Morphology of nares associated with stereo-olfaction in baleen whales

The sensory mechanisms used by baleen whales (Mysticeti) for locating ephemeral, dense prey patches in vast marine habitats are poorly understood. Baleen whales have a functional olfactory system with paired rather than single blowholes (nares), potentially enabling stereo-olfaction. Dimethyl sulfide (DMS) is an odorous gas emitted by phytoplankton in response to grazing by zooplankton. Some seabirds use DMS to locate prey, but this ability has not been demonstrated in whales. For 14 extant species of baleen whale, nares morphometrics (imagery from unoccupied aerial systems, UAS) was related to published trophic level indices using Bayesian phylogenetic mixed modelling. A significant negative relationship was found between nares width and whale trophic level (β = -0.08, lower 95% CI = -0.13, upper 95% CI = -0.03), corresponding with a 39% increase in nares width from highest to lowest trophic level. Thus, species with nasal morphology best suited to stereo-olfaction are more zooplanktivorous. These findings provide evidence that some baleen whale species may be able to localize odorants e.g. DMS. Our results help direct future behavioural trials of olfaction in baleen whales, by highlighting the most appropriate species to study. This is a research priority, given the potential for DMS-mediated plastic ingestion by whales.

Historical Mitogenomic Diversity and Population Structuring of Southern Hemisphere Fin Whales

Fin whales Balaenoptera physalus were hunted unsustainably across the globe in the 19th and 20th centuries, leading to vast reductions in population size. Whaling catch records indicate the importance of the Southern Ocean for this species; approximately 730,000 fin whales were harvested during the 20th century in the Southern Hemisphere (SH) alone, 94% of which were at high latitudes. Genetic samples from contemporary whales can provide a window to past population size changes, but the challenges of sampling in remote Antarctic waters limit the availability of data. Here, we take advantage of historical samples in the form of bones and baleen available from ex-whaling stations and museums to assess the pre-whaling diversity of this once abundant species. We sequenced 27 historical mitogenomes and 50 historical mitochondrial control region sequences of fin whales to gain insight into the population structure and genetic diversity of Southern Hemisphere fin whales (SHFWs) before and after the whaling. Our data, both independently and when combined with mitogenomes from the literature, suggest SHFWs are highly diverse and may represent a single panmictic population that is genetically differentiated from Northern Hemisphere populations. These are the first historic mitogenomes available for SHFWs, providing a unique time series of genetic data for this species.

Mid-frequency song and low-frequency calls of sei whales in the Falkland Islands

Although sei whales (Balaenoptera borealis) are distributed throughout the globe, their behaviour and vocal repertoire are poorly described. We used passive acoustic monitoring to describe the vocal behaviour of sei whales in the Falkland Islands, between December 2018 and April 2019. We isolated more than 2000 low-frequency calls for manual classification, of which 510 calls with high signal-to-noise ratio were quantitatively measured. Five categories of stereotyped call types in the 15-230 Hz range were described, some with multiple subcategories. These included some similar to previously described calls (e.g. downsweeps), but others that were novel in acoustic structure and frequency band. In the mid-frequency range, we documented a highly stereotyped, hierarchically structured and rhythmically repetitive song display. Songs were arranged in phrases with a structure composed of repetitive sub-phrases, and a diverse variety of sounds in the 1-5 kHz range. Singing commenced in late February, despite the presence of whales and calls since early December, and continued through April. These acoustic properties and behavioural characteristics indicate that this is likely a male breeding display similar to songs and singing of other balaenopterids. This is the first detailed description of a song display for sei whales, highlighting the importance of the Falkland Islands.

Scaling of maneuvering performance in baleen whales: larger whales outperform expectations

Despite their enormous size, whales make their living as voracious predators. To catch their much smaller, more maneuverable prey, they have developed several unique locomotor strategies that require high energetic input, high mechanical power output and a surprising degree of agility. To better understand how body size affects maneuverability at the largest scale, we used bio-logging data, aerial photogrammetry and a high-throughput approach to quantify the maneuvering performance of seven species of free-swimming baleen whale. We found that as body size increases, absolute maneuvering performance decreases: larger whales use lower accelerations and perform slower pitch-changes, rolls and turns than smaller species. We also found that baleen whales exhibit positive allometry of maneuvering performance: relative to their body size, larger whales use higher accelerations, and perform faster pitch-changes, rolls and certain types of turns than smaller species. However, not all maneuvers were impacted by body size in the same way, and we found that larger whales behaviorally adjust for their decreased agility by using turns that they can perform more effectively. The positive allometry of maneuvering performance suggests that large whales have compensated for their increased body size by evolving more effective control surfaces and by preferentially selecting maneuvers that play to their strengths.

