Reliable Answers Research Articles

Visualization RCD (reinforced concrete design) table advisor for decision support activity

Reinforced concrete design (RCD) activity requires the services of design table to pick bar sizes and area of specific bar groups. This allow reinforced concrete (RC) designers to use their intuition to pick the right bar size for detailing of RC Structures which virtually enhance reliable and satisfactory answers to RCD problems. With the advent of computer with its powerful memory, most RCD software available automatically generates Steel Properties thus, jeopardising user’s contribution in terms of their perception. RCD Tables are conventionally small but not limited in use. By the skilful and innovative integration of available concepts and techniques, the power of the RCD Tables are enhanced to check for deflection, minimum and maximum area of steel, and display alert to users. Visualization RCD Table interface was designed as a dialog box. Simply Supported Reinforced Concrete Beam Structure (SSRCBS) tool was modified to accommodate the new tool. Statistical analysis revealed that the significance of time was borderline between SSRCBS tool and the modified tool. It was also found that as the tasks became more complex, the modified tool advantage increases in terms of task-by-task satisfaction and users understanding of the logic behind RCD. Key words: RCD visualization, RC, PDAs, SSRCBS, visRCD table advisor, DSS.

Receiving Difficult News: Views of Patients in an Inpatient Setting

For this quantitative study, a cross-sectional design was used to assess patients' ratings regarding receiving difficult news pertaining to their psychiatric illness, such as deleterious lifestyle consequences and lifelong medications. One hundred inpatients were interviewed and completed the survey. Nearly all agreed they had a legal or moral right to information about their diagnosis, and most agreed they should be told their diagnosis. The majority believed the doctor was the best person to tell them their diagnosis, and more than half indicated that not providing a diagnosis was more concerning than be ing told. Approximately two fifths of patients indicated they would prefer to hear difficult news in the presence of key family members or over several sessions, and more than three quarters thought providing hope, regardless of circumstances, was important. The highest response rates were for staff to provide accurate and reliable information, be honest and answer patients' questions, and inform patients of their treatment options and side effects. These results indicate the importance of communicating accurate and timely information to patients in an empathic and understanding manner.

Qualità totale e mobilità totale

FIABA ONLUS (Italian Fund for Elimination of Architectural Barriers) was founded in 2000 with the aim of promoting a culture of equal opportunities and, above all, it has as its main goal to involve public and private institutions to create a really accessible and usable environment for everyone. Total accessibility, Total usability and Total mobility are key indicators to define quality of life within cities. A supportive environment that is free of architectural, cultural and psychological barriers allows everyone to live with ease and universality. In fact, people who access to goods and services in the urban context can use to their advantage time and space, so they can do their activities and can maintain relationships that are deemed significant for their social life. The main aim of urban accessibility is to raise the comfort of space for citizens, eliminating all barriers that discriminate people, and prevent from an equality of opportunity. “FIABA FUND - City of ... for the removal of architectural barriers” is an idea of FIABA that has already affected many regions of Italy as Lazio, Lombardy, Campania, Abruzzi and Calabria. It is a National project which provides for opening a bank account in the cities of referring, in which for the first time, all together, individuals and private and public institutions can make a donation to fund initiatives for the removal of architectural barriers within its own territory for a real and effective total accessibility. Last February the fund was launched in Rome with the aim of achieving a Capital without barriers and a Town European model of accessibility and usability. Urban mobility is a prerequisite to access to goods and services, and to organize activities related to daily life. FIABA promotes the concept of sustainable mobility for all, supported by the European Commission’s White Paper. We need a cultural change in management and organization of public means, which might focus on individual in its totality, with all its needs. For this reason it is necessary to focus on output of public and private transports which must be totally and globally accessible. Metropolitan and suburban transports need to have modern buses, and it has been calculated that it is possible to provide a total replacement of the fleet in a period from five to ten years. Total Quality must become the goal of every Local Government. FIABA suggests that a Total Quality Manager be always present in the institutional environment, as a guarantor of quality perceived by people living in their city for tourism, work, and leisure. It is essential to establish a favorable environment for all, to ensure the comfort of 100% of the population to give some definite and reliable answers.

