bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effects of Caffeine Consumption on Direct and Indirect Majority and Minority Influence
Authors: Martin Pearl Y. , Martin Robin
Published: September 2010

A study is reported that examines the effect of caffeine consumption on majority and minority influence. In a double blind procedure, 72 participants consumed an orange drink, which either contained caffeine (3.5mg per kilogram of body weight) or did not (placebo). After a 40‐minute delay, participants read a counter‐attitudinal message (antivoluntary euthanasia) endorsed by either a numerical majority or minority. Both direct (message issue, i.e., voluntary euthanasia) and indirect (message issue‐related, i.e., abortion) change was assessed by attitude scales completed before and after exposure to the message. In the placebo condition, the findings replicated the predictions of Moscovici's (1980) conversion theory; namely, majorities leading to compliance (direct influence) and minorities leading to conversion (indirect influence). When participants had consumed caffeine, majorities not only led to more direct influence than in the placebo condition but also to indirect influence. Minorities, by contrast, had no impact on either level of influence. The results suggest that moderate levels of caffeine increase systematic processing of the message but the consequences of this vary for each source. When the source is a majority there was increased indirect influence while for a minority there was decreased indirect influence. The results show the need to understand how contextual factors can affect social influence processes.
The Miyake Island Volcano Disaster in Japan: Loss, Uncertainty, and Relocation as Predictors of PTSD and Depression
Authors: Goto Toyomi , Wilson John P. , Kahana Boaz , Slane Steve
Published: September 2010

This study investigates the relationship between psychological well‐being and the impact of loss and psychological uncertainty after the 2000 Miyake Island volcanic eruption. 231 Japanese evacuees (ages 20‐93, average 59.52 years old) responded to mailed questionnaires 10 months after the volcanic eruption in 2000. The questionnaire included the Impact of Event Scale‐Revised (IES‐R) for posttraumatic stress disorder, an 11‐item version of the Center for Epidemiological Study‐Depression Scale (CES‐D), assessment of disaster losses, demographics, and measure of relevant pre‐ and post‐disaster activities (e.g., relocation, worry, doctor visits). Findings indicated that material loss and uncertainty of losses were significantly associated with higher rates of reported PTSD and depression symptoms. Those who relocated multiple times reported significantly higher rates of PTSD symptoms than those who relocated less frequently. Demographic characteristics such as being older, widowed, lower SES, less education, and longer length of residency on the island were also strongly associated with higher reported PTSD symptoms. Depression symptoms were strongly associated with being widowed, lower SES, longer length of residency on the island, and previous experiences of evacuations due to disasters.
The oral sucker of Gyrinocheilus aymonieri (Teleostei: Cypriniformes)
Authors: Benjamin Michael
Published: September 2010

The sucker was studied in young and mature fish by light microscopy, histochemistry, transmission and scanning electron microscopy, X‐ray probe microanalysis, dissection, staining preparations of whole skeletons, and watching the animals in aquaria. The fleshy lips are supported by highly flexible, chondroid tissues, the structure and histochemistry of which differ substantially from those of cartilage. They allow the sucker to evert when the fish attaches to a stone or aquarium wall and are connected to the maxillae, premaxillae and dentaries. Lining the inside of the lips are two horny rasps, each with several regular rows of small hooks. The scraping blades of these hooks are keratinized and point towards the mouth. They increase the coefficient of friction for adhesion and enable the fish to feed on encrusting algae. Between the posterior rasp and the ‐anterior margin of the mandible are two invaginations of the lower lip that extend the sucker chamber beneath large hollows in the dentaries. The anterior margin itself contacts the outer surface of the maxillary oral valve when the mouth is closed, and isolates the sucker chamber from the rest of the buccal and pharyngeal cavities. Contrary to previous views, it is thought that a true vacuum is produced, and that attached fish spend long periods without taking water in through the mouth. The attachments of the principal jaw muscles are described and their role in sucker action discussed. There are similarities with the jaw mechanism of catostomids.
Functioning of the wings and axillary sclerites of Heteroptera during flight
Authors: Betts C. R.
Published: September 2010

A high degree of automation of the wingstroke in the Heteroptera has resulted in the simplification of the axillae and associated musculature. The functions of the indirect, asynchronous flight muscles are summarised from previous investigations and original work. Functions are suggested for the tonic muscles but await confirmation by electrophysiological research.

The deformations seen in heteropteran wings can be explained in terms of muscularly generated and aerodynamic forces. Unsteady aerodynamic benefits of such deformations, though unproven, may be of primary importance. Torsion, camber change and transverse flexion are all candidates for the generation of unsteady effects. The ‘near clap and peel’ seen at pronation has been described in other insects by Ellington (1984a), and it seems likely that it serves the same purpose in Heteroptera.

Heteroptera, like many other insects, show wing‐tip flexion. Among several possible functions, inertial stress reduction is shown to be important.
The kinematics of Heteroptera in free flight
Authors: Betts C. R.
Published: September 2010

The kinematics of six species of Heteroptera in free flight are analysed and compared.

