Managing COVID-19 within and across health systems: why we need performance intelligence to coordinate a global response.

BACKGROUND: The COVID-19 pandemic is a complex global public health crisis presenting clinical, organisational and system-wide challenges. Different research perspectives on health are needed in order to manage and monitor this crisis. Performance intelligence is an approach that emphasises the need for different research perspectives in supporting health systems' decision-makers to determine policies based on well-informed choices. In this paper, we present the viewpoint of the Innovative Training Network for Healthcare Performance Intelligence Professionals (HealthPros) on how performance intelligence can be used during and after the COVID-19 pandemic. DISCUSSION: A lack of standardised information, paired with limited discussion and alignment between countries contribute to uncertainty in decision-making in all countries. Consequently, a plethora of different non-data-driven and uncoordinated approaches to address the outbreak are noted worldwide. Comparative health system research is needed to help countries shape their response models in social care, public health, primary care, hospital care and long-term care through the different phases of the pandemic. There is a need in each phase to compare context-specific bundles of measures where the impact on health outcomes can be modelled using targeted data and advanced statistical methods. Performance intelligence can be pursued to compare data, construct indicators and identify optimal strategies. Embracing a system perspective will allow countries to take coordinated strategic decisions while mitigating the risk of system collapse.A framework for the development and implementation of performance intelligence has been outlined by the HealthPros Network and is of pertinence. Health systems need better and more timely data to govern through a pandemic-induced transition period where tensions between care needs, demand and capacity are exceptionally high worldwide. Health systems are challenged to ensure essential levels of healthcare towards all patients, including those who need routine assistance. CONCLUSION: Performance intelligence plays an essential role as part of a broader public health strategy in guiding the decisions of health system actors on the implementation of contextualised measures to tackle COVID-19 or any future epidemic as well as their effect on the health system at large. This should be based on commonly agreed-upon standardised data and fit-for-purpose indicators, making optimal use of existing health information infrastructures. The HealthPros Network can make a meaningful contribution.

How can we monitor the impact of national health information systems? Results from a scoping review.

BACKGROUND: National health information (HI) systems provide data on population health, the determinants of health and health system performance within countries. The evaluation of these systems has traditionally focused on statistical practices and procedures, and not on data use or reuse for policy and practice. This limits the capacity to assess the impact of HI systems on healthcare provision, management and policy-making. On the other hand, the field of Knowledge Translation (KT) has developed frameworks to guide evidence into practice. METHODS: A scoping review of the KT literature to identify the essential mechanisms and determinants of KT that could help monitor the impact of HI systems. RESULTS: We examined 79 publications and we identified over 100 different KT frameworks but none of these were focused on HI systems per se. There were specific recommendations on disseminating evidence to stakeholders at the institutional and organizational level, and on sustaining the use of evidence in practice and the broader community setting. CONCLUSIONS: We developed a new model, the HI-Impact framework, in which four domains are essential for mapping the impact of national HI systems: (i) HI Evidence Quality, (ii) HI System Responsiveness, (iii) Stakeholder Engagement and (iv) Knowledge Integration. A comprehensive impact assessment of HI systems requires addressing the use of HI in public health decision-making, health service delivery and in other sectors which might have not been considered previously. Monitoring Stakeholder Engagement and Knowledge Integration certifies that the use of HI in all policies is an explicit point of assessment.

Anterior versus posterior approach in 3D correction of adolescent idiopathic thoracic scoliosis: a meta-analysis.

PURPOSE: Systematic review was conducted to compare effectiveness and safety of anterior and posterior surgical approach in 3D correction of adolescent idiopathic thoracic scoliosis. METHODS: Data sources were MEDLINE and SCOPUS databases. We included studies on the use of either anterior or posterior instrumentation, or their combination, in surgical correction of adolescent idiopathic thoracic scoliosis, with at least 10 enrolled patients, aged less than 20 years at the time of surgery, and a follow-up of at least 24 months. A study was eligible if it reported the number of patients, mean estimate and dispersion of three key outcome measures (frontal and sagittal Cobb angle, apical vertebra rotation according to Perdriolle) at three measurement points (preoperatively, postoperatively, at follow-up). The quality of studies was assessed using the scale by Pilkington. RESULTS: Although 24 articles met the inclusion criteria, no randomized controlled trials (RCT) was identified. None of the articles was of high quality. Both instrumentations provided a similar degree of reduction of frontal Cobb angle. Long-term effects of surgical correction on the sagittal Cobb angle seemed to be more stable in patients treated by posterior approach, while the anterior approach was more effective in the reduction of apical vertebral rotation. The surgery parameters were more favorable for anterior approach, particularly for the number of fused vertebrae. CONCLUSIONS: Although the available evidence favors neither of the two approaches, our study revealed several important issues: the reports are heterogeneous and provide incomplete relevant information. High quality studies, particularly RCT, are called for. LEVEL OF EVIDENCE: Level II.