Dice test – a simple method for assessment of visual acuity in infants with visual deficits

Determination of visual acuity in low vision infants or patients with additional cerebral retardation is difficult. In our low vision department we used dice of different sizes and colors as well as other defined objects to determine visual acuity (VA). In this study we compared the results of the dice test with conventional tests for measurement of visual acuity. A total of 88 children with different causes of visual impairment e.g. albinism, retinal scars, retinopathy of prematurity (ROP), achromatopsia and optic atrophy etc., were included in this longitudinal study. Median follow-up time was 8.7 years (range 2.9-18.9 years). The first reliable examination was performed between the ages of 4 and 24 months (median 11 months). We estimated VA depending on the edge length of the dice, which were recognized at a distance of 30 cm, while 4 mm complied with VA 20/200. Best corrected binocular visual acuity was compared between the dice test, measurement with the Lea symbols and with numbers or Landolt rings. Estimation of visual acuity using the dice test was possible at the end of the first year of life (median 11 months, range 4-27 months). Although observation is limited to visual acuity results in the low vision range between light reaction and 20/120 there was nearly complete agreement between all three VA measurements. Visual acuity ranged from light perception to 20/20 with a median of 20/100. In 39 patients visual acuity was 20/200 or less at the end of the observation period. Visual acuity estimation overestimated visual acuity only in 5 out of the 88 patients, while in all of the patients with later acuity measurements better than 20/200, our best value of 20/200 was achieved. Using simple visual objects, such as dice with different colors and size down to an edge length of 4 mm, it is possible to estimate visual acuity in low vision infants within the first year of life. This option is also very helpful in patients who are not able to perform other visual acuity measurements or to give reliable answers using preferential looking, such as severely handicapped patients. In contrast to preferential looking with this dice test there is not only judgment of the reaction by the observer but also activity of the patient who grips the dice he can really see. This allows better counseling of families with low vision infants concerning current and later visual functions.

Increased paclitaxel resistance in recurrent epithelial ovarian cancer: analysis of metachronous tumors

Whether or not ovarian cancer exhibits tumor heterogeneity before and after chemotherapy, demonstrated in an in vitro drug resistance assay, seems to remain controversial [1–4]. In the largest analysis of an unselected population with ovarian cancer, there was no significant difference in the proportion of extreme drug resistance (EDR) between primary and recurrent cases [1]. On the other hand, a taxane-free interval longer than 1 year among 34 cases of epithelial ovarian cancer receiving platinum and taxane combination chemotherapy showed significant increased risk of EDR to taxane: paclitaxel 89.7%, and docetaxel 82.8% [2]. Their results were supported by other investigators, and marked increased EDR ratio was seen for paclitaxel [3]. We previously demonstrated increased paclitaxel resistance after postoperative chemotherapy with platinum and taxane in epithelial ovarian, fallopian, and primary peritoneal cancers [4]. In our results, EDR to paclitaxel was more common in later recurrence, especially more than 5 years after the initial surgery [4]. However, most previous studies did not evaluate the factor of metachronous tumors, that is, tissues obtained from the same patient at diagnosis and at recurrence. Evaluation of metachronous tumors gives the most reliable answer to whether or not tumors exhibit heterogeneity between before and after chemotherapy exposure. The objective of the study was to compare in vitro drug resistance assays of primary and recurrent epithelial ovarian, fallopian, and primary peritoneal cancers exposed to platinum and taxane combination chemotherapy in the same patients. All patients who received postoperative chemotherapy with platinum and taxane after initial cytoreductive surgery between Jan 1995 and Jan 2009 were evaluated. Results from in vitro drug resistance assay (EDR Assay , Oncotech, Tustin, CA, USA) from the tumor tissues obtained at primary and recurrent surgery in the same patients were evaluated for extreme (EDR), intermediate (IDR), and low (LDR) drug resistance [5]. The proportion of assay results was compared between primary and recurrent tumor. Upgrade or down-grade of assay results was also compared. Up-grade of assay results included LDR to either IDR or EDR, and IDR to EDR. Down-grade of assay results included EDR to either IDR or LDR, and IDR to LDR. Fisher’s exact test was used for statistical evaluation. There were 29 cases identified for metachronous tumor; epithelial ovarian (93.1%), fallopian (0%), and primary peritoneal cancer (6.9%). Median time interval between initial diagnosis and recurrent surgery was 27.8 months (95% confidential interval, 6.6–58.4). All received platinum and taxane combination chemotherapy; however, only paclitaxel showed a statistical significance in the proportion of assay results demonstrating significant decrease in K. Matsuo (&) Department of Gynecologic Oncology, Unit 1362, M. D. Anderson Cancer Center, University of Texas, 1151 Herman Pressler Street, P.O. Box 301439, Houston, TX 77230-1439, USA e-mail: koji.matsuo@gmail.com

