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PubMed2006

[EURAP: the European Registry of Antiepileptic Drugs and Pregnancy].

All old-generation antiepileptic drugs (AEDs) are considered to be teratogenic. In Germany, one out of 200 pregnant women (0.5%) is treated with AEDs for epilepsy. The risk of major malformations following exposure to AEDs during the first trimester of pregnancy is two to three times the rate reported in the general population, which is estimated at 2-3%. The risks associated with the treatment of epilepsy during pregnancy are therefore of major concern to all women of childbearing potential with epilepsy. Data on the comparative teratogenicity of these AEDs in humans are, however, conflicting, mainly due to inadequate sample sizes and other methodological shortcomings of previous studies. The teratogenic potential of newer AEDs is even less well known, which prevents a rational approach to AED treatment in women of childbearing potential. The European Registry of Antiepileptic Drugs and Pregnancy is a prospective international multicentre study of pregnancies with AEDs. In Germany the project was started in 2001 and so far more than 500 pregnancies have been enrolled. The enrollment rate is 4% of 4,000 pregnancies with AEDs reported annually.

Abnormalities, Drug-Induced↗
PubMed1999

Construction of a 550 kb BAC contig spanning the genomic region containing the apple scab resistance gene Vf.

A positional cloning project was started in apple with the aim of isolating the Vf resistance gene of Malus floribunda 821. Vf confers resistance against apple scab, the most important disease in apple orchards. A chromosome walk starting from two molecular markers (M18-CAPS and AM19-SCAR) flanking Vf was performed, using a bacterial artificial chromosome (BAC) library containing inserts of the cultivar Florina, which is heterozygous for Vf. Thirteen BAC clones spanning the region between the two markers were identified in nine chromosome walking steps. The size of the resulting contig is approximately 550 kb. In order to map the Vf region in more detail, we analyzed over 2000 plants from different populations segregating for Vf with markers produced from BAC end sequences. In this way, we were able to restrict the possible location of the Vf gene to a minimum of five clones spanning an interval of approximately 350 kb.

Base Sequence↗
PubMed1999

Assessment of the quality of life of patients with advanced and end-stage cancer or serious infections with a symptom-based or an impact-based instrument.

In 1992 a project was started in which home care technology was made available to patients with cancer or serious infections. Primary care providers were trained and supported to administer parenteral drugs and fluids in the home setting. Between 1992 and 1995 we applied the Rotterdam Symptom Checklist (RSCL) and the Sickness Impact Profile (SIP) as questionnaires for quality of life (QoL) assessment in a group of 112 hospitalized patients who were prepared to receive further treatment at home. Scores on the RSCL revealed a high level of symptomatology in both the physical and the psychological dimension. Factor analysis showed a five-factor rather than a two-factor structure. The SIP showed considerable restrictions in daily living, particularly in the physical dimension. Whereas the RSCL and the SIP correlated well in the psychological and physical dimensions in advanced cancer patients, this correlation disappeared in the group of endstage cancer patients. The data indicate that the health-related QoL of end-stage cancer patients cannot be reliably be assessed with a symptom-based instrument alone; it needs to be supplemented by other instruments, such as the SIP.

Activities of Daily Living↗
PubMed2006

Structural identifiability of physiologically based pharmacokinetic models.

When starting a project in drug kinetics it is necessary to test a priori whether there is sufficient information in the experimental input-output design to estimate unique values of internal rate constants. This is an important test if the pharmacokinetics of a drug are to be characterised in some way by the parameter values estimated from the observed plasma or blood concentration profile. Various modifications of the well-perfused Physiologically Based Pharmacokinetic model (PBPK) are considered here. More complex PBPK models can be considered to consist of subsystems, representing groups of tissues, which are connected in parallel to the central compartment. A novel method of structural identifiability analysis is presented here that considers these subsystems individually. This makes analysis of subsequently modified models much simpler. It is found in a number of cases that these more complex systems remain globally identifiable and at worst reduce to locally identifiable for the additional parameters. A caveat is added about having more than one eliminating peripheral tissue.

Algorithms↗
PubMed1993

Model for selecting quality standards for a salad bar through identifying elements of customer satisfaction.

Continuous quality improvement is the new requirement of the Joint Commission on Accreditation of Healthcare Organizations. This means that meeting quality standards will not be enough. Dietitians will need to improve those standards and the way they are selected. Because quality is defined in terms of the customers, all quality improvement projects must start by defining what customers want. Using a salad bar as an example, this article presents and illustrates a technique developed in Japan to identify which elements in a product or service will satisfy or dissatisfy consumers. Using a model and a questionnaire format developed by Kano and coworkers, 273 students were surveyed to classify six quality elements of a salad bar. Four elements showed a dominant "must-be" characteristic: food freshness, labeling of the dressings, no spills in the food, and no spills on the salad bar. The two other elements (food easy to reach and food variety) showed a dominant one-dimensional characteristic. By better understanding consumer perceptions of quality elements, foodservice managers can select quality standards that focus on what really matters to their consumers.

