diagonalizing only the hole-hole and particle-particle block of the one-electron density of a lower-order method. The seminatural orbitals are shown to be a good replacement for complete active space self-consistent field orbitals and avoid the ambiguities with respect to the reference determinant introduced by the latter orbitals. The seminatural orbitals also perform well in excited state calculations, including excited states with strong double excitation contributions, which usually are difficult to describe with standard coupled-cluster methods. A set of vertical excitation energies is obtained and benchmarked against full configuration interaction calculations, and alternative hierarchies of active space coupled-cluster models are proposed. As a simple application the spectroscopic constants of the C(2) B (1)Delta(g) and B(') (1)Sigma(g) (+) states are calculated using active space coupled-cluster methods and basis sets up to quadruple-zeta quality in connection with extrapolation and additivity schemes.

Journal Article↗

Modeling early recovery of physical function following hip and knee arthroplasty.

BACKGROUND: Information on early recovery after arthroplasty is needed to help benchmark progress and make appropriate decisions concerning patient rehabilitation needs. The purpose of this study was to model early recovery of physical function in patients undergoing total hip (THA) and knee (TKA) arthroplasty, using physical performance and self-report measures. METHODS: A sample of convenience of 152 subjects completed testing, of which 69 (mean age: 66.77 +/- 8.23 years) underwent THA and 83 (mean age: 60.25 +/- 11.19 years) TKA. Postoperatively, patients were treated using standardized care pathways and rehabilitation protocols. Using a repeated measures design, patients were assessed at multiple time points over the first four postoperative months. Outcome measures included the Lower Extremity Function Scale (LEFS), the physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC PF), the 6 minute walk test (6 MWT), timed up and go test (TUG) and a timed stair test (ST). Average recovery curves for each of the measures were characterized using hierarchical linear modeling. Predictors of recovery were sequentially modeled after validation of the basic developmental models. RESULTS: Slopes of recovery were greater in the first 6 to 9 weeks with a second-degree polynomial growth term (weeks squared) providing a reasonable fit for the data over the study interval. Different patterns of recovery were observed between the self-report measures of physical function and the performance measures. In contrast to the models for the WOMAC PF and the LEFS, site of arthroplasty was a significant predictor (p = 0.001) in all of the physical performance measure models with the patients post TKA initially demonstrating higher function. Site of arthroplasty (p = 0.025) also predicted the rate of change for patients post THA and between 9 to 11 weeks after surgery, the THA group surpassed the function of the patients post TKA. CONCLUSION: Knowledge about the predicted growth curves will assist clinicians in referencing patient progress, and determining the critical time points for measuring change. The study has contributed further evidence to highlight the benefit of using physical performance measures to learn about the patients' actual level of disability.

Aged↗

Proctology in day surgery: surgical technique.

In 2002 the law number 112 defined in Italy the Elementary Assistance Levels (Livelli Essenziali di Assistenza--L.E.A.), which are the medical procedures provided to all Italian citizens by the National Health System (Servizio Sanitario Nazionale), for free or after payment of a small fee. Each Italian Regional Government has to define for each pathology (as already categorized in Disease Related Groups--D.R.G.) a benchmark, which is the percentage of cases of each pathology which should be treated in Day Surgery. The benchmarks are thresholds that should not be exceeded to avoid fines or other penalties to the hospital. In order to meet the objectives required by Italian law, a Day Surgery Unit must be able to perform as many operations as possible with high quality, high effectiveness, high efficiency, low costs and a low percentage of complications ("zero defect" objective). To get as close as possible to this objective it is necessary to seek the best organisation and the best surgical technique.

Ambulatory Surgical Procedures↗

Quality improvement methods in clinical medicine.

