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Does the mode of data collection change results in a subjective knee score? Self-administration versus interview.

Our objective was to compare the effect of two methods of data collection on results in a functional knee score. Two Lysholm scores were obtained for 61 patients 1 year after anterior cruciate ligament surgery at the same clinic visit. First, the patients completed a self-administered questionnaire, and second, the Lysholm score form was completed by the investigator in the course of a patient interview. A comparison of the scores revealed that the mean score was significantly lower with self-administration (self, 89.3 +/- 10.6; interviewer, 92.2 +/- 7.4) (P = 0.0035, Wilcoxon rank sum test). The assignment to one of four categories (excellent, good, fair, poor) was also significantly altered by the manner of data collection. Nineteen patients (31%) were assigned to different categories based on the mode of data collection. We believe that the major reason for a better score result with an interview was the presence of interview bias. The more the investigator is involved in the treatment of the patient, the greater the influence of this bias may be. To avoid such potential bias we suggest that a standardized self-administered questionnaire be used as the method of choice for obtaining subjective data in clinical settings.

Adult↗

Data collection and complication rates in clinical audit.

Audit data were collected continuously between February 1988 and July 1991. For the initial period (February 1988-June 1990) data were collected by monitoring of ward admission and discharge records and by collecting data from operating theatre records whilst complications were noted in a 'complications book' which was kept on the notes trolley. In July 1991, when a computerized system for storing and processing audit data was introduced into the department, the methods of data collection changed. For each patient a proforma was attached to the clinical notes which was filled in at each stage of the hospital stay. On this proforma was a list of possible complications which were ticked, as appropriate, at the time of discharge from hospital. We have reviewed the results of clinical audit during these two periods. The number of operations performed per month fell slightly in the latter period (p = 0.005). However, there was a significant increase in both the number of complications (p < 0.0001) and in the complication rate (p < 0.0001). Further analysis showed that there was a similar increase in the number of recorded major and minor complications, and that this increase was also seen even when changes in medical personnel were accounted for. We suggest that the increased complication rate recorded in the latter period reflects the change in the method of data collection. This has important implications when comparing outcome measures for clinical departments.

Consultants↗

[Surveillance of antibiotic therapy in a pediatric intensive care unit].

Since 1982, a pediatric intensive care unit for neonates and pediatric patients up to 15 years of age has prospectively recorded every instance of use of antimicrobials, with the reasons for use, clinical and bacteriological parameters, and outcome. This approach encourages strict adherence to established protocols and provides a basis for discussing the rationale of each antimicrobial course. Effectiveness of protocols is evaluated annually and modifications or additions are introduced, as appropriate. Patterns in the proportion and nature of antimicrobials used to treat hospital-acquired infections can be monitored on the basis of the data collected. Changes in the nature of antimicrobials used, which may have repercussions on pathogen resistance to antimicrobials, are also monitored. Reasons for use of antimicrobials are categorized as follows: A = primary infection: B = secondary infection acquired in the ICU; C: secondary infection acquired in another unit or in another hospital; D = prophylaxis. In 1987, 46% of neonates and 59% of patients above one month of age were given antimicrobial agents; these figures are similar to those recorded during the previous years. Reasons for antimicrobial therapy were as follows in neonates: A = 48.5%; B = 40%; C = 1.2%; D = 10.3%; in patients above one month of age corresponding figures were: A = 23%; B = 44%; C = 0.9%; D = 31.9%. Among the neonates, the ampicillin-aminoglycoside combinations accounted for 41.5% of treatments (1/4th of these treatments were continued); in the older patients, penicillin G and ampicillin were the most commonly used antibiotics. In all age groups, hospital-acquired infections were mainly respiratory tract infections (approximately 50% in neonates and 80% in patients above one month of age). Staphylococcus aureus was the most prevalent organism; Pseudomonas was seen virtually only among the patients above one month of age with very prolonged endotracheal intubation. From 1983 through 1987, use of third-generation cephalosporins increased from 4.5% to 28.3% in neonates and from 5.5% to 9% for patients above one month of age. The changes identified over time should be interpreted in the light of changing patterns of disease; in particular, hospital-acquired infections among neonates increased twofold, probably as a result of the rising number of very-low-birth-weight infants.