Biomechanically distinct filter-feeding behaviors distinguish sei whales as a functional intermediate and ecologically flexible species

With their ability to facultatively switch between filter-feeding modes, sei whales represent a functional and ecological intermediate in the transition between intermittent and continuous filter feeding. Morphologically resembling their lunge-feeding, rorqual relatives, sei whales have convergently evolved the ability to skim prey near the surface of the water, like the more distantly related balaenids. Because of their intermediate nature, understanding how sei whales switch between feeding behaviors may shed light on the rapid evolution and flexibility of filter-feeding strategies. We deployed multi-sensor bio-logging tags on two sei whales and measured the kinematics of feeding behaviors in this poorly understood and endangered species. To forage at the surface, sei whales used a unique combination of surface lunges and skim-feeding behaviors. The surface lunges were slow and stereotyped, and were unlike lunges performed by other rorqual species. The skim-feeding events featured a different filtration mechanism from the lunges and were kinematically different from the continuous filter feeding used by balaenids. While foraging below the surface, sei whales used faster and more variable lunges. The morphological characteristics that allow sei whales to effectively perform different feeding behaviors suggest that sei whales rapidly evolved their functionally intermediate and ecologically flexible form to compete with larger and more efficient rorqual species.

Marine mammal conservation: over the horizon

Marine mammals can play important ecological roles in aquatic ecosystems, and their presence can be key to community structure and function. Consequently, marine mammals are often considered indicators of ecosystem health and flagship species. Yet, historical population declines caused by exploitation, and additional current threats, such as climate change, fisheries bycatch, pollution and maritime development, continue to impact many marine mammal species, and at least 25% are classified as threatened (Critically Endangered, Endangered or Vulnerable) on the IUCN Red List. Conversely, some species have experienced population increases/recoveries in recent decades, reflecting management interventions, and are heralded as conservation successes. To continue these successes and reverse the downward trajectories of at-risk species, it is necessary to evaluate the threats faced by marine mammals and the conservation mechanisms available to address them. Additionally, there is a need to identify evidence-based priorities of both research and conservation needs across a range of settings and taxa. To that effect we: (1) outline the key threats to marine mammals and their impacts, identify the associated knowledge gaps and recommend actions needed; (2) discuss the merits and downfalls of established and emerging conservation mechanisms; (3) outline the application of research and monitoring techniques; and (4) highlight particular taxa/populations that are in urgent need of focus.

Predicting suitable coastal habitat for sei whales, southern right whales and dolphins around the Falkland Islands

Species distribution models (SDMs) are valuable tools for describing the occurrence of species and predicting suitable habitats. This study used generalized additive models (GAMs) and MaxEnt models to predict the relative densities of four cetacean species (sei whale Balaeanoptera borealis, southern right whale Eubalaena australis, Peale’s dolphin Lagenorhynchus australis, and Commerson’s dolphin Cephalorhynchus commersonii) in neritic waters (≤100 m depth) around the Falkland Islands, using boat survey data collected over three seasons (2017–2019). The model predictor variables (PVs) included remotely sensed environmental variables (sea surface temperature, SST, and chlorophyll-a concentration) and static geographical variables (e.g. water depth, distance to shore, slope). The GAM results explained 35 to 41% of the total deviance for sei whale, combined sei whales and unidentified large baleen whales, and Commerson’s dolphins, but only 17% of the deviance for Peale’s dolphins. The MaxEnt models for all species had low to moderate discriminatory power. The relative density of sei whales increased with SST in both models, and their predicted distribution was widespread across the inner shelf which is consistent with the use of Falklands’ waters as a coastal summer feeding ground. Peale’s dolphins and Commerson’s dolphins were largely sympatric across the study area. However, the relative densities of Commerson’s dolphins were generally predicted to be higher in nearshore, semi-enclosed, waters compared with Peale’s dolphins, suggesting some habitat partitioning. The models for southern right whales performed poorly and the results were not considered meaningful, perhaps due to this species exhibiting fewer strong habitat preferences around the Falklands. The modelling results are applicable to marine spatial planning to identify where the occurrence of cetacean species and anthropogenic activities may most overlap. Additionally, the results can inform the process of delineating a potential Key Biodiversity Area for sei whales in the Falkland Islands.

