Genetic Polymorphisms in ADORA2A and CYP1A2 Influence Caffeine's Effect on Postprandial Glycaemia.

The liver enzyme cytochrome P450 1A2 (CYP1A2) is responsible for 90% of caffeine metabolism, while caffeine exerts many of its effects via antagonist binding to adenosine A2a receptors (ADORA2A). This study aimed to examine whether functional single nucleotide polymorphisms (SNPs) in 1976T > C (ADORA2A; rs5751876) and -163C > A (CYP1A2; rs762551) influence the effect of caffeine on the postprandial glucose (GLU) response to a carbohydrate meal. We report that individuals with the 1976T > C CC, but not CT/TT genotypes display elevated GLU levels after consuming caffeine and carbohydrate (CHO + CAFF) versus carbohydrate only (CHO). The GLU area under the curve (AUC) was also greater during the CHO + CAFF condition compared to the CHO condition in CC, but not the CT/TT genotypes. The -163C > A AC/CC, but not AA, genotypes displayed greater GLU concentrations 60-min post meal during CHO + CAFF versus CHO. Our data suggest that caffeine-induced impairments in postprandial glycaemia are related to 1976T > C and -163C > A SNPs.

Dispersal of potato cyst nematodes measured using historical and spatial statistical analyses.

Rates and modes of dispersal of potato cyst nematodes (PCNs) were investigated. Analysis of records from eight countries suggested that PCNs spread a mean distance of 5.3 km/year radially from the site of first detection, and spread 212 km over ≈40 years before detection. Data from four countries with more detailed histories of invasion were analyzed further, using distance from first detection, distance from previous detection, distance from nearest detection, straight line distance, and road distance. Linear distance from first detection was significantly related to the time since the first detection. Estimated rate of spread was 5.7 km/year, and did not differ statistically between countries. Time between the first detection and estimated introduction date varied between 0 and 20 years, and differed among countries. Road distances from nearest and first detection were statistically significantly related to time, and gave slightly higher estimates for rate of spread of 6.0 and 7.9 km/year, respectively. These results indicate that the original site of introduction of PCNs may act as a source for subsequent spread and that this may occur at a relatively constant rate over time regardless of whether this distance is measured by road or by a straight line. The implications of this constant radial rate of dispersal for biosecurity and pest management are discussed, along with the effects of control strategies.

Use of administrative data to find substandard care: validation of the complications screening program.

OBJECTIVE: The use of administrative data to identify inpatient complications is technically feasible and inexpensive but unproven as a quality measure. Our objective was to validate whether a screening method that uses data from standard hospital discharge abstracts identifies complications of care and potential quality problems. DESIGN: This was a case-control study with structured implicit physician reviews. SETTING: Acute-care hospitals in California and Connecticut in 1994. PATIENTS: The study included 1,025 Medicare beneficiaries greater than 265 years of age. METHODS: Using administrative data, we stratified acute-care hospitals by observed-to-expected complication rates and randomly selected hospitals within each state. We randomly selected cases flagged with 1 of 17 surgical complications and 6 medical complications. We randomly selected controls from unflagged cases. MAIN OUTCOME MEASURE: Peer-review organization physicians' judgments about the presence of the flagged complication and potential quality-of-care problems. RESULTS: Physicians confirmed flagged complications in 68.4% of surgical and 27.2% of medical cases. They identified potential quality problems in 29.5% of flagged surgical and 15.7% of medical cases but in only 2.1% of surgical and medical controls. The rate of physician-identified potential quality problems among flagged cases exceeded 25% in 9 surgical screens and 1 medical screen. Reviewers noted several potentially mitigating circumstances that affected their judgments about quality, including factors related to the patients' illness, the complexity of the case, and technical difficulties that clinicians encountered. CONCLUSIONS: For some types of complications, screening administrative data may offer an efficient approach for identifying potentially problematic cases for physician review. Understanding the basis for physicians' judgments about quality requires more investigation.

Does the Complications Screening Program flag cases with process of care problems? Using explicit criteria to judge processes.

