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Evaluation of statistical methods for left-censored environmental data with nonuniform detection limits.

Monte Carlo simulations were used to evaluate statistical methods for estimating 95% upper confidence limits of mean constituent concentrations for left-censored data with nonuniform detection limits. Two primary scenarios were evaluated: data sets with 15 to 50% nondetected samples and data sets with 51 to 80% nondetected samples. Sample size and the percentage of nondetected samples were allowed to vary randomly to generate a variety of left-censored data sets. All statistical methods were evaluated for efficacy by comparing the 95% upper confidence limits for the left-censored data with the 95% upper confidence limits for the noncensored data and by determining percent coverage of the true mean (micro). For data sets with 15 to 50% nondetected samples, the trimmed mean, Winsorization, Aitchison's, and log-probit regression methods were evaluated. The log-probit regression was the only method that yielded sufficient coverage (99-100%) of micro, as well as a high correlation coefficient (r2 = 0.99) and small average percent residuals (-0.1%) between upper confidence limits for censored versus noncensored data sets. For data sets with 51 to 80% nondetected samples, a bounding method was effective (r2 = 0.96 - 0.99, average residual = -5% to -7%, 95-98% coverage of micro), except when applied to distributions with low coefficients of variation (standard deviation/micro < 0.5). Thus, the following recommendations are supported by this research: data sets with 15 to 50% nondetected samples--log-probit regression method and use of Chebyshev theorem to estimate 95% upper confidence limits; data sets with 51 to 80% nondetected samples-bounding method and use of Chebyshev theorem to estimate 95% upper confidence limits.

Computer Simulation↗

Estimating activity limitation in the noninstitutionalized population: a method for small areas.

OBJECTIVES: Although reliable direct state and local estimates of the activity-limited population are frequently unavailable, regression-adjusted synthetic estimates can be made. Such estimates use multivariate methods to model activity limitation at the national level and then apply model-predicted probabilities to corresponding community-specific demographic data. METHODS: Using the 1989 National Health Interview Survey and the 1991 Area Resource File System, this study produced log-linear regression models that included person-level demographic and county-level contextual variables as predictors of activity limitation. Model-predicted rates were then multiplied by corresponding intercensal population data to generate state and local synthetic estimates of activity limitation. RESULTS: Rates of activity limitation generally were found to increase with age and as the socioeconomic conditions of the county in which an individual resided worsened. Race and sex also tended to be statistically significant predictors of activity limitation. CONCLUSIONS: Activity limitation can be effectively modeled by age, sex, race, and community socioeconomic status. Synthetic estimates such as these are relatively simple to generate and can be useful for small-area planning in the absence of direct local estimates.

Activities of Daily Living↗

Sports-related flow limitations in the iliac arteries in endurance athletes: aetiology, diagnosis, treatment and future developments.

