从甲基苯丙胺的杂质分布图推断合成信息

目的通过杂质分布图,分析甲基苯丙胺(MA,俗称"冰毒")的合成路线,为公安机关打击毒品犯罪提供技术支持。方法将甲基苯丙胺样品溶于磷酸盐缓冲液,用乙酸乙酯萃取(含有4个内标,C10、C15、C20和C28),对萃取液进行GC-MS分析。结果对北京市公安局2006～2007年间缴获的8批样品进行分析,结果表明其中6批是以麻黄碱或伪麻黄碱为原料合成的,采用技术路线为碘酸/红磷方法。结论麻黄碱或伪麻黄碱是目前合成甲基苯丙胺的主要原料。     

Rapid Needs Appraisal in the modern NHS: potential and dilemmas

This paper reports on our experience of undertaking a Rapid Appraisal of Health and Social Needs (RNA) in West Cumbria, UK. RNA aims to identify community-defined problems and to collect intelligence for action rather than simply for documentation. The broad nature of the study is summarised and we reflect critically on methodological and structural issues that arose. A number of inter-related themes were significant: the limitations of a ‘rapid’ approach; within an action frame, the implications that arose from focusing on locality capacity-building; the ability that commissioning organisations had in this public health domain; and the way in which such organisations tend to construct ‘needs’. These themes then are located in problematic contexts. Primarily, we were working with a fledgling NHS organisation, arguably set unrealistically high expectations to deliver innovative public health functions. Furthermore, the desire to see the NHS working more efficiently resulted in the expectation that the exercise should be done in a particular way—within a realist tradition of arriving at quick, simple and ‘definitive’ needs. We conclude by suggesting that if such work is to be meaningful then there needs to be a number of pre-cursors: an initial consensus on the nature of ‘need’; an agreement between commissioners and researchers around common frameworks and realistic expectations of the process; and finally, an acceptance of the importance of history in this work and the way histories of local inter-agency work reflect embedded forms of local knowledge. We suggest that NHS volatility means that much of this knowledge is often lost.     

Whom Should We Profile? Examining Diabetes Care Practice Variation among Primary Care Providers,Provider Groups,and Health Care Facilities

OBJECTIVE: To evaluate the amount of variation in diabetes practice patterns at the primary care provider (PCP), provider group, and facility level, and to examine the reliability of diabetes care profiles constructed using electronic databases. DATA SOURCES/STUDY SETTING: Clinical and administrative data obtained from the electronic information systems at all facilities in a Department of Veterans Affairs' (VA) integrated service network for a study period of October 1997 through September 1998. STUDY DESIGN: This is a cohort study. The key variables of interest are different types of diabetes quality indicators, including measures of technical process, intermediate outcomes, and resource use. DATA COLLECTION/EXTRACTION METHODS: A coordinated registry of patients with diabetes was constructed by integrating laboratory, pharmacy, utilization, and primary care provider data extracted from the local clinical information system used at all VA medical centers. The study sample consisted of 12,110 patients with diabetes, 258 PCPs, 42 provider groups, and 13 facilities. PRINCIPAL FINDINGS: There were large differences in the amount of practice variation across levels of care and for different types of diabetes care indicators. The greatest amount of variance tended to be attributable to the facility level. For process measures, such as whether a hemoglobin A1c was measured, the facility and PCP effects were generally comparable. However, for three resource use measures the facility effect was at least six times the size of the PCP effect, and for inter-mediate outcome indicators, such as hyperlipidemia, facility effects ranged from two to sixty times the size of the PCP level effect. A somewhat larger PCP effect was found (5 percent of the variation) when we examined a "linked" process-outcome measure linking hyperlipidemia and treatment with statins). When the PCP effect is small (i.e., 2 percent), a panel of two hundred diabetes patients is needed to construct profiles with 80 percent reliability. CONCLUSIONS: little of the variation in many currently measured diabetes care practices is attributable to PCPs and, unless panel sizes are large, PCP profiling will be inaccurate. If profiling is to improve quality, it may be best to focus on examining facility-level performance variations and on developing indicators that promote specific, high-priority clinical actions.     