BACKGROUND: The Complications Screening Program (CSP) aims to identify 28 potentially preventable complications of hospital care using computerized discharge abstracts, including demographic information, diagnosis and procedure codes. OBJECTIVE: To validate the CSP as a quality indicator by using explicit process of care criteria to determine whether hospital discharges flagged by the CSP experienced more process problems than unflagged discharges. METHODS: The (CSP was applied to computerized hospital discharge abstracts from Mledicare beneficiaries > 65 years old admitted in 1994 to hospitals in California and Connecticut for major surgery or medical treatment. ()f 28 CSP complications, 17 occurred sufficient frequently to study. Discharges flagged (cases) and unflagged (controls) by the (CSP were sampled and photocopied medical records were obtained. Physicians specified detailed, objective, explicit criteria, itemizing 'key steps' in processes of care that could potentially have prevented or caused complications. Trained nurses abstracted medical records using these explicit criteria. Process problem rates between cases and controls were compared. RESULTS: The final sample included 740 surgical and 416 medical discharges. Rates of process problems were high, ranging from 24.4 to 82.5% across CSP screens for surgical cases. Problems were lower for medical cases, ranging from 2.0 to 69.1% across CSP screens. Problem rates were 45.7% for surgical and 5.0% for medical controls. Rates of problems did not differ significantly across flagged and unflagged discharges. CONCLUSIONS: The CSP did not flag discharges with significantly higher rates of explicit process problems than unflagged discharges. Various initiatives throughout the USA use techniques similar to the CSP to identify complications of care. Based on these CSP findings, such approaches should be evaluated cautiously.

Positive outcome after looped peripherally inserted central catheter malposition. A case study.

Tip malposition of peripherally inserted central catheters (PICCs) is a frequently encountered problem. Invasive and noninvasive techniques for resolution of malpositions described in the literature are reviewed. A positive outcome using non-invasive techniques after a looped malposition in the axillary vein is discussed.

Assessing HCFA's Health Care Quality Improvement Program.

BACKGROUND: In 1992 the Health Care Financing Administration introduced the Health Care Quality Improvement Program (HCQIP), through which quality improvement projects are conducted in partnership with quality improvement organizations (QIOs), hospitals, health plans, or physicians. An evaluation of HCQIP began in May 1996 in response to the QIOs' request for an independent assessment of their activities. METHODOLOGY: The methodology and objectives of the evaluation were determined by an independent panel. The QIOs' full cohort of 970 HQIP projects could not be reviewed in the 10-month time frame available, but two topics were chosen: the management of warfarin or aspirin in patients with atrial fibrillation and the management of community-acquired pneumonia. FINDINGS: Analyses were limited to the 49 of the 68 projects that had progressed to the "improvement plan implemented" stage. However, only 39 of these 49 projects had information on outcomes, organization changes, and/or changes in process of care--and only 20 of the 49 had moved beyond the "improvement plan implemented" phase. Feedback of data led hospitals collaborating on improvement projects to revise or create processes of care. DISCUSSION: Although the assessment is the most comprehensive of its type to date, it should be viewed as a pilot study of some of the methods that could be incorporated in a more extensive and rigorous future evaluation of the impact of the HCQIP projects. Specific recommendations include random sampling of HCQIP projects across all clinical areas, conducting both prospective and retrospective assessments, developing uniform process and outcome program impact measures, and developing sustainable, ongoing automated data abstraction and analysis systems.

Solid phase microextraction for quantitative headspace sampling of apple volatiles.

Solid phase microextraction (SPME) was evaluated for use in the quantification of aroma volatile production by Granny Smith apples during cool storage. Particular attention was paid to quantifying alpha-farnesene (3,7,11-trimethyldodeca-1,3(E),6(E),10-tetraene) due to its involvement in superficial scald, a disorder of cool stored apples. Comparison between SPME and solid phase extraction (SPE) showed that the SPME fiber had greater adsorption of high molecular weight (MW) volatiles such as alpha-farnesene. When sampling by SPME, these higher MW volatiles did not equilibrate between apples, headspace, and fiber within sampling times as long as 90 min, while lower MW volatiles equilibrated within 5 min. This behavior was also shown by a simple model system consisting of five selected volatiles dissolved in an involatile, lipophilic liquid (squalane). The less volatile high MW aroma compounds evaporated slowly from the surface of the apples and were depleted from the headspace because of very rapid adsorption by the SPME fiber. The amount of alpha-farnesene adsorbed by the fiber increased with air movement through the system. In a static headspace system, the amount of alpha-farnesene adsorbed by the fiber decreased nonlinearly with increasing distance from the apples, due to adsorption onto the glass walls. While SPME is ideal for rapid, qualitative determination of apple headspace volatiles, the slower equilibration of higher MW volatiles limits its use for quantification in more complex systems.

Variability in clinical systems: applying modern quality control methods to health care.