Changes in Na+/K+-ATPase activity, unsaturated fatty acids and metallothioneins in gills of the shore crab Carcinus aestuarii after dilute seawater acclimation.

We have assessed the activity of Na(+)/K(+)-ATPase, cAMP, free fatty acids (FFA) and metallothionein (MT) in the posterior gills of the brackish water shore crab Carcinus aestuarii during acclimation to 10 ppt dilute seawater (DSW). Following 3-18 days acclimation in DSW specific activity of Na(+)/K(+)-ATPase in native gill homogenates and partially purified membrane vesicles was progressively increased, from 1.7- to 3.9-fold. After short-term acclimation of crabs in DSW with added sucrose to make media isosmotic with the haemolymph the specific Na(+)/K(+)-ATPase activity in homogenates was not increased, relative to SW enzyme activity. Moreover, hyposmotic conditions led to depletion of cAMP in gills. In partially purified membrane vesicles isolated from posterior gills, fatty acids with compositions 16:0, 18:0, 18:1, 20:4 and 20:5 dominated in both SW- and DSW-acclimated Carcinus. During a year in which the metabolic activity of crabs was increased, the arachidonic/linoleic acids ratio (ARA/LA) for DSW-acclimated crabs was markedly increased relative to that in SW. Increased Na(+)+K(+)-ATPase activity under hyposmotic stress may be modulated at least partially by the changed proportion of fatty acids in the purified membranes of posterior gills. Long-term acclimation of shore crabs to DSW resulted in a 2.6-fold increase in cytosolic metallothionein (MT) content in posterior gills over those in SW crabs. Assuming an antioxidant role of MT associated with intracellular zinc partitioning, the observed MT induction in posterior gills may be considered an adaptive response of C. aestuarii to hyposmotic stress.

Dielectric relaxation of DNA aqueous solutions.

We report on a detailed characterization of complex dielectric response of Na-DNA aqueous solutions by means of low-frequency dielectric spectroscopy (40 Hz-110 MHz). Results reveal two broad relaxation modes of strength 20

Screening and fundamental length scales in semidilute Na-DNA aqueous solutions.

The fundamental length scales in semidilute Na-DNA aqueous solutions have been investigated by dielectric spectroscopy. The low- and the high-frequency relaxation modes are studied in detail. The length scale of the high-frequency relaxation mode at high DNA concentrations can be identified with the de Gennes-Pfeuty-Dobrynin correlation length of polyelectrolytes in semidilute solution, whereas at low DNA concentrations and in the low added salt limit the length scale shows an unusual exponent reminiscent of semidilute polyelectrolyte chains with hydrophobic backbone. The length scale of the low-frequency relaxation mode corresponds to a Gaussian chain composed of correlation blobs in the low added salt limit, and to the Odijk-Skolnick-Fixman value of the single chain persistence length in the high added salt limit.

Osteogenic protein-1 (BMP-7) accelerates healing of scaphoid non-union with proximal pole sclerosis.

We randomly assigned 17 patients with scaphoid non-union at the proximal pole to three treatment groups: (1) autologous iliac graft (n=6), (2) autologous iliac graft + osteogenic protein-1 (OP-1; n=6), and (3) allogenic iliac graft + OP-1 (n=5). Radiographic, scintigraphic, and clinical assessments were performed throughout the follow-up period of 24 months. OP-1 improved the performance of both autologous and allogenic bone implants and reduced radiographic healing time to 4 weeks compared with 9 weeks in group 1. Helical CT scans and scintigraphy showed that in OP-1-treated patients sclerotic bone was replaced by well-vascularised bone. The addition of OP-1 to allogenic bone implant equalised the clinical outcome with the autologous graft procedure. Consequently the harvesting of autologous graft can be avoided.

