Lauriston S. Taylor Lecture: The evolution of radiation protection--from erythema to genetic risks to risks of cancer to...?

Radiation Protection has evolved and will continue to evolve as new information becomes available, as the result of changes in public perception and concern and, perhaps in the future, as a result of enormous expenditures on reducing small risks. In the early part of the last century it was a sense of real danger among medical Practitioners that prompted the first set of exposure limiting suggestions. Addressing medical concerns continued to be the basis of guidance until after the Second World War. An array of new sources and applications led to new approaches, which modified many of the technical issues but didn't result in substantial changes in the dose limits. Fallout from the first generation of thermonuclear weapons in the 1950's resulted in focusing attention on genetic effects, which continued until the middle 1970's. Data from the Japanese Survivor Studies provided the information for risk based recommendations beginning in 1977 and continue to do so today. Both the ICRP and the NCRP are heavily criticized by both those groups of individuals which believe the risk estimates are underestimated and by those which believe the risks are greatly overestimated. Perhaps both organizations can take some comfort in Saint Thomas Aquinas' suggestion, "In medio virtus."     

Strengthen Quality Management of Case to Give Full Play to Its Value

This article elaborates the viewpoint that how to strengthen quality management of case to give full play to its value, the points that the author urged are in following aspects, including raising quality consciousness of case writing, upgrading the writing quality of case, paying attention to the value of case and ensuring the quality of case. 1. Training doctor‘s “basic skill”. 2. Training system of doctor, a.In the first month after check - in, arrange two lectures about writing of case to unify the requirement and inform them how to write it. b. Give them the writing standard of anamnesis, which they can refer to when writing. 3. The system that the directors spot - check the anamnesis. The American qaulity administrative power, world- famous Doctor Milan prophesied that “21 century is century of quality”, having entered 21 century, facts also further proved the facticity of this prophesy. The new era in which the quality is supreme, quality directly influences whether the case can fully play its value.     

Is patient length of stay related to quality of care?

In this article, we investigate the relationship between hospital length-of-stay (LOS) and quality of care. We use hospital claims records from Medicare beneficiaries in Michigan to estimate condition-specific models for predicting patients' LOSs. With these models and a data set provided by Michigan Peer Review Organization, Inc. (MPRO), each patient's risk-adjusted LOS is then linked to a quality-of-care judgment (good care, poor care) from physician peer reviewers. LOS is a widely used indicator of hospital performance. Most commonly, it is viewed as an indicator of hospital efficiency and as a surrogate measure for costs, with hospitals having long average LOSs considered relatively inefficient in the use of resources and those with low LOSs considered to be efficient. Sometimes, however, LOS is assumed to relate to quality. For example, if hospitals were to respond to the financial incentives of prospective payment by attempting to lower costs by prematurely discharging patients, LOSs significantly lower than expected might be considered indicative of poor quality care. On the other hand, if poor quality of care causes complications, it would tend to extend LOSs. Under this assumption, longer than expected LOSs could be viewed as indicative of poor quality care. This article shows that in every one of the 13 clinical conditions examined, cases that received poor quality care had significantly longer risk-adjusted LOSs than cases whose care was of acceptable quality.     

Comparison of different strategies of referral to a fall clinic: How to achieve an optimal casemix?

Objective  

To study the potential differences in patient characteristics between two referral methods to a fall clinic, specifically: case-finding of patients admitted to an emergency department because of a fall, compared to direct referral to the fall clinic via the general practitioner.     

Power to the people? An international review of the democratizing effects of direct elections to healthcare organizations

Ensuring that publicly funded health systems are democratically accountable is an enduring challenge in policy and practice. One strategy for enhancing public officials' accountability is to elect members of the public to oversee their performance. Several countries have experimented with direct elections to healthcare organizations. The most directly comparable examples involve some Canadian regional health authorities, New Zealand district health boards, foundation trusts in England and health boards in Scotland. We propose three aspects of the process by which the democratizing effects of elections should be judged: authorization, accountability and influence. Evidence from these countries suggests that the democratization of health systems is a complex task, which cannot be completed simply by introducing elections. Copyright © 2015 John Wiley & Sons, Ltd.     

Development of a scale to measure individuals’ ratings of peace

Background

The evolving concept of peace-building and the interplay between peace and health is examined in many venues, including at the World Health Assembly. However, without a metric to determine effectiveness of intervention programs all efforts are prone to subjective assessment. This paper develops a psychometric index that lays the foundation for measuring community peace stemming from intervention programs.