Case-mix adjusting performance measures in a veteran population: pharmacy- and diagnosis-based approaches

OBJECTIVE: To compare the rankings for health care utilization performance measures at the facility level in a Veterans Health Administration (VHA) health care delivery network using pharmacy- and diagnosis-based case-mix adjustment measures. DATA SOURCES/STUDY SETTING: The study included veterans who used inpatient or outpatient services in Veterans Integrated Service Network (VISN) 20 during fiscal year 1998 (October 1997 to September 1998; N = 126,076). Utilization and pharmacy data were extracted from VHA national databases and the VISN 20 data warehouse. STUDY DESIGN: We estimated concurrent regression models using pharmacy or diagnosis information in the base year (FY1998) to predict health service utilization in the same year. Utilization measures included bed days of care for inpatient care and provider visits for outpatient care. PRINCIPAL FINDINGS: Rankings of predicted utilization measures across facilities vary by case-mix adjustment measure. There is greater consistency within the diagnosis-based models than between the diagnosis- and pharmacy-based models. The eight facilities were ranked differently by the diagnosis- and pharmacy-based models. CONCLUSIONS: Choice of case-mix adjustment measure affects rankings of facilities on performance measures, raising concerns about the validity of profiling practices. Differences in rankings may reflect differences in comparability of data capture across facilities between pharmacy and diagnosis data sources, and unstable estimates due to small numbers of patients in a facility.     

代谢组学在临床营养研究中的应用

随着后基因组时代的到来，生物医学领域的研究策略发生了巨大改变，新的技术可以分析大量的基因产物，这使得人们有可能全面了解生物体系内的分子调节机制。代谢组学的研究目的是定性和定量分析器官及生物样品中特定状态下所有低分子量代谢产物及外源性复合物对人体所有代谢产物的影响。体液或组织的代谢谱可以作为重要的生理或病理状态的生物标志物。在饮食或营养干预下机体的代谢变化可用代谢组学的技术进行全面分析。这种技术的应用将会对健康提供更个体化的信息。本文主要对代谢组学在临床营养研究中的应用及进展加以综述。     

S-生物丙烯菊酯处理人淋巴细胞基因表达谱的变化

目的运用基因芯片技术研究S-生物丙烯菊酯对正常人淋巴细胞基因表达谱的变化。方法取3名正常人外周血淋巴细胞,加入S-生物丙烯菊酯刺激后提取总RNA,合成cRNA并分别用Cy3和Cy5标记,与AgilentHum an1B寡核苷酸基因芯片杂交,研究基因表达谱变化。结果正常淋巴细胞在S-生物丙烯菊酯刺激后共有346个基因表达发生变化,其中16个免疫和防御相关基因表达下调。结论S-生物丙烯菊酯可导致正常淋巴细胞基因表达谱改变,某些免疫和防御相关基因表达下调。     

Change in the Healthiness of Foods Sold in an Australian Supermarket Chain Following Implementation of a Shelf Tag Intervention Based on the Health Star Rating System

Introduction: Most people in Australia buy most of their food in supermarkets. Marketing techniques promoting healthy foods in supermarkets can be important to encourage healthy eating at a population level. Shelf tags that highlight the healthiness of products have been identified as one such promising initiative. The aim of this study was to assess changes in the healthiness of foods sold in an Australian supermarket chain following implementation of a shelf tag intervention based on the Australian Health Star Rating (HSR) system. Methods: A controlled, non-randomised trial was undertaken in seven supermarkets (intervention: n = 3; control: n = 4) of a single chain in Victoria, Australia, over 12 weeks (4 weeks baseline, 8 weeks intervention period) between August and November 2015. The intervention involved provision of a shelf tag indicating the HSR of all packaged products that scored 4.5 or 5 stars (‘high-HSR products’) using the Australian HSR system. Posters indicating the healthiness of fresh fruits and vegetables (not eligible for an HSR rating, as they are not packaged) were also installed. Weekly per store sales data were provided by the retailer. In an intention-to-treat analysis (with intervention status of individual products based on their eligibility to be tagged), the proportion (%) of all ‘high-HSR’ packaged food sold and the volume of key nutrients (saturated fat, total fat, sodium, total sugar, protein, carbohydrates and energy) per 100 g sold were assessed. Difference-in-difference analyses were conducted to determine the difference between intervention and control stores in terms of mean outcomes between baseline and intervention periods. Customer exit surveys (n = 304) were conducted to evaluate awareness and use of the shelf tags and posters. Results: The proportion of ‘high-HSR products’ sold increased in the intervention period compared to the baseline period in each of the three intervention stores (average increase of 0.49%, 95% CI: −0.02, 0.99), compared to a decrease of −0.15% (−0.46, 0.15) in control stores (p = 0.034). The overall increase in intervention compared to control stores (difference-in-difference) of 0.64% represents an 8.2% increase in the sales of ‘high-HSR products’. Sales of total sugar, total fat, saturated fat, carbohydrates, sodium, protein and total energy in packaged food all decreased significantly more in intervention stores compared to control stores. Sales of fresh fruits and vegetables decreased in intervention stores compared to control stores. Customer surveys found that 34.4% noticed the shelf tags. Of those who noticed the tags, 58% believed the shelf tags influenced their purchases. Conclusions: With this study, we found that the use of shelf tags that highlight the healthiest packaged foods in a supermarket setting showed promise as a mechanism to improve the healthiness of purchases. Opportunities to scale up the intervention warrant exploration, with further research needed to assess the potential impact of the intervention on overall population diets over the longer term.     