Evaluation of the Mytilus galloprovincialis Lam. digestive gland metallothionein as a biomarker in a long-term field study: seasonal and spatial variability.

A study was made of seasonal and spatial variability of metallothionein (MT) concentrations, determined spectrophotometrically in the soluble fraction of the digestive gland of mussels Mytilus galloprovincialis, collected between 1999 and 2001 from several coastal and estuarine locations along the central Eastern Adriatic coast (Croatia). The seasonal influence on the MT and metal concentrations (higher values in winter-spring season, than in summer-autumn season) is more pronounced than the local site-specific influence. Furthermore, within each season a significant site-specific dependence on the MT and trace metal variations can be detected. An inverse relationship of mussel condition index (CI) and temperature with MT and trace metals levels indicates the influence of food abundance and mussel annual reproductive cycle. Substantially higher concentrations of both MT and Cd were recorded in mussels inhabiting estuarine locations, possibly indicating a markedly higher Cd bioavailability at these locations. The positive correlations obtained between MT and Cd in all seasons except autumn support an argument for application of digestive gland MT as a biomarker of Cd exposure, providing evidence for assessing the most appropriate season for mussel sampling.

Haematological malignancies in childhood in Croatia: investigating the theories of depleted uranium, chemical plant damage and 'population mixing'.

Some of potential causes proposed to explain the reported increase of haematological malignancies in childhood during or after the war period in several countries include depleted uranium, chemical pollution and population mixing theory. The aim of this study was to define the population of Croatian children aged 0-14 years who were potentially exposed to each of those risks during the war and to investigate any possible association between the exposure and the incidence of haematological malignancies. The authors analyzed the data reported by the Cancer Registry of Croatia during the pre-war period (1986-1990), war period (1991-1995) and post-war period (1996-1999). In the group of 10 counties potentially exposed to depleted uranium and two counties where chemical war damage occurred, no significant difference in incidence of the studied haematological malignancies was noted in comparison to pre-war period. The incidence of lymphatic leukaemia significantly increased in four counties where population mixing had occurred during the war period, supporting the 'mixing theory'. In those counties, the incidence of Hodgkin's lymphoma decreased during and after the war. In Croatia as a whole, decreases in incidence of myeloid leukaemias during war and non-Hodgkin lymphoma after the war were noted.

Gender related differences of low level exposure to occupational irritants--a three-year follow-up of chemical industry workers.

The authors followed changes in the ventilatory function in a group of 102 chemical workers over a three year period to evaluate gender related differences on respiratory effects of low concentrations of occupational irritants. Measurements were performed annually and the results of ventilatory test were compared to predicted normal values. Lung function was measured by recording maximum expiratory flow-volume (MEFV) curves. Baseline data show ventilatory function impairments of the obstructive-restrictive type, as measured by the Tiffeneau index and FEV1. After one and two years of exposure, impairment in flow rates at low lung volumes became prominent. Analysis of lung function in three years of the study suggests obstructive impairments mostly in the larger airways accompanied by a restrictive component. The ventilatory flow at low lung volumes was characterized by obstruction, but not by restrictive findings. Women appear to be more sensitive than men to the irritant effects of these exposures as measured by flow rates at low lung volumes--the smaller airways (FEF50% = 82.7 +/- 23.6 in women and FEF50% = 92.1 +/- 32.1 in men; p = 0.017), while men experienced greater changes than women to irritant effects on their ventilatory capacity--the large airways (FVC = 99.6 +/- 10.6 in men and FVC = 106.74 +/- 9.8 in women; p = 0.001). The additive effect of smoking to environmental irritation is demonstrated by the proportionately lower lung capacity in smokers. Overall, the effect of these pollutants in women is more synergistic than additive.

[Use of international databases for improvement of comprehensive care of patients with head and neck cancer]. / Uporaba medunarodnih baza podataka pri unapredivanju sveobuhvatne skrbi za bolesnika s rakom glave i vrata.