Consumer Behavior↗
PubMed1993

To test or not to test, that is the question.

This paper describes a system that is used in Maastricht, the Netherlands, to provide general practitioners with feedback about the adequateness of their test requesting behaviour. The system has proven to be effective. Since the screening of test requests and additional patient data is work-intensive a project was started in the framework of the AIM programme OPENLABS to design a computer-based feedback system. In this system the general practitioner sends test requests to the laboratory decision support system by means of electronic data interchange (EDI). The authors were involved in the development of the EDI messages, which are now accepted standards in the Netherlands. The requests are stored in a database that is part of the laboratory decision support system. The other part of the decision support system, an expert system, obtains the request data (including patient data) from the database, screens the requests for adequateness and provides feedback when necessary.

Clinical Laboratory Information Systems↗
PubMed1995

A quality assurance system based on ISO standards: experience in a radiotherapy department.

The European radiotherapy society has for many years had a great interest in quality assurance. The EORTC radiotherapy group has put enormous effort into its quality assurance programmes. However, besides programmes for dosimetry and guide-lines for infrastructure, the organisation of a department should also be subject to a quality assurance system. In 1992, in the radiotherapy department in Leiden, a project was started to develop a quality assurance system based on the so-called ISO 9001 quality standards. This paper describes how these standards can be applied to create a quality assurance system in a hospital department.

Clinical Competence↗
PubMed1988

Prospects for using DRGs in Swedish hospitals.

Overall cost-containment seems satisfactory in Swedish health care. Health care's share of the Gross Domestic Product (GDP) has thus decreased from 9.7% to 9.1% between the years 1982 and 1986. A recent study indicates, however, a decreasing productivity, measured by traditional output measures. It may be argued that these measures are not adequate as they do not reflect the changing patterns of medical technology, case-mix and quality. The Swedish Planning and Rationalization Institute of the Health and Social Services (Spri) has started a project which aims at evaluating whether the Diagnosis Related Group (DRGs) could be used for planning, budgeting and follow-up in the Swedish health care system. The interest in these matters is at present great in Sweden. The feasibility and adequacy of DRGs in the Swedish context are being tested using more than 500,000 discharges from 6 counties. All the necessary variables for DRG assignment are already routinely collected in the Swedish discharge abstracts. In a comparison with an American database concerning individual DRGs, Swedish and American lengths of stay correlate rather well (r = 0.83). There is a difference in the number of diagnoses on each discharge record in the two databases. On average 1.4 diagnosis codes are used for each patient in the Swedish hospital sample compared to 2.8 codes in the United States database. This may indicate a systematic difference in coding practice of complications and co-morbidities.

Accounting↗
PubMed1995

Public health crises of cities in developing countries.

During the decade and a half after Alma Ata hundreds of projects were started in developing countries to implement the principles of PHC and start community based health care programs in the rural areas of developing countries. Until the past five years urban health was not seen as a special health problem. Population pressure in the rural areas has created shortages of land, food and employment opportunities. These forces have generated major population movements to the urban centres. The population movements have encouraged unprecedented expansion of urban centres. This sudden concentration of large populations in small geographical areas has resulted in the urban health crises of the developing world. The poor who live in the slum areas have no access to adequate health services, they experience frequent epidemics of communicable diseases like cholera, they live within a heavily polluted environment, and their children have very poor health because they are not immunized and are malnourished. The paper agrees with approaches which have been championed by development agencies to address the urban health crises. These approaches propose the reorientation of urban health systems to include adoption of PHC for urban health programs, intersectoral collaboration and extra budgetary support. The paper argues for further strengthening of the reorientation approach by adjusting the development planning model. It is proposed that the urban plan be integrated into the national development plan so that emerging urban health crises can receive special attention in resource allocation.

Adult↗
PubMed2007

Performance of the FearID earprint identification system.

The Forensic Ear Identification (FearID) research project was started in order to study the strength of evidence of earprints found on crime scenes. For this purpose, a sample of earprints from 1229 donors over three countries was collected. From each donor three left and three right earprints were gathered. On the one hand, operators denoted contours of the earprints to facilitate segmentation of the images, on the other anthropological specialists denoted anatomically specific locations. On the basis of this, methods for automated classification were developed and used for training of a system that classifies pairs of prints as 'matching' or 'non-matching'. Comparing lab quality prints, the system has an equal error rate of 4%. Starting from a reference database containing two prints per ear, hitlist behaviour is such that in 90% of all query searches the best hit is in the top 0.1% of the list. The results become less favourable (equal error rate of 9%) for print/mark comparisons.

