What is important in evaluating health care quality? An international comparison of user views

Background  

Quality of care from the perspective of users is increasingly used in evaluating health care performance. Going beyond satisfaction studies, quality of care from the users' perspective is conceptualised in two dimensions: the importance users attach to aspects of care and their actual experience with these aspects. It is well established that health care systems differ in performance. The question in this article is whether there are also differences in what people in different health care systems view as important aspects of health care quality. The aim is to describe and explain international differences in the importance that health care users attach to different aspects of health care.     

Intermittent-mode CT fluoroscopy-guided biopsy of the lung or upper abdomen with breath-hold monitoring and feedback: system development and feasibility

A bellows-based breath-hold monitoring and feedback system was developed and evaluated for use in intermittent-mode computed tomographic (CT) fluoroscopy-guided biopsy procedures in the lung or upper abdomen. The bellows system is described, and its feasibility is demonstrated in studies with a respiratory phantom and human volunteers. Results are reported for seven patients who underwent bellows-assisted biopsy. Breath-hold monitoring and feedback with the bellows system allow the patient to perform reliable breath holding at a preselected level. This optimizes intermittent-mode CT fluoroscopy-guided biopsies by allowing consistent visualization of the target lesion throughout the procedure.     

Age-related differences in the sensitivity of the fish immune response to a coplanar PCB

Polychlorinated biphenyls (PCBs) are widespread environmental pollutants. Because of their persistence and bioaccumulation in aquatic organisms (among other factors), the biological impact of PCB exposure on resident fish populations is of particular concern. To assess the effect(s) of an environmentally relevant coplanar PCB congener on the fish immune response, juvenile and aged Japanese medaka (Oryzias latipes) were injected i.p. with either vehicle or PCB 126 (at 0.01 or 1.0 µg/g BW) and examined after 3 and 14 days. CYP1A protein levels, examined as an indicator of PCB exposure, were significantly increased (compared to controls) in all fish treated with the highest PCB dose. Kidney phagocyte superoxide (O₂ ^·–) production was examined to indicate effects upon innate immune function. After 14 days, unstimulated O₂ ^·– production by kidney phagocytes from juvenile and aged medaka treated with the highest PCB dose was significantly increased compared to controls. Stimulated O₂ ^·– production by aged PCB-treated fish was unaffected (compared to controls) at both post-exposure timepoints. However, phagocytes from PCB-treated juvenile medaka demonstrated reduced O₂ ^·– production at 3 days post-exposure and increased levels after 14 days (compared to controls). These results demonstrate the sensitivity of medaka phagocyte function for examining PCB-induced immunotoxicity.     

Cognitive and motor development of children with and without congenital adrenal hyperplasia after early-prenatal dexamethasone

Dexamethasone (DEX) administration to the pregnant woman has become the treatment of choice for the prevention of genital masculinization in female fetuses affected with congenital adrenal hyperplasia (CAH). Although no somatic teratological side effects have been found to date, recent animal research has shown adverse effects of glucocorticoids on brain structures such as the hippocampus, raising concerns about possible functional side effects of DEX on human development. The current survey of 487 children, 1 month to 12 yr of age, focused on cognitive and motor development. The mothers of 174 prenatally DEX-exposed children (including 48 with CAH) and 313 unexposed children (including 195 with CAH) completed four standardized developmental questionnaires about their children. None of the comparisons of prenatally DEX-exposed children and unexposed controls was significant. Among the DEX-exposed children, increased duration of DEX exposure was correlated with significantly fewer developmental delays on three variables of one of the questionnaires, but none of the correlations reached significance, when Bonferroni corrections for multiple correlations were used. With the methods used, we were unable to document any adverse effects of early-prenatal DEX treatment in the doses recommended for the treatment of pregnancies at risk for CAH on motor and cognitive development.     

Genetic variants in SOD2, MPO, and NQO1, and risk of ovarian cancer

OBJECTIVE: One way in which parity and use of oral contraceptives may protect against ovarian cancer is by preventing inflammation and oxidative stress associated with ovulation. Since the genes superoxide dismutase (SOD2), myeloperoxidase (MPO), and NAD(P)H:quinone oxidoreductase 1 (NQO1) are involved in inflammation and oxidative stress, we investigated whether variants of these genes are associated with risk of ovarian cancer. METHODS: In a hospital-based case-control study, we compared 125 cases and 193 controls with respect to prevalence of (1) the T-->C (val-->ala) substitution at the -9 position in the signal sequence of SOD2; (2) the G-->A substitution at the -463 position in the promoter region of MPO; and (3) the C-->T (pro-->ser) change in exon 6 of NQO1. Genotyping was done using PCR and gel electrophoresis for MPO and NQO1 and using MALDI-TOF mass spectrometry for SOD2. RESULTS: For SOD2, women with the TC (val/ala) or CC (ala/ala) genotypes were at increased risk [odds ratio (OR) 2.1, 95% confidence interval (CI) 1.1-4.0]. Results for MPO and NQO1 were in the hypothesized directions but were not statistically significant. For MPO, there was a small inverse association among women with GA or AA genotypes (OR = 0.72, 95% CI 0.43-1.2). For NQO1, the TT (ser/ser) genotype was associated with somewhat increased risk (OR = 2.3, 95% CI 0.69-7.6). CONCLUSIONS: While these results need to be confirmed in other studies, they point to a possible role for genes involved in oxidative stress in the development of ovarian cancer.     

