How does study quality affect the results of a diagnostic meta-analysis?

Background: The use of systematic literature review to inform evidence based practice in diagnostics is rapidly expanding. Although the primary diagnostic literature is extensive, studies are often of low methodological quality or poorly reported. There has been no rigorously evaluated, evidence based tool to assess the methodological quality of diagnostic studies. The primary objective of this study was to determine the extent to which variations in the quality of primary studies impact the results of a diagnostic meta-analysis and whether this differs with diagnostic test type. A secondary objective was to contribute to the evaluation of QUADAS, an evidence-based tool for the assessment of quality in diagnostic accuracy studies. Methods: This study was conducted as part of large systematic review of tests used in the diagnosis and further investigation of urinary tract infection (UTI) in children. All studies included in this review were assessed using QUADAS, an evidence-based tool for the assessment of quality in systematic reviews of diagnostic accuracy studies. The impact of individual components of QUADAS on a summary measure of diagnostic accuracy was investigated using regression analysis. The review divided the diagnosis and further investigation of UTI into the following three clinical stages: diagnosis of UTI, localisation of infection, and further investigation of the UTI. Each stage used different types of diagnostic test, which were considered to involve different quality concerns. Results: Many of the studies included in our review were poorly reported. The proportion of QUADAS items fulfilled was similar for studies in different sections of the review. However, as might be expected, the individual items fulfilled differed between the three clinical stages. Regression analysis found that different items showed a strong association with test performance for the different tests evaluated. These differences were observed both within and between the three clinical stages assessed by the review. The results of regression analyses were also affected by whether or not a weighting (by sample size) was applied. Our analysis was severely limited by the completeness of reporting and the differences between the index tests evaluated and the reference standards used to confirm diagnoses in the primary studies. Few tests were evaluated by sufficient studies to allow meaningful use of meta-analytic pooling and investigation of heterogeneity. This meant that further analysis to investigate heterogeneity could only be undertaken using a subset of studies, and that the findings are open to various interpretations. Conclusion: Further work is needed to investigate the influence of methodological quality on the results of diagnostic meta-analyses. Large data sets of well-reported primary studies are needed to address this question. Without significant improvements in the completeness of reporting of primary studies, progress in this area will be limited

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

An Infrastructure for Integrated Electronic Health Record Services: The Role of XML (Extensible Markup Language)

BACKGROUND: The sharing of information resources is generally accepted as the key to substantial improvements in productivity and better quality of care. In addition, due to the greater mobility of the population, national and international healthcare networks are increasingly used to facilitate the sharing of healthcare-related information among the various actors of the field. In the context of HYGEIAnet, the regional health telematics network of Crete, an Integrated Electronic Health Record environment has been developed to provide integrated access to online clinical information, accessible throughout the island. OBJECTIVES: To make available comprehensive medical information about a patient by means of incorporating all the distributed and heterogeneous health record segments into an Integrated Electronic Health Record that can be viewed on-line through a unified user interface and visualization environment. METHODS: The technological approach for implementing this Integrated Electronic Health Record environment is based on the HYGEIAnet Reference Architecture, which provides the necessary framework for the reuse of services, components, and interfaces. Seamless presentation of information is achieved by means of the Extensible Markup Language (XML), while its underlying capabilities allow for dynamic navigation according to personalized end-user preferences and authorities. RESULTS: The Integrated Electronic Health Record environment developed in HYGEIAnet provides the basis for consistent and authenticated access to primary information over the Internet in order to support decision-making. Primary information is always kept at the place where it has been produced, and is maintained by the most appropriate clinical information system, contrasting traditional store and forward techniques, or centralized clinical data repositories. CONCLUSIONS: Since documents are much more easily accessible rather than data inside a database, Extensible Markup Language has the potential of becoming a very cheap technology provided, of course, that the underlying Healthcare Information Infrastructure exists. XML can be introduced incrementally and its implementation is completely transparent to the end user

Morphological differences between wild and farmed Mediterranean fish

Gilthead seabream (Sparus aurata L.) and European seabass (Dicentrarchus labrax L.) are important commercial marine fish species both for aquaculture and fisheries in the Mediterranean. It is known that farmed individuals escape from farm facilities, but the extent of escape events is not easy to report and estimate because of the difficulty to distinguish between wild and farmed individuals. In this study, significant differences provided through morphometry evidence that the cranial and body regions of seabream and seabass are different regarding their farm or wild origin at different scales. Morphological variations have been shown to be a valuable tool for describing changes in shape features. Therefore, the biomass contribution of escapees to local habitats could be determined by identifying escaped individuals from fisheries landings as a first step to assess the potential negative effects of fish farm escapees on the environment, and their influence on wild stocks and local fisheries.This study was financed by the EU-proyect ‘‘PreventEscape’’ (7th Framework European Commission, num. 226885; http://www.preventescape.eu/)