Using nested analysis of variance techniques, statistically significant variation was detected between species for several of the flight parameters measured: mean angular velocity; pronation/supination ratio; upstroke/downstroke ratio; and wing beat frequency. In each case this is discussed in terms of variation in flight behaviour.

Beneficial aerodynamic forces are generated during the upstroke and the downstroke, in both fast forward and rising flight.

When the insects change from level, forward flight to near vertical, rising flight, the following parameters are altered in most of the sequences analysed:

the stroke plane angle becomes steeply, negatively inclined, associated with an increase in body angle;

the stroke amplitude is reduced;

wing beat frequency is lowered, associated with a drop in mean angular velocity;

the speed of stroke reversal (rotational velocity) is increased. This may be associated with increased wing torsion and tip flexion which in turn could improve any beneficial unsteady aerodynamic effects generated at stroke reversal.

The reasons for this change in flight performance and the deviations from that seen in other insects are discussed.

It is shown that Heteroptera may make use of wing drag in flight, particularly during rising flight.
The feeding habits of six pelagic and predatory teleosts in eastern Cape coastal waters (South Africa)
Authors: Smale Malcolm J.
Published: September 2010

A four‐year study of the feeding habits of six pelagic teleost species in eastern Cape coastal waters of South Africa is analysed. These predators are Lichia amia, Pomatomus sallatrix, Seriola lalandi, Atractoscion aequidens, Katsuwonus pelamis and Thunnus albacares. All species occur in inshore coastal water (< 1 ‐8 km from shore) for at least part of the year. The tunas were also sampled from the edge of the continental shelf (40–50 km from shore). The use of squid ‘beaks' and fish otoliths allowed accurate prey identification and size estimates. Variations in prey taken are attributed to differences in locality, predator species and size. Three pelagic fish species are important to all the predators: Sardinops ocettata, Etrumeus teres and Engraulis capensis. The inshore squid, Loligo reynaudi, is another major prey item. Offshore tuna samples revealed a different prey spectrum, viz. oceanic squid and saury, Scomberesox saurus, being taken frequently.
APAF‐1 is related to an undifferentiated state in the testicular germ cell tumor pathway
Authors: Behjati Reza , Kawai Koji , Inadome Yukinori , Kano Junko , Akaza Hideyuki , Noguchi Masayuki
Published: September 2010

Apoptotic protease activating factor‐1 (APAF‐1) is a key regulator gene of apoptosis, located downstream from p53. Loss of APAF‐1 expression is associated with chemorefractory malignant melanoma and neuronal cell differentiation. In order to make clear the function of APAF‐1 in the carcinogenesis of germ cell tumors, we evaluated the expression levels of APAF‐1 and several apoptosis and differentiation markers by immunohistochemistry in formalin‐fixed paraffin‐embedded samples from 43 cases of testicular germ cell tumor (TGCT) and six specimens of normal testis tissue. Expression of cleaved caspase‐3, Oct‐3/4, and Ki‐67 were also examined by immunohistochemistry to evaluate apoptotic reactivity, tumor differentiation, and proliferation activity, respectively. APAF‐1 was downregulated in two TGCT cell lines by siRNA transfection, and subsequent expression of the Ki‐67 and Oct‐3/4 genes and differentiation markers of three embryonic germ layers including keratin16 (KRT16) for ectoderm, vimentin (VIM) for mesoderm and GATA4 for endoderm were then tested. No significant relationship was found between APAF‐1 expression and apoptotic activity in TGCTs. Expression of APAF‐1, Oct‐3/4, and Ki‐67 was significantly higher in seminomas than in non‐seminomas. In TGCTs, higher APAF‐1 expression was correlated with higher proliferation (high Ki‐67) and a lower degree of differentiation (high Oct‐3/4). Interestingly, the expression of APAF‐1 gradually decreased in accordance with tumor differentiation (seminoma and embryonal carcinoma > teratoma). Downregulation of APAF‐1 in TGCT cell lines resulted in a decrease of Ki‐67 and Oct‐3/4 and an increase of VIM and KRT16 gene expression. These data show that higher expression of APAF‐1 is related to an undifferentiated state in the TGCT pathway. (Cancer Sci 2011; 102: 267–274)
Suppression of SOCS3 increases susceptibility of renal cell carcinoma to interferon‐α
Authors: Tomita Shintaro , Ishibashi Kei , Hashimoto Koichi , Sugino Takashi , Yanagida Tomohiko , Kushida Nobuhiro , Shishido Keiichi , Aikawa Ken , Sato Yuka , Suzutani Tatsuo , Yamaguchi Osamu
Published: September 2010