Preliminary Performances of A NEW Generation Assay : VIDAS D-Dimer Exclusion II.

Abstract 4203The diagnostic value of D-dimer (DD) in the exclusion of deep venous thrombosis (DVT) and pulmonary embolism (PE) is well established. With more than 8,000 patients included in prospective management studies, VIDAS D-Dimer assays have been the most extensively assay studied. The aim of this study is to evaluate the analytical performances of a new generation of D-Dimer assay on the VIDAS instrument: VIDAS D-Dimer Exclusion II* (bioMérieux, Marcy l'Etoile, France). VIDAS D-Dimer Exclusion II (DEX2) assay principle combines a two-step enzyme immunoassay sandwich method with a final fluorescent detection. Total duration of the test is 20 minutes. Calibration is performed once every 28 days with one standard. Calibrator and controls (n=2) are reconstituted with distilled water. VIDAS D-Dimer Exclusion II has been calibrated against a panel of human plasma samples, the concentrations of which have been determined using the VIDAS D-Dimer Exclusion kit (DD2).Studies were conducted to verify analytical performances of the new assay. Precision studies were performed according to CLSI document EP5-A2 using five plasma samples covering the range of the assay. The total %CV observed was less than 7%, including for those values around the areas of clinical decision limits. Limit of blank (LoB), limit of detection (LoD) and limit of quantification (LoQ) were evaluated according to CLSI document EP17-A and they were found at 7.41, 16.47 and 29 ng/mL (FEU) respectively. Linearity from a range of 45 to 10,000 ng/mL (FEU) has been determined on plasmas according to the recommendations of CLSI document EP6-A. Deviation from linearity was found to be less than 11%. Studies were conducted to verify the performance of the assay on potentially interfering substances such as bilirubin, triglycerides, hemoglobin, human albumin, and 47 commonly used drugs and anticoagulants. Less than 10% or 12% interference was observed at 500 and 7500 ng/mL (FEU) or 250 ng/mL (FEU) levels respectively, for each interfering substance. The assay Reference Interval was determined by testing 215 citrated plasma samples obtained from healthy volunteers; 90% of those values were found to be below the clinical cut off of 500 ng/mL (FEU). A method comparison study was performed on 584 citrated samples according to the recommendations of CLSI document EP9-A2. Regression line between VIDAS D-Dimer Exclusion II (DEX2) and VIDAS D-Dimer Exclusion (DD2) was: DEX2 = 1.04 x DD2 – 20,74. Observed bias was –4.53%, -0.38% and 3.07% at 250, 500 and 3000ng/mL (FEU) respectively.In conclusion, VIDAS D-Dimer Exclusion II (DEX2) assay demonstrated good performance characteristics, particularly around the clinical cut off, as well as an excellent overall agreement with the extensively studied and published prior generation assay, VIDAS D-Dimer Exclusion (DD2). With the ability to provide results in 20 minutes and with optimized total precision, VIDAS D-Dimer Exclusion II assay (DEX2) will play a key role in the laboratory to provide accurate, rapid and reliable answers to clinicians.* Product not cleared for use in the USA Disclosures:No relevant conflicts of interest to declare.

