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PubMed2005

Assessing the potential for functional improvement of stroke patients attending a geriatric day hospital.

In the present study the potential for functional improvement in 103 stroke patients attending a geriatric day hospital was evaluated using the Orpington Prognostic Scale (OPS). This information may assist in coordinating the patients' and caregivers' expectations, allocating resources efficiently, and advance care planning. The Spearman correlation was used to calculate the association between OPS score and Functional Independent Measure (FIM), the Nottingham Extended ADL Index (NEAI), and the timed Get Up and Go test (TUG). The studied population was divided into two groups: patients with mild neurological impairment (OPS score<3.2) and those with moderate to severe neurological impairment (OPS score> or =3.2) and their performance on the above outcome measure were compared. The OPS score significantly correlated (p<0.001) with discharge scores of FIM (r=-0.730), NEAI (r=-0.675), and TUG (r=0.448). Patients with OPS score <3.2 achieved significantly higher discharge scores (p<0.001) in all three measures (FIM, TUG, and NEAI) compared to patients with OPS score > or =3.2. Nevertheless, patients with moderate to severe neurological impairment achieved greater score changes in FIM and TUG than patients with mild neurological impairment, although their discharge scores were less favorable. These results indicate that stroke patients even the more impaired, may continually recover and should be exposed to a prolonged rehabilitation program.

Aged↗

PubMed2004

Comorbid illness affects hospital costs related to hip arthroplasty: quantification of health status and implications for fair reimbursement and surgeon comparisons.

Optimized resource allocation, reimbursement negotiations, and provider comparisons hinge on an understanding of the drivers of healthcare costs. Indices of comorbid illness may be useful for stratifying patients based on cost. Total hospital cost was analyzed for 1 surgeon's hip arthroplasty patients (June 1998-March 2001). Three scales of health status were selected as independent predictors. One thousand ninety-two hip arthroplasty inpatient stays were evaluated. The median total hospital cost was 14,011 dollars. An increasing burden of comorbid illness as measured by the All Patient Refined Diagnosis Related Group Severity of Illness scale and the modified Charlson Comorbidity Index was significantly associated with increasing hospital cost. Comorbid illness is associated with cost; scales may be used to stratify patients based on risk of high cost care.

Adolescent↗

PubMed2004

Preoperative demand matching is a valid indicator of patient activity after total hip arthroplasty.

The validity of preoperative demand matching as an indicator of patient activity following total hip arthroplasty (THA) was evaluated by studying 518 patients (mean age, 67 years; range, 26-92 years) who were assigned to 4 categories of decreasing demand: I (high demand), 68 patients (13%); II, 144 patients (28%); III, 281 patients (54%); and IV (low demand), 25 patients (5%). Preoperative Lahey Clinic Demand Category (as defined by age, weight, expected activity, health, and bone stock) was significantly correlated with self-reported, postoperative patient activity (P = .0038, R2 = .2024) and was much more predictive than any individual variable. Because patient activity is related to hip joint bearing surface wear, implant selection and resource allocation could be influenced by using demand matching to identify patients with high postoperative demand who may benefit from improvements in implant technology. Demand matching may also be used to stratify patient activity in long-term outcomes studies of THA.

Activities of Daily Living↗

PubMed2004

Prospective timing under dual-task paradigms: attentional and contextual-change mechanisms.

The effect of a concurrent memory task on prospective time estimates by human participants was investigated in two experiments. The objective was to isolate task effects from those of participant timing strategy (self-paced counting) and number of contextual changes during the temporal stimulus. Accordingly, self-paced counting was suppressed by requiring participants to perform a word-reading task during the temporal stimuli, while number of stimulus changes presented during temporal stimuli was controlled. Presence versus absence of the concurrent memory task was manipulated in Experiment 1, and instruction to focus on timing or to focus on memory was manipulated in Experiment 2. There was no significant effect of presence versus absence of the concurrent memory task on time estimates; however, time estimates were shorter when participants were instructed to focus on memory versus timing. In both experiments, time estimates were positively correlated with participants' estimates of the number of words presented during the interval, even though number of words presented was invariant. These findings were generally consistent with resource-allocation attentional accounts of concurrent task effects; however, support for a contextual-change model of timing was also obtained.

Adolescent↗

PubMed2006

Women's health in developing countries.