Interferon (IFN)‐α is one of the most commonly used agents in immunotherapy for patients with advanced stage renal cell carcinoma. However, because of the drug resistance to IFN‐α, its benefits are limited. In this study, we examined whether repression of suppressor of cytokine signaling (SOCS) proteins, which are involved in the IFN‐induced signaling pathway, can overcome the IFN resistance of renal cell carcinoma. The effect of IFN‐α on SOCS3 expression and cell proliferation was examined using IFN‐resistant 786‐O and IFN‐sensitive ACHN cell lines. The effects of SOCS3‐targeted siRNA on 786‐O xenografts were determined by SOCS3 expression, morphological observation, and tumor volume. The SOCS3 mRNA expression level was significantly increased by IFN‐α stimulation in 786‐O, but not in ACHN cells. The overexpression of SOCS3 by gene transfection in ACHN cells significantly inhibited the growth‐inhibitory effect of IFN‐α. Suppression of SOCS3 expression in 786‐O cells by siRNA activated the IFN signaling pathway through signal transducer and activator of transcription 1 phosphorylation and recovered sensitivity to IFN‐α. An in vivo study indicated that co‐administration of SOCS3‐targeted siRNA promoted IFN‐α‐induced cell death and growth suppression in 786‐O cell xenograft in nude mice. Morphological observation of the tumors revealed the inhibition of SOCS3‐induced apoptosis, invasion of inflammatory cells and fibrosis. SOCS3 could be a key component in the resistance to IFN treatment of renal cell carcinoma. Silencing SOCS3 gene expression could be an effective strategy to enhance the antitumor effect of IFN in human renal cell carcinoma cells. (Cancer Sci 2011; 102: 57–63)
Clinical trial: the efficacy of open‐label prucalopride treatment in patients with chronic constipation – follow‐up of patients from the pivotal studies
Authors: Camilleri M. , Van Outryve M. J. , Beyens G. , Kerstens R. , Robinson P. , Vandeplassche L.
Published: September 2010

Aliment Pharmacol Ther 2010; 32: 1113–1123

Background  Prucalopride is approved in Europe for symptomatic treatment of chronic constipation in women with inadequate relief from laxatives.

Aim  To evaluate efficacy of prucalopride during long‐term treatment of patients with chronic constipation.

Methods  Patients from three pivotal double‐blind, placebo‐controlled, 12‐week studies with prucalopride could continue treatment in open‐label studies up to 24 months. Efficacy was evaluated every 3 months using the Patient Assessment of Constipation‐Quality of Life (PAC‐QOL) satisfaction scale. Laxative use and reasons for study discontinuation were recorded.

Results  Eighty‐six percent of patients who completed the pivotal studies continued prucalopride treatment in the open‐label studies (n = 1455, 90% female). Improvement in average PAC‐QOL satisfaction score observed after 12‐week, double‐blind prucalopride was maintained during open‐label treatment for up to 18 months; in each 3 month period, 40–50% of patients did not use any laxatives. Most frequent adverse events (AEs) resulting in discontinuation were gastrointestinal events (3.3%) and headache (1.0%). Only 10% of patients who had normalized bowel function on prucalopride at the end of pivotal trials discontinued due to insufficient response during open‐label treatment.

Conclusion  Satisfaction with bowel function is maintained for up to 18 months of treatment with prucalopride. Gastrointestinal events and headache cause discontinuation of prucalopride treatment in ∼5% of patients (ClinicalTrials.gov identifiers: NCT01070615 and NCT00987844).
Divergent resistance to a monogenean flatworm among three‐spined stickleback populations
Authors: de Roij Job , Harris Philip D. , MacColl Andrew D. C.
Published: September 2010

1. Given their ubiquity, we might expect parasites to play an important role in the adaptive divergence of host populations. Specifically, adaptation to local parasite communities is predicted to influence the evolution of a number of host traits such as parasite resistance.

2. To investigate the possibility that divergent parasite‐mediated selection drives population‐level variation in parasite resistance, we artificially infected lab‐reared three‐spined sticklebacks with the monogenean flatwormGyrodactylus gasterostei. The fish were derived from five populations from North Uist, Scotland, that were chosen because they differed in natural infection levels ofGyrodactylus arcuatus.

3. We found substantial differences in resistance toG. gasterosteiamong populations. Resistance was defined largely by the ability to limit the size of the worm population rather than by the timing of the host response.

4. Experimental resistance was not significantly correlated with natural infection levels ofG. arcuatus. However, in general, populations with greater exposure toG. arcuatuswere shown to be more resistant toG. gasterostei. Fish from the only naturally unexposed population showed the highest susceptibility, which may be the result of less selection to maintain resistance.

5. Taken together, these results suggest that the divergent selection mediated byGyrodactylusmay play a role in driving population‐level variation in resistance to this parasite.
In vivo models for early development of colorectal liver metastasis
Authors: Robertson John H. P. , Sarkar Sandip , Yang Shi Yu , Seifalian Alexander M. , Winslet Marc C.
Published: September 2010

In Europe, colorectal cancer is the second most prevalent form of cancer diagnosed. Globally each year, almost one million cases of colorectal cancer are registered and almost half a million deaths are attributed to this disease. This high mortality is associated with the development of liver metastases. For oncological advances to occur, accurate in vivo models are required to study colorectal cancer metastasis development. These models, by increasing our understanding of the early stages of colorectal liver establishment, will facilitate the development of novel therapeutic interventions and allow the clinical effects of these interventions to be studied. By analysis of current in vivo models for early development of colorectal liver metastasis, this review examines available methods of the tumour cell preparation, introduction and monitoring in vivo. An insight into the technical problems which can occur will be discussed. The implications of these different techniques on the resulting metastasis picture will be analysed. Existing in vivo models are assessed regarding the accuracy of the metastatic picture they portray.
Turbulent blood flow plays an essential localizing role in the development of atherosclerotic lesions in experimentally induced hypercholesterolaemia in rats
Authors: Prado Cibele M. , Ramos Simone G. , Elias Jorge , Rossi Marcos A.
Published: September 2010

