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PubMed2004

A human health assessment of hazardous air pollutants in Portland, OR.

Ambient air samples collected from five monitoring sites in Portland, OR during July 1999 to August 2000 were analyzed for 43 hazardous air pollutants (HAP). HAP concentrations were compared to carcinogenic and non-carcinogenic benchmark levels. Carcinogenic benchmark concentrations were set at a risk level of one-in-one-million (1x10(-6)). Hazard ratios of 1.0 were used when comparing HAP concentrations to non-carcinogenic benchmarks. Emission sources (point, area, and mobile) were identified and a cumulative cancer risk and total hazard index were calculated for HAPs exceeding these health benchmark levels. Seventeen HAPs exceeded a cancer risk level of 1x10(-6) at all five monitoring sites. Nineteen HAPs exceeded this level at one or more site. Carbon tetrachloride, 1,3-butadiene, formaldehyde, and 1,1,2,2-tetrachloroethane contributed more than 50% to the upper-bound lifetime cumulative cancer risk of 2.47x10(-4). Acrolein was the only non-carcinogenic HAP with hazard ratios that exceeded 1.0 at all five sites. Mobile sources contributed the greatest percentage (68%) of HAP emissions. Additional monitoring and health assessments for HAPs in Portland, OR are warranted, including addressing issues that may have overestimated or underestimated risks in this study. Abatement strategies for HAPs that exceeded health benchmarks should be implemented to reduce potential adverse health risks.

Air Pollutants↗
PubMed2005

Teaching inpatient communication skills to medical students: an innovative strategy.

At the University of Washington, a group of medical educators defined a set of communication skills, or "benchmarks," that are expected of second-year medical students conducting history and physical examinations on hospitalized patients. In order to teach the skills listed in the communication benchmarks, an educational strategy was devised that included training sessions for 30 medical teachers and the development of an innovative videotape tool used to train the teachers and their students. The benchmarks were designed in 2003 for the developmental level of the students and were based on key communication concepts and essential elements of medical communication. A set of five short videotaped scenarios was developed that illustrated various segments of a student history and physical examination. Each scenario consisted of an "OK" version of communication and a "better" version of the same scenario. The video scenarios were used in teaching sessions to help students identify effective communication techniques and to stimulate discussion about the communication benchmarks. After the training sessions, teachers and students were surveyed to assess the effectiveness of the educational methods. The majority of students felt that the educational design stimulated discussion and improved their understanding of communication skills. Faculty found the educational design useful and 95% felt that the curriculum and videotape contributed to their own education. The development of communication benchmarks illustrated with short videotaped scenarios contrasting "OK" with "better" communication skills is a useful technique that is transferable to other institutions.

Benchmarking↗
PubMed1999

Characteristics of best gastroenterology practices.

OBJECTIVE: As health care costs continue to rise, competition among providers is increasing. Although this competition is currently based on price, quality of care will become an increasingly important issue. One popular method to assess quality is by comparing physicians' performance with that of a representative group of physicians, in a process called benchmarking. The purpose of this study was to survey private practice gastroenterologists to identify the practice characteristics, so-called "best practices," associated with high-quality health care delivery to provide data for use as benchmarks. METHODS: Three hundred randomly selected gastroenterology practices were surveyed regarding practice demographics, administration, financial management, and use of outcomes techniques by mail questionnaire. Analogous questionnaires were completed by representatives of the gastroenterology practices comprising the Gastroenterology Practice Management Group, LLC (GMPG). RESULTS: One hundred and eighty-two (61%) of the 300 eligible practices responded to the questionnaire. Increasing differences between survey and benchmark GPMG practices were observed as the complexity of quality measures increased. Among structure measures, the groups were similar. By contrast, significant differences were observed between survey and benchmark groups with regards to outcomes measures such as the use of practice guidelines, continuous quality improvement, and outcomes assessment. CONCLUSIONS: These results provide a snapshot of gastroenterology practices across the country and can be used as a benchmark for quality assessment purposes to compare with one's practice, suggesting areas for change or improvement. It seems clear that the defining characteristic of best gastroenterology practices is the demonstration of quality patient care. It also appears that many practices' efforts in this regard could be increased.

Gastroenterology↗
PubMed2000

Dietary exposures to food contaminants across the United States.