Breakthrough Pain in Advanced Cancer Patients Followed at Home: A Longitudinal Study

The aim of this study was to longitudinally assess breakthrough pain (BP) in advanced cancer patients who were admitted to home palliative care. One hundred and one consecutive patients who were admitted to one of the two home care programs and were representative of the cancer population followed at home in Italy were included. Patients were excluded only if at admission they were cognitively impaired or too unwell to provide reliable answers to questions regarding data collection. At admission ( T 0), and one month later ( T 1), data were recorded about the pharmacological treatment of background pain and its effectiveness; the presence of BP and its intensity, duration, and number of episodes; the occurrence of BP induced by movement; spontaneous relief after stopping activity and limitation of physical activity because of pain on movement; the analgesic drugs prescribed for BP; and the effectiveness of BP medication. After the initial assessment, patients received analgesics for background pain and BP, as well as symptomatic treatment usually provided at home, according to local policies and protocols. At T 0, 70.2% of patients were receiving analgesic drugs, and 52% of them had uncontrolled pain. BP was reported by 49.2% of these patients and had a mean duration and number of episodes per day of 35.1 minutes (±35.0) and 2.4 (±1.5), respectively. Of patients with BP, 65.7% had pain on movement, which decreased spontaneously after stopping activity in 73.9%. Physical activity was strongly limited in 78.2% of these patients. Most patients did not have a BP medication prescription. At T 1, a larger number of patients were receiving analgesics ( P < 0.002), and the number of patients with BP medication significantly increased ( P < 0.001). The incidence of BP and pain on movement decreased (33% and 38.5%, respectively). This longitudinal study suggests that BP is a dynamic entity dependent on several factors, including analgesic treatment and the course of disease. This helps explain the different incidences reported in previous studies performed in different settings and conditions.

La valutazione economica delle risorse culturali. Un'applicazione della Contingent Valuation

-The case study examines the economic aspects of cultural heritage conservation and deals the valuation of economic value in monetary terms, using the application of the contingent valuation method to the castle of Nicastro (Catanzaro, Italy). For the construction of the hypothetical market and the selection criteria and approach to subjects of the statistic sample, the proposed solutions work with operative adjustments, dictated by the characteristics of the resource in question and in general for all cultural resources. The study has produced reliable answers to questions of willingness to pay, expressing the measure of the different components of the value (use value and existence value) contribute to the composition of the total economic value. The study allowed to verify the possibility of using the contingent valuation as a political tool. The particular question format, which combines ‘double bounded dichotomous choice' and ‘open ended' techniques has allowed us to take a sensitivity analysis, defining the measure of willingness to pay.Key words: evaluation cultural resource, contingent valuation method, willingness to payParole chiave: valutazione, beni culturali, metodo di valutazione contingente, disponibilitŕ a pagare

Rationale, design, and baseline characteristics of the Acetylcystein for Contrast-Induced nephropaThy (ACT) Trial: a pragmatic randomized controlled trial to evaluate the efficacy of acetylcysteine for the prevention of contrast-induced nephropathy

BackgroundAceltylcysteine has been evaluated in several small trials as a means of reducing the risk of contrast-induced nephropathy (CIN), however systematic reviews of these studies do not provide conclusive answers. Therefore, a large randomized controlled trial (RCT) is needed to provide a reliable answer as to whether acetylcysteine is effective in decreasing the risk of CIN in high-risk patients undergoing angiographic procedures.MethodsACT is a RCT of acetylcysteine versus placebo in 2,300 patients at-risk for CIN undergoing an intravascular angiographic procedure. The randomization list will be concealed. Participants, health care staff, investigators and outcome assessors will be blinded to whether patients receive acetylcysteine or placebo. All analysis will follow the intention-to-treat principle. The study drugs (acetylcysteine 1200 mg or placebo) will be administered orally twice daily for two doses before and two doses after the procedure. The primary outcome is the occurrence of CIN, defined as a 25% elevation of serum creatinine above baseline between 48 and 96 hours after angiography.DiscussionThe first patient entered the trial on September, 2008. Up to April 7, 2009, 810 patients had been included in 35 centers. The mean age was 69 (Standard deviation: 10), 18% had a baseline serum creatinine >1.5 mg/dL, 57% were diabetics and 13% had a history of heart failure. The ongoing ACT Trial is the largest multicentre RCT that will determine whether acetylcysteine is effective in decreasing the risk of CIN in patients at risk undergoing angiography.Trial registrationClinicaltrials.gov NCT00736866