Approximately one in five top-level cyclists will develop sports-related flow limitations in the iliac arteries. These flow limitations may be caused by a vascular lumen narrowing due to endofibrotic thickening of the intima and/or by kinking of the vessels. In some athletes, extreme vessel length contributes to this kinking. Endofibrotic thickening is a result of a repetitive vessel damage due to haemodynamic and mechanical stress. Atherosclerotic intimal thickening is seldom encountered in these young athletes. This type of sports-related flow limitation shows no relationship with the classical risk factors for atherosclerosis like smoking, hypercholesterolaemia or family predisposition for arterial diseases. The patient's history is paramount for diagnosis. If an athlete reports typical claudication-like complaints in a leg at maximal effort, which disappear quickly at rest, approximately two out of three will have a flow limitation in the iliac artery. In current (sports) medical practice, this diagnosis is often missed, since a vascular cause is not expected in this healthy athletic population. Even if suspected, the routinely available diagnostic tests often appear insufficient. Definite diagnosis can be made by a combination of the patient's history and special designed tests consisting of a maximal cycle ergometer test with ankle blood pressure measurements and/or an echo-Doppler examination with provocative manoeuvres like hip flexion and exercise. Conservative treatment consists of diminishing or even completely stopping the provocative sports activity. If conservative treatment is insufficient or deemed unacceptable, surgical treatment might be considered. As surgery needs to be tailored to the underlying lesions, a detailed analysis before surgery is necessary. Standard clinical tests, used for visualising atherosclerotic diseases, are inadequate to identify and quantify the causes of flow limitations. Echo-Doppler examination and magnetic resonance angiography with both flexed and extended hips have been proven to be adequate tools. In particular, overprojection and eccentric location of the lesions seriously limit the usefulness of a two-dimensional technique like digital subtraction angiography. In the early stages, when kinking has not yet led to intimal thickening or excessive lengthening, simple surgical release of the iliac artery is effective. However, for patients with excessive vessel lengths or extensive endofibrotic thickening, a vascular reconstruction may be necessary. A major drawback of these interventions is that long-term effects and complications are unknown. As both the diagnostic methods and the treatments for this type of flow limitation differ substantially from routine vascular procedures, these patients should be examined in specialised research centres with appropriate diagnostic tools and medical experience.

Blood Flow Velocity↗

[Kinematic analysis of limitation of mouth opening of temporomandibular disorders by rotation and translation of the condyle].

PURPOSE: The purpose of this study was to determine whether rotation and translation of the condyle were useful parameters for identifying causes of limitation of mouth opening in patients with temporomandibular disorders (TMD). METHODS: In 7 healthy volunteers and 55 patients with TMD, rotation and translation of the condyle were measured using a 6 degree-of-freedom jaw movement tracking device. Patients were divided into two groups: those who could open their mouth 40 mm or greater, and those who could not open their mouth 40 mm. In each group, the relationship of rotation and translation of the condyle to maximum mouth opening, condition of the articular disc, and pain was determined. RESULTS: Both correlations between maximum mouth opening and rotation and translation of the condyle were strong, especially the former correlation. There was no marked difference in the distribution of range of mouth opening, and rotation and translation of the condyle with respect to condition of the artticular disc. Muscle pain was associated with reduced mouth opening. Even in patients without limited mouth opening, their range of mouth opening was actually reduced when they had muscle pain. Among the patients with limited mouth opening, joint pain correlated to limited translation of the condyle. However, in patients with Wo-Wo condition of articular disc, their translation of the condyle was not limited even with joint pain, but it was limited with muscle pain. CONCLUSIONS: Rotation of the condyle indicated strong correlation with muscle pain, and so is a useful parameter for estimating treatment methods by a surgical approach. On the other hand, translation of the condyle showed variations in correspondence with combinations of several factors such as opening limitation, condition of the articular disc, and pain.

Biomechanical Phenomena↗

Limited coronal CT: an alternative screening examination for sinonasal inflammatory disease.

Coronal CT is the definitive procedure for radiologic evaluation of sinonasal inflammatory disease, yet many clinicians rely on the less expensive plain film sinus series. We designed a limited four slice coronal CT and prospectively compared it with conventional coronal CT and plain film sinus series in 25 patients to determine whether a limited CT examination is a suitable alternative to these other radiologic procedures in screening for sinonasal inflammatory disease. The presence, amount, and location of mucous membrane disease, opacification, air fluid levels, retention cysts, erosions, and anomalies were recorded for each technique. The limited CT agreed with the complete CT in 82% of the 200 sinus compartments reviewed. Localized disease, usually mucosal thickening of 3 mm or less and missed on the limited CT, but detected on the complete CT, accounted for 22 of 36 errors of interpretation. Underestimation of mucosal disease, usually 2 mm or less, accounted for eight errors and misinterpretation of partial volume effect for three errors. Using complete CT a s the established standard, plain film missed 37 instances of disease detected on the limited CT; 73% involved an error of mucosal thickening 4 mm or greater. A limited coronal CT of the paranasal sinuses offers a potentially lower cost alternative to complete CT in screening for sinonasal inflammatory disease. It is more accurate than plain film series. Localized disease and osteomeatal disease is underestimated with the current protocol, and so a limited CT should not be used for evaluating potential cancer patients or for surgical planning.