Food consumption is an important route of human exposure to pesticides and industrial pollutants. Average dietary exposures to 37 pollutants were calculated for the whole United States population and for children under age 12 years by combining contaminant data with food consumption data and summing across food types. Pollutant exposures were compared to benchmark concentrations, which are based on standard toxicological references, for cancer and noncancer health effects. Average food ingestion exposures for the whole population exceeded benchmark concentrations for arsenic, chlordane, DDT, dieldrin, dioxins, and polychlorinated biphenyls, when nondetects were assumed to be equal to zero. For each of these pollutants, exposure through fish consumption accounts for a large percentage of food exposures. Exposure data for childhood age groups indicated that benchmark concentrations for the six identified pollutants are exceeded by the time age 12 years is reached. The methods used in this analysis could underestimate risks from childhood exposure, as children have a longer time to develop tumors and they may be more susceptible to carcinogens; therefore, there may be several additional contaminants of concern. In addition, several additional pollutants exceeded benchmark levels when nondetects were assumed to be equal to one half the detection limit. Uncertainties in exposure levels may be large, primarily because of numerous samples with contaminant levels below detection limits.

Adolescent↗
PubMed2005

Can the wrong statistic be bad for health? Improving the reporting of door-to-needle time performance in acute myocardial infarction.

BACKGROUND: Current acute myocardial infarction (AMI) guidelines call for reperfusion to be given to all eligible patients within a set time interval after hospital arrival, yet current hospital performance benchmarks are based on the median door-to-intervention time among treated patients. Our objective is to compare hospital performance rankings when door-to-needle time (DNT) is measured at the current benchmark (median < or = 30 minutes) versus those obtained with more stringent benchmarks common for other AMI treatments. METHODS: A secondary analysis of data from the EFFECT study from 52 small, community and teaching hospitals in Ontario. All Ontario hospital corporations that treated > or = 30 patients with AMI from 1999 to 2001 participated. The charts of approximately 125 patients with AMI per hospital were reviewed; median and 85th percentile DNTs were then calculated for patients with ST-elevation AMI given thrombolysis at each site along with the proportion of patients thrombolysed within the recommended time. Hospitals were then ranked according to each indicator. RESULTS: Data were obtained on 1,578 patients given thrombolytic drugs at 52 hospitals. The median and 85th percentile DNTs were 37 and 82 minutes, respectively; the proportion of patients treated in < or = 30 minutes ranged from 8.5% to 60%. Hospitals that achieved a median DNT of < or = 30 minutes treated 40% to 50% of their patients outside that time frame. The ranks of the top 15 median DNT hospitals changed substantially when re-ranked according to the 85th percentile (average change in rank -16, range +6 to -40). If DNT improved such that a 30-minute median target was achieved, the estimated reduction for the average patient would be 13 minutes versus a 43-minute reduction if the 85th percentile target was achieved. CONCLUSION: Hospitals that achieve a 30-minute median DNT benchmark still treat 40% to 50% of their patients outside the recommended time, which is not consistent with current AMI treatment guidelines. Door-to-needle time for the average patient would be up to 43 minutes faster if the DNT target was achieved at the 85th percentile.

Benchmarking↗
PubMed2006

A method to improve the nutritional quality of foods and beverages based on dietary recommendations.

OBJECTIVE: The increasing consumer interest in health prompted Unilever to develop a globally applicable method (Nutrition Score) to evaluate and improve the nutritional composition of its foods and beverages portfolio. METHODS: Based on (inter)national dietary recommendations, generic benchmarks were developed to evaluate foods and beverages on their content of trans fatty acids, saturated fatty acids, sodium and sugars. High intakes of these key nutrients are associated with undesirable health effects. In principle, the developed generic benchmarks can be applied globally for any food and beverage product. Product category-specific benchmarks were developed when it was not feasible to meet generic benchmarks because of technological and/or taste factors. RESULTS: The whole Unilever global foods and beverages portfolio has been evaluated and actions have been taken to improve the nutritional quality. The advantages of this method over other initiatives to assess the nutritional quality of foods are that it is based on the latest nutritional scientific insights and its global applicability. CONCLUSIONS: The Nutrition Score is the first simple, transparent and straightforward method that can be applied globally and across all food and beverage categories to evaluate the nutritional composition. It can help food manufacturers to improve the nutritional value of their products. In addition, the Nutrition Score can be a starting point for a powerful health indicator front-of-pack. This can have a significant positive impact on public health, especially when implemented by all food manufacturers.