BACKGROUND: Quality health care depends on timely completion of sequences of clinical care. This study evaluated the concepts and tools of quality management for measuring system performance in ambulatory care. STUDY DESIGN: Clinical staff in nine centers of a group model health maintenance organization described the procedure for ordering and completing a complete blood count, mammogram, and surgical consultation. Variability was noted among the processes as intended and as actually performed, as well as inconsistencies reported within and among centers. In two centers investigators tracked performance of key sequences of care and the achievement of other key quality characteristics believed desired by physicians and patients. Computerized patient records and departmental files were the only available sources of data for assessing completion and followup of tests and consultations. Even these data were difficult to obtain and, in many instances, incomplete. RESULTS: Although data were often difficult to obtain, the quality management techniques used were helpful in revealing process failures that appeared to be the result of design flaws built into the clinical systems. CONCLUSION: Robust process designs and improved management information systems for monitoring these processes are recommended to reduce variability and improve the quality of clinical care.

Designing and using measures of quality based on physician office records.

This article presents our principles for developing performance measures to assess the quality of ambulatory care. The measures were developed as part of a project for developing and evaluating methods to promote ambulatory care quality (DEMPAQ). We describe our design for the performance measures, present examples of the DEMPAQ review criteria, and show the formats we used to feed back information to physicians. We conclude by presenting the results of our appraisal of the performance measures showing how evaluation can aid in the interpretation of measurement findings.

Body image measurement in overweight females.

This article details two studies of the reliability and validity of three instruments to measure body image and suggestions for their use in interventions for weight control programs. Weight control programs often fail because there is no attempt to modify clients' negative body images; hence clients may regain weight to match incorrect images. Short, easily administered instruments, such as the Nash Body Image Scale, the Body Image Photo Technique, and the Body Shape Questionnaire used in these studies, are needed to evaluate clients' progress in weight control programs. Subjects were 120 women who were either satisfied or dissatisfied with their body image and weight. All subjects completed body image measures at the outset of the study and 43 subjects completed measures again to determine trait stability of body image at 1 year. Cronbach's alpha estimates provided evidence of reliability, with internal consistency coefficients ranging from .83 to .96. Validity of the measures was supported by significant correlations with scores on the Physical subscale of the Tennessee Self-Concept Scale (r = .60 to .63) as well as by significant differences on the three measures between normal-weight and overweight groups (Nash: F = 28.03, p = .001; Photo: F = 11.58, p = .001). Body image was found to be stable over the 1-year period on the Nash Body Image Scale and the Body Image Photo Technique. These instruments can provide valuable information and potential intervention content for practitioners and researchers alike. The three body image instruments discussed were found to have sufficient reliability and validity to warrant their use in practice and research.

Improving the quality of ambulatory health care with enhanced medical information systems: using the computer to diagnose faulty clinical processes.

The lack of consistency in the performance of the processes which implement clinical decisions is an important problem in ambulatory care. Since delayed or neglected actions in patient care may have serious consequences, we studied the use of industrial quality management techniques to determine where three clinical processes could be improved. These quantitative and graphical tools were useful in showing that in some processes, the failure rate could be as high as 33%. However, lack of readily available process data prevented a full analysis of the extent of the failures, so specific suggestions for improvement could not be made. Medical informatics and management specialists have an important role in designing enhanced medical information systems with which to examine and improve patient care processes. This new generation of MIS's should include order entry systems with flags for selected transactions, audit trails for all automated processes, functional integration of the separate departmental information systems, and enhanced communications features.

Clinical reminders in ambulatory care.

Computerized reminders are a tool to improve patient care, increase compliance, and reduce medical liability in ambulatory health care. Continuity of care is often hard to achieve given large patient loads, cost containment pressures, and regulatory requirements. Recall reminders prompt patients to make or keep appointments for health maintenance or screening exams. Physician reminders are issued to clinicians at or between visits when their patients have specific screening or diagnostic needs. Reminder systems based on clinical protocols have the added advantage of providing explicit instructions for workup or treatment of abnormal conditions. These reminder systems are especially useful to standardize care in offices with many providers. Implementation of reminder systems is aided by careful staff preparation and resource allocation. Ultimately, reminder systems enhance quality of care, increase patient satisfaction, and reduce costs through improved continuity of care and early detection of serious illness.

A microELISA Raji cell assay to detect immune complexes.

The Raji cell assay to detect immune complexes has been modified to a microtiter ELISA system. Raji cells were fixed to microplate wells, then reacted with serum samples or aggregated human IgG. Horseradish peroxidase-conjugated anti-human IgG was used to detect bound complexes. There was a linear relationship between aggregated IgG added and optical density reading, with less than 2 micrograms/ml of aggregated IgG readily detected. When applied to human serum this technique gave results comparable to those obtained with the standard Raji cell assay. The Raji micro-ELISA is simpler to perform than the standard assay, is equally reliable, and avoids the hazards of radioactivity.