Adult↗

Effectiveness of prophylactic hyperextension elbow braces on limiting active and passive elbow extension prephysiological and postphysiological loading.

STUDY DESIGN: Experimental 3-factor design with repeated measures on all factors. OBJECTIVES: The purpose of this study was to determine the effectiveness of 3 prophylactic hyperextension elbow braces on limiting active and passive elbow extension before and after exercise. BACKGROUND: Prophylactic hyperextension elbow braces are used to protect the joint against excessive extension, but their effectiveness for this purpose has not been determined. METHODS AND MATERIALS: Twenty Division I intercollegiate football players (mean +/- SD age, 20.2 +/- 1.3 years; mean +/- SD height, 184.4 +/- 9.9 cm, mean +/- SD mass, 102.9 +/- 22.0 kg) completed all phases of the study. The Breg Functional Elbow Brace, PRO 470 Kendall Elbow Brace, and DonJoy Elbow Guard were tested both actively and passively before and after an isokinetic exercise session on a Biodex Multi-Joint Testing and Exercise Dynamometer. For all tests, the braces were set at a 30 degrees flexion limit angle. The exercise session consisted of 1 set of reciprocal elbow extension and flexion at an angular velocity of 360 degrees/s, totaling 1627 J of work. RESULTS: None of the braces limited elbow extension to the 30 degrees flexion limit. However, all of the braces were successful in preventing the elbow from reaching the vulnerable position of hyperextension. The Breg Functional Elbow Brace was the most effective for limiting elbow extension near its set angle, followed by the DonJoy Elbow Guard, and the PRO 470 Kendall Elbow Brace across all test conditions. CONCLUSION: The braces' effectiveness to limit motion is enhanced when limits are set higher than the desired angle of the protected motion.

Adult↗

Performance, digestion, and mastication efficiency of Holstein steers fed whole or processed corn in limit- or full-fed growing-finishing systems.

We conducted two trials to examine the effects of restricted vs full feeding and of grain processing method on feedlot performance, digestion, and mastication efficiency by Holstein steers in different growing-finishing systems. In Trial 1, 272 Holstein steers (177 +/- 9.98 kg) were blocked by weight and assigned to growing phase diets based on corn silage (SIL), steam-flaked corn that was either limit-fed (SFLF) or full-fed (SFFF), or whole corn that was limit-fed (WCLF) or full-fed (WCFF). Limit-fed steers were fed at levels predicted to allow daily gain of 1 kg/d. On d 112, all steers were switched to WCFF or SFFF diets until the mean BW of each treatment group was 545 kg. Overall, steers fed WCLF and SFLF during the growing phase and finished on SF were 8.1 and 6.6% more efficient at converting dietary ME to gain (P = .02 and .04, respectively) than steers in the SFFF group. In Trial 2, three ruminally and duodenally cannulated Holstein steers were fed whole (WC) and rolled corn (RC) diets at FF and LF intake in an incomplete replicated 2 x 2 switchback design. Ad libitum access to feed resulted in higher (P = .02) ruminal starch digestibility than did limit-feeding, and calves had higher total tract DM (P = .05) and starch (P = .03) digestion at the heavier BW. Limit-feeding whole corn resulted in increased particle size of masticate (P = .06) compared with full-feeding whole corn. Because of apparent differences in mastication efficiency between limit-fed and full-fed calves, grain processing method during periods of restriction and compensatory growth may be important considerations for managing growth in systems that incorporate limit-feeding.

Animal Feed↗

Analysis of proteinuria: reference limits for urine excretion of albumin, protein HC, immunoglobulin G, kappa- and lambda-immunoreactivity, orosomucoid and alpha 1-antitrypsin.