Healthcare priorities are different in developing and developed countries. A more effective resource allocation, complemented by efforts to implement only those practices that are effective, should be a priority for improving reproductive health services in developing countries. A large burden of gynaecological disease exists in developing countries and it is difficult to envisage serious reforms and improvements without an increase in public-sector spending. However, communities themselves could assume some responsibility for women's health in ways that prioritize women's own perceptions and primary needs. In this chapter we have compiled existing evidence regarding various gynaecological problems faced by women in developing countries. To name a few: sexual health issues, abortion, subfertility, cancer, and genital fistulae. We believe that there is a large knowledge gap in the area of women's health in developing countries, and there is an urgent need to conduct appropriately designed studies.

Abortion, Induced↗

PubMed2005

Reinstatement of fear responses in human aversive conditioning.

The treatment of choice for a number of anxiety disorders is exposure therapy. However, successful reduction of fear through exposure is sometimes followed by a (partial) return of symptoms of fear (return of fear, ROF; Clin. Psychol. Rev. 9 (1989) 147). Several possible learning mechanisms have been suggested to explain ROF (e.g. mechanisms related to spontaneous recovery, renewal, reacquisition and reinstatement). The present study focuses on reinstatement, which refers to the observation that mere US-only presentations can 'reinstate' previously extinguished fear responses. Although animal research has repeatedly demonstrated this phenomenon, little is known about fear reinstatement in humans. The present study employed a differential aversive conditioning procedure: after acquisition and a subsequent extinction procedure, a series of four unpredicted US-only trials was scheduled in the reinstatement group. The control group did not receive additional US presentations. A significant reinstatement effect was observed for US-expectancy ratings and fear ratings in the reinstatement group, but not in the control group. No differences were observed in a reaction time measure of resource allocation to the conditioned stimuli. These findings constitute a first demonstration of reinstatement of conditioned fear responses in humans. Implications for exposure treatment and suggestions for future research are discussed.

Adult↗

PubMed2006

The cost of a hot drink scald.

Approximately 6400 children per year are admitted to UK hospitals for treatment of burns [National Burn Care Review Committee Report (NBCRC). Standards and Strategy for Burn Care: a review of burn care in the British Isles. 2001.]. This paper investigates the financial costs involved in the management of uncomplicated, minor paediatric scalds. Three cases (2-4% TBSA scalds) were studied to quantify consumables used, services required during management and costs obtained from appropriate Purchasing Departments and Directorate Accountants. Management in all cases involved a general anaesthetic for cleaning of wounds, application of BioBrane (Bertek Pharmaceuticals) and dressings, observation on Children's Ward and discharge following wound review at 48 h. The calculated mean average cost per case was pound1850. In the period 01/12/2002-30/11/2003, 144 children were admitted to Frenchay hospital, Bristol, for treatment of a minor burn or scald (less than 10%TBSA). This caseload is therefore estimated to currently cost pound266,400 per year. These findings may facilitate improved planning for future resource allocation and could also contribute evidence towards the cost effectiveness of prevention strategies.

Beverages↗

PubMed2006

Egg components, egg size, and hatchling size in leatherback turtles.

Relationships between egg size, egg components, and neonate size have been investigated across a wide range of oviparous taxa. Differences in egg traits among taxa reflect not only phylogenetic differences, but also interactions between biotic (i.e., maternal resource allocation) and abiotic (i.e. nest environment conditions) factors. We examined relationships between egg mass, egg composition, and hatchling size in leatherback turtles (Dermochelys coriacea) because of the unique egg and reproductive characteristics of this species and of sea turtles in general. Albumen comprised 63.0%+/-2.8% (mean+/-S.D.) of egg mass and explained most of the variation in egg mass, whereas yolk comprised only 33.0%+/-2.7%. Additionally, leatherback albumen dry mass was approximately 16% of albumen wet mass. Whereas hatchling mass increased significantly with egg mass (n = 218 clutches), hatchling mass increased by only approximately 2 g for each 10 g increase in egg mass and was approximately 10-20 g greater than yolk mass. Taken together, our results indicate that albumen might play a particularly significant role in leatherback embryonic development, and that leatherback eggs are both capable of water uptake from the nest substrate and also possess a large reservoir of water in the albumen. Relationships between egg mass and egg components, such as variation in egg mass being largely explained by variation in albumen mass and egg mass containing a relatively high proportion of albumen solids, are more similar to bird eggs than to eggs of other non-avian reptiles. However, hatchling mass correlates more with yolk mass than with albumen mass, unlike patterns observed in bird eggs of similar composition.