Adolescent↗

Changes in payments for general practice consultations 1989-93.

AIMS: Information generated by the computer systems of general practitioners was examined to determine whether general practitioners fee structures during 1993 were different from those reported in 1989. METHODS: Copies of the general medical services (GMS) claims and actual consultation charges to patients were examined to determine whether patients had been charged the doctors' regular fee or an amount greater or less than this, in 1993. These data were compared with results from a previous study describing charging data in 1989. RESULTS: Information on 59,215 consultations was collected in 1993 and compared with information on 97,869 consultations collected in 1989. The proportion of consultations which resulted in a regular fee being charge had reduced from 47.0% in 1989 to 34.1% in 1993 (p < 0.001). The proportion of cases in which a less than normal fee was charged had risen 7.9 times from 3.5% in 1989 to 27.5% in 1993 (p < 0.001). The contribution of Accident Compensation (ACC) funding for general practitioner consultations had reduced from 17.5% of consultations in 1989 to 10.1% of 1993 consultations (p < 0.001). Excluding consultations in which a maternity or immunisation claim was made, 19.4% of consultations in 1993 generated no fee to the patient. CONCLUSION: In the 4 years between these two data collections, changes in the contribution of different agencies funding general practice care is marked. Public agencies have diminished input and both patients and practitioners are carrying more of the financial burden for access to primary care.

Adult↗

Cancer mortality in Russia and Ukraine: validity, competing risks and cohort effects.

BACKGROUND: The dramatic increase in mortality in Russia and Ukraine in the late 1980s and 1990s has been due to increases in certain causes of death, particularly cardiovascular disease and accidents and violence. In contrast, there has been a slight fall in mortality from cancer. METHODS: This paper presents an analysis of trends and patterns in cancer mortality and examines four possible explanations for its recent fall: changes in data collection; cohort effects; competing mortality from other causes of death; and improvements in health care. RESULTS: All contribute to some extent to the observed changes, with each affecting predominantly different age groups. There is evidence of a significant underrecording of cancer deaths among the elderly especially in rural areas and of significant changes in coding practices in the early 1990s. Competing mortality from cardiovascular diseases and accidents can explain some reduction in male deaths from cancer in middle age. Birth cohort effects can explain some reduction among males after early middle age and among females at all ages. The impact of changes in health care are more difficult to identify with certainty but there is evidence of reduced deaths from childhood leukaemia. IMPLICATIONS: Recent changes in mortality in Russia are complex and their understanding will require a multidisciplinary approach embracing demography, epidemiology and health services research.

Adolescent↗

How surveys are changing at the U.S. Bureau of the Census.

"This article describes the survey activities of the U.S. Census Bureau and recent efforts by the bureau to move toward a more fully automated environment....[It] focuses on four areas in which the Census Bureau is changing its approach to surveys: (1) redesigning the questionnaire for the Current Population Survey to better reflect current labor force conditions; (2) redesigning the same questionnaire to gain advantages from computer-assisted interviewing; (3) redesigning the samples for household surveys to be used during the next decade, a task undertaken after every decennial census; and (4) progress in changing to a computer-assisted survey information collection (CASIC) system and developing a data management network for all Census Bureau surveys."

Americas↗

Flux and stability: individual fluctuations, regression towards the mean and collective changes in alcohol consumption.

AIM: First, to extend the predictions of the collectivity theory of drinking cultures to contexts of ordinary panel data, thereby integrating collective change and individual fluctuations in consumption. Secondly, to develop a technique for controlling the regression towards the mean effect, in order to estimate the pattern of individual change, net of this effect. DESIGN: The task is, first and foremost, to develop a theoretical model, guided by earlier contributions and empirical results. The applicability of the model is illustrated through re-analyses of panel data on annual intake of alcoholic beverages from the Finnish alcohol reform in 1968-69, and Norwegian panel data from 1975 to 1976. FINDINGS: The model offers a reasonable fit to the data. It is demonstrated that a previous attempt at controlling the regression effect has overlooked a methodological complication, and therefore underestimates the real change. CONCLUSION: Analysis of the Finnish data demonstrates that the large increase in average consumption was due to approximately the same percentage-wise increase in the consumption level of drinkers at all levels, when the regression effect was controlled for. Thus, in absolute terms the increase was largest among the heavier drinkers.