Efficient use of assessment of urine protein excretion in nephrological practice requires adequate reference intervals. To determine the upper reference limits of urine albumin, protein HC (alpha 1-microglobulin, immunoglobulin G (IgG), orosomucoid (alpha 1-acid glycoprotein, alpha 1-antitrypsin, and kappa- and lambda-chain immunoreactivities, the concentrations of these proteins were measured in urine samples from 95 healthy, adult individuals, using rapid, generally available methods and with conditions for urine collection which secured stable protein levels. The obtained values were expressed in mg 1(-1), as the urine protein-creatinine index and as fractional protein-creatinine clearance. No differences were found between the upper reference limits in the first voided morning urine samples and the randomly collected urine samples, nor between the upper reference limits in urine samples collected from males and females. The urinary excretion of the tested proteins did not correlate to age, positive dipsticks for haematuria nor to granular casts in urine sediment. Thus, the same upper reference limits can be used for both sexes and regardless of the type of urine collection. The upper reference limits of urine protein-creatinine index found in this study were: for albumin, 3.8 mg mmol(-1); for protein HC, 0.7 mg mmol; for IgG, 0.8 mg mmol(-1); for orosomucoid, 0.7 mg mmol(-1); for alpha 1-antitrypsin, 0.2 mg mmol(-1), and for kappa-immunoreactivity 0.7 mg mmol(-1). The upper reference limit for lambda-immunoreactivity was below the detection limit.

Adult↗

The Utility of Hybrid III and THOR Chest Deflection for Discriminating Between Standard and Force-Limiting Belt Systems.

Recent field data studies have shown that force-limiting belt systems reduce the occurrence of thoracic injuries in frontal crashes relative to standard (not force-limiting) belt systems. Laboratory cadaver tests have also shown reductions in trauma, as well as in chest deflection, associated with a force-limiting belt. On the other hand, tests using anthropomorphic test devices (ATDs) have shown trends indicating increased, decreased, or unchanged chest deflection. This paper attempts to resolve previous experimental studies by comparing the anterior-posterior and lateral chest deflections measured by the THOR and Hybrid III (H-III) dummies over a range of experimental conditions. The analysis involves nineteen 48-km/h and 57-km/h sled tests utilizing force-limiting and standard seat belt systems, both with an air bag. Tests on both the driver side and the passenger side are considered. The purpose of the study is to evaluate whether either dummy could differentiate between the two belt types over a range of sled pulse shapes, seating positions, and belt force limits. The comparison shows that both dummies exhibit significantly (p<0.05) greater maximum chest deflection (Cmax) with the standard belt. In the driver-side tests (3 kN force limit), Cmax for THOR and H-III was 51.6% and 64.4% greater while, in the passenger-side tests (4 kN force limit), Cmax was 16.6% and 30.6% greater. Lateral deflections increased similarly, as did resultant chest acceleration. It is concluded that, over the range of conditions considered here, both dummies consistently ranked the restraint systems appropriately. We conclude by hypothesizing several potential explanations for the different findings among studies in the literature.

Journal Article↗

Psychosocial job factors and the one-year evolution of back-related functional limitations.

OBJECTIVES: This 1-year prospective study aimed at assessing the association between some psychosocial job characteristics and back-related functional limitations. METHODS: The participants were 849 workers who sought medical consultation for nonspecific back pain in primary care settings of the Quebec City area. Information on job decision latitude, psychological demands, and social support at work was collected during a telephone interview conducted after the medical consultation. Back-related functional limitations were measured at baseline and 1 year later with the Roland-Morris Disability Questionnaire. The analyses were stratified by gender. Social support at work and the type of back pain were considered potential effect modifiers. Several potential confounders were also considered in the multiple regression analyses that were conducted to isolate the effect of the job psychological demands and decision latitude on the 1-year level of back-related functional limitations. RESULTS: A modest difference in the 1-year Roland-Morris average scores was found only among the women and only for the association between job decision latitude with back-related functional limitations, according to the level of social support at work. This difference was of limited clinical significance. Analyses by type of back pain showed, however, a clinically significant association between the combination of high psychological demands and low decision latitude and back-related functional limitations only for subjects with persistent pain. CONCLUSIONS: Job psychological demands and decision latitude have little influence on the 1-year evolution of back-related functional limitations for one-time and recurrent back-pain problems. However, our results suggest that this association could be important for workers with persistent pain.