Implementation and limitations of meta-analysis of randomized trials from the clinical biostatistician’s point of view

fore, cannot be meaningfully combined, even if analyses are stratifi ed by trial. Advocates of large trials claim that only such trials can give conclusive answers to a major clinical question. However, these “defi nitive” trials would typically require several thousand patients, with the corresponding need for massive databases, the maintenance of high-quality data across many centers and often many countries, and therefore huge budgets that are not always available. Several trials looking at related questions may be easier to organize and more cost-effective, leaving a metaanalysis as the best way to combine all the available evidence and draw reliable conclusions about the treatment benefi ts and harms. Several large trials for patients with colorectal tumors have recently been implemented in the United States, Europe, and Japan. Nonetheless, most randomized clinical trials performed in the world are still relatively small-sized, with the number of patients rarely exceeding 500, and as such these trials are underpowered and insuffi cient from a statistical point of view. Do we have to believe the results of such small-sized randomized trials? Probably not, because negative results might result from the inadequate sample size, while positive results would tend to be prominently reported and published sooner than negative results, a phenomenon known as publication bias. Last but not least, some of the trials may be affected by methodological fl aws that may or may not be obvious from their published reports. It is unlikely that all trials are subject to similar fl aws, which is why the replication of an experiment is such an essential principle in science generally, and in clinical research in particular. Meta-analyses that are likely to yield reliable answers to important clinical questions should be based on two key principles. First, they should use individual patient data obtained from the principal investigators of all trials included in the meta-analysis. Second, they should use all relevant trials and not just those that happen to be published or are otherwise available. Investigators must also be aware of meta-analyses that intentionally eliminate inconvenient data and that may appear respectable, but may lead to seriously misleading results. Received: February 16, 2009

Low-Density-Lipoprotein-Apherese bei familiärer Hypercholesterinämie

□ Background and Purpose: Low-density lipoprotein (LDL) apheresis is indicated in patients with familial hypercholesterolemia who are resistant to drug therapy. The study evaluates whether the various apheresis techniques available result in relevant improvement of clinical endpoints (cardiovascular morbidity and mortality, quality of life). □ Material and Methods: A systematic literature review in standard data-bases (Medline, EMBASE, CRD York, Cochrane, and others) was conducted. Extraction of core data, assessment of study quality and evidence rating according to the GRADE method were undertaken in an internal peer-review process. □ Results: Evidence from the ten studies included weakly indicates an improvement in angina symptoms and reduced mortality. However, due to limited study quality, no reliable answers are possible concerning the question whether LDL apheresis results in reduced cardiovascular morbidity/mortality or improved quality of life. D Conclusion: The available evidence indicates a possible net benefit of LDL apheresis. However, since the quality of the evidence is very low, treatment should be strictly restricted to patients with severe familial hypercholesterolemia who are resistant to standard care.

Prophylactic antibiotics in vesicoureteric reflux: Evidence-based analysis

Objectives:The aim of this review was to systematically examine the available evidence for the effectiveness of prophylactic antibiotics in cases of vesicoureteric reflux (VUR).Materials and Methods:We searched the relevant data on medical management of VUR and the date of last search was June 2008. The search included both randomized controlled trials as well as the nonrandomized trials and the data sources were; MEDLINE, online peer reviewed journals, Cochrane database and abstracts from conference proceedings.Results:Barring few most of the studies published on medical management were nonrandomized. Besides being small in number many of these studies were of poor-quality and poorly designed eventually failing in giving a reliable answer in this regard. Few of the studies suggest that the children with low grade VUR might do well even without antibiotic prophylaxis.Conclusions:In the absence of properly designed, randomized controlled trials and long-term follow-up the question of antibiotic prophylaxis in cases of VUR remains unanswered in large part of it. Whether to give prophylactic antibiotics or not would ultimately need a shared decision-making involving both the treating physician and the parents assessing both the risks and the benefits.

