Effect of different questionnaire formats on reporting of occupational exposures

During an exposure monitoring study, 78 saw maintenance tradesmen were randomly assigned to be interviewed about their exposures using one of two questionnaire formats: open-ended and partly prompted questions about five categories of materials; and detailed prompting about 75 agents. The more open-ended questionnaire elicited fewer exposure responses overall, but more responses about agents not included on the detailed questionnaire. Composite materials and trade name products were more frequently cited as exposures than individual metals or compounds. Validity of responses was ascertained using air measurements (individual metals) or observations of the employees (composite materials). Sums of sensitivities and specificities were very low (near 1.0) for most of the metals for both types of questionnaire. For composite materials, validity improved substantially. Sensitivities with the partly prompted format (0.44–0.85) were always lower than with detailed prompting (0.80–1.00). Specificities were usually, but not always, higher with partial prompting (0.66–0.92) than with detailed prompting (0.18–0.86). Selection of questionnaire format for an epidemiologic study would depend on the likely prevalence of exposure in controls and the effects of trade-offs in sensitivity and specificity.     

Development of quality of care indicators for Parkinson's disease.

Parkinson's disease (PD) is a major cause of disability. To date, there have been no large-scale efforts to measure the quality of PD care because of a lack of quality indicators for conducting an explicit review of PD care processes. We present a set of quality indicators for PD care. Based on a structured review of the medical literature, 79 potential indicators were drafted. Through a two-round modified Delphi process, an expert panel of seven movement disorders specialists rated each indicator on criteria of validity, feasibility, impact on outcomes, room for improvement, and overall utility. Seventy-one quality indicators met validity and feasibility thresholds. Applying thresholds for impact on outcomes, room for improvement, and overall utility, a subset of 29 indicators was identified, spanning dopaminergic therapy, assessment of functional status, assessment and treatment of depression, coordination of care, and medication use. Multivariable analysis showed that overall utility ratings were driven by validity and impact on outcomes (P < 0.01). An expert panel can reach consensus on a set of highly rated quality indicators for PD care, which can be used to assess quality of PD care and guide the design of quality improvement projects.     

Inter-rater reliability of the International Cooperative Ataxia Rating Scale (ICARS).

We assessed the inter-rater reliability of the 100-point International Cooperative Ataxia Rating Scale (ICARS). Three neurologists independently rated videotaped ICARS examinations of 22 subjects with genetically determined ataxias (spinocerebellar ataxia [SCA] Type 1 in 11; SCA Type 2 in 1; Friedreich's ataxia in 10) and 4 controls. Scores on live ICARS assessment had ranged from 0 to 7 for controls and 11 to 74 for ataxic subjects (clinically very mildly affected to wheelchair-bound). Inter-rater correlation was very high for the total score (Kendall's omega 0.994, 95% confidence interval, 0.988-0.997), and high to very high for each component subscore (0.791 for speech to 0.994 for posture/gait). All correlations were significant at P < 0.00001. The ICARS exhibits very high inter-rater reliability even without prior observer standardisation and is sensitive to a range of ataxia severities from very mild to severe.     

A Bayesian approach to aid in formulary decision making: incorporating institution-specific cost-effectiveness data with clinical trial results.

Pharmacy and therapeutics committees commonly cite a lack of generalizability as a reason for not incorporating cost-effectiveness information into decision making. To address this concern, many committees undertake site-specific economic evaluations, which are often limited by small sample sizes and nonrandomized designs. We show how 2 complementary approaches were used to minimize these limitations in an economic evaluation of abciximab at 1 institution. Using a propensity score methodology, we selected patients who did not receive abciximab for the comparison cohort. Then, we adopted a Bayesian, hierarchical, random-effects model to integrate site-specific and clinical trial data. We applied the posterior distributions of effectiveness with local cost data in a traditional decision-analytic model. In 74% of the simulations, abciximab was cost-effective at 1 institution at the $50,000 per life year saved threshold, assuming a 50:50 split of patients undergoing coronary stenting and angioplasty. Among patients undergoing coronary stenting, the cost-effectiveness ratio of the addition of abciximab was at or below the $50,000 per life year saved threshold in 66.0% of the simulations.     

Lack of effect of a single dose of hydrocortisone on serotonin(1A) receptors in recovered depressed patients measured by positron emission tomography with [11C]WAY-100635.

BACKGROUND: Elevated cortisol levels might account for the reduction in central serotonin 1A (5-hydroxytryptamine [5-HT](1A)) receptor binding and function observed in patients with major depression. We tested this hypothesis by studying the effect of acute administration of hydrocortisone on 5-HT(1A) receptor binding potential (BP) in subjects recovered from depression. METHODS: We studied 14 subjects (8 male, 6 female) who had recovered from at least two episodes of major depression and had been euthymic and drug free for at least 6 months. Serotonin 1A receptor BP was measured by [(11)C]WAY-100635 in conjunction with positron emission tomography. Subjects were tested on two occasions in a double-blind, random-order, crossover design after administration of either hydrocortisone (100 mg orally) or placebo 12 hours previously. Positron emission tomography scans were analyzed with a region of interest analysis. RESULTS: Hydrocortisone treatment did not decrease 5-HT(1A) receptor BP either in the hippocampus, which was our a priori hypothesis, or in other cortical 5-HT(1A) regions; however, female subjects had a higher 5-HT(1A) receptor BP in certain brain areas compared with male subjects. CONCLUSIONS: These data are consistent with an earlier study in healthy volunteers and do not support the proposal that decreased 5-HT(1A) receptor BP in patients with acute major depression is a consequence of cortisol hypersecretion.     

Evaluation of variable line-shape models and prior information in automated 1H spectroscopic imaging analysis.

Analysis of in vivo short TE 1H spectra is complicated by broad baseline signal contributions and resonance line-shape distortions. Although the assumptions of ideal metabolite resonance line-shapes and slowly varying baseline signals can be used to separate these signals, the presence of broad or asymmetric line-shapes can invalidate this model. More complex line-shape models are computationally expensive or difficult to constrain, particularly for the low signal-to-noise commonly found for in vivo MR spectroscopic imaging applications. In this study, two time-domain models for fitting variable spectral line-shapes are examined, one using B-splines and another using summed sinusoids. The methods were verified using both phantom and human data, and Monte Carlo simulations were used to evaluate variations in calculated metabolite amplitudes due to interactions between the baseline and line-shape estimations. Additional studies investigated the use of prior line-shape information, obtained from either a water MRSI measurement or calculations from B(0) maps, to determine parameter starting values or optimization constraints. Both line-shape models showed the ability to fit the variety of line-shapes present in both the phantom and human MRSI data, with similar or improved accuracy over a Gaussian line-shape model; however, this improvement resulted in only minor improvement for the high-SNR phantom data and moderate improvements in regions with asymmetry for the fitted in vivo metabolite images. The use of prior line-shape information was of most benefit when applied toward setting optimization constraints but was of limited benefit when used to define initial starting values.