The incidence of bent dorsal fins in free-ranging cetaceans

Laterally bent dorsal fins are rarely observed in free-ranging populations of cetaceans, contrary to captivity, where most killer whale Orcinus orca adult males have laterally collapsed fins. This topic has been poorly explored, and data/information on its occurrence and possible causes are limited. The present study: (i) undertakes a review of the available information on bent dorsal fins in free-ranging cetaceans, and updates it with new records, (ii) reports on the proportion of bent fins in different study populations, and (iii) discusses possible causes. An empirical approach based on bibliographic research and compilation of 52 new records collected worldwide resulted in a total of 17 species of cetaceans displaying bent dorsal fins. The species with the highest number of records (64%) and from most locations was O. orca. On average, individuals with bent dorsal fins represent < 1% of their populations, with the exception of false killer whales Pseudorca crassidens and O. orca. While line injuries associated with fisheries interactions may be the main cause for P. crassidens, and the vulnerability to health issues caused by the evolutionary enlargement of the fin may be the cause for O. orca adult males, factors contributing to this abnormality for other species are still unclear. The occurrence of bent dorsals could be influenced by a set of variables rather than by a single factor but, irrespective of the cause, it is suggested that it does not directly affect the animals' survivorship. While still rare in nature, this incident is more common (at least 101 known cases) and widespread (geographically and in species diversity) than hypothesized, and is not confined only to animals in captive environments. Investigation into the occurrence of bent fins may be an interesting avenue of research.

Vertebral column anomalies in Indo-Pacific and Atlantic humpback dolphins Sousa spp

Conspicuous vertebral column abnormalities in humpback dolphins (genus Sousa) were documented for the first time during 3 photo-identification field studies of small populations in Taiwan, Senegal and Angola. Seven Taiwanese humpback dolphins S. chinensis taiwanensis with vertebral column anomalies (lordosis, kyphosis or scoliosis) were identified, along with 2 possible cases of vertebral osteomyelitis. There was evidence from several individuals photographed over consecutive years that the anomalies became more pronounced with age. Three Atlantic humpback dolphins S. teuszii were observed with axial deviations of the vertebral column (lordosis and kyphosis). Another possible case was identified in a calf, and 2 further animals were photographed with dorsal indents potentially indicative of anomalies. Vertebral column anomalies of humpback dolphins were predominantly evident in the lumbo-caudal region, but one Atlantic humpback dolphin had an anomaly in the cervico-thoracic region. Lordosis and kyphosis occurred simultaneously in several individuals. Apart from the described anomalies, all dolphins appeared in good health and were not obviously underweight or noticeably compromised in swim speed. This study presents the first descriptions of vertebral column anomalies in the genus Sousa. The causative factors for the anomalies were unknown in every case and are potentially diverse. Whether these anomalies result in reduced fitness of individuals or populations merits attention, as both the Taiwanese and Atlantic humpback dolphin are species of high conservation concern.

Neuro-ophthalmic complications after coronary angiography

Diplopia and gaze palsies are extremely disabling and distressing problems, especially in patients with significant cardiac co-morbidity. A case of Parinaud syndrome and oculomotor nerve palsy following coronary angiography (CA) is reported. These neuro-ophthalmic complications are not previously documented in the literature in association with CA. The case raises awareness of potential ocular motility deficits that may occur following CA. Potential risk factors during CA are analysed and the mechanisms of the embolic pathway are discussed.

A Review of the Geographical Distribution and Habitat of the Atlantic Humpback Dolphin (Sousa teuszii)

Understanding of the distributional ecology of the Atlantic humpback dolphin (Sousa teuszii) has been hampered by a lack of systematic and consistent sampling effort. The only comprehensive species distribution review was published in 2004; since then a considerable amount of novel information has emerged. We compiled 853 sighting, capture and specimen records of the species, and produced global and regional distribution maps. Of the 830 records where year was available, 63.1% dated from ≥2005 and confirm a contemporary occurrence in six marine ecoregions and 11 countries: Western Sahara, Mauritania, Senegal, Gambia, Guinea-Bissau, Guinea, Benin, Cameroon, Gabon, Congo Republic and Angola. Additionally, Togo is a recently confirmed range state. Group sizes ranged from 1 to 45 animals, with small groups of 1 to 10 animals comprising 65% of the sightings. Similarities were noted in the regions inhabited by Atlantic humpback dolphins across their range, particularly an occurrence in relatively shallow (predominantly ≤20 m) depths, in warm waters (average SSTs of 15.8-31.8°C) and in dynamic habitat strongly influenced by tidal patterns. These conditions occur in various habitats occupied by the species, including estuarine systems, open coasts, archipelagos, tidal mud-flats and sheltered bays. Sightings were recorded at distances of 13 m to 12.8 km (mean of 573 m) from land, indicating that the species occurs several kilometres from shore when suitable shallow habitat is present. The Atlantic humpback dolphin may be a 'nearshore' species based on oceanographic definitions incorporating water depth, wave action and sedimentation rather than on spatial distance from the coast.