Taking into account that atherosclerosis is a focal disease and high levels of plasma cholesterol are closely correlated with its pathogenesis, it is a challenge to explain how equal concentrations of cholesterol bathing the endothelium can produce local, rather than global, effects on arteries. The focal distribution of atherosclerotic lesions has been considered to be dependent, at least in part, on hydrodynamic factors. The present study was carried out to further test the hypothesis that these forces are an important localizing factor in rats feeding a hypercholesterolaemic diet and submitted to infra‐diaphragmatic aortic constriction. These animals develop a normotensive prestenotic region with laminar blood flow that serves as control for a normotensive poststenotic region with turbulent blood flow. Our findings clearly demonstrated that the combination of turbulent blood flow and low wall shear stress (WSS) in the presence of hypercholesterolaemia and oxidative stress creates conditions to the formation of focally distributed incipient atherosclerotic lesions observed in the poststenotic segment. In contrast, only diffuse fatty streaks could be observed in the normotensive prestenotic segment with laminar blood flow and normal WSS in the presence of hypercholesterolaemia and oxidative stress. Although haemodynamic forces are not by themselves responsible for the pathogenesis of atherosclerosis, they prime the local vascular wall in which the lesion develop. Further studies are required to establish how haemodynamic forces are detected and transduced into chemical signalling by the cells of the artery wall and then converted into pathophysiologically relevant phenotypic changes.
Improving the organization of consultation departments in university hospitals
Authors: Dechartres Agnès , Mazeau Valérie , Grenier‐Sennelier Catherine , Brézin Antoine P. , Vidal‐Trecan Gwenaelle M.
Published: September 2010

Rationale  Changes in the demography of doctors require changes in care practices.

Objectives  The aim of this study was to identify factors associated with doctors’ workload in the ophthalmology consultation department of a university hospital, with a view to developing methods to improve the organization of hospital outpatient clinics.

Methods  A 10‐day cross‐sectional survey was carried out in an ophthalmology outpatient clinic (in‐ and outpatient consultations, including emergencies) specializing in the uveitis care. Demographic and management data for each patient were collected on a structured form. The doctor’s workload was assessed, using a scale taking into account the duration of the consultation and the number of diagnostic tests performed, as a function of management complexity.

Results  Of the 861 consultations studied, 39.7% were highly complex. The level of complexity of consultations was correlated with the type of referral (phi = 0.602), consultation duration (phi = 0.545), the number of consultations in the previous year (phi = 0.499), and the number of diagnostic tests performed (phi = 0.445). Consultations were longer and diagnostic tests were more frequently performed if patients had been referred by an ophthalmologist, consulted a faculty doctor or a fellow, or presented with uveitis. Consultations were also more complex for patients with at least four previous consultations in the past year.

Conclusions  Type of referral, status of the attending doctor and number of consultations within the course of 1 year were associated with doctors’ workload and could be taken into account to predict the duration of complexity of consultations when scheduling appointments.
Validation of the German Glasgow children’s benefit inventory
Authors: Schwentner Ilona , Schwentner Christian , Schmutzhard Joachim , Radmayr Christian , Grabher Gudrun , Sprinzl Georg , Höfer Stefan
Published: September 2010

Objective  The aim of this study was to validate the German Glasgow Children’s Benefit Inventory (GCBI) in children with different surgical interventions.

Material and methods  The GCBI was translated by using accepted forward–backward translation techniques and mailed to 741 parents whose children underwent either an otorhinolaryngological (n = 641) or an urological intervention (n = 100). The assessment was performed in a retrospective manner at the Medical University Innsbruck, Austria between January and March 2006. An exploratory principal component factor analysis with varimax rotation using factor loadings of ≥0.40 to allocate items to a scale was performed. Frequencies, means and standard deviations were used to describe patient, clinical, sociodemographic, and scale characteristics.

Results  The questionnaire was completed and returned by 325 patients (43.9%). The GCBI showed a high internal consistency (α = 0.84). The four‐factor solution, emotional, vitality, learning and physical health explained 55.7% of variance.

Conclusion  The German version of the GCBI was proven to be valid and reliable. It is suitable for subjective outcome analysis of different paediatric interventions from infants to adolescents.
Evaluating effectiveness of preoperative testing procedure: some notes on modelling strategies in multi‐centre surveys
Authors: Gregori Dario , Lusa Lara , Rosato Rosalba , Silvestri Luciano
Published: September 2010

Rationale  In technology assessment in health‐related fields the construction of a model for interpreting the economic implications of the introduction of a technology is only a part of the problem. The most important part is often the formulation of a model that can be used for selecting patients to submit to the new cost‐saving procedure or medical strategy. The model is usually complicated by the fact that data are often non‐homogeneous with respect to some uncontrolled variables and are correlated. The most typical example is the so‐called hospital effect in multi‐centre studies.

