Health-related quality of life after stroke a comprehensive review.
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BACKGROUND AND PURPOSE: We performed a comprehensive review of all quality-of-life (QOL) estimates for stroke appearing in the peer-reviewed literature between 1985 and 2000. We examine variation in QOL weights and the rigor of methods used to assess QOL and discuss the implications for cost-utility assessment and resource allocation decisions. METHODS: Through a systematic search, we identified 67 articles that met our inclusion criteria. A team of trained researchers read each article and followed detailed guidelines to extract QOL weights and other parameters. This effort yielded 161 QOL estimates for stroke-related health states. All estimates were measured on a 0 to 1 scale, with 0 representing the worst outcome and 1 representing the best. RESULTS: QOL estimates range from -0.02 to 0.71 (n=67) for major stroke, from 0.12 to 0.81 (n=14) for moderate stroke, from 0.45 to 0.92 (n=38) for minor stroke, and from 0.29 to 0.903 (n=42) for general stroke. Although QOL should decrease with severity, there were many instances in which the QOL for major stroke as reported by one study exceeded the QOL for moderate stroke as reported by another. The same reversal was found for moderate and minor stroke, and it occurred even when both authors used similar assessment methods and subject populations. Authors of cost-utility and decision analyses rarely base their choice of QOL weights on their own primary data (19%). When obtaining weights from secondary sources, some authors (23%) chose QOL weights for a severity of stroke that did not match the severity for which they sought data. CONCLUSIONS: QOL estimates for stroke vary greatly and are not always estimated in sound fashion. This impedes the comparability and quality of the cost-effectiveness studies that use these QOL weights and hampers good resource allocation decisions. (+info)
Hypothetical ratings of coronary angiography appropriateness: are they associated with actual angiographic findings, mortality, and revascularisation rate? The ACRE study.
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OBJECTIVE: To determine whether ratings of coronary angiography appropriateness derived by an expert panel on hypothetical patients are associated with actual angiographic findings, mortality, and subsequent revascularisation in the ACRE (appropriateness of coronary revascularisation) study. DESIGN: Population based, prospective study. The ACRE expert panel rated hypothetical clinical indications as inappropriate, uncertain, or appropriate before recruitment of a cohort of real patients. SETTING: Royal Hospitals Trust, London, UK. PARTICIPANTS: 3631 consecutive patients undergoing coronary angiography (no exclusion criteria). MAIN OUTCOME MEASURES: Angiographic findings, mortality (n = 226 deaths), and revascularisation (n = 1556 procedures) over 2.5 years of follow up. RESULTS: The indications for coronary angiography were rated appropriate in 2253 (62%) patients. 166 (5%) coronary angiograms were performed for indications rated inappropriate, largely for asymptomatic or atypical chest pain presentations. The remaining 1212 (33%) angiograms were rated uncertain, of which 47% were in patients with mild angina and no exercise ECG or in patients with unstable angina controlled by inpatient management. Three vessel disease was more likely among appropriate cases and normal coronaries were more likely among inappropriate cases (p < 0.001). Mortality and revascularisation rates were highest among patients with an appropriate indication, intermediate in those with an uncertain indication, and lowest in the inappropriate group (log rank p = 0.018 and p < 0.0001, respectively). CONCLUSION: The ACRE ratings of appropriateness for angiography predicted angiographic findings, mortality, and revascularisation rates. These findings support the clinical usefulness of expert panel methods in defining criteria for performing coronary angiography. (+info)
DNA evidence will be admissible if the proper foundation is laid: advice for a forensic medicine expert.
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The use and advance of DNA evidence in courts of law has mushroomed in the last few years to the point that it can almost be assumed that DNA evidence will be admitted if the proper foundation is laid. While a few basic principles are necessary for admissibility in all cases, each case stands on its own and depends upon its own fact situation and evidence to determine admissibility. The more advanced the science and specificity in each case, the easier for admissibility. To challenge admissibility, a lawyer has to challenge the foundation laid for the evidence. It only stands to reason that if you cannot attack the science, you have to attack the scientist, ie, the expert witness. This presentation is based upon the author's six years as a prosecutor and almost 23 years as a judge. It will give attendees some helpful advice on the purpose of an expert witness, how to be qualified as an expert witness, and some dos and don'ts, as well as hints as to how to become a better expert witness. (+info)
Preservation and collection of biological evidence.
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As the courts have placed greater emphasis on physical evidence during the past few decades, the initial stages of evidence examination have become increasingly important to the successful resolution of many criminal investigations. This emphasis on evidence collection and preservation is often manifested by many rigorous court challenges. This article reviews how the ability to introduce DNA test results in court is affected by methods used to recognize, document, collect, and preserve biological evidence. (+info)
Interpretation of complex forensic DNA mixtures.
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Forensic evidentiary samples routinely contain DNA from multiple contributors. The interpretation of these mixtures can be a challenging task for the DNA scientist. Several approaches are discussed (no calculation- qualitative statement; probability of exclusion; likelihood ratio estimates; presumptive genotype assignment based on peak heights), which have been employed to assess the significance of an inclusion/match when DNA mixtures have been detected in casework samples. These statistical approaches are discussed in light of technical challenges that can arise when evaluating evidentiary samples. (+info)
Untruths and consequences: the false hypothesis linking CHAT type 1 polio vaccination to the origin of human immunodeficiency virus.
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A book published in 1999 hypothesized that the scientists who worked with the CHAT type 1 attenuated polio strain tested in the former Belgian Congo in the late 1950s had covertly prepared the vaccine in chimpanzee kidney cells contaminated with a simian immunodeficiency virus, which evolved into HIV-1 group M. This paper summarizes the results of the investigation conducted by the author to determine the legitimacy of the accusation. Testimony by eyewitnesses, documents of the time, epidemiological analysis, and ancillary phylogenetic, virologic and PCR data all concur to reject the hypothesis as false and without factual foundation. (+info)
Postscript relating to new allegations made by Edward Hooper at The Royal Society Discussion Meeting on 11 September 2000.
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At The Royal Society Discussion Meeting, Origins of HIV and the AIDS epidemic, which this issue records, Edward Hooper added two new 'smoking guns' to the accusations published previously in The river. These were proposed as conclusive evidence for the hypothesis that simian immunodeficiency virus-contaminated CHAT polio vaccine caused the HIV-1 group M epidemic. We have investigated the facts in relation to these 'smoking guns'. (+info)
No-fault malparactice insurance. Proximate cause and the quality of medical care.
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No-fault medical malpractice insurance has been proposed as an alternative to the present tort liability approach. Statistical examination of the concept of proximate cause reveals not only that the question of acceptable care, and therefore of fault, is unavoidable in identifying patients deserving compensation, but also that specifying fault in an individual case is scientifically untenable. A simple formula for a Coefficient of Causality clarifies the question of proximate cause in existing trial practices and suggests that many of the threats associated with malpractice suits arise from the structure of the tort-insurance system rather than from professional responsibility for medical injury. The concepts could provide the basis for a revised claims and compensation procedure. (+info)