Should Episode‐Based Economic Profiles Be Risk Adjusted to Account for Differences in Patients' Health Risks?

OBJECTIVE: To determine whether additional risk adjustment is necessary in economic profiling of physicians when claims data are already grouped into episodes of care, and to measure effects of risk adjustment on cost efficiency rankings of physicians. DATA SOURCES: Four years of inpatient, outpatient, professional, and pharmacy claims data from a mixed model HMO. STUDY DESIGN: Claims data were processed through Symmetry Health Data Systems' episode treatment group (ETG) grouper to define episodes of care and Symmetry's episode risk group (ERG) software to define measures of patients' health risk scores. For each episode type (ETG), ETG-mean expected costs were calculated as the mean costs of all episodes of that type, and risk-adjusted expected costs were calculated using three alternative risk model formulations. DATA COLLECTION: Within specialties, physicians were ranked from most cost efficient to least cost efficient, based on standardized difference between actual and expected costs. ETG-mean based rankings were compared with risk-adjusted rankings. Analyses were performed for cardiologists, family practitioners, general surgeons, and neurologists. PRINCIPAL FINDINGS: With all three risk models, risk scores were essentially unrelated to episode costs in approximately three-fourths of episode categories (ETGs). In a sample of ETGs for which risks-costs relationships appeared to exist, split sample validation showed the relationships to be unstable or spurious in all except one ETG. Within specialties, risk-adjusted cost efficiency rankings differ little from ETG-mean adjusted rankings. CONCLUSIONS: Depending upon the purpose for which economic profiling is performed, additional risk adjustment, beyond that already provided by episode grouping, may be unnecessary. Additional research may be needed to identify and validate ETG-level relationships between patient risks and episode costs.     

Correction to “Constructs of Burden of Illness in Older Patients with Breast Cancer: A Comparison of Measurement Methods”

OBJECTIVE: Many performance measurement systems are designed to identify differences in the quality provided by health plans or facilities. However, we know little about whether different methods of performance measurement provide similar answers about the quality of care of health care organizations. To examine this question, we used three different measurement approaches to assess quality of care delivered in veteran affairs (VA) facilities. DATA SOURCES/STUDY SETTING: Medical records for 621 patients at 26 facilities in two VA regions. STUDY DESIGN: We examined agreements in quality conclusions using: focused explicit (38 measures for six conditions/prevention), global explicit (372 measures for 26 conditions/prevention), and structured implicit review physician-rated care (a single global rating of care for three chronic conditions and overall acute, chronic and preventive care). Trained nurse abstractors and physicians reviewed all medical records. Correlations between scores from the three systems were adjusted for measurement error in each using multilevel regression models. RESULTS: Intercorrelations of scores were generally moderate to high across all three systems, and rose with adjustment for measurement error. Site-level correlations for prevention and diabetes care were particularly high. For example, adjusted for measurement error at the site level, prevention quality was correlated at 0.89 between the implicit and global systems, 0.67 between implicit and focused, and 0.73 between global and focused systems. CONCLUSIONS: We found moderate to high agreement in quality scores across the three profiling systems for most clinical areas, indicating that all three were measuring a similar construct called "quality." Adjusting for measurement error substantially enhanced our ability to identify this underlying construct.     

Personalised nutrition: What makes you so special?