Are Orthoptic Exercises an Effective Treatment for Convergence and Fusion Deficiencies?

PURPOSE

To investigate whether orthoptic exercises are an effective way to influence the near point of convergence, fusion range and asthenopic symptoms.

METHODS

Seventy-eight patients met the inclusion criteria of visual acuity 6/9 or better, no history of orthoptic treatment, squint surgery or Meares Irlen syndrome/dyslexia. Information was collected from case records related to diagnosis, near point of convergence, fusion range, prism and cover test measurements and symptoms. Type, duration and frequency of exercises were also recorded. Non-parametric statistics were applied.

RESULTS

Patients ranged in age from 5 to 73 years (mean 11.9). Females outnumbered males (46:32). The diagnoses were: decompensating heterophoria (n = 50) or convergence insufficiency (n = 28: primary 27; secondary 1). Exophoria was more common (n = 65), than esophoria (n = 11) or orthophoria (n = 1). Treatments were aimed at improving near point of convergence and/or reduced fusional reserves. The mean treatment period was 8.2 months. Reduced near point of convergence normalized following treatment in 47/55 cases, and mean near point of convergence improved from 16.6 to 8.4 cm (p = 0.0001). Fusional reserves normalized in 29/50. Fusional convergence improved significantly for those with exodeviation (p > 0.0006). Asthenopic symptoms improved in 65 patients. A reduction in deviation of 5 pd or more occurred in 20 patients.

CONCLUSIONS

Orthoptic exercises are an effective means of reducing symptoms in patients with convergence insufficiency and decompensating exophoria, and appear to target the proximal and fusional components of convergence. Their role in esophoria is unclear and needs further study.

Comparative review of marine mammal guidance implemented during naval exercises

This article reviews the types and effectiveness of marine mammal mitigation measures used during some naval activities worldwide. The three main standard methods used to mitigate the potential impacts of naval sonar sound on marine mammals are (1) time/area planning (of exercises/active sonar use) to avoid marine mammals; (2) implementation of operational procedures (e.g. 'soft start' - where sound levels are gradually increased over time); and (3) monitoring of animals for the purpose of maintaining an 'exclusion zone' around the sound source. Suggestions towards a minimum worldwide mitigation standard are made.

Direct text entry in electronic progress notes. An evaluation of input errors

OBJECTIVES

It is not uncommon that the introduction of a new technology fixes old problems while introducing new ones. The Veterans Administration recently implemented a comprehensive electronic medical record system (CPRS) to support provider order entry. Progress notes are entered directly by clinicians, primarily through keyboard input. Due to concerns that there may be significant, invisible disruptions to information flow, this study was conducted to formally examine the incidence and characteristics of input errors in the electronic patient record.

METHODS

Sixty patient charts were randomly selected from all 2,301 inpatient admissions during a 5-month period. A panel of clinicians with informatics backgrounds developed the review criteria. After establishing inter-rater reliability, two raters independently reviewed 1,891 notes for copying, copying errors, inconsistent text, inappropriate object insertion and signature issues.

RESULTS

Overall, 60% of patients reviewed had one or more input-related errors averaging 7.8 errors per patient. About 20% of notes showed evidence of copying, with an average of 1.01 error per copied note. Copying another clinician's note and making changes had the highest risk of error. Templating resulted in large amounts of blank spaces. Overall, MDs make more errors than other clinicians even after controlling for the number of notes.

CONCLUSIONS

Moving towards a more progressive model for the electronic medical record, where actions are recorded only once, history and physical information is encoded for use later, and note generation is organized around problems, would greatly minimize the potential for error.

Modification of smooth pursuit initiation by a nonvisual, afferent feedback signal

PURPOSE

To investigate the role of extraocular muscle afferent signals in the initiation and early maintenance of smooth-pursuit eye movements.

METHODS

A suction scleral contact lens was used to impede the movements of the right eye while subjects tracked small targets in a step-ramp pursuit paradigm. Movements of the left eye were measured by infrared oculography. Pursuit latency, eye acceleration, and velocity were analyzed trial-by-trial and compared before, while, and after the right eye was impeded.