Alcohol Drinking↗

Surgical risk management: the value of a weekly surgical radio-pathological meeting.

BACKGROUND: Clinical risk management in surgery involves organizational practices focused on the prevention of adverse outcomes. The present study evaluates the value of a weekly clinical meeting involving surgeons, radiologists and pathologists as a model of clinical risk management within a general surgical department. METHODS: Data for all meetings conducted over a 6-month period were prospectively collected. Changes to previously reported pathology and radiology results, revisions to patient diagnosis, management and recommendations for subsequent patient care arising from the meetings were recorded. RESULTS: Data were collected for 18 meetings. One hundred and eleven patients were reviewed. Seventy-six patients had previously reported radiological investigations. Sixty-five patients had previously reported pathology specimens. Four per cent of radiology reports and 8% of pathology reports were amended at the meeting. Seven per cent of patients received a revised diagnosis. Twenty-seven per cent of patients had suggestions for changes in management. Changes to patient care arose from pathologist input in seven patients, from radiologist input in nine patients and from clinician input in 14 patients. Four patients were recommended for an alternative surgical procedure. Five patients were recommended for cancellation of a planned procedure. Adjuvant chemo/radiotherapy was considered for four patients. Referral to specialist surgeons was suggested for two patients. CONCLUSIONS: Weekly multidisciplinary clinical meetings allow early revision and refinement of patient diagnosis and management. As such, they are an effective pre-emptive incident monitoring system, facilitating regular audit and quality control as part of an overall strategy for surgical clinical risk management.

Disease Management↗

Neurotransmitters in central respiratory control.

A diverse group of processes are involved in central control of ventilation. Both fast acting neurotransmitters and slower acting neuromodulators are involved in the central respiratory drive. This review deals with fast acting neurotransmitters that are essential centrally in the ventilatory response to H(+)/CO(2) and to acute hypoxia. Data are reviewed to show that the central response to H(+)/CO(2) is primarily at sites in the medulla, the most prominent being the ventral medullary surface (VMS), and that acetylcholine is the key neurotransmitter in this process. Genetic abnormalities in the cholinergic system lead to states of hypoventilation in man and that knock out mice for genes responsible for neural crest development have none or diminished CO(2) ventilatory response. In the acute ventilatory response to hypoxia the afferent impulses from the carotid body reach the nucleus tractus solitarius (NTS) releasing glutamate which stimulates ventilation. Glutamate release also occurs in the VMS. Hypoxia is also associated with release of GABA in the mid-brain and a biphasic change in concentration of another inhibitory amino acid, taurine. Collectively changes in these amino acids can account for the ventilatory output in response to acute hypoxia. Future studies should provide more data on molecular and genetic basis of central respiratory drive and the role of neurotransmitter in this essential function.

Animals↗

Social class, drinking and alcohol-related mortality.

The main purpose of this study is to investigate the magnitude of class differences in the distribution of alcohol consumption in Sweden, and to assess whether this is compatible with the observed pattern in class-specific mortality. The emphasis is put on analyses of survey data from 1990, but we also provide an overview of earlier published data. The findings suggest that, over the past 20-30 years, there has been an equalization, or even reversal, between social strata in the average consumption of alcohol, such that the consumption level for manual laborers is now at parity with, or possibly exceeds, the level for non-manual employees. This shift may also have been accompanied by a shift in the dispersion: the 1990 survey data indicate that the consumption distribution for the manual laborers is more skewed than that for the non-manual employees, while no such tendency was detected in the early data. Calculations demonstrated that this difference in dispersion may well account for the elevated rate of alcohol-related mortality among manual laborers. The results are finally discussed as a case of deviation from the general rule of collective change in consumption.

Adolescent↗

A theory of nonvertical triplet energy transfer in terms of accurate potential energy surfaces: the transfer reaction from pi,pi* triplet donors to 1,3,5,7-cyclooctatetraene.