Benchmarking↗
PubMed2002

Integration and added value of the modern noninvasive vascular laboratory in vascular diseases management.

BACKGROUND AND PURPOSE: Today's vascular laboratory technology offers broad applications throughout vascular medicine. We explore the diagnostic work-up and management of selected peripheral vascular diseases by benchmarking the institutional mix of invasive and noninvasive technology utilization and associated cost burdens. METHODS: Specialized diagnostic studies for prevention of stroke and pulmonary embolism, and diagnosis and management of femoral pseudoaneurysm were reviewed for our 355-physician clinic and hospital practice. The proportions and costs for invasive and noninvasive diagnostic procedures were tabulated for carotid stenosis, deep venous thrombosis (DVT), and iatrogenic femoral pseudoaneurysm. Current technology utilization mix cost burdens were compared to projected cost burdens for hypothetical equivalent medical value (i.e., the same total test volume) in the theoretical absence of noninvasive laboratory services. RESULTS: The technology utilization mix was dominated by noninvasive duplex ultrasonography for all 3 vascular disease workups. The technology utilization mix benchmarks were 92% noninvasive for carotid stenosis, 98% noninvasive for DVT, and 100% noninvasive for pseudoaneurysm. Under hypothetical constant test volume normalized to utilization level for the 2-year period, the maximal range in cost burdens between current reliance on noninvasive diagnoses versus projected 100% reliance on invasive procedures for the 3 vascular applications is approximately $6 million. CONCLUSION: Benchmark indices reveal near total adoption of noninvasive technology for vascular diagnostic workups at our center. The benefits to institutions of benchmarking their technology utilization mix and costs are discussed in relation to identifying potential for cost-containment from modifying technology utilization practices.

Benchmarking↗
PubMed2006

Waiting and interaction times for patients in a developing country accident and emergency department.

OBJECTIVE: To determine the interaction and waiting times of patients in Barbados Queen Elizabeth Hospital Accident and Emergency Department (A&E), identify their determinants, and compare them to international benchmarks. METHODS: Trained research assistants monitored all patients attending A&E during a one week period in 2003. The time in and out of each step in the process of care was recorded along with demographic data, diagnosis, and acuity. Time elapsed was calculated for various steps in care and compared to international benchmarks. Determinants of timely care were identified. RESULTS: Of 882 eligible A&E patients, 675 (77%) had accurate data and were entered into the study. Interaction times were short, with median total interaction time 13 (IQR 9-21) minutes. Waiting times were long ranging from median 6.5 (IQR 2-22) minutes for registration to 213 (IQR 154-316) minutes for lab results. Of concern was a median wait of 10 (IQR 2-46) minutes for triage and 178 (IQR 105-305) minutes to be seen by a doctor. Mean total length of stay was 377 (SD 261) minutes compared to US benchmark of 90 minutes. All other waiting times were at least twice US benchmarks. Paediatrics cases and children aged 0-11 years had the shortest waiting times and length of stay, whereas medicine patients and those over 49 years had the longest. Those with highest acuity had the shortest waiting times and length of stay. CONCLUSIONS: The A&E could improve patient care processes by shortening waiting times, especially for laboratory results, triage, and seeing a doctor, particularly for older medicine patients.

Adolescent↗
PubMed2005

Project examining effectiveness in clinical ethics (PEECE): phase 1-- descriptive analysis of nine clinical ethics services.

OBJECTIVE: The field of clinical ethics is relatively new and expanding. Best practices in clinical ethics against which one can benchmark performance have not been clearly articulated. The first step in developing benchmarks of clinical ethics services is to identify and understand current practices. DESIGN AND SETTING: Using a retrospective case study approach, the structure, activities, and resources of nine clinical ethics services in a large metropolitan centre are described, compared, and contrasted. RESULTS: The data yielded a unique and detailed account of the nature and scope of clinical ethics services across a spectrum of facilities. General themes emerged in four areas-variability, visibility, accountability, and complexity. There was a high degree of variability in the structures, activities, and resources across the clinical ethics services. Increasing visibility was identified as a significant challenge within organisations and externally. Although each service had a formal system for maintaining accountability and measuring performance, differences in the type, frequency, and content of reporting impacted service delivery. One of the most salient findings was the complexity inherent in the provision of clinical ethics services, which requires of clinical ethicists a broad and varied skill set and knowledge base. Benchmarks including the average number of consults/ethicist per year and the hospital beds/ethicist ratio are presented. CONCLUSION: The findings will be of interest to clinical ethicists locally, nationally, and internationally as they provide a preliminary framework from which further benchmarking measures and best practices in clinical ethics can be identified, developed, and evaluated.