HRM and Performance: Achievements, Methodological Issues and Prospects

Twenty years ago Guest (1987) published his normative framework describing the essence of HRM. He presented HRM as a new approach to personnel management, emphasizing its strategic contribution, its closer alignment to business, the involvement of line management, and focusing on HRM outcomes like commitment, flexibility and quality. The achievement of these human resource outcomes was, in turn, expected to contribute to a range of positive organizational outcomes, including high job performance, low turnover, low absence and high cost-effectiveness through the full utilization of employees, now relabelled as human resources. Put this way, it is not difficult to understand the wide appeal that the notion of HRM had (and still has) to academics and practitioners alike. It led to the renaming of chairs/departments within universities and to changed job titles in the business community. The attractiveness of the concept of HRM increased considerably when Huselid, in 1995, published a ground-breaking paper in the Academy of Management Journal in which he demonstrated a correlation between the degree of sophistication of HR-systems and the market value per employee among a range of publicly quoted companies in the USA. The paper generated admiration, criticism and an abundance of 'me too' research, trying to replicate the proclaimed relationship between HRM and Performance (Delery and Doty, 1996; Guthrie, 2001; Koch and McGrath, 1996; Wright et al., 2003). Since then many academics on both sides of the Atlantic have become active in this field, with a special focus on the relationship between HRM and Performance. Within this rapidly expanding field of study, the HRM–Performance relationship has been approached from a variety of perspectives rooted in organizational behaviour, sociology, economics, industrial relations and organizational psychology, with a particular emphasis placed on the impact of various combinations of human resource practices on a range of performance outcomes at the individual and organizational level of analysis.

Interpretation of tests of heterogeneity and bias in meta‐analysis

Statistical tests of heterogeneity and bias, in particular publication bias, are very popular in meta-analyses. These tests use statistical approaches whose limitations are often not recognized. Moreover, it is often implied with inappropriate confidence that these tests can provide reliable answers to questions that in essence are not of statistical nature. Statistical heterogeneity is only a correlate of clinical and pragmatic heterogeneity and the correlation may sometimes be weak. Similarly, statistical signals may hint to bias, but seen in isolation they cannot fully prove or disprove bias in general, let alone specific causes of bias, such as publication bias in particular. Both false-positive and false-negative signals of heterogeneity and bias can be common and their prevalence may be anticipated based on some rational considerations. Here I discuss the major common challenges and flaws that emerge in using and interpreting statistical tests of heterogeneity and bias in meta-analyses. I discuss misinterpretations that can occur at the level of statistical inference, clinical/pragmatic inference and specific cause attribution. Suggestions are made on how to avoid these flaws, use these tests properly and learn from them.

The Role of Abdominal Radiography in the Evaluation of the Nontrauma Emergency Patient: New Thoughts on an Old Problem

Ronald L. Eisenberg, MD, JD M ore than one-quarter of a century ago, our group challenged the indiscriminate use of ordinary abdominal radiographs, demonstrating that 53.7% of them could be eliminated without missing any clinically important findings (1). We recommended that abdominal radiography could safely be restricted to those suffering from moderate to severe abdominal tenderness and patients with clinical signs and symptoms highly suggestive of bowel obstruction, ureteral calculi, ischemia, or gallbladder disease. However, our article had little effect on ordering patterns, despite the continuing need to control overuse of imaging resources and the emergence of newer technologies that may provide more precise and reliable answers to clinical questions. In this issue of Radiology, Kellow et al (2) again address this important and provocative issue. Showing a high incidence of positive computed tomography (CT), ultrasonography (US), or upper gastrointestinal imaging findings, even in patients whose abdominal radiograph was interpreted as normal or nonspecific (81% of the total studies), they confirm the frequent futility of conventional imaging for many abdominal conditions and the continuing overuse of abdominal radiographs 25 years after our article was published. They make the sweeping statement that, “with the exception of localization of catheter placement, there no longer remains a role for abdominal radiography in nontrauma emergency room patients,” arguing that “when imaging is needed, the emergency physician should be encouraged to immediately request more definitive imaging modalities [eg, CT and US],” which were not readily available when our article was published. Although I completely agree that abdominal radiography is overused and could be eliminated in many cases, I would suggest that a somewhat more temperate and nuanced approach is needed. Ultimately, it is not sufficient to merely state the futility of abdominal radiography in most clinical settings, but to evaluate the reasons why emergency room physicians order this modality for situations in which no imaging is required. Unfortunately, Kellow et al (2) performed their study in an institution in which emergency room physicians did not read their own images. Consequently, they were forced to use the official radiology report as a surrogate for the emergency room interpretation. Although I certainly would agree that “one may assume that the radiologists’ report is more often accurate, so use of the official report would overestimate, rather than underestimate, the use of radiography,” this is not the major issue. Rather, it is the lack of information about the interpretation of the emergency room physician that is the problem, as this is critical to further understanding the role of radiography in the emergency department setting. In many cases, if not most, the interpretation of the radiologist has little bearing on health care decisions, since the patient has already been treated on the basis of the referring clinician’s assessment of the images. The major issue, which is impossible to assess in a retrospective study, is the thought process of the ordering physician in the emergency room. Did the doctor in the emergency room expect to discover an abnormality on the abdominal radiograph? Or, was the study ordered merely to placate the patient, to assure someone with a low probability of disease that there was no acute abnormality? Of the patients with abdominal radiographs that were interpreted as normal on review by the radioloPublished online 10.1148/radiol.2483080863