Aims and objectives  We show the implications derived by different choices in modelling strategies when evaluating the usefulness of preoperative chest radiography, an exam performed before surgery, usually with the aim to detect unsuspected abnormalities that could influence the anaesthetic management and/or surgical plan.

Method  We analyze the data from a multi‐centre study including more than 7000 patients. We use about 6000 patients to fit regression models using both a population averaged and a subject‐specific approach. We explore the limitations of these models when used for predictive purposes using a validation set of more than 1000 patients.

Results  We show the importance of taking into account the heterogeneity among observations and the correlation structure of the data and propose an approach for integrating a population‐averaged and subject specific approach into a single modeling strategy. We find that the hospital represents an important variable causing heterogeneity that influences the probability of a useful POCR.

Conclusions  We find that starting with a marginal model, evaluating the shrinkage effect and eventually move to a more detailed model for the heterogeneity is preferable. This kind of flexible approach seems to be more informative at various phases of the model‐building strategy.
The uptake of technologies designed to influence medication safety in Canadian hospitals
Authors: Saginur Michael , Graham Ian D. , Forster Alan J. , Boucher Michel , Wells George A.
Published: September 2010

Background  There are many technologies designed to improve medication safety. Although limited evidence supports their use, there are pressures to implement them.

Objective  To determine the uptake of technologies designed to improve medication safety, plans for adopting technologies, attitudes towards technology use, and perceptions of medication error.

Methods  We performed a cross‐sectional survey of pharmacy directors at Canada’s 100 largest acute‐care hospitals.

Results  Seventy‐eight per cent of surveyed hospitals responded. Responding hospitals averaged 499 beds and 29% were teaching facilities. Hospital frequently used clinical pharmacy services (97% of hospitals), pharmacy‐based intravenous admixture services (81%), computerized decision support modules for pharmacy order entry systems (77%), unit‐dose drug distribution systems (75%) and computerized medication administration records (67%). Hospitals infrequently used bar‐coding (9% of hospitals) and computerized physician order entry (9%). A majority of respondents and hospitals favoured expanded use of new technologies and planned for increased uptake. Respondents chose as their hospital’s next investment: automated dispensing (33%), bar‐coding (25%) and computerized physician order entry (12%).

Conclusion  Canadian hospitals appear poised to make sizeable investments in poorly evaluated technologies that address medication safety.
Project management can help to reduce costs and improve quality in health care services
Authors: Sa Couto Joaquim
Published: September 2010

Rationale, aims and objectives  Health care spending has increased steadily over the last 50 years, but there is a consensus that this trend cannot continue indefinitely. The ideal solution would bring about cost reductions coupled with improvements in quality, but this has remained an elusive goal. In this article, a novel idea is proposed that consists of adopting a project type of production in health care, instead of the current mass production methods used in the modern ‘health care factories’.

Methods  The author demonstrates that health care services in general, and medical services in particular, fit the category of projects. This is accomplished through a comprehensive study of the main features of projects and medical services and a comparative analysis.

Results and Conclusion  The author infers that the productivity gains brought by project management to so many other human endeavours can be brought to health care. It is also claimed that if project management is adopted in health care, then physicians would be the natural project managers because of their proficiency with the casuistic method (one‐off, non‐repetitive production) and because of their experience in ‘managing’ their patient’s cases that is indeed what doctors have been doing for as long as their profession exists.
Illness severity and total visits in family medicine
Authors: Rohrer James E. , Rasmussen Norman , Adamson Steven A.
Published: September 2010

Objective  The purpose of this study was to estimate the independent effect of clinical severity on visit utilization by family medicine patients so that disease management programmes can be targeted accurately and immediately towards patients most likely to benefit from them.

Design  A convenience sample of 698 primary care patients was analysed. All patients had been referred to a medical specialist. Utilization of all types of medical services including laboratory, radiology and ancillary services was used to classify patients as high‐utilizers (the top 20%) or not high‐utilizers. Patients were stratified into three severity categories based on point scores assigned to specific diseases. The diagnoses included in the Charlson severity index were used to score each patient and the Charlson point scores were used to measure severity. The odds of being a high‐utilizer were adjusted for severity category and demographic variables.

Results  Severity was independently related to the odds of being a high‐user (adjusted odds ratio = 2.7 for severity = 1 and 5.7 for severity = 2, with the reference category being severity = 0). Age was related to high‐use in univariate analyses but not in multivariate analyses.

Conclusions  Case management programmes in primary care practices should consider using disease severity to identify cases. Severity data can be abstracted by medical secretaries who review narrative problem lists as well as billing codes.
Patient‐based evaluations of primary care for cardiovascular diseases: a comparison between conventional and complementary medicine
Authors: Matter‐Walstra Klazien , Schoeni‐Affolter Franziska , Widmer Marcel , Busato André
Published: September 2010

Background  Patients with chronic diseases, including cardiovascular conditions, increasingly rely on complementary and alternative medical (CAM) therapies.