Animals↗

PubMed2005

P3 amplitude and time-on-task effects in distractible adolescents.

OBJECTIVE: The aim of our study was to examine the role of brain activity related to stimulus evaluation processes in distractibility by analyzing the P3 event-related potential. METHODS: We studied the P3 response to target stimuli at the beginning, in the middle, and at the end of a two-tone auditory oddball task in easily distractible (n = 16) and non-distractible (n = 16) adolescents. RESULTS: Easily distractible adolescents showed enhanced frontal and reduced parietal P3 amplitude across the blocks relative to non-distractible adolescents. Also, the usual decline in P3 amplitude at the end of the task was significantly larger in distractible than in non-distractible adolescents. CONCLUSIONS: These results suggests that the P3 effects are not limited to the neuropsychiatric disorders, and that increased distractibility may be characterized by reduced amount of resources allocated to the task with continued testing. SIGNIFICANCE: The results of this study contribute to elucidation of the functional basis of distractibility.

Acoustic Stimulation↗

PubMed2005

Attentional load of the primary task influences the frontal but not the temporal generators of mismatch negativity.

According to the model hypothesized by Näätänen and Michie, the generation of the mismatch negativity (MMN) requires a mismatch detection, taking place in temporal areas, followed by the activation of frontal generators, underlying attention switching toward the deviant stimulus. We aimed at verifying whether the activation of temporal and frontal regions is dependent on the amount of attentional resources allocable toward the deviant stimulus. We recorded event-related potentials (ERPs) in nine healthy subjects while reading and during a demanding visual task (Multiple Features Target Cancellation, MFTC). Raw data were further evaluated by Brain Electrical Source Analysis (BESA). During the Reading condition, distraction toward the unattended auditory stimuli was reflected by the enhancement of the N1 response to frequent stimuli and by the elicitation of a P3a response to deviant ones. The MMN distribution was explained by bilateral temporal dipoles. During the MFTC condition, no P3a was detected, while source analysis showed the activation of a right frontal generator. Temporal dipoles showed no change between the two conditions: we thus conclude that the earlier mismatch detection is independent on the attentional load. By contrast, the activation of a right frontal subcomponent occurred only during the high-load task, independently on any actual attention shift reflected by the P3a component. We thus discuss the hypothesis whether the right frontal MMN generator, rather than subserving a simple attention switching toward the deviant stimulus, plays a role in modulating the auditory change detection system ("contrast enhancement" model).

Acoustic Stimulation↗

PubMed2006

Seasonal population dynamics of Eisenia fetida (Savigny, 1826) (Oligochaeta, Lumbricidae) in the field.

In order to assess the response of epigeic earthworms to seasonal changes we monitored the population dynamics of Eisenia fetida (Oligochaeta, Lumbricidae) in a manure heap in the field during a year. Earthworms were hand-sorted from five 0.25 x 0.25 x 0.20 m blocks around the heap in November (autumn) 1999 and in January (winter), April (spring) and August (summer) 2000 to determine earthworm population dynamics. Earthworms of each block were classified into different age classes: mature, preclitellate, juvenile, hatchling and cocoon, and afterwards counted and weighed. Seasonality had a strong effect on the density, biomass and reproductive activity of the population. The population of E. fetida was characterized by a high density of individuals and the predominance of mature individuals throughout the year. Maximum density, mating activity and size of cocoons were achieved in spring, but there were not changes in the number of cocoons per mature earthworm throughout the year. Unexpectedly, the smallest cocoons were produced in winter by the largest individuals. These results suggest that E. fetida is able to allocate resources to growth and/or reproduction in response to environmental fluctuations.

Aging↗

PubMed2006

Sexual behavior: a seminal peptide stimulates appetites.

A new study shows that female fruitflies eat more after mating, and that a multi-functional peptide provided in the seminal fluid of their mates induces this behavior. These findings contribute significantly to our understanding of mating behaviors and resource allocation, and may provide insights useful for controlling the reproduction of insect pests.

Animals↗

PubMed2006

A controlled trial of skin-to-skin contact in extremely preterm infants.