Triplet energy transfer (TET) from aromatic donors to 1,3,5,7-cyclooctatetraene (COT) is an extreme case of "nonvertical" behavior, where the transfer rate for low-energy donors is considerably faster than that predicted for a thermally activated (Arrhenius) process. To explain the anomalous TET of COT and other molecules, a new theoretical model based on transition state theory for nonadiabatic processes is proposed here, which makes use of the adiabatic potential energy surfaces (PES) of reactants and products, as computed from high-level quantum mechanical methods, and a nonadiabatic transfer rate constant. It is shown that the rate of transfer depends on a geometrical distortion parameter gamma=(2g(2)/kappa(1))(1/2) in which g stands for the norm of the energy gradient in the PES of the acceptor triplet state and kappa(1) is a combination of vibrational force constants of the ground-state acceptor in the gradient direction. The application of the model to existing experimental data for the triplet energy transfer reaction to COT from a series of pi,pi(*) triplet donors, provides a detailed interpretation of the parameters that determine the transfer rate constant. In addition, the model shows that the observed decrease of the acceptor electronic excitation energy is due to thermal activation of C=C bond stretchings and C-C bond torsions, which collectively change the ground-state COT bent conformation (D(2d)) toward a planar triplet state (D(8h)).

Journal Article↗

The folding energy landscape and phosphorylation: modeling the conformational switch of the NFAT regulatory domain.

An energy landscape approach predicts the conformational changes of the configurations of the regulatory domain of the protein nuclear factor of activated T cells (NFAT) caused by phosphorylation of specific multiple sites. Structurally local effects and secondary structural changes are modeled using all-atom Brownian dynamics to investigate the changes of the backbone torsional distributions upon phosphorylation. For tertiary and global changes, we employ a coarse-grained model to sample ensembles of conformations both with and without phosphorylation. At the secondary structure level, phosphorylation moderately increases the helical propensity and gives a more rigid local backbone conformation. The tertiary effects of phosphorylation caused by the extensive charge modification are more pronounced and collectively change the conformation of the regulatory domain of NFAT from a flexible globular ensemble to a rather rigid helical bundle, blocking access to the nuclear localization sequence. These studies give computational support to one scenario conjectured from experiments.

Amino Acid Sequence↗

Mechanism of acrolein-induced vascular toxicity.

Acrolein, an environmental pollutant and a lipid peroxidation product, is implicated in vascular pathogenesis. Although evidence indicates a link between vascular pathogenesis and acrolein, no direct studies relating to effects of acrolein on vascular function and responses are known. This study investigated the effects of acrolein on vascular function to understand the underlying mechanism of acrolein-induced vascular responses. Male Sprague-Dawley rats were treated with acrolein (2 or 4 mg/kg; i.p.) for 3 or 7 days. Urine and blood samples were collected. Changes in systolic blood pressure (SBP) and responses to acetylcholine and phenylephrine were determined. Acrolein (4 mg/kg, 7 days) significantly increased SBP by 25%, phenylephrine vasoconstriction by 2-fold, but decreased urinary excretion of nitrite by 25%. Acrolein inhibited generation of cyclic guanosine 3'5'-monophosphate (cGMP) by 98%, and did not alter expression of nitric oxide synthase (eNOS). Acrolein increased the generation of lipid hydroperoxide in plasma and aortic tissue by 21% and 124% respectively, increased glutathione-S-transferase (GST) and glutathione peroxidase (GSH-Px) activities. Acrolein up-regulated the expression of GST by 2 fold. These data suggest that induced SBP and altered vasoconstriction/vasodilatation in acrolein treated rats may be due to reduced availability of NO via increased free radical generation and reduced antioxidant defense.

Acrolein↗

Isolation of novel pelagic bacteria from the German bight and their seasonal contributions to surface picoplankton.