Objectives  The Swiss Program for Complementary Medicine Evaluation offers a unique opportunity to analyse cardiovascular patients’ satisfaction with CAM and conventional medical (COM) therapies. The treatment choices of doctors certified in conventional as well as complementary therapies also could be studied.

Methods  A national observational evaluation on treatment satisfaction of patients consulting COM or CAM doctors. Out of this evaluation project, data related to patients with cardiovascular diseases were specifically analysed for patient satisfaction with treatment and outcome when treated by COM or CAM doctors.

Results  Of 199 included doctors (78 COM, 121 CAM) treating cardiovascular patients, COM doctors treated twice as many cardiovascular patients per doctor than CAM doctors. CAM doctors treated less than 1/3 of their cardiovascular patients solely by CAM, while they treated 42% exclusively by COM therapies. Patients seeing a CAM doctor had a significantly longer consultation and were more likely to be highly satisfied with overall treatment outcome and patient‐practitioner communication. Moreover, patients seeing a CAM doctor and being treated solely by a CAM therapy more often report ‘complete fulfilment of outcome expectation’ and ‘high overall satisfaction with treatment’, although their symptoms less often disappear totally than those of COM therapy‐treated patients.

Conclusion  CAM therapies are not the first treatment choice for cardiovascular diseases. However, even though CAM doctors preferentially apply COM therapies, cardiovascular patients treated by CAM doctors are more likely to be satisfied with the overall treatment outcome, possibly because of the longer and better patient–practitioner interaction.
Our genes are not our destiny: incorporating molecular medicine into clinical practice
Authors: Genuis Stephen J.
Published: September 2010

In many developed nations, the state of publicly administered health care is increasingly precarious as a result of escalating numbers of chronically ill patients, inadequate medical personnel and hospital facilities, as well as sparse funding for ongoing upgrades to state‐of‐the‐art diagnostic and therapeutic technology – an increased emphasis on aetiology‐centred medicine should be considered in order to achieve improved health for patients and populations. Medical practice patterns which are designed to provide quick and effective amelioration of signs and symptoms are frequently not an enduring solution to many health afflictions and chronic disease states. Recent scientific discovery has rendered the drug‐oriented algorithmic paradigm commonly found in contemporary evidence‐based medicine to be a reductionist approach to clinical practice. Unfolding evidence appears to support a genetic predisposition model of health and illness rather than a fatalistic predestination construct – modifiable epigenetic and environmental factors have enormous potential to influence clinical outcomes. By understanding and applying fundamental clinical principles relating to the emerging fields of molecular medicine, nutrigenomics and human exposure assessment, doctors will be empowered to address causality of affliction when possible and achieve sustained reprieve for many suffering patients.
Optimizing the design of visual analogue scales for assessing quality of life: a semi‐qualitative study among Chinese‐speaking Singaporeans
Authors: Wee Hwee‐Lin , Fong Kok‐Yong , Tse Connie , Machin David , Cheung Yin‐Bun , Luo Nan , Thumboo Julian
Published: September 2010

Objectives  Current recommendations for visual analogue scale (VAS) design are largely derived from studies on pain assessment. We evaluated respondent preferences for VAS design for health‐related quality of life (HRQoL) assessment.

Methods  In‐depth interviews were conducted among Chinese‐speaking rheumatology outpatients and caregivers (age ≥ 21 years) to determine preferences for the following: (1) VAS orientation (horizontal/vertical); (2) length of instructions (long/intermediate/short); (3) scale range (0–10/0–100 points); (4) indicator for computerized touchscreen VAS (bar/column). Responses in subjects expressing a preference were compared using tests of proportions.

Results  Among 101 subjects, more subjects preferred a horizontal over a vertical format (48 vs. 37, P = 0.23; 16 no preference), and intermediate length over long/short instructions (44 vs. 14 vs. 31, P = 0.004; 12 no preference). A scale range of 0–10 was preferred over 0–100 (62 vs. 21, P < 0.001; 18 no preference). A bar indicator was preferred over a column for computerized touchscreen VAS (54 vs. 44, P = 0.31; 3 no preference). Only presence of chronic medical conditions influenced subject preference [odds ratio (95% confidence interval): 3.9 (1.6–9.6), P = 0.002].

Conclusion  Chinese‐speaking subjects preferred a 0–10‐point VAS with intermediate length instructions for HRQoL assessment. Thus, a 0–10‐point VAS with intermediate length instructions may be more useful for HRQoL assessment among Chinese subjects.
Validity of retrospective review of medical records as a means of identifying adverse events: comparison between medical records and accident reports
Authors: Kobayashi Mia , Ikeda Shunya , Kitazawa Naomi , Sakai Hideto
Published: September 2010

Aims  This study was undertaken to investigate whether the adverse events recorded in accident reports could be properly identified by a retrospective review of medical records.