Personalised nutrition can be defined as developing unique nutrition guidelines for each individual; precision nutrition seeks to develop effective approaches based on the combination of an individual's genetic, environmental and lifestyle factors. The former infers variants that underlie traits are largely fixed (i.e. stable across time) and appeals to the notion that we are inherently different from one another. The latter opens up the possibility that what we do and where we are may be more important than what we are. While there are undoubtedly a specific minority of individuals who clearly require a more personalised approach to nutrition, several criteria must be fulfilled before we can justify or implement personalised nutrition for the general population. These would include identifying a desired health outcome and a valid predictor of how that outcome changes, which can be measured with sufficient accuracy and exhibit a robust correlation and/or causal relationship in the required direction (i.e. predictor‐response). Many attempts to personalise nutrition, such as profiling the genome or microbiome, do not currently meet all these criteria. Therefore, we argue that there is presently insufficient rationale for truly personalised nutrition for the majority of people based on the inter‐individual differences that separate them. Conversely, we propose that precision nutrition based on the environmental and/or behavioural ‘lifestyle’ variance within each person may provide a more effective basis for adjusting diet dynamically, with recognition of varying physiological demands and requirements over time.     

Gene expression profiling toward the next generation safety control of influenza vaccines and adjuvants in Japan

Influenza becomes epidemic worldwide every year, and many individuals receive vaccination annually. Quality control relating to safety and potency of influenza vaccines is important to maintain public confidence. The safety of influenza vaccines has been assessed by clinical trials, and animal safety tests are performed to monitor the consistent quality between vaccines used for clinical trials and marketing; the biological responses in vaccinated animals are evaluated, including changes in body weight and white blood cell count. Animal safety tests have been contributing to the quality relating to the safety of influenza vaccines for decades, but improvements are needed. Although precise mechanisms involving biological changes in animal safety tests have not been fully elucidated, the application of cDNA microarray technology make it possible to reliably identify genes related to biological responses in vaccinated animals. From analysis of the expression profile of >10,000 genes of lung in animals treated with an inactivated whole virion influenza vaccine, we identified 17 marker genes whose expression patterns correlated well to changes in body weight and leukocyte count in vaccinated animals. In influenza HA vaccine-treated animals exhibiting subtle changes in biological responses, a robust expression pattern of marker genes was found. Furthermore, these marker genes could also be used in the evaluation of adjuvanted influenza vaccines. The expression profile of marker genes is expected to be an alternative indicator for safety control of various influenza vaccines conferring high sensitivity and short turnaround time. Thus, gene expression profiling may be a powerful tool for safety control of vaccines in the future.     

Understanding the metabolome – challenges for metabolomics

Metabolomics is a comprehensive method for metabolite assessment, measuring the overall metabolic signature of biological samples. This approach opens up many possibilities in areas such as new biomarker discovery and hypothesis generation. The application of metabolomics is growing rapidly but many challenges must first be addressed before it can reach its true potential. Metabolomics organisations are currently working towards guidelines for commonality in metabolomics experiments as development of optimal methodologies and study designs are needed. Blood and urine appear to be the most useful biofluids for nutrition research, but an array of biofluids, cells and tissues can be used. The key steps required for the successful understanding of metabolomics data are compound identification and biological interpretation. Many databases of compounds are available but are still under construction with much information remaining to be populated. An understanding of the effects of normal physiological variation on metabolic profiles is essential for accurate interpretation of profile changes, particularly in human studies, because of diversity in lifestyle and environmental factors. The effects of factors such as ethnicity, gender, age, body composition, health, dietary intake, physical activity, gut microflora and stress need to be further explored in order to advance the understanding of the human metabolome and therefore improve data interpretation.     

Potential impact of the Choices Programme on nutrient intakes in the Dutch population