Adult↗

Limitations on physical performance and daily activities among long-term survivors of childhood cancer.

BACKGROUND: Survivors of childhood cancer may experience important disease- and treatment-related late effects, including functional limitations. OBJECTIVE: This study evaluated performance limitations and restricted abilities to participate in personal care, to engage in routine activities like shopping or housework, and to attend work or school (participation restrictions) in a cohort of survivors of childhood cancer. SETTING: Epidemiologic survey and 26 institutions that treat childhood cancer. PATIENTS: Participants included 11 481 persons who were treated for primary brain cancer, leukemia, Hodgkin disease, non-Hodgkin lymphoma, kidney tumor, neuroblastoma, soft-tissue sarcoma, or malignant bone tumor before the age of 21 years and who survived at least 5 years after diagnosis. The comparison group included 3839 siblings of survivors of childhood cancer. MEASUREMENT: Medical data were abstracted, and participants or parents (if the participants were <18 years of age at survey completion) completed a 24-page questionnaire. RESULTS: Compared with siblings, survivors were more likely to report performance limitations (risk ratio, 1.8 [95% CI, 1.7 to 2.0]) and to report restricted participation in personal care skills (risk ratio, 4.7 [CI, 3.0 to 7.2]), routine activities (risk ratio, 4.7 [CI, 3.6 to 6.2]), and the ability to attend work or school (risk ratio, 5.9 [CI, 4.5 to 7.6]). Survivors of brain (26.6%) and bone (36.9%) cancer were most likely to report performance limitations, restricted ability to do routine activities (20.9% and 8.5%, respectively), and restricted ability to attend work or school (20.0% and 11.2%, respectively). Survivors of brain cancer were also most likely to report restricted abilities to perform personal care (10.5%). LIMITATIONS: There was the potential for participants to be healthier or more physically capable than nonparticipants or for persons to be more motivated to participate in this study if they had functional deficits. In addition, the nature of the questionnaire did not allow specific physical limitations to be measured. CONCLUSION: Long-term survivors of childhood cancer are at increased risk for functional limitations in physical performance and in participation in activities needed for daily living.

Absenteeism↗

A tale of two limits.

As they do with other potentially hazardous agents, occupational health and safety professionals in the United States take a two-pronged approach to controlling noise exposure. We assure compliance with OSHA's regulatory limits to satisfy lawyers and compliance officers while using TLVs to protect worker health. Unfortunately, using both the TLV and OSHA limits for noise exposure may involve considerably more work than for most chemical exposures. Using both limits for noise may require different measuring equipment or multiple measurements of exposure. Using the TLV also may require noise measurement at the abdomen, as well as the ear and consideration of concomitant chemical exposures. Finally, using the TLV requires the OHS professional to confront the fact that no exposure value can claim to protect all workers and that employee rotation may result in more hearing loss than would exposing a smaller group of workers to more noise. These facts make it clear why OHS professionals should never use exposure limits as just numbers. Rather, we strive to understand the basis for the limits we are using, to be sure we understand the limitations of those limits and how they might uniquely affect our workers in their work environments.

Guidelines as Topic↗

Medicare program; reasonable charge limitations--HCFA. Final rule with comment period.