Methods  In an acute‐care hospital, a retrospective review of 200 medical records, consisting of the medical records for the 100 cases for which accident reports were reported and an additional 100 cases extracted at random from the medical records of patients discharged in FY 2002, was conducted. The retrospective review of the medical records consisted of two stages. In the first stage, the medical records were screened by a nurse leader (Review A) and by a group of nurses trained by the nurse leader (Review B). In the second stage, a doctor review team determined the presence of adverse events.

Results  Of the 61 accident reports that satisfied at least one of the 18 criteria to screen potential adverse events, 28 were ultimately judged to be adverse events in this study. Of these 28 events, Review A identified 25 (89.3%) and Review B identified 24 (85.7%). One adverse event was overlooked during Review A, and two events were overlooked during Review B. The two adverse events not identified by either Review A or Review B were not adequately described in the medical records.

Conclusions  Some adverse events could not be identified by retrospective reviews of medical records, partly because of inadequate descriptions. However, when adequate information was available, adverse events could be identified with a very high degree of accuracy.
Implications of rigid adherence to a protocol of investigation for patients undergoing thyroidectomy
Authors: Hardy Robert , Moss Andrew , Lee David
Published: September 2010

Rationale, aims and objectives  Protocols may improve patient care by standardizing investigations performed. In pre‐operative surgical patients this should ensure all patients undergo essential investigations while limiting unnecessary tests. Previous studies have shown poor protocol adherence within 6 weeks of implementation unless strictly enforced. With this in mind, we analysed clinical and financial implications of rigid adherence to a protocol of pre‐operative investigation for patients undergoing thyroidectomy in a single centre.

Methods  A protocol for investigation of patients undergoing thyroidectomy was introduced, with investigations being performed at the surgical out patient clinic. Where already performed by the referring doctor, they were not to be repeated. Protocol adherence was measured over a 6‐month period and strictly enforced to try to ensure 100% compliance.

Results  35 consecutive patients underwent thyroidectomy over the study period. Compliance with the protocol was obtained for between 86% and 100% of tests required by the protocol. In addition, numerous tests specified by the protocol were performed more than once, and additional tests outside the protocol were done, with an average excess cost per patient of £121.38.

Conclusions  A protocol for pre‐operative investigation of a common surgical procedure can be achieved. Rigid enforcement of the protocol can lead to over‐investigation because of concerns about test omission, with associated financial implications. Furthermore, a rigid protocol does not always prevent performance of unnecessary investigations.
Models based on value and probability in health improve shared decision making
Authors: Ortendahl Monica
Published: September 2010

Rationale, aims and objectives  Diagnostic reasoning and treatment decisions are a key competence of doctors. A model based on values and probability provides a conceptual framework for clinical judgments and decisions, and also facilitates the integration of clinical and biomedical knowledge into a diagnostic decision.

Method  Both value and probability are usually estimated values in clinical decision making. Therefore, model assumptions and parameter estimates should be continually assessed against data, and models should be revised accordingly. Introducing parameter estimates for both value and probability, which usually pertain in clinical work, gives the model labelled subjective expected utility. Estimated values and probabilities are involved sequentially for every step in the decision‐making process.

Results  Introducing decision‐analytic modelling gives a more complete picture of variables that influence the decisions carried out by the doctor and the patient.

Conclusion  A model revised for perceived values and probabilities by both the doctor and the patient could be used as a tool for engaging in a mutual and shared decision‐making process in clinical work.
Evidence‐based medicine and limits to the literature search
Authors: Nunn Robin
Published: September 2010

Rationale, aims and objectives  Searching the literature, a core requirement of evidence‐based medicine has been impossibly oversold. The literature search is supposed to provide evidence independent from expert opinion, which has been deemed to be low on the evidence hierarchy. Yet freedom from expertise is not free. Paradoxically, practitioners are told to search the literature to avoid authority, but because there is too much information and too little time, they are urged to rely on authoritative digests. But the chain of errors inherent in searching literature for decision making, whether in scoping the decision, finding relevant documents, or in the document content, cannot be ignored. This article explores those errors.

Method  With examples from signal theory and decision theory, the literature search is analyzed in light of fundamental limits in the nature of informaiton. You can run from expertise but you cannot hide. Expertise is inevitably required to deal with these errors. So do‐it‐yourself searching is inadequate in the absence of expertise. The best decisions result from collaboration with subject matter experts and decision‐making experts.
Relationships between statistical measures of agreement: sensitivity, specificity and kappa
Authors: Feuerman Martin , Miller Allen R.
Published: September 2010

Objectives  Cohen's kappa coefficient is presently a standard tool for the analysis of agreement on a binary outcome between two tests. In view of the ubiquity of the use of sensitivity, specificity, raw agreement and kappa in clinical studies, clearly it is advantageous to have a useful analytic relation connecting these measures of agreement.

Methods  We elaborate on previous work, comment on other results appearing in the literature and discuss analytic formulas relevant to various problems connecting specificity, sensitivity and kappa.

Results  For selected values of kappa that range from good to excellent, a graph of the curves representing minimal pairs of sensitivity and specificity is provided.