RESULTS

When the right eye was impeded, initial acceleration and eye velocity were reduced. Pursuit latency was unchanged. The velocity effect had a rapid onset and offset; there was no evidence that the effects built up over a number of trials. Detailed analysis suggested that the reduction in velocity occurred approximately 40 msec after pursuit was initiated.

CONCLUSIONS

These results are consistent with the hypothesis that extraocular muscle afferent signals provide a feedback signal of the movements of the eyes that may be used to modify the initiation and early maintenance of smooth pursuit on-line. It appears that for pursuit, as with saccades, the priority in these conditions is to maintain conjugacy.

Spatial localization after different types of retinal detachment surgery

PURPOSE

To compare the effect on spatial localization of two different forms of surgery for primary rhegmatogenous retinal detachment.

METHODS

Two groups of 30 patients (one group undergoing conventional external scleral-buckling procedures, the other undergoing vitrectomy procedures) were recruited. They pointed at targets appearing on a computer touchscreen without being able to see their hands, while viewing targets with the non-surgically treated eye. The sizes of the horizontal pointing errors were recorded on three separate occasions: before surgery, on the first postoperative day, and approximately 10 days later.

RESULTS

On the first postoperative day a significant change in localization of 2.9 +/- 0.9 degrees [SD]) was observed in the scleral-buckling group, compared with 1.3 +/- 0.6 degrees in the vitrectomy group. These changes resolved by the second postoperative assessment.

CONCLUSIONS

These results, particularly in patients in the scleral-buckling group in whom greater manipulation of the extraocular muscles inevitably occurs, are consistent with an alteration in the extraretinal eye position information that is used in spatial localization. This is likely to be a consequence of modified efference copy and/or extraocular muscle proprioception.

Developing a taxonomy for research in adverse drug events: potholes and signposts

Computerized decision support and order entry shows great promise for reducing adverse drug events (ADEs). The evaluation of these solutions depends on a framework of definitions and classifications that is clear and practical. Unfortunately the literature does not always provide a clear path to defining and classifying adverse drug events. While not a systematic review, this paper uses examples from the literature to illustrate problems that investigators will confront as they develop a conceptual framework for their research. It also proposes a targeted taxonomy that can facilitate a clear and consistent approach to the research of ADEs and aid in the comparison to results of past and future studies. The taxonomy addresses the definition of ADE, types, seriousness, error, and causality.

Spatial localization in esotropia: does extraretinal eye position information change?

PURPOSE

To investigate the accuracy of spatial localization in children with a specific type of convergent strabismus, fully accommodative esotropia.

METHODS

Two groups of children, with right and left fully accommodative esotropia, respectively, pointed at targets located centrally and eccentrically on a computer touchscreen without being able to see their hands. The size and the direction of the horizontal pointing responses were recorded under two conditions: when their eyes were aligned (wearing spectacles) and when they were squinting (not wearing spectacles). A group of children without strabismus but with hypermetropia were assessed as controls.

RESULTS

For both fully accommodative groups, the pointing responses to the central target shifted in the direction of the nonsquinting eye when deviations were manifest. No difference was found for the eccentric targets. No difference was found for the hypermetropia group with any target.

CONCLUSIONS

These results are consistent with an alteration in the extraretinal eye position information (efference copy, extraocular muscle proprioception, or both) that is used in spatial localization.

Spatial localisation: does extraocular muscle proprioception play a role?

Our ability to determine the position of targets in surrounding visual space (spatial localisation) is an important aspect of visual function and requires the integration of both visual (ie retinal) and non-visual (ie extraretinal) information. Afferent signals derived from extraocular muscle proprioceptors are though to contribute to this extraretinal information. However, this has proved to be a contentious issue. This article considers the role of extraocular muscle proprioception in spatial localisation in greater detail by discussing the evidence supporting this viewpoint. This is obtained from two main sources: firstly observations in patients in whom the proprioceptive input has been disrupted either pathologically or surgically, and secondly experimental studies in normal subjects in whom the proprioceptive input has been manipulated. The review concludes by emphasising that whilst proprioception is not the predominant source of extraretinal information that helps us determine visual direction, it is still likely to be a contributory factor.

Modification of visually guided saccades by a nonvisual afferent feedback signal

PURPOSE

To investigate the role of extraocular muscle afferent signals in the control of saccadic eye movements.