This article surveys the methods and tools of quality improvement used today in health care. Specifically, we describe how clinicians can use these methods to impact the clinical practice of medicine. Improvement teams from a variety of health care organizations have reported the successful use of basic methods such as group work, flowcharting, data collection, and graphical data analysis. In addition to these incremental, problem-solving methods borrowed from the industrial practice of improvement, we have also seen the use of specific process design methods in health care applications such as care path development. The pace of change in health care has also led to the practical development of newer methods for rapid cycle improvement. We will review the basic approach behind these methods and illustrate key elements such as the ideas of change concepts and small-scale tests of change. Unfortunately, whereas these methods have been very successful and highly appealing to improvement practitioners, they may also have inadvertently widened a gulf between these practitioners and traditional health-services and clinical researchers. We offer an assessment of this issue and suggest ways to narrow the communication gap. Measurement has also traditionally been a part of the thinking about quality assurance and improvement in health care. We review the new philosophy of measurement that has emerged from recent improvement thinking and describe the use of control charts in clinical improvement. Benchmarking and multiorganizational collaboratives are more recent innovations in the ways we approach improvement in health care. These efforts go beyond simple measurement and explore the why and how associated with the widespread variation in performance in health care. We explore a variety of health care examples to illustrate these methods and the lessons learned in their use. We conclude the article with an overview of four habits that we believe are essential for health care organizations and individual clinicians to adopt to bring about real improvement in the clinical practice of medicine. These are the habits for: 1) viewing clinical practice as a process; 2) evidence-based practice; 3) collaborative learning; and 4) change.

Clinical Medicine↗

Recall-by-genotype of neurodevelopmental disorder copy number variants in a multi-ancestry, healthcare-system biobank.

Clinical biobanks linking electronic health records (EHRs) with genotype data enable the study of genomic risk factors in real-world populations. However, recall-by-genotype (RbG) of psychiatric risk variants in diverse healthcare-system biobanks remains scarce. Leveraging BioMe, a multi-ancestry biobank within the Mount Sinai Health System, we recalled carriers of rare copy number variants (CNVs) that confer increased risk for neurodevelopmental disorders (NDDs) to establish empirical benchmarks for RbG implementation. We recontacted 892 participants: 335 NDD CNV carriers, 217 individuals with schizophrenia without NDD CNVs, and 340 neurotypical controls without NDD CNVs. Participants completed clinical and cognitive assessments. Overall, 18% of recontacted participants responded to recruitment, and 8% completed the study: 30 NDD CNV carriers, 20 individuals with schizophrenia, and 23 controls. The mean age was 48.8 years, 66% were female, and self-reported ancestry was 37% African, 34% Hispanic, and 26% European. Seventy percent of NDD CNV carriers had at least one neuropsychiatric or developmental condition, including mood or anxiety disorders (40%). Among 22 NDD CNV carriers at loci implicated in impaired cognition, performance was lower than controls on Digit Span Backward (β = -1.76, FDR = 0.04) and Digit Span Sequencing (β = -2.01, FDR = 0.04). NDD CNV carriers also outperformed the schizophrenia group on verbal learning (β = 4.5, FDR = 0.05). Recall of individuals-including those with psychiatric illness-yielded phenotypes not captured in EHRs and provides empirical benchmarks relevant to RbG implementation and precision psychiatry in diverse healthcare systems.

Journal Article↗

On the performance of neuronal matching algorithms.

For a solution of the visual correspondence problem we have modified the Self Organizing Map (SOM) to map image planes onto another in a neighborhood- and feature-preserving way. We have investigated the convergence speed of this SOM and Dynamic Link Matching (DLM) on a benchmark problem for the solution of which both algorithms are good candidates. We show that even after careful parameter adjustment the SOM needs a large number of simple update steps and DLM a small number of complicated ones. The results are consistent with an exponential vs. polynomial scaling behavior with increased pattern size. Finally, we present and motivate a rule for adjusting the parameters of DLM for all problem sizes, which we could not find for SOM.

Journal Article↗

Discrepancies in performing target weight assessments in haemodialysis patients.

