Impact of regionalisation of cardiac surgery in Emilia-Romagna, Italy

STUDY OBJECTIVE

Assessment of the impact of the regionalisation of cardiac surgery through the organisational form of a hub&spoke model introduced in the year 2000.

DESIGN

Case mix adjusted before (1998-1999)-after (2000-2002) comparison of: (a) in-hospital and 30 days mortality rates; (b) proportion of patients timely (within one day) referred for surgery from spoke to hub centres; (c) patients' waiting times to surgery.

SETTING

Emilia-Romagna, an Italian region with four million residents.

PATIENTS

16,512 patients aged > or =18 years and referred to cardiac surgery over the period 1998-2002.

MAIN RESULTS

Overall, taking into account differences in case mix across the whole study period, the implementation of the regionalisation policy was associated with a 22% reduction (OR: 0.79, 95%CI: 0.66 to 0.93) in in-hospital mortality rate. The corresponding figure for 30 day mortality was 18% (OR: 0.82: 95%CI: 0.69 to 0.98). The individual centres' volume of cases changed over the study period for all hospitals but two, and the biggest reduction in mortality was seen at the centre with the largest increase in caseload.

CONCLUSIONS

This study provides additional evidence on the benefit of regionalisation of cardiac surgery interventions. The system allowed each centre to reach the minimum caseload required to assure good quality of care. These findings suggest that policies aimed at increasing cooperation rather than competition among health service providers have a positive impact on quality of care. Timely referrals for surgery increased by 21% (95%CI: 1.12 to 1.31), and mean waiting times were reduced by 7.5 average days (95%CI: -10.33 to -4.71).

Development and assessment of a priority score for cataract surgery

BACKGROUND

Point-count measures of clinical priority are increasingly put forward for managing waiting lists. However, their development does not consider explicitly the appropriateness of the indications. Furthermore, an estimate of their effect in clinical practice is needed, assessing the amount of gains and losses in terms of time waited for patients with different priority scores.

METHODS

We developed appropriateness criteria for cataract surgery using the RAND method and applied them to a sample of 567 patients consecutively placed on a waiting list for cataract surgery. In addition, clinicians were asked to express the priority attributed to each patient using a 10-cm visual analogue scale, where 0 = minimal priority and 10 = maximum priority. We developed a priority score, using regression analysis to identify the set of clinical characteristics that best predicted clinicians' priority rating and to estimate their individual weight. We used a computer simulation model to compare mean waiting times with management of the waiting list using the priority score and using the "first-come, first-served" approach.

RESULTS

Overall, 332 patients (60.8%) were referred for cataract surgery for indications deemed appropriate, and their mean priority rating was 5.9 (95% confidence interval [CI] 5.7-6.1). The corresponding figures for the 201 (36.8%) uncertain indications and the 13 (2.4%) inappropriate indications were 4.5 (95% CI 4.1-4.7) and 2.6 (95% CI 1.3-3.9) respectively. The clinical characteristics included in the priority score (visual acuity in the operated eye and in the contralateral eye, visual function and ability to live or work independently) accounted for 35% of the variance in clinicians' ratings of priority. In the computer simulation model, patients with the highest priority experienced a variable reduction in mean waiting time (9% to 27%) depending to how time spent waiting was integrated into the clinical score.

INTERPRETATION

We conclude that the use of priority ratings in the management of a waiting list for cataract surgery leads to results that maintain the desirable coherence between priority and appropriateness of indication. The results also suggest that the implementation in clinical practice of priority scores may be worth the effort, given the potential reduction in waiting time for patients at high priority.

A general approach to Bayesian networks for the interpretation of evidence

Bayesian networks (BNs) are mathematically and statistically rigorous techniques for handling uncertainty. The field of forensic science has recently attributed increased attention to the many advantages of this graphical method for assisting the evaluation of scientific evidence. However, the majority of contributions that relate to this topic restrict themselves to the presentation of already "constructed" BNs, and often, only a few explanations are given as to how one obtains a specific BN structure for a given problem. Based on several examples, the present paper will therefore attempt to explain in more detail some guiding considerations that might be helpful for the elicitation of appropriate structures for BNs.