Benchmarking↗
PubMed2005

Usefulness of database studies as applied to managed care.

Benchmarking, an industry comparison tool and a well-known business technology, offers health care a method of establishing standards for health care use with clinical governance. Benchmarking can lead to practice innovations necessary for survival in a managed care environment that has a need for decreasing cost and increasing quality. Information gleaned from the benchmarking dataset can be used to determine where limited resources for disease management programs should be directed. It can also be used to help decision makers manage a drug formulary by providing a basic knowledge about the environment in which a drug will be used and prescribed. This article describes the relationship of database studies and benchmarking and the usefulness as applied to managed care.

Benchmarking↗
PubMed2003

Call-to-needle times for thrombolysis in acute myocardial infarction in Victoria.

OBJECTIVE: To determine the proportion of patients in Victoria treated within the British Heart Foundation 90-minute call-to-needle (CTN) time benchmark for thrombolysis of ST-elevation myocardial infarction (STEMI), and to validate the British Heart Foundation 90-minute benchmark with respect to mortality. DESIGN: Cohort study. SETTING: 20 hospitals and two ambulance services in the State of Victoria, Australia. PARTICIPANTS: 1147 patients with STEMI transported to hospital by ambulance and eligible for thrombolysis. MAIN OUTCOME MEASURES: CTN time, and in-hospital mortality. RESULTS: Median CTN time was 83 minutes (mean, 93.2 min; range, 29-894 min). Median door-to-needle (DTN) time was 37 minutes (mean, 46.5 min; range, 0-853 min). 61% of patients received thrombolysis within the 90-minute benchmark. Patients with CTN times > 90 minutes had an increased risk of dying (relative risk, 1.8; 95% CI, 1.3-2.7). Factors associated with CTN time < 90 minutes were lower DTN time, prior notification of the receiving hospital and transport time less than 20 minutes. CONCLUSION: The British Heart Foundation CTN time benchmark is being met for 61% of eligible STEMI patients in Victoria. Strategies to reduce CTN time should be region-specific, and should include attempts to reduce DTN and to enhance ambulance-hospital communication. Prehospital thrombolysis may be appropriate for some regions.

Adult↗
PubMedDate not supplied

Essence of Care: making a difference.

Essence of Care (DoH 2001) developed from a commitment to explore the benefits of benchmarking in improving the quality of the fundamental and essential aspects of care (DoH 1999). The NHS Plan (DoH 2000) reinforced the importance of getting the basics right and improving the patient's experience. During the 18 months since the publication of the Essence of Care clinical benchmarks (DoH 2001), it has moved steadily from political rhetoric to clinical reality in the Central South Regional Group (CSRG). This article describes the role of the CSRG steering committee in co-ordinating the implementation of Essence of Care. This involved: Education about the benchmarking process. Support for implementation of the benchmarks. Evaluation of the process to date. Direction for future developments. The CSRG steering committee comprises representation from many of the trusts in the CSRG (Table 1), as well as the University of Southampton and New Forest PCT.

Benchmarking↗
PubMed1997

Study provides comparative targets to help reduce costs of surgical procedures.

Data Benchmarks: Cost and LOS benchmarks can help your organization target and reduce costs of surgical procedures. Setting up clinical pathways to improve quality and reduce costs requires good benchmarking data to zero in on the appropriate clinical services or procedures. This month's Data Benchmarks offers good comparative data on the most cost-intensive surgical procedures performed at U.S. hospitals.

Ancillary Services, Hospital↗
PubMed2000

Assessment of patient waiting times for vascular surgery.