In May 2006, the Choices Programme was launched in The Netherlands – products can qualify for a health stamp by meeting pre‐set nutritional criteria. Currently, more than 120 partners in food manufacturing, retail and catering have joined the initiative. There is an increasing recognition and appreciation of the health stamp by consumers. Moreover, the initiative has given a clear incentive to participating companies to reformulate products to give them a healthier profile. The objective of the present study is to assess the potential effect on nutrient intakes in the Dutch population after replacing normally consumed foods in diets with foods that are eligible to carry a Choices stamp. Usual nutrient intakes were calculated using deterministic modelling with the Monte Carlo risk assessment model. Inputs for the modelling were food intakes (Dutch Food Consumption Survey 2003) and composition of foods from the Dutch food composition database. For a selection of nutrients, three scenarios were calculated and compared: (1) nutrient intakes ‘as measured’, based on the original Dutch Food Consumption Survey data; (2) replacement of all non‐complying foods, where possible, with a food complying with the Choices criteria; and, because this could lead to a decreased energy intake, (3) same as (2) but nutrient intakes corrected for the difference in energy content between the original and the replacement food. Calculations of usual intake distributions showed that energy intakes were reduced by 15% by replacing normally consumed foods with foods carrying the Choices stamp. Intakes of nutrients with a maximal intake limit were also reduced (between ?23% for sodium and ?63% for trans fatty acids). Intakes of nutrients with a minimal intake limit increased (between +5% for folic acid and +28% for fibre), except for carbohydrate (?16%) and unsaturated fatty acids (polyunsaturated fatty acids ?1% and monounsaturated fatty acids ?28%). When the data were corrected for energy intake, the difference was still apparent, but smaller for the nutrients with maximal intake limits and larger for most of the nutrients with minimal intake limits, except for carbohydrate and unsaturated fatty acids. From the results, it can be concluded, based on data from the Dutch Food Consumption Survey 2003, that replacing normally consumed foods in the diet with foods that carry the Choices health stamp can potentially lead to substantial improvements in nutrient intakes. These results demonstrate the potential positive impact of the Choices Programme on nutrient intakes in the Dutch population.     

A Fit-for-Purpose Nutrient Profiling Model to Underpin Food and Nutrition Policies in South Africa

South Africa (SA) is facing a rising prevalence of obesity and diet-related chronic diseases. The government is seeking to develop effective, evidence-based policy measures to address this. A well-designed, fit-for-purpose nutrient profiling model (NPM) can aid policy development. The aim of this study was to develop a fit-for-purpose NPM in SA. Steps included: (1) determining the purpose and target population; (2) selecting appropriate nutrients and other food components to include; (3) selecting a suitable NPM type, criteria and base; and (4) selecting appropriate numbers and thresholds. As part of the evaluation, the nutritional composition of packaged foods containing nutritional information (n = 6747) in the SA food supply chain was analyzed, a literature review was undertaken and various NPMs were evaluated. Our findings indicated that it is most appropriate to adapt an NPM and underpin regulation with a restrictive NPM that limits unhealthy food components. The Chile 2019 NPM was identified as suitable to adapt, and total sugar, saturated fat, sodium and non-sugar sweetener were identified as appropriate to restrict. This NPM has the potential to underpin restrictive policies, such as front-of-package labelling and child-directed marketing regulations in SA. These policies will support the fight against obesity and NCDs in the country.     

MALDI-TOF MS Characterisation of the Serum Proteomic Profile in Insulin-Resistant Normal-Weight Individuals

Insulin resistance (IR) is one of the most common metabolic disorders worldwide and is involved in the development of diseases, such as diabetes and cardiovascular diseases, affecting civilisations. The possibility of understanding the molecular mechanism and searching for new biomarkers useful in assessing IR can be achieved through modern research techniques such as proteomics. This study assessed the protein–peptide profile among normal-weight patients with IR to understand the mechanisms and to define new risk biomarkers. The research involved 21 IR and 43 healthy, normal-weight individuals, aged 19–65. Serum proteomic patterns were obtained using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry. The proposed methodology identified six proteins differentiating normal weight IR and insulin sensitive individuals. They were fibrinogen alpha chain, serum albumin, kininogen-1, complement C3, serotransferrin, and Ig gamma-1 chain, which could potentially be related to inflammation. However, further investigation is required to confirm their correlation with IR.     