The aim of this paper was to examine the usefulness of CancerNet in the improvement of knowledge of general practitioners on specific types of cancer and the procedures for patient management, thus indirectly producing an impact on quality improvement in comprehensive health care of patients with the head and neck cancer. Data on 58 patients with the head and neck cancer were collected from medical records in 28 general practices of the "Novi Zagreb" Health Center and from GPs' information. The GPs' knowledge on cancer of the larynx and hypopharynx was examined before and after they had studied the information provided by CancerNet. The mechanism of transferring information from the clinical and public health levels towards GPs was examined on GPs having in their care patients with the head and neck cancer. The following methodological characteristics were determined to have had an impact on patient care: within the structure of health care, a possible contribution of this procedure was identified in completing patient medical documentation as well as GPs' specific knowledge; within the health care process, a possible impact of this procedure on the quality of monitoring of a population health status, on more regular referrals to specialist consultations, as well as on pain and anxiety management, and a higher quality education on elimination of risk factors in patients' lifestyles. In average, the usefulness was scored by GPs with 4.0 for improving the communication with patients, and with 4.3 for expanding the GPs' knowledge. Three fifths of GPs involved in the study considered the contact range provided by CancerNet sufficient. All GPs assessed such information as useful for GPs in Croatia.

Haloperidol-stomach lesions attenuation by pentadecapeptide BPC 157, omeprazole, bromocriptine, but not atropine, lansoprazole, pantoprazole, ranitidine, cimetidine and misoprostol in mice.

The focus was on haloperidol (central dopamine antagonist)-stomach lesion, a longly described suitable counterpart of dopamine blocker cysteamine-duodenal lesion. In this, the contribution of blockade of central/peripheral dopamine receptors and prostaglandins synthesis, along with influence of antiulcer agents was evaluated in mice. Male NMRI Hannnover mice were sacrificed 24 h after haloperidol (25 mg/kg b.w. i.p., given alone or with saline (haloperidol+saline) (i) or in combination (ii,iii)). Supporting central dopamine predominance for haloperidol stomach lesion induction, co-administration of peripheral dopamine receptor antagonist domperidone (5 mg/kg i.p.) (haloperidol+ domperidone) (ii), or prostaglandin synthesis inhibitor indomethacin (10 mg/kg s.c.) (haloperidol+ indomethacin) (iii) did not aggravate this lesion. (i) In haloperidol+saline challenged mice the lesions were inhibited by co-administration (/kg i.p.) of a gastric pentadecapeptide BPC 157, GlyGluProProProGlyLysProAlaAspAspAlaGlyLeuVal, M.W. 1419 (10 microg, 10 ng, 10 pg, but not 1 pg, 100 fg, 10 fg), bromocriptine (10 mg), omeprazole (10 mg, 100 mg, but not 1 mg). Atropine (10, 100, 200 mg), pirenzepine (10, 100, 200 mg), misoprostol (10, 100, 200 microg), pantoprazole (1, 10, 100 mg), lansoprazole (0.1, 1, 10 mg), cimetidine (10, 100, 200 mg) and ranitidine (10, 100, 200 mg) were not effective. (ii) Dopamine peripheral blockade influence: in haloperidol+domperidone mice, previously effective bromocriptine, pentadecapeptide BPC 157 (10 microg) or omeprazole (10 mg) did not attenuate stomach lesions. (iii) Prostaglandins synthesis blockade effect: in haloperidol+indomethacin mice, previously effective agents, bromocriptine or omeprazole were not active, while BPC 157 effect was only lessened.

Patients' views on the professional behaviour of family physicians.