Perineal body length and lacerations at delivery

OBJECTIVE: To define normal perineal body length during labor and determine if a shortened perineal body is associated with perineal lacerations or operative vaginal delivery. STUDY DESIGN: We reviewed charts of patients admitted for labor over a 4-month period. The perineal body was measured by the admitting physician and delivery outcomes obtained from inpatient records. Patients were excluded for malpresentation, multiple gestation, gestational age < 36 weeks, incomplete records and scheduled cesarean delivery. To determine if differences existed between patients with perineal body measurements available and those without, chi2 analysis was used, with P<.05 considered significant. Multiple logistic regression was used to control for confounding variables and determine if a shortened perineal body affected the incidence of operative vaginal delivery and significant lacerations at vaginal delivery. RESULTS: A total of 234 patients met our inclusion criteria; perineal body measurements were available for 133 (57%). The average perineal body length was 3.90 cm (+/-0.70). Patients with a perineal body of < or = 2.5 cm had a significantly higher chance of sustaining a third- or fourth-degree laceration (40% vs. 5.6%, P=.004). This risk remained after controlling for both operative vaginal delivery and episiotomy. The incidence of operative vaginal delivery was greater (28.5% vs. 9.2%, P =.006) for patients with a perineal body < or = 3.5 cm. CONCLUSION: There is an increased risk of significant lacerations and operative vaginal delivery in patients with a shortened perineal body.     

Laparoscopic exposure in obese high-risk patients with mechanical displacement of the abdominal wall

BACKGROUND: Patients with morbid obesity or pulmonary disease are at a higher risk for complications during advanced laparoscopic procedures. Higher intraperitoneal carbon dioxide pressures required to elevate the pannus can negatively impact hemodynamic and respiratory parameters. CASES: We describe a technique that uses a combination of a mechanical retractor and a Foley catheter inserted midway between the umbilicus and the pubic symphysis that assists in elevating the anterior abdominal wall. In 3 cases this technique allowed for a low-pressure pneumoperitoneum during advanced laparoscopic pelvic surgery, which resulted in improved hemodynamic parameters and pulmonary function in these high-risk patients. CONCLUSION: The Foley Lap-Lift facilitated laparoscopy through mechanical abdominal wall elevation and allowed for a lower-pressure pneumoperitoneum. This technique is an addition to traditional operative laparoscopy in select high-risk patients.     

Factors that influence the completion of breast reconstruction

Post mastectomy breast reconstruction continues to evolve in both timing and technique; however, multiple surgical procedures are usually required. The purpose of this report was to determine the number of secondary procedures required to complete the breast reconstruction and factors that influence this process. All patients who underwent breast reconstruction at Emory University Hospital between 1975 and 2000 were reviewed. The end point and inclusion criterion was completion to nipple reconstruction. Secondary procedures were determined per patient for either unilateral or bilateral reconstructions, and defined as any surgical manipulation of the reconstructed breast, contralateral breast, or donor site. The cohort was stratified by timing and method of reconstruction. Additional variables included risk factors, radiation therapy, and complications. A total of 888 patients completed the reconstructive process (738 unilateral and 150 bilateral). The average number of secondary procedures was 3.99 for unilateral, and 5.54 for bilateral. Delayed reconstructions had a higher number of secondary procedures in both groups. Transverse rectus abdominus musculocutaneous flap reconstruction tended to have more secondary procedures than implant or latissimus dorsi with or without implant reconstructions. Radiation therapy increased the number of secondary procedures in unilateral (3.9 versus 4.6, P < 0.001) and in bilateral reconstructions (5.7 versus 6.4, P = 0.032). The number of secondary procedures also increased exponentially with the number of risk factors (0-4), and patients with any complication had a higher number of secondary procedures for unilateral (4.5 versus 3.6, P < 0.001) and bilateral reconstructions (6.4 versus 4.5, P < 0.001). Secondary breast and donor site procedures were used as an outcome measure to formulate comparisons. Autologous tissue reconstruction required more secondary procedures, likely in part to donor site revisions. Delayed reconstruction, the need for radiation therapy, any complication, and more risk factors significantly increased the number of secondary procedures required to complete the reconstructive process.