Conclusions  The analytic formulas and graph could be potentially useful to clinicians and biostatisticians in better interpreting the outcomes of an alternative diagnostic test whenever the measures sensitivity, specificity and kappa are employed together.
Bayesian clinical reasoning: does intuitive estimation of likelihood ratios on an ordinal scale outperform estimation of sensitivities and specificities?
Authors: Moreira Juan , Bisoffi Zeno , Narváez Alberto , Van den Ende Jef
Published: September 2010

Rationale:  Bedside use of Bayes' theorem for estimating probabilities of diseases is cumbersome. An alternative approach based on five categories of powers of tests from ‘useless’ to ‘very strong’ has been proposed. The performance of clinicians using it was assessed.

Methods  Fifty clinicians attending a course of tropical medicine estimated powers of tests and post‐test probabilities using the classical vs. the categorical Bayesian approach. The estimation of post‐test probability was assessed for real and dummy diseases in order to avoid the bias of previous knowledge. Accuracy of answers was measured by the difference with reference values obtained from an expert system (Kabisa).

Results  Clinicians estimated positive likelihood ratios (LRs) a median of −1.07 log10 lower than Kabisa [interquartile range (IQR): −1.47; −0.80] when derived classically and −0.17 (IQR: −0.42; +0.04) when estimated categorically (P < 0.001). For negative LRs the median was +0.39 log10 higher (IQR: +0.71; +0.08) when derived classically and −0.18 log10 lower (IQR: +0.03; −0.36) when estimated categorically (P < 0.001).

Twenty (40%) disclosed not being able to calculate post‐test probabilities using sensitivities and specificities. Regardless the approach post‐test probabilities were overestimated both for real and dummy diseases [respectively +1.23 log10 (IQR: +0,67; +2.08) and +2.03 log10 (IQR: +0.49; +2.42)] (P = 0277), but the range was wider for the latter (P = 0.001).

Conclusions  Participants were more accurate in estimating powers with a categorical approach than with sensitivities and specificities. Post‐test probabilities were overestimated with both approaches. Knowledge of the disease did not influence the estimation of post‐test probabilities. A categorical approach might be an interesting instructional tool, but the effect of training with this approach needs assessment.
Knowing – in Medicine
Authors: Sturmberg Joachim P. , Martin Carmel M.
Published: September 2010

In this paper we argue that knowledge in health care is a multidimensional dynamic construct, in contrast to the prevailing idea of knowledge being an objective state. Polanyi demonstrated that knowledge is personal, that knowledge is discovered, and that knowledge has explicit and tacit dimensions.

Complex adaptive systems science views knowledge simultaneously as a thing and a flow, constructed as well as in constant flux. The Cynefin framework is one model to help our understanding of knowledge as a personal construct achieved through sense making. Specific knowledge aspects temporarily reside in either one of four domains – the known, knowable, complex or chaotic, but new knowledge can only be created by challenging the known by moving it in and looping it through the other domains.

Medical knowledge is simultaneously explicit and implicit with certain aspects already well known and easily transferable, and others that are not yet fully known and must still be learned. At the same time certain knowledge aspects are predominantly concerned with content, whereas others deal with context.

Though in clinical care we may operate predominately in one knowledge domain, we also will operate some of the time in the others. Medical knowledge is inherently uncertain, and we require a context‐driven flexible approach to knowledge discovery and application, in clinical practice as well as in health service planning.
Protocol‐based care: impact on roles and service delivery*
Authors: Rycroft‐Malone Jo , Fontenla Marina , Bick Debra , Seers Kate
Published: September 2010

Objective  To evaluate the impact of protocol‐based care on nursing roles, practice and service delivery.

Design  Case study evaluation informed by realistic evaluation methodology. Qualitative data collection methods were used including non‐participant observation, post‐observation interviews with nurses and patients, key informant interviews, tracking patient journeys and document review.

Participants  141 participants took part including 73 nurses, midwives and health visitors, 4 allied health professionals, 20 doctors, 5 support staff and 39 patients.

Settings  Five sites were purposively sampled and included acute and primary care service provision.

Findings  As a mechanism for standardization, the use of protocol‐based care approaches such as guidelines, care pathways, protocols and algorithms was patchy and dependent on contextual, professional and individual factors. Protocol‐based care approaches were commonly used as checklists and for reference; nurses and doctors expressed concern that such use could lead to a ‘tick box mentality’ and restricted judgement. By using standardized care approaches nurses were taking on new tasks and developing skills beyond the traditional scope of practice including prescribing, diagnosing, ordering tests and sometimes deciding on treatments. The ability to perform these roles meant that they were able to run clinics or services independently. The extension of roles to incorporate prescribing, for example, meant that nurses were able to provide a more streamlined service for patients because they did not have to refer to doctors. In turn, it was reported that this reduced doctors' workload. Protocol‐based care was viewed as a ‘nurses' thing’; however, some General Practitioners and junior doctors were using available standardized care approaches.

Conclusions  The potential of standardization was mediated by the patchy use of protocol‐based care approaches and negative perceptions about standardization. Use of protocol‐based care has the potential to impact on nurses' roles, increasing their autonomy and subsequently impacting on service delivery.