Databases, Factual↗
PubMed2002

Selecting chemical substances for the UN-ECE POP protocol.

In 1998 the UN-ECE POP Protocol was signed. Sixteen substances are included in the protocol. They can be characterised as persistent, bioaccumulating and toxic organic substances prone to long-range atmospheric transport. The Dutch Ministry of Housing, Physical Planning and the Environment started a project to select possible candidates for the protocol. In the first phase of the project possible candidates were selected using the so-called 'PTB-database' applying the criteria from the protocol. From the 12 substances that met the criteria four substances were selected for which preliminary risk profiles were drafted: polychlorinated naphthalenes, dicofol, hexachlorobutadiene and pentachlorobenzene. These profiles are presented. Revised profiles have to be prepared for the UN-ECE LRTAP Ad hoc Expert Group on persistent organic pollutants (POPs). Ultimately, the process should lead to a proposal to include additional POPs to the UN-ECE POP Protocol.

Biological Availability↗
PubMed2002

Treatment of chronic suppurative otitis media with ofloxacin in hydroxypropyl methylcellulose ear drops: a clinical/bacteriological study in a rural area of Malawi.

Chronic suppurative otitis media in young children is a major problem in Africa, with socio-economic consequences at a later age. Common treatment regimens with antibiotics are expensive and often not practically feasible. Therefore, a project was started to develop a low-cost and effective treatment in a rural area of Malawi by studying the clinical efficacy of an inexpensive application regimen of ofloxacin (0.075%) in hydroxypropyl methylcellulose (1.5%) ear drops. In earlier studies with this treatment regimen, it was possible to cure approximately 70% of ears. The aim of this study was to find out whether the bacteriological spectrum cultured from wet ears before and after treatment, and patterns of resistance to antibiotics, played a role in the percentage of cures. Patients with long-standing chronic suppurative otitis media were clinically assessed and treated with suction cleaning and instillation of ear drops on days 1, 3, 7 and 10. Bacterial swabs were taken for culture and sensitivity tests for ofloxacin were on days 1 and 10 from the ears that were still discharging. After 21 weeks, the ears were assessed again clinically. Clinical cure was considered to be complete cessation of otorrhea. Ninety of 104 tested patients (124 ears) completed the study. About 73% of the ears had become dry by day 10. This dropped to 42% after 21 weeks. Before treatment, most ears (91%) harbored fecal bacteria, Proteus mirabilis (74%) and enterococci (60%) being the most frequently isolated microbes. The second group of frequently cultured bacteria were water bacteria e.g. Pseudomonas species and other non-fermenters (69%), whereas the classical otitis media pathogens were detected only in 15% of ears. Before treatment, 9.7% of strains were resistant to ofloxacin, most (30/35) of which were cultured from ears that were eventually cured. After treatment, fecal and water bacteria were still the most frequently found, with 36% new strains and an overall sensitivity to ofloxacin of 58%. Bacterial resistance did not appear to play an important role in the outcome of treatment. These data rather suggest a very high risk of infection due to poor hygiene conditions. Medical treatment can only have a longer-lasting effect if accompanied by community-based programs that focus on improvement of hygiene. A public health approach is necessary alongside a medical approach for the management of CSOM.

Adolescent↗
PubMed2001

PACS in Töölö hospital.

A 3-year PACS project was started in 1997 and completed in 1999 with filmless radiology and surgery. An efficient network for transferring images provides the infrastructure for integration of different distributed imaging systems and enables efficient handling of all patient-related information on one display station. Because of the need for high-speed communications and the massive amount of image data transferred in radiology, ATM (25, 155 Mbit/s) was chosen to be the main technology used. Both hardware and software redundancy of the system have been carefully planned. The size of the Dicom image library utilizing MO discs is currently 1.2 TB with 300 GB RAID capacity. For the increasing amount of teleradiologic consultations, a special Dicom gateway is planned. It allows a centralized and resilient handling and routing of received images around the hospital. Hospital-wide PACS has already improved the speed and quality of patient care by providing instant access to diagnostic information at multiple locations simultaneously. The benefits of PACS are considered from the viewpoint of the entire hospital: PACS offers a method for efficiently transporting patient-related images and reports to the referring physicians.

Finland↗
PubMed2000

Three-dimensional transesophageal echocardiography (TEE) and other future directions.

As faster imaging systems enter the market, three-dimensional echocardiography is gearing up to become a useful tool in assisting the clinician to image the heart in many innovative projections. What started out as a novel idea of displaying a three-dimensional anatomic picture of the heart now provides a multitude of views of the heart and its structures. Information gained from anatomic and dynamic data has helped clinicians and surgeons in making clinical decisions. In the future, this imaging modality may become a routine imaging modality for assessing cardiac pathology and may serve to increase understanding of the dynamics of the heart.