Methods

After developing a working definition of ‘peace’ and delineating a Peace Evaluation Across Cultures and Environments (PEACE) scale with seven constructs comprised of 71 items, a beta version of the index was pilot-tested. Two hundred and fifty subjects in three sites in the U.S. were studied using a five-point Likert scale to evaluate the psychometric functioning of the PEACE scale. Known groups validation was performed using the SOS-10. In addition, test-retest reliability was performed on 20 subjects.

Results

The preliminary data demonstrated that the scale has acceptable psychometric properties for measuring an individual’s level of peacefulness. The study also provides reliability and validity data for the scale. The data demonstrated internal consistency, correlation between data and psychological well-being, and test-retest reliability.

Conclusions

The PEACE scale may serve as a novel assessment tool in the health sector and be valuable in monitoring and evaluating the peace-building impact of health initiatives in conflict-affected regions.

     

Does assessment of signs and symptoms add to the predictive value of an algorithm to rule out pregnancy?

BACKGROUND: A World Health Organization-endorsed algorithm, widely published in international guidance documents and distributed in the form of a 'pregnancy checklist', has become a popular tool for ruling out pregnancy among family planning clients in developing countries. The algorithm consists of six criteria excluding pregnancy, all conditional upon a seventh 'master criterion' relating to signs or symptoms of pregnancy. Few data exist on the specificity to pregnancy among family planning clients of long-accepted signs and symptoms of pregnancy. The aim of the present study was to assess whether reported signs and symptoms of pregnancy add to the predictive value of an algorithm to rule out pregnancy. METHODS: Data from a previous observational study were used to assess the performance of the algorithm with and without the 'signs and symptoms' criterion. The study group comprised 1852 new, non-menstruating family planning clients from seven clinics in Kenya. RESULTS: Signs and symptoms of pregnancy were rare (1.5%) as was pregnancy (1%). Signs and symptoms were more common (18.2%) among the 22 clients who tested positive for pregnancy than among the 1830 clients (1.3%) who tested negative, but did not add significantly to the predictive value of the algorithm. Most women with signs or symptoms were not pregnant and would have been unnecessarily denied a contraceptive method using the current criteria. CONCLUSIONS: The 'signs and symptoms' criterion did not substantially improve the ability of the algorithm to exclude pregnant clients, but several reasons (including use of the algorithm for intrauterine device clients) render it unlikely that the algorithm will be changed.     

The Physiological Response of Animals to β-Nitronaphthalene

The effect of lead exposure on blood pressure in the modern industrial setting is controversial. In this study, we followed 67 workers in a lead-battery plant for 6–10 y, and blood pressure and blood lead levels were measured every 6 mo. Weight, height, alcohol intake, cigarette smoking, and age were recorded. Partial correlation coefficients showed that initial systolic blood pressure, age, and body mass index (i.e., weight/height squared) accounted for 25%, 30.9%, and 20.2%, respectively, of the variance in systolic blood pressure (p < .001 in all cases). Conversely, average blood lead levels (13 ± 3 tests/worker) accounted for only 0.4% of the variance (not significant). Repeated-measures analysis of variance showed a small—but significant—association between blood lead levels and systolic blood pressure. There was a negative correlation between blood lead levels and diastolic blood pressure. There were 18 men with average blood lead levels that were less than 30 μg/dl (average = 25 ± 3 μg/dl), and 32 men had levels of 40 μg/dl or more (average = 47 ± 6 μg/dl). The mean final systolic blood pressure, adjusted for age, and initial systolic blood pressure were 117 ± 13 mm Hg and 114 ± 11 mm Hg, respectively. We concluded that blood lead levels had no clinically significant effect on blood pressure in lead-battery workers. The main predictors of the follow-up systolic blood pressure were age, body mass index, and initial systolic blood-pressure measurements.     

Back to work? Gendered experiences of rehabilitation

Gendered experiences of rehabilitation were studied in a strategic sample of young people with work-related disorders. Thematic interviews were conducted with seven women and four men, and analysed from a gender perspective using grounded theory. In comparison with women, men were more likely to receive specific diagnoses, to demand actions, and to strive for full-time waged work. Women experienced more often than men that doctors distrusted them, and that social insurance officers made decisions for them. The outcome of rehabilitation was better for men, whether they adapted to the offered measures or not. Gendered structures in the rehabilitation system, the construction of gender in the meeting between the client and the doctor/social security officer, as well as the division of domestic duties within marriage, strongly influenced the outcome of the rehabilitation process in favour of men.     