Tunisian population data on 10 Y-chromosomal loci

Alleles and haplotypes frequencies for 10 Y-chromosome STR loci (DYS19, DYS385 I/II, DYS389I, DYS389II, DYS390, DYS391, DYS392, DYS393, DYS438 and DYS439), included in the Y-Plex6 and Y-Plex5 kits were determined for a Tunisian population sample of 100 male individuals.

A neuropathological, stereo-EEG, and MRI study of subcortical band heterotopia

The authors performed an MRI, stereo-EEG, and pathology study on a woman with subcortical band heterotopia and partial epilepsy. Clinical manifestations of seizures always started when ictal discharges were present in outer and heterotopic cortices. Simultaneous activation of both cortices and presence of differentiated neurons in the white matter and the heterotopia strongly suggest that the cortices were anatomically and functionally interconnected.

Comparisons of American, Israeli, Italian and Mexican physicians and nurses on the total and factor scores of the Jefferson scale of attitudes toward physician-nurse collaborative relationships

This cross-cultural study was designed to compare the attitudes of physicians and nurses toward physician-nurse collaboration in the United States, Israel, Italy and Mexico. Total participants were 2522 physicians and nurses who completed the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration (15 Likert-type items, (Hojat et al., Evaluation and the Health Professions 22 (1999a) 208; Nursing Research 50 (2001) 123). They were compared on the total scores and four factors of the Jefferson Scale (shared education and team work, caring as opposed to curing, nurses, autonomy, physicians' dominance). Results showed inter- and intra-cultural similarities and differences among the study groups providing support for the social role theory (Hardy and Conway, Role Theory: Perspectives for Health Professionals, Appelton-Century-Crofts, New York, 1978) and the principle of least interest (Waller and Hill, The Family: A Dynamic Interpretation, Dryden, New York, 1951) in inter-professional relationships. Implications for promoting physician-nurse education and inter-professional collaboration are discussed.

A methodology for illicit heroin seizures comparison in a drug intelligence perspective using large databases

To characterise links between different illicit drugs chemical profiles, various distance or correlation measurements are available.Different comparison methods have been tested and a method based on a correlation coefficient using a square cosine function was chosen to compare heroin chemical profiles. Its functioning and graphical representation are described. An assessment of the number of false positives is calculated and lead to a negligible number.Moreover, it emerges from the studies that possible variations in impurity peak areas subject to possible degradations do not influence the C correlation value nor question the already established links. This solid, reliable and simple method appears therefore suitable for heroin samples comparison, links profiling and routine use.

Evaluation of links in heroin seizures

The evaluation of a link between two heroin seizures using a descriptive method is presented. It is based on the measure of the angles between two chromatograms assimilated to vectors, and interpreted using a continuous approach based on the likelihood ratio of Bayes' theorem. A complete evaluation model thus avoids the drawbacks of decision thresholds used until now to establish a link. Validation is obtained through tests and simulation methods.

Tunisian population data on 15 PCR-based loci

Genotype and allele frequencies distribution for 15 PCR-based loci included in the Promega PowerPlex 16 kit were determined for a Tunisian population sample of 196 unrelated individuals.

Evaluation and presentation of forensic DNA evidence in European laboratories

The first part of this article describes Bayes' theorem and its practical application to scientific evidence. Secondly, statements proposed by European DNA laboratories are presented, analysed and commented upon. Finally, the authors reiterate their proposal of adopting a likelihood ratio framework justified by the usefulness of the approach in practical context of DNA cases. Note that this framework underlines the main questions the experts have to answer at trial: to what degree does the evidence support the prosecutor's hypothesis? and to what degree does the evidence support the defence's hypothesis?

Phenotype and genotype variation in primary carnitine deficiency

PURPOSE

Primary carnitine deficiency is an autosomal recessive disorder of fatty acid oxidation resulting from defective carnitine transport. This disease is caused by mutations in the carnitine transporter gene SLC22A5. The objective of this study was to extend mutational analysis to four additional families with this disorder and determine whether recurrent mutations could be found.

METHODS

The SLC22A5 gene encoding the OCTN2 carnitine transporter was sequenced, and the missense mutations identified were expressed in Chinese hamster ovary (CHO) cells.