Echocardiography, Doppler, Color↗
PubMed2002

Telemedicine for cardiac surgery candidates.

BACKGROUND: Cardiac surgery is generally well or over-represented in many Western countries. Since the southern part of Switzerland relies on 300 km distance centers for cardiac surgery, we started a project of telemedicine for the distant evaluation of cardiac surgery candidates. We report our experience of the results of the diagnosis made by telemedicine and by direct scrutiny of coronary angiograms. METHODS: Coronary angiography was performed at the distant hospital by an invasive cardiology team. Teletransmission of images was performed using three Integrated Service Digital Network (ISDN) lines by direct transmission of recent recording. A total of 98 cases were reviewed (87 aorto-coronary bypass candidates, seven valvular and four congenital heart disease). We further performed a prospective blinded comparison of 47 consecutive cases with severe coronary artery disease (CAD) with respect to localization and number of significant coronary lesions, obtained by direct scrutiny of the original angiograms and the evaluation obtained with the teletransmitted images. RESULTS: In 89 cases of the 98 analyzed (91%) correct diagnosis and surgical approach could be established by distant transmission. In nine cases (9%, all aortocoronary bypass candidates) definitive diagnosis and treatment was feasible only by direct scrutiny of the original angiograms. Five critically ill patients were urgently referred to the surgical care center based on the correct distant diagnosis. The blinded comparison of distant diagnosis and direct scrutiny of angiograms in defining 1-2-3 vessel CAD was good: r=0.87, P<0.01. CONCLUSION: Initial experience using non-sophisticated telemedical transmission of angiograms of cardiac surgery candidates seems to be a promising facility for distantly located centers.

Cardiac Surgical Procedures↗
PubMed2001

[Circular spine retractor: preliminary results].

In 1992 it was started the project for the construction of an interchanging blades retractor, that could be used for the microsurgery of both cervical and lumbar spine. It was initially presented on June 1994. I present my experience with the use of this spine circular retractor, the modifications made during the last years and the results obtained.

Equipment Design↗
PubMed2006

Changes in perceptions of quality of, and access to, services among clients of a fractional franchise network in Nepal.

With declining levels of international donor funding for financing reproductive health programmes, developing country governments and international donors are looking towards private sector strategies to expand the supply of quality reproductive health services. One of the challenges of a health franchise is to improve the quality of services provided by independent private practitioners. Private providers are more likely to abide by the quality standards set by a franchiser if they see a financial benefit resulting from franchise participation. This study was conducted to measure whether (a) there were improvements in perceived quality of care and perceived access to health facilities once these facilities became part of a franchise and (b) improvements in perceived quality and perceived access were associated with increased client loyalty to franchised clinics. Franchisees were given basic reproductive health training for seven days and services marketing training for two days. Exit interviews were conducted with male and female clients at health facilities. A pre-test measurement was taken in April 2001, prior to the start of project activities. A post-test measurement was taken in February/March 2002, about 9 months after the pre-test. Multilevel regression analysis, which takes the hierarchical structure of the data into account, was used for the analysis. After taking provider-level variation into account and controlling for client characteristics, the analyses showed significant improvements in perceived quality of care and perceived access to services. Private provider participation in a franchise network helps improve client perceptions of quality of, and access to, services. Improvements in client perceptions of quality and access contribute to increased client loyalty to franchised clinics. Once increased client loyalty translates into higher client volumes, providers are likely to see the benefits of franchise participation. In turn, this should lead to increased provider willingness to remain part of the franchise and to abide by the standards of quality set by the franchiser.

Adult↗
PubMed1999

Use of resources and costs of palliative care with parenteral fluids and analgesics in the home setting for patients with end-stage cancer.

BACKGROUND: In 1992 a home care technology project was started in which infusion therapy in the home setting was made available for patients with end-stage cancer. Beside aspects of feasibility and quality of life the resource utilization and costs of this transition was studied. PATIENTS AND METHODS: We conducted a cost evaluation study, to determine the actual cost of managing patients with endstage cancer who require parenteral administration of fluid or analgesics in the home setting. A total of 128 patients were prospectively followed, with a detailed analysis of some aspects in a sample of 24 patients. RESULTS: The cost for each patient was found to be between $250.00 and $300.00 per day, half of which are for hospital charges, even with this active home care technology program. One-third of the costs can be attributed to primary health care activities, in particular those of the district nurses. A hypothetical control group (n = 25) was constructed based on current practice and chart review. Patients in this group would have cost around $750.00 per day. With a median treatment period of 16 days this means a saving of $8000.00 per patient. CONCLUSION: Our data suggest that significant savings can be obtained by implementing programs transferring palliative care technology to the home setting.

Adult↗