High tolerance of lampreys to Kepone® toxicity

Larval sea lampreys (Petromyzon marinus) were exposed to the organochlorine insecticide Kepone^® in freshwater solution in a continuous flow diluter system at 12 and 20°C. At 12°, the 36-hr LC50, 96-hr LC50, and incipient lethal concentrations were 1,100, 444 and 145 g Kepone/ L, respectively, while at 20°, the 96-hr LC50 was 414 g/L. These are the highest LC50 values for Kepone ever reported for a fish species. Rates at which larval lampreys accumulate and clear Kepone were measured at 12°C. The depuration rate constant (K_d: 0.13–0.46 per day) was the highest ever reported in a fish species, so rapid elimination may contribute to the exceptional ability of lampreys to survive acute Kepone poisoning. The uptake rate constant (K_u) was 450–650 per day, and the bioconcentration factor averaged about 1900. The most likely source of high tolerance of lampreys to Kepone is an ability to withstand high tissue levels: Lampreys survived body burdens of 500–600 g Kepone/g, exceeding all other known vertebrates. Technical difficulties associated with the use of Kepone solutions are discussed, such as precipitation and loss from solution through apparent volatilization.     

What to add to nothing? Use and avoidance of continuity corrections in meta‐analysis of sparse data

OBJECTIVES: To compare the performance of different meta-analysis methods for pooling odds ratios when applied to sparse event data with emphasis on the use of continuity corrections. BACKGROUND: Meta-analysis of side effects from RCTs or risk factors for rare diseases in epidemiological studies frequently requires the synthesis of data with sparse event rates. Combining such data can be problematic when zero events exist in one or both arms of a study as continuity corrections are often needed, but, these can influence results and conclusions. METHODS: A simulation study was undertaken comparing several meta-analysis methods for combining odds ratios (using various classical and Bayesian methods of estimation) on sparse event data. Where required, the routine use of a constant and two alternative continuity corrections; one based on a function of the reciprocal of the opposite group arm size; and the other an empirical estimate of the pooled effect size from the remaining studies in the meta-analysis, were also compared. A number of meta-analysis scenarios were simulated and replicated 1000 times, varying the ratio of the study arm sizes. RESULTS: Mantel-Haenszel summary estimates using the alternative continuity correction factors gave the least biased results for all group size imbalances. Logistic regression was virtually unbiased for all scenarios and gave good coverage properties. The Peto method provided unbiased results for balanced treatment groups but bias increased with the ratio of the study arm sizes. The Bayesian fixed effect model provided good coverage for all group size imbalances. The two alternative continuity corrections outperformed the constant correction factor in nearly all situations. The inverse variance method performed consistently badly, irrespective of the continuity correction used. CONCLUSIONS: Many routinely used summary methods provide widely ranging estimates when applied to sparse data with high imbalance between the size of the studies' arms. A sensitivity analysis using several methods and continuity correction factors is advocated for routine practice.     

What Do the Theories of Egon Brunswik Have to Say to Medical Education?

Every day physicians make judgments about patient management and diagnosis based on less than perfect information from many different sources. Judgment and decision-making research has taught us a great deal about such decisions, but these insights rarely find their way into the medical curriculum. One productive line of investigation in the study of judgment and decision making has followed the insights and theories developed by the psychologist, Egon Brunswik. His theories are becoming increasingly relevant to modern judgment problems. In this paper, I outline Brunswik’s theories, trace their development over the last 50 years and speculate on what role they should play in medical education.     

Time to include time to death? The future of health care expenditure predictions

Government projections of future health care expenditures--a great concern given the aging baby-boom generation--are based on econometric regressions that control explicitly for age but do not control for end-of-life expenditures. Because expenditures increase dramatically on average at the end of life, predictions of future cost distributions based on regressions that omit time to death as an explanatory variable will be biased upward (or, more explicitly, the coefficients on age will be biased upward) if technology or other social factors continue to prolong life. Although health care expenditure predictions for a current sample will not be biased, predictions for future cohorts with greater longevity will be biased upwards, and the magnitude of the bias will increase as the expected longevity increases. We explore the empirical implications of incorporating time to death in longitudinal models of health expenditures for the purpose of predicting future expenditures. Predictions from a simple model that excludes time to death and uses current life tables are 9% higher than from an expanded model controlling for time to death. The bias increases to 15% when using projected life tables for 2020. The predicted differences between the models are sufficient to justify reassessment of the value of inclusion of time to death in models for predicting health care expenditures.