We tested new strategies for the isolation of abundant bacteria from coastal North Sea surface waters, which included reducing by several orders of magnitude the concentrations of inorganic N and P compounds in a synthetic seawater medium. Agar plates were resampled over 37 days, and slowly growing colonies were allowed to develop by repeatedly removing all newly formed colonies. A fivefold increase of colonies was observed on plates with reduced nutrient levels, and the phylogenetic composition of the culture collection changed over time, towards members of the Roseobacter lineage and other alpha-proteobacteria. Novel gamma-proteobacteria from a previously uncultured but cosmopolitan lineage (NOR5) formed colonies only after 12 days of plate incubation. A time series of German Bight surface waters (January to December 1998) was screened by fluorescence in situ hybridization (FISH) with isolate-specific and general probes. During spring and early summer, a prominent fraction of FISH-detectable bacteria (mean, 51%) were affiliated with the Cytophaga-Flavobacterium group (CF) of the Bacteroidetes. One Cytophaga sp. lineage with cultured representatives formed almost 20% of the CF group. Members of the Roseobacter cluster constituted approximately 50% of alpha-proteobacteria, but none of the Roseobacter-related isolates formed populations of >1% in the environment. Thus, the readily culturable members of this clade are probably not representative of Roseobacter species that are common in the water column. In contrast, members of NOR5 were found at high abundances (>10(5) cells ml(-1)) in the summer plankton. Some abundant pelagic bacteria are apparently able to form colonies on solid media, but appropriate isolation techniques for different species need to be developed.

Animals↗

Finding time, stopping the frenzy.

While the deleterious consequences of long hours of work for individuals, families and communities have previously been documented, the assumption that long hours are necessary to get the work done, especially in a world where speed is becoming increasingly critical to corporate success, has prompted little challenge. So Leslie Perlow, an assistant professor of business at the University of Michigan, Ann Arbor, set out to explore the necessity for the seemingly endless workdays that so many postindustrial settings require. Her study of a group of software engineers at a Fortune 500 company--identified only as the Ditto Corp--is detailed in her book, Finding Time: How Corporations, Individuals, and Families Can Benefit from New Work Practices (Cornell University Press, 1997). Perlow's research reveals a "sad and all too common tale" of workers harried by competing demands, frequent interruptions and shifting deadlines. To meet the firm's expectations, the engineers she studied sacrificed home life, focused on individual tasks to the detriment of group goals and, in many cases, eventually lost any enthusiasm they'd had for working for the company. There has been some recognition that stress and burnout may be bad for a corporation as employees become less committed, decide to leave or get fired and that this kind of turnover can hurt the firm in the longer term. But Perlow documented the additional, and quite significant, shorter-term costs to the corporation of the current way of using time at work. What she found was a "vicious time cycle:" Time pressures led to a crisis mentality, which led to "individual heroics." That is, I'll do whatever it takes to do my job--even if it means interrupting you while you try to do yours. For the engineers Perlow studied, the lack of helping, the constant interruptions and the perpetual crises--clearly illustrated by the daily log that appears on page 34--made it harder to develop products. Ultimately, they worked long hours to complete tasks they'd been too busy to do earlier because of the constant interruptions. Worse, because everyone was busy responding to crises, no one had time to prevent future crises, thus perpetuating the cycle. But as dire as the situation sometimes seemed, change was possible. The "quiet time" phase of the author's nine-month study indicated that productivity could be enhanced by structuring work time to allow the engineers intervals to work alone, uninterrupted. After this first phase, about two out of three of the 17 people involved said their productivity during quiet time was above average. Nearly as many said overall productivity was above average as well. This implies that the costs of the current way of using time exceed the benefits. The data further show that change must be collective, addressing all elements of the vicious cycle. The promising implication is that collective change could benefit everyone--corporations, individuals and families. The work process could be made more efficient and effective. At the same time, individuals could succeed at work and still have time for responsibilities outside of work; people might not have to choose so definitively between their work and their home lives. To make the necessary changes, however, will require a shift from a system that rewards individuals heroics and long hours to one that rewards individuals' contributions to their teams--without the accompanying emphasis on visible work hours. That is, there must be a shift in emphasis from individual to collective achievement. And there must be a sharing of the resulting gains in efficiency between employees and employers. In the following excerpt from her book, Perlow describes what is needed to turn a vicious time cycle into a "virtuous" one:

Burnout, Professional↗