Soft tissue handling during implant placement

The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, Medline and Embase were searched. Handsearching included several dental journals. Authors of all identified trials, an internet discussion group and 55 dental implant manufacturers were contacted to find unpublished randomised controlled trials (RCT). All RCT of root-form osseo-integrated dental implants comparing various techniques to handle soft tissues when placing dental implants were included. Outcome measures considered were: prosthetic and implant failures, aesthetics evaluated by patients and dentists, biological complications, postoperative pain, patient preference, ease of maintenance by patient, and width of the attached or keratinised mucosa. Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Authors were contacted for missing information. Results were expressed as random-effects models using mean differences for continuous outcomes, and risk ratios for dichotomous outcomes, with 95% confidence intervals. Heterogeneity was to be investigated, including both clinical and methodological factors. Eight RCT were identified and five trials, which included 140 patients in total, were selected. Two trials (comprising 100 patients) compared flapless placement of dental implants with conventional flap elevation, two trials (20 patients) crestal versus vestibular incisions. On a patient (rather than per-implant) basis, implants placed with a flapless technique and implant exposures performed with a laser induced significantly less postoperative pain than flap elevation. There were no statistically significant differences for any of the other analyses. Flapless implant placement is feasible and has been shown to reduce patient postoperative discomfort in appropriately selected patients. Sufficient, reliable evidence is not available for recommendations to be made about which techniques or materials for incision or suture are most beneficial to patients. This is also the case for techniques to correct or augment perimplant soft tissues or to increase the width of keratinised or attached mucosa. Properly designed and conducted RCT are needed to provide reliable answers to these questions.

Benchmarking of Intra-Operative Process Times in a Prospective Multi-centre Comparison: Limited Informative Value

This article’s title arouses the expectation that measuring and comparing figures relating to operating room processing times will help optimize the processes concerned. It seems, however, that this was not really the purpose of the study, which rather served to document the contention that the greater amount of educational activity occurring in large hospitals lengthens operating room processing times, but is not adequately compensated by the DRG system. This hypothesis seems plausible, and it is certainly worthy of being examined. The authors’ research revealed that the anesthesia preparation time, perioperative time, and anesthesia time after the end of surgery were longer in university hospitals than elsewhere, and that this finding was locally statistically significant. From a process management point of view, an interesting observation was that the hospitals with better results – i.e., shorter processing times – showed lower variances, indicating that the processes were relatively stable. Although the method of the study was well-conceived and well-structured, I would nonetheless like to offer two critical remarks. First, each of the participating hospitals was represented, in the end, by only 7 to 12 data sets, which is not a very large number. This limits the informative value of the study. Second, the conclusion seems problematic. The authors’ step-by-step segmentation of operative room processing still contains no information about the actual occurrence of educational activity, which is merely surmised. The individual processes in the operating rooms of university hospitals were not inspected any more closely to see whether they fulfilled their intended purposes. Could there not be other factors at work, besides educational necessity, to explain the longer processing times? To put it a bit more pointedly: How can we be sure it is not the case that operations in university hospitals take longer, while the need for adequate training remains unmet? For a reliable answer to this question, it is necessary to examine the processes involved critically and in greater detail, with closer questioning of the participants.