BACKGROUND: Patient satisfaction is an important part and a measure of the quality of health care. Patient satisfaction with family physicians was studied within the project 'Analysis of Transition of Health Care System in Croatia'. OBJECTIVES: The aim of this study was to explore patient satisfaction with family physicians through evaluation of some characteristics of physician behaviour. The specific goals of this study were to determine whether there were differences in the evaluation of patient satisfaction with physician behaviour with regard to some sociodemographic characteristics of the respondents. METHODS: The study group consisted of 1217 respondents: 479 (39.4%) men and 738 (60.6%) women. Medical students interviewed the respondents 'face-to-face' immediately after their consultation with the physician. An anonymous questionnaire was created providing answers to 10 questions on patient satisfaction. Data on sociodemographic characteristics and the reason for encounter of the respondents were also collected. RESULTS: The average positive rating over 10 questions on patient satisfaction was 85.3%. There was a statistically significant difference in age distribution between geographic areas (P < 0.001). Differences in answers were found regarding sex, age, educational level (P < 0.001) and reason for encounter (P < 0.01). Two factors were obtained by factor analysis: the first could be called physician's competence/expertise estimated by respondents, and the other physician's empathy evaluated by respondents. The respondents were divided into two groups based on the reason for encounter as a criterion for discriminant analysis: acute (symptoms and complaints, injuries; n = 553) and other reasons (n = 664). The discriminant function obtained was statistically significant (P < 0.01). Younger respondents, regardless of sex, whose reason for encounter was an acute condition, were less satisfied with the physician's expertise, agreeableness during the consultation, physician's interest in what they were saying and physician's friendliness. CONCLUSION: Considering the difficulties present in the health systems of countries in transition, the results of our study were surprisingly encouraging, showing that the respondents were satisfied with the physician's behaviour and that the physicians fulfilled the basic elements of professional behaviour.

The Croatian health survey--patient's satisfaction with medical service in primary health care in Croatia.

The aim of the study was to investigate patient satisfaction with nurses and general practice organization in Croatia. A total of 2,252 patients 18 years of age and over from 47 randomly selected general practices were included in the study. 72.1% of patients were satisfied with nurses and general practice organization. Older and less educated patients were generally more satisfied. Patients were more pleased with nurses' behavior (81.9%) than with practice organization (62.3%). Factor analysis revealed two underlying discriminates of patient satisfaction--"positive attitude towards the nurse" and "inaccessibility of practice". The former discriminate emphasized a great potential of nursing, which should be taken into consideration in the transformation of health care system in Croatia.

Genealogical structuring of a population.

The study observed population of 484 generation restrictive genealogies collected in four Croatian regions during 1970/71 within "The study of fat and carbohydrate metabolism indicators correlated with the occurrence of diabetes in animal fat and oil consuming population groups". The genealogies were collected on two islands (Brac and Hvar) and in two continental regions (Sinjska Krajina and Srijem). Genealogy Structure Index (GSI) was defined as quantitative indicator of genealogy structure. GSI was continuos variable which, by its extreme, describes vertical and horizontal type of genealogy structure, independently of the way genealogies were collected. Genealogy structure of surveyed population was described on the basis of participation of different genealogy types. Populations of the island Hvar and Brac showed to have horizontal genealogy type, continental population of Sinjska Krajina showed to have mixed type and continental population of Srijem showed to have vertical type of genealogy structure.

Sonographic measurement of detrusor muscle thickness in healthy children.

The aim was to measure detrusor thickness in healthy children, using high frequency ultrasonography, to determine normal values that could be used for the evaluation of pathological bladder conditions. Ultrasound (US) was performed in 62 children (38 boys, 24 girls, 20 months - 18 years, mean 8.4+/-4.5 years) with the absence of clinical or laboratory pathological changes of the urinary tract. The detrusor thickness was measured at the posterior, anterior and lateral bladder walls, and the average thickness was calculated for each bladder wall in every child. The mean detrusor thickness was 1.17+/-0.45 mm (range 0.4-2.8 mm) for the anterior bladder wall, 1.25+/-0.45 mm (range 0.5-3.0 mm) for the posterior bladder wall, 1.18+/-0.44 mm (range 0.4-2.9 mm) for the left lateral wall, and 1.19+/-0.45 mm (range 0.4-2.8 mm) for the right lateral wall. There was a significant correlation of mean detrusor thickness with age. Using high-frequency US transducers it was possible to measure the detrusor thickness of the anterior and posterior bladder walls in all children. The mean normal detrusor thickness is 1.2+/-0.45 mm (range 0.4-3 mm) when the bladder is full. Future studies should evaluate this method in children with functional, neuropathic and anatomical dysfunctions of the lower urinary system.

Video-densitometric quantitation of fluorescence quenching on totally irradiated thin-layer chromatographic plates.