BACKGROUND: Extremely preterm birth, even in the absence of significant neurological impairment, is associated with altered pain responses and impaired memory and behaviour. Preterm birth increases the risk of maternal depression and may impede the development of the mother-infant relationship, factors that in turn are also associated with impaired infant outcome. Mother-infant skin-to-skin contact has been recommended as a simple means of ameliorating these effects. METHODS: We conducted a pragmatic, prospective, controlled, intention-to-treat trial in two neonatal intensive care units. Infants born below 32 weeks gestation were recruited within the first week after birth and assigned to a control group receiving standard care, or an intervention group in which mothers were encouraged to provide a session of skin-to-skin contact once daily for 4 weeks. We assessed infant behaviour at time of discharge from hospital, responses to immunisation at 4 and 12 months of age, and memory, behaviour and development at 1 year corrected (postmenstrual) age. Indices of maternal depression, stress, anxiety, lactation performance and infant interaction were assessed at time of infant discharge, 4 months and 1 year. RESULTS: No significant difference was identified in any infant or maternal measure at any time point. CONCLUSIONS: Mother-infant skin-to-skin contact after extremely preterm birth results in neither benefit nor adverse consequences. Although there is no reason to dissuade mothers who wish to provide STS contact, we are unable to recommend resource allocation for the implementation of STS programmes for extremely preterm infants in a neonatal intensive care unit setting.

Adult↗

PubMed2004

The transition from an analog to a digital echocardiography laboratory: the Mayo experience.

Our echocardiography laboratory has completed the transition from an analog to a digital imaging laboratory. The process involved a thorough analysis of the practice and design of a complete digital solution. After an effective implementation of a robust reporting solution, the transition to digital imaging ensued. The implementation plan for digital imaging enabled the transition to be made without adversely affecting the practice, which has an average daily examination load of more than 200 patients. Full-load testing simulations were required on high-end image processing review workstations, high-speed local area network connections to each imaging suite, and new clustered imaging servers. We had to test the ability of approximately 100 ultrasound machines with 3 idiosyncratic ultrasound platforms to allow digital image transfer to the new imaging servers over the local area network. Our sonographer, allied health, and physician staff of more than 250 persons had to be trained to adapt to important changes that the digital echocardiographic image acquisition and review platform would have on their specific roles in the laboratory. The efficiency of the implementation, reporting, and imaging resulted in improved staff resource allocation. The lessons learned may benefit laboratories with a similar interest in making the transition to a digital imaging laboratory with minimal effect on patient scheduling and staff satisfaction. The effect of the transition to a completely digital laboratory on operating expenses, imaging, and reviewing systems and the impact on the clinical practice of echocardiography at our institution are presented, with emphasis on the particular aspects of transitioning to digital imaging.

Cardiology↗

PubMed2004

Promoting good medical care.

This paper sets out the policy of the Union Europeenne des Medecins Specialistes/European Union of Medical Specialists (UEMS) on quality assurance (QA), which is defined here as the regular review against defined standards of medical care. Its aim is to provide a framework for confirming the good quality of health care in Europe and, specifically, of the contribution of specialist doctors. The paper provides guidelines that can be adopted for use in QA systems in all European countries. It will show that this can best be achieved when QA is based on valid evidence, which can also facilitate improvements in medical care and justify the provision of necessary resources. This UEMS policy paper builds upon considerable evidence of successful, well-established QA systems that are found in many parts of Europe. Fundamental features of these are that they are led by specialist doctors who control resources allocated solely for the purpose of QA. Accordingly, the UEMS recognises its responsibility to develop policy based on this experience and invites all interested parties to support this. The UEMS considers QA to be an essential component of an agenda focused on high standards of medical practice. The other parts of that agenda include continuing professional development as a form of quality improvement-covered separately in the 2001 UEMS policy document "The Basel Declaration"-and its policy being developed on regulating the medical profession. This paper is addressed to all who have an interest in the quality of health care provision: patients, doctors, medical associations, health service employers and hospitals, fund holders, regulatory authorities and national and European legislators. The UEMS considers that, in the context of the QA of medical care, all share the following agenda: The UEMS draws attention to the lack of evidence demonstrating any additional effectiveness of mandatory systems over the model described here. The following list of key points drawn from the text expands this summary. It also serves as an index to specific paragraphs of the paper. KEY POINTS:

Journal Article↗

PubMed2005

Compensation processes of Aleppo pine (Pinus halepensis Mill.) to ozone exposure and drought stress.