Synopsis diffusion for robust aggregation in sensor networks

Previous approaches for computing duplicate-sensitive aggregates in wireless sensor networks have used a tree topology, in order to conserve energy and to avoid double-counting sensor readings. However, a tree topology is not robust against node and communication failures, which are common in sensor networks. In this article, we present synopsis diffusion , a general framework for achieving significantly more accurate and reliable answers by combining energy-efficient multipath routing schemes with techniques that avoid double-counting. Synopsis diffusion avoids double-counting through the use of order- and duplicate-insensitive (ODI) synopses that compactly summarize intermediate results during in-network aggregation. We provide a surprisingly simple test that makes it easy to check the correctness of an ODI synopsis. We show that the properties of ODI synopses and synopsis diffusion create implicit acknowledgments of packet delivery. Such acknowledgments enable energy-efficient adaptation of message routes to dynamic message loss conditions, even in the presence of asymmetric links. Finally, we illustrate using extensive simulations the significant robustness, accuracy, and energy-efficiency improvements of synopsis diffusion over previous approaches.

Self-monitoring of blood glucose in type 2 diabetes: a new look at published trials

To the Editor: Published randomised controlled trials (RCTs) of self-monitoring of blood glucose (SMBG) in type 2 diabetes have not reached a consistent conclusion with regard to the benefit of using SMBG, especially in non-insulin-treated patients. As a consequence, there is worldwide variability in the use of glucose test strips and policies on reimbursement [1]. We analysed 18 relevant RCTs [2–19], some of which had not been included in previous meta-analyses [20–25]. Why do these trials not provide a reliable answer? The main reason appears to be conceptual. SMBG per se is a diagnostic procedure and not an intervention. Clinical trials, though, compare different types of intervention vs outcome. Hence, the 18 RCTs did not simply compare the same treatment protocol plus/minus SMBG but compared intervention strategies, which differed in many aspects, i.e. SMBG-guided disease management strategies. Each of the RCTs studied a different strategy for SMBG-guided disease management. As a consequence, the clinical outcomes of the different trials can hardly be combined in a metaanalysis. This renders safe conclusions virtually impossible. An SMBG-guided disease management strategy should include some type of algorithm enabling the patient to translate SMBG readings into changes of diet, daily exercise and/or of dose of glucose-lowering medication. Next there should be some guidance for patients during their first months of using SMBG, and, finally, decisions on medication and advice from nurses or doctors should also make use of documented SMBG results. For this advice, some rules or an algorithm on how to translate blood glucose profiles into medical advice should exist in the context of a RCT. We have analysed the RCTs for the SMBG-based disease management strategy employed. Unfortunately, information on this crucial point is quite brief in most reports. Only seven of the 18 study protocols included an algorithm or some guideline to teach patients how to respond to elevated SMBG readings, whether they were fasting or postprandial (Table 1). Reinforcement of patient education by guidance during the study ranged from one visit in 6 months to initially weekly meetings, to continuous support via the Internet. Six trials did not report a procedure for consideration of documented SMBG data for making medical treatment decisions by doctors or nurses; a further two trials apparently evaluated fasting but not postprandial values (Table 1). We conclude that most RCTs of SMBG in type 2 diabetes do not provide a sufficiently detailed description of the SMBG-guided disease management strategy used, even though it is this intervention strategy that is analysed in the trial. As judged from the information provided, there is Diabetologia (2008) 51:686–688 DOI 10.1007/s00125-008-0946-7

Win, lose, or draw? China’s quarter century war on corruption

In 1982, the leadership of the Chinese Communist Party ordered a crackdown on corruption. As China’s war on corruption enters its 25 year an obvious question is whether the party winning? Because there is no direct way to measure the actual rate of corruption (ARC) and the data we have on the revealed rate of corruption (RRC) may not perfectly reflect changes in the ARC while changes in the perceived level of corruption (PLC) may be subject to subjective distortion, trends in the RRC and the PLC may not provide reliable answers. The mathematical relationship between the ARC and the RRC, however, can be defined as a function of risk. Increases in risk can be interpreted as signaling a narrowing of the ARC–RRC gap. Decreases in risk can be interpreted as signaling a widening of the ARC–RRC gap. By combining data on changes in risk with data on movement in the RRC it is possible, therefore, to assess (in broad terms) the movement of the ARC even though it remains technically unknowable. Using data on the lag between when officials first engage in corruption and when they are prosecuted to measure changes in risk, this article raises doubts about whether Chinese Communist Party (CCP) is winning its war on corruption.