This final rule implements section 9304(a) of the Consolidated Omnibus Budget Reconciliation Act of 1985 which enacted section 1842(b)(8) of the Social Security Act (Act). In accordance with section 1842(b)(8) of the Act, we specify the circumstances under which HCFA or its Medicare Part B carriers will consider establishing special reasonable charge payment limits for services (including supplies and equipment) reimbursed under Part B of the Medicare program. The rule describes the factors HCFA or a carrier will consider and the procedures it will follow in establishing them. The limits would be either an upper limit to correct a grossly excessive charge or a lower limit to correct a grossly deficient charge. In either case, the limit would be either a specific dollar amount, or a special method used in determining reasonable charges to be allowed for a particular service or category of service. The purpose of this rule is to establish a stronger framework for setting special reasonable charge limits for services when the standard reimbursement methodology results in payments that are grossly excessive or deficient. A related purpose is to protect the Medicare program from excessive outlays and to prevent any adverse effects on both Medicare beneficiaries and consumers in general that we believe would result from a lack of such limits. The rule also will protect suppliers from reimbursement that is grossly deficient.

Centers for Medicare and Medicaid Services, U.S.↗

The biologic lower detection limit of six ultrasensitive PSA assays.

BACKGROUND: The benefit of monitoring patients with prostate cancer (PCA) by ultrasensitive measurement of prostate specific antigen (PSA) is frequently discussed. Usually, the analytic lower detection limit of an ultrasensitive assay is determined by the manufacturer. As the analytic lower detection limit does not take into account interfering factors of human serum, the biologic lower detection limit, which is defined as PSA concentration detected in PSA-free human serum, plus 3 standard deviations, is of greater interest. MATERIALS AND METHODS: We investigated the biologic lower detection limit of six ultrasensitive PSA assays. Sera from 15 men with bladder cancer after radical cystoprostatectomy and from 30 healthy women were applied. Hence, we expected no PSA of prostatic origin. RESULTS: The biologic lower detection limit obtained using these sera was up to 30 fold higher (men, 0.29-0.63 ng/ml; women, 0.03-0.69 ng/ml) than the analytic lower detection limit (0.01-0.09 ng/ml). CONCLUSIONS: PSA measurement in sera obtained from men without prostate and women results in PSA values above the ultrasensitive range. Therefore, advantages provided by ultrasensitive PSA measurement in monitoring PCA patients after radical prostatectomy are limited.

Environmental Monitoring↗

Effect of mass-transfer limitations on the selectivity of immobilized alpha-chymotrypsin biocatalysts prepared for use in organic medium.

The selectivity of preparations of alpha-chymotrypsin immobilized on Celite or polyamide and carrying out syntheses of di- and tripeptides in acetonitrile medium were studied. The study concerns the effect of mass-transfer limitations on three different kinds of selectivity: acyl donor, stereo- and nucleophile selectivities, defined respectively as the ratio of initial rates with different acyl donors; the enantioselectivity factor (E); and the ratio of initial rates of peptide synthesis and hydrolysis of the acyl donor. Strong mass-transfer limitations caused by increased enzyme loading had a very strong effect on acyl donor selectivity, with reductions of up to 79%, and on stereoselectivity, with reductions of up to 77% in relation to optimum values, both on Celite. Nucleophile selectivity was not affected as strongly by mass-transfer limitations. Using a small molecule (AlaNH(2)) as nucleophile, the onset of these limitations caused only minor reductions in selectivity, while when using a larger nucleophilic species (AlaPheNH(2)) it was reduced by up to 60% when increasing enzyme loading on Celite from 2 to 100 mg/g. The different way these kinds of selectivity are affected by the onset of mass-transfer limitations can be explained by a combination of different aspects: the kinetic behavior of the enzyme toward nucleophile and acyl donor concentrations, the relative concentrations of reagents used in the reaction media, and their relative diffusion coefficients. In short, higher concentrations of nucleophile than acyl donor are generally used, and the nucleophile most often used in the experiments hereby described (AlaNH(2)) diffuses faster than the acyl donors employed. These factors combined are expected to give rise to concentration gradients inside porous biocatalyst particles higher for acyl donor than for nucleophile under conditions of mass-transfer limitations. This explains why acyl donor selectivity and stereoselectivity are much more influenced by mass transfer limitations than nucleophile selectivity.