The influence of the instrumental settings of a video-imaging system on the quality of captured images was studied. The performance of the Camag video documentation system was evaluated by measurements of fluorescence quenching of a model compound (the pesticide atrazine) in the UV spectral region. The effects of different camera settings (aperture and number of accumulated frames) on background response, baseline noise, and sensitivity and reproducibility of detection were studied for different commercial thin-layer chromatographic (TLC) and high-performance TLC (HPTLC) plates. The results showed that as the number of frames, in other words, the image brightness and background response, increased, the sensitivity also increased, reaching a maximum at settings that gave an image of moderate luminosity. Additional frame accumulation caused a decrease in sensitivity. A similar pattern was observed by measuring the limit of detection (LOD). If the f-stop number (aperture) was too large, the image was too bright, and if the aperture was too small, the image was too dark. Both of these extremes resulted in a higher LOD. However, good sensitivity does not necessarily mean a low detection limit because of the high baseline noise at the same capturing conditions. Evaluation of dark or moderately luminous video images gave more repeatable results than did evaluation of very bright images. With HPTLC silica gel plates, the relative standard deviation ranged from 1.8 to 2.5% for settings that resulted in moderately bright images, and from 5 to 8% for settings that resulted in bright images.

Doppler sonographic renal resistance index in healthy children.

The objective of the study was to determine the values of Doppler resistance indices (RIs) in intrarenal arteries in healthy children. Color duplex Doppler sonography of intrarenal arteries was performed in 163 children and 58 adult patients, with the absence of clinical or laboratory pathologic changes of the urinary tract. All patients were classified following results of exploratory data analysis into three age groups: (a) 51 children between 2 and < 6 years of age; (b) 112 children 6-16 years of age; and (c) adults. The RIs were compared between different age groups. The mean RI +/- 1 SD values in group 1 were 0.705 +/- 0.018 (range 0.67-0.75), in group 2 0.605 +/- 0.029 (range 0.55-0.65), and in the adult group 0.604 +/- 0.035 (range 0.54-0.68). In the group of the youngest children (group 1), the RIs were significantly higher (p < 0.01) in comparison with the other group of children and the adult group. No statistically significant difference was observed between the group of children 6-16 years of age and the adult group. RI < 0.70 was noted in all children above 6 years of age; however, in younger children, RI > or = 0.70 was observed in 72.5% (37 of 51) of children. Resistance index in early childhood was considerably higher as compared with older children and the adult population: Apparently the RI value drops to adult level at approximately 6 years of age. The utilization of a threshold RI value of 0.70 for the increased renal vascular resistance in adults can also be applied to children over 6 years of age.

Interferon treatment of uterine cervical carcinoma: 20 years of follow-up.

Twenty-seven randomized patients with biopsy proven carcinoma of the uterine cervix were treated with human natural leucocytic interferon (HNLI) and followed up, while 30 randomized patients were followed up in the control group and were not treated with HNLI. International Federation of Gynecology and Obstetrics (FIGO) classification of HNLI-treated patients was IA: 8, IB: 9, IIA and IIB: 10. FIGO classification of control non-treated patients was IA: 9, IB: 10, IIA and IIB: 12. HNLI was applied locally at 2x10(6) U daily in pessaries for 21 days before surgery. Survival analysis of the HNLI-treated patients after 240 months of observation showed that 20 patients (74.07%) out of 27 survived, and in the control group 14 patients (46.67%) out of 30 survived. Statistical difference between the HNLI-treated group and control group of patients is significant P<0.05.

The Croatian Health Survey--SF-36: I. General quality of life assessment.

The objective of the Croatian Health Survey was the assessment of population health related quality of life in the transitional environment of Croatia. Health status measures incorporate dimensions such as physical, psychological, and social functioning, role performance and perception of wellbeing. In order to assess health status, "The medical outcome study 36-item short-form health survey (SF-36) model" was used. A total sample of 5048 inhabitants (1983 males and 3065 females), 18 years and over, represents approximately 1% of the general population of Croatia. Mean scores were as follows: physical functioning (PF) 69.94, role-physical (RP) 63.01, bodily pain (BP) 64.51, general health (GH) 53.40, vitality (VT) 51.85, social functioning (SF) 72.96, role-emotional (RE) 72.42, mental health (MH) 61.71 and health transition (HT) 44.79. Results of the SF-36 health survey in Croatia are very much like the results in other European countries with indication that general quality of life is lower in Croatia.