A long-term experiment was performed to study the effects of O3 and drought-stress (DS) on Aleppo pine seedlings (Pinus halepensis Mill.) exposed in open-top chambers. Ozone reduced gas exchange rates, ribulose-1,5-biphosphate carboxylase/oxygenase activity (Rubisco), aboveground C and needle N concentrations and C/N ratio and Ca concentrations of the twigs under 3 mm (twigs<3) and the aerial biomass. Also it increased phosphoenolpyruvate carboxylase (PEPc) and N and K concentrations of the twigs<3. Water stress decreased gas exchange rates, predawn needle water potential (PsiPd), C/N ratio, twigs<3 Ca, plant growth, aerial biomass and increased N, twigs with a diameter above 3 mm P and Mg concentrations. The combined exposure to both stresses increased N concentrations of twigs<3 and roots and aboveground biomass K content and decreased root C, maximum daily assimilation rate and instantaneous water use efficiency. The sensitivity of Aleppo pine to both stresses is determined by plant internal resource allocation and compensation mechanisms to cope with stress.

Air Pollutants↗

PubMed2006

The importance of process issues as predictors of time to endoscopy in patients with acute upper-GI bleeding using the RUGBE data.

BACKGROUND: Early endoscopy has been shown to improve outcomes and optimize cost-effectiveness in nonvariceal upper-GI bleeding (NVUGIB). However, there is little information regarding clinical and process determinants that affect the time from onset of bleeding to performance of the endoscopy. OBJECTIVE: The aim of this study was to identify factors that predict time to endoscopy in patients with new onset NVUGIB. DESIGN: Linear regression models were constructed with time between triage (outpatients) or onset of bleeding (inpatients) and the performance of endoscopy. SETTING: The RUGBE is a nationwide, multicenter database collected for the purpose of obtaining descriptive data on patients with NVUGIB. PATIENTS: The study population consisted of 1500 patients (89.6%) who underwent gastroscopy within 48 hours. RESULTS: Median time to endoscopy was 12 hours (95% CI 11.0, 13.0). Endoscopy after working hours (regression coefficient [beta] -3.52; 95% CI -5.47, -1.58), availability of an endoscopy nurse on-call for the procedure (beta -2.48; 95% CI -3.83, -1.14), and admission to a hospital unit were associated with a shorter interval to endoscopy. In contrast, the presence of chest pain (beta 3.65; 95% CI 1.64, 5.67) or dyspnea (beta 2.79; 95% CI 1.10, 4.48), absence of gross blood on rectal examination (beta 2.20; 95% CI 0.69, 3.71), and inpatient status at onset of bleeding (beta 14.6; 95% CI 8.70, 20.4) were independent predictors of a delayed endoscopy. Subgroup analysis showed that actual time intervals as well as independent predictors of time until endoscopy differed between inpatients and outpatients. LIMITATIONS: Retrospective analysis. CONCLUSIONS: The timing of endoscopy in patients with NVUGIB is dependent on both clinical and process parameters, which differ between inpatient and outpatient settings. They bear implications with regards to shaping practice and deciding on resource allocation in order to facilitate an early endoscopy, which is currently recommended for improved patient outcomes.

Aged↗

PubMed2004

A note on a discussion group study of public preferences regarding priorities in the allocation of donor kidneys.

OBJECTIVE: To explore whether and how people wish to give differential priority based on certain characteristics of the potential recipient of a donor kidney. DESIGN: A random sample of people resident in York was invited to attend two focus group meetings each, a fortnight apart. SETTING: The City of York. PARTICIPANTS: Twenty-three randomly chosen people meeting in four groups of five or six. MAIN OUTCOME MEASURES: Those factors that people think should be taken into account when allocating donor kidneys, in addition to the expected benefits from transplantation. RESULTS: People are willing and able to distinguish between potential recipients of a kidney transplantation according to a range of characteristics beyond the expected benefits from treatment. There is a clear consensus across the four groups that one of the most important considerations is what will happen to the patient without treatment, and so priority is given to those with a poor prognosis. There is also a strong view that priority should be given to younger patients and to those with dependants. The time spent waiting for a transplant is also important, but less so. CONCLUSIONS: A sample of the general public, after discussion and debate, wish to take account of a number of patient characteristics when allocating donor kidneys. There is some degree of consensus about what these factors should be and this suggests that it might be possible to develop a set of guidelines for the allocation of donor kidneys.

Adolescent↗