OBJECTIVES: To assess patient waiting times for vascular surgery and to determine if complications of the disease develop while the patients are awaiting surgery. DESIGN: Prospective cohort study. SETTING: A university-affiliated tertiary care institution. PATIENTS: All 554 patients who underwent scheduled vascular surgical procedures between April 1995 and October 1996. OUTCOME MEASURES: A literature review carried out to develop guidelines for acceptable waiting times for surgery associated with various vascular disorders based on their natural history (benchmark target); actual waiting times, defined as the interval from the date each patient was booked for surgery to the date of admission to hospital for the procedure; the proportion of patients admitted within the benchmark targets; and whether prolonged waiting time placed patients at risk for complications of their disease. RESULTS: Of the 554 patients, 382 (69%) were admitted within the benchmark waiting times. Of 84 patients having an abdominal aortic aneurysm, the aneurysm ruptured during the waiting period in 6, and 4 of them died, for a complication rate of 7% and a death rate of 5%. Two of the 6 aneurysms ruptured after the patient had waited longer than the target time. Three of 100 patients with symptomatic carotid artery stenosis awaiting admission for carotid endarterectomy suffered ischemic stroke, for a 3% complication rate; all had waited longer than the target period. One patient suffered occlusion of a femoropopliteal bypass graft while awaiting revision of a stenosed bypass graft. CONCLUSIONS: This study suggests that although most patients are admitted for operation within the benchmark time, one-third are admitted late and may suffer serious complications of their disease while awaiting admission for the procedure.

Aortic Aneurysm, Abdominal↗
PubMed2003

Variations in product choices of frequently purchased herbs: caveat emptor.

BACKGROUND: Patients who report use of herbs to their physicians may not be able to accurately describe the ingredients or recommended dosage because the products for the same herb may differ. The purpose of this study was to describe variations in label information of products for each of the 10 most commonly purchased herbs. METHODS: Products for each of 10 herbs were surveyed in a convenience sample of 20 retail stores in a large metropolitan area. Herbs were those with the greatest sales dollars in 1998: echinacea, St John's wort, Ginkgo biloba, garlic, saw palmetto, ginseng, goldenseal, aloe, Siberian ginseng, and valerian. RESULTS: Each herb had a large range in label ingredients and recommended daily dose (RDD) across available products. Strengths were not directly comparable because of ingredient variability. Among 880 products, 43% were consistent with a benchmark in ingredients and RDD, 20% in ingredients only, and 37% were either not consistent or label information was insufficient. Price per RDD was a significant predictor of consistency with the benchmark, but store type was not. CONCLUSIONS: Persons self-medicating with an herb may be ingesting ingredients substantially different from that recommended by a benchmark, both in quantity and content. Higher price per label RDD was the best predictor of consistency with a benchmark. This study demonstrates that health providers and consumers need to closely examine label ingredients of presumably the same or similar herbal products.

Cross-Sectional Studies↗
PubMed1996

Dose-response relationship of teratogenicity and prenatal-toxic risk estimation of 6-mercaptopurine riboside in mice.

6-Mercaptopurine riboside (6-MPr) is used as a cytostatic chemotherapeutic. The teratogenic potential in rodents has been well known for several decades. In this study, the teratogenic risk of low doses of 6-MPr in NMRI mice was estimated based on a dose-response study. The effective doses corresponding to the incidences of 5%, 1%, and 0.1% were calculated using the probit and Weibull model. The evaluation was performed on the basis of both the fetus and the litter by evaluating the variable all gross structural abnormalities. From these experiments, benchmark doses were obtained which were used in low-dose risk assessment to define a reference dose. Depending on the biometrical model and the statistical unit used, values between 1.9 and 5.2 mg/kg (benchmark ED1) and 3.8 and 6.7 mg/kg (benchmark ED5) were obtained. These values were compared to the no observed adverse effect level (NOAEL) which was determined experimentally. The NOAEL was found to be 5 mg/kg, which is quite similar to the ED5 benchmark doses.

Abnormalities, Drug-Induced↗
PubMed2000

Chlorpromazine versus placebo for schizophrenia.