Acetonitriles↗

Effects of age and functional limitation on leg joint power and work during stance phase of gait.

It is commonly accepted that leg muscle power is an important component of functional ability. Paced gait data for 20 healthy young women (27+/-4.2 yrs), 16 healthy old women (72.5+/-5.6 yrs), and 24 functionally limited old women (73.5+/-7.2 yrs) were analyzed during stance phase to investigate whether power calculations from motion analysis data were sensitive to impairments beyond the differences expected with aging. Healthy women included in the study functioned at a high/moderate level with no limitations, while functionally limited women functioned at a much lower level and exhibited one or more functional limitations as defined by the SF36 physical function scale. Single support time (SSUP), stance duration (SDUR), average forward center of gravity velocity (GVEL), and three-dimensional net power and work of the ankle (APOW/AWRK), knee (KPOW/KWRK), and hip (HPOW/ HWRK) were computed for the stance limb during the stance phase of gait. Univariate ANCOVA was used to examine which variables were most sensitive to functional limitations. We found that SDUR and SSUP were not different among the three groups when controlling for height and weight. Although differences in CG velocity between healthy and functionally limited old women were not significant, both elderly groups translated their CG slower than did the younger women (p<0.0001) when walking at the same cadence. Controlling for CG velocity eliminated all significant differences among groups except for APOW and AWRK in late stance phase between healthy and functionally limited elderly women (p<0.003). These results suggest that decreased ankle plantar-flexor power in late stance of gait may be an impairment-related characteristic more than an age-related characteristic.

Activities of Daily Living↗

Soil pollution and soil limit values.

One of the tools for preventing soil pollution and thus protection of public health is the application of appropriate limit values. Policies on soil protection in relation to soil pollution include two basic strategies: a preventive approach and a remediation or cleanup approach. Preventive, multifunctional limit values are independent from present or future land use. Remediation limit values are connected with land use--these are functional limit values. Both types of limit values are applied in Hungary. Determination of soil limit values demands long-term field investigations, but to estimate allowable concentration for a given site reverse risk assessment methods are well applicable. A comparison and evaluation of the calculated data and the measurement results obtained at the use of the area is indispensable. Further investigations are needed for establishment of combined limit values when more polluting components are present simultaneously in the soil.

Environmental Monitoring↗

[Which objectively assessed limitations in health status, activities of daily living, or in psychological and social spheres are decisive for referral to a nursing home or to a home for the aged].

Which type of limitation is most decisive for a positive indication for a residential home or a somatic or psycho-geriatric nursing home, and to what extent do data on living situation (independent, adapted or intramural) and the social situation (alone or living together) influence this qualification? To obtain an answer to this question three experiments with an integrated, objective and independent assessment-for-care system were set up in the Netherlands. We studied one of them, in the town of Meppel, started in 1996. The study population consisted of all older people living in and around Meppel who had a positive indication for either a residential home, or a somatic or psycho-geriatric nursing home (N = 206 in 1998). Differences in limitations were computed by means of analysis of variance and the types of limitation and their impact on the type of allocated institutions were computed by logistic regression. The limitations only partially explain the types of indication. Indication for a residential home is based on physical limitations. When these increase they become a contra-indication for a residential home and a somatic nursing home indication is given. Mental limitations primarily yield indications for psycho-geriatric nursing homes. Social limitations have a higher incidence among persons with an indication for a somatic nursing home but cannot fully explain this indication. Persons with a residential home indication were significantly more often from an adapted living situation background. The living situation -alone or together-does not have an impact on the indication. We may not conclude that the assessment took place objectively, for, based on the registration it is impossible to conclude for what criteria a person was indicated for a specific type of institution. The objective of assessment, the allocation and distribution of collectively financed care in residential homes and nursing homes based on verifiable assessment methodology could not be realised.

Activities of Daily Living↗