苯作业工人淋巴细胞p53相关基因mRNA表达水平分析

目的 了解苯环境作业工人外周血淋巴细胞中,经p53介导的DNA损伤修复路径相关基因表达水平.方法 选择某喷涂厂直接接苯工人46人(直接接苯组)、间接接苯工人26人(间接接苯组)和无苯及其他毒物接触工人29人(对照组),应用SYBR GreenI嵌合荧光法实时RT-PCR分析技术,检测外周血淋巴细胞p53及相关基因mRNA表达水平,比较对照组与作业组问P53及相关基因mRNA表达倍数差异.结果 直接接苯组和间接接苯组p53、Ku80、Ape1和Mdm-2 mRNA表达水平与对照组比较磋异无统计学意义(P＞0.05);p21有增高趋势,但差异无统计学意义(P＞0.05).直接接苯组的Rad51、Bcl-2、Bax、Xpa和Xpc mRNA表达水平下调、间接接苯组Rad51 mRNA表达下调,与对照组比较,差异有统计学意义(P＜0.05或P＜0.01).直接接苯组的白细胞、血红蛋白和血小板分别为(4.93±1.27)×10- /L、(123.97+11.80)g/L和(124.02±41.22)×109 /L,间接接苯组血小板为(135.80±39.44)×109 /L,均低于对照组,差异均有统计学意义(P＜0.05或P＜0.01).结论 长期慢性的低浓度苯接触可使工人淋巴细胞中p53介导的部分DNA损伤修复相关基因mRNA表达水平发生改变,直接接苯工人的外周血白细胞、血红蛋白、血小板减低以及Bcl-2、Bax、Xpa和Xpc mRNA表达水平改变明显.     

NMR-metabolic methodology in the study of GM foods

The 1H-NMR methodology used in the study of genetically modified (GM) foods is discussed. Transgenic lettuce (Lactuca sativa cv "Luxor") over-expressing the ArabidopsisKNAT1 gene is presented as a case study. Twenty-two water-soluble metabolites (amino acids, organic acids, sugars) present in leaves of conventional and GM lettuce were monitored by NMR and quantified at two developmental stages. The NMR spectra did not reveal any difference in metabolite composition between the GM lettuce and the wild type counterpart. Statistical analyses of metabolite variables highlighted metabolism variation as a function of leaf development as well as the transgene. A main effect of the transgene was in altering sugar metabolism.     

Classification accuracy of claims‐based methods for identifying providers failing to meet performance targets

Quality assessment is critical for healthcare reform, but data sources are lacking for measurement of many important healthcare outcomes. With over 49 million people covered by Medicare as of 2010, Medicare claims data offer a potentially valuable source that could be used in targeted health care quality improvement efforts. However, little is known about the operating characteristics of provider profiling methods using claims‐based outcome measures that may estimate provider performance with error. Motivated by the example of screening mammography performance, we compared approaches to identifying providers failing to meet guideline targets using Medicare claims data. We used data from the Breast Cancer Surveillance Consortium and linked Medicare claims to compare claims‐based and clinical estimates of cancer detection rate. We then demonstrated the performance of claim‐based estimates across a broad range of operating characteristics using simulation studies. We found that identification of poor performing providers was extremely sensitive to algorithm specificity, with no approach identifying more than 65% of poor performing providers when claims‐based measures had specificity of 0.995 or less. We conclude that claims have the potential to contribute important information on healthcare outcomes to quality improvement efforts. However, to achieve this potential, development of highly accurate claims‐based outcome measures should remain a priority. Copyright © 2014 John Wiley & Sons, Ltd.     

Patients' preferences for technical versus interpersonal quality when selecting a primary care physician

OBJECTIVE: To assess patients' use of and preferences for information about technical and interpersonal quality when using simulated, computerized health care report cards to select a primary care provider (PCP). DATA SOURCES/STUDY SETTING: Primary data collected from 304 adult consumers living in Los Angeles County in January and February 2003. STUDY DESIGN/DATA COLLECTION: We constructed computerized report cards for seven pairs of hypothetical individual PCPs (two internal validity check pairs included). Participants selected the physician that they preferred. A questionnaire collected demographic information and assessed participant attitudes towards different sources of report card information. The relationship between patient characteristics and number of times the participant selected the physician who excelled in technical quality are estimated using an ordered logit model. PRINCIPAL FINDINGS: Ninety percent of the sample selected the dominant physician for both validity checks, indicating a level of attention to task comparable with prior studies. When presented with pairs of physicians who varied in technical and interpersonal quality, two-thirds of the sample (95 percent CI: 62, 72 percent) chose the physician who was higher in technical quality at least three out of five times (one-sample binomial test of proportion). Age, gender, and ethnicity were not significant predictors of choosing the physician who was higher in technical quality. CONCLUSIONS: These participants showed a strong preference for physicians of high technical quality when forced to make tradeoffs, but a substantial proportion of the sample preferred physicians of high interpersonal quality. Individual physician report cards should contain ample information in both domains to be most useful to patients.