METHODS

A suction scleral contact lens was used to impede the movements of the right eye while subjects executed visually guided saccades to briefly presented targets. Movements of the left eye were measured using infrared oculography. Saccade amplitude, peak velocity, and duration were analyzed trial by trial and compared before, during, and after the right eye was impeded.

RESULTS

When the right eye was impeded, the amplitudes of saccades executed by the left eye were reduced. There was no alteration in the main sequence relationships. The amplitude effect had a rapid onset and offset. There was no evidence that the effects built up over a number of trials, nor was there evidence that individual saccades were modified on-line.

CONCLUSIONS

These results are consistent with the hypothesis that extraocular muscle afferent signals provide a feedback signal of the movements of the eyes that is used to produce rapid adjustments of oculomotor output when required.

Does user satisfaction relate to adoption behavior?: an exploratory analysis using CPRS implementation

User satisfaction is commonly assessed in evaluations of information systems as a proxy for user adoption. However few studies actually report directly assessing the relationship between the two constructs. In this study the relationship between four user satisfaction measures and five adoption behaviors were explored in the context of the implementation of the Veteran's Health Administration Computerized Patient Record System 1.0. Findings suggest that the relationship is modest and depends on the measurement system used. Specifically, direct reports of affect and judgements of specific task efficacy related to behavior more often than usability and a general user satisfaction instrument.

An appraisal of the disc-macula distance to disc diameter ratio in the assessment of optic disc size

The disc-macula distance to disc diameter ratio (DM:DD ratio) has been advocated as a method of supporting the diagnosis of optic nerve hypoplasia. A DM:DD ratio of 3.00 has been claimed to be a satisfactory threshold value for this purpose. This study has critically evaluated the above claim and found a value of 3.00 to be too low. The threshold DM:DD ratio values for the diagnosis of unequivocal ONH for an adult population, 5 and 2 years of age were found to be respectively 4.20, 3.93 and 3.70, the values for the diagnosis of mild ONH being 3.68, 3.44 and 3.23. Lower computed values reduce the predictive power. The method of computation of the DM:DD ratio was modified to abolish potential error due to disc rotation and foveal displacement. In an adult population, there was no correlation between the DM:DD ratio and amblyopia or disc ovalness. There was a trend of increasing DM:DD ratio towards myopia and decreasing DM:DD ratio towards hypermetropia; the DM:DD ratio may therefore be falsely high in high myopia. DM:DD ratio values below threshold should therefore be interpreted with care until formal optic disc biometry can be performed.

Linking information needs with evaluation: the role of task identification

Action Identification Theory was used to explore user's subjective constructions of information tasks in a primary care setting. The first part of the study involved collecting clinician's descriptions of their information tasks. These items were collated and then rated by another larger group of clinicians. Results clearly identified 6 major information tasks, including communication, patient assessment, work monitoring, seeking science information, compliance with policies and procedures, and data integration. Results discussed in terms of implications for evaluation and assessing information needs in a clinical setting.

Validity of utilization management criteria for psychiatry

OBJECTIVE

This study examined the validity of four psychiatric utilization management criteria sets: the 1992 and 1993 InterQual Intensity, Severity, and Discharge (ISD) criteria, the Managed Care Appropriateness Protocol, and an instrument developed by the Department of Veterans Affairs (VA).

METHOD

The appropriateness of acute care admission and continued stay for 70 randomly selected VA psychiatric inpatients was retrospectively assessed with each criteria set. The sensitivity and specificity of each instrument were evaluated by comparing its assessments to the consensus of judgments of a panel of expert psychiatrists who reviewed the same cases. Sensitivity was defined as the proportion of admissions or continued-stay days the panel found appropriate for acute care that the criteria judged to be appropriate for acute care; specificity was the proportion the panel found inappropriate for acute care that the criteria judged to be inappropriate for acute care.

RESULTS

For admissions, there were only minor differences in the validity of the four criteria sets as assessed by agreement with the panel's judgments. For each of 4 continued-stay days studied, either the sensitivity or specificity of the 1993 InterQual ISD criteria was below 0.30. The specificity of the 1992 InterQual ISD criteria was below 0.60 for 2 days. In contrast, for the Managed Care Appropriateness Protocol, sensitivity was 0.73-0.93 and specificity was 0.78-0.88 over the 4 days.

CONCLUSIONS

The findings raise major concerns about the validity of the widely used InterQual ISD psychiatry criteria, suggest that the Managed Care Appropriateness Protocol may be a useful tool for psychiatric utilization management, strongly underline the need to validate all criteria used to assess medical care, and support the appropriateness of the procedures used to perform these assessments.