BACKGROUND: Chlorpromazine, formulated in the 1950s, remains a benchmark treatment for those with schizophrenia. OBJECTIVES: To evaluate the effects of chlorpromazine for schizophrenia in comparison to placebo. SEARCH STRATEGY: Electronic searches of Biological Abstracts (1982-1995), The Cochrane Library (1999, Issue 2), The Cochrane Schizophrenia Group's Register (October 1999), EMBASE (1980-1995), MEDLINE (1966-1995), PsycLIT (1974-1995) were undertaken. References of all identified studies were searched for further trial citations. Pharmaceutical companies and authors of trials were contacted. SELECTION CRITERIA: Randomised controlled trials relating to people with schizophrenia, and non-affective serious/chronic mental illness irrespective of mode of diagnosis evaluating chlorpromazine (any dose) versus placebo. Primary outcomes of interest were death, violent behaviours, overall improvement, relapse and satisfaction with care. DATA COLLECTION AND ANALYSIS: Citations and, where possible, abstracts were independently inspected by reviewers, papers ordered, re-inspected and quality assessed. Data were extracted by BT with CA and GA independently checking a 10% sample for reliability. Dichotomous data were analysed using random effects relative risk (RR) and the 95% confidence interval around this was estimated. Where possible the number needed to treat (NNT) or number needed to harm statistics (NNH) were calculated. Continuous data were excluded if more than 50% of people were lost to follow up, but, where possible, weighted mean difference was calculated. Sensitivity analyses have not been undertaken for this version of the review. MAIN RESULTS: Over 1000 electronic records were inspected. The review currently mentions 202 papers in its Excluded Studies section and 45 studies in its Included Studies table. Six papers await assessment. Chlorpromazine reduces relapse over six months to two years (RR 0.65 CI 0.5-0.9, NNT 3 CI 2.5-4) and there is convincing evidence from trials that it promotes a global improvement in a person's symptoms and functioning (RR 0.76 CI 0.7-0.9, NNT 7 CI 5-10) although the placebo response is also considerable (nearly 40%). Fewer people allocated to chlorpromazine leave trials early (RR 0.76 CI 0.6-1.1). There are many adverse effects. Chlorpromazine is clearly sedating (RR 2.4 CI 1.7-3.3, NNH 6 CI 4-8), it increases a person's chances of experiencing acute movement disorders (RR 3.1 CI 1.3-7.6, NNH 24 CI 14-77), parkinsonism (RR 2.6 CI 1.2-5.4, NNH 10 CI 8-16) and fits (RR 2.4 CI 0.4-16). Amongst other things it clearly causes a lowering of blood pressure with accompanying dizziness (RR 1.9 CI 1. 3-2.6, NNH 12 CI 8-22) and considerable increases in weight (RR 4.4 CI 2.1-9, NNH 3 CI 2-5). REVIEWER'S CONCLUSIONS: This review will confirm much that clinicians and recipients of care already know but provides quantification to support clinical impression. Despite the humbling 40% improvement rate in those who were allocated to placebo, chlorpromazine's global position as the 'benchmark' treatment of those with psychoses is not threatened by this review. Chlorpromazine, in common use for nearly half a century, is a well established but imperfect treatment. Judicious use of this best available evidence should lead to better informed decisions both by carers and those with psychotic illnesses.

Antipsychotic Agents↗
PubMed2001

What are the dielectric "constants" of proteins and how to validate electrostatic models?

Implicit models for evaluation of electrostatic energies in proteins include dielectric constants that represent effect of the protein environment. Unfortunately, the results obtained by such models are very sensitive to the value used for the dielectric constant. Furthermore, the factors that determine the optimal value of these constants are far from being obvious. This review considers the meaning of the protein dielectric constants and the ways to determine their optimal values. It is pointed out that typical benchmarks for validation of electrostatic models cannot discriminate between consistent and inconsistent models. In particular, the observed pK(a) values of surface groups can be reproduced correctly by models with entirely incorrect physical features. Thus, we introduce a discriminative benchmark that only includes residues whose pK(a) values are shifted significantly from their values in water. We also use the semimacroscopic version of the protein dipole Langevin dipole (PDLD/S) formulation to generate a series of models that move gradually from microscopic to fully macroscopic models. These include the linear response version of the PDLD/S models, Poisson Boltzmann (PB)-type models, and Tanford Kirkwwod (TK)-type models. Using our different models and the discriminative benchmark, we show that the protein dielectric constant, epsilon(p), is not a universal constant but simply a parameter that depends on the model used. It is also shown in agreement with our previous works that epsilon(p) represents the factors that are not considered explicitly. The use of a discriminative benchmark appears to help not only in identifying nonphysical models but also in analyzing effects that are not reproduced in an accurate way by consistent models. These include the effect of water penetration and the effect of the protein reorganization. Finally, we show that the optimal dielectric constant for self-energies is not the optimal constant for charge-charge interactions.

Ions↗