RESULTS

DNA sequencing revealed four novel mutations (Y4X; dup 254-264, 133X; R19P; R399Q). Alleles introducing premature STOP codons reduced the levels of OCTN2 mRNA. Carnitine transport in CHO cells expressing the R19P and R399Q mutations was reduced to < 5% of normal. The 133X mutation was found in two unrelated European families. Two patients within the same family, both homozygous for the same mutation (R399Q) had completely different clinical presentation.

CONCLUSIONS

Heterogeneous mutations in the SLC22A5 gene cause primary carnitine deficiency. Different presentations are observed even in children with identical mutations.

Detection of nandrolone metabolites in urine after a football game in professional and amateur players: a Bayesian comparison

Nandrolone (19-nortestosterone) is a widely used anabolic steroid in sports where strength plays an essential role. Once nandrolone has been metabolised, two major metabolites are excreted in urine, 19-norandrosterone (NA) and 19-noretiocholanolone (NE). In 1997, in France, quite a few sportsmen had concentrations of 19-norandrosterone very close to the IOC cut off limit (2ng/ml). At that time, a debate took place about the capability of the human male body to produce by itself these metabolites without any intake of nandrolone or related compounds. The International Football Federation (FIFA) was very concerned with this problematic, especially because the World Cup was about to start in France. In this respect, a statistical study was held with all football players from the first and second divisions of the Swiss Football National League. All players gave a urine sample after effort and around 6% of them showed traces of 19-norandrosterone. These results were compared with amateur football players (control group) and around 6% of them had very small amounts of 19-norandrosterone and/or 19-noretiocholanolone in urine after effort, whereas none of them had detectable traces of one or the other metabolite before effort. The origin of these compounds in urine after a strenuous physical activity is still unknown, but three hypotheses can be put forward. First, an endogenous production of nandrolone metabolites takes place. Second, nandrolone metabolites are released from the fatty tissues after an intake of nandrolone, some related compounds or some contaminated nutritive supplements. Finally, the sportsmen may have taken something during or just before the football game.

Sexual dimorphism of the human mandible: demonstration by elliptical Fourier analysis

A new quantitative approach of the mandibular sexual dimorphism, based on computer-aided image analysis and elliptical Fourier analysis of the mandibular outline in lateral view is presented. This method was applied to a series of 117 dentulous mandibles from 69 male and 48 female individuals native of Rhenish countries. Statistical discriminant analysis of the elliptical Fourier harmonics allowed the demonstration of a significant sexual dimorphism in 97.1% of males and 91.7% of females, i.e. in a higher proportion than in previous studies using classical metrical approaches. This original method opens interesting perspectives for increasing the accuracy of sex identification in current anthropological practice and in forensic procedures.

Lethal neonatal presentation of carnitine palmitoyltransferase I deficiency

A neonate subsequently diagnosed with carnitine palmitoyltransferase I deficiency died at 34 h of untreatable bradycardia. There was fatty infiltration of the liver and increased free carnitine and reduced acylcarnitines in the blood.

Superoxide dismutase gene mutations in Italian patients with familial and sporadic amyotrophic lateral sclerosis: identification of three novel missense mutations

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder affecting motor neurons. The majority of the patients are sporadic cases (SALS), while 5-10% of the patients have a family history of ALS (familial ALS or FALS). Mutations in the gene coding for cytoplasmic Cu/Zn superoxide dismutase (SOD1) have been identified in about 20% of FALS cases. We found SOD1-gene mutations in five of 34 unrelated FALS, and in two of 44 SALS patients. Three FALS patients carried the previously described A4V (two cases) and L84F mutations (one case), while two FALS patients carried new missense mutations: a G12R substitution in exon 1, and a F45C substitution in exon 2, respectively. The newly identified mutations were both associated with a slowly progressive disease course. Two SALS patients carried the homozygous D90A and the heterozygous I113T mutation, respectively. In addition, in one SALS patient we identified an A95T amino acid substitution, that is apparently a non-pathogenic SOD1 variant. Our study increases the number of ALS-associated SOD1 gene mutations.