Roberts and White (1) state that the main reason for hospitalisation of dialysis patients is due to 'fluid Volume excess'. Fluid/target weight assessments should routinely be carried out for chronic haemodialysis patients prior to each treatment by experienced renal nurses, but Welsh (2) states that the assessment of the patient and clinical skills may be underused because of poor staffing levels. Using a qualitative design study based on a group of experienced renal nurses, the author sought to determine which clinical signs and symptoms were assessed, how often they were carried out and what similarities were demonstrated. Elements such as the patient's blood pressure, evidence of peripheral oedema and dyspnoea were used as benchmarks for good practice, based on literature and the author's extensive experience. The author also believed that the standard fluid assessment could be improved by expanding the nurse's role to incorporate chest auscultation. Results demonstrated that a variety of reasons determined whether such assessments were carried out, and that there was wide variation as to what nurses considered essential in performing the assessment.

Attitude of Health Personnel↗

Fundamentals of financial statement analysis for academic physician managers.

Academic medical centers (i.e., teaching hospitals) and academic medical practices are under pressure to control costs to compete with for-profit health care institutions. The authors explain how academic physician managers who want to control costs wisely must first understand the cost structure of the medical center or practice and compare that structure with those of for-profit institutions. Doing this requires a firm understanding of how to use a valuable tool, financial statement analysis, to assess an institution's health and performance. Such analysis consists of calculating a variety of financial ratios (e.g., operating income divided by revenues; net income divided by total assets) and then comparing them with the corresponding ratios that are considered industry norms. Three types of financial statements (defined in detail) lend themselves to this approach: the balance sheet, income statement, and statement of cash flows. The authors define standard financial ratios, point out their uses and limitations, and emphasize that a ratio's meaning derives from comparing it with the corresponding benchmark ratio in the industry as a whole. Ratios should be used not as the end point of assessing financial status, but as ways to identify possible problems that require further investigation. Analysis of trends of ratios over time within an institution is a complementary approach. The authors then discuss the use of ratios in three standard types of institutional evaluation: of performance, of liquidity and leverage, and of strategic planning. In addition, they present the financial statement of a fictitious academic medical center as an example of how to use ratios for financial statement analysis. The authors emphasize that the key to using the ratios they discuss and hundreds of others is first to decide what question needs answering and then to choose the relevant ratios to provide a basis for finding the answer.

Academic Medical Centers↗

Evaluating a benchmarking database and identifying cost reduction opportunities by diagnosis-related group.

Pharmacy cost data from the University HealthSystem Consortium (UHC) Clinical Database for specific diagnosis-related groups (DRGs) were reviewed to assess their applicability to a university medical center and to identify opportunities to reduce costs. UHC headquarters was contacted by telephone to determine UHC's data collection methods. Pharmacy costs for DRG 302 (kidney transplant) at the University of Kansas Medical Center (KUMC) were compared with the costs shown in the UHC Clinical Database. Appropriate drug use for DRGs 302 and 480 (liver transplant) was assessed by contacting transplant pharmacists and pharmacy administrators at the five top-performing hospitals (in terms of cost per DRG) as listed in the UHC database to find opportunities for reducing pharmacy costs. KUMC's actual pharmacy costs for DRG 302 ($4635) were 46% lower than those listed in the UHC Clinical Database ($8546). There was a disparity between the amount of both intravenous immune globulin (IVIG) and lymphocyte immune globulin used by KUMC and the top-performing hospitals. Guidelines for use of IVIG, acyclovir, and azathioprine in liver transplant patients at KUMC were revised. A potential cost saving of $53,000 was identified in relation to the use of lymphocyte immune globulin in kidney transplant patients. Data in the UHC Clinical Database were not representative of pharmacy costs at a university medical center for DRG 302 (kidney transplant), overstating pharmacy costs by 46%; benchmarking was found to be a useful tool for identifying opportunities for reducing costs.

Benchmarking↗